NUR205/NUR 205 Final Exam Review Multiple Choice Questions and
Answers | Saint Paul's School of Nursing
NUR205 Final Exam
Multiple Choice
1. A client has been showing the rhythm below for the past three days and is not responding to treatment. What
history will the nurse most likely find in this client as possibly causing this dysrhythmia?
(atrial fibrillation)
a. Pulmonary embolism
b. Orthostatic hypotension
c. Mitral valve disease
d. Hypothyroidism
2. A client who has a right-sided chest tube following a thoracotomy has continuous gentle bubbling in the suction-
control chamber of the wet chest drain collection device. What is the most appropriate action by the nurse?
a. Notify the surgeon of a possible pneumothorax
b. Document the presence of a large air leak
c. Document these findings on the chart
d. Obtain and attach a new collection device
3. The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse
assesses a blood pressure of 70/50 mmHg, HR 45 beats/minute, and RR 26 breaths/minute. The client’s skin is
warm and flushed. What is the best interpretation of these findings by the nurse?
a. The client is experiencing an allergic reaction.
b. The client is developing neurogenic shock.
c. The client most likely has an elevated temperature.
d. The vital signs are normal for this client.
4. A nurse admits a client transferred from the emergency room with a diagnosis of acute coronary syndrome. The
client has a BP of 132/98, HR 110, ST elevation with T wave inversion on the monitor, is complaining of severe
substernal chest pain, diaphoresis, and nausea. What is the priority action by the nurse?
a. Draw blood for cardiac enzymes
b. Elevate the client’s legs
c. Measure vital signs
d. Administer morphine sulfate as ordered
5. Ten minutes following administration of an antibiotic, the nurse assesses a client to have edematous lips,
hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 80/40 mmHg, heart
rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention?
a. Diphenhydramine 50mg intravenously
b. Ranitidine 50mg intravenously
c. Epinephrine 1:1000 solution intravenously
d. Methylprednisolone 125mg intravenously
6. A client with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which
action is most important for the nurse to take?
,a. Avoid venipunctures
b. Apply sterile dressings to the sites
c. Notify the client’s physician
d. Give prescribed proton pump inhibitors (PPIs)
7. An elderly client with diabetes insipidus is receiving IV fluid therapy. Which assessment finding best
demonstrates adequacy of a client’s fluid resuscitation?
a. Decreased skin turgor
b. Decreased thirst
c. Decreased pulse pressure
d. Increased urine specific gravity
8. The nurse assessing a client 1 day after a subtotal thyroidectomy notes that the client’s color is poor, the pulse
and respirations are rapid, and she feels very warm to the touch. Blood pressure is 174/105 mmHg, heart rate
121 bpm. The client says that she feels frightened. What is the nurse’s initial implementation?
a. Ask her if she would like pain medication.
b. Tell her that there is nothing to be afraid of, and stay to calm client.
c. Report it immediately to the primary health care provider.
d. Get a tracheostomy set at the bedside.
9. Which is an appropriate nursing intervention designed to decrease risk of increased ICP in the client with a head
injury?
a. Encourage deep breathing and coughing
b. Place in Trendelenburg’s position
c. Administer enemas daily
d. Keep neck in alignment
10. The nurse is caring for a client with cardiac and renal disease who has a serum potassium level of 5.6 mEq/L.
What medication could be administered to this client?
a. Administer PO patiromer treatment for Apotassium
b. Administer 5% dextrose in water IV
c. Administer IV spironolactone
d. Administer IV regular insulin
11. A client has been tentatively diagnosed with Graves’ disease. Which of the following symptoms noted on the
initial nursing assessment is expected?
a. Recent weight gain
b. Inattentiveness
c. Protruding eyeballs
d. Cold intolerance
12. The nurse is caring for a client two hours after a right lower lobectomy. The client has one chest tube attached
to a wet chest drainage system. In evaluating the water-seal chamber, it is noted that the fluid level bubbles
constantly and the blood drainage has stopped. After performing protocol for checking for leaks, the nurse does
not find any air leaks in the system. What is the next action for the nurse to take?
a. Disconnect client from the tube
b. Call the physician immediately
c. Perform gentle hand over hand milking
d. Clamp the tube
13. A nurse notes that the PR interval on a client’s electrocardiograph (ECG) tracing is 0.14 second. What action
does the nurse take?
a. Administer oxygen via nasal cannula.
