NSG 252 Test 3 – Questions With Appropriate
Solutions
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Terms in this set (123)
A 39 year-old client is admitted with a D. Initiate intravenous fluid resuscitation
severely abscessed tooth. The nurse
assess vitals signs of BP 92/44, HR 134, Initiating IV fluids is the primary intervention, followed
RR 26, SpO2 90% on room air, by obtaining laboratory values, blood cultures, and
temperature 38.9C. What is the priority providing oxygen. Antibiotics should be started ASAP,
nursing intervention? however, after blood cultures are obtained. An
indwelling urinary catheter is lower in the list of
A. Administer prescribed antibiotics necessary priority interventions.
B. Obtain blood cultures and other
labs
C. Insert an indwelling urinary catheter
D. Initiate intravenous fluid
resuscitation
,Which assessment finding in a client in D. Bleeding, oozing from IV sites
the refractory phase of shock requires
immediate nursing intervention? The onset of DIC is evidenced by bleeding or oozing
from IV sites; this indicates a consumption of clotting
A. Warm, flushed skin factors that occurs in the refractory stage of shock
B. Urine output of 20 mL/hr
C. Increasing respiratory rate
D. Bleeding, oozing from IV sites
The nurse is assessing the client's C. Normal sinus rhythm
cardiac rhythm and notes the
following: HR 64, regular rhythm, PR
interval 0.20, QRS 0.10. How will the
nurse document this rhythm
interpretation in the electronic health
record?
A. Sinus tachycardia
B. Sinus bradycardia
C. Normal sinus rhythm
D. Sinus arrhythmia
The nurse is caring for client who is D. History of smoking
experiencing occasional premature
ventricular contractions. What
assessment data are most concerning
to the nurse?
A. Potassium 4.8
B. Magnesium 2
C. Heart rate 90
D. History of smoking
,Upon entering a client's room, the C. Notify the Rapid Response Team
nurse finds the client unresponsive. In D. Get the crash cart/AED
what order will the nurse provide B. Check carotid pulse
care? A. Begin chest compressions
E. Provide rescue breaths
A. Begin chest compressions
B. Check carotid pulse
C. Notify the Rapid Response Team
D. Get the crash cart/AED
E. Provide rescue breaths
While suctioning a client with a B. Stop suctioning the patient
tracheostomy, the client becomes
diaphoretic and nauseous and the
heart rate decreases to 37 beats/min.
What is the priority nursing action?
A. Continue to clear the airway
B. Stop suctioning the patient
C. Administer atropine
D. Call the health care provider
immediately
A client in the telemetry unit is on a D. Assess the client and check lead placement
cardiac monitor. The monitor
technician alerts the nurse that there
are no ECG complexes and the alarm
is sounding. What is the first action by
the nurse?
A. Suspend the alarm
B. Call the emergency response team
C. Press the record button to get an
ECG strip
D. Assess the client and check lead
placement
, The primary health care provider C. "I'm glad I don't need to change my diet. Salads are
prescribes warfarin for a client with my favorite food."
atrial fibrillation. Which client
statement indicates that additional
education is needed?
A. "I need to go to the clinic once a
week to have my blood level checked."
B. "If my stools turn black, I will be sure
to call my primary health care
provider."
C. "I'm glad I don't need to change my
diet. Salads are my favorite food."
D. "I need to stop taking my herbal
supplement."
A client in the progressive stage of A. Increasing pallor
hypovolemic shock has all of the B. Increasing thirst
following signs, symptoms, or changes. D. Increasing heart rate
Which signs will the nurse attribute to E. Increasing respiratory rate
ongoing compensatory mechanisms? H. Decreasing urine output
Select all that apply.
