NUR 417 EXAM 1,2,3 & FINAL EXAM
QUESTIONS AND CORRECT ANSWERS-
Concordia University-St. Paul
Question 1
. The nurse is caring for a patient who has an intraaortic balloon pump in place. Which
action would the nurse include in the plan of care?
a. Avoid the use of anticoagulant medications.
b. Monitor the patient's urinary output every hour.
c. Provide passive range of motion for all extremities.
d. Position the patient supine with head flat at all times.
Correct Answer
ANS: B Monitoring urine output will help determine whether the patient's cardiac
output has improved. It also will help assess for balloon displacement blocking the
renal arteries. The head of the bed can be elevated up to 30 degrees. Heparin is
used to prevent thrombus formation. Limited movement is allowed for the
extremity with the balloon insertion site to prevent displacement of the balloon.
Question 2
**A patient is admitted to the emergency department (ED) in shock of unknown
etiology. Which action would the nurse take first?
a. Obtain the blood pressure.
b. Check the level of orientation.
c. Administer supplemental oxygen.
d. Obtain a 12-lead electrocardiogram.
Correct Answer
ANS: C The initial actions of the nurse are focused on the ABCs—airway, breathing,
and circulation— and administration of O2 should be done first. The other actions
should be accomplished as rapidly as possible after providing O2.
Page 1 of 711
,Question 3
**A patient has been admitted with dehydration and hypotension after 4 days of
vomiting and diarrhea. Which finding is most important for the nurse to report to the
health care provider? SIMILAR TO BOW TIE
a. New onset of confusion
b. Decreased bowel sounds
c. Heart rate 112 beats/min
d. Pale, cool, and dry extremities
Correct Answer
ANS: A The changes in mental status are indicative that the patient is in the
progressive stage of shock and that rapid intervention is needed to prevent further
deterioration. The other information is consistent with compensatory shock.
Question 4
a nurse is planning care for a client who has septic shock. which is the priority
a. maintain adequate fluid volume with IV infusions
b. administer antibiotic therapy
c. monitor hemodynamic status
d. admin vasopressor
Correct Answer
a
Question 5
**Which assessment information is most important for the nurse to obtain when
evaluating whether treatment of a patient with anaphylactic shock has been effective?
a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
Correct Answer
ANS: D Because the airway edema that is associated with anaphylaxis can affect
airway and breathing, the O2 saturation is the most critical assessment.
Improvements in the other assessments will also be expected with effective
treatment of anaphylactic shock.
Page 2 of 711
,Question 6
A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated
a parenteral nutrition (PN) infusion. Which action would the nurse take?
a. Obtain a venous blood glucose specimen.
b. Slow the infusion rate of the PN infusion.
c. Recheck the blood glucose level in 4 to 6 hours
d. Contact the health care provider for infusion rate changes
Correct Answer
ANS: C Mild hyperglycemia is expected during the first few days after PN is started
and requires ongoing monitoring. Because the glucose elevation is small and
expected, infusion rate changes are not needed. There is no need to obtain a
venous specimen for comparison. Slowing the rate of the infusion is beyond the
nurse's scope of practice and will decrease the patient's nutritional intake.
Question 7
A patient requires arterial pressure monitoring. Which action would the nurse plan to
take?
a. Balance and calibrate the monitoring equipment every 2 hours.
b. Position the zero-reference stopcock line level with the phlebostatic axis.
c. Disconnect the low pressure alarm to avoid disturbing the patient's sleep.
d. Ensure that the patient is supine with the head of the bed flat for all readings.
Correct Answer
ANS: B For accurate measurement of pressures, the zero-reference level would be at
the phlebostatic axis. There is no need to rebalance and recalibrate monitoring
equipment every 2 hours. Accurate hemodynamic readings are possible with the
patient's head raised to 45 degrees or in the prone position. Alarms should be
activated; if the pressure in the line falls (e.g., when the line is disconnected), the
low-pressure alarm sounds immediately and notifies staff to promptly correct the
problem.
Page 3 of 711
, Question 8
**Which assessment finding would the nurse expect when a patient with acute kidney
injury (AKI) has an arterial blood pH of 7.30?
a. Persistent skin tenting
b. Rapid, deep respirations
c. Hot, flushed face and neck
d. Bounding peripheral pulses
Correct Answer
ANS: B Patients with metabolic acidosis caused by AKI may have Kussmaul
respirations to eliminate carbon dioxide. Bounding pulses and vasodilation are not
associated with metabolic acidosis. Because the patient is likely to have fluid
retention, poor skin turgor would not be a finding in AKI
Question 9
Which problem would the nurse anticipate for a patient admitted to the hospital with
diabetes insipidus?
a. Generalized edema
b. Respiratory distress
c. Fluid volume overload
d. Disturbed sleep pattern
Correct Answer
ANS: D Nocturia occurs because of the polyuria caused by diabetes insipidus.
Edema, excess fluid volume, and respiratory distress are not expected.
