NUR 493 EAQ NEWEST 2025 ACTUAL EXAM WITH COMPLETE
200 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+|BRAND NEW!!
When teaching the patient about the use of range of motion (ROM), which
explanations would the nurse give to the patient? Select all that apply. - ANSWER-
ROM will show the patient that movement still is possible.
Active and passive ROM maintain function of body parts.
Movement facilitates mobilization of leaked exudates back into the vascular bed.
The explanations that should be used are that active and passive ROM maintain
the function of body parts and reassure the patient that movement still is
possible. Contractures are prevented with ROM as well as splints. Movement
facilitates mobilization of fluid in the interstitial fluid back into the vascular bed.
Although it is good to collaborate with physical therapy to perform ROM during
dressing changes because the patient has already taken analgesics, ROM can and
should be done throughout the day.
Which discharge instructions would the nurse include when teaching a patient
with partial-thickness burns on the hands about rehabilitation at home? Select all
that apply. - ANSWER-Recommend exercises.
Take low-dose antihistamines.
Apply water-based creams on healed areas.
Protect healed areas from direct sunlight.
The nurse should advise the patient to take low-dose antihistamines because
these can be used at bedtime if itching persists. The nurse should instruct the
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patient to protect healed areas from direct sunlight for 3 months to prevent
hyperpigmentation and sunburn injury. Only water-based creams that penetrate
into the dermis should be used routinely on healed areas to keep the skin supple
and well moisturized. This helps to decrease itching and flaking. The nurse should
also encourage the patient to perform physical and occupational therapy routines
and recommended exercises. The patient may have small, unhealed wounds, and
it is therefore important to carry out dressing changes and wound care at home.
Which clinical manifestations of acute respiratory distress syndrome (ARDS) are
caused by increased pulmonary capillary permeability during the initial phase of
ARDS? Select all that apply. - ANSWER-Decreasing oxygen saturation
Crackles
Intercostal retractions
An increase in pulmonary capillary permeability results in fluid movement from
the pulmonary capillaries into the interstitial space and alveoli, causing crackles
with breathing. Fluid within the alveoli and interstitium also decreases oxygen
saturation between the alveoli and pulmonary capillaries, leading to hypoxemia.
Interstitial fluid also makes the lungs stiffer and less compliant, increasing the
work of breathing and causing labored respirations with intercostal retractions.
Tracheal deviation occurs with tension pneumothorax and is not a symptom of
ARDS. The lungs have infiltrates with ARDS and will be dull to percussion.
Which early clinical manifestations of acute respiratory distress syndrome (ARDS)
will the nurse monitor for when caring for a patient admitted with sepsis? Select
all that apply. - ANSWER-Cough and restlessness
Dyspnea and tachypnea
Adventitious lung sounds
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Early clinical manifestations of ARDS usually appear within 24 to 48 hours after a
lung injury. The patient may cough, feel restless, and exhibit signs of dyspnea and
tachypnea. Chest auscultation reveals adventitious lung sounds that can include
crackles and rhonchi. Oliguria caused by acute kidney injury may occur later as a
complication of ARDS. Because respiratory rate increases early in ARDS, the
patient will initially have respiratory alkalosis. Respiratory acidosis is a later
complication as the patient is no longer able to compensate.
A patient is admitted to the emergency department following a near-drowning
event. Two sets of arterial blood gases (ABGs) were prescribed. The first set was
done before oxygen therapy; the second was done after the patient received high-
flow oxygenation therapy with continuous positive airway pressure (CPAP) for 30
minutes. The nurse reviews the results and suspects which condition? - ANSWER-
Acute respiratory distress syndrome (ARDS)
Refractory hypoxemia with increasing oxygenation is a hallmark sign of acute
respiratory distress syndrome (ARDS). An indirect cause of ARDS is near-drowning.
Acute pneumonia may create a respiratory acidosis but also produces a
productive cough. Hypoxemic respiratory failure is defined as a PaO2 less than 60
mm Hg while the patient is receiving inspired O2 concentration of 60% or more.
Hypercapnic respiratory failure is a PaCO2 greater than 50 mm Hg with acidemia.
Which action will the nurse take first for a patient who has new onset confusion
and agitation? - ANSWER-Check oxygen saturation.
Since hypoxemia affects the central nervous system very quickly, confusion and
agitation are frequently the initial manifestations of hypoxemia. The nurse's first
action will be to check the patient's oxygen saturation. Oxygen administration may
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be initiated if the oxygen saturation is low. The Rapid Response Team may be
notified about the changes in the patient condition, but assessment of oxygen
saturation and other parameters is needed first. Benzodiazepines such as
midazolam may be appropriate for agitation, but further assessment of patient
status is needed first.
Before administering prescribed oxygen therapy via face mask, the nurse would
assess whether the patient has a history of which problem? - ANSWER-
Claustrophobia
Face masks may cause anxiety in the patient with claustrophobia, worsening the
symptoms of respiratory distress. Hyperglycemia is not a contraindication to or
complication of face mask use. Deviated septum may make a nasal cannula
uncomfortable but would not affect the use of a face mask. Addison's disease will
not affect the use of a face mask, although prescribed corticosteroid dose may be
affected by Addison's disease.
Which finding in patient with possible acute respiratory distress syndrome (ARDS)
is most important for the nurse to communicate to the health care provider? -
ANSWER-PaO2/FIO2 (P/F) ratio decrease from 300 to 100
Since a P/F ratio change from 300 to 100 indicates severe ARDS, the nurse will
rapidly report this change to the health care provider and expect immediate
changes in the patient's treatment such as use of noninvasive positive pressure
ventilation, intubation, and mechanical ventilation. The elevated heart rate is a
compensatory mechanism for hypoxemia but is not as clear an indicator of ARDS.
A chest x-ray showing bilateral infiltrates helps to confirm a diagnosis of ARDS but
does not necessarily need rapid intervention. Bilateral crackles are a common
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