nurs 3000 final UPDATED ACTUAL Questions and
CORRECT Answers
When analyzing the waveforms of a client's QRS interval of 0.14 second
electrocardiogram (ECG), the nurse will need to
investigate further upon assessing which of the following
findings?
a. A P-R interval of 0.18 seconds
b. A QRS interval of 0.14 seconds
c. Q-T interval of 0.34 seconds
d. T wave of 0.16 seconds
Unconsciousness without response to painful stimuli is Respiratory rate
assessed in a client with a head injury who has been
admitted to the emergency department. To promote
cerebral blood flow in the client, initially what is the most
important for the nurse to monitor?
a. Arterial blood pressure
b. Arterial blood gas results
c. Respiratory rate
d. Level of consciousness
A nurse is obtaining a health history from a client with a "Have you been to the dentist lately?"
prosthetic mitral valve who has symptoms of infective
endocarditis (IE). Which of the following questions by the
nurse is best?
a. "Have you had any recent immunizations?"
b. "Do you have a history of heart attack?"
c. "Have you been to the dentist lately?"
d. "Do you have a family history of endocarditis?"
Which of the following assessment data obtained by the b. Jugular vein distension (JVD) to the level of the jaw
nurse when assessing a client with acute pericarditis
should be reported immediately to the health care
provider?
a. Blood pressure (BP) of 146/86
b. Jugular vein distension (JVD) to the level of the jaw
c. Pulsus paradoxus 8 mm Hg
d. Level 6 (0-10) chest pain with deep inspiration
The nurse is interpreting an ECG strip to determine P wave
whether there is a delay in impulse conduction through
the atria. Which of the following components of an ECG
strip should the nurse interpret?
a. QRS complex
b. QT interval
c. P wave
d. PR interval
,Which of the following actions should the nurse take first Auscultate the client's lung sounds
when a client arrives in the emergency department with
facial and chest burns caused by a house fire?
a. Infuse the ordered IV solution
b. Auscultate the client's lung sounds
c. Determine the extent and depth of the burns
d. Administer the ordered opioid pain medications
The nurse is caring for a client who has had recent Ibuprofen 800mg PO
cardiac surgery and develops pericarditis, with symptoms
of chest pain at a level 6 (0-10 scale) when inhaling
deeply. Which of the following prescribed PRN
medications should the nurse administer?
a. Acetaminophen 650mg PO
b. Fentanyl 2mg IV
c. Morphine sulphate 6mg IV
d. Ibuprofen 800mg PO
The 1-hour sepsis bundle recommends administeing a Hypotension
30mL/kg bolus of crystalloid IV fluids to treat:
a. Dehydration
b. Hypoxemia
c. Hypotension
d. Renal failure
The nurse is caring for a patient with diabetic pH 7.28, PaCO2 58, HCO-3 38
ketoacidosis. Which arterial blood gas analysis is
consistent with this type of condition?
a. pH 7.28, PaCO2 58, HCO-3 38
b. ph 7.51, PaCO2 51, HCO-3 37
c. pH 7.49, PaCO2 32, HCO-3 22
d. pH 7.21, PaCO2 28, HCO-3 18
The nurse is caring for a client following an incisional Client education about low-fat food choices
cholecystectomy for cholelithiasis. Which of the following
actions is priority for the nurse to implement?
a. Ambulate the evening of the operative day
b. Turn, cough, and deep breath every 2 hours
c. Client education about low-fat food choices
d. Perform leg exercises hourly while awake
Which of the following findings in a client with infective Janeways lesions on the palms
endocarditis (IE) is the most important for the nurse to
communicate to the health care provider?
a. Janeways lesions on the palms
b. Temperature of 38.1 degrees celcius
Name each factor that is a part of Virchow's Triad and 1. Venous stasis: prolonged immobility
provide one example for each factor that could lead to a 2. Endothelial injury: trauma, surgery of abdomen or pelvis
venous thrombosis. 3. Hypercoagulability of blood: malnutrition or dehydration
, The nurse is caring for a client who underwent a left total Sit the client up in bed as tolerated and apply oxygen
knee arthroplasty. On the third postoperative day, the
client has symptoms of shortness of breath, slight chest
pain and that "something is wrong". Temperature is 36.9,
blood pressure 130/88 mm Hg, respirations 36
breaths/minute and oxygen saturation 91% on room air.
