NR 464 - Exam 4 (BoostGrade) Questions With Complete
Solutions
A 19-year-old patient with massive trauma and possible spinal
cord injury is admitted to the emergency department (ED).
Which assessment finding by the nurse will help confirm a
diagnosis of neurogenic shock?
a. Inspiratory crackles.
b. Cool, clammy extremities.
c. Apical heart rate 45 beats/min.
d. Temperature 101.2° F (38.4° C). Correct Answers c. Apical
heart rate 45 beats/min.
Neurogenic shock is characterized by hypotension and
bradycardia. The other findings would be more consistent with
other types of shock.
A 78-kg patient with septic shock has a urine output of 30 mL/hr
for the past 3 hours. The pulse rate is 120/minute and the central
venous pressure and pulmonary artery wedge pressure are low.
Which order by the health care provider will the nurse question?
a. Give PRN furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 250 mL/hr.
c. Administer hydrocortisone (Solu-Cortef) 100 mg IV.
,d. Titrate norepinephrine (Levophed) to keep systolic BP >90
mm Hg. Correct Answers a. Give PRN furosemide (Lasix) 40
mg IV.
Furosemide will lower the filling pressures and renal perfusion
further for the patient with septic shock. The other orders are
appropriate.
A chemotherapy drug that causes alopecia is prescribed for a
patient. Which action should the nurse take to maintain the
patient's self-esteem?
a. Tell the patient to limit social contacts until regrowth of the
hair occurs.
b. Encourage the patient to purchase a wig or hat and wear it
once hair loss begins.
c. Teach the patient to gently wash hair with a mild shampoo to
minimize hair loss.
d. Inform the patient that hair usually grows back once the
chemotherapy is complete. Correct Answers b. Encourage the
patient to purchase a wig or hat and wear it once hair loss
begins.
The patient is taught to anticipate hair loss and to be prepared
with wigs, scarves, or hats. Limiting social contacts is not
appropriate at a time when the patient is likely to need a good
social support system. The damage occurs at the hair follicle and
,will occur regardless of gentle washing or use of a mild
shampoo. The information that the hair will grow back is not
immediately helpful in maintaining the patient's self-esteem.
A hospitalized patient who has received chemotherapy for
leukemia develops neutropenia. Which observation by the nurse
would indicate a need for further teaching?
a. The patient ambulates several times a day in the room.
b. The patient's visitors bring in some fresh peaches from home.
c. The patient cleans with a warm washcloth after having a stool.
d. The patient uses soap and shampoo to shower every other
day. Correct Answers b. The patient's visitors bring in some
fresh peaches from home.
Fresh, thinned-skin fruits are not permitted in a neutropenic diet
because of the risk of bacteria being present. The patient should
ambulate in the room rather than the hospital hallway to avoid
exposure to other patients or visitors. Because overuse of soap
can dry the skin and increase infection risk, showering every
other day is acceptable. Careful cleaning after having a bowel
movement will help prevent skin breakdown and infection.
A nurse is assessing a patient who is receiving a nitroprusside
(Nipride) infusion to treat cardiogenic shock. Which finding
indicates that the medication is effective?
a. No new heart murmurs
, b. Decreased troponin level
c. Warm, pink, and dry skin
d. Blood pressure 92/40 mm Hg Correct Answers c. Warm,
pink, and dry skin
Warm, pink, and dry skin indicates that perfusion to tissues is
improved. Since nitroprusside is a vasodilator, the blood
pressure may be low even if the medication is effective.
Absence of a heart murmur and a decrease in troponin level are
not indicators of improvement in shock.
A nurse is caring for a patient who has burns of the ears, head,
neck, and right arm and hand. The nurse should place the patient
in which position?
a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the
fingers.
c. Assist the patient to a supine position with a small pillow
under the head.
d. Position the patient in a side-lying position with rolled towel
under the neck. Correct Answers b. Elevate the right arm and
hand on pillows and extend the fingers.
