NURS 327 Midterm Exam with verified
| | | | | |
answers
A |76-year-old |client |had |surgery |for |an |abdominal |hernia. |The |PACU |nurse |observes |that |the |client |is |
confused |and |is |trying |to |climb |out |of |the |bed |and |pull |at |the |cardiac |monitor |lines. |At |this |time, |
what |interventions |by |the |nurse |are |appropriate? |Select |all |that |apply. |- |correct |answer | |Reorient |the
|client.
Assess |for |hypoxia.
Assess |urine |output.
A |client |arrives |in |the |emergency |department |reporting |shortness |of |breath. |She |has |3+ |pitting |
edema |below |the |knees, |a |respiratory |rate |of |36 |breaths |per |minute, |and |heaving |respirations. |The |
nurse |auscultates |the |client's |lungs |to |reveal |coarse, |moist, |high-pitched, |and |non-continuous |sounds |
that |do |not |clear |with |coughing. |The |nurse |will |document |these |sounds |as |which |type? |- |correct |
answer | |Crackles
A |client |has |a |nursing |diagnosis |of |ineffective |airway |clearance |related |to |excessive |mucus |
production. |The |best |short-term |goal |is |for |the |client |to |- |correct |answer | |Report |decreased |
congestion.
A |client |has |suspected |fluid |accumulation |in |the |pleural |space |of |the |lungs |and |is |scheduled |for |a |
thoracentesis. |The |nurse |will |implement |which |of |the |following |for |this |procedure? |Select |all |that |
apply. |- |correct |answer | |-Complete |a |respiratory |assessment |after |the |procedure.
-Educate |the |client |about |the |need |to |cleanse |the |thoracic |area.
-Apply |pressure |to |the |puncture |site |after |the |procedure
A |client |is |being |prepared |for |a |same-day |surgical |procedure |and |is |discussing |with |the |nurse |what |
potential |ramifications |this |type |of |surgery |has. |Which |of |the |following |would |the |nurse |correctly |
identify? |Select |all |that |apply. |- |correct |answer | |-Need |for |teaching |is |increased.
-The |client |will |leave |the |hospital |sooner |than |in |the |past.
-The |client |must |be |prepared |to |take |on |more |self-care |than |he |or |she |may |have |done |in |the |past.
, A |client |is |receiving |moderate |sedation |while |undergoing |bronchoscopy. |Which |assessment |finding |
should |the |nurse |attend |to |immediately? |- |correct |answer | |Oxygen |saturation |of |90%
A |client |is |recovering |from |abdominal |surgery. |The |statement |by |the |client |that |most |indicates |the |
nurse |needs |to |educate |the |client |about |pain |and |pain |control |is |- |correct |answer | |"I |should |expect |to
|have |pain."
A |client |presents |to |the |ED |after |being |in |a |boating |accident |about |3 |hours |ago. |Now |the |client |
reports |headache, |fatigue, |and |the |feeling |that |he |"just |can't |breathe |enough." |The |nurse |notes |that |
the |client |is |restless |and |tachycardic |with |an |elevated |blood |pressure. |This |client |may |be |in |the |early |
stages |of |what |respiratory |problem? |- |correct |answer | |Acute |respiratory |failure
A |client |who |has |developed |a |painless |penile |ulcer |is |diagnosed |with |syphilis. |What |treatment |would |
physician |prescribe? |- |correct |answer | |IV |penicillin |G; |single |dose
A |client |with |a |decreased |level |of |consciousness |is |in |a |recumbent |position. |How |should |the |nurse |
best |assess |the |lung |fields |for |a |client |in |this |position? |- |correct |answer | |Turn |the |client |to |enable |
assessment |of |all |the |patient's |lung |fields.
A |client |with |emphysema |informs |the |nurse, |"The |surgeon |will |be |removing |about |30% |of |my |lung |so
|that |I |will |not |be |so |short |of |breath |and |will |have |an |improved |quality |of |life." |What |surgery |does |
the |nurse |understand |the |surgeon |will |perform? |- |correct |answer | |A |lung |volume |reduction
A |client |with |thoracic |trauma |is |admitted |to |the |ICU. |The |nurse |notes |the |client's |chest |and |neck |are |
swollen |and |there |is |a |crackling |sensation |when |palpated. |The |nurse |consequently |identifies |the |
presence |of |subcutaneous |emphysema. |If |this |condition |becomes |severe |and |threatens |airway |
patency, |what |intervention |is |indicated? |- |correct |answer | |A |tracheostomy
A |mechanically |ventilated |client |is |receiving |a |combination |of |atracurium |and |the |opioid |analgesic |
morphine. |The |nurse |monitors |the |client |for |which |potential |complication? |- |correct |answer | |Venous |
thromboemboli
A |nurse |implements |aseptic |technique |as |a |means |to |break |the |chain |of |infection |at |which |element? |-
|correct |answer | |Portal |of |entry
| | | | | |
answers
A |76-year-old |client |had |surgery |for |an |abdominal |hernia. |The |PACU |nurse |observes |that |the |client |is |
confused |and |is |trying |to |climb |out |of |the |bed |and |pull |at |the |cardiac |monitor |lines. |At |this |time, |
what |interventions |by |the |nurse |are |appropriate? |Select |all |that |apply. |- |correct |answer | |Reorient |the
|client.
