Nursing 3 Final &EXAM 2 NURSE 315 Exam COMBINATION examination 2025 -
2026 QUESTIONS WITH CORRECT ANSWERS VERIFIED 100% GRADED A+
Nursing 3 Final Exam
The nurse is caring for a client newly diagnosed with a deep vein thrombosis.
The order is written to infuse heparin 1250 units/hr. The IV bag contains 25,000
units of heparin in 250mL D5W. Calculate the IV rate in mL/hr. ____ mL/hr
(Round the answer to the nearest tenth. Type only the numbers, not the units
of measurement.)
12.5
A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for a
client who has GERD. Available is famotidine 40 mg/5 mL. How many mL
should the nurse administer? ____ mL. (Round the answer to the nearest
tenth. Use a leading zero if it applies. Do not use a trailing zero. Type only the
numbers, not the units of measurement.)
2.5
A patient is 3 days post op from a laparoscopic cholecystectomy and asks
"When can I get rid of this foley catheter?" What is the most appropriate
response from the nurse?
Let me check to see if there is an order to keep it in, if not, we can remove it."
The nurse understands that giving a patient their scheduled dose of
metoprolol before surgery will help reduce the risk for which of the following
complications?
perioperative myocardial ischemia
Before the patient undergoes computed tomographic (CT) scanning with a
contrast medium, the nurse should:
verify that the patient is not allergic to seafood or iodine.
The Glasgow coma scale is a screening tool used to assess level of
consciousness in three major areas. They are
Eye, motor, verbal
,If a patient with a head injury has drainage from the nose or ears, which
nursing intervention would be appropriate?
Allow the patient to wipe the nose or ears, but not blow the nose or place anything in
the external ear
A patient has recently suffered a stroke with left-sided weakness. She has
problems with choking, especially when she drinks thin liquids. What nursing
interventions would be most helpful in assisting this patient to swallow safely?
Instructing her to tuck her chin when swallowing
A patient, age 52, is brought to the emergency department by ambulance after
she hit her head on her bathroom sink and fell unconscious to the floor. Which
assessment should the nurse perform first?
Patency of airway
The patient, injured in an automobile accident, is being evaluated in the
emergency department for possible head injury. Which test should not be
done if there is an indication of increased intracranial pressure?
Lumbar puncture
A patient's neurological status deteriorates over hours, and a craniotomy is
performed to evacuate the hematoma. Which nursing intervention is indicated
to help decrease the threat of increased intracranial pressure?
Elevate the head of the bed 30 degrees.
A patient has been injured in a motorcycle accident and is presenting with
signs and symptoms of increased intracranial pressure. What is the most
significant sign or symptom of increased intracranial pressure?
Decrease in the level of consciousness
The three components of Cushing's Triad response are: Select all that apply.
Widened pulse pressure
Bradycardia
Increased systolic blood pressure
A patient has a head injury and is presenting with signs and symptoms of
increased intracranial pressure. Which nursing intervention would be helpful
in reducing this pressure?
Place the neck in a neutral position to promote venous drainage.
,A patient has been diagnosed with organic brain pathology. He is presenting
with signs and symptoms of total or partial loss of the ability to recognize
familiar objects or people through sensory stimulation. The nurse correctly
identifies the signs and symptoms as which of the following?
agnosia
As the result of a stroke, a patient has difficulty discerning the position of his
body without looking at it. In the nurse's documentation, which would best
describe the patient's inability to assess spatial position of his body?
Proprioception
Sudden chest pain combined with dyspnea, cyanosis, and tachycardia is an
indication of
pulmonary embolus
A client arrives in the emergency department with an ischemic stroke.
Because the healthcare team is considering administering tissue plasminogen
activator (t-PA), what should the nurse preform first?
Identify the time of onset of the stroke
The client who preparing for an open reduction internal fixation (ORIF) of the
femur has a new serum potassium level of 5.8 mEq/L. What should be the
nurse's first response?
