NSG 209 Final || 100% accurate answers.
A client with a 10 yr. history of emphysema is admitted in acute respiratory distress. During the
assessment, what does the nurse expect?
a. S/S of respiratory alkalosis
b. Decreased RR
c. Prolonged expiration with use of accessory muscles
d. Chest pain on inspiration correct answers c. Prolonged expiration with use of accessory
muscles
The nurse is providing pre-op education regarding transplant rejection & GVHD to a client who
is scheduled to have a kidney transplant. The nurse states "the most common problem with
GVHD is"?
a. Immune response/infection
b. Hypokalemia
c. Constipation
d. Shingles correct answers a. Immune response/infection
When caring for a preoperative patient on the day of surgery, which actions include in the plan of
care can the nurse delegate to UAP? SATA
a. Teach incentive spirometer use
b. Explain routine pre-op care
c. Obtain & document baseline vitals
d. Remove nail polish & apply pulse Ox
e. Transport the patient to the operating room by stretcher correct answers c. Obtain & document
baseline vitals
d. Remove nail polish & apply pulse Ox
e. Transport the patient to the operating room by stretcher
,The nurse is educating the client who has been diagnosed with Hep C about the disease. Which
statements made by the client indicated that the client understood the teaching?
a. I should avoid sharing drinking cups & eating utensils with my family
b. I should not drink any wine, beer, or other alcoholic beverages
c. I will plan to do all my activities in the morning when I am most rested
d. It is important for me to not use barrier protection when I have sex correct answers b. I should
not drink any wine, beer, or other alcoholic beverages
A nurse is making initial rounds on assigned clients at the beginning of the shift. One client is
receiving a heparin infusion at 5 mL/hr. The nurse notes that 25,000 units of heparin are mixed in
250 mL of solution. How many units/hr is the client receiving? correct answers a. 500 units/hr
The client is diagnosed with an ischemic stroke & being evaluated for thrombolytic therapy.
Which assessment finding should prompt the nurse to withhold thrombolytic therapy?
a. History of T1 DM
b. Neurologic deficits started 2 hr ago
c. History of serious head injury 4 weeks ago
d. Brain CT scan results show no bleeding correct answers c. History of serious head injury 4
weeks ago
The nurse is caring for a client status post bone marrow transplant. The client's current vital signs
are: temp 38.1, HR 84, BP 120/80, RR 18. The nurse recognizes the following as signs of
GVHD. SATA
a. Rash & itching
b. Yellowing of sclera
c. Rectal pain
d. 40mL/hr output of clear amber urine
e. WBC of 22,000 correct answers a. Rash & itching
b. Yellowing of sclera
,What is an expected client nursing diagnosis when admitted to the hospital with symptoms of
DI?
a. Impaired gas exchange r/t fluid retention in lungs
b. Risk for impaired skin integrity r/t generalized edema
c. Excess fluid vol. r/t intake greater than output
d. Sleep pattern disturbance r/t frequent waking to void correct answers d. Sleep pattern
disturbance r/t frequent waking to void
The nurse is caring for the client with problems of anxiety & confusion in the acute phase of
burn management. Which intervention should the nurse implement? SATA
a. Repeat orientation statements of person, place, & time
b. Turn & reposition the client at least every hour
c. Place familiar objects from home near the client
d. Implement a schedule for regular sleep-wake cycles
e. Reduce distractions by keeping the television in the room off correct answers a. Repeat
orientation statements of person, place, & time
c. Place familiar objects from home near the client
d. Implement a schedule for regular sleep-wake cycles
During change of shift report, the nurse is informed that the client has a high bilirubin level.
Which assessment finding would the nurse expect with the client with an elevated bilirubin
level?
a. Erythema of the sclera
b. Dark brown stool
c. Dark brown urine
d. Foamy light-colored urine correct answers c. Dark brown urine
The nurse is determining the IV fluid needs for the 110 lbs client with partial thickness burns to
40% TBSA. Using the parkland formula, how many mL of IV fluids are needed during the 1st 8
hrs after injury? correct answers 4000mL
, Which of the following side effects might be expected for a client taking iron supplements?
SATA
a. Constipation
b. Dysphagia
c. Decreased appetite
d. Black stool
e. Insomnia correct answers a. Constipation
d. Black stool
Hepatitis is a viral infection that affects the entire body. What other signs & symptoms can a
client with hepatitis present with? SATA
a. Runny eyes & nose
b. Distaste for cigarettes
c. HOH
d. Pruritis
e. Light colored stools correct answers b. Distaste for cigarettes
d. Pruritis
e. Light colored stools
The nurse is caring for a client who is 20 days post stem cell transplant. Upon physical
assessment, the nurse notes a red, raised rash to the client's lower extremities. The client reports
diarrhea, constant nausea, & feels bloated. The nurse recognizes that the client is exhibiting
manifestations related to?