Which of the following actions should the nurse take
first?
a. Conduct a thorough assessment of the chest pain
b. Administer a nitroglycerine tablet sublingually
c. Notify the health care provider
d. Sit the client up in bed as tolerated and apply oxygen
The nurse is admitting a client with possible acute Echocardiography
pericarditis. Which of the following diagnostic
assessments should the nurse plan to teach the client
about?
a. Electrolyte levels
b. Cardiac catheterization
c. Daily blood cultures
d. Echocardiography
The nurse is caring for a patient with an electrical burn pH 7.28, PaCO2 58, HCO-3 38
injury. Which arterial blood gas analysis would alert the
nurse to problem consistent with this type of injury?
a. pH 7.30, PaCO2 31, HCO-3 19
b. pH 7.49, PaCO2 32, HCO-3 22
c. pH 7.28, PaCO2 58, HCO-3 38
d. pH 7.51, PaCO2 51, HCO-3 37
The nurse is providing discharge instructions to a patient "This condition happens suddenly without any warning signs."
who recovered from hyperglycemic hyperosmolar non-
ketotic syndrome (HHNS). Which statement by the patient
requires additional teaching about this condition?
a. "This condition happens suddenly without any warning
signs."
b. "I will monitor my blood glucose levels regularly."
c. "It is important I take my medications as prescribed."
d. "If I become sick, I will monitor my blood glucose
more frequently and drink lots of fluids."
In the first 24 hours after a traumatic head injury, what is Hypotension
the most significant factor in poor outcomes and
increased morbidity (death)?
a. Hyperglycemia
b. Hypotension
c. Hypocarbia
d. Hypotension
CORRECT Answers
When analyzing the waveforms of a client's QRS interval of 0.14 second
electrocardiogram (ECG), the nurse will need to
investigate further upon assessing which of the following
findings?
a. A P-R interval of 0.18 seconds
b. A QRS interval of 0.14 seconds
c. Q-T interval of 0.34 seconds
d. T wave of 0.16 seconds
Unconsciousness without response to painful stimuli is Respiratory rate
assessed in a client with a head injury who has been
admitted to the emergency department. To promote
cerebral blood flow in the client, initially what is the most
important for the nurse to monitor?
a. Arterial blood pressure
b. Arterial blood gas results
c. Respiratory rate
d. Level of consciousness
A nurse is obtaining a health history from a client with a "Have you been to the dentist lately?"
prosthetic mitral valve who has symptoms of infective
endocarditis (IE). Which of the following questions by the
nurse is best?
a. "Have you had any recent immunizations?"
b. "Do you have a history of heart attack?"
c. "Have you been to the dentist lately?"
d. "Do you have a family history of endocarditis?"
Which of the following assessment data obtained by the b. Jugular vein distension (JVD) to the level of the jaw
nurse when assessing a client with acute pericarditis
should be reported immediately to the health care
provider?
a. Blood pressure (BP) of 146/86
b. Jugular vein distension (JVD) to the level of the jaw
c. Pulsus paradoxus 8 mm Hg
d. Level 6 (0-10) chest pain with deep inspiration
The nurse is interpreting an ECG strip to determine P wave
whether there is a delay in impulse conduction through
the atria. Which of the following components of an ECG
strip should the nurse interpret?
a. QRS complex
b. QT interval
c. P wave
d. PR interval
,Which of the following actions should the nurse take first Auscultate the client's lung sounds
when a client arrives in the emergency department with
facial and chest burns caused by a house fire?
