NUR 1140 Exam Questions with Correct
Answers
A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the
client is breathing rapidly. What response by
the charge nurse is best?
a. Anxiety is causing the client to breathe rapidly.
b. The client is trying to get rid of excess body acids.
c. The rapid respirations cause buildup of bicarbonate.
d. An increased respiratory rate is due to increased metabolism.
ANS: B
The client is acidotic, and the respiratory system is attempting to compensate by "blowing
off" excess acid in the form of carbon
dioxide. The increased respiratory rate is not due to anxiety or increased metabolism. An
increased respiratory rate does not cause a
buildup of bicarbonate.
A client had a recent thromboembolism and must resume work which requires frequent
car and plane travel. What self-care
measure does the nurse teach to reduce the risk of impaired clotting in this client?
a. Get up and walk around at least every 2 hours while traveling.
b. Use a soft toothbrush and an electric razor for safety.
c. Be sure to sit with the legs elevated as much as possible.
d. Increase fiber in the diet so as not to strain to move the bowels.
,ANS: A
Clients who are at risk of increased clotting (as evidenced by prior thromboembolic event)
can take several measures to reduce their risk of further problems. One measure is to get up
and walk frequently when sitting for a long period of time. Using a soft toothbrush and an
electric razor and needing to prevent constipation would be important for a client at risk of
bleeding. Elevating the legs is not as beneficial as ambulating.
A nurse is caring for four clients. Which client does the nurse assess first for impaired
cognition?
a. A 28-year-old client 2 days post-open cholecystectomy
b. An 88-year-old client 3 days post-hemorrhagic stroke
c. A 32-year-old client with a 20-pack-year history of smoking
d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L)
ANS: B
There are many risk factors for impaired cognition including advanced age and diseases and
disorders that affect the brain. The
88-year-old client who is recovering from a stroke has two such risk factors and is at highest
risk for impaired cognition. The nurse
assesses this client first. The other clients have a much lower risk of developing impaired
cognition.
The assistive personnel (AP) reports to the registered nurse that a postoperative client
has a pulse of 132 beats/min and a blood
,pressure of 168/90 mm Hg. What response by the nurse is most appropriate?
a. Ask the AP to repeat the client's vital signs in 15 minutes.
b. Assess the client for pain.
c. Ask the client if something is bothersome.
d. Instruct the AP to reposition the client
ANS: B
The "fight-or-flight" syndrome can occur from sympathetic nervous stimulation due to acute
pain. Symptoms can include nausea, vomiting, diaphoresis, tachycardia, tachypnea,
hypertension, and dilated pupils. Since this client is postoperative, it is reasonable to believe
that he or she might be in pain. The nurse first assesses for pain or discomfort and treats it. If
the client is not in pain, the nurse would conduct further assessments to determine the cause
of the abnormal vital signs.
A client has urinary incontinence. Which assessment finding indicates that outcomes for
a priority nursing diagnosis have been
met?
a. Client reports satisfaction with undergarments for incontinence.
b. Client reports drinking 8 to 9 glasses of water each day.
c. Skin in perineal area is intact without redness on inspection.
d. Family states that client is more active and socializes more.
ANS: C
, Urinary incontinence can lead to skin breakdown and possibility of infection. Skin that is
intact without redness shows that a major goal for this client has been met. Becoming more
social is a positive finding as many adults with incontinence limit their social activities, but
this psychosocial outcome is not the priority over a physical outcome. Being satisfied with
undergarments is also not the priority. Drinking adequate water can sometimes help with
incontinence and is important for general health, but is not directly related to an important
goal for this client.
The registered nurse asks the nursing assistant why a cardiac client's morning weight
has not yet been done. The nursing assistant
says, "I'll get to it, what's the big deal?" When deciding how to respond, the nurse
considers what information about weight?
a. Decisions on treatment often depend on the daily weight.
b. The nursing assistant needs to ensure that tasks are done on time.
c. Weight is the most accurate noninvasive indicator of fluid status.
d. A change in weight may indicate the need to change IV fluids.
ANS: C
Weight is the best (noninvasive) indicator of fluid status. Primary health care providers may
base treatment decisions on weight, because the weight reflects fluid balance, but this answer
does not explain why. IV fluid rates or solutions may change for the same reason. The
nursing assistant would perform tasks on a timely basis, but this is not related to information
about weight.
Answers
A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the
client is breathing rapidly. What response by
the charge nurse is best?
a. Anxiety is causing the client to breathe rapidly.
b. The client is trying to get rid of excess body acids.
c. The rapid respirations cause buildup of bicarbonate.
d. An increased respiratory rate is due to increased metabolism.
ANS: B
The client is acidotic, and the respiratory system is attempting to compensate by "blowing
off" excess acid in the form of carbon
dioxide. The increased respiratory rate is not due to anxiety or increased metabolism. An
increased respiratory rate does not cause a
buildup of bicarbonate.
A client had a recent thromboembolism and must resume work which requires frequent
car and plane travel. What self-care
measure does the nurse teach to reduce the risk of impaired clotting in this client?
a. Get up and walk around at least every 2 hours while traveling.
b. Use a soft toothbrush and an electric razor for safety.
c. Be sure to sit with the legs elevated as much as possible.
d. Increase fiber in the diet so as not to strain to move the bowels.
,ANS: A
Clients who are at risk of increased clotting (as evidenced by prior thromboembolic event)
can take several measures to reduce their risk of further problems. One measure is to get up
and walk frequently when sitting for a long period of time. Using a soft toothbrush and an
electric razor and needing to prevent constipation would be important for a client at risk of
bleeding. Elevating the legs is not as beneficial as ambulating.
A nurse is caring for four clients. Which client does the nurse assess first for impaired
cognition?
a. A 28-year-old client 2 days post-open cholecystectomy
b. An 88-year-old client 3 days post-hemorrhagic stroke
c. A 32-year-old client with a 20-pack-year history of smoking
d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L)
ANS: B
There are many risk factors for impaired cognition including advanced age and diseases and
disorders that affect the brain. The
88-year-old client who is recovering from a stroke has two such risk factors and is at highest
risk for impaired cognition. The nurse
assesses this client first. The other clients have a much lower risk of developing impaired
cognition.
The assistive personnel (AP) reports to the registered nurse that a postoperative client
has a pulse of 132 beats/min and a blood
,pressure of 168/90 mm Hg. What response by the nurse is most appropriate?
a. Ask the AP to repeat the client's vital signs in 15 minutes.
b. Assess the client for pain.
c. Ask the client if something is bothersome.
d. Instruct the AP to reposition the client
ANS: B
The "fight-or-flight" syndrome can occur from sympathetic nervous stimulation due to acute
pain. Symptoms can include nausea, vomiting, diaphoresis, tachycardia, tachypnea,
hypertension, and dilated pupils. Since this client is postoperative, it is reasonable to believe
that he or she might be in pain. The nurse first assesses for pain or discomfort and treats it. If
the client is not in pain, the nurse would conduct further assessments to determine the cause
of the abnormal vital signs.
A client has urinary incontinence. Which assessment finding indicates that outcomes for
a priority nursing diagnosis have been
met?
a. Client reports satisfaction with undergarments for incontinence.
b. Client reports drinking 8 to 9 glasses of water each day.
c. Skin in perineal area is intact without redness on inspection.
d. Family states that client is more active and socializes more.
ANS: C
, Urinary incontinence can lead to skin breakdown and possibility of infection. Skin that is
intact without redness shows that a major goal for this client has been met. Becoming more
social is a positive finding as many adults with incontinence limit their social activities, but
this psychosocial outcome is not the priority over a physical outcome. Being satisfied with
undergarments is also not the priority. Drinking adequate water can sometimes help with
incontinence and is important for general health, but is not directly related to an important
goal for this client.
The registered nurse asks the nursing assistant why a cardiac client's morning weight
has not yet been done. The nursing assistant
says, "I'll get to it, what's the big deal?" When deciding how to respond, the nurse
considers what information about weight?
a. Decisions on treatment often depend on the daily weight.
b. The nursing assistant needs to ensure that tasks are done on time.
c. Weight is the most accurate noninvasive indicator of fluid status.
d. A change in weight may indicate the need to change IV fluids.
ANS: C
Weight is the best (noninvasive) indicator of fluid status. Primary health care providers may
base treatment decisions on weight, because the weight reflects fluid balance, but this answer
does not explain why. IV fluid rates or solutions may change for the same reason. The
nursing assistant would perform tasks on a timely basis, but this is not related to information
about weight.
