Nursing 3 Final Exam Questions With Complete Solutions
A 56 year old client comes to the triage area with left-sided
chest pain, diaphoresis, and dizziness. What is the priority
action? Correct Answers Administer oxygen via nasal cannula
A burn patient is brought into the emergency department with
the following burns: half of the front torso, entire left arm, front
of left leg. The nurse should record the TBSA burns as: Correct
Answers 27% TBSA
A client arrives in the emergency department with an ischemic
stroke. Because the healthcare team is considering administering
tissue plasminogen activator (t-PA) administration, the nurse
should first: Correct Answers Identify the time of onset of the
stroke
A client arrives in the emergency department with an ischemic
stroke. Because the healthcare team is considering administering
tissue plasminogen activator (t-PA), what should the nurse
preform first? Correct Answers Identify the time of onset of the
stroke
A client has accidentally received twice the normal dose of
medication that was administered on the previous shift. What
should the nurse who discovers the error do first? Correct
Answers Assess the client, and note any changes in condition
A client has been admitted with chest trauma after a motor
vehicle crash and has undergone subsequent intubation. The
nurse checks the client when the high-pressure alarm on the
,ventilator sounds, and notes that the client has absence of breath
sounds in the right upper lobe of the lung. The nurse
immediately assesses for other signs of which condition?
Correct Answers Right pneumothorax
A client has experienced pulmonary embolism. A nurse assesses
for which symptom, which is most commonly reported? Correct
Answers chest pain that occurs suddenly
A client is admitted to the emergency department with a full-
thickness burn to the right arm. Upon assessment, the arm is
edematous, fingers are mottled, and radial pulse is now absent.
The client states that the pain is 8 on a scale of 1 to 10. The
nurse should: Correct Answers Call the healthcare provider
(HCP) to report the loss of the radial pulse
A client who has undergone preadmission laboratory studies,
including a complete blood count, coagulation studies, and
electrolytes and creatinine levels. Which of the following
laboratory results should be reported to the surgeon's office by
the nurse, knowing that it could cause surgery to be postponed?
Correct Answers Hemoglobin, 8.0 g/dL
A client with a chest injury has suffered flail chest. The nurse
assesses the client for which most distinctive sign of flail chest?
Correct Answers Paradoxical chest movement
A client with a history of myocardial infarction 3 years ago was
admitted at 0700 for a cholecystectomy scheduled at 0900. The
client has been NPO since midnight. At 0830, the client reports
having chest pains. At 0700, the client's vital signs were pulse
, 80 bpm, respirations, 14 breaths/min; and blood pressure,
110/70 mm Hg. At 0830 the nurse takes the vital signs again:
pulse is 110 bpm; respirations, 20 breaths/min; and blood
pressures, 90/60 mm Hg. The nurse calls the surgeon and, using
the SBAR communication protocol, should discuss which
information with the surgeon? Select all that apply. Correct
Answers History of myocardial infarction and current report of
chest pains
The change in vital signs
Request for ECG
Request to administer nitroglycerin tablet
A client with a serious head injury with increase intracranial
pressure is to be discharged to a rehabilitation facility. Which
outcome of rehabilitation would be appropriate for the client?
The client will: Correct Answers Actively participate in the
rehabilitation process as appropriate
A client with acute pancreatitis has an order of IV infusion of
Insulin. Which electrolyte is vital to monitor during
administration? Correct Answers Potassium
A nurse assesses a client's surgical incision for signs of
infection. Which finding by the nurse would be interpreted as a
normal finding at the surgical site? Correct Answers Serous
drainage
A nurse is assessing a client who has advanced cirrhosis. The
nurse should identify which finding as an indicator of hepatic
encephalopathy? Correct Answers fetor hepaticus
A 56 year old client comes to the triage area with left-sided
chest pain, diaphoresis, and dizziness. What is the priority
action? Correct Answers Administer oxygen via nasal cannula
A burn patient is brought into the emergency department with
the following burns: half of the front torso, entire left arm, front
of left leg. The nurse should record the TBSA burns as: Correct
Answers 27% TBSA
A client arrives in the emergency department with an ischemic
stroke. Because the healthcare team is considering administering
tissue plasminogen activator (t-PA) administration, the nurse
should first: Correct Answers Identify the time of onset of the
stroke
A client arrives in the emergency department with an ischemic
stroke. Because the healthcare team is considering administering
tissue plasminogen activator (t-PA), what should the nurse
preform first? Correct Answers Identify the time of onset of the
stroke
A client has accidentally received twice the normal dose of
medication that was administered on the previous shift. What
should the nurse who discovers the error do first? Correct
Answers Assess the client, and note any changes in condition
A client has been admitted with chest trauma after a motor
vehicle crash and has undergone subsequent intubation. The
nurse checks the client when the high-pressure alarm on the
,ventilator sounds, and notes that the client has absence of breath
sounds in the right upper lobe of the lung. The nurse
immediately assesses for other signs of which condition?
Correct Answers Right pneumothorax
A client has experienced pulmonary embolism. A nurse assesses
for which symptom, which is most commonly reported? Correct
Answers chest pain that occurs suddenly
A client is admitted to the emergency department with a full-
thickness burn to the right arm. Upon assessment, the arm is
edematous, fingers are mottled, and radial pulse is now absent.
The client states that the pain is 8 on a scale of 1 to 10. The
nurse should: Correct Answers Call the healthcare provider
(HCP) to report the loss of the radial pulse
A client who has undergone preadmission laboratory studies,
including a complete blood count, coagulation studies, and
electrolytes and creatinine levels. Which of the following
laboratory results should be reported to the surgeon's office by
the nurse, knowing that it could cause surgery to be postponed?
Correct Answers Hemoglobin, 8.0 g/dL
A client with a chest injury has suffered flail chest. The nurse
assesses the client for which most distinctive sign of flail chest?
Correct Answers Paradoxical chest movement
A client with a history of myocardial infarction 3 years ago was
admitted at 0700 for a cholecystectomy scheduled at 0900. The
client has been NPO since midnight. At 0830, the client reports
having chest pains. At 0700, the client's vital signs were pulse
, 80 bpm, respirations, 14 breaths/min; and blood pressure,
110/70 mm Hg. At 0830 the nurse takes the vital signs again:
pulse is 110 bpm; respirations, 20 breaths/min; and blood
pressures, 90/60 mm Hg. The nurse calls the surgeon and, using
the SBAR communication protocol, should discuss which
information with the surgeon? Select all that apply. Correct
Answers History of myocardial infarction and current report of
chest pains
The change in vital signs
Request for ECG
Request to administer nitroglycerin tablet
A client with a serious head injury with increase intracranial
pressure is to be discharged to a rehabilitation facility. Which
outcome of rehabilitation would be appropriate for the client?
The client will: Correct Answers Actively participate in the
rehabilitation process as appropriate
A client with acute pancreatitis has an order of IV infusion of
Insulin. Which electrolyte is vital to monitor during
administration? Correct Answers Potassium
A nurse assesses a client's surgical incision for signs of
infection. Which finding by the nurse would be interpreted as a
normal finding at the surgical site? Correct Answers Serous
drainage
A nurse is assessing a client who has advanced cirrhosis. The
nurse should identify which finding as an indicator of hepatic
encephalopathy? Correct Answers fetor hepaticus
