NUR 131 FINAL EXAM - PRACTICE
QUESTIONS WITH 100% ACCURATE
ANSWERS
a) does not follow the tenets of a specific faith - Accurate answers The nurses
notes on the admission form that the patient has indication "no religious preference."
What does this indicate to the nurse about the patient?
a) does not follow the tenets of a specific faith
b) is in denial about his religious beliefs
c) doesn't believe in God or a "higher power"
d) will not want to pray or visit with the chaplain
d) hold her hand, sit with her, & listen - Accurate answers Your pt is a 17 year old
who lost her right leg in a MVA. After her parents leave, she asks you, "Why did God let
this happen to me? I have always followed his commandments." Which action best
depicts the "caring" aspect of SENC?
a) "Let me call your parents back to support you."
b) I think the chaplain can provide the support you need."
c) cry with the pt as you hug her
d) hold her hand, sit with her, & listen
d) perceived - Accurate answers The student nurse has earned A's in all of her
prerequisite courses. For the first exam in a nursing course, she earns a D and now
feels that she may not be smart enough to become a nurse. What type of "loss" is the
student experiencing?
a) actual
b) external
c) physical
d) perceived
d) "Tell me how you are feeling right now" - Accurate answers Your 55 year old pt
was just informed that she has metastatic pancreatic cancer and has 4 months to live.
After the provider leaves, she says to you, "I don't want my family to know. But they
have to know. Please don't tell them. Please tell me what to do, help me." What is your
best response?
a) "I know this is difficult for you. Take time to thin about it."
b) "You should get a second opinion before you alarm your family."
c) "Let me hold your hand to make you feel better."
d) "Tell me how you are feeling right now."
,a) "You sound very upset. Tell me more about your dad." - Accurate answers The
pt is dying of cancer and can no longer swallow. The son states to the nurse, "You
MUST give dad some water, he always drank a lot of water." The nurse's best response
is
a) "You sound very upset. Tell me more about your dad."
b) "Your father is dying from cancer and water will not stop this process."
c) "Research shows that withholding oral fluids decreases edema."
d) "I will call the provider & get a prescription to insert a NG tube for the water."
d) this is an example of distress & could affect the pt's health status - Accurate
answers The hospitalized pt states, "I need to know when I'm going to be
discharged. I'm so upset & worried that I'm missing work." The nurse knows:
a) this is an example of "eustress" & no intervention is necessary
b) this is an example of psychological stress & the pt should be placed on
antidepressants
c) this is an example of developmental stress & the pt should talk to someone his own
age
d) this is an example of distress & could affect the pt's health status
a) true
Tenormin is a beta-blocker (or otherwise a anti-hypertensive medication) - Accurate
answers A pt who is taking atenolol (Tenormin) may not exhibit a rise in blood
pressure & pulse during the alarm stage of the general adaptation syndrome
a) true
b) false
c) the occurrence of stress in pts is unpredictable - Accurate answers The nurse
should assess every pt to determine if stress reduction interventions should be part of
the plan of care. The rationale for this action is that:
a) there are more persons experiencing mental illness now than in the past
b) life is so much more stressful than it has ever been
c) the occurrence of stress in pts is unpredictable
d) pts often develop maladaptive coping strategies
c) close the blinds, dim the lights, and ask the pt what other measures would help him
rest - Accurate answers Mr. Arbor complains to the nurse that he is feeling
anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy
here at night." Mr. Arbor's pulse is 110 bpm and his blood pressure is 140/70 mmHg.
Nursing actions should include which of the following?
,a) turn on the TV to provide distraction
b) ask the pt if he would like to discuss his anxiety further
c) close the blinds, dim the lights, and ask the pt what other measures would help him
rest
d) call the physician and obtain an order for an anti-anxiety medication for PRN use
a) true
GCS correlates to the patient's ability to function. The lower the score, the more nursing
intervention required. - Accurate answers For any patient with an altered level of
consciousness, the Glasgow Coma Scale score will help the nurse in planning care.
a) true
b) false
a) investigate why
It's important to understand why the pt hasn't been adhering to the scheduled med
schedule
Issues like vision, literacy, & side effects could be easily rectified if investigated -
Accurate answers When conducting a weekly home visit with an older pt, the nurse
realized the pt has not been adhering to his recommended medication schedule. What
should the nurse do next?
a) investigate why
b) reprimand the pt for being noncompliant and explain how important it is to not miss
dosages of medications
c) explain the effects of missing dosages of certain medications
d) evaluate the medication schedule
c) maintaining the child's home sleep routine - Accurate answers A 4 year old
patient resists going to sleep. To assist this pt, the best action to take would be:
a) adding a daytime nap
b) allowing the child to sleep longer in the morning
c) maintaining the child's home sleep routine
d) offering the child a bedtime snack
d) sleep apnea - Accurate answers During rounds on the night shift, you note that
a pt stops breathing for 1-2 minutes several times during the shift. This condition is
known as:
a) cataplexy
b) insomnia
c) narcolepsy
, d) sleep apnea
a) amount drained - Accurate answers What is missing from the documentation
regarding the emptying of draining from a wound?
