NUR 216 Final Exam NEW MATERIAL UPDATED ACTUAL
Questions and CORRECT Answers
A student is caring for a client who suffered massive B ~ Lower blood volume will decrease MAP. The other answers are not accurate.
blood loss after trauma. How does the student correlate
the blood loss with the client's mean arterial pressure
(MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.
A nurse is caring for a client after surgery. The client's B ~ Signs of the earliest stage of shock are subtle and may manifest in slight
respiratory rate has increased from 12 to 18 breaths/min increases in heart rate, respiratory rate, or blood pressure. Even though these
and the pulse rate increased from 86 to 98 beats/min readings are not out of the normal range, the nurse should conduct a thorough
since they were last assessed 4 hours ago. What action assessment of the client, focusing on indicators of perfusion. The client may need
by the nurse is best? pain medication, but this is not the priority at this time. Documentation should be
a. Ask if the client needs pain medication. done thoroughly but is not the priority either. The nurse should not increase the
b. Assess the client's tissue perfusion further. rate of the IV infusion without an order.
c. Document the findings in the client's chart.
d. Increase the rate of the client's IV infusion.
The nurse gets the hand-off report on four clients. Which A ~ This client has a falling systolic blood pressure, rising diastolic blood pressure,
client should the nurse assess first? and narrowing pulse pressure, all of which may be indications of the progressive
a. Client with a blood pressure change of 128/74 to 110/88 stage of shock. The nurse should assess this client first. The client with the
mm Hg unchanged oxygen saturation is stable at this point. Although the client with a
b. Client with oxygen saturation unchanged at 94% change in pulse has a slower rate, it is not an indicator of shock since the pulse is
c. Client with a pulse change of 100 to 88 beats/min still within the normal range; it may indicate the client's pain or anxiety has been
d. Client with urine output of 40 mL/hr for the last 2 hours relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only
slightly above the normal range, which is 30 mL/hr.
A nurse is caring for a client after surgery who is restless B ~ Urine output changes are a sensitive early indicator of shock. The nurse should
and apprehensive. The unlicensed assistive personnel delegate emptying the urinary catheter and measuring output to the UAP as a
(UAP) reports the vital signs and the nurse sees they are baseline for hourly urine output measurements. The UAP cannot assess for pain.
only slightly different from previous readings. What action Repositioning may or may not be effective for decreasing restlessness, but does
does the nurse delegate next to the UAP? not take priority over physical assessments. Reassurance is a therapeutic nursing
a. Assess the client for pain or discomfort. action, but the nurse needs to do more in this situation.
b. Measure urine output from the catheter.
c. Reposition the client to the unaffected side.
d. Stay with the client and reassure him or her.
,A client is in shock and the nurse prepares to administer A ~ High glucose readings are common in shock, and best outcomes are the
insulin for a blood glucose reading of 208 mg/dL. The result of treating them and maintaining glucose readings in the normal range.
spouse asks why the client needs insulin as the client is Medications and IV solutions may raise blood glucose levels, but this is not the
not a diabetic. What response by the nurse is best? most accurate answer. The stress of the illness has not made the client diabetic.
a. High glucose is common in shock and needs to be
treated.
b. Some of the medications we are giving are to raise
blood sugar.
c. The IV solution has lots of glucose, which raises blood
sugar.
d. The stress of this illness has made your spouse a
diabetic.
A nurse caring for a client notes the following C ~ This client has several indicators of sepsis with systemic inflammatory
assessments: white blood cell count 3800/mm3, blood response. The nurse should notify the health care provider immediately.
glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). Documentation needs to be thorough but does not take priority. The client may
What action by the nurse takes priority? appreciate warm blankets, but comfort measures do not take priority. The client
a. Document the findings in the client's chart. may or may not need insulin.
b. Give the client warmed blankets for comfort.
c. Notify the health care provider immediately.
d. Prepare to administer insulin per sliding scale.
A nurse works at a community center for older adults. B ~ Preventing dehydration in older adults is important because the age-related
What self-management measure can the nurse teach the decrease in the thirst mechanism makes them prone to dehydration. Having older
clients to prevent shock? adults drink fluids on a regular schedule will help keep them hydrated without the
a. Do not get dehydrated in warm weather. influence of thirst (or lack of thirst). Telling clients not to get dehydrated is
b. Drink fluids on a regular schedule. important, but not the best answer because it doesn't give them the tools to
c. Seek attention for any lacerations. prevent it from occurring. Older adults should seek attention for lacerations, but
d. Take medications as prescribed. this is not as important an issue as staying hydrated. Taking medications as
prescribed may or may not be related to hydration.