Assess |for |hypoxia.
Assess |urine |output.
A |client |arrives |in |the |emergency |department |reporting |shortness |of |breath. |She |has |3+ |pitting |
edema |below |the |knees, |a |respiratory |rate |of |36 |breaths |per |minute, |and |heaving |respirations. |The |
nurse |auscultates |the |client's |lungs |to |reveal |coarse, |moist, |high-pitched, |and |non-continuous |sounds |
that |do |not |clear |with |coughing. |The |nurse |will |document |these |sounds |as |which |type? |- |correct |
answer | |Crackles
A |client |has |a |nursing |diagnosis |of |ineffective |airway |clearance |related |to |excessive |mucus |
production. |The |best |short-term |goal |is |for |the |client |to |- |correct |answer | |Report |decreased |
congestion.
A |client |has |suspected |fluid |accumulation |in |the |pleural |space |of |the |lungs |and |is |scheduled |for |a |
thoracentesis. |The |nurse |will |implement |which |of |the |following |for |this |procedure? |Select |all |that |
apply. |- |correct |answer | |-Complete |a |respiratory |assessment |after |the |procedure.
-Educate |the |client |about |the |need |to |cleanse |the |thoracic |area.
-Apply |pressure |to |the |puncture |site |after |the |procedure
A |client |is |being |prepared |for |a |same-day |surgical |procedure |and |is |discussing |with |the |nurse |what |
potential |ramifications |this |type |of |surgery |has. |Which |of |the |following |would |the |nurse |correctly |
identify? |Select |all |that |apply. |- |correct |answer | |-Need |for |teaching |is |increased.
-The |client |will |leave |the |hospital |sooner |than |in |the |past.
-The |client |must |be |prepared |to |take |on |more |self-care |than |he |or |she |may |have |done |in |the |past.
, A |client |is |receiving |moderate |sedation |while |undergoing |bronchoscopy. |Which |assessment |finding |
should |the |nurse |attend |to |immediately? |- |correct |answer | |Oxygen |saturation |of |90%
A |client |is |recovering |from |abdominal |surgery. |The |statement |by |the |client |that |most |indicates |the |
nurse |needs |to |educate |the |client |about |pain |and |pain |control |is |- |correct |answer | |"I |should |expect |to
|have |pain."
A |client |presents |to |the |ED |after |being |in |a |boating |accident |about |3 |hours |ago. |Now |the |client |
reports |headache, |fatigue, |and |the |feeling |that |he |"just |can't |breathe |enough." |The |nurse |notes |that |
the |client |is |restless |and |tachycardic |with |an |elevated |blood |pressure. |This |client |may |be |in |the |early |
stages |of |what |respiratory |problem? |- |correct |answer | |Acute |respiratory |failure
A |client |who |has |developed |a |painless |penile |ulcer |is |diagnosed |with |syphilis. |What |treatment |would |
physician |prescribe? |- |correct |answer | |IV |penicillin |G; |single |dose
A |client |with |a |decreased |level |of |consciousness |is |in |a |recumbent |position. |How |should |the |nurse |
best |assess |the |lung |fields |for |a |client |in |this |position? |- |correct |answer | |Turn |the |client |to |enable |
assessment |of |all |the |patient's |lung |fields.
A |client |with |emphysema |informs |the |nurse, |"The |surgeon |will |be |removing |about |30% |of |my |lung |so
|that |I |will |not |be |so |short |of |breath |and |will |have |an |improved |quality |of |life." |What |surgery |does |
the |nurse |understand |the |surgeon |will |perform? |- |correct |answer | |A |lung |volume |reduction
A |client |with |thoracic |trauma |is |admitted |to |the |ICU. |The |nurse |notes |the |client's |chest |and |neck |are |
swollen |and |there |is |a |crackling |sensation |when |palpated. |The |nurse |consequently |identifies |the |
presence |of |subcutaneous |emphysema. |If |this |condition |becomes |severe |and |threatens |airway |
patency, |what |intervention |is |indicated? |- |correct |answer | |A |tracheostomy
A |mechanically |ventilated |client |is |receiving |a |combination |of |atracurium |and |the |opioid |analgesic |
morphine. |The |nurse |monitors |the |client |for |which |potential |complication? |- |correct |answer | |Venous |
thromboemboli
A |nurse |implements |aseptic |technique |as |a |means |to |break |the |chain |of |infection |at |which |element? |-
|correct |answer | |Portal |of |entry
