NURS 355 Exam 1
. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment
is most important for the nurse to monitor while the patient is receiving this infusion?
a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema - ansLung sounds
. A patient who has an infected abdominal wound develops a temperature of 104° F
(40° C). All the following interventions are included in the patient's plan of care. In which
order should the nurse perform the following actions? (Put a comma and a space
between each answer choice [A, B, C, D]).
a. Administer IV antibiotics.
b. Sponge patient with cool water.
c. Perform wet-to-dry dressing change.
d. Administer acetaminophen (Tylenol). - ansA. Administer IV antibiotics
D. Administer acetaminophen (Tylenol)
B. Sponge patient with cool water
C. Perform wet-to-dry dressing change
. A patient's 4 × 3-cm leg wound has a 0.4-cm black area in the center of the wound
surrounded by yellow-green semiliquid material. Which dressing should the nurse apply
to the wound?
a. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing - ansHydrocolloid dressing
. A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from
an admission blood pressure of 140/86 to 102/60 mm Hg with a pulse change of 70 to
96 beats/min. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take
these actions? (Put a comma and a space between each answer choice [A, B, C, D].)
a. Increase the IV infusion rate.
b. Assess the patient's dressing.
c. Increase the oxygen flowrate.
d. Check the patient's temperature. - ansA. Increase the IV infusion rate
C. Increase the oxygen flowrate
B. Assess the patient's dressing
,D. Check the patient's temperature
. A young male patient with paraplegia who has a stage 2 sacral pressure injury is being
cared for at home by his family. To prevent further tissue damage, what instructions are
most important for the nurse to teach the patient and family?
a. Change the patient's bedding frequently.
b. Apply a hydrocolloid dressing over the injury.
c. Change the patient's position every 1 to 2 hours.
d. Record the size and appearance of the injury weekly. - ansChange the patient's
position every 1 to 2 hours
. An older adult patient presents with a broken arm and visible scattered bruises healing
at different stages. Which action should the nurse take first?
a. Notify an elder protective services agency about possible abuse.
b. Make a referral for a home assessment visit by the home health nurse.
c. Have the family member stay in the waiting area while the patient is assessed.
d. Ask the patient how the injury occurred and observe the family member's reaction.
ANS: C - ansHave the family member stay in the waiting area while the patient is
assessed
. An unconscious patient who was transferred from surgery to the postanesthesia care
unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the
nurse take first?
a. Suction the patient's mouth.
b. Increase the oxygen flowrate.
c. Perform the jaw-thrust maneuver.
d. Elevate the patient's head on two pillows. - ansPerform the jaw-thrust maneuver
. The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall
and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years.
She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics
will the nurse plan to include in patient teaching about cancer screening and decreasing
cancer risk? (Select all that apply.)
a. Pap testing
b. Tobacco use
c. Sunscreen use
d. Mammography
e. Colorectal screening
ANS: A, C, D, E - ans-Pap testing
-Sunscreen use
-Mammography
-Colorectal screening
,. The nurse is caring for an Asian patient who is being admitted to the hospital. Which
action would be most appropriate for the nurse to take when interviewing this patient?
a. Avoid eye contact with the patient.
b. Observe the patient's use of eye contact.
c. Look directly at the patient when interacting.
d. Ask a family member about the patient's cultural beliefs. - ansObserve the patient's
use of eye contact
. The nurse is performing an admission assessment for a patient from China who does
not speak English. Which actions could the nurse take to enhance communication?
(Select all that apply.)
a. Ask the patient's young child to interpret.
b. Use a telephone-based medical interpreter.
c. Wait until an agency interpreter is available.
d. Use exaggerated gestures to convey information.
e. Use an electronic translation software application. - ansUse a telephone-based
medical interpreter
Wait until an agency interpreter is available
Use an electronic translation software application
. The nurse plans health care for a community with a large number of recent immigrants
from Vietnam. Which intervention is the most important for the nurse to implement?
a. Hepatitis testing
b. Tuberculosis screening
c. Contraceptive teaching
d. Colonoscopy information - anstuberculosis screenin
. The nurse teaches a patient with liver cancer about high-protein, high-calorie diet
choices. Which snack choice by the patient indicates that the teaching has been
effective?
a. Lime sherbet
b. Blueberry yogurt
c. Fresh strawberries
d. Cream cheese bagel - ansBlueberry yogurt
. What information should the nurse collect when assessing the health status of a
community?
