NUR 216 Final Exam NEW MATERIAL – questions with
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answers |/
1.A student is caring for a client who suffered massive blood loss after trauma.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ How does the student correlate the blood loss with the client's mean arterial
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ pressure (MAP)? |/
a. It causes vasoconstriction and increased MAP.
|/ |/ |/ |/ |/
b. Lower blood volume lowers MAP. |/ |/ |/ |/
c. There is no direct correlation to MAP.
|/ |/ |/ |/ |/ |/
d. It raises cardiac output and MAP.: B ~ Lower blood volume will decrease
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ MAP. The other answers are not accurate.
|/ |/ |/ |/ |/ |/
2.A nurse is caring for a client after surgery. The client's respiratory rate has
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ increased from 12 to 18 breaths/min and the pulse rate increased from 86 to
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ 98 beats/min since they were last assessed 4 hours ago. What action by the
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ nurse is best? |/ |/
a. Ask if the client needs pain medication.
|/ |/ |/ |/ |/ |/
b. Assess the client's tissue perfusion further. |/ |/ |/ |/ |/
c. Document the findings in the client's chart. |/ |/ |/ |/ |/ |/
d. Increase the rate of the client's IV infusion.: B ~ Signs of the earliest
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ stage of shock are subtle and may manifest in slight increases in heart
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ rate, respiratory rate, or blood pressure. Even though these readings are
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ not out of the normal range, the nurse should conduct a thorough
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ assessment of the client, focusing on indicators of perfusion. The client |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ may need pain medication, but this is not the priority at this time.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ Documentation should be done thoroughly but is not the priority either. |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
1 |//
|/299
,|/ The nurse should not increase the rate of the IV infusion without an
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ order.
3.The nurse gets the hand-off report on four clients. Which client should the
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ nurse assess first? |/ |/
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
b. Client with oxygen saturation unchanged at 94%
|/ |/ |/ |/ |/ |/
c. Client with a pulse change of 100 to 88 beats/min
|/ |/ |/ |/ |/ |/ |/ |/ |/
d. Client with urine output of 40 mL/hr for the last 2 hours: A ~ This client has
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ a falling systolic blood pressure, rising diastolic blood pressure, and
|/ |/ |/ |/ |/ |/ |/ |/ |/
|/ narrowing pulse pressure, all of which may be indications of the
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ progressive stage of shock. The nurse should assess this client first. The
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ client with the unchanged oxygen saturation is stable at this point.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ Although the client with a change in pulse has a slower rate, it is not an
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ indicator of shock since the pulse is still within the normal range; it may
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ indicate the client's pain or anxiety has been relieved, or he or she is
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ sleeping or relaxing. A urine output of 40 mL/hr is only slightly above
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ the normal range, which is 30 mL/hr.
|/ |/ |/ |/ |/ |/
4.A nurse is caring for a client after surgery who is restless and apprehensive.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ The unlicensed assistive personnel (UAP) reports the vital signs and the nurse
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ sees they are only slightly different from previous readings. What action does
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
2 |//
|/299
,the nurse delegate next to the UAP?
|/ |/ |/ |/ |/ |/
a. Assess the client for pain or discomfort. |/ |/ |/ |/ |/ |/
b. Measure urine output from the catheter. |/ |/ |/ |/ |/
c. Reposition the client to the unaffected side. |/ |/ |/ |/ |/ |/
d. Stay with the client and reassure him or her.: B ~ Urine output changes
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ are a sensitive early indicator of shock. The nurse should delegate
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ emptying the urinary catheter and measuring output to the UAP as a
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ baseline for hourly urine output measurements. The UAP cannot assess
|/ |/ |/ |/ |/ |/ |/ |/ |/
|/ for pain. Repositioning may or may not
|/ |/ |/ |/ |/ |/
be effective for decreasing restlessness, but does not take priority over
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ physical assessments. Reassurance is a therapeutic nursing action, but
|/ |/ |/ |/ |/ |/ |/ |/
|/ the nurse needs to do more in this situation.
|/ |/ |/ |/ |/ |/ |/ |/
5.A client is in shock and the nurse prepares to administer insulin for a blood
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ glucose reading of 208 mg/dL. The spouse asks why the client needs insulin
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ as the client is not a diabetic. What response by the nurse is best?
