NURS 213 Proctored Exam 4 2024
1. A client has an AV fistula in the right upper arm for hemodialysis
treatments. When planning care for this client, which measure should
the nurse implement to promote client safety?
o A) Take blood pressures only on the right side to ensure accuracy
o B) Use the fistula for all venipunctures and IV infusions
o C) Ensure that small clamps are attached to the fistula dressing at all
times
o D) Assess the fistula for the presence of a bruit and a thrill every 4
hours
Answer: D
2. A client is scheduled for hydrotherapy for a burn dressing change.
Which action should the nurse take to ensure that the procedure is most
tolerable for the client?
o A) Ensure the client has a robe and slippers
o B) Administer an analgesic 20 mins before therapy
o C) Send dressing supplies with the client to hydrotherapy
o D) Administer an IV antibiotic 30 mins prior to therapy
Answer: B
,3. A client with Myasthenia Gravis is admitted to the hospital, and the
nursing history reveals that the client is taking pyridostigmine. When
assessing the client for the side effects of this medication, the nurse
should ask the client about the presence of which occurrence?
o A) Mouth ulcers
o B) Muscle cramps
o C) Feelings of depression
o D) Unexplained weight gain
Answer: B
4. The nurse notes an isolated premature ventricular contraction (PVC)
on the cardiac monitor. Which action should the nurse take?
o A) Prepare for defibrillation
o B) Continue to monitor the rhythm
o C) Notify the HCP
o D) Prepare to administer lidocaine hydrochloride
Answer: B
5. A client was admitted to the hospital 24 hours ago after sustaining blunt
force trauma to the chest. Which earliest clinical manifestations of acute
respiratory distress syndrome (ARDS) should the nurse monitor for?
o A) Cyanosis and pallor
, o B) Diffuse crackles and rhonchi on chest auscultation
o C) Increase in respiratory rate from 18 to 30 breaths per minute
o D) Haziness or "white out" appearance of lungs on chest X-ray
Answer: C
6. A client has developed atrial fibrillation and has a ventricular rate of
150 beats per minute. The nurse should assess the client for which
effects of this cardiac occurrence?
o A) Flat neck veins
o B) Nausea and vomiting
o C) Hypotension and dizziness
o D) Hypertension and headache
Answer: C
7. The home care nurse is making a follow-up visit to a client after a renal
transplant. The nurse should assess the client for which manifestations
of acute graft rejection?
o A) Hypotension, graft tenderness, and anemia
o B) Hypertension, oliguria, thirst, and hypothermia
o C) Fever, hypertension, graft tenderness, and malaise
, o D) Fever, vomiting, hypotension, and copious amounts of dilute urine
output
Answer: C
8. A client with a burn injury receives a prescription for a regular diet.
Which is the best meal for the nurse to provide to the client to promote
wound healing?
o A) Peanut butter & jelly sandwich, apple, tea
o B) Chicken breast, broccoli, strawberries, milk
o C) Veal chop, boiled potatoes, jell-o, orange juice
o D) Pasta with tomato sauce, garlic bread, ginger ale
Answer: B
9. An adult client arrives in the emergency department with burns to both
entire legs and the perineal area. Using the rule of nines, the nurse could
determine that approximately what percentage of the client’s body
surface area has been burned?
Answer: 37%
10.A client who is unresponsive and pulseless and has a possible neck
injury is brought into the emergency department after a motor vehicle
crash. What should the nurse do to open the client’s airway?
• A) Insert an oropharyngeal airway
1. A client has an AV fistula in the right upper arm for hemodialysis
treatments. When planning care for this client, which measure should
the nurse implement to promote client safety?
o A) Take blood pressures only on the right side to ensure accuracy
o B) Use the fistula for all venipunctures and IV infusions
o C) Ensure that small clamps are attached to the fistula dressing at all
times
o D) Assess the fistula for the presence of a bruit and a thrill every 4
hours
Answer: D
2. A client is scheduled for hydrotherapy for a burn dressing change.
Which action should the nurse take to ensure that the procedure is most
tolerable for the client?
o A) Ensure the client has a robe and slippers
o B) Administer an analgesic 20 mins before therapy
o C) Send dressing supplies with the client to hydrotherapy
o D) Administer an IV antibiotic 30 mins prior to therapy
Answer: B
,3. A client with Myasthenia Gravis is admitted to the hospital, and the
nursing history reveals that the client is taking pyridostigmine. When
assessing the client for the side effects of this medication, the nurse
should ask the client about the presence of which occurrence?
o A) Mouth ulcers
o B) Muscle cramps
o C) Feelings of depression
o D) Unexplained weight gain
Answer: B
4. The nurse notes an isolated premature ventricular contraction (PVC)
on the cardiac monitor. Which action should the nurse take?
o A) Prepare for defibrillation
o B) Continue to monitor the rhythm
o C) Notify the HCP
o D) Prepare to administer lidocaine hydrochloride
Answer: B
5. A client was admitted to the hospital 24 hours ago after sustaining blunt
force trauma to the chest. Which earliest clinical manifestations of acute
respiratory distress syndrome (ARDS) should the nurse monitor for?
o A) Cyanosis and pallor
, o B) Diffuse crackles and rhonchi on chest auscultation
o C) Increase in respiratory rate from 18 to 30 breaths per minute
o D) Haziness or "white out" appearance of lungs on chest X-ray
Answer: C
6. A client has developed atrial fibrillation and has a ventricular rate of
150 beats per minute. The nurse should assess the client for which
effects of this cardiac occurrence?
o A) Flat neck veins
o B) Nausea and vomiting
o C) Hypotension and dizziness
o D) Hypertension and headache
Answer: C
7. The home care nurse is making a follow-up visit to a client after a renal
transplant. The nurse should assess the client for which manifestations
of acute graft rejection?
o A) Hypotension, graft tenderness, and anemia
o B) Hypertension, oliguria, thirst, and hypothermia
o C) Fever, hypertension, graft tenderness, and malaise
, o D) Fever, vomiting, hypotension, and copious amounts of dilute urine
output
Answer: C
8. A client with a burn injury receives a prescription for a regular diet.
Which is the best meal for the nurse to provide to the client to promote
wound healing?
o A) Peanut butter & jelly sandwich, apple, tea
o B) Chicken breast, broccoli, strawberries, milk
o C) Veal chop, boiled potatoes, jell-o, orange juice
o D) Pasta with tomato sauce, garlic bread, ginger ale
Answer: B
9. An adult client arrives in the emergency department with burns to both
entire legs and the perineal area. Using the rule of nines, the nurse could
determine that approximately what percentage of the client’s body
surface area has been burned?
Answer: 37%
10.A client who is unresponsive and pulseless and has a possible neck
injury is brought into the emergency department after a motor vehicle
crash. What should the nurse do to open the client’s airway?
• A) Insert an oropharyngeal airway