A. Increasing pallor
B. Increasing thirst
C. Increasing confusion
D. Increasing heart rate
E. Increasing respiratory rate
F. Decreasing systolic blood pressure
G. Decreasing blood pH
H. Decreasing urine output
Solutions
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Match Blocks Charms NEW
Terms in this set (123)
A 39 year-old client is admitted with a D. Initiate intravenous fluid resuscitation
severely abscessed tooth. The nurse
assess vitals signs of BP 92/44, HR 134, Initiating IV fluids is the primary intervention, followed
RR 26, SpO2 90% on room air, by obtaining laboratory values, blood cultures, and
temperature 38.9C. What is the priority providing oxygen. Antibiotics should be started ASAP,
nursing intervention? however, after blood cultures are obtained. An
indwelling urinary catheter is lower in the list of
A. Administer prescribed antibiotics necessary priority interventions.
B. Obtain blood cultures and other
labs
C. Insert an indwelling urinary catheter
D. Initiate intravenous fluid
resuscitation
,Which assessment finding in a client in D. Bleeding, oozing from IV sites
the refractory phase of shock requires
immediate nursing intervention? The onset of DIC is evidenced by bleeding or oozing
from IV sites; this indicates a consumption of clotting
A. Warm, flushed skin factors that occurs in the refractory stage of shock
B. Urine output of 20 mL/hr
C. Increasing respiratory rate
D. Bleeding, oozing from IV sites
The nurse is assessing the client's C. Normal sinus rhythm
cardiac rhythm and notes the
following: HR 64, regular rhythm, PR
interval 0.20, QRS 0.10. How will the
nurse document this rhythm
interpretation in the electronic health
record?
A. Sinus tachycardia
B. Sinus bradycardia
C. Normal sinus rhythm
D. Sinus arrhythmia
The nurse is caring for client who is D. History of smoking
experiencing occasional premature
ventricular contractions. What
assessment data are most concerning
to the nurse?
A. Potassium 4.8
B. Magnesium 2
C. Heart rate 90
D. History of smoking
,Upon entering a client's room, the C. Notify the Rapid Response Team
nurse finds the client unresponsive. In D. Get the crash cart/AED
what order will the nurse provide B. Check carotid pulse
care? A. Begin chest compressions
E. Provide rescue breaths
A. Begin chest compressions
B. Check carotid pulse
C. Notify the Rapid Response Team
D. Get the crash cart/AED
E. Provide rescue breaths
While suctioning a client with a B. Stop suctioning the patient
tracheostomy, the client becomes
diaphoretic and nauseous and the
heart rate decreases to 37 beats/min.
What is the priority nursing action?
A. Continue to clear the airway
B. Stop suctioning the patient
C. Administer atropine
D. Call the health care provider
immediately
A client in the telemetry unit is on a D. Assess the client and check lead placement
cardiac monitor. The monitor
technician alerts the nurse that there
are no ECG complexes and the alarm
is sounding. What is the first action by
the nurse?
A. Suspend the alarm
B. Call the emergency response team
C. Press the record button to get an
ECG strip
D. Assess the client and check lead
placement
, The primary health care provider C. "I'm glad I don't need to change my diet. Salads are
prescribes warfarin for a client with my favorite food."
atrial fibrillation. Which client
statement indicates that additional
education is needed?
A. "I need to go to the clinic once a
week to have my blood level checked."
B. "If my stools turn black, I will be sure
to call my primary health care
provider."
C. "I'm glad I don't need to change my
diet. Salads are my favorite food."
D. "I need to stop taking my herbal
supplement."
A client in the progressive stage of A. Increasing pallor
hypovolemic shock has all of the B. Increasing thirst
following signs, symptoms, or changes. D. Increasing heart rate
Which signs will the nurse attribute to E. Increasing respiratory rate
ongoing compensatory mechanisms? H. Decreasing urine output
Select all that apply.
A. Increasing pallor
B. Increasing thirst
C. Increasing confusion
D. Increasing heart rate
E. Increasing respiratory rate
F. Decreasing systolic blood pressure
G. Decreasing blood pH
H. Decreasing urine output
