NUR401 Final Exam – Correct Solutions To All
Questions
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Terms in this set (100)
1. When caring for a client who has just d. Urinary output 15 mL for 2 hours
been admitted with septic shock,
which of these assessment data will be
of greatest concern to the nurse?
a. Arterial oxygen saturation 90%
b. Apical pulse 110 beats/min
c. Blood pressure 88/56 mm Hg
d. Urinary output 15 mL for 2 hours
2. A client is recovering from a c. Pink-tinged
cystoscopy. The nurse would expect
to assess Explanation: The bladder and urethra are usually
which of the following regarding the irritated as a result of the procedure. This causes
client's urine after the procedure? pink-tinged urine. Large amounts of blood in the
urine, anuria, or blood clots are not expected
a. Hematuria findings after this procedure.
b. Blood clots
c. Pink-tinged
d. Anuria
,3. A client with congestive heart d. Maintaining cardiac output
failure and pulmonary edema
develops early symptoms of acute Rationale: The primary goal of treatment for ARF is to
renal failure (ARF). The nurse plans eliminate the cause and provide supportive care
care for the client based on the while the kidneys recover. Because this patient's heart
knowledge that collaborative care of failure is causing ARF, the care will be directed
the renal failure will be directed toward treatment of the heart failure. For renal failure
towards which of the following goals? caused by hypertension, hypovolemia, or
nephrotoxins, the other responses would be correct.
a. Diluting nephrotoxic substances
b. Replacing fluid volume
c. Promoting diuresis
d. Maintaining cardiac output
4. Which of the following is the proper d. Supine with feet elevated - shock position
positioning for a client experiencing
hypovolemic shock?
a. Trendelenburg
b. Reverse Trendelenburg
c. Supine with head on a pillow
d. Supine with feet elevated
5. During discharge teaching for the a. Exposure to crowds
client with sickle cell anemia, which of
the following precipitating factors for rationale: Exposure to crowds increases the patient's
sickle cell crisis should the nurse risk for infection, the most common cause of sickle
instruct the client to avoid? cell crisis. There is no restriction on caffeine use. Iron
supplementation is generally not recommended. A
a. Exposure to crowds high-fluid intake is recommended.
b. Limiting fluids to 2 L per day
c. Excessive dietary iron intake
d. Caffeine and alcohol intake
,6. A client with chronic lymphocytic a. Plan care to alternate periods of rest and activity.
leukemia is hospitalized for the
treatment of severe hemolytic anemia. Rationale: Nursing care for patients with anemia
Which of the following is an should alternate periods of rest and activity to
appropriate nursing intervention for maintain patient mobility without causing undue
the client? fatigue. High vitamin K diets might be used for a
patient with a bleeding disorder. There is no
a. Plan care to alternate periods of indication that the patient is neutropenic, so isolation
rest and activity. is not needed. Increased intake of fluid and fiber will
b. Isolate the client from visitors and not improve the anemia.
other clients.
c. Encourage increased intake of fluid
and fibre in the diet.
d. Provide a diet high in vitamin K and
folic acid.
7. A client is scheduled for a fistula d. One needle will be inserted for each dialysis
creation due to end-stage renal treatment
disease. The
nurse would include which of the couldn't find on google, seems right though
following in teaching the client about
the fistula?
a. A vein and an artery will be
attached surgically.
b. The fistula can be used 2 to 4 weeks
after the surgery for dialysis treatment.
c. The arm should be immobilized for
4 to 6 weeks.
d. One needle will be inserted for
each dialysis treatment.
, 8. A 12 years old is admitted to the c. 1, 3 ,2, 4
emergency department after being
stung by a 1. Airway swelling
bee. The client's mother tells the nurse 3. Tachypnea
that her son has an allergy to bees 2. Hypotension
and he has been stung before. In what 4. Tachycardia
order of priority will the nurse address
the complications?
