NURS 315 Exam 2 – (Clicker & Book): Questions &
Correct Answers
Two hours after a kidney transplant, the nurse obtains all these data when
assessing the client. Which information is most important to communicate to
the health care provider?
a. The BUN and creatinine levels are elevated.
b. The urine output is 900 to 1100 ml/hr.
c. The blood pressure is 88/50 mmHg.
d. The pain level is 8/10 at incision when client coughs. Right Ans - c
Which potential complications would you monitor during postop period of
kidney transplant?
a. Acute tubular necrosis
b. Pneumonia
c. Wound infection
d. Hypokalemia
e. Hypernatremia
f. Diabetes insipidus
g. Dehydration
h. Fluid overload
I. Pneumothorax Right Ans - a, b, c, d, g, h
Which client does the nurse assess to be at greatest risk for pressure ulcer
development?
a. Client who has pneumonia
b. Client who requires assistance with ambulation
c. Client with hypertension on multiple medications
d. Incontinent client with limited mobility Right Ans - d
The charge nurse observes a new graduate performing a dressing change on a
stage II left heel pressure ulcer. Which action by the new graduate indicates a
need for further education about pressure ulcer care?
a. The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the
ulcer.
b. The new graduate inserts a sterile cotton-tipped applicator into the
pressure ulcer.
,c. The new graduate irrigates the pressure ulcer with a 30-ml syringe using
sterile saline.
d. The new graduate cleans the ulcer with a sterile dressing soaked in a
cytotoxic solution half-strength peroxide. Right Ans - d
A fair-skinned 32-year-old client whose mother recently died from Squamous
Cell Carcinoma asks the nurse, "what can I do to prevent Squamous Cell
Carcinoma from developing?" The best response by the nurse is that
a. The avoidance of excessive sun exposure will decrease risk.
b. Individuals with fair skin and blue eyes are at increased risk.
c. Squamous Cell Carcinoma is a relatively rare type of skin cancer.
d. The client is at high risk for skin cancer because of family history. Right
Ans - a
Which nursing intervention would be most helpful in managing a patient
newly admitted with cellulitis of the right foot?
a. Applying warm, moist heat
b. Wrapping the foot snugly in blankets
c. Encouraging frequent ambulation
d. Not elevating the affected extremity Right Ans - a
In preparation for a client being admitted with herpes zoster, what does the
nurse do? (Select all that apply.)
a. Prepare a room for reverse isolation.
b. Assess staff for a history of or vaccination for chickenpox.
c. Check the admission orders for analgesia.
d. Choose a roommate who also is immune suppressed.
e. Ensure that gloves are available in the room. Right Ans - b, c, e
The patient has dry skin and pruritis on the legs that causes the patient to
scratch at the skin uncontrollably. What measures can the nurse use to help
stop the itch/scratch cycle? Select all that apply.
a. Moisturize the skin on the legs
b. Provide a warm blanket and room
c. Administer antihistamines at bedtime
d. Use careful hand washing after rubbing her legs
e. Cleanse the legs with a saline solution twice daily Right Ans - a, c
, A client has a blood pressure of 120/60 mmHg and an intracranial pressure
(ICP) of 24 mmHg. The nurse determines that the cerebral perfusion pressure
(CPP) of this client indicates
a. High blood flow to the brain
b. Adequate cerebral perfusion
c. Impaired brain blood flow
d. Normal ICP Right Ans - c
When being assessed for airway and breathing, the client presenting with
increased intracranial pressure would most likely exhibit which of the
following vital signs?
a. BP 190/84, HR 150, and an irregular respiratory pattern
b. BP 80/50, HR 50, and Kussmaul respiration
c. BP 80/50, HR 150, and Cheyne-Stokes respirations
d. BP 190/84, HR 50, and an irregular respiratory pattern Right Ans - d
Which of the symptoms listed below indicate early , later, and very late stages
of increased intracranial pressure (ICP)
1. Altered level of consciousness
2. Absence of motor function
3. Sluggish pupil reaction
4. Headache
5. Decreased systolic BP
6. Vomiting
7. Decreased pulse rate
8. Increased systolic BP
9. Decorticate posturing
10. Increased pulse rate
11. Decreased visual acuity
12. Pupils dilated and fixed Right Ans - Early: 1, 3, 4, 6, 11
Later: 7, 8, 9
Very Late: 2, 5, 10, 12
A client with increased intracranial pressure (ICP) will undergo lumbar
puncture for cerebrospinal fluid (CSF) drainage. In which order are the
necessary actions performed for intermittent CSF drainage?
a. Allow CSF to drain for 2 to 3 minutes.
b. Open the ventriculostomy system at the indicated ICP.
c. Close the stopcock to return the ventriculostomy to a closed system.
