NUR 445 Exam 2022
QUESTION AND
ANSWERS {A
GRADE}
,1. When developing the plan of care for the surgical client having sedation, which
intervention has the highest priority?
a. Assess the client’s respiratory status
b. Monitor the client’s urinary output
c. Get a 12 lead EKG prior to injection
d. Attempt to keep the client focused
2. The nurse interprets which of the following as an early sign of acute respiratory distress
syndrome (ARDS) in a client at risk?
a. Elevated carbon dioxide level
b. Hypoxia not responsive to oxygen therapy
c. Metabolic acidosis
d. Severe, unexplained electrolyte imbalance
3. The client has arterial blood gas values of pH 7.38, PaO2 77, PaCO2 40, HCO3 24. Which
intervention should the nurse implement?
a. Administer oxygen 6L/min via nasal canula per protocol
b. Encourage the client to take deep breaths
c. Administer intravenous sodium bicarbonate per protocol
d. Assess the client’s gastrointestinal status
4. Potassium chloride intravenously is prescribed for a client with hypokalemia. Which
actions should the nurse take to plan for preparation and administration of the
potassium. Select all that apply
a. Obtain an IV pump
b. Monitor urine output during administration
c. Prepare the medication for bolus administration
d. Monitor the IV site for signs of infiltration and phlebitis
e. Ensure the medication is diluted in the appropriate volume fluid
5. The nurse is caring for a client with emphysema and respiratory failure who is receiving
mechanical ventilation through an endotracheal tube. To prevent ventilator-associated
pneumonia (VAP), which action is most important to include in the plan of care ?
a. Administer ordered antibiotics as scheduled
b. Hyperoxygenate the client before suctioning
c. Maintain the head at a 30-to-40 degree angle
d. Suction the airway when coarse crackles are audible
6. The nurse caring for a client who has been receiving intravenous (IV) diuretics suspect
that’s the client is experiencing a fluid volume deficit. Which assessment finding would
the nurse note in a client with this condition?
a. Weight loss and poor skin turgor
b. Lung congestion and increased heart rate
c. Decreased hematocrit and increased urine output
d. Increased respirations and increased blood pressure
7. The client on long-term mechanical ventilation becomes very frustrated when he tries to
communicate. What intervention should the nurse implement to assist the client?
a. Assure the client that everything will be all right and that he should not become
upset.
, b. Ask a family member to interpret what the client is trying to communicate.
c. Ask the provider to wean the client off the mechanical ventilator to allow them
to talk.
d. Ask the client to write, use a picture board, or spell words with an alphabet
board.
8. Which outcome should the nurse identify for the client diagnosed with fluid volume
excess?
a. The client will void a minimum of 30mL per hour
b. The client will has elastic skin turgor
c. The client will have no adventitious breath sounds
d. The client will have a serum creatinine of 1.4mg/dL
9. The nurse is caring for a client on a mechanical ventilator. Which intervention should be
included in the nursing care plan addressing the endotracheal tube care?
a. Do not move or touch the ET tube
b. Obtain a chest X-ray daily
c. Determine if the ET cuff id deflated
d. Ensure that the ET tube is secure
10. The client is admitted with a serum sodium level of 110mEq/L. Which nursing
intervention should be implemented?
a. Encourage fluids orally
b. Administer 10% saline solution IVPB
c. Administer antidiuretic hormone intranasally
d. Place on seizure precautions
11. A client has a chest tube. What assessment findings require immediate intervention
from the nurse. Select all that apply
a. Intermittent bubbling in the water seal chamber in the client with a
pneumothorax
b. No drainage in the chest tube of a client with a pneumothorax
c. The chest tube falls out of the client’s chest
d. Bloody drainage in the tubing of a client with a hemothorax
e. Tracheal deviation in a client after chest trauma
12. The client is NPO is receiving total parenteral nutrition (TPN) via a subclavian line. Which
precautions should the nurse implement? Select all that apply
a. Place the solution on an IV pump at the prescribed rate
b. Monitor blood glucose every 6 hours
c. Weigh the client weekly, first thing in the morning
d. Change the IV tubing every three days
e. Monitor intake and output every shift
13. A client is scheduled to have hemodialysis in 30 minutes and is due for the following
medications: vitamins C, B-complex vitamin, and cimetidine. Which action by the nurse
is best?
a. Give medications with a small sip of water.
b. Hold all medications until after dialysis.
c. Give the supplements, but hold the cimetidine.
