Nursing 308 Exam Questions AND Correct Answers
A 25-year-old male is admitted in sickle cell crisis. Which of the following
interventions would be of highest priority for this client?
A) Taking hourly blood pressures with mechanical cuff
B) Encouraging fluid intake of at least 200mL per hour
C) Position in high Fowler's with knee gatch raised
D) Administering Tylenol as ordered - ✔✔Answer:
B: Encouraging fluid intake of at least 200ml per hour
Rationale:
It is important to keep the client in sickle cell crisis hydrated to prevent further
sickling of the blood. Dehydration is a common cause of sickling. Answer A is
incorrect because a mechanical cuff places too much pressure on the arm.
Answer C is incorrect because raising the knee gatch impedes circulation.
Answer D is incorrect because Tylenol is too mild an analgesic for the client in
crisis.
A 60-year-old comes into the emergency department with crushing substernal
chest pain that radiates to the shoulder and left arm. The admitting diagnosis is
acute myocardial infarction (MI). Admission prescriptions include oxygen by
nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-
lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse
should first:
A. Administer the morphine
B. Obtain a 12-lead ECG
C. Obtain the blood work
D. Prescribe the chest radiograph - ✔✔A. Administer the morphine
,Rationale: Although obtaining the ECG, chest radiograph, and blood work are all
important, the nurse's priority action should be to relieve the crushing chest
pain. Therefore, administering morphine sulfate is the priority action.
A 68-year-old woman is diagnosed with thrombocytopenia due to acute
lymphocytic leukemia. She is admitted to the hospital for treatment. The nurse
should assign the patient:
A. to a private room so she will not infect other patients and health care
workers.
B. to a private room so she will not be infected by other patients and health
care workers.
C. to a semiprivate room so she will have stimulation during her hospitalization.
D. to a semiprivate room so she will have the opportunity to express her
feelings about her illness. - ✔✔Answer: B
What are the needs of the patient with acute lymphocytic leukemia and
thrombocytopenia?
Needed Info: Lymphocytic leukemia, disease characterized by proliferation of
immature WBCs. Immature cells unable to fight infection as competently as
mature white cells. Treatment: chemotherapy, antibiotics, blood transfusions,
bone marrow transplantation. Nursing responsibilities: private room, no raw
fruits or vegs, small frequent meals, O2, good skin care.
B. to a private room so she will not be infected by other patients and health
care workers - CORRECT: protects patient from exogenous bacteria, risk for
developing infection from others due to depressed WBC count, alters ability to
fight infection
,A client comes into the emergency room with complaints of sudden onset of
severe right flank pain. While tests are being performed, it is MOST important
for the nurse to take which of the following actions?
a) Make sure the the patient does not eat or drink anything
b) Strain all the patient's urine through several layers of gauze
c) Check the patient's grip strength and pupil reactivity
d) Send blood and urine specimens to the lab for analysis - ✔✔B) Strain all the
patient's urine through several layers of gauze
Rationale: "b" is the correct answer. "MOST" indicates a priority question.
Symptoms suggest urinary caculi and should strain urine for stone. Needed
information: Symptoms of renal calculi include- pain, diaphoresis, nausea and
vomiting, fever and chills, hematuria. Nursing care: monitor I&O and temp,
suggest increase in fluids, strain urine and check pH of urine, and administer
analgesics. Diet for prevention of stones: consume foods low in calcium,
sodium, and oxalates, avoid vitamin D enriched foods, decrease purine sources,
restrict citrus fruits, milk, and potatoes.
A client had a right total hip arthroplasty 2 days ago. Which precautions will the
nurse teach the client to prevent surgical complications? Select all that apply.
A. "Stand on your right leg to pivot to the chair"
B. "Do not bend your leg more than 90 degrees"
C. "Cross your legs to be more comfortable"
D. "Avoid twisting your body when moving"
E. "Use a long-handled shoe horn to put on your shoes" - ✔✔Correct Answers:
B, D, and E
Rationale:
, B, D, and E are proper ways to care for clients with THA. A and C can lead to
dislocation of the affected hip. Chart 18-3 on page 298 contains information on
precautions, pain management, and care for patients with THA
A client had surgery two (2) days ago and reports having a moderate amount of
pain, stating that it is "a 7 on a 1 to 10 scale" of intensity. What intervention has
the highest priority in the client's nursing care plan?
A. Encouraging diversional activities
B. Incorporating ADLs as soon as possible
C. Teaching key points of the relaxation response
D. Using preemptive analgesia - ✔✔Answer: D: Using preemptive analgesia
Rationale:
Use of preemptive analgesia is a technique designed to decrease pain in the
postoperative period, decrease the requirements for a postoperative analgesic,
prevent morbidity, and decrease the hospital stay.
A client has taken steroids for 12 years to help manage chronic obstructive
pulmonary disease (COPD). When making a home visit, which nursing function is
of greatest importance to this client? Assess the client's
A. Pulse rate, both apically and radially
B. Blood pressure, both standing and sitting.
C. Temperature
D. Skin color and turgor - ✔✔Correct Answer: C. Temperature
Rationale:
A 25-year-old male is admitted in sickle cell crisis. Which of the following
interventions would be of highest priority for this client?
