NURS 315 Exam 2 Questions With
Answers 100% Correct.
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. - ANSWER- 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 - ANSWER- 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 - ANSWER- 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. - ANSWER- 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. - ANSWER- 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 - ANSWER- 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. - ANSWER- 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 - ANSWER- 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 - ANSWER- 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 - ANSWER- 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 - ANSWER- 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.
d. Determine that the ICP is above the indicated level. - ANSWER- d, b, a, c
A client with an increased ICP does not open his eyes to any stimulus, has no verbal
response except moaning and muttering when stimulated, and flexed his arm in
response to painful stimuli. The nurse records the client's GCS score as
6
7
9
11 - ANSWER- b
eyes: +1
verbal response: +2
motor response: +4
total 7
The nurse is positioning the client with increased intracranial pressure. Which of the
following positions would the nurse choose?
a. Flexion of the hips
b. Head turned to the side
c. Neck in neutral position
d. Trendelenburg's position - ANSWER- c
A client with a suspected traumatic brain injury has bloody nasal drainage. What
observation should cause the nurse to suspect that this client has a cerebrospinal fluid
(CSF) leak?
a. A halo sign on the nasal drip pad
b. Decreased blood pressure and urinary output
Answers 100% Correct.
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. - ANSWER- 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 - ANSWER- 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 - ANSWER- 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. - ANSWER- 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. - ANSWER- 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 - ANSWER- 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. - ANSWER- 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 - ANSWER- 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 - ANSWER- 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 - ANSWER- 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 - ANSWER- 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.
d. Determine that the ICP is above the indicated level. - ANSWER- d, b, a, c
A client with an increased ICP does not open his eyes to any stimulus, has no verbal
response except moaning and muttering when stimulated, and flexed his arm in
response to painful stimuli. The nurse records the client's GCS score as
6
7
9
11 - ANSWER- b
eyes: +1
verbal response: +2
motor response: +4
total 7
The nurse is positioning the client with increased intracranial pressure. Which of the
following positions would the nurse choose?
a. Flexion of the hips
b. Head turned to the side
c. Neck in neutral position
d. Trendelenburg's position - ANSWER- c
A client with a suspected traumatic brain injury has bloody nasal drainage. What
observation should cause the nurse to suspect that this client has a cerebrospinal fluid
(CSF) leak?
a. A halo sign on the nasal drip pad
b. Decreased blood pressure and urinary output