1. Airway swelling
2. Hypotension
3. Tachypnea
4. Tachycardia
a. 2, 4, 1, 3
b. 1, 2, 3, 4
c. 1, 3 ,2, 4
d. 3, 1, 2, 4
9. A client with multiple trauma is d. 0.9% saline
brought to the emergency
department. The Fluid resuscitation is accomplished by using normal
nurse initiates two peripheral saline, that is, 0.9% saline.
intravenous (IV) sites and begins fluid
resuscitation with which of the
following fluids?
a. Dextran
b. 3.0% saline
c. Dextrose 5% in water in one-half
normal saline
d. 0.9% saline
Questions
Save Groups
Terms in this set (100)
1. When caring for a client who has just d. Urinary output 15 mL for 2 hours
been admitted with septic shock,
which of these assessment data will be
of greatest concern to the nurse?
a. Arterial oxygen saturation 90%
b. Apical pulse 110 beats/min
c. Blood pressure 88/56 mm Hg
d. Urinary output 15 mL for 2 hours
2. A client is recovering from a c. Pink-tinged
cystoscopy. The nurse would expect
to assess Explanation: The bladder and urethra are usually
which of the following regarding the irritated as a result of the procedure. This causes
client's urine after the procedure? pink-tinged urine. Large amounts of blood in the
urine, anuria, or blood clots are not expected
a. Hematuria findings after this procedure.
b. Blood clots
c. Pink-tinged
d. Anuria
,3. A client with congestive heart d. Maintaining cardiac output
failure and pulmonary edema
develops early symptoms of acute Rationale: The primary goal of treatment for ARF is to
renal failure (ARF). The nurse plans eliminate the cause and provide supportive care
care for the client based on the while the kidneys recover. Because this patient's heart
knowledge that collaborative care of failure is causing ARF, the care will be directed
the renal failure will be directed toward treatment of the heart failure. For renal failure
towards which of the following goals? caused by hypertension, hypovolemia, or
nephrotoxins, the other responses would be correct.
a. Diluting nephrotoxic substances
b. Replacing fluid volume
c. Promoting diuresis
d. Maintaining cardiac output
4. Which of the following is the proper d. Supine with feet elevated - shock position
positioning for a client experiencing
hypovolemic shock?
a. Trendelenburg
b. Reverse Trendelenburg
c. Supine with head on a pillow
d. Supine with feet elevated
5. During discharge teaching for the a. Exposure to crowds
client with sickle cell anemia, which of
the following precipitating factors for rationale: Exposure to crowds increases the patient's
sickle cell crisis should the nurse risk for infection, the most common cause of sickle
instruct the client to avoid? cell crisis. There is no restriction on caffeine use. Iron
supplementation is generally not recommended. A
a. Exposure to crowds high-fluid intake is recommended.
b. Limiting fluids to 2 L per day
c. Excessive dietary iron intake
d. Caffeine and alcohol intake
,6. A client with chronic lymphocytic a. Plan care to alternate periods of rest and activity.
leukemia is hospitalized for the
treatment of severe hemolytic anemia. Rationale: Nursing care for patients with anemia
Which of the following is an should alternate periods of rest and activity to
appropriate nursing intervention for maintain patient mobility without causing undue
the client? fatigue. High vitamin K diets might be used for a
patient with a bleeding disorder. There is no
a. Plan care to alternate periods of indication that the patient is neutropenic, so isolation
rest and activity. is not needed. Increased intake of fluid and fiber will
b. Isolate the client from visitors and not improve the anemia.
other clients.
c. Encourage increased intake of fluid
and fibre in the diet.
d. Provide a diet high in vitamin K and
folic acid.
7. A client is scheduled for a fistula d. One needle will be inserted for each dialysis
creation due to end-stage renal treatment
disease. The
nurse would include which of the couldn't find on google, seems right though
following in teaching the client about
the fistula?
a. A vein and an artery will be
attached surgically.
b. The fistula can be used 2 to 4 weeks
after the surgery for dialysis treatment.
c. The arm should be immobilized for
4 to 6 weeks.
d. One needle will be inserted for
each dialysis treatment.
, 8. A 12 years old is admitted to the c. 1, 3 ,2, 4
emergency department after being
stung by a 1. Airway swelling
bee. The client's mother tells the nurse 3. Tachypnea
that her son has an allergy to bees 2. Hypotension
and he has been stung before. In what 4. Tachycardia
order of priority will the nurse address
the complications?
1. Airway swelling
2. Hypotension
3. Tachypnea
4. Tachycardia
a. 2, 4, 1, 3
b. 1, 2, 3, 4
c. 1, 3 ,2, 4
d. 3, 1, 2, 4
9. A client with multiple trauma is d. 0.9% saline
brought to the emergency
department. The Fluid resuscitation is accomplished by using normal
nurse initiates two peripheral saline, that is, 0.9% saline.
intravenous (IV) sites and begins fluid
resuscitation with which of the
following fluids?
a. Dextran
b. 3.0% saline
c. Dextrose 5% in water in one-half
normal saline
d. 0.9% saline