Notify the surgeon.
The emergency department nurse is assessing a client who has sustained a
blunt injury to the chest wall. Which finding would indicate the presence of a
pneumothorax in this client?
Diminished breath sounds
The nurse is assessing the respiratory status of a client who has suffered a
fractured rib. The nurse should expect to note which finding?
Pain, especially with inspiration
A client with a chest injury has suffered flail chest. The nurse assesses the
client for which most distinctive sign of flail chest?
Paradoxical chest movement
A client has been admitted with chest trauma after a motor vehicle crash and
has undergone subsequent intubation. The nurse checks the client when the
high-pressure alarm on the ventilator sounds, and notes that the client has
, absence of breath sounds in the right upper lobe of the lung. The nurse
immediately assesses for other signs of which condition?
Right pneumothorax
The client who is two days postoperative following a pneumonectomy has an
apical pulse (AP) rate of 128 beats per minutes and a blood pressured (BP) of
80/50 mm Hg. Which intervention should the nurse implement first?
Notify the healthcare provider (HCP) immediately
The client who is 1-day postoperative following chest surgery is having
difficulty breathing, has bilateral rales, and is confused and restless. Which
intervention should the nurse implement first?
Notify the Rapid Response Team
The intensive care unit (ICU) nurse is caring for a client on a ventilator who is
exhibiting respiratory distress. The ventilator alarms are going off. Which
interventions should the nurse implement first?
Check the ventilator to resolve the problem
The client in the intensive care unit is on a ventilator. Which interventions
should the nurse implement? Select all that apply.
Ensure there is manual resuscitation bag at the bedside
Assess the client's respiratory status every 2 hours
Check the ventilatory setting at least every 8 hours
Collaborate with the respiratory therapist
Which actions are essential for the nurse caring for a mechanically ventilated
patient to prevent ventilator-acquired pneumonia (VAP)? Select all that apply.
Keep the HOB elevated at least 30 degrees
Prevent aspiration
Turn and reposition patient every 2 hours
Prevent pressure ulcers around the mouth
2026 QUESTIONS WITH CORRECT ANSWERS VERIFIED 100% GRADED A+
Nursing 3 Final Exam
The nurse is caring for a client newly diagnosed with a deep vein thrombosis.
The order is written to infuse heparin 1250 units/hr. The IV bag contains 25,000
units of heparin in 250mL D5W. Calculate the IV rate in mL/hr. ____ mL/hr
(Round the answer to the nearest tenth. Type only the numbers, not the units
of measurement.)
12.5
A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for a
client who has GERD. Available is famotidine 40 mg/5 mL. How many mL
should the nurse administer? ____ mL. (Round the answer to the nearest
tenth. Use a leading zero if it applies. Do not use a trailing zero. Type only the
numbers, not the units of measurement.)
2.5
A patient is 3 days post op from a laparoscopic cholecystectomy and asks
"When can I get rid of this foley catheter?" What is the most appropriate
response from the nurse?
Let me check to see if there is an order to keep it in, if not, we can remove it."
The nurse understands that giving a patient their scheduled dose of
metoprolol before surgery will help reduce the risk for which of the following
complications?
perioperative myocardial ischemia
Before the patient undergoes computed tomographic (CT) scanning with a
contrast medium, the nurse should:
verify that the patient is not allergic to seafood or iodine.
The Glasgow coma scale is a screening tool used to assess level of
consciousness in three major areas. They are
Eye, motor, verbal
,If a patient with a head injury has drainage from the nose or ears, which
nursing intervention would be appropriate?
Allow the patient to wipe the nose or ears, but not blow the nose or place anything in
the external ear
A patient has recently suffered a stroke with left-sided weakness. She has
problems with choking, especially when she drinks thin liquids. What nursing
interventions would be most helpful in assisting this patient to swallow safely?
Instructing her to tuck her chin when swallowing
A patient, age 52, is brought to the emergency department by ambulance after
she hit her head on her bathroom sink and fell unconscious to the floor. Which
assessment should the nurse perform first?
