NURS 2003 exam review questions
A 65-year-old client who has had a stroke and has limited mobility has a purple area of
suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses are
most appropriate (select all that apply)
a) Acute pain related to physical injury agent
b) impaired skin integrity related to pressure over bony prominence
c) Impaired tissue integrity related to insufficient knowledge about protecting tissue integrity
d) Risk for infection as evidenced by malnutrition - correct answer-b) Impaired skin integrity
related to pressure over bony prominence
A client has the following arterial blood gas results: pH, 7.52; partial pressure of CO2 in the
arterial blood, 30 mm Hg; HCO-3 level, 24 mmol/l. These results indicate the presence of
which acid-base distribution
a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis - correct answer-d) Respiratory alkalosis
A client in the unit has a 39.8 degree Celsius temperature. Which intervention would be most
effective in restoring normal body temperature?
a) Use a cooling blanket while the client is febrile
b) Administer antipyretic on an around-the-clock schedule
c) Provide increased fluids and instruct the unlicensed assistive personal to give sponge
baths
d) Give prescribed antibiotics and provide warm blankets for comfort - correct answer-b)
Administer antipyretic on an around-the-clock schedule
A client is admitted to the ED with chest pain of 2 hours' duration, ECG findings consistent
with an acute MI, and occasional ventricular dysrhythmias. With what pharmacological
therapy would the nurse expect the client to be managed initially
a) Diuretics
b) Nitroglycerin spray
c) B-Adrenergic blockers
d) Thrombolytic therapy with tissue plasminogen activator - correct answer-b) Nitroglycerin
spray
A client who has undergone extensive surgery for multiple injuries has a period of increasing
blood pressure, heart rate, and alertness. Which stage of general adaptation syndrome are
these symptoms most characteristic of?
a) The resistance state of general adaptations syndrome
b) The alarm reaction of the general adaptation syndrome
c) The stage of exhaustion of general adaptation syndrome
d) An individual response stereotype. - correct answer-b) the alarm reaction of the general
adaptation syndrome
, A hospital client with angina tells the nurse that she is having chest pain. What best
described the nature of anginal pain?
a) It will be relieved by rest, nitroglycerin or both
b) It is less severe than the pain of myocardial infarction
c) It indicates that irreversible cellular damage is occurring
d) It is frequently associated with vomiting and extreme fatigue - correct answer-a) It will be
relieved by rest, nitroglycerin or both
A nurse is caring for a client who has a pressure injury that is treated with debridement,
irrigation's, and moist gauze dressings. How should the nurse anticipate healing to occur?
a) Tertiary intention
b) Secondary intention
c) Regeneration of cells
d) Remodelling of tissues - correct answer-b) Secondary intention
A nurse is caring for a client with diabetes who is scheduled for amputation of his necrotic
left great toe. The client's WBC count is 15.0x 10^9/L and he has coolness of the lower
extremities, weighs 34 Kg more than his ideal body weight, and smokes two packs of
cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting
the client's ability to heal?
a) Readiness for enhanced nutrition
b) Impaired tissue integrity related to insufficient knowledge about protecting tissue integrity
c) Ineffective peripheral tissue perfusion related to sedentary lifestyle
d) Ineffective coping related to ineffective tension release strategies - correct answer-b)
Impaired tissue integrity related to insufficient knowledge about protecting tissue integrity
A nurse is teaching a client about coronary artery disease. Which changes occur in this
disorder and should be included in the explanation? (Select all that apply)
a) Diffuse involvement of plaque in coronary veins
b) Abnormal levels of cholesterol, especially low-density lipoproteins
c) Accumulation of lipid plaques or calcification within the coronary arteries
d) Development of angina due to decreased blood supply to the heart muscle
e) Chronic vasoconstriction of coronary arteries leading to permanent vasospasm - correct
answer-b) Abnormal levels of cholesterol, especially low-density lipoproteins
c) Accumulation of lipid plaques or calcification within the coronary arteries
d) Development of angina due to decreased blood supply to the heart muscle
An 82-year-old man is being cared for at home by his family> a pressure injury on his right
buttock measures 1x2x0.8 cm in depth, and pink subcutaneous tissue is completely visible
on the wound bed. Which stage would the nurse document on the wound assessment form?
a) Stage 1
b) Stage 2
c) Stage 3
d) Stage 4 - correct answer-c) Stage 3
An 89-year-old client with end-stage renal disease is assessed to have a score of 16 on the
Braden scale. On the basis of this information, how should the nurse plan for this client's
care?