QUESTION AND
ANSWERS {A
GRADE}
,1. When developing the plan of care for the surgical client having sedation, which
intervention has the highest priority?
a. Assess the client’s respiratory status
b. Monitor the client’s urinary output
c. Get a 12 lead EKG prior to injection
d. Attempt to keep the client focused
2. The nurse interprets which of the following as an early sign of acute respiratory distress
syndrome (ARDS) in a client at risk?
a. Elevated carbon dioxide level
b. Hypoxia not responsive to oxygen therapy
c. Metabolic acidosis
d. Severe, unexplained electrolyte imbalance
3. The client has arterial blood gas values of pH 7.38, PaO2 77, PaCO2 40, HCO3 24. Which
intervention should the nurse implement?
a. Administer oxygen 6L/min via nasal canula per protocol
b. Encourage the client to take deep breaths
c. Administer intravenous sodium bicarbonate per protocol
d. Assess the client’s gastrointestinal status
4. Potassium chloride intravenously is prescribed for a client with hypokalemia. Which
actions should the nurse take to plan for preparation and administration of the
potassium. Select all that apply
a. Obtain an IV pump
b. Monitor urine output during administration
c. Prepare the medication for bolus administration
d. Monitor the IV site for signs of infiltration and phlebitis
e. Ensure the medication is diluted in the appropriate volume fluid
5. The nurse is caring for a client with emphysema and respiratory failure who is receiving
mechanical ventilation through an endotracheal tube. To prevent ventilator-associated
pneumonia (VAP), which action is most important to include in the plan of care ?
a. Administer ordered antibiotics as scheduled
b. Hyperoxygenate the client before suctioning
c. Maintain the head at a 30-to-40 degree angle
d. Suction the airway when coarse crackles are audible
6. The nurse caring for a client who has been receiving intravenous (IV) diuretics suspect
that’s the client is experiencing a fluid volume deficit. Which assessment finding would
the nurse note in a client with this condition?
a. Weight loss and poor skin turgor
b. Lung congestion and increased heart rate
c. Decreased hematocrit and increased urine output
d. Increased respirations and increased blood pressure
7. The client on long-term mechanical ventilation becomes very frustrated when he tries to
communicate. What intervention should the nurse implement to assist the client?
a. Assure the client that everything will be all right and that he should not become
upset.
, b. Ask a family member to interpret what the client is trying to communicate.
c. Ask the provider to wean the client off the mechanical ventilator to allow them
to talk.
d. Ask the client to write, use a picture board, or spell words with an alphabet
board.
8. Which outcome should the nurse identify for the client diagnosed with fluid volume
excess?
a. The client will void a minimum of 30mL per hour
b. The client will has elastic skin turgor
c. The client will have no adventitious breath sounds
d. The client will have a serum creatinine of 1.4mg/dL
9. The nurse is caring for a client on a mechanical ventilator. Which intervention should be
included in the nursing care plan addressing the endotracheal tube care?
a. Do not move or touch the ET tube
b. Obtain a chest X-ray daily
c. Determine if the ET cuff id deflated
d. Ensure that the ET tube is secure
10. The client is admitted with a serum sodium level of 110mEq/L. Which nursing
intervention should be implemented?
a. Encourage fluids orally
b. Administer 10% saline solution IVPB
c. Administer antidiuretic hormone intranasally
d. Place on seizure precautions
11. A client has a chest tube. What assessment findings require immediate intervention
from the nurse. Select all that apply
a. Intermittent bubbling in the water seal chamber in the client with a
pneumothorax
b. No drainage in the chest tube of a client with a pneumothorax
c. The chest tube falls out of the client’s chest
d. Bloody drainage in the tubing of a client with a hemothorax
e. Tracheal deviation in a client after chest trauma
12. The client is NPO is receiving total parenteral nutrition (TPN) via a subclavian line. Which
precautions should the nurse implement? Select all that apply
a. Place the solution on an IV pump at the prescribed rate
b. Monitor blood glucose every 6 hours
c. Weigh the client weekly, first thing in the morning
d. Change the IV tubing every three days
e. Monitor intake and output every shift
13. A client is scheduled to have hemodialysis in 30 minutes and is due for the following
medications: vitamins C, B-complex vitamin, and cimetidine. Which action by the nurse
is best?
a. Give medications with a small sip of water.
b. Hold all medications until after dialysis.
c. Give the supplements, but hold the cimetidine.
