lOMoARcPSD|26582732
NR 341 EXAM 1 WITH CORRECT
ANSWERS
A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate
way for the nurse to evaluate fluid balance? A. Skin turgor
b. Daily weight
c. Urine output
d. Edema presence
A patient receives 3% nacl solution for correction of hyponatremia. Which assessment is most
important for the nurse to monitor while the patient is receiving this infusion? A. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema
Following a thyroidectomy, a patient reports “a tingling feeling around my mouth.” Which assessment
should the nurse complete first?
a. Verify the serum potassium level.
b. Test for presence of chvostek’s sign.
c. Observe for blood on the neck dressing.
d. Confirm a prescription for thyroid replacement.
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place.
If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
A. Encourage increased incentive spirometer use.
b. Encourage the patient to increase oral fluid intake.
c. Put on sterile gloves and use a sterile catheter to suction.
d. Preoxygenate the patient for 3 minutes before suctioning.
Which action should the nurse take first when a patient develops epistaxis?
A. Pack the affected nare tightly with an epistaxis balloon.
b. Apply squeezing pressure to the nostrils for 10 minutes.
c. Obtain silver nitrate that may be needed for cauterization.
d. Instill a vasoconstrictor medication into the affected nare.
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A patient arrives in the emergency department with a possible nasal fracture after being hit by a
baseball. Which finding by the nurse is most important to report to the health care provider? A.
Clear nasal drainage
b. Report of nasal pain
c. Bilateral nose swelling and bruising
d. Inability to breathe through the nose
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a
temperature of 101.6° f (38.7° c), and yellow patches on the tonsils. Which action will the nurse
anticipate taking?
a. Teach the patient about the use of expectorants.
b. Use a swab to obtain a sample for a rapid strep antigen test.
c. Discuss the need to rinse the mouth out after using any inhalers.
d. Teach the patient to avoid nonsteroidal anti-inflammatory drugs (nsaids).
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation
( spo2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
A. Administration of 100% o2 by non-rebreather mask
b. Endotracheal intubation and positive pressure ventilation
c. Insertion of a mini-tracheostomy with frequent suctioning
The oxygen saturation (spo2) for a patient with left lower lobe pneumonia is 90%. The patient has
wheezes and a weak cough effort. Which action should the nurse take? A. Position the patient on
the left side.
b. Assist the patient with staged coughing.
c. Place a humidifier in the patient’s room.
d. Schedule a 4-hour rest period for the patient.
A nurse is caring for a patient with right lower lobe pneumonia who is obese. Which position will
provide the best gas exchange? A. On the left side
b. On the right side
c. In the tripod position
d. In the high-fowler’s position
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease
the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? A.
Elevate head of bed to 30 to 45 degrees.
b. Give enteral feedings at no more than 10 ml/hr.
c. Suction the endotracheal tube every 2 to 4 hours.
d. Limit the use of positive end-expiratory pressure.
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NR 341 EXAM 1 WITH CORRECT
ANSWERS
A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate
way for the nurse to evaluate fluid balance? A. Skin turgor
b. Daily weight
c. Urine output
d. Edema presence
A patient receives 3% nacl solution for correction of hyponatremia. Which assessment is most
important for the nurse to monitor while the patient is receiving this infusion? A. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema
Following a thyroidectomy, a patient reports “a tingling feeling around my mouth.” Which assessment
should the nurse complete first?
a. Verify the serum potassium level.
b. Test for presence of chvostek’s sign.
c. Observe for blood on the neck dressing.
d. Confirm a prescription for thyroid replacement.
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place.
If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
A. Encourage increased incentive spirometer use.
b. Encourage the patient to increase oral fluid intake.
c. Put on sterile gloves and use a sterile catheter to suction.
d. Preoxygenate the patient for 3 minutes before suctioning.
Which action should the nurse take first when a patient develops epistaxis?
A. Pack the affected nare tightly with an epistaxis balloon.
b. Apply squeezing pressure to the nostrils for 10 minutes.
c. Obtain silver nitrate that may be needed for cauterization.
d. Instill a vasoconstrictor medication into the affected nare.
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
A patient arrives in the emergency department with a possible nasal fracture after being hit by a
baseball. Which finding by the nurse is most important to report to the health care provider? A.
Clear nasal drainage
b. Report of nasal pain
c. Bilateral nose swelling and bruising
d. Inability to breathe through the nose
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a
temperature of 101.6° f (38.7° c), and yellow patches on the tonsils. Which action will the nurse
anticipate taking?
a. Teach the patient about the use of expectorants.
b. Use a swab to obtain a sample for a rapid strep antigen test.
c. Discuss the need to rinse the mouth out after using any inhalers.
d. Teach the patient to avoid nonsteroidal anti-inflammatory drugs (nsaids).
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation
( spo2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
A. Administration of 100% o2 by non-rebreather mask
b. Endotracheal intubation and positive pressure ventilation
c. Insertion of a mini-tracheostomy with frequent suctioning
The oxygen saturation (spo2) for a patient with left lower lobe pneumonia is 90%. The patient has
wheezes and a weak cough effort. Which action should the nurse take? A. Position the patient on
the left side.
b. Assist the patient with staged coughing.
c. Place a humidifier in the patient’s room.
d. Schedule a 4-hour rest period for the patient.
A nurse is caring for a patient with right lower lobe pneumonia who is obese. Which position will
provide the best gas exchange? A. On the left side
b. On the right side
c. In the tripod position
d. In the high-fowler’s position
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease
the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? A.
Elevate head of bed to 30 to 45 degrees.
b. Give enteral feedings at no more than 10 ml/hr.
c. Suction the endotracheal tube every 2 to 4 hours.
d. Limit the use of positive end-expiratory pressure.
Downloaded by NELSON KIIRU ()