a. Air pollution levels
b. Number of healthy food stores
c. Most common causes of death
, d. Education level of the individuals - ansMost common causes of death
. When counseling a couple in which the man has an autosomal recessive disorder and
the woman has no gene for the disorder, the nurse uses Punnett squares to show the
couple the probability of their having a child with the disorder. Which statement by the
nurse is accurate?
a. "Each child would be a carrier of the disorder."
b. "Each child would have 50% chance of having the disorder."
c. "Your male children would display characteristics of the disorder."
d. "Your female children would display characteristics of the disorder." - ans"Each child
would be a carrier of the disorder."
6. On the second postoperative day after abdominal surgery for removal of a large
pancreatic cyst, a patient has an oral temperature of 100.8° F (38.2° C). Which action
should the nurse take next?
a. Place ice packs in the patient's axillae.
b. Have the patient use the incentive spirometer.
c. Request a prescription for acetaminophen suppositories.
d. Ask the health care provider to change the antibiotic prescription. - ansHave the
patient use the incentive spirometer
A 38-yr-old woman is admitted for an elective surgical procedure. Which information
obtained by the nurse during the preoperative assessment must be communicated to
the anesthesiologist and surgeon before surgery?
a. The patient's lack of knowledge about postoperative pain control
b. The patient's history of an infection following a cholecystectomy
c. The patient's report that her last menstrual period was 8 weeks ago
d. The patient's concern about being able to resume lifting heavy items - ansThe
patient's report that her last menstrual period was 8 weeks ago
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action
should the nurse take to support the patient's self-esteem?
a. Suggest that the patient limit social contacts until hair regrowth occurs.
b. Encourage the patient to purchase a wig or hat to wear when hair loss begins.
c. Teach the patient to wash hair gently with mild shampoo to minimize hair loss.
d. Inform the patient that hair usually grows back once chemotherapy is complete. -
ansEncourage the patient to purchase a wig or hat to war when hair loss begins.
A family caregiver tells the home health nurse, "I feel like I can never get away to do
anything for myself." Which action by the nurse would directly address this concern?
a. Assist the caregiver in finding respite services.
. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment
is most important for the nurse to monitor while the patient is receiving this infusion?
a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema - ansLung sounds
. A patient who has an infected abdominal wound develops a temperature of 104° F
(40° C). All the following interventions are included in the patient's plan of care. In which
order should the nurse perform the following actions? (Put a comma and a space
between each answer choice [A, B, C, D]).
a. Administer IV antibiotics.
b. Sponge patient with cool water.
c. Perform wet-to-dry dressing change.
d. Administer acetaminophen (Tylenol). - ansA. Administer IV antibiotics
D. Administer acetaminophen (Tylenol)
B. Sponge patient with cool water
C. Perform wet-to-dry dressing change
. A patient's 4 × 3-cm leg wound has a 0.4-cm black area in the center of the wound
surrounded by yellow-green semiliquid material. Which dressing should the nurse apply
to the wound?
a. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing - ansHydrocolloid dressing
. A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from
an admission blood pressure of 140/86 to 102/60 mm Hg with a pulse change of 70 to
96 beats/min. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take
these actions? (Put a comma and a space between each answer choice [A, B, C, D].)
a. Increase the IV infusion rate.
b. Assess the patient's dressing.
c. Increase the oxygen flowrate.
d. Check the patient's temperature. - ansA. Increase the IV infusion rate
C. Increase the oxygen flowrate
B. Assess the patient's dressing
,D. Check the patient's temperature
. A young male patient with paraplegia who has a stage 2 sacral pressure injury is being
cared for at home by his family. To prevent further tissue damage, what instructions are
most important for the nurse to teach the patient and family?
a. Change the patient's bedding frequently.
b. Apply a hydrocolloid dressing over the injury.
c. Change the patient's position every 1 to 2 hours.
d. Record the size and appearance of the injury weekly. - ansChange the patient's
position every 1 to 2 hours
. An older adult patient presents with a broken arm and visible scattered bruises healing
at different stages. Which action should the nurse take first?
a. Notify an elder protective services agency about possible abuse.
b. Make a referral for a home assessment visit by the home health nurse.
c. Have the family member stay in the waiting area while the patient is assessed.
d. Ask the patient how the injury occurred and observe the family member's reaction.
