Practice Questions for NUR 233 FINAL
Complete Answers
After receiving a change-of-shift report, which patient should the nurse assess first? -
ANSWER-The patient receiving chemotherapy who has a temperature of 102
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL.
What prescribed action should the nurse take first? - ANSWER-Obtain cultures of
the wound.
An older patient receiving iso-osmolar continuous tube feedings develops
restlessness, agitation, and weakness. Which laboratory result should the nurse
report to the health care provider immediately? - ANSWER-Na+ 154 mEq/L (154
mmol/L)
IV potassium Chloride (KCl) 60 mEq is prescribed for treatment of a patient with
severe hypokalemia. Which action should the nurse take? - ANSWER-Infuse the KCl
at a rate of 10 mEQ/hour
A patient comes to the clinic complaining of frequent, watery stools for the past 2
days. What action should the nurse take first? - ANSWER-Check the patient's blood
pressure
It is important for the nurse to assess for which clinical manifestation(s) in a patient
who has undergone a total thyroidectomy. - ANSWER-Positive Chvostek's sign
Implementation of nursing care for a patient with hyponatremia includes - ANSWER-
fluid restriction
The client's pulse oximetry is reading 90%. What action should the nurse take first? -
ANSWER-Move the sensor to another area
The client diagnosed with a community-acquired pneumonia is being admitted to the
medical unit. Which nursing intervention has the highest priority? - ANSWER-Obtain
a sputum specimen for culture and sensitivity.
Which client problems are appropriate for the nurse to include in the plan of care for
the client diagnosed with COPD? Select all that apply - ANSWER-A. Impaired gas
exchange
B. Inability to tolerate temperature extremes
C. Activity intolerance
D. Inability to cope with changes in roles
E. Alteration in nutrition
, The nurse is planning the care of a client diagnosed with pneumonia and writes a
problem of "impaired gas exchange." Which is the expected outcome for this
problem? - ANSWER-Alert and oriented to person, place, time and events
The nurse identifies the diagnosis of Ineffective Breathing Pattern relatedto inability
to maintain adequate rate and depth of respirations for a client with an acute
respiratory problem resulting from lung disease. Which nursing intervention should
be listed first on the care plan? - ANSWER-Determine airway adequacy hourly and
as needed.
A nursing instructor asked a group of nursing students to discuss experiences with
charting assessment data. Which comment by the student indicates the need for
further teaching? - ANSWER-My patient was really quiet and didn't say much, so i
documented that he acted depressed."
The nurse is caring for a patient with a diagnosis of hypernatremia. The following
orders are written on the client's chart. Which order should the nurse question? -
ANSWER-Restrict oral intake to 900ml every 24hrs
A patient at risk for hypernatremia is one who - ANSWER-Has impaired
consciousness and decreased thirst sensitivity
The nurse assesses a patient who has been hospitalized for 2 days. The patient has
been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction,
and is NPO. Which assessment finding would be a priority for the nurse to report to
the health care provider? - ANSWER-Gradually decreasing level of consciousness
(LOC)
The nurse is administering a sustained-release capsule to a new patient. The patient
insists that he cannot swallow pills. What is the nurse's next best course of action? -
ANSWER-Ask the prescriber to change the order
The client is being prescribed alendronate (Fosamax) to slow the progression of her
osteoporosis. You know she will need more patient teaching when she says: -
ANSWER-"Now that I am taking this medication, I will not need to take vitamin D with
my calcium supplement."
The nurse is working on an orthopedic floor. Which client should the nurse assess
first after the change-of-shift report? - ANSWER-The 64-year-old female with a left
total knee replacement who has confusion.
The nurse is discharging a patient who had a total hip replacement. Which statement
indicates that further teaching is needed? - ANSWER-"After three (3) weeks I do not
have to worry about infections."
Which intervention is an example of secondary prevention when discussing
osteoporosis? - ANSWER-Obtain a bone density evaluation test.
