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Nursing 308 Exam – Questions With Reliable
Solutions
Save
Terms in this set (86)
The nurse is caring for the following Answer: C
clients. Which client should the nurse Rationale:
assess FIRST? A normal range for PTT is 32 to 39 seconds.
A. the client whose partial These are normal hemoglobin/hematocrit levels for
thromboplastin time (PTT) is 38 either a male or female client.
seconds. A PLATELET COUNT OF LESS THAN 100,000 PER
B. The client whose hemoglobin is 14 CUBIC MILLIMETER OF BLOOD INDICATES
g/dl and hematocrit is 45%. THROMBOCYTOPENIA.
C. The client whose platelet count is This is a normal red blood cell count.
75,000 per cubic millimeter of blood.
D. The client whose red blood cell
count is 4.8 x 10^6/mm^3.
,Which cast care instructions should Answer:
the nurse provide to a client who just A: Keep the cast clean and dry.
had a plaster cast applied to the right B: Allow cast 24-72 hours to dry
forearm? Select all that apply. C: Keep the cast and extremity elevated
a. Keep the cast clean and dry
b. Allow the cast 24-72 hours to dry Rationale: A plaster cast takes 24-72 hours to dry
c. Keep the cast and extremity (synthetic casts dry in 20 minutes). The cast and
elevated extremity should be elevated to reduce edema if
d. Use a hairdryer set on warm to hot prescribed. A wet cast is handled with the palms of
setting to dry the cast the hand until it is dry, and the extremity is turned
e. Use a soft padded object that will fit (unless contraindicated) so that all sides of the wet
under the cast to scratch the skin cast will dry. A cool setting on the hair dryer can be
under the cast used to dry a plaster cast (heat can not be used on a
plaster cast because the cast heats us and burns
skin). The cast needs to be kept clean and dry, and
the client is instructed not to stick anything under the
cast because of the risk of breaking skin integrity. The
client is instructed to monitor the extremity for
circulatory impairment, such as pain, swelling,
discoloration, tingling, numbness, coolness, or
diminished pulse. The health care provider is notified
immediately if circulatory impairment occurs.
The nurse is caring for a patient with a D. administer albuterol (Proventil), two puffs per
diagnosis of COPD, bronchitis-type, in metered dose inhaler
the long-term care facility. The patient
is wheezing, and his oxygen saturation
is 85%. Four hours ago, the oxygen
saturation was 88 percent. It is MOST
important for the nurse to take which
of the following actions?
A. administer beclomethasone
(Vanceril), two puffs per metered
dose inhaler
B. listen to breath sounds
C. increase oxygen to 4 L per mask
D. administer albuterol (Proventil), two
puffs per metered dose inhaler
,What is the most important nursing CORRECT ANSWER: B: Straining all urine
priority for a client who has been
admitted for a possible kidney stone? RATIONALE: Straining all urine (B) is the most
A. Reducing dairy products in the diet important nursing action to take in this case.
B. Straining all urine Encouraging fluid intake (D) is important for any
C. Measuring intake and output client who may have a kidney stone, but is even more
D. Increasing fluid intake important to strain all urine. Straining urine will
enable the nurse to determine when the kidney stone
has been passed and may prevent the need for
surgery. (C) is not the highest priority action. (A) is
usually not recommended until the stone is obtained
and the content of the stone is determined. Even
then, dietary restrictions are controversial.
After receiving a change-of-shift Answer: D: A 63-year-old with MS who has an oral
report at 7:00 AM, the nurse should temperature of 101.8 and flank pain.
assess which of these clients first?
Rationale: Urinary tract infections are a frequent
A. A 23-year-old with a migraine complication in clients with multiple sclerosis
headache who has severe nausea because of the effect on bladder function; therefore,
associated with retching. that client should been seen first by the nurse. The
B. A 45-year-old who is scheduled for elevated temperature and flank pain suggest that this
a craniotomy in 30 minutes and needs patient may have pyelonephritis. The physician
preoperative teaching. should be notified immediately so that antibiotic
C. A 59-year-old with Parkinson's therapy can be started quickly. The other clients
disease who will need a swallowing should be assessed soon, but do not have needs as
assessment before breakfast. urgent as this client. (Billings & Hensel, 2014, p. 599)
D. A 63-year-old with multiple
sclerosis who has an oral temperature
of 101.8^\circF and flank pain.
