nurs 3000 final UPDATED ACTUAL
Questions and CORRECT Answers
When analyzing the waveforms of a client's electrocardiogram (ECG), the nurse will need to investigate
further upon assessing which of the following findings?
a. A P-R interval of 0.18 seconds
b. A QRS interval of 0.14 seconds
c. Q-T interval of 0.34 seconds
d. T wave of 0.16 seconds - CORRECT ANSWER -QRS interval of 0.14 second
Unconsciousness without response to painful stimuli is assessed in a client with a head injury who has
been admitted to the emergency department. To promote cerebral blood flow in the client, initially what is
the most important for the nurse to monitor?
a. Arterial blood pressure
b. Arterial blood gas results
c. Respiratory rate
d. Level of consciousness - CORRECT ANSWER -Respiratory rate
A nurse is obtaining a health history from a client with a prosthetic mitral valve who has symptoms of
infective endocarditis (IE). Which of the following questions by the nurse is best?
a. "Have you had any recent immunizations?"
b. "Do you have a history of heart attack?"
c. "Have you been to the dentist lately?"
d. "Do you have a family history of endocarditis?" - CORRECT ANSWER -"Have you been to the
dentist lately?"
Which of the following assessment data obtained by the nurse when assessing a client with acute
pericarditis should be reported immediately to the health care provider?
a. Blood pressure (BP) of 146/86
b. Jugular vein distension (JVD) to the level of the jaw
c. Pulsus paradoxus 8 mm Hg
,d. Level 6 (0-10) chest pain with deep inspiration - CORRECT ANSWER -b. Jugular vein
distension (JVD) to the level of the jaw
The nurse is interpreting an ECG strip to determine whether there is a delay in impulse conduction
through the atria. Which of the following components of an ECG strip should the nurse interpret?
a. QRS complex
b. QT interval
c. P wave
d. PR interval - CORRECT ANSWER -P wave
Which of the following actions should the nurse take first when a client arrives in the emergency
department with facial and chest burns caused by a house fire?
a. Infuse the ordered IV solution
b. Auscultate the client's lung sounds
c. Determine the extent and depth of the burns
d. Administer the ordered opioid pain medications - CORRECT ANSWER -Auscultate the client's
lung sounds
The nurse is caring for a client who has had recent cardiac surgery and develops pericarditis, with
symptoms of chest pain at a level 6 (0-10 scale) when inhaling deeply. Which of the following prescribed
PRN medications should the nurse administer?
a. Acetaminophen 650mg PO
b. Fentanyl 2mg IV
c. Morphine sulphate 6mg IV
d. Ibuprofen 800mg PO - CORRECT ANSWER -Ibuprofen 800mg PO
The 1-hour sepsis bundle recommends administeing a 30mL/kg bolus of crystalloid IV fluids to treat:
a. Dehydration
b. Hypoxemia
c. Hypotension
d. Renal failure - CORRECT ANSWER -Hypotension
, The nurse is caring for a patient with diabetic ketoacidosis. Which arterial blood gas analysis is consistent
with this type of condition?
a. pH 7.28, PaCO2 58, HCO-3 38
b. ph 7.51, PaCO2 51, HCO-3 37
c. pH 7.49, PaCO2 32, HCO-3 22
d. pH 7.21, PaCO2 28, HCO-3 18 - CORRECT ANSWER -pH 7.28, PaCO2 58, HCO-3 38
The nurse is caring for a client following an incisional cholecystectomy for cholelithiasis. Which of the
following actions is priority for the nurse to implement?
a. Ambulate the evening of the operative day
b. Turn, cough, and deep breath every 2 hours
c. Client education about low-fat food choices
d. Perform leg exercises hourly while awake - CORRECT ANSWER -Client education about low-
fat food choices
Which of the following findings in a client with infective endocarditis (IE) is the most important for the
nurse to communicate to the health care provider?
a. Janeways lesions on the palms
b. Temperature of 38.1 degrees celcius - CORRECT ANSWER -Janeways lesions on the palms
Name each factor that is a part of Virchow's Triad and provide one example for each factor that could
lead to a venous thrombosis. - CORRECT ANSWER -1. Venous stasis: prolonged immobility
2. Endothelial injury: trauma, surgery of abdomen or pelvis
3. Hypercoagulability of blood: malnutrition or dehydration
The nurse is caring for a client who underwent a left total knee arthroplasty. On the third postoperative
day, the client has symptoms of shortness of breath, slight chest pain and that "something is wrong".
