NUR 254 Exam3 QUESTIONS AND
VERIFIED CORRECT ANSWERS
GRADED A+ [LATEST 2026-2027] 100%
GUARANTEED PASS
9. A primary care provider is going to perform a thoracentesis. The nurse's role will include
which action?
1. Place the client supine in the Trendelenburg position.
2. Position the client in a seated position with elbows on the overbed table.
3. Instruct the UAP to measure vital signs.
4. Administer an opioid analgesic. - CORRECT ANSWER-Answer: 2. Rationale: The puncture site
is usually on the posterior chest. The client should be positioned leaning forward. This will allow
the ribs to separate for exposure of the site. Option 1 is incorrect. The client should not be
placed in the Trendelenburg position because the site would not be exposed. Option 3 is
incorrect since changes in vital signs do not routinely occur with this procedure. Option 4 is
incorrect. The client does not need to be medicated for pain with this procedure.
10. The nurse needs to collect a sputum specimen to identify the presence of tuberculosis (TB).
Which nursing action(s) is/are indicated for this type of specimen? Select all that apply.
1. Collect the specimen in the evening. 2. Send the specimen immediately to the laboratory.
3. Ask the client to spit into the sputum container.
4. Offer mouth care before and after collection of the sputum specimen.
,5. Collect a specimen for 3 consecutive days. - CORRECT ANSWER-Answer: 2, 4, and 5.
Rationale: The sputum specimen should be sent immediately to the laboratory. The client
should be provided mouth care before and after the specimen is collected. The sputum
specimen should be collected for three consecutive days. Option 1 is incorrect because the
sputum specimen is collected in the morning not in the evening. Option 3 is incorrect because
the term spit indicates that saliva is being examined. The client needs to cough up or
expectorate mucus or sputum.
1. Which test is the best resource for determining the preoperative status of a client's liver
function?
1. Serum electrolytes
2. Blood urea nitrogen (BUN), creatinine
3. Alanine aminotransferase (ALT), aspirate aminotransferase (AST), bilirubin
4. Serum albumin - CORRECT ANSWER-Answer: 3. Rationale: These tests are specific to liver
function. Option 1 evaluates fluid and electrolyte status. Option 2 evaluates renal status; option
4 evaluates nutritional status.
2. A client who is having a mastectomy expresses sadness about losing her breast. Based on this
information, the nurse would identify that the client is at risk for which nursing diagnosis?
1. Disturbed Body Image
2. Grieving
3. Fear
4. Ineffective Coping - CORRECT ANSWER-Answer: 2. Rationale: Grieving is the state in which an
individual experiences reactions in response to an expected significant loss. The definition for
option 1 is "confusion in mental picture of one's self " and is often characterized by negative
responses such as shame, embarrassment, guilt, or revulsion. Option 3, fear, is usually
characterized by feelings of dread, fright, apprehension, or alarm. Ineffective coping, option 4, is
usually characterized by verbalization of inability to cope or ask for help, inappropriate use of
defense mechanisms, or inability to meet role expectations.
3. Which statement by the client indicates that the preoperative teaching regarding gallbladder
surgery has been effective?
, 1. "I cannot eat or drink anything after midnight."
2. "I'm not going to cough after surgery because it might open my incision."
3. "I might have a stroke if I stop taking my anticoagulant."
4. "The nurse showed me how to contract and relax my calf muscles." - CORRECT ANSWER-
Answer: 4. Rationale: Option 1 is incorrect because of the ASA guidelines for preoperative
fasting. Option 2 is incorrect because clients are taught how to cough and also how to splint
their incision to prevent complications. Option 3 is incorrect because anticoagulants are
discontinued a few days before surgery to avoid excessive bleeding postoperatively.
4. The nurse assesses a postoperative client who has a rapid, weak pulse; urine output of less
than 30 mL/h; and decreased blood pressure. The client's skin is cool and clammy. What
complication should the nurse suspect?
1. Thrombophlebitis
2. Hypovolemic shock
3. Pneumonia
4. Wound dehiscence - CORRECT ANSWER-Answer: 2. Rationale: The symptoms describe
decreased cardiac output and not any of the other listed complications.
5. The client is most likely to require the greatest amount of analgesia for pain during which
period?
1. Immediately after surgery
2. 4 hours after surgery
3. 12 to 36 hours after surgery
4. 48 to 60 hours after surgery - CORRECT ANSWER-Answer: 3. Rationale: Options 1 and 2 are
incorrect because the client is still recovering from the anesthesia used during surgery. Option 4
is incorrect because pain usually decreases after the second or third postoperative day.