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
a. High glucose is common in shock and needs to be treated.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
b. Some of the medications we are giving are to raise blood sugar.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
c. The IV solution has lots of glucose, which raises blood sugar.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
d.The stress of this illness has made your spouse a diabetic.: A ~ High
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ glucose readings are common in shock, and best outcomes are the
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ result of treating them and maintaining glucose readings in the normal
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ range. Medications and IV solutions may raise blood glucose levels, but
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ this is not the most accurate answer. The stress of the illness has not
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ made the client diabetic. |/ |/ |/
3 |//
|/299
, 6.A nurse caring for a client notes the following assessments: white blood cell
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ C). What action by the nurse takes priority?
|/ |/ |/ |/ |/ |/ |/
a. Document the findings in the client's chart. |/ |/ |/ |/ |/ |/
b. Give the client warmed blankets for comfort. |/ |/ |/ |/ |/ |/
c. Notify the health care provider immediately. |/ |/ |/ |/ |/
d. Prepare to administer insulin per sliding scale.: C ~ This client has |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ several indicators of sepsis with systemic inflammatory response. The
|/ |/ |/ |/ |/ |/ |/ |/
|/ nurse should notify the health care provider immediately. Documentation
|/ |/ |/ |/ |/ |/ |/ |/
|/ needs to be thorough but does not take priority. The client may
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ appreciate warm blankets, but comfort measures do not take priority. |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ The client may or may not need insulin.
|/ |/ |/ |/ |/ |/ |/
7.A nurse works at a community center for older adults. What self-manage-
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ ment measure can the nurse teach the clients to prevent shock?
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
a. Do not get dehydrated in warm weather.
|/ |/ |/ |/ |/ |/
b. Drink fluids on a regular schedule. |/ |/ |/ |/ |/
c. Seek attention for any lacerations. |/ |/ |/ |/
d. Take medications as prescribed.: B ~ Preventing dehydration in older
|/ |/ |/ |/ |/ |/ |/ |/ |/
|/ adults is |/
4 |//
|/299
|/ |/ |/ |/ |/ |/ |/ |/
answers |/
1.A student is caring for a client who suffered massive blood loss after trauma.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ How does the student correlate the blood loss with the client's mean arterial
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ pressure (MAP)? |/
a. It causes vasoconstriction and increased MAP.
|/ |/ |/ |/ |/
b. Lower blood volume lowers MAP. |/ |/ |/ |/
c. There is no direct correlation to MAP.
|/ |/ |/ |/ |/ |/
d. It raises cardiac output and MAP.: B ~ Lower blood volume will decrease
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ MAP. The other answers are not accurate.
|/ |/ |/ |/ |/ |/
2.A nurse is caring for a client after surgery. The client's respiratory rate has
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ increased from 12 to 18 breaths/min and the pulse rate increased from 86 to
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ 98 beats/min since they were last assessed 4 hours ago. What action by the
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ nurse is best? |/ |/
a. Ask if the client needs pain medication.
|/ |/ |/ |/ |/ |/
b. Assess the client's tissue perfusion further. |/ |/ |/ |/ |/
c. Document the findings in the client's chart. |/ |/ |/ |/ |/ |/
d. Increase the rate of the client's IV infusion.: B ~ Signs of the earliest
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ stage of shock are subtle and may manifest in slight increases in heart
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ rate, respiratory rate, or blood pressure. Even though these readings are
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ not out of the normal range, the nurse should conduct a thorough
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ assessment of the client, focusing on indicators of perfusion. The client |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ may need pain medication, but this is not the priority at this time.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ Documentation should be done thoroughly but is not the priority either. |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
1 |//
|/299
,|/ The nurse should not increase the rate of the IV infusion without an
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ order.
