NUR 3400 / FINAL EXAM
1. The client has just had emergency intubation for respiratory distress.
Immediately after endotracheal tube insertion, which of the following actions
by the nurse is more important?
A. Call for a chest X-ray to determine placement.
B. Assess for bilateral breath sounds.
C. Tape the tube securely in place.
D. Assure the client that alternative communication means will be provided.
2. A nurse is monitoring a pregnant client with suspected partial placenta
previa who is experiencing vaginal bleeding. Which finding would the
nurse expect to note on assessment of the client?
a. Painful vaginal bleeding
b. Complaints of abdominal pain
c. Soft, relaxed, nontender uterus
d. Sustained tetanic contractions
3. The nurse is assessing a client in an outpatient clinic. Which client statement
alerts the nurse to possible left-sided heart failure?
a. "I have been drinking more water than usual."
b. "I have experienced blurred vision on several occasions."
c. "I have to stop halfway up the stairs to catch my breath."
d. "I have been awakened by the need to urinate at night."
4. A nurse is reviewing the EKG strip of a pt who has prolonged vomiting. Which
of the following abnormalities on the pts EKG should the nurse interpret as a
sign of kypokalemia?
a. Abnormally prominent U wave
b. Wide QRS
c. Elevated ST segment
d. Inverted P wave
5. The nurse is the first responder at the scene of a bus crash. After a quick
assessment of the victims, which one does the nurse care for first?
a. A victim with an open fracture of the arm that is bleeding profusely
b. A victim with a twisted ankle and leg bruises
c. A victim who is anxiously moving among the victims, searching for her
husband
d. A victim who is unresponsive, with severe swelling and bruising around the
eyes, and is not breathing
,NUR 3400 / FINAL EXAM
6. The nurse is caring for a client with continuous ECG monitoring. The nurse
observes that the client's rhythm has changed to ventricular fibrillation. After
activating the emergency response system, the next best action by the nurse
is to:
a. Immediately defibrillate the client.
b. Call the physician to report the change in rhythm.
c. Administer intravenous lidocaine.
d. Check the client's blood pressure.
7. Which of the following nursing actions would take priority when caring for the
woman with a suspected ectopic pregnancy?
a. Administering oxygen
b. Obtaining surgical consent
c. Monitoring vital signs
d. Providing emotional support
8. Which of the following patients is at the highest risk for hyperosmolar
hyperglycemic syndrome?
a. A 45-year-old woman with type 1 diabetes who usually forgets to take her
insulin in the morning
b. An 83-year-old, long-term care resident with type 2 diabetes and
advanced Alzheimer's disease who recently developed influenza
c. An 18-year-old college student with type 1 diabetes who exercises
excessively every day.
d. A 75-year-old man with type 2 diabetes and coronary artery disease who has
recently started
9. A 7-year-old child is admitted to the hospital with acute
glomerulonephritis (AGN). When obtaining the nursing history, which finding
should the nurse expect to obtain?
a. A recent DPT immunization.
b. Increased thirst and urination.
c. A recent strep throat infection.
d. High blood cholesterol levels on routine screening.
10.A patient with Type II diabetes informs a nurse that he has not felt well since
beginning therapy with metformin (Glucophage) about 2 weeks ago. When
asked to provide more detail, the patient relates that he has
been experiencing nausea and diarrhea consistently. The best reply by the
nurse would be:
, NUR 3400 / FINAL EXAM
a. "Your symptoms might be related to a contagious influenza."
b. "Your symptoms are expected and should decrease with time."
c. "We will have to run some tests to find out what is going on."
d. "You are probably allergic to metformin."
11. The nurse in the labor and delivery department is caring for a client
whose abdomen remains hard and rigid between contractions and the fetal
heart rate is 100. Which client problem is priority?
a. Alteration in comfort.
b. Fluid and electrolyte imbalance.
c. Ineffective breathing pattern.
d. Risk for fetal death.
12. The nurse is assigned to care for a 3-year-old child admitted with the
tentative diagnosis of nephrotic syndrome. According to the child's mother,
the child has not been feeling well for several weeks. The child has been
irritable and withdrawn and has not eaten well for the past week. Which of
the following clinical profiles would substantiate the tentative diagnosis of
nephrotic syndrome?
a. proteinuria, polyuria, hyperalbuminemia
b. hematuria, hypertension, glycosuria
c. hyperlipidemia, hypertension, hyperthermia
d. hyperlipidemia, proteinuria, hypoalbuminemia
13. The client has been diagnosed with Cushing's syndrome. The nurse would
monitor this client for which of the following expected signs of this
disorder? Select all that apply.
a. Moon face
b. Purple striations
c. Tremors
d. Alopecia
e. Buffalo hump
client with myasthenia gravis is taking neostigmine bromide. The nurse
determines that the client is experiencing the intended therapeutic
effect from the medication after noting:
a. Improved swallowing function
b. Decreased blood pressure
c. Bradycardia
d. Increased heart rate
1. The client has just had emergency intubation for respiratory distress.
Immediately after endotracheal tube insertion, which of the following actions
by the nurse is more important?
