NR 464 - Exam 3 (Saunders) ACTUAL EXAM QUESTIONS AND
ANSWERS WITH DEEP EXPLANATIONS(GUARANTEED PASS 100%)//
ALL YOU NEED TO PASS NUR 464E XAM WITH MOST TESTED
QUESTIONS
The nurse provides home care instructions to a client with systemic lupus erythematosus and tells
the client about methods to manage fatigue. Which statement by the client indicates a need for
further instruction?
1. "I should take hot baths because they are relaxing."
2. "I should sit whenever possible to conserve my energy."
3. "I should avoid long periods of rest because it causes joint stiffness."
4. "I should do some exercises, such as walking, when I am not fatigued." - ANSWER-1. "I should
take hot baths because they are relaxing."
To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the
client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule
moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is
instructed to avoid long periods of rest because it promotes joint stiffness.
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should
incorporate which action as a priority in the plan?
1. Protecting the client from infection
2. Providing emotional support to decrease fear
3. Encouraging discussion about lifestyle changes
4. Identifying factors that decreased the immune function - ANSWER-1. Protecting the client from
infection
A client with acquired immunodeficiency syndrome (AIDS) has a respiratory infection from
Pneumocystis jiroveci and has been experiencing difficulty breathing and resultant problems with gas
exchange. Which finding indicates that the expected outcome of care has yet to be achieved?
1. The client limits fluid intake.
2. The client has clear breath sounds.
3. The client expectorates secretions easily.
,4. The client is free of complaints of shortness of breath. - ANSWER-1. The client limits fluid intake.
The status of the client with a problem concerning gas exchange would be evaluated against the
standard outcome criteria for a P. jiroveci infection. These would include options 2, 3, and 4 where
breath sounds are clear, the nurse notes that secretions are being coughed up effectively, and the
client states that breathing is easier. The client should not limit fluid intake because fluids are needed
to decrease the viscosity of secretions for expectoration.
The nurse caring for a client who has undergone kidney transplantation is monitoring the client for
organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select
all that apply.
1. Oliguria
2. Hypotension
3. Fluid retention
4. Temperature of 99.6°F (37.6°C)
5. Serum creatinine of 3.2 mg/dL (282 mcmol/L) - ANSWER-1. Oliguria
3. Fluid retention
5. Serum creatinine of 3.2 mg/dL (282 mcmol/L)
Rejection is the most serious complication of transplantation and the leading cause of graft loss. In
rejection, a reaction occurs between the tissues of the transplanted kidney and the antibiodies and
cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader
and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection is the most
common type that occurs with kidney transplants and occurs 1 week to any time postoperatively. It
occurs over days to weeks. Findings consistent with acute rejection include oliguria or anuria;
temperature higher than 100°F (37.8°C); increased blood pressure; enlarged, tender kidney; lethargy;
elevated serum creatinine, blood urea nitrogen, and potassium levels; and fluid retention.
The nurse works with high-risk clients in an urban outpatient setting. Which groups should be tested
for human immunodeficiency virus (HIV)? Select all that apply.
1. Injection drug abusers
2. Prostitutes and their clients
3. People with sexually transmitted infections (STIs)
4. People who have had frequent episodes of pneumonia
5. People who recently received a blood transfusion for a surgical procedure - ANSWER-1.
Injection drug abusers
2. Prostitutes and their clients
,3. People with sexually transmitted infections (STIs)
The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use
which technique to test the client's peripheral response to pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle - ANSWER-2. Nail bed pressure
The nurse is caring for the client with increased intracranial pressure. The nurse would note which
trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure -
ANSWER-2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
A client recovering from a head injury is participating in care. The nurse determines that the client
understands measures to prevent elevations in intracranial pressure if the nurse observes the client
doing which activity?
1. Blowing the nose
2. Isometric exercises
3. Coughing vigorously
4. Exhaling during repositioning - ANSWER-4. Exhaling during repositioning
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would
alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
3. Fluid clumps together on the dressing and has a pH of 7.
, 4. Fluid separates into concentric rings and tests positive for glucose. - ANSWER-4. Fluid separates
into concentric rings and tests positive for glucose.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should
include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.
1. Keeping the linens wrinkle-free under the client
2. Preventing unnecessary pressure on the lower limbs
3. Limiting bladder catheterization to once every 12 hours
4. Turning and repositioning the client at least every 2 hours
5. Ensuring that the client has a bowel movement at least once a week - ANSWER-1. Keeping the
linens wrinkle-free under the client
2. Preventing unnecessary pressure on the lower limbs
4. Turning and repositioning the client at least every 2 hours
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury.
Which observation indicates that spinal shock persists?
1. Hyperreflexia
2. Positive reflexes
3. Flaccid paralysis
4. Reflex emptying of the bladder - ANSWER-3. Flaccid paralysis
Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious
cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for
increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should
safely place the client in which positions? Select all that apply.
