NRS 204 EXAM 3 | 139 QUESTIONS | WITH COMPLETE
SOLUTIONS.
The nurse and physician are explaining the home care that will be needed by a
patient after discharge. The patient's spouse states angrily that it will not be
possible to provide the care recommended. What is the best response by the
nurse?
a. "Let me review what is needed again."
b. "It is important that you do what the physician has prescribed."
c. "What concerns do you have about the prescribed care?"
d. "I can come back after you talk with your spouse about the care." Answer - c
Dr. Jones, this is Deb McDonald RN, I am calling from ABC Hospital about your
patient Jane Smith."
"Mrs. Smith is having increasing dyspnea and is complaining of chest pain."
"I'm thinking she may be having a cardiac event or a pulmonary embolism."
"I recommend that you see her immediately and that we start her on O2 stat.
Do you agree?"
What element is missing from the above SBAR communication? Answer -
background
A nurse is facilitating discharge for a patient. Which statement reflects best
practice in nurse/ patient communication?
a. A nurse tells the patient "You should eat less salt."
,b. Working with a patient who speaks a different language, a nurse asks a
family member to translate for them.
c. A nurse hands a sheet of printed discharge instructions to the patient, gives
them a moment to read them, and asks, "Do you have any questions?"
d. After explaining the dosage and purpose of the new medication regime, the
nurse asks, "to make sure I've covered everything, will you please tell me about
these new medications, and the prescribed dosage you will be taking?"
Answer - D
A hospitalized patient is unable to brush their teeth because they recently
experienced a stroke that left them unable to use their dominant hand. Which
of the following nursing diagnoses is both appropriate and properly formatted?
A. Potential for injury related to use of the non-dominant hand for brushing the
teeth as evidenced by visible plaque on the teeth
B. Acute pain related to right hand immobility as manifested by lack of
movement in the right hand
C. Self-care deficit (hygiene) related to immobility of the right hand as
manifested by visible plaque on the teeth
D. Fluid volume deficit related to difficulty swallowing Answer - C
You are starting your shift with two patients. Patient A had surgery the previous
day, is due for their pain meds, is having trouble getting comfortable, and their
spouse is complaining that the medications are not coming quickly enough.
Patient B is determined to brush their teeth right now and is crawling over their
bedrail. State the order in which the nurse should take the following actions.
A. Get patient A their pain medication.
B. Gently help patient B back into bed and assure them that you'll help them
brush their teeth in a few minutes.
C. Call the charge nurse for extra help.
, D. Lower patient B's bed as close as possible to the floor and lower one of the
bedrails.
E. Assess patient B's confusion.
F. Assess patient A's pain. Answer - B, C, D, E, F, A
The muscular walls of the left ventricle of the heart are thicker than those of
the right ventricle. Why is this the case?
A. The right ventricle has to pump against greater pressures
B. The left ventricle has to pump against greater pressures.
C. The left ventricle contains all of the heart's pacemaking cells
D. The right ventricle pumps less volume than the left Answer - B
A patient's partner reports that the patient is agitated and confused. The nurse
calculates a Glasgow coma score (GCS) of 12. Which of the following
assessments should the nurse conduct before notifying the provider? Select all
that apply. Please also indicate which assessment you might choose to do first.
A. Vital signs
B. Cardiovascular assessment
C. Respiratory assessment
D. Gait assessment
E. Rapid stroke assessment Answer - A,B,C,E and rapid stroke assessment
should be done first
In order to legally use medical restraints on a patient, the nurse must do which
of the following? Select all that apply.
SOLUTIONS.
The nurse and physician are explaining the home care that will be needed by a
patient after discharge. The patient's spouse states angrily that it will not be
possible to provide the care recommended. What is the best response by the
nurse?
a. "Let me review what is needed again."
b. "It is important that you do what the physician has prescribed."
c. "What concerns do you have about the prescribed care?"
d. "I can come back after you talk with your spouse about the care." Answer - c
Dr. Jones, this is Deb McDonald RN, I am calling from ABC Hospital about your
patient Jane Smith."
"Mrs. Smith is having increasing dyspnea and is complaining of chest pain."
"I'm thinking she may be having a cardiac event or a pulmonary embolism."
"I recommend that you see her immediately and that we start her on O2 stat.
Do you agree?"
What element is missing from the above SBAR communication? Answer -
background
A nurse is facilitating discharge for a patient. Which statement reflects best
practice in nurse/ patient communication?
a. A nurse tells the patient "You should eat less salt."
,b. Working with a patient who speaks a different language, a nurse asks a
family member to translate for them.
c. A nurse hands a sheet of printed discharge instructions to the patient, gives
them a moment to read them, and asks, "Do you have any questions?"
d. After explaining the dosage and purpose of the new medication regime, the
nurse asks, "to make sure I've covered everything, will you please tell me about
these new medications, and the prescribed dosage you will be taking?"
Answer - D
A hospitalized patient is unable to brush their teeth because they recently
experienced a stroke that left them unable to use their dominant hand. Which
of the following nursing diagnoses is both appropriate and properly formatted?
A. Potential for injury related to use of the non-dominant hand for brushing the
teeth as evidenced by visible plaque on the teeth
B. Acute pain related to right hand immobility as manifested by lack of
movement in the right hand
C. Self-care deficit (hygiene) related to immobility of the right hand as
manifested by visible plaque on the teeth
D. Fluid volume deficit related to difficulty swallowing Answer - C
You are starting your shift with two patients. Patient A had surgery the previous
day, is due for their pain meds, is having trouble getting comfortable, and their
spouse is complaining that the medications are not coming quickly enough.
Patient B is determined to brush their teeth right now and is crawling over their
bedrail. State the order in which the nurse should take the following actions.
A. Get patient A their pain medication.
B. Gently help patient B back into bed and assure them that you'll help them
brush their teeth in a few minutes.
C. Call the charge nurse for extra help.
, D. Lower patient B's bed as close as possible to the floor and lower one of the
bedrails.
E. Assess patient B's confusion.
F. Assess patient A's pain. Answer - B, C, D, E, F, A
The muscular walls of the left ventricle of the heart are thicker than those of
the right ventricle. Why is this the case?
A. The right ventricle has to pump against greater pressures
B. The left ventricle has to pump against greater pressures.
C. The left ventricle contains all of the heart's pacemaking cells
D. The right ventricle pumps less volume than the left Answer - B
A patient's partner reports that the patient is agitated and confused. The nurse
calculates a Glasgow coma score (GCS) of 12. Which of the following
assessments should the nurse conduct before notifying the provider? Select all
that apply. Please also indicate which assessment you might choose to do first.
A. Vital signs
B. Cardiovascular assessment
C. Respiratory assessment
D. Gait assessment
E. Rapid stroke assessment Answer - A,B,C,E and rapid stroke assessment
should be done first
In order to legally use medical restraints on a patient, the nurse must do which
of the following? Select all that apply.