6. A postop client who had abdominal surgery is holding a pillow against his abdomen during
deep-breathing and coughing exercises. What term does the nurse use to describe this
VERIFIED CORRECT ANSWERS
GRADED A+ [LATEST 2026-2027] 100%
GUARANTEED PASS
9. A primary care provider is going to perform a thoracentesis. The nurse's role will include
which action?
1. Place the client supine in the Trendelenburg position.
2. Position the client in a seated position with elbows on the overbed table.
3. Instruct the UAP to measure vital signs.
4. Administer an opioid analgesic. - CORRECT ANSWER-Answer: 2. Rationale: The puncture site
is usually on the posterior chest. The client should be positioned leaning forward. This will allow
the ribs to separate for exposure of the site. Option 1 is incorrect. The client should not be
placed in the Trendelenburg position because the site would not be exposed. Option 3 is
incorrect since changes in vital signs do not routinely occur with this procedure. Option 4 is
incorrect. The client does not need to be medicated for pain with this procedure.
10. The nurse needs to collect a sputum specimen to identify the presence of tuberculosis (TB).
Which nursing action(s) is/are indicated for this type of specimen? Select all that apply.
1. Collect the specimen in the evening. 2. Send the specimen immediately to the laboratory.
3. Ask the client to spit into the sputum container.
4. Offer mouth care before and after collection of the sputum specimen.
,5. Collect a specimen for 3 consecutive days. - CORRECT ANSWER-Answer: 2, 4, and 5.
Rationale: The sputum specimen should be sent immediately to the laboratory. The client
should be provided mouth care before and after the specimen is collected. The sputum
specimen should be collected for three consecutive days. Option 1 is incorrect because the
sputum specimen is collected in the morning not in the evening. Option 3 is incorrect because
the term spit indicates that saliva is being examined. The client needs to cough up or
expectorate mucus or sputum.
1. Which test is the best resource for determining the preoperative status of a client's liver
function?
1. Serum electrolytes
2. Blood urea nitrogen (BUN), creatinine
3. Alanine aminotransferase (ALT), aspirate aminotransferase (AST), bilirubin
4. Serum albumin - CORRECT ANSWER-Answer: 3. Rationale: These tests are specific to liver
function. Option 1 evaluates fluid and electrolyte status. Option 2 evaluates renal status; option
4 evaluates nutritional status.
2. A client who is having a mastectomy expresses sadness about losing her breast. Based on this
information, the nurse would identify that the client is at risk for which nursing diagnosis?
1. Disturbed Body Image
2. Grieving
3. Fear
4. Ineffective Coping - CORRECT ANSWER-Answer: 2. Rationale: Grieving is the state in which an
individual experiences reactions in response to an expected significant loss. The definition for
option 1 is "confusion in mental picture of one's self " and is often characterized by negative
responses such as shame, embarrassment, guilt, or revulsion. Option 3, fear, is usually
characterized by feelings of dread, fright, apprehension, or alarm. Ineffective coping, option 4, is
usually characterized by verbalization of inability to cope or ask for help, inappropriate use of
defense mechanisms, or inability to meet role expectations.
3. Which statement by the client indicates that the preoperative teaching regarding gallbladder
surgery has been effective?
, 1. "I cannot eat or drink anything after midnight."
2. "I'm not going to cough after surgery because it might open my incision."
3. "I might have a stroke if I stop taking my anticoagulant."
4. "The nurse showed me how to contract and relax my calf muscles." - CORRECT ANSWER-
Answer: 4. Rationale: Option 1 is incorrect because of the ASA guidelines for preoperative
fasting. Option 2 is incorrect because clients are taught how to cough and also how to splint
their incision to prevent complications. Option 3 is incorrect because anticoagulants are
discontinued a few days before surgery to avoid excessive bleeding postoperatively.
4. The nurse assesses a postoperative client who has a rapid, weak pulse; urine output of less
than 30 mL/h; and decreased blood pressure. The client's skin is cool and clammy. What
complication should the nurse suspect?
1. Thrombophlebitis
2. Hypovolemic shock
3. Pneumonia
4. Wound dehiscence - CORRECT ANSWER-Answer: 2. Rationale: The symptoms describe
decreased cardiac output and not any of the other listed complications.
5. The client is most likely to require the greatest amount of analgesia for pain during which
period?
1. Immediately after surgery
2. 4 hours after surgery
3. 12 to 36 hours after surgery
4. 48 to 60 hours after surgery - CORRECT ANSWER-Answer: 3. Rationale: Options 1 and 2 are
incorrect because the client is still recovering from the anesthesia used during surgery. Option 4
is incorrect because pain usually decreases after the second or third postoperative day.
6. A postop client who had abdominal surgery is holding a pillow against his abdomen during
deep-breathing and coughing exercises. What term does the nurse use to describe this
