NUR 2310 Final Questions With Complete Solutions
•A 20-yr-old patient who sustained a T2 spinal cord injury 10
days ago tells the nurse, "I want to be transferred to a hospital
where the nurses know what they are doing." Which action by
the nurse is appropriate?
•A. respond that abusive language will not be tolerated
•B. Request that the patient provide input for the plan of care
•C. Perform care without responding to the patient's comments
•D. Reassure the patient about the competence of the nursing
staff Correct Answers Ans: B
The patient is demonstrating behaviors consistent with the anger
phase of the grief process, and the nurse should allow expression
of anger and seek the patient's input into care. Expression of
anger is appropriate at this stage, and should be accepted by the
nurse. Reassurance about the competency of the staff will not be
helpful in responding to the patient's concerns. Ignoring the
patient's comments will increase the patient's anger and sense of
helplessness.
•A new nurse performs a dressing change on a stage II left heel
pressure ulcer. Which action by the new nurse indicates a need
for further teaching about pressure ulcer care?
•A. The new nurse cleans the ulcer with half strength peroxide
•B. The new nurse uses a hydrocolloid dressing (DuoDerm) on
the ulcer
•C. The new nurse irrigates the pressure ulcer with saline using a
30-mL syringe
•D. The new nurse inserts a sterile cotton-tipped applicator into
the pressure ulcer Correct Answers ANS: A
,Rationale: Pressure ulcers should not be cleaned with solutions
that are cytotoxic, such as hydrogen peroxide. The other actions
by the new nurse are appropriate.
•A nurse is developing a plan of care for a patient admitted with
a diagnosis of bipolar disorder, manic phase. Which nursing
diagnoses address priority needs for the patient? (Select all that
apply)
•A. Risk for caregiver strain
•B. Impaired verbal communication
•C. Risk for injury
•D. Imbalanced nutrition, less than body requirements
•E. Ineffective coping
F. Sleep deprivation Correct Answers ANS: CDF
Risk for injury, poor nutrition, and impaired sleep are priority
needs of the patient experiencing mania related to their
impulsivity, inability to attend to activities of daily living such
as diet and hygiene, and disruption of sleep. Caregiver strain is
important to be addressed but is not a priority need on admission
for the patient. Verbal communication improves when the mania
is managed, and racing thoughts return to normal patterns.
Ineffective coping will require stabilization of the acute phase
along with cognitive therapy over time.
•A patient arrives in the emergency department with facial and
chest burns caused by a house fire. Which action should the
nurse take first?
•A. auscultate the patient's lung sounds
•B. determine the extent and depth of the burns
•C. give the prescribed hydromorphone (Dilaudid)
,•D. infuse the prescribed lactated ringer's soluction Correct
Answers ANS: A
Rationale: A patient with facial and chest burns is at risk for
inhalation injury and assessment of airway and breathing is the
priority. The other actions will be completed after airway
management is assured.
•A patient being admitted with an acute exacerbation of
ulcerative colitis reports crampy abdominal pain and passing 15
or more bloody stools a day. The nurse will plan to
a. Administer IV metoclopramide (Reglan).
b. Discontinue the patient's oral food intake.
c. Administer cobalamin (vitamin B12) injections.
d. Teach the patient about total colectomy surgery. Correct
Answers Ans: B
Rationale: An initial therapy for an acute exacerbation of
inflammatory bowel disease (IBD) is to rest the bowel by
making the patient NPO. Metoclopramide increases peristalsis
and will worsen symptoms. Cobalamin (vitamin B12) is
absorbed in the ileum, which is not affected by ulcerative colitis.
Although total colectomy is needed for some patients, there is
no indication that this patient is a candidate.
•A patient from a long-term care facility is admitted to the
hospital with a sacral pressure ulcer. The base of the wound
involves subcutaneous tissue. How should the nurse classify this
pressure ulcer?
•A. Stage I
•B. Stage II
•C. Stage III
D. Stage IV Correct Answers ANS: C
, Rationale: A stage III pressure ulcer has full-thickness skin
damage and extends into the subcutaneous tissue. A stage I
pressure ulcer has intact skin with some observable damage such
as redness or a boggy feel. Stage II pressure ulcers have partial-
thickness skin loss. Stage IV pressure ulcers have full-thickness
damage with tissue necrosis, extensive damage, or damage to
bone, muscle, or supporting tissue
•A patient had an incisional cholecystectomy 6 hours ago. The
nurse will place the highest priority on assisting the patient to
a. Perform leg exercises hourly while awake.
b. Ambulate the evening of the operative day.
c. Turn, cough, and deep breathe every 2 hours.
d. Choose preferred low-fat foods from the menu. Correct
Answers Ans: C
Rationale: Postoperative nursing care after a cholecystectomy
focuses on prevention of respiratory complications because the
surgical incision is high in the abdomen and impairs coughing
and deep breathing. The other nursing actions are also important
to implement but are not as high a priority as ensuring adequate
ventilation.
•A patient has been prescribed a selective serotonin reuptake
inhibitor (SSRI) antidepressant. After taking the new
medication, the patient states, "This medication isn't working. I
don't feel any different." What is the best response by the nurse?
•A. "I will call your care provider. Perhaps you need a different
medication."
•B. "Don't worry. You can try taking it at a different time of day
to help it work better."
