NUR 304 Exam 1 Testbank Questions With Complete
Solutions
A client had a surgical procedure with spinal anesthesia. The
client's blood pressure was
122/78 mm Hg 30 minutes ago and is now 138/60 and the client
reports nausea. What action
by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Notify the primary health care provider.
d. Nothing; this is expected. Correct Answers ANS: C
A widening pulse pressure (44 to 78 mm Hg) and nausea may
indicate autonomic blockade, a
complication of spinal anesthesia causing widespread
vasodilation. The nurse would notify
the primary health care provider. The Rapid Response Team is
not yet warranted; the nurse
would not increase the IV rate without a prescription.
A client has a great deal of pain when coughing and deep
breathing after abdominal surgery
despite having pain medication. What action by the nurse is
best?
a. Call the primary health care provider to request more
analgesia.
b. Demonstrate how to splint the incision.
c. Have the client take shallower breaths.
d. Tell the client that a little pain is expected. Correct Answers
ANS: B
,Splinting an incision provides extra support during coughing and
activity and helps decrease
pain. If the client is otherwise comfortable, no more analgesia is
required. Shallow breathing
can lead to atelectasis and pneumonia. The client should know
that some pain is normal and
expected after surgery, but that answer alone does not provide
any interventions to help the
client.
A client has a tracheostomy that is 3 days old. Upon assessment,
the nurse notes that the
client's face is puffy and the eyelids are swollen. What action by
the nurse takes best?
a. Assess the client's oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest. Correct Answers ANS: A
This client may have subcutaneous emphysema, which is air that
leaks into the tissues
surrounding the tracheostomy. The nurse would first assess the
client's oxygen saturation and
other indicators of oxygenation. If the client is stable, the nurse
can palpate the skin of the
upper chest to feel for the air. If the client is unstable, the nurse
calls the Rapid Response
Team. Using a bag-valve-mask device may or may not be
appropriate for the unstable client.
A client has a tracheostomy tube in place. When the nurse
suctions the client, food particles
,are noted. What action by the nurse is best?
a. Elevate the head of the client's bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
d. Request that the client have a swallow study Correct Answers
ANS: B
Constant pressure from the tracheostomy tube cuff can cause
tracheomalacia, leading to
dilation of the tracheal passage. This can be manifested by food
particles seen in secretions or
by noting that larger and larger amounts of pressure are needed
to keep the tracheostomy cuff
inflated. The nurse would measure the pressures and compare
them to previous ones to detect
a trend. Elevating the head of the bed, placing the client on NPO
status, and requesting a
swallow study will not correct this situation
A client has arrived in the inpatient postoperative unit. What
action by the inpatient nurse
takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report Correct Answers ANS: D
Hand-offs are a critical time in client care, and poor
communication during this time can lead
to serious errors. The inpatient nurse and postanesthesia care
nurse participate in hand-off
report as the priority. Assessing fluid losses and dressings can be
done together as part of the
, report. Ensuring the client is warm is a lower priority
A client has been placed on Contact Precautions. The client's
family is very afraid to visit for
fear of being "contaminated" by the client. What action by the
nurse is best?
a. Explain to them that these precautions are mandated by law.
b. Show the family how to avoid spreading the disease.
c. Reassure the family that they will not get the infection.
d. Tell the family it is important that they visit the client. Correct
Answers ANS: B
Visitors may be apprehensive about visiting a client in
Transmission-Based Precautions. The
nurse would reassure the visitors that taking appropriate
precautions will minimize their risks.
The nurse would then demonstrate what precautions were
needed. The other options do
nothing to ease the family's fears
A client has multiple lesions all over the body and a family
history of skin cancer. The nurse
teaches the client to perform a total skin self-examinations on a
monthly basis. Which
statements will the nurse include in this patient's teaching?
(Select all that apply.)
a. "Look for asymmetry of shape and irregular borders."
b. "Assess for color variation within each lesion."
c. "Examine the distribution of lesions over a section of the
body."
d. "Monitor for edema or swelling of tissues."
e. "Focus your assessment on skin areas that itch."