Temperature is 36.9, blood pressure 130/88 mm Hg, respirations 36 breaths/minute and oxygen saturation
91% on room air. Which of the following actions should the nurse take first?
a. Conduct a thorough assessment of the chest pain
b. Administer a nitroglycerine tablet sublingually
c. Notify the health care provider
Questions and CORRECT Answers
When analyzing the waveforms of a client's electrocardiogram (ECG), the nurse will need to investigate
further upon assessing which of the following findings?
a. A P-R interval of 0.18 seconds
b. A QRS interval of 0.14 seconds
c. Q-T interval of 0.34 seconds
d. T wave of 0.16 seconds - CORRECT ANSWER -QRS interval of 0.14 second
Unconsciousness without response to painful stimuli is assessed in a client with a head injury who has
been admitted to the emergency department. To promote cerebral blood flow in the client, initially what is
the most important for the nurse to monitor?
a. Arterial blood pressure
b. Arterial blood gas results
c. Respiratory rate
d. Level of consciousness - CORRECT ANSWER -Respiratory rate
A nurse is obtaining a health history from a client with a prosthetic mitral valve who has symptoms of
infective endocarditis (IE). Which of the following questions by the nurse is best?
a. "Have you had any recent immunizations?"
b. "Do you have a history of heart attack?"
c. "Have you been to the dentist lately?"
d. "Do you have a family history of endocarditis?" - CORRECT ANSWER -"Have you been to the
dentist lately?"
Which of the following assessment data obtained by the nurse when assessing a client with acute
pericarditis should be reported immediately to the health care provider?
a. Blood pressure (BP) of 146/86
b. Jugular vein distension (JVD) to the level of the jaw
c. Pulsus paradoxus 8 mm Hg
,d. Level 6 (0-10) chest pain with deep inspiration - CORRECT ANSWER -b. Jugular vein
distension (JVD) to the level of the jaw
The nurse is interpreting an ECG strip to determine whether there is a delay in impulse conduction
through the atria. Which of the following components of an ECG strip should the nurse interpret?
a. QRS complex
b. QT interval
c. P wave
d. PR interval - CORRECT ANSWER -P wave
Which of the following actions should the nurse take first when a client arrives in the emergency
department with facial and chest burns caused by a house fire?
a. Infuse the ordered IV solution
b. Auscultate the client's lung sounds
c. Determine the extent and depth of the burns
d. Administer the ordered opioid pain medications - CORRECT ANSWER -Auscultate the client's
lung sounds
The nurse is caring for a client who has had recent cardiac surgery and develops pericarditis, with
symptoms of chest pain at a level 6 (0-10 scale) when inhaling deeply. Which of the following prescribed
PRN medications should the nurse administer?
a. Acetaminophen 650mg PO
b. Fentanyl 2mg IV
c. Morphine sulphate 6mg IV
d. Ibuprofen 800mg PO - CORRECT ANSWER -Ibuprofen 800mg PO
The 1-hour sepsis bundle recommends administeing a 30mL/kg bolus of crystalloid IV fluids to treat:
a. Dehydration
b. Hypoxemia
c. Hypotension
d. Renal failure - CORRECT ANSWER -Hypotension
, The nurse is caring for a patient with diabetic ketoacidosis. Which arterial blood gas analysis is consistent
with this type of condition?
a. pH 7.28, PaCO2 58, HCO-3 38
b. ph 7.51, PaCO2 51, HCO-3 37
c. pH 7.49, PaCO2 32, HCO-3 22
d. pH 7.21, PaCO2 28, HCO-3 18 - CORRECT ANSWER -pH 7.28, PaCO2 58, HCO-3 38
The nurse is caring for a client following an incisional cholecystectomy for cholelithiasis. Which of the
following actions is priority for the nurse to implement?
a. Ambulate the evening of the operative day
b. Turn, cough, and deep breath every 2 hours
c. Client education about low-fat food choices
d. Perform leg exercises hourly while awake - CORRECT ANSWER -Client education about low-
fat food choices
Which of the following findings in a client with infective endocarditis (IE) is the most important for the
nurse to communicate to the health care provider?
a. Janeways lesions on the palms
b. Temperature of 38.1 degrees celcius - CORRECT ANSWER -Janeways lesions on the palms
Name each factor that is a part of Virchow's Triad and provide one example for each factor that could
lead to a venous thrombosis. - CORRECT ANSWER -1. Venous stasis: prolonged immobility
2. Endothelial injury: trauma, surgery of abdomen or pelvis
3. Hypercoagulability of blood: malnutrition or dehydration
The nurse is caring for a client who underwent a left total knee arthroplasty. On the third postoperative
day, the client has symptoms of shortness of breath, slight chest pain and that "something is wrong".
Temperature is 36.9, blood pressure 130/88 mm Hg, respirations 36 breaths/minute and oxygen saturation
91% on room air. Which of the following actions should the nurse take first?
a. Conduct a thorough assessment of the chest pain
b. Administer a nitroglycerine tablet sublingually
c. Notify the health care provider