ANS: C - ansHave the family member stay in the waiting area while the patient is
assessed
. An unconscious patient who was transferred from surgery to the postanesthesia care
unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the
nurse take first?
a. Suction the patient's mouth.
b. Increase the oxygen flowrate.
c. Perform the jaw-thrust maneuver.
d. Elevate the patient's head on two pillows. - ansPerform the jaw-thrust maneuver
. The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall
and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years.
She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics
will the nurse plan to include in patient teaching about cancer screening and decreasing
cancer risk? (Select all that apply.)
a. Pap testing
b. Tobacco use
c. Sunscreen use
d. Mammography
e. Colorectal screening
ANS: A, C, D, E - ans-Pap testing
-Sunscreen use
-Mammography
-Colorectal screening
,. The nurse is caring for an Asian patient who is being admitted to the hospital. Which
action would be most appropriate for the nurse to take when interviewing this patient?
a. Avoid eye contact with the patient.
b. Observe the patient's use of eye contact.
c. Look directly at the patient when interacting.
d. Ask a family member about the patient's cultural beliefs. - ansObserve the patient's
use of eye contact
. The nurse is performing an admission assessment for a patient from China who does
not speak English. Which actions could the nurse take to enhance communication?
(Select all that apply.)
a. Ask the patient's young child to interpret.
b. Use a telephone-based medical interpreter.
c. Wait until an agency interpreter is available.
d. Use exaggerated gestures to convey information.
e. Use an electronic translation software application. - ansUse a telephone-based
medical interpreter
Wait until an agency interpreter is available
Use an electronic translation software application
. The nurse plans health care for a community with a large number of recent immigrants
from Vietnam. Which intervention is the most important for the nurse to implement?
a. Hepatitis testing
b. Tuberculosis screening
c. Contraceptive teaching
d. Colonoscopy information - anstuberculosis screenin
. The nurse teaches a patient with liver cancer about high-protein, high-calorie diet
choices. Which snack choice by the patient indicates that the teaching has been
effective?
a. Lime sherbet
b. Blueberry yogurt
c. Fresh strawberries
d. Cream cheese bagel - ansBlueberry yogurt
. What information should the nurse collect when assessing the health status of a
community?
a. Air pollution levels
b. Number of healthy food stores
c. Most common causes of death
, d. Education level of the individuals - ansMost common causes of death
. When counseling a couple in which the man has an autosomal recessive disorder and
the woman has no gene for the disorder, the nurse uses Punnett squares to show the
couple the probability of their having a child with the disorder. Which statement by the
nurse is accurate?
a. "Each child would be a carrier of the disorder."
b. "Each child would have 50% chance of having the disorder."
c. "Your male children would display characteristics of the disorder."
d. "Your female children would display characteristics of the disorder." - ans"Each child
would be a carrier of the disorder."
6. On the second postoperative day after abdominal surgery for removal of a large
pancreatic cyst, a patient has an oral temperature of 100.8° F (38.2° C). Which action
should the nurse take next?
a. Place ice packs in the patient's axillae.
b. Have the patient use the incentive spirometer.
c. Request a prescription for acetaminophen suppositories.
d. Ask the health care provider to change the antibiotic prescription. - ansHave the
patient use the incentive spirometer
A 38-yr-old woman is admitted for an elective surgical procedure. Which information
obtained by the nurse during the preoperative assessment must be communicated to
the anesthesiologist and surgeon before surgery?
a. The patient's lack of knowledge about postoperative pain control
b. The patient's history of an infection following a cholecystectomy
c. The patient's report that her last menstrual period was 8 weeks ago
d. The patient's concern about being able to resume lifting heavy items - ansThe
patient's report that her last menstrual period was 8 weeks ago
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action
should the nurse take to support the patient's self-esteem?
a. Suggest that the patient limit social contacts until hair regrowth occurs.
b. Encourage the patient to purchase a wig or hat to wear when hair loss begins.
c. Teach the patient to wash hair gently with mild shampoo to minimize hair loss.
d. Inform the patient that hair usually grows back once chemotherapy is complete. -
ansEncourage the patient to purchase a wig or hat to war when hair loss begins.
A family caregiver tells the home health nurse, "I feel like I can never get away to do
anything for myself." Which action by the nurse would directly address this concern?
a. Assist the caregiver in finding respite services.