, The nurse employed in an emergency Answer: D. A client with chest paint who states that
department is assigned to triage he just ate pizza that was made with a very spicy
clients coming to the emergency sauce.
department for treatment on the
evening shift. The nurse should assign Rationale: in an ED, triage involves brief client
priority to which client? assessment to classify clients according to their need
A. A client complaining of muscle for care and includes establishing priorities of care.
aches, a headache, and malaise Clients with trauma, chest pain, severe respiratory
B. A client who twisted her ankle when distress or cardiac arrest, limb amputation, and acute
she fell while rollerblading neurological deficits, or who have sustained chemical
C. A client with a minor laceration on splashes to the eyes, are classified as emergent and
the index finger while cutting an are the number 1 priority. Clients with conditions such
eggplant as simple fracture, asthma without respiratory
D. A client with chest pain who states distress, fever, hypertension, abdominal pain, or a
that he just ate pizza that was made renal stone have urgent needs and are classified as a
with a very spicy sauce number 2 priority. Clients with conditions such as
laceration, sprain, or cold symptoms are classified as
nonurgent are a number 3 priority.
An older client presents to the Correct: A bronchodilator would help decrease
emergency department (ED) with a 2- bronchospasm
day history of cough, pain on
inspiration, shortness of breath, and Rationale: A bronchodilator would help decrease
dyspnea. The client never had a bronchospasm and would open up the airways, so it
pneumococcal vaccine. The client's would be beneficial for this client
chest x-ray shows density in both
bases. The client has wheezing upon
auscultation of both lungs. Would a
bronchodilator be beneficial for this
client?
A. A bronchodilator would not be
beneficial for this client
B. A bronchodilator would help
decrease the bronchospasm
C. It would clear up the density in the
base of the client's lungs
D. It will decrease the client's pain on
inspiration
Nursing 308 Exam – Questions With Reliable
Solutions
Save
Terms in this set (86)
The nurse is caring for the following Answer: C
clients. Which client should the nurse Rationale:
assess FIRST? A normal range for PTT is 32 to 39 seconds.
A. the client whose partial These are normal hemoglobin/hematocrit levels for
thromboplastin time (PTT) is 38 either a male or female client.
seconds. A PLATELET COUNT OF LESS THAN 100,000 PER
B. The client whose hemoglobin is 14 CUBIC MILLIMETER OF BLOOD INDICATES
g/dl and hematocrit is 45%. THROMBOCYTOPENIA.
C. The client whose platelet count is This is a normal red blood cell count.
75,000 per cubic millimeter of blood.
D. The client whose red blood cell
count is 4.8 x 10^6/mm^3.
,Which cast care instructions should Answer:
the nurse provide to a client who just A: Keep the cast clean and dry.
had a plaster cast applied to the right B: Allow cast 24-72 hours to dry
forearm? Select all that apply. C: Keep the cast and extremity elevated
a. Keep the cast clean and dry
b. Allow the cast 24-72 hours to dry Rationale: A plaster cast takes 24-72 hours to dry
c. Keep the cast and extremity (synthetic casts dry in 20 minutes). The cast and
elevated extremity should be elevated to reduce edema if
d. Use a hairdryer set on warm to hot prescribed. A wet cast is handled with the palms of
setting to dry the cast the hand until it is dry, and the extremity is turned
e. Use a soft padded object that will fit (unless contraindicated) so that all sides of the wet
under the cast to scratch the skin cast will dry. A cool setting on the hair dryer can be
under the cast used to dry a plaster cast (heat can not be used on a
plaster cast because the cast heats us and burns
skin). The cast needs to be kept clean and dry, and
the client is instructed not to stick anything under the
cast because of the risk of breaking skin integrity. The
client is instructed to monitor the extremity for
circulatory impairment, such as pain, swelling,
discoloration, tingling, numbness, coolness, or
diminished pulse. The health care provider is notified
immediately if circulatory impairment occurs.
