Nursing 3 Final Exam Questions with
Verified Answers
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.) - ANSWERS12.5
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.) - ANSWERS2.5
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? -
ANSWERSLet 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? -
ANSWERSperioperative myocardial ischemia
Before the patient undergoes computed tomographic (CT) scanning with a contrast
medium, the nurse should: - ANSWERSverify 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 - ANSWERSEye, motor, verbal
If a patient with a head injury has drainage from the nose or ears, which nursing
intervention would be appropriate? - ANSWERSAllow 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? - ANSWERSInstructing 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? - ANSWERSPatency 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? - ANSWERSLumbar 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? - ANSWERSElevate 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? - ANSWERSDecrease in the level of
consciousness
The three components of Cushing's Triad response are: Select all that apply. -
ANSWERSWidened 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? - ANSWERSPlace 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? - ANSWERSagnosia
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? - ANSWERSProprioception
Sudden chest pain combined with dyspnea, cyanosis, and tachycardia is an indication
of - ANSWERSpulmonary 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? - ANSWERSIdentify 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? -
ANSWERSNotify the surgeon.
Verified Answers
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.) - ANSWERS12.5
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.) - ANSWERS2.5
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? -
ANSWERSLet 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? -
ANSWERSperioperative myocardial ischemia
Before the patient undergoes computed tomographic (CT) scanning with a contrast
medium, the nurse should: - ANSWERSverify 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 - ANSWERSEye, motor, verbal
If a patient with a head injury has drainage from the nose or ears, which nursing
intervention would be appropriate? - ANSWERSAllow 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? - ANSWERSInstructing 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? - ANSWERSPatency 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? - ANSWERSLumbar 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? - ANSWERSElevate 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? - ANSWERSDecrease in the level of
consciousness
The three components of Cushing's Triad response are: Select all that apply. -
ANSWERSWidened 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? - ANSWERSPlace 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? - ANSWERSagnosia
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? - ANSWERSProprioception
Sudden chest pain combined with dyspnea, cyanosis, and tachycardia is an indication
of - ANSWERSpulmonary 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? - ANSWERSIdentify 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? -
ANSWERSNotify the surgeon.