a. Chronic transplant rejection
b. Acute transplant rejection
c. GVHD
d. Hyperacute transplant rejection correct answers c. GVHD
A client with a 10 yr. history of emphysema is admitted in acute respiratory distress. During the
assessment, what does the nurse expect?
a. S/S of respiratory alkalosis
b. Decreased RR
c. Prolonged expiration with use of accessory muscles
d. Chest pain on inspiration correct answers c. Prolonged expiration with use of accessory
muscles
The nurse is providing pre-op education regarding transplant rejection & GVHD to a client who
is scheduled to have a kidney transplant. The nurse states "the most common problem with
GVHD is"?
a. Immune response/infection
b. Hypokalemia
c. Constipation
d. Shingles correct answers a. Immune response/infection
When caring for a preoperative patient on the day of surgery, which actions include in the plan of
care can the nurse delegate to UAP? SATA
a. Teach incentive spirometer use
b. Explain routine pre-op care
c. Obtain & document baseline vitals
d. Remove nail polish & apply pulse Ox
e. Transport the patient to the operating room by stretcher correct answers c. Obtain & document
baseline vitals
d. Remove nail polish & apply pulse Ox
e. Transport the patient to the operating room by stretcher
,The nurse is educating the client who has been diagnosed with Hep C about the disease. Which
statements made by the client indicated that the client understood the teaching?
a. I should avoid sharing drinking cups & eating utensils with my family
b. I should not drink any wine, beer, or other alcoholic beverages
c. I will plan to do all my activities in the morning when I am most rested
d. It is important for me to not use barrier protection when I have sex correct answers b. I should
not drink any wine, beer, or other alcoholic beverages
A nurse is making initial rounds on assigned clients at the beginning of the shift. One client is
receiving a heparin infusion at 5 mL/hr. The nurse notes that 25,000 units of heparin are mixed in
250 mL of solution. How many units/hr is the client receiving? correct answers a. 500 units/hr
The client is diagnosed with an ischemic stroke & being evaluated for thrombolytic therapy.
Which assessment finding should prompt the nurse to withhold thrombolytic therapy?
a. History of T1 DM
b. Neurologic deficits started 2 hr ago
c. History of serious head injury 4 weeks ago
d. Brain CT scan results show no bleeding correct answers c. History of serious head injury 4
weeks ago
The nurse is caring for a client status post bone marrow transplant. The client's current vital signs
are: temp 38.1, HR 84, BP 120/80, RR 18. The nurse recognizes the following as signs of
GVHD. SATA
a. Rash & itching
b. Yellowing of sclera
c. Rectal pain
d. 40mL/hr output of clear amber urine
e. WBC of 22,000 correct answers a. Rash & itching
b. Yellowing of sclera
,What is an expected client nursing diagnosis when admitted to the hospital with symptoms of
DI?
a. Impaired gas exchange r/t fluid retention in lungs
b. Risk for impaired skin integrity r/t generalized edema
c. Excess fluid vol. r/t intake greater than output
d. Sleep pattern disturbance r/t frequent waking to void correct answers d. Sleep pattern
disturbance r/t frequent waking to void
The nurse is caring for the client with problems of anxiety & confusion in the acute phase of
burn management. Which intervention should the nurse implement? SATA
a. Repeat orientation statements of person, place, & time
b. Turn & reposition the client at least every hour
c. Place familiar objects from home near the client
d. Implement a schedule for regular sleep-wake cycles
e. Reduce distractions by keeping the television in the room off correct answers a. Repeat
orientation statements of person, place, & time
c. Place familiar objects from home near the client
d. Implement a schedule for regular sleep-wake cycles
During change of shift report, the nurse is informed that the client has a high bilirubin level.
Which assessment finding would the nurse expect with the client with an elevated bilirubin
level?
a. Erythema of the sclera
b. Dark brown stool
c. Dark brown urine
d. Foamy light-colored urine correct answers c. Dark brown urine
The nurse is determining the IV fluid needs for the 110 lbs client with partial thickness burns to
40% TBSA. Using the parkland formula, how many mL of IV fluids are needed during the 1st 8
hrs after injury? correct answers 4000mL
, Which of the following side effects might be expected for a client taking iron supplements?
SATA
a. Constipation
b. Dysphagia
c. Decreased appetite
d. Black stool
e. Insomnia correct answers a. Constipation
d. Black stool
Hepatitis is a viral infection that affects the entire body. What other signs & symptoms can a
client with hepatitis present with? SATA
a. Runny eyes & nose
b. Distaste for cigarettes
c. HOH
d. Pruritis
e. Light colored stools correct answers b. Distaste for cigarettes
d. Pruritis
e. Light colored stools
The nurse is caring for a client who is 20 days post stem cell transplant. Upon physical
assessment, the nurse notes a red, raised rash to the client's lower extremities. The client reports
diarrhea, constant nausea, & feels bloated. The nurse recognizes that the client is exhibiting
manifestations related to?
a. Chronic transplant rejection
b. Acute transplant rejection
c. GVHD
d. Hyperacute transplant rejection correct answers c. GVHD
