NUR 265 EXAM 1 QUESTIONS
WITH 100% CORRECT
ANSWERS
Position the client with the HOB elevated - Answer-The nurse is developing a POC for a
client who has cirrhosis and is scheduled to have a paracentesis performed. Which of
the following should the nurse include in the POC
I should avoid constipation to decrease my risk of bleeding - Answer-The nurse is
providing discharge instructions for a client with cirrhosis. Which of the following
statements best indicates that the client has understood the teaching
55yr old who has cirrhosis of the liver and has tachypneic - Answer-The nurse has
received handoff report for the following assigned clients. Which client should the nurse
see first
The ammonia level - Answer-The nurse is caring for a client who has cirrhosis and has
been prescribed lactulose. It would indicate that the client is having an expected
outcome from his medication if the client experiences a decrease in
Pancreatitis and has had a temperature of 101.1F for the past hr - Answer-The nurse is
caring for assigned clients. The nurse should first plan to assess the client who has
Administer O2 via NC - Answer-The nurse working in a cardiac unit is admitting a client
who has unstable angina. Which of the following actions should the nurse take
Sinus tachycardia with PVC's - Answer-The nurse is caring for a client who was
admitted 45 min ago with a diagnosis of MI. Which of the following findings should the
nurse anticipate may occur within the first few hrs after an MI
Crackles auscultated to the midline of the lung fields - Answer-The nurse is caring for a
client who experienced an acute MI 24 hrs ago. It would be necessary for the nurse to
immediately notify the PCP if the client has
Being treated for AFIB with an amiodarone drip analysis to have dysarthria - Answer-
The nurse caring for a group of client's on the cardiac floor, the nurse should
immediately follow up on the client who is
Increase the infusion rate to 6ml/hr - Answer-The nurse has received a handoff report
for a client who was admitted with chest pain and is receiving Nitro 50mg/250ml D5W at
, a rate of 10mcg/min, the client weighs 187lbs. The nurse observes that the clients IV
pump is set at a rate of 3ml/hr. Which of the following should the nurse take
Oozing blood at the IV site - Answer-The nurse in the ER is caring for a client who just
had an MI and is receiving a continuous infusion of TPA. It would be most important for
the nurse to notify the PCP if the client develops
Do you currently take blood thinners - Answer-The nurse is caring for a client who has
had chest pain for the past 45 min and has been prescribed the intravenous
thrombolytic Tenecteplase. Which of the following questions is the most important for
the nurse to ask the client before administering the medication
Systolic bp has decreased from 126/96 to 106/68mmhg - Answer-The nurse working in
a rehab is assisting a client who had an MI to increase activity tolerance. Which of the
following client symptoms indicates a need to stop the clients current activity
A. 20ml/hr B. 5ml/hr C. 15ml/hr D. 10ml/hr - Answer-The nurse has received a
prescription to increase a clients dopamine drip from 3mcg/kg/min to 5mcg/kg/min. The
concentration of dopamine is 400mg/250ml D5W and the client weighs 235lbs. What
would the nurse increase the clients infusion pump
BUN of 26mg/dl - Answer-The nurse working in the tele step down unit is caring for a
client who is scheduled for a cardiac catheterization and an angioplasty. Which of the
following lab findings is most important for the nurse to report to the PCP
This test is performed to help detect problems with my heart valves and chambers -
Answer-The nurse has instructed a client who is scheduled to have a cardiac
catheterization. Which of the following client statements would indicate a correct
understanding of the teaching
Had CABG surgery 24 hrs ago and has developed distant muffled heart sounds -
Answer-The nurse has been made aware of the following client situation. The nurse
should initially plan to assess the client
Sharp pain in the anterior chest
A right sternal border heart murmur - Answer-The nurse is assessing a client who has a
suspected aortic dissection. Which of the following findings should the nurse anticipate
the client to have
Has a suspected thoracic aortic aneurysm and is reporting the development of back
pain - Answer-The nurse is caring for assigned clients. It would be priority for the nurse
to follow up with the PCP of a client who
Jugular venous distention with clear lung sounds - Answer-The nurse is assessing a
client who has developed cardiac tamponade. Which of the following findings should the
