NR341 WEEK 4 EXAM 1
Question 38: A nurse in an emergency department is assessing a new client. Which clinical
manifestation is the priority for the nurse to address?
Answers:
• A Diaphoresis and circumoral cyanosis
• B Client rates pain scale 9/10, with 10 being the worst
• C Respiratory rate of 28 breaths/minute
• D Blood pressure of 101/54 mmHg
Right Answer and Rationale
The right answer is A.
,A. Diaphoresis and circumoral cyanosis
• Circumoral cyanosis is a bluish discoloration around the mouth. This is a critical sign that
indicates inadequate oxygenation or poor tissue perfusion.
• In emergency nursing, the ABCs (Airway, Breathing, Circulation) take top priority. Cyanosis
directly relates to problems with breathing and/or circulation. It signifies a lifethreatening
emergency.
• Diaphoresis (sweating) combined with cyanosis suggests the client's body is under significant
stress, often due to shock, respiratory distress, or severe cardiovascular issues.
Question 12: A nurse enters a client's room and finds the client unresponsive and without a pulse.
The client's son was considering changing the status to a do-not-resuscitate (DNR), but the request has
not been made, and the healthcare provider has not provided an order for a DNR. What action should
the nurse take next?
,Answers:
• A Call the health care provider and ask for a DNR order
• B Call the client's son and ask about the DNR request
• C Call for assistance and begin cardiopulmonary resuscitation
• D Obtain immediate assistance from a more experienced nurse
Right Answer and Rationale
The right answer is C.
C. Call for assistance and begin cardiopulmonary resuscitation
• Rationale: In a medical setting, the legal and ethical standard is that all clients are full code
(to be resuscitated) unless a valid, written Do-Not-Resuscitate (DNR) order is present in
the client's medical record.
• Since the client is unresponsive and pulseless (indicating cardiac arrest) and a DNR order is
NOT in place, the nurse's immediate priority is to activate the emergency response system (call
for assistance) and begin CPR according to standard resuscitation protocols.
• The fact that the son was "considering" a DNR is irrelevant to the nurse's immediate action, as
consideration does not equal a signed, legal order.
, Question 36: A nurse is planning to implement prone positioning as prescribed for a client with adult
respiratory distress syndrome (ARDS) who is intubated and has several intravenous lines and a
gastric tube for nutrition. Which action should the nurse plan to take?
Answers:
• A Use a mechanical lift if no one is available to help reposition.
• B Keep the client in the prone position for at least 18 hours daily.
• C Remove the client's intravenous lines before repositioning.
• D Stop the client's gastric tube feeding before positioning.
Right Answer and Rationale
The right answer is D.
D. Stop the client's gastric tube feeding before positioning.
• Rationale: Prone positioning involves turning a client from their back onto their stomach.
Moving a client's position, especially in this manner, significantly increases the risk of
regurgitation and aspiration of gastric contents, which can lead to aspiration pneumonia.
• To prevent this complication, the nurse must stop the gastric tube feeding for a period (often
30 minutes to an hour, as per facility policy or provider order) before starting the prone
procedure. This allows the stomach time to empty.
Question 38: A nurse in an emergency department is assessing a new client. Which clinical
manifestation is the priority for the nurse to address?
Answers:
• A Diaphoresis and circumoral cyanosis
• B Client rates pain scale 9/10, with 10 being the worst
• C Respiratory rate of 28 breaths/minute
• D Blood pressure of 101/54 mmHg
Right Answer and Rationale
The right answer is A.
,A. Diaphoresis and circumoral cyanosis
• Circumoral cyanosis is a bluish discoloration around the mouth. This is a critical sign that
indicates inadequate oxygenation or poor tissue perfusion.
• In emergency nursing, the ABCs (Airway, Breathing, Circulation) take top priority. Cyanosis
directly relates to problems with breathing and/or circulation. It signifies a lifethreatening
emergency.
• Diaphoresis (sweating) combined with cyanosis suggests the client's body is under significant
stress, often due to shock, respiratory distress, or severe cardiovascular issues.
Question 12: A nurse enters a client's room and finds the client unresponsive and without a pulse.
The client's son was considering changing the status to a do-not-resuscitate (DNR), but the request has
not been made, and the healthcare provider has not provided an order for a DNR. What action should
the nurse take next?
,Answers:
• A Call the health care provider and ask for a DNR order
• B Call the client's son and ask about the DNR request
• C Call for assistance and begin cardiopulmonary resuscitation
• D Obtain immediate assistance from a more experienced nurse
Right Answer and Rationale
The right answer is C.
C. Call for assistance and begin cardiopulmonary resuscitation
• Rationale: In a medical setting, the legal and ethical standard is that all clients are full code
(to be resuscitated) unless a valid, written Do-Not-Resuscitate (DNR) order is present in
the client's medical record.
• Since the client is unresponsive and pulseless (indicating cardiac arrest) and a DNR order is
NOT in place, the nurse's immediate priority is to activate the emergency response system (call
for assistance) and begin CPR according to standard resuscitation protocols.
• The fact that the son was "considering" a DNR is irrelevant to the nurse's immediate action, as
consideration does not equal a signed, legal order.
, Question 36: A nurse is planning to implement prone positioning as prescribed for a client with adult
respiratory distress syndrome (ARDS) who is intubated and has several intravenous lines and a
gastric tube for nutrition. Which action should the nurse plan to take?
Answers:
• A Use a mechanical lift if no one is available to help reposition.
• B Keep the client in the prone position for at least 18 hours daily.
• C Remove the client's intravenous lines before repositioning.
• D Stop the client's gastric tube feeding before positioning.
Right Answer and Rationale
The right answer is D.
D. Stop the client's gastric tube feeding before positioning.
• Rationale: Prone positioning involves turning a client from their back onto their stomach.
Moving a client's position, especially in this manner, significantly increases the risk of
regurgitation and aspiration of gastric contents, which can lead to aspiration pneumonia.
• To prevent this complication, the nurse must stop the gastric tube feeding for a period (often
30 minutes to an hour, as per facility policy or provider order) before starting the prone
procedure. This allows the stomach time to empty.