Correct Answers
Two hours after a kidney transplant, the nurse obtains all these data when
assessing the client. Which information is most important to communicate to
the health care provider?
a. The BUN and creatinine levels are elevated.
b. The urine output is 900 to 1100 ml/hr.
c. The blood pressure is 88/50 mmHg.
d. The pain level is 8/10 at incision when client coughs. Right Ans - c
Which potential complications would you monitor during postop period of
kidney transplant?
a. Acute tubular necrosis
b. Pneumonia
c. Wound infection
d. Hypokalemia
e. Hypernatremia
f. Diabetes insipidus
g. Dehydration
h. Fluid overload
I. Pneumothorax Right Ans - a, b, c, d, g, h
Which client does the nurse assess to be at greatest risk for pressure ulcer
development?
a. Client who has pneumonia
b. Client who requires assistance with ambulation
c. Client with hypertension on multiple medications
d. Incontinent client with limited mobility Right Ans - d
The charge nurse observes a new graduate performing a dressing change on a
stage II left heel pressure ulcer. Which action by the new graduate indicates a
need for further education about pressure ulcer care?
a. The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the
ulcer.
b. The new graduate inserts a sterile cotton-tipped applicator into the
pressure ulcer.
,c. The new graduate irrigates the pressure ulcer with a 30-ml syringe using
sterile saline.
d. The new graduate cleans the ulcer with a sterile dressing soaked in a
cytotoxic solution half-strength peroxide. Right Ans - d
A fair-skinned 32-year-old client whose mother recently died from Squamous
Cell Carcinoma asks the nurse, "what can I do to prevent Squamous Cell
Carcinoma from developing?" The best response by the nurse is that
a. The avoidance of excessive sun exposure will decrease risk.
b. Individuals with fair skin and blue eyes are at increased risk.
c. Squamous Cell Carcinoma is a relatively rare type of skin cancer.
d. The client is at high risk for skin cancer because of family history. Right
Ans - a
Which nursing intervention would be most helpful in managing a patient
newly admitted with cellulitis of the right foot?
a. Applying warm, moist heat
b. Wrapping the foot snugly in blankets
c. Encouraging frequent ambulation
d. Not elevating the affected extremity Right Ans - a
In preparation for a client being admitted with herpes zoster, what does the
nurse do? (Select all that apply.)
a. Prepare a room for reverse isolation.
b. Assess staff for a history of or vaccination for chickenpox.
c. Check the admission orders for analgesia.
d. Choose a roommate who also is immune suppressed.
e. Ensure that gloves are available in the room. Right Ans - b, c, e
The patient has dry skin and pruritis on the legs that causes the patient to
scratch at the skin uncontrollably. What measures can the nurse use to help
stop the itch/scratch cycle? Select all that apply.
a. Moisturize the skin on the legs
b. Provide a warm blanket and room
c. Administer antihistamines at bedtime
d. Use careful hand washing after rubbing her legs
e. Cleanse the legs with a saline solution twice daily Right Ans - a, c
, A client has a blood pressure of 120/60 mmHg and an intracranial pressure
(ICP) of 24 mmHg. The nurse determines that the cerebral perfusion pressure
(CPP) of this client indicates
a. High blood flow to the brain
b. Adequate cerebral perfusion
c. Impaired brain blood flow
d. Normal ICP Right Ans - c
When being assessed for airway and breathing, the client presenting with
increased intracranial pressure would most likely exhibit which of the
following vital signs?
a. BP 190/84, HR 150, and an irregular respiratory pattern
b. BP 80/50, HR 50, and Kussmaul respiration
c. BP 80/50, HR 150, and Cheyne-Stokes respirations
d. BP 190/84, HR 50, and an irregular respiratory pattern Right Ans - d
Which of the symptoms listed below indicate early , later, and very late stages
of increased intracranial pressure (ICP)
1. Altered level of consciousness
2. Absence of motor function
3. Sluggish pupil reaction
4. Headache
5. Decreased systolic BP
6. Vomiting
7. Decreased pulse rate
8. Increased systolic BP
9. Decorticate posturing
10. Increased pulse rate
11. Decreased visual acuity
12. Pupils dilated and fixed Right Ans - Early: 1, 3, 4, 6, 11
Later: 7, 8, 9
Very Late: 2, 5, 10, 12
A client with increased intracranial pressure (ICP) will undergo lumbar
puncture for cerebrospinal fluid (CSF) drainage. In which order are the
necessary actions performed for intermittent CSF drainage?
a. Allow CSF to drain for 2 to 3 minutes.
b. Open the ventriculostomy system at the indicated ICP.
c. Close the stopcock to return the ventriculostomy to a closed system.