A. Call for a chest X-ray to determine placement.
B. Assess for bilateral breath sounds.
C. Tape the tube securely in place.
D. Assure the client that alternative communication means will be provided.
2. A nurse is monitoring a pregnant client with suspected partial placenta
previa who is experiencing vaginal bleeding. Which finding would the
nurse expect to note on assessment of the client?
a. Painful vaginal bleeding
b. Complaints of abdominal pain
c. Soft, relaxed, nontender uterus
d. Sustained tetanic contractions
3. The nurse is assessing a client in an outpatient clinic. Which client statement
alerts the nurse to possible left-sided heart failure?
a. "I have been drinking more water than usual."
b. "I have experienced blurred vision on several occasions."
c. "I have to stop halfway up the stairs to catch my breath."
d. "I have been awakened by the need to urinate at night."
4. A nurse is reviewing the EKG strip of a pt who has prolonged vomiting. Which
of the following abnormalities on the pts EKG should the nurse interpret as a
sign of kypokalemia?
a. Abnormally prominent U wave
b. Wide QRS
c. Elevated ST segment
d. Inverted P wave
5. The nurse is the first responder at the scene of a bus crash. After a quick
assessment of the victims, which one does the nurse care for first?
a. A victim with an open fracture of the arm that is bleeding profusely
b. A victim with a twisted ankle and leg bruises
c. A victim who is anxiously moving among the victims, searching for her
husband
d. A victim who is unresponsive, with severe swelling and bruising around the
eyes, and is not breathing
,NUR 3400 / FINAL EXAM
6. The nurse is caring for a client with continuous ECG monitoring. The nurse
observes that the client's rhythm has changed to ventricular fibrillation. After
activating the emergency response system, the next best action by the nurse
is to:
a. Immediately defibrillate the client.
b. Call the physician to report the change in rhythm.
c. Administer intravenous lidocaine.
d. Check the client's blood pressure.
7. Which of the following nursing actions would take priority when caring for the
woman with a suspected ectopic pregnancy?
a. Administering oxygen
b. Obtaining surgical consent
c. Monitoring vital signs
d. Providing emotional support
8. Which of the following patients is at the highest risk for hyperosmolar
hyperglycemic syndrome?
a. A 45-year-old woman with type 1 diabetes who usually forgets to take her
insulin in the morning
b. An 83-year-old, long-term care resident with type 2 diabetes and
advanced Alzheimer's disease who recently developed influenza
c. An 18-year-old college student with type 1 diabetes who exercises
excessively every day.
d. A 75-year-old man with type 2 diabetes and coronary artery disease who has
recently started
9. A 7-year-old child is admitted to the hospital with acute
glomerulonephritis (AGN). When obtaining the nursing history, which finding
should the nurse expect to obtain?
a. A recent DPT immunization.
b. Increased thirst and urination.
c. A recent strep throat infection.
d. High blood cholesterol levels on routine screening.
10.A patient with Type II diabetes informs a nurse that he has not felt well since
beginning therapy with metformin (Glucophage) about 2 weeks ago. When
asked to provide more detail, the patient relates that he has
been experiencing nausea and diarrhea consistently. The best reply by the
nurse would be:
, NUR 3400 / FINAL EXAM
a. "Your symptoms might be related to a contagious influenza."
b. "Your symptoms are expected and should decrease with time."
c. "We will have to run some tests to find out what is going on."
d. "You are probably allergic to metformin."
11. The nurse in the labor and delivery department is caring for a client
whose abdomen remains hard and rigid between contractions and the fetal
heart rate is 100. Which client problem is priority?
a. Alteration in comfort.
b. Fluid and electrolyte imbalance.
c. Ineffective breathing pattern.
d. Risk for fetal death.
12. The nurse is assigned to care for a 3-year-old child admitted with the
tentative diagnosis of nephrotic syndrome. According to the child's mother,
the child has not been feeling well for several weeks. The child has been
irritable and withdrawn and has not eaten well for the past week. Which of
the following clinical profiles would substantiate the tentative diagnosis of
nephrotic syndrome?
a. proteinuria, polyuria, hyperalbuminemia
b. hematuria, hypertension, glycosuria
c. hyperlipidemia, hypertension, hyperthermia
d. hyperlipidemia, proteinuria, hypoalbuminemia
13. The client has been diagnosed with Cushing's syndrome. The nurse would
monitor this client for which of the following expected signs of this
disorder? Select all that apply.
a. Moon face
b. Purple striations
c. Tremors
d. Alopecia
e. Buffalo hump
client with myasthenia gravis is taking neostigmine bromide. The nurse
determines that the client is experiencing the intended therapeutic
effect from the medication after noting:
a. Improved swallowing function
b. Decreased blood pressure
c. Bradycardia
d. Increased heart rate
