NUR 2755 MDC4 exam 1 copy Q&A

With what we have… the test taker got 84% 1. No picture : D 2. No picture: B 3. No picture: B - constrict 4. No picture: D or C 5. A nurse is assessing a client in postoperative recovery. The client complains of the following symptoms. Which of the following is abnormal and should be reported immediately? a. Emesis that is red b. Complaint of feeling cold c. Nausea d. Complaint of pain 6. A client's neurological status deteriorates over hours, and a craniotomy is performed to evacuate a hematoma. Which nursing intervention is indicated to help decrease the threat of increased intracranial pressure? a. Elevate the head of the bed 30 degrees b. Cluster nursing interventions to provide uninterrupted periods of rest c. Teach the client to cough and deep breathe to prevent the necessity for suctioning d. Teach the client to hold his breath and bear down while repositioning in bed. 7. A client presents to the emergency room with complaints of bilateral lower extremity loss of sensation that started in the feet but has now progressed to the knees and hips. The nurse interprets these symptoms to indicate an immediate workup for which of the following diseases? a. Myasthenia gravis b. Simple, partial seizure c. guillain- barre syndrome d. Cerebrovascular accident 8. The charge nurse is obtaining the client’s signature on a surgical consent form. The client states, I didn’t really understand what my surgeon explained, but I trust him completely, “which response by the charge nurse is correct? a. I need to contact your surgeon so your questions can be answered b. I can answer any questions that you might have regarding your surgery. c. As long as you are comfortable, then you may sign the consent form. d. Maybe you should call your surgeon to be sure it is okay to sign the consent. 9. A client has a head injury and is presenting with signs and symptoms of increased intracranial pressure. Which nursing intervention would be helpful in reducing this pressure? a. Place the neck in a neutral position to promote venous drainage b. Suction hourly to stimulate the cough reflex c. Add extra blankets to keep the client warm. d. Turn the client frequently to prevent skin impairment 10. A client has recently suffered a stroke with left-sided weakness. The nurse assesses for dysphagia, especially with thin liquids. Which nursing intervention is most helpful in assisting this patient to swallow safely? a. The client should avoid all liquids. b. Instructing to tuck the chin when swallowing c. Give sips of water with each bite d. Turn head to the left. 11. A client has a comminuted fracture of T6-T7, resulting in paraplegia. The nurse educates the client on preventing autonomic dysreflexia. Which of the following is the priority intervention in this medical emergency? a. Scheduled bladder and bowel training b. Choosing foods to prevent nausea c. Avoiding food allergies d. Preventing electrolyte imbalances 12. The nurse develops a care plan for a client recovering from surgery. What nursing interventions will the nurse include to minimize the effects of venous stasis? a. Pillows under the knee in a position of comfort b. Sitting with feet flat on the floor c. Early ambulation d. Gentle leg massage 13. The client has an order for 0.45% sodium chloride 1 liter to infuse over 15 hours.At what rate in mL/hr would the nurse set the infusion pump? (Round to the nearest whole number, do not use a trailing zero.) 67mL/hr 14. A client with multiple sclerosis (MS) is receiving baclofen. The nurse determines that the drug is effective when it causes which action? a. Induces sleep b. Stimulates the client’s appetite c. Relieves muscular spasticity d. Reduces the urine bacterial count 15. Sudden chest pain combined with dyspnea, cyanosis, and tachycardia are symptoms associated with which of the following complications of surgery? a. Hypovolemic shock b. Dehiscence c. Atelectasis d. Pulmonary embolus 16. A client presents to the emergency department with signs of a stroke. After a computed tomography (CT) scan, which revealed a hemorrhage, the nurse anticipates directives for which one of the following plans? a. TPA administration a. Call a code blue b. Prep for a client surgery c. Place the client in Trendelenburg 17. A client arrives in the emergency department with an ischemic stroke. Because the healthcare team is considering tissue plasminogen activator (tPA), what should the nurse perform FIRST? a. Ask what medications the client is taking b. Complete the history and health assessment c. Identify the time of onset of the stroke d. Determine if the client is scheduled for any surgical procedures 18. The client has presented with a basilar skull fracture. While assessing the client, the nurse notes clear drainage from the nose with a “halo sign” and is concerned about a potential cerebrospinal fluid (CSF) leakage. What should the nurse do next? a. Document this as serous drainage and continue to monitor the client b. Check for the presence of glucose in the drainage and report to the provider c. Apply an ice pack to the nasal bridge and a large, fluffy dressing. d. Assist the client in blowing his nose to clear secretions and re-evaluate. 19. The nurse is discussing different types of anesthesia with a group of nursing students. The student nurse correctly identifies which type of anesthesia requires both inhalation and IV administration routes? a. General b. Regional c. Specific d. Preoperative 20. The nurse is evaluating a client with a head injury and finds drainage from the client’s nose and ears. Which of the following is the priority teaching for this client? a. Cleanse the ear and nose with a soft cotton tipped swab and hydrogen peroxide b. Gently suction the nasal cavity to reduce the amount of secretions c. Wipe the nose or ears, but do not blow the nose or place anything in the ear d. Place a pressure dressing over the affected areas to reduce leakage. 21. The nurse is assisting with the sponge and instrument count in the operating room. Which operative phase does this occur in? a. Perioperative phase b. Preoperative phase c. Intraoperative phase d. Postoperative phase 22. A client has been diagnosed with an ischemic stroke. The nurse realizes this client cannot have fibrinolytic therapy until which vital sign is addressed and treated? a. Blood pressure of 220/120 mm HG b. Oxygen saturation of 92% c. A heart rate of 86 bpm d. RR of 24 bpm 23. During a nutritional therapy class, the nurse educates a group of migraine sufferers on foods that may worsen headaches. The clients are advised to avoid which of the following food choices? (SATA) a. Yogurt b. Caffeine c. Beef d. Pears e. Marinated food f. milk 24. The nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent respiratory complications in the client? a. Keep an oral airway at the bedside b. Ensure fluid intake of at least 3L/day c. Teach the client pursed lip breathing techniques d. Maintain the head of bed at 30 degrees or greater 25. A client has been injured in a motorcycle accident and is presenting with signs and symptoms of increased intracranial pressure. What is the most significant sign or symptom of increased intracranial pressure? a. Pupil changes b. Ipsilateral paralysis c. Vomiting d. Decrease in the level of consciousness