a. Infuse the ordered IV solution
b. Auscultate the client's lung sounds
c. Determine the extent and depth of the burns
d. Administer the ordered opioid pain medications
The nurse is caring for a client who has had recent Ibuprofen 800mg PO
cardiac surgery and develops pericarditis, with symptoms
of chest pain at a level 6 (0-10 scale) when inhaling
deeply. Which of the following prescribed PRN
medications should the nurse administer?
a. Acetaminophen 650mg PO
b. Fentanyl 2mg IV
c. Morphine sulphate 6mg IV
d. Ibuprofen 800mg PO
The 1-hour sepsis bundle recommends administeing a Hypotension
30mL/kg bolus of crystalloid IV fluids to treat:
a. Dehydration
b. Hypoxemia
c. Hypotension
d. Renal failure
The nurse is caring for a patient with diabetic pH 7.28, PaCO2 58, HCO-3 38
ketoacidosis. Which arterial blood gas analysis is
consistent with this type of condition?
a. pH 7.28, PaCO2 58, HCO-3 38
b. ph 7.51, PaCO2 51, HCO-3 37
c. pH 7.49, PaCO2 32, HCO-3 22
d. pH 7.21, PaCO2 28, HCO-3 18
The nurse is caring for a client following an incisional Client education about low-fat food choices
cholecystectomy for cholelithiasis. Which of the following
actions is priority for the nurse to implement?
a. Ambulate the evening of the operative day
b. Turn, cough, and deep breath every 2 hours
c. Client education about low-fat food choices
d. Perform leg exercises hourly while awake
Which of the following findings in a client with infective Janeways lesions on the palms
endocarditis (IE) is the most important for the nurse to
communicate to the health care provider?
a. Janeways lesions on the palms
b. Temperature of 38.1 degrees celcius
Name each factor that is a part of Virchow's Triad and 1. Venous stasis: prolonged immobility
provide one example for each factor that could lead to a 2. Endothelial injury: trauma, surgery of abdomen or pelvis
venous thrombosis. 3. Hypercoagulability of blood: malnutrition or dehydration
, The nurse is caring for a client who underwent a left total Sit the client up in bed as tolerated and apply oxygen
knee arthroplasty. On the third postoperative day, the
client has symptoms of shortness of breath, slight chest
pain and that "something is wrong". Temperature is 36.9,
blood pressure 130/88 mm Hg, respirations 36
breaths/minute and oxygen saturation 91% on room air.
Which of the following actions should the nurse take
first?
a. Conduct a thorough assessment of the chest pain
b. Administer a nitroglycerine tablet sublingually
c. Notify the health care provider
d. Sit the client up in bed as tolerated and apply oxygen
The nurse is admitting a client with possible acute Echocardiography
pericarditis. Which of the following diagnostic
assessments should the nurse plan to teach the client
about?
a. Electrolyte levels
b. Cardiac catheterization
c. Daily blood cultures
d. Echocardiography
The nurse is caring for a patient with an electrical burn pH 7.28, PaCO2 58, HCO-3 38
injury. Which arterial blood gas analysis would alert the
nurse to problem consistent with this type of injury?
a. pH 7.30, PaCO2 31, HCO-3 19
b. pH 7.49, PaCO2 32, HCO-3 22
c. pH 7.28, PaCO2 58, HCO-3 38
d. pH 7.51, PaCO2 51, HCO-3 37
The nurse is providing discharge instructions to a patient "This condition happens suddenly without any warning signs."
who recovered from hyperglycemic hyperosmolar non-
ketotic syndrome (HHNS). Which statement by the patient
requires additional teaching about this condition?
a. "This condition happens suddenly without any warning
signs."
b. "I will monitor my blood glucose levels regularly."
c. "It is important I take my medications as prescribed."
d. "If I become sick, I will monitor my blood glucose
more frequently and drink lots of fluids."
In the first 24 hours after a traumatic head injury, what is Hypotension
the most significant factor in poor outcomes and
increased morbidity (death)?
a. Hyperglycemia
b. Hypotension
c. Hypocarbia
d. Hypotension