The nurse is caring for a patient with a D. administer albuterol (Proventil), two puffs per
diagnosis of COPD, bronchitis-type, in metered dose inhaler
the long-term care facility. The patient
is wheezing, and his oxygen saturation
is 85%. Four hours ago, the oxygen
saturation was 88 percent. It is MOST
important for the nurse to take which
of the following actions?
A. administer beclomethasone
(Vanceril), two puffs per metered
dose inhaler
B. listen to breath sounds
C. increase oxygen to 4 L per mask
D. administer albuterol (Proventil), two
puffs per metered dose inhaler
,What is the most important nursing CORRECT ANSWER: B: Straining all urine
priority for a client who has been
admitted for a possible kidney stone? RATIONALE: Straining all urine (B) is the most
A. Reducing dairy products in the diet important nursing action to take in this case.
B. Straining all urine Encouraging fluid intake (D) is important for any
C. Measuring intake and output client who may have a kidney stone, but is even more
D. Increasing fluid intake important to strain all urine. Straining urine will
enable the nurse to determine when the kidney stone
has been passed and may prevent the need for
surgery. (C) is not the highest priority action. (A) is
usually not recommended until the stone is obtained
and the content of the stone is determined. Even
then, dietary restrictions are controversial.
After receiving a change-of-shift Answer: D: A 63-year-old with MS who has an oral
report at 7:00 AM, the nurse should temperature of 101.8 and flank pain.
assess which of these clients first?
Rationale: Urinary tract infections are a frequent
A. A 23-year-old with a migraine complication in clients with multiple sclerosis
headache who has severe nausea because of the effect on bladder function; therefore,
associated with retching. that client should been seen first by the nurse. The
B. A 45-year-old who is scheduled for elevated temperature and flank pain suggest that this
a craniotomy in 30 minutes and needs patient may have pyelonephritis. The physician
preoperative teaching. should be notified immediately so that antibiotic
C. A 59-year-old with Parkinson's therapy can be started quickly. The other clients
disease who will need a swallowing should be assessed soon, but do not have needs as
assessment before breakfast. urgent as this client. (Billings & Hensel, 2014, p. 599)
D. A 63-year-old with multiple
sclerosis who has an oral temperature
of 101.8^\circF and flank pain.
, The nurse employed in an emergency Answer: D. A client with chest paint who states that
department is assigned to triage he just ate pizza that was made with a very spicy
clients coming to the emergency sauce.
department for treatment on the
evening shift. The nurse should assign Rationale: in an ED, triage involves brief client
priority to which client? assessment to classify clients according to their need
A. A client complaining of muscle for care and includes establishing priorities of care.
aches, a headache, and malaise Clients with trauma, chest pain, severe respiratory
B. A client who twisted her ankle when distress or cardiac arrest, limb amputation, and acute
she fell while rollerblading neurological deficits, or who have sustained chemical
C. A client with a minor laceration on splashes to the eyes, are classified as emergent and
the index finger while cutting an are the number 1 priority. Clients with conditions such
eggplant as simple fracture, asthma without respiratory
D. A client with chest pain who states distress, fever, hypertension, abdominal pain, or a
that he just ate pizza that was made renal stone have urgent needs and are classified as a
with a very spicy sauce number 2 priority. Clients with conditions such as
laceration, sprain, or cold symptoms are classified as
nonurgent are a number 3 priority.
An older client presents to the Correct: A bronchodilator would help decrease
emergency department (ED) with a 2- bronchospasm
day history of cough, pain on
inspiration, shortness of breath, and Rationale: A bronchodilator would help decrease
dyspnea. The client never had a bronchospasm and would open up the airways, so it
pneumococcal vaccine. The client's would be beneficial for this client
chest x-ray shows density in both
bases. The client has wheezing upon
auscultation of both lungs. Would a
bronchodilator be beneficial for this
client?
A. A bronchodilator would not be
beneficial for this client
B. A bronchodilator would help
decrease the bronchospasm
C. It would clear up the density in the
base of the client's lungs
D. It will decrease the client's pain on
inspiration