,b. Administer 1 mg epinephrine IV.
c. Prepare the client for external pacing.
d. Document the finding in the client’s chart.
14. Profound disruptions of fluid and electrolyte and acid-base balance occur as a result of the fluid shift and cell
damage. Which imbalances will be observed during the first phase of the burn injury?
a. Hyperkalemia and hypernatremia
b. Hypokalemia and hyponatremia
c. Hypokalemia and hypernatremia
d. Hyperkalemia and hyponatremia
15. After and ischemic stroke, the client has a cerebral edema on the CT scan and is rousable but the GCS score is
still 14, BP of 150/89 mmHg. The client is ordered to remain on strict intake and output (I&O) monitoring and
maintain proper hydration. What is the rationale for this treatment protocol?
a. Strict intake and output (I&O) monitoring will maintain the client’s readiness for emergency craniotomy.
b. The client will be administered an anticoagulant to dissolve the clot and restore perfusion.
c. Dehydration can adversely affect cerebral perfusion.
d. The client will be needing furosemide treatment to decrease cerebral edema.
16. The nurse sees the following rhythm on a client’s cardiac monitor. How will the nurse interpret this rhythm?
a. Sinus rhythm with multifocal premature ventricular contractions
b. Sinus rhythm with paired premature ventricular contractions (couplets)
c. Sinus rhythm with unifocal premature ventricular contractions
d. Sinus rhythm with bigeminal premature ventricular contractions
17. The nurse is caring for a client with a burn injury. The client fell into a tank of unknown liquid chemical, upon
arrival to the hospital, the client is screaming and crying. What is the first nursing intervention?
a. Initiate cardiopulmonary resuscitation.
b. Help the client bathe or shower.
c. Obtain an electrocardiogram (ECG).
d. Remove the client’s clothing.
18. A client was injured as follows: the client sustained partial and full-thickness burns to
the whole posterior side of the left arm, his entire left lower extremity, and perineum.
Using the rule of nines, how much is the client’s extent of burn injury?
a. 28%
b. 13.5%
c. 16%
d. 23.5%
19. A student nurse asks the primary care nurse about the use of antibiotics to help prevent infection in the client
who has sustained a burn. What information should be provided to the student nurse?
, a. Antibiotics are indicated in the event of a temperature increase of more than 1 degree from the client’s
baseline.
b. Topical antimicrobial drugs are used for infection prevention in burn wounds.
c. Systemic antibiotics are necessary to prevent colonization of bacteria at the site of the burn.
d. Systemic antibiotics are used whether burn clients have symptoms of an actual infection or not.
20. The nurse is conducting an admission assessment of an 82-year-old client who sustained a 42% burn from
spilling hot coffee over his body. Which question is important to ask to determine this client’s prognosis?
a. “Do you have any drug or food allergies?”
b. “Have you had any surgeries?”
c. “Do you live alone?”
d. “Do you have kidney or heart failure?
21. The nurse assesses a client who is ordered to receive oxygen via a partial rebreather mask. For which
assessment finding below should the nurse intervene?
a. The client’s pulse oximetry reading is 95%. 60 701 at 114
6min
b. The arterial oxygen level is 90.
c. The oxygen flow rate is set at 2 L/min. to bow
d. The reservoir bag is two thirds inflated.
22. The nurse has been administering 0.9% normal saline intravenous fluids in a client with severe sepsis. To
evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the
nurse to assess?
a. Lactate levels and hourly urine output
b. Skin color and oral temperature
c. Blood pressure and neutrophil count
d. Oral temperature and capillary refill
23. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would
anticipate which of the following assessment findings?
a. Hypertension
b. Diarrhea hyper
hyper
c. Lethargy
d. Heat intolerance
hyper
24. A client is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively,
the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/75 mmHg; pulmonary
artery wedge pressure is 2 mmHg; ejection fraction is increased; chest tube drainage is 200 mL/hr. What is the
best interpretation by the nurse?
a. The client is at risk for developing hypovolemic shock.
b. The client is at risk for developing cardiogenic shock.
c. The assessed values are within normal limits.
d. The client is at risk for developing fluid volume overload.
25. A client is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes were heard. But
an hour later, the lung sounds have decreased and no wheezes are audible. What is the best action for the nurse
to take?
a. Document the results and continue to monitor the client’s respiratory rate
b. Reposition the client in high-Fowler’s position and reassess breath sounds
c. Notify the health care provider and prepare for endotracheal intubation
d. Encourage the client to cough and auscultate the lungs again
Answers | Saint Paul's School of Nursing
NUR205 Final Exam
Multiple Choice
1. A client has been showing the rhythm below for the past three days and is not responding to treatment. What
history will the nurse most likely find in this client as possibly causing this dysrhythmia?