•A 20-yr-old patient who sustained a T2 spinal cord injury 10
days ago tells the nurse, "I want to be transferred to a hospital
where the nurses know what they are doing." Which action by
the nurse is appropriate?
•A. respond that abusive language will not be tolerated
•B. Request that the patient provide input for the plan of care
•C. Perform care without responding to the patient's comments
•D. Reassure the patient about the competence of the nursing
staff Correct Answers Ans: B
The patient is demonstrating behaviors consistent with the anger
phase of the grief process, and the nurse should allow expression
of anger and seek the patient's input into care. Expression of
anger is appropriate at this stage, and should be accepted by the
nurse. Reassurance about the competency of the staff will not be
helpful in responding to the patient's concerns. Ignoring the
patient's comments will increase the patient's anger and sense of
helplessness.
•A new nurse performs a dressing change on a stage II left heel
pressure ulcer. Which action by the new nurse indicates a need
for further teaching about pressure ulcer care?
•A. The new nurse cleans the ulcer with half strength peroxide
•B. The new nurse uses a hydrocolloid dressing (DuoDerm) on
the ulcer
•C. The new nurse irrigates the pressure ulcer with saline using a
30-mL syringe
•D. The new nurse inserts a sterile cotton-tipped applicator into
the pressure ulcer Correct Answers ANS: A
,Rationale: Pressure ulcers should not be cleaned with solutions
that are cytotoxic, such as hydrogen peroxide. The other actions
by the new nurse are appropriate.
•A nurse is developing a plan of care for a patient admitted with
a diagnosis of bipolar disorder, manic phase. Which nursing
diagnoses address priority needs for the patient? (Select all that
apply)
•A. Risk for caregiver strain
•B. Impaired verbal communication
•C. Risk for injury
•D. Imbalanced nutrition, less than body requirements
•E. Ineffective coping
F. Sleep deprivation Correct Answers ANS: CDF
Risk for injury, poor nutrition, and impaired sleep are priority
needs of the patient experiencing mania related to their
impulsivity, inability to attend to activities of daily living such
as diet and hygiene, and disruption of sleep. Caregiver strain is
important to be addressed but is not a priority need on admission
for the patient. Verbal communication improves when the mania
is managed, and racing thoughts return to normal patterns.
Ineffective coping will require stabilization of the acute phase
along with cognitive therapy over time.
•A patient arrives in the emergency department with facial and
chest burns caused by a house fire. Which action should the
nurse take first?
•A. auscultate the patient's lung sounds
•B. determine the extent and depth of the burns
•C. give the prescribed hydromorphone (Dilaudid)
,•D. infuse the prescribed lactated ringer's soluction Correct
Answers ANS: A
Rationale: A patient with facial and chest burns is at risk for
inhalation injury and assessment of airway and breathing is the
priority. The other actions will be completed after airway
management is assured.
•A patient being admitted with an acute exacerbation of
ulcerative colitis reports crampy abdominal pain and passing 15
or more bloody stools a day. The nurse will plan to
a. Administer IV metoclopramide (Reglan).
b. Discontinue the patient's oral food intake.
c. Administer cobalamin (vitamin B12) injections.
d. Teach the patient about total colectomy surgery. Correct
Answers Ans: B
Rationale: An initial therapy for an acute exacerbation of
inflammatory bowel disease (IBD) is to rest the bowel by
making the patient NPO. Metoclopramide increases peristalsis
and will worsen symptoms. Cobalamin (vitamin B12) is
absorbed in the ileum, which is not affected by ulcerative colitis.
Although total colectomy is needed for some patients, there is
no indication that this patient is a candidate.
•A patient from a long-term care facility is admitted to the
hospital with a sacral pressure ulcer. The base of the wound
involves subcutaneous tissue. How should the nurse classify this
pressure ulcer?
•A. Stage I
•B. Stage II
•C. Stage III
D. Stage IV Correct Answers ANS: C
, Rationale: A stage III pressure ulcer has full-thickness skin
damage and extends into the subcutaneous tissue. A stage I
pressure ulcer has intact skin with some observable damage such
as redness or a boggy feel. Stage II pressure ulcers have partial-
thickness skin loss. Stage IV pressure ulcers have full-thickness
damage with tissue necrosis, extensive damage, or damage to
bone, muscle, or supporting tissue
•A patient had an incisional cholecystectomy 6 hours ago. The
nurse will place the highest priority on assisting the patient to
a. Perform leg exercises hourly while awake.
b. Ambulate the evening of the operative day.
c. Turn, cough, and deep breathe every 2 hours.
d. Choose preferred low-fat foods from the menu. Correct
Answers Ans: C
Rationale: Postoperative nursing care after a cholecystectomy
focuses on prevention of respiratory complications because the
surgical incision is high in the abdomen and impairs coughing
and deep breathing. The other nursing actions are also important
to implement but are not as high a priority as ensuring adequate
ventilation.
•A patient has been prescribed a selective serotonin reuptake
inhibitor (SSRI) antidepressant. After taking the new
medication, the patient states, "This medication isn't working. I
don't feel any different." What is the best response by the nurse?
•A. "I will call your care provider. Perhaps you need a different
medication."
•B. "Don't worry. You can try taking it at a different time of day
to help it work better."