Page 4 of 711
QUESTIONS AND CORRECT ANSWERS-
Concordia University-St. Paul
Question 1
. The nurse is caring for a patient who has an intraaortic balloon pump in place. Which
action would the nurse include in the plan of care?
a. Avoid the use of anticoagulant medications.
b. Monitor the patient's urinary output every hour.
c. Provide passive range of motion for all extremities.
d. Position the patient supine with head flat at all times.
Correct Answer
ANS: B Monitoring urine output will help determine whether the patient's cardiac
output has improved. It also will help assess for balloon displacement blocking the
renal arteries. The head of the bed can be elevated up to 30 degrees. Heparin is
used to prevent thrombus formation. Limited movement is allowed for the
extremity with the balloon insertion site to prevent displacement of the balloon.
Question 2
**A patient is admitted to the emergency department (ED) in shock of unknown
etiology. Which action would the nurse take first?
a. Obtain the blood pressure.
b. Check the level of orientation.
c. Administer supplemental oxygen.
d. Obtain a 12-lead electrocardiogram.
Correct Answer
ANS: C The initial actions of the nurse are focused on the ABCs—airway, breathing,
and circulation— and administration of O2 should be done first. The other actions
should be accomplished as rapidly as possible after providing O2.
Page 1 of 711
,Question 3
**A patient has been admitted with dehydration and hypotension after 4 days of
vomiting and diarrhea. Which finding is most important for the nurse to report to the
health care provider? SIMILAR TO BOW TIE
a. New onset of confusion
b. Decreased bowel sounds
c. Heart rate 112 beats/min
d. Pale, cool, and dry extremities
Correct Answer
ANS: A The changes in mental status are indicative that the patient is in the
progressive stage of shock and that rapid intervention is needed to prevent further
deterioration. The other information is consistent with compensatory shock.
Question 4
a nurse is planning care for a client who has septic shock. which is the priority
a. maintain adequate fluid volume with IV infusions
b. administer antibiotic therapy
c. monitor hemodynamic status
d. admin vasopressor
Correct Answer
a
Question 5
**Which assessment information is most important for the nurse to obtain when
evaluating whether treatment of a patient with anaphylactic shock has been effective?
a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
Correct Answer
ANS: D Because the airway edema that is associated with anaphylaxis can affect
airway and breathing, the O2 saturation is the most critical assessment.
Improvements in the other assessments will also be expected with effective
treatment of anaphylactic shock.
Page 2 of 711
,Question 6
A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated
a parenteral nutrition (PN) infusion. Which action would the nurse take?
a. Obtain a venous blood glucose specimen.
b. Slow the infusion rate of the PN infusion.
c. Recheck the blood glucose level in 4 to 6 hours
d. Contact the health care provider for infusion rate changes
Correct Answer
ANS: C Mild hyperglycemia is expected during the first few days after PN is started
and requires ongoing monitoring. Because the glucose elevation is small and
expected, infusion rate changes are not needed. There is no need to obtain a
venous specimen for comparison. Slowing the rate of the infusion is beyond the
nurse's scope of practice and will decrease the patient's nutritional intake.
Question 7
A patient requires arterial pressure monitoring. Which action would the nurse plan to
take?
a. Balance and calibrate the monitoring equipment every 2 hours.
b. Position the zero-reference stopcock line level with the phlebostatic axis.
c. Disconnect the low pressure alarm to avoid disturbing the patient's sleep.
d. Ensure that the patient is supine with the head of the bed flat for all readings.
Correct Answer
ANS: B For accurate measurement of pressures, the zero-reference level would be at
the phlebostatic axis. There is no need to rebalance and recalibrate monitoring
equipment every 2 hours. Accurate hemodynamic readings are possible with the
patient's head raised to 45 degrees or in the prone position. Alarms should be
activated; if the pressure in the line falls (e.g., when the line is disconnected), the
low-pressure alarm sounds immediately and notifies staff to promptly correct the
problem.
Page 3 of 711
, Question 8
**Which assessment finding would the nurse expect when a patient with acute kidney
injury (AKI) has an arterial blood pH of 7.30?
a. Persistent skin tenting
b. Rapid, deep respirations
c. Hot, flushed face and neck
d. Bounding peripheral pulses
Correct Answer
ANS: B Patients with metabolic acidosis caused by AKI may have Kussmaul
respirations to eliminate carbon dioxide. Bounding pulses and vasodilation are not
associated with metabolic acidosis. Because the patient is likely to have fluid
retention, poor skin turgor would not be a finding in AKI
Question 9
Which problem would the nurse anticipate for a patient admitted to the hospital with
diabetes insipidus?
a. Generalized edema
b. Respiratory distress
c. Fluid volume overload
d. Disturbed sleep pattern
Correct Answer
ANS: D Nocturia occurs because of the polyuria caused by diabetes insipidus.
Edema, excess fluid volume, and respiratory distress are not expected.
Page 4 of 711
