NSG 321 V4 EXAM QUESTIONS AND ANSWERS
1. A client diagnosed with a deep vein thrombus (DVT), followed by a
diagnosis of pulmonary embolism (PE), is receiving heparin via an infusion
pump at a rate of 1400 U/hr. The client tells the nurse, “I wish this medicine
would hurry up and dissolve this clot in my lung so that I can go home.” What
response is best for the nurse to provide?
A. “Heparin prevents future blood clot formation, but your risk of bleeding
needs to be monitored closely.”
2. A male translator is working with the nurse who is giving discharge
instructions to a non-English speaking client. When the translator restates
what he nurse is saying, it appears that he is saying much more than what the
nurse said. What action should the nurse take?
A. Ask the translator if there is a reason for the lengthiness of the translation.
3. A nurse is named as a defendant in a malpractice case. What action should
the nurse take?
A. Contact the nurse’s professional liability insurance company.
4. A female client admitted to a long-term care facility appears to be confused
and frightened. She offers her belongings, including valuable jewelry, to
members of the nursing staff if they promise to stay with her and not leave her
alone. What action should the nurse implement?
A. Make and inventory of the belongings and send the valuables home with a
family member.
,5. The nurse is teaching a childbirth education class to prospective parents
and describing possible signs of labor. Class participants should be taught that
which sign should be reported to the healthcare provider immediately?
A. Leaking of fluid from the vagina.
6. The nurse performs a series of heel sticks to obtain glucose levels on a
large-for-gestational age (LGA) newborn. Because the glucose was 48 mg/dl
on admission and 39 mg/dl one hour later, a venous specimen for laboratory
analysis of serum glucose concentration is obtained. What action is most
important for the nurse to implement?
A. Take the newborn to the mother to breastfeed.
7. A home health care agency set the goal: “Use informatics as a method for
improving health care delivery.” What nursing action is directed toward
achieving this goal?
A. Enter accurate client data into clients’ computerized medical records.
8. A 15-year-old client with a spinal cord injury develops spastic leg tremors,
sweating, and a headache. Which action should the nurse implement ?
Palpate the bladder for distention
9. The DASH (Dietary Approaches to Stop Hypertension) diet is prescribed for
a client with uncontrolled hypertension. Which dietary choices should the
nurse instruct the client to eat?
Shredded wheat
10. An adult female client is admitted to the psychiatric unit because of a
complex hand washing ritual she performs daily that takes two hours or
longer to complete. She worries about staying clean and refuses to sit on any
of the chairs in the day area. This client’s hand washing is an example of which
clinical behavior?
, Compulsion
11. The nurse should instruct the parents of an 11-year-old with Type I
diabetes mellitus to carefully watch their child for the symptoms of diabetic
ketoacidosis. In which situation is the child most at risk for becoming
ketoacidotic ?
During the course of an acute illness
12. A man who has a known problem with alcohol is accused of stealing from
his employer. When he returns home that evening, he accuses his son of
stealing from school, and physically abuses the child for what the father
describes as the child’s dishonest behavior. Which two defense mechanisms
are being used by the father
Projection and displacement
13. ACE inhibitor is prescribed for male with diabetes whose BP is 120/60. He
asks the nurse why he is getting the med when his BP is normal. Response?
It slows the progression of kidney damage often associated with diabetes
14. When irrigating an occluded NG tube, what action should the nurse
include?
Measure the amount of fluid instilled and returned
15. Nursing diagnosis, “high risk for infection” is most relevant for client with
which hematologic problem?
Agranulocystosis
16. 36hrs after delivery, nurse assesses client’s fundus just above the
umbilicus and displaces to the right of midline. What action?
Palpate bladder for distention
1. A client diagnosed with a deep vein thrombus (DVT), followed by a
diagnosis of pulmonary embolism (PE), is receiving heparin via an infusion
pump at a rate of 1400 U/hr. The client tells the nurse, “I wish this medicine
would hurry up and dissolve this clot in my lung so that I can go home.” What
response is best for the nurse to provide?
A. “Heparin prevents future blood clot formation, but your risk of bleeding
needs to be monitored closely.”
2. A male translator is working with the nurse who is giving discharge
instructions to a non-English speaking client. When the translator restates
what he nurse is saying, it appears that he is saying much more than what the
nurse said. What action should the nurse take?
A. Ask the translator if there is a reason for the lengthiness of the translation.
3. A nurse is named as a defendant in a malpractice case. What action should
the nurse take?
A. Contact the nurse’s professional liability insurance company.
4. A female client admitted to a long-term care facility appears to be confused
and frightened. She offers her belongings, including valuable jewelry, to
members of the nursing staff if they promise to stay with her and not leave her
alone. What action should the nurse implement?
A. Make and inventory of the belongings and send the valuables home with a
family member.
,5. The nurse is teaching a childbirth education class to prospective parents
and describing possible signs of labor. Class participants should be taught that
which sign should be reported to the healthcare provider immediately?
A. Leaking of fluid from the vagina.
6. The nurse performs a series of heel sticks to obtain glucose levels on a
large-for-gestational age (LGA) newborn. Because the glucose was 48 mg/dl
on admission and 39 mg/dl one hour later, a venous specimen for laboratory
analysis of serum glucose concentration is obtained. What action is most
important for the nurse to implement?
A. Take the newborn to the mother to breastfeed.
7. A home health care agency set the goal: “Use informatics as a method for
improving health care delivery.” What nursing action is directed toward
achieving this goal?
A. Enter accurate client data into clients’ computerized medical records.
8. A 15-year-old client with a spinal cord injury develops spastic leg tremors,
sweating, and a headache. Which action should the nurse implement ?
Palpate the bladder for distention
9. The DASH (Dietary Approaches to Stop Hypertension) diet is prescribed for
a client with uncontrolled hypertension. Which dietary choices should the
nurse instruct the client to eat?
Shredded wheat
10. An adult female client is admitted to the psychiatric unit because of a
complex hand washing ritual she performs daily that takes two hours or
longer to complete. She worries about staying clean and refuses to sit on any
of the chairs in the day area. This client’s hand washing is an example of which
clinical behavior?
, Compulsion
11. The nurse should instruct the parents of an 11-year-old with Type I
diabetes mellitus to carefully watch their child for the symptoms of diabetic
ketoacidosis. In which situation is the child most at risk for becoming
ketoacidotic ?
During the course of an acute illness
12. A man who has a known problem with alcohol is accused of stealing from
his employer. When he returns home that evening, he accuses his son of
stealing from school, and physically abuses the child for what the father
describes as the child’s dishonest behavior. Which two defense mechanisms
are being used by the father
Projection and displacement
13. ACE inhibitor is prescribed for male with diabetes whose BP is 120/60. He
asks the nurse why he is getting the med when his BP is normal. Response?
It slows the progression of kidney damage often associated with diabetes
14. When irrigating an occluded NG tube, what action should the nurse
include?
Measure the amount of fluid instilled and returned
15. Nursing diagnosis, “high risk for infection” is most relevant for client with
which hematologic problem?
Agranulocystosis
16. 36hrs after delivery, nurse assesses client’s fundus just above the
umbilicus and displaces to the right of midline. What action?
Palpate bladder for distention
