NUR 3112 Final Questions With Complete Solutions
A 42-year-old female patient is transferred to a surgical unit
after a colostomy. The nurse observes the stoma to be deep pink
with edema and a small amount of sanguineous (red) drainage.
The nurse should:
A. Place ice packs around the stoma.
B. Notify the surgeon about the stoma.
C. Monitor the stoma every 30 minutes.
D. Document stoma assessment findings. Correct Answers D
Document stoma assessment findings.
A 43 yo patient is going to have stomach surgery. Which of the
following is a major pre-op concern?
A. Brother had a tonsillectomy at age 11
B. Patient has IV fluids running at 50 mL/hr
C. Patient smokes 1 pack per day
D. Patient had surgery 6 months ago Correct Answers C.
Patient smokes 1 pack per day
A 50-year-old patient is admitted to the ED with severe
abdominal pain and rebound tenderness. Vital signs include
temperature 102° F, pulse 127, respirations 31, and blood
pressure 80/54. Which prescribed intervention should the nurse
implement first?
A. Administer IV ketorolac (Toradol) 15 mg.
B. Draw blood for a complete blood count (CBC).
C. Obtain a computed tomography (CT) scan of the abdomen.
D. Infuse 1 liter bolus of 0.9% Normal Saline. Correct Answers
D
Infuse 1 liter bolus if 0.9% Normal Saline
,A 56-year-old patient arrives in the emergency department with
left-sided weakness and slurred speech that started 2 hours
previously. The patient's past medical history includes several
transient ischemic attacks (TIAs). The nurse anticipates
preparing the patient for:
a. balloon angioplasty
b. carotid endarterectomy
c. alteplase (tPA) administration
d. continuous heparin administration Correct Answers C. The
patient's history of TIAs and clinical manifestations suggest an
acute ischemic stroke. The patient's onset of symptoms is within
the window for alteplase administration. A head CT would be
necessary to determine ischemic versus hemorrhagic stroke.
A client develops an anaphylactic reaction after receiving
morphine. The nurse should plan to institute which actions?
Select all that apply.
A. Administer oxygen.
B. Quickly assess the client's respiratory status.
C. Document the event, interventions, and client's response.
D. Leave the client briefly to contact a primary health care
provider (PHCP).
E. Keep the client supine regardless of the blood pressure
readings.
F. Start an intravenous (IV) infusion of D5W and administer a
500-mL bolus. Correct Answers A, B, C
A client has had radical neck dissection and begins to
hemorrhage at the incision site. The nurse should take which
actions in this situation? Select all that apply.
,A. Monitor vital signs.
B. Monitor the client's airway.
C. Apply manual pressure over the site.
D. Lower the head of the bed to a flat position.
E. Call the primary health care provider (PHCP) immediately.
Correct Answers A, B, C, E
A client has undergone esophagogastroduodenoscopy. The nurse
should place highest priority on which item as part of the client's
care plan?
A. Monitoring the temperature
B. Monitoring complaints of heartburn
C. Giving warm gargles for a sore throat
D. Assessing for the return of the gag reflex Correct Answers
D
A client is admitted to the ambulatory surgery center for elective
surgery. The nurse asks the client whether any food, fluid, or
medication was taken today. Which medication, if taken by the
client, should indicate to the nurse the need to contact the
surgeon?
A. A beta-blocker
B. An antibiotic
C. An anticoagulant
D. A calcium-channel blocker Correct Answers C
A client is admitted to the hospital with a diagnosis of
neurogenic shock after a traumatic motor vehicle collision.
Which manifestation best characterizes this diagnosis?
A. Bradycardia
B. Hyperthermia
, C. Hypoglycemia
D. Increased cardiac output Correct Answers A
A client is brought to the emergency department with partial-
thickness burns to his face, neck, arms, and chest after trying to
put out a car fire. The nurse should implement which nursing
actions for this client? Select all that apply.
A. Restrict fluids.
B. Assess for airway patency.
C. Administer oxygen as prescribed.
D. Place a cooling blanket on the client.
E. Elevate extremities if no fractures are present.
F. Prepare to give oral pain medication as prescribed. Correct
Answers B, C, E
A client is undergoing fluid replacement after being burned on
20% of her body 12 hours ago. The nursing assessment reveals a
blood pressure of 90/50 mm Hg, a pulse rate of 110
beats/minute, and a urine output of 20 mL over the past hour.
The nurse reports the findings to the primary health care
provider (PHCP) and anticipates which prescription?
A. Transfusing 1 unit of packed red blood cells
B. Administering a diuretic to increase urine output
C. Increasing the amount of intravenous (IV) lactated Ringer's
solution administered per hour
D. Changing the IV lactated Ringer's solution to one that
contains 5% dextrose in water Correct Answers C
A client with a gastric ulcer is scheduled for surgery. The client
cannot sign the operative consent form because of sedation from
A 42-year-old female patient is transferred to a surgical unit
after a colostomy. The nurse observes the stoma to be deep pink
with edema and a small amount of sanguineous (red) drainage.