A client arrives in the emergency department after being B ~ Airway is the priority, followed by breathing and circulation (IVs and direct
in a car crash with fatalities. The client has a nearly pressure). Obtaining consent is done by the physician.
amputated leg that is bleeding profusely. What action by
the nurse takes priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters.
A client is receiving norepinephrine (Levophed) for A ~ Normal cognitive function is a good indicator that the client is receiving the
shock. What assessment finding best indicates a benefits of norepinephrine. The brain is very sensitive to changes in oxygenation
therapeutic effect from this drug? and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so
a. Alert & oriented, answering questions the absence of chest pain does not indicate therapeutic effect. The IV site is
b. Client denial of chest pain or chest pressure normal. The urine output is normal, but only minimally so.
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours
, A student nurse is caring for a client who will be receiving C ~ Nitroprusside degrades in the presence of light, so it must be protected by
sodium nitroprusside (Nipride) via IV infusion. What action leaving it in the original brown plastic bag when infusing. The other actions are
by the student causes the registered nurse to intervene? correct, although a smart pump is not necessarily required if the facility does not
a. Assessing the IV site before giving the drug have them available. The drug must be administered via an IV pump, although the
b. Obtaining a programmable (smart) IV pump programmable pump is preferred for safety.
c. Removing the IV bag from the brown plastic cover
d. Taking and recording a baseline set of vital signs
A client has been brought to the emergency department A ~ The nurses priority is to care for the client. Since the client has gunshot
after being shot multiple times. What action should the wounds and is bleeding, the nurse applies personal protective equipment (i.e.,
nurse perform first? gloves) prior to care. This takes priority over calling law enforcement. Requesting
a. Apply personal protective equipment. blood bank products can be delegated. The nurse may or may not have to
b. Notify local law enforcement officials. prepare the client for emergency surgery.
c. Obtain universal donor blood.
d. Prepare the client for emergency surgery.
A nurse is caring for several clients at risk for shock. B ~ A lactate level of 6 mmol/L is high and is indicative of possible shock. A
Which laboratory value requires the nurse to creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but
communicate with the health care provider? that is not related directly to shock. A white blood cell count of 11,000/mm3 is
a. Creatinine: 0.9 mg/dL slightly high but is not as critical as the lactate level.
b. Lactate: 6 mmol/L
c. Sodium: 150 mEq/L
d. White blood cell count: 11,000/mm3
A client in shock is apprehensive and slightly confused. A ~ The nurses presence will be best to reassure this client. Antianxiety medication
What action by the nurse is best? is not warranted as this will lower the clients blood pressure. Using all four side-
a. Offer to remain with the client for awhile. rails on a hospital bed is considered a restraint in most facilities, although the
b. Prepare to administer antianxiety medication. nurse should ensure the client's safety. Telling a confused client that everything is
c. Raise all four siderails on the client's bed. being done is not the most helpful response.
d. Tell the client everything possible is being done.
A client is being discharged home after a large B ~ All these statements indicate a potential for leading to infection once the
myocardial infarction and subsequent coronary artery client gets back home. A large party might include individuals who are themselves
bypass grafting surgery. The client's sternal wound has ill and contagious. Having litter boxes in the home can expose the client to
not yet healed. What statement by the client most microbes that can lead to infection. Small children often have upper respiratory
indicates a higher risk of developing sepsis after infections and poor hand hygiene that spread germs. However, the most
discharge? worrisome statement is the lack of running water for handwashing and general
a. All my friends and neighbors are planning a party for hygiene and cleaning purposes.
me.
b. I hope I can get my water turned back on when I get
home.
c. I am going to have my daughter scoop the cat litter
box.
d. My grandkids are so excited to have me coming home!
A client in shock has been started on dopamine. What C ~ Chest heaviness or pain indicates myocardial ischemia, a possible adverse
assessment finding requires the nurse to communicate effect of dopamine. While taking dopamine, the oxygen requirements of the heart
with the provider immediately? are increased due to increased myocardial workload, and may cause ischemia.
a. Blood pressure of 98/68 mm Hg Without knowing the client's previous blood pressure or pedal pulses, there is not
b. Pedal pulses 1+/4+ bilaterally enough information to determine if these are an improvement or not. A urine
c. Report of chest heaviness output of 32 mL/hr is acceptable.
d. Urine output of 32 mL/hr
Questions and CORRECT Answers
A student is caring for a client who suffered massive B ~ Lower blood volume will decrease MAP. The other answers are not accurate.
blood loss after trauma. How does the student correlate
the blood loss with the client's mean arterial pressure
(MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.
