209 Exam #3 Practice Questions
1. The nurse recognizes that the most likely contributing factor to FTR event in a client that
just underwent a surgery is what?
a. Completing hourly rounding
b. The type of surgery the client had
c. Inappropriate surveillance (monitoring) by the nurse
d. Not practicing to the full scope of the nursing practice
2. A brain injured client responds to external painful stimuli by internal rotation &
adduction of the arms with flexion of the elbows, wrists, & fingers. How should the
nurse document & report the client’s position?
a. Localization of pain
b. Flexion withdrawal
c. Decorticate position
d. Repositioning to noxious stimuli
3. The doctor has ordered dopamine to infuse at 3 mcg/kg/min. the drip comes as
dopamine 250 mg in 250 mL. The client weights 132 lbs. How many mL/hr should the
pump be set at?
a. 10.8
4. During a presurgical admission assessment, the client states “I’ve told my surgeon that I
am Jehovah’s witness & I will not accept a blood transfusion.” Which assessment by the
nurse would be most appropriate?
a. Your request not to receive a blood transfusion will be honored
b. Why don’t you talk this over with someone before you make your final decision
c. Don’t worry, there is less blood loss with our newer surgical equipment
d. Are you sure you wouldn’t want a transfusion if one is needed
5. During the assessment of a client experiencing acute hemorrhage & anemia, the nurse
would most likely expect which findings? SATA
a. Pallor
b. Increased urine output
c. Tachycardia
d. HTN (HTN can cause a hemorrhagic stroke)
e. Spoon shaped fingernails
,6. The client in end stage liver failure has vit k deficiency. Which intervention should the
nurse implement? SATA
a. Assess for asterixis
b. Use small gauge needles
c. Monitor the platelet count
d. Avoid rectal temperatures
e. Use only a soft toothbrush
7. The nurse is explaining to a student the rationale why infusing a unit of blood should not
exceed over four hours. Which statement made by the student nurse indicates an
understanding of this rationale?
a. The blood has a potential for bacterial growth if allowed to infuse longer than 4
hours.
b. The blood will coagulate if left out of the refrigerator for greater than 4 hours
c. The blood components begin to break down after 4 hours
d. The blood tubing has a transfusion life of only 4 hours
8. The male client presents to the ED complaining of fatigue, abdominal pain, N/V, &
informs the nurse that he has been eating lunch every day for the past 2 weeks from the
food trucks outside of his office building. He has a fever of 38.9 & yellowing of the
sclera. The nurse suspects that the client has which of the hepatitis?
a. B
b. A
c. C
d. F
9. The outpatient clinic transplant nurse is providing care to a client who received a lung
transplant 7 weeks ago & is reporting new onset coughing with SOB & fever for 1 week.
The nurse recognizes that the client may be experiencing what type of transplant
rejection?
a. Chronic
b. Acute
c. Hyperacute
d. GVHD
10. The client has liver cirrhosis with severe splenomegaly. What lab values/ S/S should the
nurse monitor for?
a. Polycythemia
b. Thrombocytopenia
, c. Vison changes
d. Hives to the upper torso
~ Increased PT/INR
~ Leukopenia
11. The nurse responds to the scene of a bus crash involving multiple victims. Which of the
following clients would the nurse triage as category green?
a. Client who is unconscious with a weak pulse & obvious deep laceration to the
head
b. Client who is ambulatory with multiple contusions & minor lacerations
c. Client who is conscious with garbled speech & abnormal behavior
d. Client who is pregnant with multiple fractures to bilateral lower extremities &
experiencing paresthesia
12. The nurse is providing oral care to a 64 y/o client with late-stage cirrhosis & ascites. The
nurse notes the client’s breath has a sweet, musty smell. This condition is known as:
a. Hepatico halitosis
b. Metallica hepaticus
c. Asterixis
d. Fetor hepaticus
13. The nurse assesses that the client with hemolytic anemia has weakness, fatigue,
malaise, with skin & mucous membrane pallor. Which finding should the nurse also
associate with hemolytic anemia?
a. Smooth, red tongue
b. Scleral jaundice
c. Craving for ice to chew
d. Poor intake of fresh veggies
14. A client is admitted to the ED with a diagnosis of blunt trauma to the abdomen after a
MVA. What should the emergency nurse assess 1st as part of the primary survey?
a. Abdomen for any abnormalities
b. Airway for patency
c. Cervical spine for tenderness
d. Signs of neurological defects
15. The nurse is caring for a client with increased ICP. Which action is contraindicated?
a. Clustering many nursing activities
b. Aligning the neck with the body
c. Elevating the HOB to 30 degrees
1. The nurse recognizes that the most likely contributing factor to FTR event in a client that
just underwent a surgery is what?