3.The nurse gets the hand-off report on four clients. Which client should the
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ nurse assess first? |/ |/
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
b. Client with oxygen saturation unchanged at 94%
|/ |/ |/ |/ |/ |/
c. Client with a pulse change of 100 to 88 beats/min
|/ |/ |/ |/ |/ |/ |/ |/ |/
d. Client with urine output of 40 mL/hr for the last 2 hours: A ~ This client has
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ a falling systolic blood pressure, rising diastolic blood pressure, and
|/ |/ |/ |/ |/ |/ |/ |/ |/
|/ narrowing pulse pressure, all of which may be indications of the
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ progressive stage of shock. The nurse should assess this client first. The
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ client with the unchanged oxygen saturation is stable at this point.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ Although the client with a change in pulse has a slower rate, it is not an
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ indicator of shock since the pulse is still within the normal range; it may
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ indicate the client's pain or anxiety has been relieved, or he or she is
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ sleeping or relaxing. A urine output of 40 mL/hr is only slightly above
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ the normal range, which is 30 mL/hr.
|/ |/ |/ |/ |/ |/
4.A nurse is caring for a client after surgery who is restless and apprehensive.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ The unlicensed assistive personnel (UAP) reports the vital signs and the nurse
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ sees they are only slightly different from previous readings. What action does
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
2 |//
|/299
,the nurse delegate next to the UAP?
|/ |/ |/ |/ |/ |/
a. Assess the client for pain or discomfort. |/ |/ |/ |/ |/ |/
b. Measure urine output from the catheter. |/ |/ |/ |/ |/
c. Reposition the client to the unaffected side. |/ |/ |/ |/ |/ |/
d. Stay with the client and reassure him or her.: B ~ Urine output changes
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ are a sensitive early indicator of shock. The nurse should delegate
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ emptying the urinary catheter and measuring output to the UAP as a
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ baseline for hourly urine output measurements. The UAP cannot assess
|/ |/ |/ |/ |/ |/ |/ |/ |/
|/ for pain. Repositioning may or may not
|/ |/ |/ |/ |/ |/
be effective for decreasing restlessness, but does not take priority over
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ physical assessments. Reassurance is a therapeutic nursing action, but
|/ |/ |/ |/ |/ |/ |/ |/
|/ the nurse needs to do more in this situation.
|/ |/ |/ |/ |/ |/ |/ |/
5.A client is in shock and the nurse prepares to administer insulin for a blood
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ glucose reading of 208 mg/dL. The spouse asks why the client needs insulin
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ as the client is not a diabetic. What response by the nurse is best?
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
a. High glucose is common in shock and needs to be treated.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
b. Some of the medications we are giving are to raise blood sugar.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
c. The IV solution has lots of glucose, which raises blood sugar.
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
d.The stress of this illness has made your spouse a diabetic.: A ~ High
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ glucose readings are common in shock, and best outcomes are the
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ result of treating them and maintaining glucose readings in the normal
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ range. Medications and IV solutions may raise blood glucose levels, but
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ this is not the most accurate answer. The stress of the illness has not
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ made the client diabetic. |/ |/ |/
3 |//
|/299
, 6.A nurse caring for a client notes the following assessments: white blood cell
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ C). What action by the nurse takes priority?
|/ |/ |/ |/ |/ |/ |/
a. Document the findings in the client's chart. |/ |/ |/ |/ |/ |/
b. Give the client warmed blankets for comfort. |/ |/ |/ |/ |/ |/
c. Notify the health care provider immediately. |/ |/ |/ |/ |/
d. Prepare to administer insulin per sliding scale.: C ~ This client has |/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ several indicators of sepsis with systemic inflammatory response. The
|/ |/ |/ |/ |/ |/ |/ |/
|/ nurse should notify the health care provider immediately. Documentation
|/ |/ |/ |/ |/ |/ |/ |/
|/ needs to be thorough but does not take priority. The client may
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ appreciate warm blankets, but comfort measures do not take priority. |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ The client may or may not need insulin.
|/ |/ |/ |/ |/ |/ |/
7.A nurse works at a community center for older adults. What self-manage-
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/ |/
|/ ment measure can the nurse teach the clients to prevent shock?
|/ |/ |/ |/ |/ |/ |/ |/ |/ |/
a. Do not get dehydrated in warm weather.
|/ |/ |/ |/ |/ |/
b. Drink fluids on a regular schedule. |/ |/ |/ |/ |/
c. Seek attention for any lacerations. |/ |/ |/ |/
d. Take medications as prescribed.: B ~ Preventing dehydration in older
|/ |/ |/ |/ |/ |/ |/ |/ |/
|/ adults is |/
4 |//
|/299
