Exam 1- NUR 221 Questions and Answers 100% Correct
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment
findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min,
respiratory rate 30 breaths/min, and temperature of 100.5° F. The patient is lethargic,
responds to voice but falls asleep readily when not stimulated. Which nursing action is most
important to include in this patient's plan of care?
A. Frequent neurological assessments
B. Side to side position changes
C. Range of motion to extremities
D. Frequent oropharyngeal suctioning Correct-A. Frequent neurological assessments
The nurse has just received a patient from the emergency department with an admitting
diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other
patients, what is the best action by the nurse?
A. Implement droplet precautions upon admission.
, Exam 1- NUR 221 Questions and Answers 100% Correct
B. Wash hands thoroughly before leaving the room.
C. Scrub the hub of all central line ports prior to use.
D. Dispose of all bloody dressings in biohazard bags. Correct-A. Implement droplet
precautions upon admission.
The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the
nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30
breaths/min, oxygen saturation (SpO 2 ) 95% on supplemental oxygen at 3 L/min, and a
temperature 103.5° F. What is the priority nursing action?
A. Elevate the head of the bed 30 degrees.
B. Keep lights dim at all times.
C. Implement seizure precautions.
D. Maintain bed rest at all times. Correct-C. Implement seizure precautions.
A patient seeks treatment for progressively deteriorating motor and sensory function. What
question is essential for the nurse to ask when completing this patient's health history?
, Exam 1- NUR 221 Questions and Answers 100% Correct
A. "Have you been around any small children?"
B. "When was the last time you had anything to eat?"
C. "When was the last time you traveled out of the country?"
D. "Have you recently experienced any lung or stomach infections?" Correct-D. "Have you
recently experienced any lung or stomach infections?"
A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the
nurse respond about the pathophysiology of the disorder?
A. "An infection eats away at the nerve endings."
B. "An infection enters the spinal cord and erodes the nerves at the roots."
C. "The nerves are killed by infiltration of your body's white blood cells used to fight an
infection."
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment
findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min,
respiratory rate 30 breaths/min, and temperature of 100.5° F. The patient is lethargic,
responds to voice but falls asleep readily when not stimulated. Which nursing action is most
important to include in this patient's plan of care?
A. Frequent neurological assessments
B. Side to side position changes
C. Range of motion to extremities
D. Frequent oropharyngeal suctioning Correct-A. Frequent neurological assessments
The nurse has just received a patient from the emergency department with an admitting
diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other
patients, what is the best action by the nurse?
A. Implement droplet precautions upon admission.
, Exam 1- NUR 221 Questions and Answers 100% Correct
B. Wash hands thoroughly before leaving the room.
C. Scrub the hub of all central line ports prior to use.
D. Dispose of all bloody dressings in biohazard bags. Correct-A. Implement droplet
precautions upon admission.
The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the
nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30
breaths/min, oxygen saturation (SpO 2 ) 95% on supplemental oxygen at 3 L/min, and a
temperature 103.5° F. What is the priority nursing action?
A. Elevate the head of the bed 30 degrees.
B. Keep lights dim at all times.
C. Implement seizure precautions.
D. Maintain bed rest at all times. Correct-C. Implement seizure precautions.
A patient seeks treatment for progressively deteriorating motor and sensory function. What
question is essential for the nurse to ask when completing this patient's health history?
, Exam 1- NUR 221 Questions and Answers 100% Correct
A. "Have you been around any small children?"
B. "When was the last time you had anything to eat?"
C. "When was the last time you traveled out of the country?"
D. "Have you recently experienced any lung or stomach infections?" Correct-D. "Have you
recently experienced any lung or stomach infections?"
A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the
nurse respond about the pathophysiology of the disorder?
A. "An infection eats away at the nerve endings."
B. "An infection enters the spinal cord and erodes the nerves at the roots."
C. "The nerves are killed by infiltration of your body's white blood cells used to fight an
infection."