Solutions
A client had a surgical procedure with spinal anesthesia. The
client's blood pressure was
122/78 mm Hg 30 minutes ago and is now 138/60 and the client
reports nausea. What action
by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Notify the primary health care provider.
d. Nothing; this is expected. Correct Answers ANS: C
A widening pulse pressure (44 to 78 mm Hg) and nausea may
indicate autonomic blockade, a
complication of spinal anesthesia causing widespread
vasodilation. The nurse would notify
the primary health care provider. The Rapid Response Team is
not yet warranted; the nurse
would not increase the IV rate without a prescription.
A client has a great deal of pain when coughing and deep
breathing after abdominal surgery
despite having pain medication. What action by the nurse is
best?
a. Call the primary health care provider to request more
analgesia.
b. Demonstrate how to splint the incision.
c. Have the client take shallower breaths.
d. Tell the client that a little pain is expected. Correct Answers
ANS: B
,Splinting an incision provides extra support during coughing and
activity and helps decrease
pain. If the client is otherwise comfortable, no more analgesia is
required. Shallow breathing
can lead to atelectasis and pneumonia. The client should know
that some pain is normal and
expected after surgery, but that answer alone does not provide
any interventions to help the
client.
A client has a tracheostomy that is 3 days old. Upon assessment,
the nurse notes that the
client's face is puffy and the eyelids are swollen. What action by
the nurse takes best?
a. Assess the client's oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest. Correct Answers ANS: A
This client may have subcutaneous emphysema, which is air that
leaks into the tissues
surrounding the tracheostomy. The nurse would first assess the
client's oxygen saturation and
other indicators of oxygenation. If the client is stable, the nurse
can palpate the skin of the
upper chest to feel for the air. If the client is unstable, the nurse
calls the Rapid Response
Team. Using a bag-valve-mask device may or may not be
appropriate for the unstable client.
A client has a tracheostomy tube in place. When the nurse
suctions the client, food particles
,are noted. What action by the nurse is best?
a. Elevate the head of the client's bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
d. Request that the client have a swallow study Correct Answers
ANS: B
Constant pressure from the tracheostomy tube cuff can cause
tracheomalacia, leading to
dilation of the tracheal passage. This can be manifested by food
particles seen in secretions or
by noting that larger and larger amounts of pressure are needed
to keep the tracheostomy cuff
inflated. The nurse would measure the pressures and compare
them to previous ones to detect
a trend. Elevating the head of the bed, placing the client on NPO
status, and requesting a
swallow study will not correct this situation
A client has arrived in the inpatient postoperative unit. What
action by the inpatient nurse
takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report Correct Answers ANS: D
Hand-offs are a critical time in client care, and poor
communication during this time can lead
to serious errors. The inpatient nurse and postanesthesia care
nurse participate in hand-off
report as the priority. Assessing fluid losses and dressings can be
done together as part of the
, report. Ensuring the client is warm is a lower priority
A client has been placed on Contact Precautions. The client's
family is very afraid to visit for
fear of being "contaminated" by the client. What action by the
nurse is best?
a. Explain to them that these precautions are mandated by law.
b. Show the family how to avoid spreading the disease.
c. Reassure the family that they will not get the infection.
d. Tell the family it is important that they visit the client. Correct
Answers ANS: B
Visitors may be apprehensive about visiting a client in
Transmission-Based Precautions. The
nurse would reassure the visitors that taking appropriate
precautions will minimize their risks.
The nurse would then demonstrate what precautions were
needed. The other options do
nothing to ease the family's fears
A client has multiple lesions all over the body and a family
history of skin cancer. The nurse
teaches the client to perform a total skin self-examinations on a
monthly basis. Which
statements will the nurse include in this patient's teaching?
(Select all that apply.)
a. "Look for asymmetry of shape and irregular borders."
b. "Assess for color variation within each lesion."
c. "Examine the distribution of lesions over a section of the
body."
d. "Monitor for edema or swelling of tissues."
e. "Focus your assessment on skin areas that itch."