"03/12/16 07:50: Hemovac drained serosanguinous fluid over 12 hours. No odor or
perulent material noted at drainage site."
a) amount drained
b) AM or PM
c) description of color at the drainage site
d) materials used
b) increase protein foods in the diet - Accurate answers The nurse is working with
a patient with low total protein & serum albumin levels. The patient presents with
bilateral pitting lower extremity edema. Which education should the nurse provide to
decrease and prevent edema formation?
a) increase cholesterol in the diet
b) increase protein in the diet
c) increase vitamin C in the diet
d) increase fluid intake during the day
b) evisceration involves the protrusion of internal viscera from the incision site; with
dehiscence, there is a separation of one or more layers of wound tissue - Accurate
answers A student nurse asks the nurse the difference between dehiscence &
evisceration. Which would be the best explanation?
a) dehiscence is an urgent complication that requires surgery ASAP; evisceration is not
as urgent
b) evisceration involves the protrusion of internal viscera from the incision site; with
dehiscence, there is a separation of one or more layers of wound tissue
c) dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to
dermal tissue
a) infection at the incisional site - Accurate answers 3 days after abdominal
surgery, the nurse notes a 2cm area of erythema & swelling at the proximal end of the
incision. The area is tender & warm to the touch. Staples are in tact along the incision,
no obvious drainage. Temp 100.8 F. The nurse suspects:
a) infection at the incisional site
b) dehiscence of the wound
c) hematoma under the skin
d) formation of granulation tissue
to prevent cutting off circulation - Accurate answers The nurse avoid placing a
dressing that wraps around an extremity to prevent what complication?
QUESTIONS WITH 100% ACCURATE
ANSWERS
a) does not follow the tenets of a specific faith - Accurate answers The nurses
notes on the admission form that the patient has indication "no religious preference."
What does this indicate to the nurse about the patient?
a) does not follow the tenets of a specific faith
b) is in denial about his religious beliefs
c) doesn't believe in God or a "higher power"
d) will not want to pray or visit with the chaplain
d) hold her hand, sit with her, & listen - Accurate answers Your pt is a 17 year old
who lost her right leg in a MVA. After her parents leave, she asks you, "Why did God let
this happen to me? I have always followed his commandments." Which action best
depicts the "caring" aspect of SENC?
a) "Let me call your parents back to support you."
b) I think the chaplain can provide the support you need."
c) cry with the pt as you hug her
d) hold her hand, sit with her, & listen
d) perceived - Accurate answers The student nurse has earned A's in all of her
prerequisite courses. For the first exam in a nursing course, she earns a D and now
feels that she may not be smart enough to become a nurse. What type of "loss" is the
student experiencing?
a) actual
b) external
c) physical
d) perceived
d) "Tell me how you are feeling right now" - Accurate answers Your 55 year old pt
was just informed that she has metastatic pancreatic cancer and has 4 months to live.
After the provider leaves, she says to you, "I don't want my family to know. But they
have to know. Please don't tell them. Please tell me what to do, help me." What is your
best response?
a) "I know this is difficult for you. Take time to thin about it."
b) "You should get a second opinion before you alarm your family."
c) "Let me hold your hand to make you feel better."
d) "Tell me how you are feeling right now."