a. Completing hourly rounding
b. The type of surgery the client had
c. Inappropriate surveillance (monitoring) by the nurse
d. Not practicing to the full scope of the nursing practice
2. A brain injured client responds to external painful stimuli by internal rotation &
adduction of the arms with flexion of the elbows, wrists, & fingers. How should the
nurse document & report the client’s position?
a. Localization of pain
b. Flexion withdrawal
c. Decorticate position
d. Repositioning to noxious stimuli
3. The doctor has ordered dopamine to infuse at 3 mcg/kg/min. the drip comes as
dopamine 250 mg in 250 mL. The client weights 132 lbs. How many mL/hr should the
pump be set at?
a. 10.8
4. During a presurgical admission assessment, the client states “I’ve told my surgeon that I
am Jehovah’s witness & I will not accept a blood transfusion.” Which assessment by the
nurse would be most appropriate?
a. Your request not to receive a blood transfusion will be honored
b. Why don’t you talk this over with someone before you make your final decision
c. Don’t worry, there is less blood loss with our newer surgical equipment
d. Are you sure you wouldn’t want a transfusion if one is needed
5. During the assessment of a client experiencing acute hemorrhage & anemia, the nurse
would most likely expect which findings? SATA
a. Pallor
b. Increased urine output
c. Tachycardia
d. HTN (HTN can cause a hemorrhagic stroke)
e. Spoon shaped fingernails
,6. The client in end stage liver failure has vit k deficiency. Which intervention should the
nurse implement? SATA
a. Assess for asterixis
b. Use small gauge needles
c. Monitor the platelet count
d. Avoid rectal temperatures
e. Use only a soft toothbrush
7. The nurse is explaining to a student the rationale why infusing a unit of blood should not
exceed over four hours. Which statement made by the student nurse indicates an
understanding of this rationale?
a. The blood has a potential for bacterial growth if allowed to infuse longer than 4
hours.
b. The blood will coagulate if left out of the refrigerator for greater than 4 hours
c. The blood components begin to break down after 4 hours
d. The blood tubing has a transfusion life of only 4 hours
8. The male client presents to the ED complaining of fatigue, abdominal pain, N/V, &
informs the nurse that he has been eating lunch every day for the past 2 weeks from the
food trucks outside of his office building. He has a fever of 38.9 & yellowing of the
sclera. The nurse suspects that the client has which of the hepatitis?
a. B
b. A
c. C
d. F
9. The outpatient clinic transplant nurse is providing care to a client who received a lung
transplant 7 weeks ago & is reporting new onset coughing with SOB & fever for 1 week.
The nurse recognizes that the client may be experiencing what type of transplant
rejection?
a. Chronic
b. Acute
c. Hyperacute
d. GVHD
10. The client has liver cirrhosis with severe splenomegaly. What lab values/ S/S should the
nurse monitor for?
a. Polycythemia
b. Thrombocytopenia
, c. Vison changes
d. Hives to the upper torso
~ Increased PT/INR
~ Leukopenia
11. The nurse responds to the scene of a bus crash involving multiple victims. Which of the
following clients would the nurse triage as category green?
a. Client who is unconscious with a weak pulse & obvious deep laceration to the
head
b. Client who is ambulatory with multiple contusions & minor lacerations
c. Client who is conscious with garbled speech & abnormal behavior
d. Client who is pregnant with multiple fractures to bilateral lower extremities &
experiencing paresthesia
12. The nurse is providing oral care to a 64 y/o client with late-stage cirrhosis & ascites. The
nurse notes the client’s breath has a sweet, musty smell. This condition is known as:
a. Hepatico halitosis
b. Metallica hepaticus
c. Asterixis
d. Fetor hepaticus
13. The nurse assesses that the client with hemolytic anemia has weakness, fatigue,
malaise, with skin & mucous membrane pallor. Which finding should the nurse also
associate with hemolytic anemia?
a. Smooth, red tongue
b. Scleral jaundice
c. Craving for ice to chew
d. Poor intake of fresh veggies
14. A client is admitted to the ED with a diagnosis of blunt trauma to the abdomen after a
MVA. What should the emergency nurse assess 1st as part of the primary survey?
a. Abdomen for any abnormalities
b. Airway for patency
c. Cervical spine for tenderness
d. Signs of neurological defects
15. The nurse is caring for a client with increased ICP. Which action is contraindicated?
a. Clustering many nursing activities
b. Aligning the neck with the body
c. Elevating the HOB to 30 degrees