A) Taking hourly blood pressures with mechanical cuff
B) Encouraging fluid intake of at least 200mL per hour
C) Position in high Fowler's with knee gatch raised
D) Administering Tylenol as ordered - ✔✔Answer:
B: Encouraging fluid intake of at least 200ml per hour
Rationale:
It is important to keep the client in sickle cell crisis hydrated to prevent further
sickling of the blood. Dehydration is a common cause of sickling. Answer A is
incorrect because a mechanical cuff places too much pressure on the arm.
Answer C is incorrect because raising the knee gatch impedes circulation.
Answer D is incorrect because Tylenol is too mild an analgesic for the client in
crisis.
A 60-year-old comes into the emergency department with crushing substernal
chest pain that radiates to the shoulder and left arm. The admitting diagnosis is
acute myocardial infarction (MI). Admission prescriptions include oxygen by
nasal cannula at 4 L/min, complete blood count (CBC), a chest radiograph, a 12-
lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse
should first:
A. Administer the morphine
B. Obtain a 12-lead ECG
C. Obtain the blood work
D. Prescribe the chest radiograph - ✔✔A. Administer the morphine
,Rationale: Although obtaining the ECG, chest radiograph, and blood work are all
important, the nurse's priority action should be to relieve the crushing chest
pain. Therefore, administering morphine sulfate is the priority action.
A 68-year-old woman is diagnosed with thrombocytopenia due to acute
lymphocytic leukemia. She is admitted to the hospital for treatment. The nurse
should assign the patient:
A. to a private room so she will not infect other patients and health care
workers.
B. to a private room so she will not be infected by other patients and health
care workers.
C. to a semiprivate room so she will have stimulation during her hospitalization.
D. to a semiprivate room so she will have the opportunity to express her
feelings about her illness. - ✔✔Answer: B
What are the needs of the patient with acute lymphocytic leukemia and
thrombocytopenia?
Needed Info: Lymphocytic leukemia, disease characterized by proliferation of
immature WBCs. Immature cells unable to fight infection as competently as
mature white cells. Treatment: chemotherapy, antibiotics, blood transfusions,
bone marrow transplantation. Nursing responsibilities: private room, no raw
fruits or vegs, small frequent meals, O2, good skin care.
B. to a private room so she will not be infected by other patients and health
care workers - CORRECT: protects patient from exogenous bacteria, risk for
developing infection from others due to depressed WBC count, alters ability to
fight infection
,A client comes into the emergency room with complaints of sudden onset of
severe right flank pain. While tests are being performed, it is MOST important
for the nurse to take which of the following actions?
a) Make sure the the patient does not eat or drink anything
b) Strain all the patient's urine through several layers of gauze
c) Check the patient's grip strength and pupil reactivity
d) Send blood and urine specimens to the lab for analysis - ✔✔B) Strain all the
patient's urine through several layers of gauze
Rationale: "b" is the correct answer. "MOST" indicates a priority question.
Symptoms suggest urinary caculi and should strain urine for stone. Needed
information: Symptoms of renal calculi include- pain, diaphoresis, nausea and
vomiting, fever and chills, hematuria. Nursing care: monitor I&O and temp,
suggest increase in fluids, strain urine and check pH of urine, and administer
analgesics. Diet for prevention of stones: consume foods low in calcium,
sodium, and oxalates, avoid vitamin D enriched foods, decrease purine sources,
restrict citrus fruits, milk, and potatoes.
A client had a right total hip arthroplasty 2 days ago. Which precautions will the
nurse teach the client to prevent surgical complications? Select all that apply.
A. "Stand on your right leg to pivot to the chair"
B. "Do not bend your leg more than 90 degrees"
C. "Cross your legs to be more comfortable"
D. "Avoid twisting your body when moving"
E. "Use a long-handled shoe horn to put on your shoes" - ✔✔Correct Answers:
B, D, and E
Rationale:
, B, D, and E are proper ways to care for clients with THA. A and C can lead to
dislocation of the affected hip. Chart 18-3 on page 298 contains information on
precautions, pain management, and care for patients with THA
A client had surgery two (2) days ago and reports having a moderate amount of
pain, stating that it is "a 7 on a 1 to 10 scale" of intensity. What intervention has
the highest priority in the client's nursing care plan?
A. Encouraging diversional activities
B. Incorporating ADLs as soon as possible
C. Teaching key points of the relaxation response
D. Using preemptive analgesia - ✔✔Answer: D: Using preemptive analgesia
Rationale:
Use of preemptive analgesia is a technique designed to decrease pain in the
postoperative period, decrease the requirements for a postoperative analgesic,
prevent morbidity, and decrease the hospital stay.
A client has taken steroids for 12 years to help manage chronic obstructive
pulmonary disease (COPD). When making a home visit, which nursing function is
of greatest importance to this client? Assess the client's
A. Pulse rate, both apically and radially
B. Blood pressure, both standing and sitting.
C. Temperature
D. Skin color and turgor - ✔✔Correct Answer: C. Temperature
Rationale:
