NUR 2755 ACTUAL FINAL EXAMS QUESTIONS
AND ANSWERS SET A+
✔✔What should the nurse monitor first in a client with a traumatic brain injury at risk for
diabetes insipidus? - ✔✔Monitor urine output and specific gravity.
✔✔What actions should the nurse take to maintain adequate cerebral perfusion
pressure in a client with a traumatic brain injury? - ✔✔Administer hypertonic saline to
reduce cerebral edema and maintain blood volume.
✔✔What is the priority action for a nurse caring for a client with severe headaches from
a metastatic brain tumor? - ✔✔Administer prescribed analgesics and assess the client's
pain level regularly.
✔✔What is the nurse's best initial action for a client showing signs of wound infection
post-surgery? - ✔✔Reinforce the dressing and notify the surgeon.
✔✔What priority nursing action can prevent perioperative positioning injury in a client in
the Trendelenburg position? - ✔✔Use padded shoulder braces to prevent sliding.
✔✔What interventions should the nurse implement to prevent further embolic events in
a client with atrial fibrillation? - ✔✔Administer enoxaparin subcutaneously, encourage
early ambulation, and apply sequential compression devices.
✔✔What action should the nurse take to reduce the risk of septic shock in an
immunocompromised client with a UTI? - ✔✔Remove invasive devices as soon as they
are no longer needed.
✔✔What actions should the nurse implement for a client experiencing a generalized
tonic-clonic seizure? - ✔✔Place the client in a side-lying position and stay with the client
until they are fully oriented.
, ✔✔What activities should a client avoid after a craniotomy to prevent cerebrospinal fluid
leak? - ✔✔Blowing the nose and strenuous exercise.
✔✔What reasons should the nurse give for administering morphine sulfate IV to a client
with cardiogenic shock? - ✔✔It dilates blood vessels, helps manage chest pain, and
promotes coping while slowing catecholamine release.
✔✔What interventions should be included in the care plan for a client in the ICU with
multiple organ dysfunction syndrome (MODS)? - ✔✔Promote communication with the
client and family along with addressing end-of-life issues.
✔✔What assessments should the nurse prioritize for a client in the ICU receiving
dopamine infusion? - ✔✔Frequent monitoring of vital signs, monitoring the central line
site, and providing accurate drug titration.
✔✔What laboratory findings should the nurse refer to gauge the onset of acute kidney
injury in a client with neurogenic shock? - ✔✔Blood urea nitrogen (BUN) level,
creatinine level, and urine specific gravity.
✔✔What action should the nurse take after the high-pressure alarm sounds on the
ventilator? - ✔✔Suction the client to remove excess secretions.
✔✔What nursing action is most appropriate for a client experiencing autonomic
dysreflexia? - ✔✔Identify and remove the triggering stimulus.
✔✔What should be done first for an unresponsive 80-year-old with hypovolemic shock?
- ✔✔Administer oxygen by nasal cannula
✔✔What action should a nurse take first for a client who develops a loud, brassy cough
after a home fire? - ✔✔Apply oxygen and continuous pulse oximetry
✔✔What is an appropriate nursing intervention for a client with expressive aphasia? -
✔✔Use a picture board, ask client to point to appropriate pictures
✔✔What assessment data indicates a client has developed multiple organ dysfunction
syndrome (MODS)? - ✔✔Oliguria, increased liver enzymes, absent bowel sounds
✔✔What assessment finding supports the presence of a pneumothorax? -
✔✔Diminished or absent breath sounds on the affected side
✔✔What intervention should be included in the care plan for a client with severe flail
chest injury? - ✔✔Immediately sedate and intubate the client
AND ANSWERS SET A+
✔✔What should the nurse monitor first in a client with a traumatic brain injury at risk for
diabetes insipidus? - ✔✔Monitor urine output and specific gravity.
✔✔What actions should the nurse take to maintain adequate cerebral perfusion
pressure in a client with a traumatic brain injury? - ✔✔Administer hypertonic saline to
reduce cerebral edema and maintain blood volume.
✔✔What is the priority action for a nurse caring for a client with severe headaches from
a metastatic brain tumor? - ✔✔Administer prescribed analgesics and assess the client's
pain level regularly.
✔✔What is the nurse's best initial action for a client showing signs of wound infection
post-surgery? - ✔✔Reinforce the dressing and notify the surgeon.
✔✔What priority nursing action can prevent perioperative positioning injury in a client in
the Trendelenburg position? - ✔✔Use padded shoulder braces to prevent sliding.
✔✔What interventions should the nurse implement to prevent further embolic events in
a client with atrial fibrillation? - ✔✔Administer enoxaparin subcutaneously, encourage
early ambulation, and apply sequential compression devices.
✔✔What action should the nurse take to reduce the risk of septic shock in an
immunocompromised client with a UTI? - ✔✔Remove invasive devices as soon as they
are no longer needed.
✔✔What actions should the nurse implement for a client experiencing a generalized
tonic-clonic seizure? - ✔✔Place the client in a side-lying position and stay with the client
until they are fully oriented.
, ✔✔What activities should a client avoid after a craniotomy to prevent cerebrospinal fluid
leak? - ✔✔Blowing the nose and strenuous exercise.
✔✔What reasons should the nurse give for administering morphine sulfate IV to a client
with cardiogenic shock? - ✔✔It dilates blood vessels, helps manage chest pain, and
promotes coping while slowing catecholamine release.
✔✔What interventions should be included in the care plan for a client in the ICU with
multiple organ dysfunction syndrome (MODS)? - ✔✔Promote communication with the
client and family along with addressing end-of-life issues.
✔✔What assessments should the nurse prioritize for a client in the ICU receiving
dopamine infusion? - ✔✔Frequent monitoring of vital signs, monitoring the central line
site, and providing accurate drug titration.
✔✔What laboratory findings should the nurse refer to gauge the onset of acute kidney
injury in a client with neurogenic shock? - ✔✔Blood urea nitrogen (BUN) level,
creatinine level, and urine specific gravity.
✔✔What action should the nurse take after the high-pressure alarm sounds on the
ventilator? - ✔✔Suction the client to remove excess secretions.
✔✔What nursing action is most appropriate for a client experiencing autonomic
dysreflexia? - ✔✔Identify and remove the triggering stimulus.
✔✔What should be done first for an unresponsive 80-year-old with hypovolemic shock?
- ✔✔Administer oxygen by nasal cannula
✔✔What action should a nurse take first for a client who develops a loud, brassy cough
after a home fire? - ✔✔Apply oxygen and continuous pulse oximetry
✔✔What is an appropriate nursing intervention for a client with expressive aphasia? -
✔✔Use a picture board, ask client to point to appropriate pictures
✔✔What assessment data indicates a client has developed multiple organ dysfunction
syndrome (MODS)? - ✔✔Oliguria, increased liver enzymes, absent bowel sounds
✔✔What assessment finding supports the presence of a pneumothorax? -
✔✔Diminished or absent breath sounds on the affected side
✔✔What intervention should be included in the care plan for a client with severe flail
chest injury? - ✔✔Immediately sedate and intubate the client