(atrial fibrillation)
a. Pulmonary embolism
b. Orthostatic hypotension
c. Mitral valve disease
d. Hypothyroidism
2. A client who has a right-sided chest tube following a thoracotomy has continuous gentle bubbling in the suction-
control chamber of the wet chest drain collection device. What is the most appropriate action by the nurse?
a. Notify the surgeon of a possible pneumothorax
b. Document the presence of a large air leak
c. Document these findings on the chart
d. Obtain and attach a new collection device
3. The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse
assesses a blood pressure of 70/50 mmHg, HR 45 beats/minute, and RR 26 breaths/minute. The client’s skin is
warm and flushed. What is the best interpretation of these findings by the nurse?
a. The client is experiencing an allergic reaction.
b. The client is developing neurogenic shock.
c. The client most likely has an elevated temperature.
d. The vital signs are normal for this client.
4. A nurse admits a client transferred from the emergency room with a diagnosis of acute coronary syndrome. The
client has a BP of 132/98, HR 110, ST elevation with T wave inversion on the monitor, is complaining of severe
substernal chest pain, diaphoresis, and nausea. What is the priority action by the nurse?
a. Draw blood for cardiac enzymes
b. Elevate the client’s legs
c. Measure vital signs
d. Administer morphine sulfate as ordered
5. Ten minutes following administration of an antibiotic, the nurse assesses a client to have edematous lips,
hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 80/40 mmHg, heart
rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention?
a. Diphenhydramine 50mg intravenously
b. Ranitidine 50mg intravenously
c. Epinephrine 1:1000 solution intravenously
d. Methylprednisolone 125mg intravenously
6. A client with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which
action is most important for the nurse to take?
,a. Avoid venipunctures
b. Apply sterile dressings to the sites
c. Notify the client’s physician
d. Give prescribed proton pump inhibitors (PPIs)
7. An elderly client with diabetes insipidus is receiving IV fluid therapy. Which assessment finding best
demonstrates adequacy of a client’s fluid resuscitation?
a. Decreased skin turgor
b. Decreased thirst
c. Decreased pulse pressure
d. Increased urine specific gravity
8. The nurse assessing a client 1 day after a subtotal thyroidectomy notes that the client’s color is poor, the pulse
and respirations are rapid, and she feels very warm to the touch. Blood pressure is 174/105 mmHg, heart rate
121 bpm. The client says that she feels frightened. What is the nurse’s initial implementation?
a. Ask her if she would like pain medication.
b. Tell her that there is nothing to be afraid of, and stay to calm client.
c. Report it immediately to the primary health care provider.
d. Get a tracheostomy set at the bedside.
9. Which is an appropriate nursing intervention designed to decrease risk of increased ICP in the client with a head
injury?
a. Encourage deep breathing and coughing
b. Place in Trendelenburg’s position
c. Administer enemas daily
d. Keep neck in alignment
10. The nurse is caring for a client with cardiac and renal disease who has a serum potassium level of 5.6 mEq/L.
What medication could be administered to this client?
a. Administer PO patiromer treatment for Apotassium
b. Administer 5% dextrose in water IV
c. Administer IV spironolactone
d. Administer IV regular insulin
11. A client has been tentatively diagnosed with Graves’ disease. Which of the following symptoms noted on the
initial nursing assessment is expected?
a. Recent weight gain
b. Inattentiveness
c. Protruding eyeballs
d. Cold intolerance
12. The nurse is caring for a client two hours after a right lower lobectomy. The client has one chest tube attached
to a wet chest drainage system. In evaluating the water-seal chamber, it is noted that the fluid level bubbles
constantly and the blood drainage has stopped. After performing protocol for checking for leaks, the nurse does
not find any air leaks in the system. What is the next action for the nurse to take?
a. Disconnect client from the tube
b. Call the physician immediately
c. Perform gentle hand over hand milking
d. Clamp the tube
13. A nurse notes that the PR interval on a client’s electrocardiograph (ECG) tracing is 0.14 second. What action
does the nurse take?
a. Administer oxygen via nasal cannula.
,b. Administer 1 mg epinephrine IV.
c. Prepare the client for external pacing.
d. Document the finding in the client’s chart.