A nurse is caring for a client after surgery. The client's B ~ Signs of the earliest stage of shock are subtle and may manifest in slight
respiratory rate has increased from 12 to 18 breaths/min increases in heart rate, respiratory rate, or blood pressure. Even though these
and the pulse rate increased from 86 to 98 beats/min readings are not out of the normal range, the nurse should conduct a thorough
since they were last assessed 4 hours ago. What action assessment of the client, focusing on indicators of perfusion. The client may need
by the nurse is best? pain medication, but this is not the priority at this time. Documentation should be
a. Ask if the client needs pain medication. done thoroughly but is not the priority either. The nurse should not increase the
b. Assess the client's tissue perfusion further. rate of the IV infusion without an order.
c. Document the findings in the client's chart.
d. Increase the rate of the client's IV infusion.
The nurse gets the hand-off report on four clients. Which A ~ This client has a falling systolic blood pressure, rising diastolic blood pressure,
client should the nurse assess first? and narrowing pulse pressure, all of which may be indications of the progressive
a. Client with a blood pressure change of 128/74 to 110/88 stage of shock. The nurse should assess this client first. The client with the
mm Hg unchanged oxygen saturation is stable at this point. Although the client with a
b. Client with oxygen saturation unchanged at 94% change in pulse has a slower rate, it is not an indicator of shock since the pulse is
c. Client with a pulse change of 100 to 88 beats/min still within the normal range; it may indicate the client's pain or anxiety has been
d. Client with urine output of 40 mL/hr for the last 2 hours relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only
slightly above the normal range, which is 30 mL/hr.
A nurse is caring for a client after surgery who is restless B ~ Urine output changes are a sensitive early indicator of shock. The nurse should
and apprehensive. The unlicensed assistive personnel delegate emptying the urinary catheter and measuring output to the UAP as a
(UAP) reports the vital signs and the nurse sees they are baseline for hourly urine output measurements. The UAP cannot assess for pain.
only slightly different from previous readings. What action Repositioning may or may not be effective for decreasing restlessness, but does
does the nurse delegate next to the UAP? not take priority over physical assessments. Reassurance is a therapeutic nursing
a. Assess the client for pain or discomfort. action, but the nurse needs to do more in this situation.
b. Measure urine output from the catheter.
c. Reposition the client to the unaffected side.
d. Stay with the client and reassure him or her.
,A client is in shock and the nurse prepares to administer A ~ High glucose readings are common in shock, and best outcomes are the
insulin for a blood glucose reading of 208 mg/dL. The result of treating them and maintaining glucose readings in the normal range.
spouse asks why the client needs insulin as the client is Medications and IV solutions may raise blood glucose levels, but this is not the
not a diabetic. What response by the nurse is best? most accurate answer. The stress of the illness has not made the client diabetic.
a. High glucose is common in shock and needs to be
treated.
b. Some of the medications we are giving are to raise
blood sugar.
c. The IV solution has lots of glucose, which raises blood
sugar.
d. The stress of this illness has made your spouse a
diabetic.
A nurse caring for a client notes the following C ~ This client has several indicators of sepsis with systemic inflammatory
assessments: white blood cell count 3800/mm3, blood response. The nurse should notify the health care provider immediately.
glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). Documentation needs to be thorough but does not take priority. The client may
What action by the nurse takes priority? appreciate warm blankets, but comfort measures do not take priority. The client
a. Document the findings in the client's chart. may or may not need insulin.
b. Give the client warmed blankets for comfort.
c. Notify the health care provider immediately.
d. Prepare to administer insulin per sliding scale.
A nurse works at a community center for older adults. B ~ Preventing dehydration in older adults is important because the age-related
What self-management measure can the nurse teach the decrease in the thirst mechanism makes them prone to dehydration. Having older
clients to prevent shock? adults drink fluids on a regular schedule will help keep them hydrated without the
a. Do not get dehydrated in warm weather. influence of thirst (or lack of thirst). Telling clients not to get dehydrated is
b. Drink fluids on a regular schedule. important, but not the best answer because it doesn't give them the tools to
c. Seek attention for any lacerations. prevent it from occurring. Older adults should seek attention for lacerations, but
d. Take medications as prescribed. this is not as important an issue as staying hydrated. Taking medications as
prescribed may or may not be related to hydration.
