NUR 265 EXAM 3 PRACTICE QUESTIONS & ANSWERS GRADED A

The nurse is caring for a patient who sustained a traumatic brain injury 4 days ago. The patient remains in a pharmacologic induced coma while receiving mechanical ventilation. The patient is on NPO status and the vital signs are within the normal range. The patients bowel sounds are absent and nasogastric tube is connected to low, intermittent suction. The nurse should prepare to begin: a. NG feeding b. Rapid weaning from the ventilator c. Total parenteral nutrition d. Chest physiotherapy A patient with bacterial meningitis is treated with intravenous antimicrobial agent. Which of the following BEST indicates effectiveness of treatment? a. Severe headache b. Negative kernig’s sign c. Nuchal rigidity d. Photophobia A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate decreases. Which of the following is the most appropriate nursing intervention? a. Ensure that the suction is limited to 15 seconds b. Continue to suction c. Hold the procedure and re-oxygenate the client d. Notify the physician immediately. The nurse is caring for an adult patient with extensive burns on the front of the trunk, including the genitalia, and the fronts of right legs. Using the rule of nines, the nurse would document that the burn size as: a. 13% b. 17% c. 28% d. 37% Signs and symptoms of Hypovolemic shock are all of the following except: a) Tachycardia b) Hypertension c) Pallor and cyanosis d) Tachypnea A 35-year-old male was knifed in the street fight, admitted through the ER, and is now in the ICU. An assessment of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm H2O, BP 90 mm Hg systolic, skin cold and pale, urinary output 30 mL/hr for the last 2 hours. Analyzing these symptoms, the nurse will base a nursing diagnosis on the conclusion that the client has which of the following conditions? a. Hypovolemic shock b. Cardiac tamponade c. Wound dehiscence d. Atelectasis While caring for a patient in the post-anesthesia care unit (PACU) Who has developed Hypovolemic shock, a nurse should position the patient: a. Flat with legs elevated b. In Trendelenburg position c. With the head of the bed elevated 45 degrees d. Completely flat What occurs during cardiogenic shock and result in inadequate tissue perfusion? a. Increased resistance of arterial vessels b. Decreased effectiveness of the heart as a pump c. Increased shunting of critical blood flow to heart d. Decreased capacity of the venous beds Three days ago a patient underwent an invasive surgery with an open wound. The patient is febrile with drop in blood pressure. Laboratory test results shows elevated WBC count. This could be possible presentation of : • a. Sepsis • Atelectasis • Internal hemorrhaging • Excess fluid volume The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning 707. A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose. 708. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1. Taking medications as scheduled 2. Eating large, well-balanced meals 3. Doing muscle-strengthening exercises 4. Doing all chores early in the day while less fatigued The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? 1. “I will wash my face with cotton pads.” 2. “I’ll have to start chewing on my unaffected side.” 3. “I should rinse my mouth if toothbrushing is painful.” 4. “I’ll try to eat my food either very warm or very cold.” 717. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month 718. A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1. Giving client full control over care decisions and restricting visitors 2. Providing positive feedback and encouraging active range of motion 3. Providing information, giving positive feedback, and encouraging relaxation