nurse expect to observe
WITH 100% CORRECT
ANSWERS
Position the client with the HOB elevated - Answer-The nurse is developing a POC for a
client who has cirrhosis and is scheduled to have a paracentesis performed. Which of
the following should the nurse include in the POC
I should avoid constipation to decrease my risk of bleeding - Answer-The nurse is
providing discharge instructions for a client with cirrhosis. Which of the following
statements best indicates that the client has understood the teaching
55yr old who has cirrhosis of the liver and has tachypneic - Answer-The nurse has
received handoff report for the following assigned clients. Which client should the nurse
see first
The ammonia level - Answer-The nurse is caring for a client who has cirrhosis and has
been prescribed lactulose. It would indicate that the client is having an expected
outcome from his medication if the client experiences a decrease in
Pancreatitis and has had a temperature of 101.1F for the past hr - Answer-The nurse is
caring for assigned clients. The nurse should first plan to assess the client who has
Administer O2 via NC - Answer-The nurse working in a cardiac unit is admitting a client
who has unstable angina. Which of the following actions should the nurse take
Sinus tachycardia with PVC's - Answer-The nurse is caring for a client who was
admitted 45 min ago with a diagnosis of MI. Which of the following findings should the
nurse anticipate may occur within the first few hrs after an MI
Crackles auscultated to the midline of the lung fields - Answer-The nurse is caring for a
client who experienced an acute MI 24 hrs ago. It would be necessary for the nurse to
immediately notify the PCP if the client has
Being treated for AFIB with an amiodarone drip analysis to have dysarthria - Answer-
The nurse caring for a group of client's on the cardiac floor, the nurse should
immediately follow up on the client who is
Increase the infusion rate to 6ml/hr - Answer-The nurse has received a handoff report
for a client who was admitted with chest pain and is receiving Nitro 50mg/250ml D5W at
, a rate of 10mcg/min, the client weighs 187lbs. The nurse observes that the clients IV
pump is set at a rate of 3ml/hr. Which of the following should the nurse take
Oozing blood at the IV site - Answer-The nurse in the ER is caring for a client who just
had an MI and is receiving a continuous infusion of TPA. It would be most important for
the nurse to notify the PCP if the client develops
Do you currently take blood thinners - Answer-The nurse is caring for a client who has
had chest pain for the past 45 min and has been prescribed the intravenous
thrombolytic Tenecteplase. Which of the following questions is the most important for
the nurse to ask the client before administering the medication
Systolic bp has decreased from 126/96 to 106/68mmhg - Answer-The nurse working in
a rehab is assisting a client who had an MI to increase activity tolerance. Which of the
following client symptoms indicates a need to stop the clients current activity
A. 20ml/hr B. 5ml/hr C. 15ml/hr D. 10ml/hr - Answer-The nurse has received a
prescription to increase a clients dopamine drip from 3mcg/kg/min to 5mcg/kg/min. The
concentration of dopamine is 400mg/250ml D5W and the client weighs 235lbs. What
would the nurse increase the clients infusion pump
BUN of 26mg/dl - Answer-The nurse working in the tele step down unit is caring for a
client who is scheduled for a cardiac catheterization and an angioplasty. Which of the
following lab findings is most important for the nurse to report to the PCP
This test is performed to help detect problems with my heart valves and chambers -
Answer-The nurse has instructed a client who is scheduled to have a cardiac
catheterization. Which of the following client statements would indicate a correct
understanding of the teaching
Had CABG surgery 24 hrs ago and has developed distant muffled heart sounds -
Answer-The nurse has been made aware of the following client situation. The nurse
should initially plan to assess the client
Sharp pain in the anterior chest
A right sternal border heart murmur - Answer-The nurse is assessing a client who has a
suspected aortic dissection. Which of the following findings should the nurse anticipate
the client to have
Has a suspected thoracic aortic aneurysm and is reporting the development of back
pain - Answer-The nurse is caring for assigned clients. It would be priority for the nurse
to follow up with the PCP of a client who
Jugular venous distention with clear lung sounds - Answer-The nurse is assessing a
client who has developed cardiac tamponade. Which of the following findings should the
nurse expect to observe