A client arrives in the emergency department after being B ~ Airway is the priority, followed by breathing and circulation (IVs and direct
in a car crash with fatalities. The client has a nearly pressure). Obtaining consent is done by the physician.
amputated leg that is bleeding profusely. What action by
the nurse takes priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters.
A client is receiving norepinephrine (Levophed) for A ~ Normal cognitive function is a good indicator that the client is receiving the
shock. What assessment finding best indicates a benefits of norepinephrine. The brain is very sensitive to changes in oxygenation
therapeutic effect from this drug? and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so
a. Alert & oriented, answering questions the absence of chest pain does not indicate therapeutic effect. The IV site is
b. Client denial of chest pain or chest pressure normal. The urine output is normal, but only minimally so.
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours
, A student nurse is caring for a client who will be receiving C ~ Nitroprusside degrades in the presence of light, so it must be protected by
sodium nitroprusside (Nipride) via IV infusion. What action leaving it in the original brown plastic bag when infusing. The other actions are
by the student causes the registered nurse to intervene? correct, although a smart pump is not necessarily required if the facility does not
a. Assessing the IV site before giving the drug have them available. The drug must be administered via an IV pump, although the
b. Obtaining a programmable (smart) IV pump programmable pump is preferred for safety.
c. Removing the IV bag from the brown plastic cover
d. Taking and recording a baseline set of vital signs
A client has been brought to the emergency department A ~ The nurses priority is to care for the client. Since the client has gunshot
after being shot multiple times. What action should the wounds and is bleeding, the nurse applies personal protective equipment (i.e.,
nurse perform first? gloves) prior to care. This takes priority over calling law enforcement. Requesting
a. Apply personal protective equipment. blood bank products can be delegated. The nurse may or may not have to
b. Notify local law enforcement officials. prepare the client for emergency surgery.
c. Obtain universal donor blood.
d. Prepare the client for emergency surgery.
A nurse is caring for several clients at risk for shock. B ~ A lactate level of 6 mmol/L is high and is indicative of possible shock. A
Which laboratory value requires the nurse to creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but
communicate with the health care provider? that is not related directly to shock. A white blood cell count of 11,000/mm3 is
a. Creatinine: 0.9 mg/dL slightly high but is not as critical as the lactate level.
b. Lactate: 6 mmol/L
c. Sodium: 150 mEq/L
d. White blood cell count: 11,000/mm3
A client in shock is apprehensive and slightly confused. A ~ The nurses presence will be best to reassure this client. Antianxiety medication
What action by the nurse is best? is not warranted as this will lower the clients blood pressure. Using all four side-
a. Offer to remain with the client for awhile. rails on a hospital bed is considered a restraint in most facilities, although the
b. Prepare to administer antianxiety medication. nurse should ensure the client's safety. Telling a confused client that everything is
c. Raise all four siderails on the client's bed. being done is not the most helpful response.
d. Tell the client everything possible is being done.
A client is being discharged home after a large B ~ All these statements indicate a potential for leading to infection once the
myocardial infarction and subsequent coronary artery client gets back home. A large party might include individuals who are themselves
bypass grafting surgery. The client's sternal wound has ill and contagious. Having litter boxes in the home can expose the client to
not yet healed. What statement by the client most microbes that can lead to infection. Small children often have upper respiratory
indicates a higher risk of developing sepsis after infections and poor hand hygiene that spread germs. However, the most
discharge? worrisome statement is the lack of running water for handwashing and general
a. All my friends and neighbors are planning a party for hygiene and cleaning purposes.
me.
b. I hope I can get my water turned back on when I get
home.
c. I am going to have my daughter scoop the cat litter
box.
d. My grandkids are so excited to have me coming home!
A client in shock has been started on dopamine. What C ~ Chest heaviness or pain indicates myocardial ischemia, a possible adverse
assessment finding requires the nurse to communicate effect of dopamine. While taking dopamine, the oxygen requirements of the heart
with the provider immediately? are increased due to increased myocardial workload, and may cause ischemia.
a. Blood pressure of 98/68 mm Hg Without knowing the client's previous blood pressure or pedal pulses, there is not
b. Pedal pulses 1+/4+ bilaterally enough information to determine if these are an improvement or not. A urine
c. Report of chest heaviness output of 32 mL/hr is acceptable.
d. Urine output of 32 mL/hr