Solutions
A 19-year-old patient with massive trauma and possible spinal
cord injury is admitted to the emergency department (ED).
Which assessment finding by the nurse will help confirm a
diagnosis of neurogenic shock?
a. Inspiratory crackles.
b. Cool, clammy extremities.
c. Apical heart rate 45 beats/min.
d. Temperature 101.2° F (38.4° C). Correct Answers c. Apical
heart rate 45 beats/min.
Neurogenic shock is characterized by hypotension and
bradycardia. The other findings would be more consistent with
other types of shock.
A 78-kg patient with septic shock has a urine output of 30 mL/hr
for the past 3 hours. The pulse rate is 120/minute and the central
venous pressure and pulmonary artery wedge pressure are low.
Which order by the health care provider will the nurse question?
a. Give PRN furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 250 mL/hr.
c. Administer hydrocortisone (Solu-Cortef) 100 mg IV.
,d. Titrate norepinephrine (Levophed) to keep systolic BP >90
mm Hg. Correct Answers a. Give PRN furosemide (Lasix) 40
mg IV.
Furosemide will lower the filling pressures and renal perfusion
further for the patient with septic shock. The other orders are
appropriate.
A chemotherapy drug that causes alopecia is prescribed for a
patient. Which action should the nurse take to maintain the
patient's self-esteem?
a. Tell the patient to limit social contacts until regrowth of the
hair occurs.
b. Encourage the patient to purchase a wig or hat and wear it
once hair loss begins.
c. Teach the patient to gently wash hair with a mild shampoo to
minimize hair loss.
d. Inform the patient that hair usually grows back once the
chemotherapy is complete. Correct Answers b. Encourage the
patient to purchase a wig or hat and wear it once hair loss
begins.
The patient is taught to anticipate hair loss and to be prepared
with wigs, scarves, or hats. Limiting social contacts is not
appropriate at a time when the patient is likely to need a good
social support system. The damage occurs at the hair follicle and
,will occur regardless of gentle washing or use of a mild
shampoo. The information that the hair will grow back is not
immediately helpful in maintaining the patient's self-esteem.
A hospitalized patient who has received chemotherapy for
leukemia develops neutropenia. Which observation by the nurse
would indicate a need for further teaching?
a. The patient ambulates several times a day in the room.
b. The patient's visitors bring in some fresh peaches from home.
c. The patient cleans with a warm washcloth after having a stool.
d. The patient uses soap and shampoo to shower every other
day. Correct Answers b. The patient's visitors bring in some
fresh peaches from home.
Fresh, thinned-skin fruits are not permitted in a neutropenic diet
because of the risk of bacteria being present. The patient should
ambulate in the room rather than the hospital hallway to avoid
exposure to other patients or visitors. Because overuse of soap
can dry the skin and increase infection risk, showering every
other day is acceptable. Careful cleaning after having a bowel
movement will help prevent skin breakdown and infection.
A nurse is assessing a patient who is receiving a nitroprusside
(Nipride) infusion to treat cardiogenic shock. Which finding
indicates that the medication is effective?
a. No new heart murmurs
, b. Decreased troponin level
c. Warm, pink, and dry skin
d. Blood pressure 92/40 mm Hg Correct Answers c. Warm,
pink, and dry skin
Warm, pink, and dry skin indicates that perfusion to tissues is
improved. Since nitroprusside is a vasodilator, the blood
pressure may be low even if the medication is effective.
Absence of a heart murmur and a decrease in troponin level are
not indicators of improvement in shock.
A nurse is caring for a patient who has burns of the ears, head,
neck, and right arm and hand. The nurse should place the patient
in which position?
a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the
fingers.
c. Assist the patient to a supine position with a small pillow
under the head.
d. Position the patient in a side-lying position with rolled towel
under the neck. Correct Answers b. Elevate the right arm and
hand on pillows and extend the fingers.