1. Head midline
2. Neck in neutral position
3. Head of bed elevated 30 to 45 degrees
4. Head turned to the side when flat in bed
5. Neck and jaw flexed forward when opening the mouth - ANSWER-1. Head midline
2. Neck in neutral position
ANSWERS WITH DEEP EXPLANATIONS(GUARANTEED PASS 100%)//
ALL YOU NEED TO PASS NUR 464E XAM WITH MOST TESTED
QUESTIONS
The nurse provides home care instructions to a client with systemic lupus erythematosus and tells
the client about methods to manage fatigue. Which statement by the client indicates a need for
further instruction?
1. "I should take hot baths because they are relaxing."
2. "I should sit whenever possible to conserve my energy."
3. "I should avoid long periods of rest because it causes joint stiffness."
4. "I should do some exercises, such as walking, when I am not fatigued." - ANSWER-1. "I should
take hot baths because they are relaxing."
To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the
client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule
moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is
instructed to avoid long periods of rest because it promotes joint stiffness.
The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should
incorporate which action as a priority in the plan?
1. Protecting the client from infection
2. Providing emotional support to decrease fear
3. Encouraging discussion about lifestyle changes
4. Identifying factors that decreased the immune function - ANSWER-1. Protecting the client from
infection
A client with acquired immunodeficiency syndrome (AIDS) has a respiratory infection from
Pneumocystis jiroveci and has been experiencing difficulty breathing and resultant problems with gas
exchange. Which finding indicates that the expected outcome of care has yet to be achieved?
1. The client limits fluid intake.
2. The client has clear breath sounds.
3. The client expectorates secretions easily.
,4. The client is free of complaints of shortness of breath. - ANSWER-1. The client limits fluid intake.
The status of the client with a problem concerning gas exchange would be evaluated against the
standard outcome criteria for a P. jiroveci infection. These would include options 2, 3, and 4 where
breath sounds are clear, the nurse notes that secretions are being coughed up effectively, and the
client states that breathing is easier. The client should not limit fluid intake because fluids are needed
to decrease the viscosity of secretions for expectoration.
The nurse caring for a client who has undergone kidney transplantation is monitoring the client for
organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select
all that apply.
1. Oliguria
2. Hypotension
3. Fluid retention
4. Temperature of 99.6°F (37.6°C)
5. Serum creatinine of 3.2 mg/dL (282 mcmol/L) - ANSWER-1. Oliguria
3. Fluid retention
5. Serum creatinine of 3.2 mg/dL (282 mcmol/L)
Rejection is the most serious complication of transplantation and the leading cause of graft loss. In
rejection, a reaction occurs between the tissues of the transplanted kidney and the antibiodies and
cytotoxic T-cells in the recipient's blood. These substances treat the new kidney as a foreign invader
and cause tissue destruction, thrombosis, and eventual kidney necrosis. Acute rejection is the most
common type that occurs with kidney transplants and occurs 1 week to any time postoperatively. It
occurs over days to weeks. Findings consistent with acute rejection include oliguria or anuria;
temperature higher than 100°F (37.8°C); increased blood pressure; enlarged, tender kidney; lethargy;
elevated serum creatinine, blood urea nitrogen, and potassium levels; and fluid retention.
The nurse works with high-risk clients in an urban outpatient setting. Which groups should be tested
for human immunodeficiency virus (HIV)? Select all that apply.
1. Injection drug abusers
2. Prostitutes and their clients
3. People with sexually transmitted infections (STIs)
4. People who have had frequent episodes of pneumonia
5. People who recently received a blood transfusion for a surgical procedure - ANSWER-1.
Injection drug abusers
2. Prostitutes and their clients
,3. People with sexually transmitted infections (STIs)
The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use
which technique to test the client's peripheral response to pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle - ANSWER-2. Nail bed pressure
The nurse is caring for the client with increased intracranial pressure. The nurse would note which
trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure -
ANSWER-2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
A client recovering from a head injury is participating in care. The nurse determines that the client
understands measures to prevent elevations in intracranial pressure if the nurse observes the client
doing which activity?
1. Blowing the nose
2. Isometric exercises
3. Coughing vigorously
4. Exhaling during repositioning - ANSWER-4. Exhaling during repositioning
A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would
alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
3. Fluid clumps together on the dressing and has a pH of 7.
, 4. Fluid separates into concentric rings and tests positive for glucose. - ANSWER-4. Fluid separates
into concentric rings and tests positive for glucose.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should
include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.
1. Keeping the linens wrinkle-free under the client
2. Preventing unnecessary pressure on the lower limbs
3. Limiting bladder catheterization to once every 12 hours
4. Turning and repositioning the client at least every 2 hours
5. Ensuring that the client has a bowel movement at least once a week - ANSWER-1. Keeping the
linens wrinkle-free under the client
2. Preventing unnecessary pressure on the lower limbs
4. Turning and repositioning the client at least every 2 hours
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury.
Which observation indicates that spinal shock persists?
1. Hyperreflexia
2. Positive reflexes
3. Flaccid paralysis
4. Reflex emptying of the bladder - ANSWER-3. Flaccid paralysis
Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious
cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for
increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should
safely place the client in which positions? Select all that apply.
1. Head midline
2. Neck in neutral position
3. Head of bed elevated 30 to 45 degrees
4. Head turned to the side when flat in bed
5. Neck and jaw flexed forward when opening the mouth - ANSWER-1. Head midline
2. Neck in neutral position