,a) "You sound very upset. Tell me more about your dad." - Accurate answers The
pt is dying of cancer and can no longer swallow. The son states to the nurse, "You
MUST give dad some water, he always drank a lot of water." The nurse's best response
is
a) "You sound very upset. Tell me more about your dad."
b) "Your father is dying from cancer and water will not stop this process."
c) "Research shows that withholding oral fluids decreases edema."
d) "I will call the provider & get a prescription to insert a NG tube for the water."
d) this is an example of distress & could affect the pt's health status - Accurate
answers The hospitalized pt states, "I need to know when I'm going to be
discharged. I'm so upset & worried that I'm missing work." The nurse knows:
a) this is an example of "eustress" & no intervention is necessary
b) this is an example of psychological stress & the pt should be placed on
antidepressants
c) this is an example of developmental stress & the pt should talk to someone his own
age
d) this is an example of distress & could affect the pt's health status
a) true
Tenormin is a beta-blocker (or otherwise a anti-hypertensive medication) - Accurate
answers A pt who is taking atenolol (Tenormin) may not exhibit a rise in blood
pressure & pulse during the alarm stage of the general adaptation syndrome
a) true
b) false
c) the occurrence of stress in pts is unpredictable - Accurate answers The nurse
should assess every pt to determine if stress reduction interventions should be part of
the plan of care. The rationale for this action is that:
a) there are more persons experiencing mental illness now than in the past
b) life is so much more stressful than it has ever been
c) the occurrence of stress in pts is unpredictable
d) pts often develop maladaptive coping strategies
c) close the blinds, dim the lights, and ask the pt what other measures would help him
rest - Accurate answers Mr. Arbor complains to the nurse that he is feeling
anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy
here at night." Mr. Arbor's pulse is 110 bpm and his blood pressure is 140/70 mmHg.
Nursing actions should include which of the following?
,a) turn on the TV to provide distraction
b) ask the pt if he would like to discuss his anxiety further
c) close the blinds, dim the lights, and ask the pt what other measures would help him
rest
d) call the physician and obtain an order for an anti-anxiety medication for PRN use
a) true
GCS correlates to the patient's ability to function. The lower the score, the more nursing
intervention required. - Accurate answers For any patient with an altered level of
consciousness, the Glasgow Coma Scale score will help the nurse in planning care.
a) true
b) false
a) investigate why
It's important to understand why the pt hasn't been adhering to the scheduled med
schedule
Issues like vision, literacy, & side effects could be easily rectified if investigated -
Accurate answers When conducting a weekly home visit with an older pt, the nurse
realized the pt has not been adhering to his recommended medication schedule. What
should the nurse do next?
a) investigate why
b) reprimand the pt for being noncompliant and explain how important it is to not miss
dosages of medications
c) explain the effects of missing dosages of certain medications
d) evaluate the medication schedule
c) maintaining the child's home sleep routine - Accurate answers A 4 year old
patient resists going to sleep. To assist this pt, the best action to take would be:
a) adding a daytime nap
b) allowing the child to sleep longer in the morning
c) maintaining the child's home sleep routine
d) offering the child a bedtime snack
d) sleep apnea - Accurate answers During rounds on the night shift, you note that
a pt stops breathing for 1-2 minutes several times during the shift. This condition is
known as:
a) cataplexy
b) insomnia
c) narcolepsy
, d) sleep apnea
a) amount drained - Accurate answers What is missing from the documentation
regarding the emptying of draining from a wound?
"03/12/16 07:50: Hemovac drained serosanguinous fluid over 12 hours. No odor or
perulent material noted at drainage site."
a) amount drained
b) AM or PM
c) description of color at the drainage site
d) materials used
b) increase protein foods in the diet - Accurate answers The nurse is working with
a patient with low total protein & serum albumin levels. The patient presents with
bilateral pitting lower extremity edema. Which education should the nurse provide to
decrease and prevent edema formation?
a) increase cholesterol in the diet
b) increase protein in the diet
c) increase vitamin C in the diet
d) increase fluid intake during the day
b) evisceration involves the protrusion of internal viscera from the incision site; with
dehiscence, there is a separation of one or more layers of wound tissue - Accurate
answers A student nurse asks the nurse the difference between dehiscence &
evisceration. Which would be the best explanation?
a) dehiscence is an urgent complication that requires surgery ASAP; evisceration is not
as urgent
b) evisceration involves the protrusion of internal viscera from the incision site; with
dehiscence, there is a separation of one or more layers of wound tissue
c) dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to
dermal tissue
a) infection at the incisional site - Accurate answers 3 days after abdominal
surgery, the nurse notes a 2cm area of erythema & swelling at the proximal end of the
incision. The area is tender & warm to the touch. Staples are in tact along the incision,
no obvious drainage. Temp 100.8 F. The nurse suspects:
a) infection at the incisional site
b) dehiscence of the wound
c) hematoma under the skin
d) formation of granulation tissue
to prevent cutting off circulation - Accurate answers The nurse avoid placing a
dressing that wraps around an extremity to prevent what complication?
