Practice Exam Answers NUR 221
,Question 1
A nurse is completing a health screening activity to identify at which point in
the menstrual cycle a client’s problem occurs. Place the pathophysiologic
steps of the menstrual cycle listed below in the correct sequential order. All
options must be used.
Correct response:
•
The top layer of the endometrium breaks down and sloughs.
•
The endometrium begins thickening.
•
The level of estrogen in the blood peaks.
•
A follicle matures and ovulation occurs.
•
Peak endometrial thickening occurs.
•
Increased estrogen and progesterone levels inhibit luteinizing hormone.
Question 2
The nurse is caring for a client during the postsurgical period after having
a right femoral–popliteal bypass graft. The nurse enters the room to
conduct a nursing assessment and care. Order the nurse’s actions according
to priority. All options must be used.
Correct response:
•
Assess peripheral pulses.
•
Assess incision site.
•
Assess lung fields.
•
Assess pain/obtain medication.
•
Instruct on client positioning.
•
Offer clear fluids.
Question 3
All of the children were admitted yesterday. In which order from first to last
would the nurse assess these children? All options must be used.
Correct response:
•
a 12-year-old child with a fractured femur and lacerated liver
•
a 6-year-old child with a concussion and little change in vital signs
•
a 3-year-old child with acute pyelonephritis and a temperature of
104.5° F (40.3° C)
•
a 10-month-old infant with pneumonia and respiratory rate of 50
breaths/minute
•
a 3-month-old infant with respiratory syncytial virus and stable vital signs
,Question 4
A 4-year-old postoperative child is found unresponsive. Place the following
actions in the correct sequence to perform CPR after the child has been
assessed for responsiveness and help has been called. All options must be
used.
Correct response:
•
Feel for the carotid pulse.
•
Perform 30 compressions.
•
Open the airway.
•
Check for breathing.
•
Provide 2 rescue breaths.
Question 5
A client on a stretcher in the emergency department begins to thrash
around, slap the sheets, and yell, “Get these bugs off of me.” The client is
disoriented and has a blood pressure of 189/75 mm Hg and a pulse of 96
bpm. The friend who is with the client says, “My friend was drinking a lot 3
days ago and asked me for money to get more vodka, but I didn’t have
any.” What should the nurse do in order of priority from first to last? All
options must be used.
Correct response:
•
Remind the client that they are in the hospital and the nurse is with them.
•
Implement constant observation.
•
Administer haloperidol and lorazepam IM as prescribe.
•
Monitor vital signs every 15 minutes.
•
Obtain a prescription to place the client in restraints, if needed.
•
Chart the client’s response to the interventions.
Question 6
A nurse is caring for a client with a spinal cord injury who has a urinary
catheter. The nurse finds the client in a recumbent position and notices
that the client’s blood pressure is rapidly increasing. The client reports
having a pounding headache and is damp from sweating. Place the nursing
actions in the order in which the nurse should perform them to properly
respond to this client’s situation. All options must be used.
Correct response:
•
Notify the health care provider.
•
Sit the client up.
•
Loosen the client’s clothing.
•
Check the urinary catheter for kinks.
, Question 7
The nurse received an order for a sputum sample to be obtained in the
morning. Prior to the client’s breakfast, the nurse explains the procedure to
the client, obtains all equipment, washes hands, and dons clean gloves.
Place the next nursing actions in proper sequence. All options must be
used.
Correct response:
•
Place the client in a Fowler position.
•
Instruct the client to cough.
•
Obtain the sample.
•
Perform oral hygiene.
•
Remove gloves/hand hygiene.
•
Label the container/take for analysis.
Question 8
A nurse assesses a client who has manifestations of peripheral intravenous
extravasation. List the actions to take in order of priority. All options must be
used.
Correct response:
•
Discontinue the intravenous tubing as close to the hub as possible.
•
Notify the healthcare provider.
•
Elevate the affected arm on pillows.
•
Apply ice in short intervals to the affected site.
•
Photograph the site with the client’s written permission.
Question 9
At 0500, the nurse on the antepartum reviews all remaining tasks to
complete before giving the change of shift handoff at 0700. In what order
from first to last should the nurse should complete the tasks? All options
must be used.
Correct response:
•
fetal monitor strip for one-half hour every shift
•
magnesium sulfate draw at 0600
•
documentation check, final check of each client
•
point-of-care blood glucose and sliding scale insulin due at 0700, 1100,
1600, and bedtime
Question 10
A parent brings her 3-month-old child into the emergency department. The
child is listless with dry mucous membranes, tenting of the skin on the
forehead, a depressed fontanel, and a history of vomiting and diarrhea for
the last 36 hours. In what order from first to last should the nurse implement
the primary care provider’s prescriptions? All options must be used.