The nurse is discussing osteoporosis with a group of women. Which factor will the
nurse identify as a nonmodifiable risk factor? - ANSWER-female gender
Complete Answers
After receiving a change-of-shift report, which patient should the nurse assess first? -
ANSWER-The patient receiving chemotherapy who has a temperature of 102
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL.
What prescribed action should the nurse take first? - ANSWER-Obtain cultures of
the wound.
An older patient receiving iso-osmolar continuous tube feedings develops
restlessness, agitation, and weakness. Which laboratory result should the nurse
report to the health care provider immediately? - ANSWER-Na+ 154 mEq/L (154
mmol/L)
IV potassium Chloride (KCl) 60 mEq is prescribed for treatment of a patient with
severe hypokalemia. Which action should the nurse take? - ANSWER-Infuse the KCl
at a rate of 10 mEQ/hour
A patient comes to the clinic complaining of frequent, watery stools for the past 2
days. What action should the nurse take first? - ANSWER-Check the patient's blood
pressure
It is important for the nurse to assess for which clinical manifestation(s) in a patient
who has undergone a total thyroidectomy. - ANSWER-Positive Chvostek's sign
Implementation of nursing care for a patient with hyponatremia includes - ANSWER-
fluid restriction
The client's pulse oximetry is reading 90%. What action should the nurse take first? -
ANSWER-Move the sensor to another area
The client diagnosed with a community-acquired pneumonia is being admitted to the
medical unit. Which nursing intervention has the highest priority? - ANSWER-Obtain
a sputum specimen for culture and sensitivity.
Which client problems are appropriate for the nurse to include in the plan of care for
the client diagnosed with COPD? Select all that apply - ANSWER-A. Impaired gas
exchange
B. Inability to tolerate temperature extremes
C. Activity intolerance
D. Inability to cope with changes in roles
E. Alteration in nutrition
, The nurse is planning the care of a client diagnosed with pneumonia and writes a
problem of "impaired gas exchange." Which is the expected outcome for this
problem? - ANSWER-Alert and oriented to person, place, time and events
The nurse identifies the diagnosis of Ineffective Breathing Pattern relatedto inability
to maintain adequate rate and depth of respirations for a client with an acute
respiratory problem resulting from lung disease. Which nursing intervention should
be listed first on the care plan? - ANSWER-Determine airway adequacy hourly and
as needed.
A nursing instructor asked a group of nursing students to discuss experiences with
charting assessment data. Which comment by the student indicates the need for
further teaching? - ANSWER-My patient was really quiet and didn't say much, so i
documented that he acted depressed."
The nurse is caring for a patient with a diagnosis of hypernatremia. The following
orders are written on the client's chart. Which order should the nurse question? -
ANSWER-Restrict oral intake to 900ml every 24hrs
A patient at risk for hypernatremia is one who - ANSWER-Has impaired
consciousness and decreased thirst sensitivity
The nurse assesses a patient who has been hospitalized for 2 days. The patient has
been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction,
and is NPO. Which assessment finding would be a priority for the nurse to report to
the health care provider? - ANSWER-Gradually decreasing level of consciousness
(LOC)
The nurse is administering a sustained-release capsule to a new patient. The patient
insists that he cannot swallow pills. What is the nurse's next best course of action? -
ANSWER-Ask the prescriber to change the order
The client is being prescribed alendronate (Fosamax) to slow the progression of her
osteoporosis. You know she will need more patient teaching when she says: -
ANSWER-"Now that I am taking this medication, I will not need to take vitamin D with
my calcium supplement."
The nurse is working on an orthopedic floor. Which client should the nurse assess
first after the change-of-shift report? - ANSWER-The 64-year-old female with a left
total knee replacement who has confusion.
The nurse is discharging a patient who had a total hip replacement. Which statement
indicates that further teaching is needed? - ANSWER-"After three (3) weeks I do not
have to worry about infections."
Which intervention is an example of secondary prevention when discussing
osteoporosis? - ANSWER-Obtain a bone density evaluation test.
The nurse is discussing osteoporosis with a group of women. Which factor will the
nurse identify as a nonmodifiable risk factor? - ANSWER-female gender