14. Profound disruptions of fluid and electrolyte and acid-base balance occur as a result of the fluid shift and cell
damage. Which imbalances will be observed during the first phase of the burn injury?
a. Hyperkalemia and hypernatremia
b. Hypokalemia and hyponatremia
c. Hypokalemia and hypernatremia
d. Hyperkalemia and hyponatremia
15. After and ischemic stroke, the client has a cerebral edema on the CT scan and is rousable but the GCS score is
still 14, BP of 150/89 mmHg. The client is ordered to remain on strict intake and output (I&O) monitoring and
maintain proper hydration. What is the rationale for this treatment protocol?
a. Strict intake and output (I&O) monitoring will maintain the client’s readiness for emergency craniotomy.
b. The client will be administered an anticoagulant to dissolve the clot and restore perfusion.
c. Dehydration can adversely affect cerebral perfusion.
d. The client will be needing furosemide treatment to decrease cerebral edema.
16. The nurse sees the following rhythm on a client’s cardiac monitor. How will the nurse interpret this rhythm?
a. Sinus rhythm with multifocal premature ventricular contractions
b. Sinus rhythm with paired premature ventricular contractions (couplets)
c. Sinus rhythm with unifocal premature ventricular contractions
d. Sinus rhythm with bigeminal premature ventricular contractions
17. The nurse is caring for a client with a burn injury. The client fell into a tank of unknown liquid chemical, upon
arrival to the hospital, the client is screaming and crying. What is the first nursing intervention?
a. Initiate cardiopulmonary resuscitation.
b. Help the client bathe or shower.
c. Obtain an electrocardiogram (ECG).
d. Remove the client’s clothing.
18. A client was injured as follows: the client sustained partial and full-thickness burns to
the whole posterior side of the left arm, his entire left lower extremity, and perineum.
Using the rule of nines, how much is the client’s extent of burn injury?
a. 28%
b. 13.5%
c. 16%
d. 23.5%
19. A student nurse asks the primary care nurse about the use of antibiotics to help prevent infection in the client
who has sustained a burn. What information should be provided to the student nurse?
, a. Antibiotics are indicated in the event of a temperature increase of more than 1 degree from the client’s
baseline.
b. Topical antimicrobial drugs are used for infection prevention in burn wounds.
c. Systemic antibiotics are necessary to prevent colonization of bacteria at the site of the burn.
d. Systemic antibiotics are used whether burn clients have symptoms of an actual infection or not.
20. The nurse is conducting an admission assessment of an 82-year-old client who sustained a 42% burn from
spilling hot coffee over his body. Which question is important to ask to determine this client’s prognosis?
a. “Do you have any drug or food allergies?”
b. “Have you had any surgeries?”
c. “Do you live alone?”
d. “Do you have kidney or heart failure?
21. The nurse assesses a client who is ordered to receive oxygen via a partial rebreather mask. For which
assessment finding below should the nurse intervene?
a. The client’s pulse oximetry reading is 95%. 60 701 at 114
6min
b. The arterial oxygen level is 90.
c. The oxygen flow rate is set at 2 L/min. to bow
d. The reservoir bag is two thirds inflated.
22. The nurse has been administering 0.9% normal saline intravenous fluids in a client with severe sepsis. To
evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the
nurse to assess?
a. Lactate levels and hourly urine output
b. Skin color and oral temperature
c. Blood pressure and neutrophil count
d. Oral temperature and capillary refill
23. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would
anticipate which of the following assessment findings?
a. Hypertension
b. Diarrhea hyper
hyper
c. Lethargy
d. Heat intolerance
hyper
24. A client is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively,
the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/75 mmHg; pulmonary
artery wedge pressure is 2 mmHg; ejection fraction is increased; chest tube drainage is 200 mL/hr. What is the
best interpretation by the nurse?
a. The client is at risk for developing hypovolemic shock.
b. The client is at risk for developing cardiogenic shock.
c. The assessed values are within normal limits.
d. The client is at risk for developing fluid volume overload.
25. A client is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes were heard. But
an hour later, the lung sounds have decreased and no wheezes are audible. What is the best action for the nurse
to take?
a. Document the results and continue to monitor the client’s respiratory rate
b. Reposition the client in high-Fowler’s position and reassess breath sounds
c. Notify the health care provider and prepare for endotracheal intubation
d. Encourage the client to cough and auscultate the lungs again