,Question 1
A nurse is completing a health screening activity to identify at which point in
the menstrual cycle a client’s problem occurs. Place the pathophysiologic
steps of the menstrual cycle listed below in the correct sequential order. All
options must be used.
Correct response:
•
The top layer of the endometrium breaks down and sloughs.
•
The endometrium begins thickening.
•
The level of estrogen in the blood peaks.
•
A follicle matures and ovulation occurs.
•
Peak endometrial thickening occurs.
•
Increased estrogen and progesterone levels inhibit luteinizing hormone.
Question 2
The nurse is caring for a client during the postsurgical period after having
a right femoral–popliteal bypass graft. The nurse enters the room to
conduct a nursing assessment and care. Order the nurse’s actions according
to priority. All options must be used.
Correct response:
•
Assess peripheral pulses.
•
Assess incision site.
•
Assess lung fields.
•
Assess pain/obtain medication.
•
Instruct on client positioning.
•
Offer clear fluids.
Question 3
All of the children were admitted yesterday. In which order from first to last
would the nurse assess these children? All options must be used.
Correct response:
•
a 12-year-old child with a fractured femur and lacerated liver
•
a 6-year-old child with a concussion and little change in vital signs
•
a 3-year-old child with acute pyelonephritis and a temperature of
104.5° F (40.3° C)
•
a 10-month-old infant with pneumonia and respiratory rate of 50
breaths/minute
•
a 3-month-old infant with respiratory syncytial virus and stable vital signs
,Question 4
A 4-year-old postoperative child is found unresponsive. Place the following
actions in the correct sequence to perform CPR after the child has been
assessed for responsiveness and help has been called. All options must be
used.
Correct response:
•
Feel for the carotid pulse.
•
Perform 30 compressions.
•
Open the airway.
•
Check for breathing.
•
Provide 2 rescue breaths.
Question 5
A client on a stretcher in the emergency department begins to thrash
around, slap the sheets, and yell, “Get these bugs off of me.” The client is
disoriented and has a blood pressure of 189/75 mm Hg and a pulse of 96
bpm. The friend who is with the client says, “My friend was drinking a lot 3
days ago and asked me for money to get more vodka, but I didn’t have
any.” What should the nurse do in order of priority from first to last? All
options must be used.
Correct response:
•
Remind the client that they are in the hospital and the nurse is with them.
•
Implement constant observation.
•
Administer haloperidol and lorazepam IM as prescribe.
•
Monitor vital signs every 15 minutes.
•
Obtain a prescription to place the client in restraints, if needed.
•
Chart the client’s response to the interventions.
Question 6
A nurse is caring for a client with a spinal cord injury who has a urinary
catheter. The nurse finds the client in a recumbent position and notices
that the client’s blood pressure is rapidly increasing. The client reports
having a pounding headache and is damp from sweating. Place the nursing
actions in the order in which the nurse should perform them to properly
respond to this client’s situation. All options must be used.
Correct response:
•
Notify the health care provider.
•
Sit the client up.
•
Loosen the client’s clothing.
•
Check the urinary catheter for kinks.
, Question 7
The nurse received an order for a sputum sample to be obtained in the
morning. Prior to the client’s breakfast, the nurse explains the procedure to
the client, obtains all equipment, washes hands, and dons clean gloves.
Place the next nursing actions in proper sequence. All options must be
used.
Correct response:
•
Place the client in a Fowler position.
•
Instruct the client to cough.
•
Obtain the sample.
•
Perform oral hygiene.
•
Remove gloves/hand hygiene.
•
Label the container/take for analysis.
Question 8
A nurse assesses a client who has manifestations of peripheral intravenous
extravasation. List the actions to take in order of priority. All options must be
used.
Correct response:
•
Discontinue the intravenous tubing as close to the hub as possible.
•
Notify the healthcare provider.
•
Elevate the affected arm on pillows.
•
Apply ice in short intervals to the affected site.
•
Photograph the site with the client’s written permission.
Question 9
At 0500, the nurse on the antepartum reviews all remaining tasks to
complete before giving the change of shift handoff at 0700. In what order
from first to last should the nurse should complete the tasks? All options
must be used.
Correct response:
•
fetal monitor strip for one-half hour every shift
•
magnesium sulfate draw at 0600
•
documentation check, final check of each client
•
point-of-care blood glucose and sliding scale insulin due at 0700, 1100,
1600, and bedtime
Question 10
A parent brings her 3-month-old child into the emergency department. The
child is listless with dry mucous membranes, tenting of the skin on the
forehead, a depressed fontanel, and a history of vomiting and diarrhea for
the last 36 hours. In what order from first to last should the nurse implement
the primary care provider’s prescriptions? All options must be used.