The nurse should:
A. Place ice packs around the stoma.
B. Notify the surgeon about the stoma.
C. Monitor the stoma every 30 minutes.
D. Document stoma assessment findings. Correct Answers D
Document stoma assessment findings.
A 43 yo patient is going to have stomach surgery. Which of the
following is a major pre-op concern?
A. Brother had a tonsillectomy at age 11
B. Patient has IV fluids running at 50 mL/hr
C. Patient smokes 1 pack per day
D. Patient had surgery 6 months ago Correct Answers C.
Patient smokes 1 pack per day
A 50-year-old patient is admitted to the ED with severe
abdominal pain and rebound tenderness. Vital signs include
temperature 102° F, pulse 127, respirations 31, and blood
pressure 80/54. Which prescribed intervention should the nurse
implement first?
A. Administer IV ketorolac (Toradol) 15 mg.
B. Draw blood for a complete blood count (CBC).
C. Obtain a computed tomography (CT) scan of the abdomen.
D. Infuse 1 liter bolus of 0.9% Normal Saline. Correct Answers
D
Infuse 1 liter bolus if 0.9% Normal Saline
,A 56-year-old patient arrives in the emergency department with
left-sided weakness and slurred speech that started 2 hours
previously. The patient's past medical history includes several
transient ischemic attacks (TIAs). The nurse anticipates
preparing the patient for:
a. balloon angioplasty
b. carotid endarterectomy
c. alteplase (tPA) administration
d. continuous heparin administration Correct Answers C. The
patient's history of TIAs and clinical manifestations suggest an
acute ischemic stroke. The patient's onset of symptoms is within
the window for alteplase administration. A head CT would be
necessary to determine ischemic versus hemorrhagic stroke.
A client develops an anaphylactic reaction after receiving
morphine. The nurse should plan to institute which actions?
Select all that apply.
A. Administer oxygen.
B. Quickly assess the client's respiratory status.
C. Document the event, interventions, and client's response.
D. Leave the client briefly to contact a primary health care
provider (PHCP).
E. Keep the client supine regardless of the blood pressure
readings.
F. Start an intravenous (IV) infusion of D5W and administer a
500-mL bolus. Correct Answers A, B, C
A client has had radical neck dissection and begins to
hemorrhage at the incision site. The nurse should take which
actions in this situation? Select all that apply.
,A. Monitor vital signs.
B. Monitor the client's airway.
C. Apply manual pressure over the site.
D. Lower the head of the bed to a flat position.
E. Call the primary health care provider (PHCP) immediately.
Correct Answers A, B, C, E
A client has undergone esophagogastroduodenoscopy. The nurse
should place highest priority on which item as part of the client's
care plan?
A. Monitoring the temperature
B. Monitoring complaints of heartburn
C. Giving warm gargles for a sore throat
D. Assessing for the return of the gag reflex Correct Answers
D
A client is admitted to the ambulatory surgery center for elective
surgery. The nurse asks the client whether any food, fluid, or
medication was taken today. Which medication, if taken by the
client, should indicate to the nurse the need to contact the
surgeon?
A. A beta-blocker
B. An antibiotic
C. An anticoagulant
D. A calcium-channel blocker Correct Answers C
A client is admitted to the hospital with a diagnosis of
neurogenic shock after a traumatic motor vehicle collision.
Which manifestation best characterizes this diagnosis?
A. Bradycardia
B. Hyperthermia
, C. Hypoglycemia
D. Increased cardiac output Correct Answers A
A client is brought to the emergency department with partial-
thickness burns to his face, neck, arms, and chest after trying to
put out a car fire. The nurse should implement which nursing
actions for this client? Select all that apply.
A. Restrict fluids.
B. Assess for airway patency.
C. Administer oxygen as prescribed.
D. Place a cooling blanket on the client.
E. Elevate extremities if no fractures are present.
F. Prepare to give oral pain medication as prescribed. Correct
Answers B, C, E
A client is undergoing fluid replacement after being burned on
20% of her body 12 hours ago. The nursing assessment reveals a
blood pressure of 90/50 mm Hg, a pulse rate of 110
beats/minute, and a urine output of 20 mL over the past hour.
The nurse reports the findings to the primary health care
provider (PHCP) and anticipates which prescription?
A. Transfusing 1 unit of packed red blood cells
B. Administering a diuretic to increase urine output
C. Increasing the amount of intravenous (IV) lactated Ringer's
solution administered per hour
D. Changing the IV lactated Ringer's solution to one that
contains 5% dextrose in water Correct Answers C
A client with a gastric ulcer is scheduled for surgery. The client
cannot sign the operative consent form because of sedation from