Patency of airway
The patient, injured in an automobile accident, is being evaluated in the
emergency department for possible head injury. Which test should not be
done if there is an indication of increased intracranial pressure?
Lumbar puncture
A patient's neurological status deteriorates over hours, and a craniotomy is
performed to evacuate the hematoma. Which nursing intervention is indicated
to help decrease the threat of increased intracranial pressure?
Elevate the head of the bed 30 degrees.
A patient has been injured in a motorcycle accident and is presenting with
signs and symptoms of increased intracranial pressure. What is the most
significant sign or symptom of increased intracranial pressure?
Decrease in the level of consciousness
The three components of Cushing's Triad response are: Select all that apply.
Widened pulse pressure
Bradycardia
Increased systolic blood pressure
A patient has a head injury and is presenting with signs and symptoms of
increased intracranial pressure. Which nursing intervention would be helpful
in reducing this pressure?
Place the neck in a neutral position to promote venous drainage.
,A patient has been diagnosed with organic brain pathology. He is presenting
with signs and symptoms of total or partial loss of the ability to recognize
familiar objects or people through sensory stimulation. The nurse correctly
identifies the signs and symptoms as which of the following?
agnosia
As the result of a stroke, a patient has difficulty discerning the position of his
body without looking at it. In the nurse's documentation, which would best
describe the patient's inability to assess spatial position of his body?
Proprioception
Sudden chest pain combined with dyspnea, cyanosis, and tachycardia is an
indication of
pulmonary embolus
A client arrives in the emergency department with an ischemic stroke.
Because the healthcare team is considering administering tissue plasminogen
activator (t-PA), what should the nurse preform first?
Identify the time of onset of the stroke
The client who preparing for an open reduction internal fixation (ORIF) of the
femur has a new serum potassium level of 5.8 mEq/L. What should be the
nurse's first response?
Notify the surgeon.
The emergency department nurse is assessing a client who has sustained a
blunt injury to the chest wall. Which finding would indicate the presence of a
pneumothorax in this client?
Diminished breath sounds
The nurse is assessing the respiratory status of a client who has suffered a
fractured rib. The nurse should expect to note which finding?
Pain, especially with inspiration
A client with a chest injury has suffered flail chest. The nurse assesses the
client for which most distinctive sign of flail chest?
Paradoxical chest movement
A client has been admitted with chest trauma after a motor vehicle crash and
has undergone subsequent intubation. The nurse checks the client when the
high-pressure alarm on the ventilator sounds, and notes that the client has
, absence of breath sounds in the right upper lobe of the lung. The nurse
immediately assesses for other signs of which condition?
Right pneumothorax
The client who is two days postoperative following a pneumonectomy has an
apical pulse (AP) rate of 128 beats per minutes and a blood pressured (BP) of
80/50 mm Hg. Which intervention should the nurse implement first?
Notify the healthcare provider (HCP) immediately
The client who is 1-day postoperative following chest surgery is having
difficulty breathing, has bilateral rales, and is confused and restless. Which
intervention should the nurse implement first?
Notify the Rapid Response Team
The intensive care unit (ICU) nurse is caring for a client on a ventilator who is
exhibiting respiratory distress. The ventilator alarms are going off. Which
interventions should the nurse implement first?
Check the ventilator to resolve the problem
The client in the intensive care unit is on a ventilator. Which interventions
should the nurse implement? Select all that apply.
Ensure there is manual resuscitation bag at the bedside
Assess the client's respiratory status every 2 hours
Check the ventilatory setting at least every 8 hours
Collaborate with the respiratory therapist
Which actions are essential for the nurse caring for a mechanically ventilated
patient to prevent ventilator-acquired pneumonia (VAP)? Select all that apply.
Keep the HOB elevated at least 30 degrees
Prevent aspiration
Turn and reposition patient every 2 hours
Prevent pressure ulcers around the mouth
