NUR401 Practice Exam Questions with 100% Correct Answers

1. When caring for a client who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a. Arterial oxygen saturation 90% b. Apical pulse 110 beats/min c. Blood pressure 88/56 mm Hg d. Urinary output 15 mL for 2 hours Correct Answer d. Urinary output 15 mL for 2 hours 2. A client is recovering from a cystoscopy. The nurse would expect to assess which of the following regarding the client's urine after the procedure? a. Hematuria b. Blood clots c. Pink-tinged d. Anuria Correct Answer c. Pink-tinged Explanation: The bladder and urethra are usually irritated as a result of the procedure. This causes pink-tinged urine. Large amounts of blood in the urine, anuria, or blood clots are not expected findings after this procedure. 3. A client with congestive heart failure and pulmonary edema develops early symptoms of acute renal failure (ARF). The nurse plans care for the client based on the knowledge that collaborative care of the renal failure will be directed towards which of the following goals? a. Diluting nephrotoxic substances b. Replacing fluid volume c. Promoting diuresis d. Maintaining cardiac output Correct Answer d. Maintaining cardiac output Rationale: The primary goal of treatment for ARF is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing ARF, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct. 4. Which of the following is the proper positioning for a client experiencing hypovolemic shock? a. Trendelenburg b. Reverse Trendelenburg c. Supine with head on a pillow d. Supine with feet elevated Correct Answer d. Supine with feet elevated - shock position 5. During discharge teaching for the client with sickle cell anemia, which of the following precipitating factors for sickle cell crisis should the nurse instruct the client to avoid? a. Exposure to crowds b. Limiting fluids to 2 L per day c. Excessive dietary iron intake d. Caffeine and alcohol intake Correct Answer a. Exposure to crowds rationale: Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended. 6. A client with chronic lymphocytic leukemia is hospitalized for the treatment of severe hemolytic anemia. Which of the following is an appropriate nursing intervention for the client? a. Plan care to alternate periods of rest and activity. b. Isolate the client from visitors and other clients. c. Encourage increased intake of fluid and fibre in the diet. d. Provide a diet high in vitamin K and folic acid. Correct Answer a. Plan care to alternate periods of rest and activity. Rationale: Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue. High vitamin K diets might be used for a patient with a bleeding disorder. There is no indication that the patient is neutropenic, so isolation is not needed. Increased intake of fluid and fiber will not improve the anemia. 7. A client is scheduled for a fistula creation due to end-stage renal disease. The nurse would include which of the following in teaching the client about the fistula? a. A vein and an artery will be attached surgically. b. The fistula can be used 2 to 4 weeks after the surgery for dialysis treatment. c. The arm should be immobilized for 4 to 6 weeks. d. One needle will be inserted for each dialysis treatment. Correct Answer d. One needle will be inserted for each dialysis treatment couldn't find on google, seems right though 8. A 12 years old is admitted to the emergency department after being stung by a bee. The client's mother tells the nurse that her son has an allergy to bees and he has been stung before. In what order of priority will the nurse address the complications? 1. Airway swelling 2. Hypotension 3. Tachypnea 4. Tachycardia