A 65-year-old client who has had a stroke and has limited mobility has a purple area of
suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses are
most appropriate (select all that apply)
a) Acute pain related to physical injury agent
b) impaired skin integrity related to pressure over bony prominence
c) Impaired tissue integrity related to insufficient knowledge about protecting tissue integrity
d) Risk for infection as evidenced by malnutrition - correct answer-b) Impaired skin integrity
related to pressure over bony prominence
A client has the following arterial blood gas results: pH, 7.52; partial pressure of CO2 in the
arterial blood, 30 mm Hg; HCO-3 level, 24 mmol/l. These results indicate the presence of
which acid-base distribution
a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis - correct answer-d) Respiratory alkalosis
A client in the unit has a 39.8 degree Celsius temperature. Which intervention would be most
effective in restoring normal body temperature?
a) Use a cooling blanket while the client is febrile
b) Administer antipyretic on an around-the-clock schedule
c) Provide increased fluids and instruct the unlicensed assistive personal to give sponge
baths
d) Give prescribed antibiotics and provide warm blankets for comfort - correct answer-b)
Administer antipyretic on an around-the-clock schedule
A client is admitted to the ED with chest pain of 2 hours' duration, ECG findings consistent
with an acute MI, and occasional ventricular dysrhythmias. With what pharmacological
therapy would the nurse expect the client to be managed initially
a) Diuretics
b) Nitroglycerin spray
c) B-Adrenergic blockers
d) Thrombolytic therapy with tissue plasminogen activator - correct answer-b) Nitroglycerin
spray
A client who has undergone extensive surgery for multiple injuries has a period of increasing
blood pressure, heart rate, and alertness. Which stage of general adaptation syndrome are
these symptoms most characteristic of?
a) The resistance state of general adaptations syndrome
b) The alarm reaction of the general adaptation syndrome
c) The stage of exhaustion of general adaptation syndrome
d) An individual response stereotype. - correct answer-b) the alarm reaction of the general
adaptation syndrome
, A hospital client with angina tells the nurse that she is having chest pain. What best
described the nature of anginal pain?
a) It will be relieved by rest, nitroglycerin or both
b) It is less severe than the pain of myocardial infarction
c) It indicates that irreversible cellular damage is occurring
d) It is frequently associated with vomiting and extreme fatigue - correct answer-a) It will be
relieved by rest, nitroglycerin or both
A nurse is caring for a client who has a pressure injury that is treated with debridement,
irrigation's, and moist gauze dressings. How should the nurse anticipate healing to occur?
a) Tertiary intention
b) Secondary intention
c) Regeneration of cells
d) Remodelling of tissues - correct answer-b) Secondary intention
A nurse is caring for a client with diabetes who is scheduled for amputation of his necrotic
left great toe. The client's WBC count is 15.0x 10^9/L and he has coolness of the lower
extremities, weighs 34 Kg more than his ideal body weight, and smokes two packs of
cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting
the client's ability to heal?
a) Readiness for enhanced nutrition
b) Impaired tissue integrity related to insufficient knowledge about protecting tissue integrity
c) Ineffective peripheral tissue perfusion related to sedentary lifestyle
d) Ineffective coping related to ineffective tension release strategies - correct answer-b)
Impaired tissue integrity related to insufficient knowledge about protecting tissue integrity
A nurse is teaching a client about coronary artery disease. Which changes occur in this
disorder and should be included in the explanation? (Select all that apply)
a) Diffuse involvement of plaque in coronary veins
b) Abnormal levels of cholesterol, especially low-density lipoproteins
c) Accumulation of lipid plaques or calcification within the coronary arteries
d) Development of angina due to decreased blood supply to the heart muscle
e) Chronic vasoconstriction of coronary arteries leading to permanent vasospasm - correct
answer-b) Abnormal levels of cholesterol, especially low-density lipoproteins
c) Accumulation of lipid plaques or calcification within the coronary arteries
d) Development of angina due to decreased blood supply to the heart muscle
An 82-year-old man is being cared for at home by his family> a pressure injury on his right
buttock measures 1x2x0.8 cm in depth, and pink subcutaneous tissue is completely visible
on the wound bed. Which stage would the nurse document on the wound assessment form?
a) Stage 1
b) Stage 2
c) Stage 3
d) Stage 4 - correct answer-c) Stage 3
An 89-year-old client with end-stage renal disease is assessed to have a score of 16 on the
Braden scale. On the basis of this information, how should the nurse plan for this client's
care?
