NURS 322 Exam 1 With Complete Solutions
A 22-year-old client presents with appendicitis and is preparing
for surgery. What gauge catheter will the ED nurse select for
this client?
a. 22
b. 14
c. 18
d. 24 Correct Answers c. 18
A circulating nurse has transferred an older client to the
operating room. What action by the nurse is most important for
this client?
a. Allow the client to keep hearing aids in until anesthesia
begins.
b. Pad the table as appropriate for the surgical procedure.
c. Position the client for maximum visualization of the site.
d. Stay with the client, providing emotional comfort and support.
Correct Answers ANS: A
Many older clients have sensory loss. To help prevent
disorientation, facilities often allow older clients to keep their
eyeglasses on and hearing aids in until the start of anesthesia.
The other actions are appropriate for all operative clients.
A circulating nurse wishes to provide emotional support to a
client who was just transferred to the operating room. What
action by the nurse would be best?
a. Administer anxiolytics.
,b. Give the client warm blankets.
c. Introduce the surgical staff.
d. Remain with the client. Correct Answers ANS: D
The nurse can provide emotional support by remaining with the
client until anesthesia has been provided. An extremely anxious
client may need anxiolytics, but not all clients require this for
emotional support. Physical comfort and introductions can also
help decrease anxiety.
A client asks the nurse if eating only preservative- and dye-free
foods will decrease cancer risk. What response by the nurse is
best?
a. Maybe; preservatives, dyes, and preparation methods may be
risk factors.
b. No; research studies have never shown those things to cause
cancer.
c. There are other things you can do that will more effectively
lower your risk.
d. Yes; preservatives and dyes are well known to be
carcinogens. Correct Answers ANS: A
Dietary factors related to cancer development are poorly
understood, although dietary practices are suspected to alter
cancer risk. Suspected dietary risk factors include low fiber
intake and a high intake of red meat or animal fat. Preservatives,
preparation methods, and additives (dyes, flavorings,
sweeteners) may have cancer- promoting effects. It is correct to
say that other things can lower risk more effectively, but this
does not give the client concrete information about how to do so,
and also does not answer the clients question.
,A client comes to the family medicine clinic and reports joint
pain and stiffness. The nurse is asked to assess the client for
Heberdens nodules. What assessment technique is correct?
a. Inspect the clients distal finger joints.
b. Palpate the clients abdomen for tenderness.
c. Palpate the clients upper body lymph nodes.
d. Perform range of motion on the clients wrists. Correct
Answers ANS: A
Herberdens nodules are seen in osteoarthritis and are bony
nodules at the distal interphalangeal joints. To assess for this
finding, the nurse inspects the clients distal fingertips. These
nodules are not found in the abdomen, lymph nodes, or wrists.
A client had a surgical procedure with spinal anesthesia. The
nurse raises the head of the clients bed. The clients blood
pressure changes from 122/78 mm Hg to 102/50 mm Hg. What
action by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Lower the head of the bed.
d. Nothing; this is expected. Correct Answers ANS: C
A client who had epidural or spinal anesthesia may become
hypotensive when the head of the bed is raised. If this occurs,
the nurse should lower the head of the bed to its original
position. The Rapid Response Team is not needed, nor is an
increase in IV rate.
A client has a continuous passive motion (CPM) device after a
total knee replacement. What action does the nurse delegate to
, the unlicensed assistive personnel (UAP) after the affected leg is
placed in the machine while the client is in bed?
a. Assess the distal circulation in 30 minutes.
b. Change the settings based on range of motion.
c. Raise the lower siderail on the affected side.
d. Remind the client to do quad-setting exercises. Correct
Answers ANS: C
Because the clients leg is strapped into the CPM, if it falls off
the bed due to movement, the clients leg (and new joint) can be
injured. The nurse should instruct the UAP to raise the siderail
to prevent this from occurring. Assessment is a nursing
responsibility. Only the surgeon, physical therapist, or specially
trained technician adjusts the CPM settings. Quad-setting
exercises are not related to the CPM machine.
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 provider to request more analgesia.
b. Demonstrate how to splint the incision.
c. Have the client take shallower breaths.
d. Tell the client 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
some pain is normal and expected after surgery, but that answer
alone does not provide any interventions to help the client.
A 22-year-old client presents with appendicitis and is preparing
for surgery. What gauge catheter will the ED nurse select for
this client?
a. 22
b. 14
c. 18
d. 24 Correct Answers c. 18
A circulating nurse has transferred an older client to the
operating room. What action by the nurse is most important for
this client?
a. Allow the client to keep hearing aids in until anesthesia
begins.
b. Pad the table as appropriate for the surgical procedure.
c. Position the client for maximum visualization of the site.
d. Stay with the client, providing emotional comfort and support.
Correct Answers ANS: A
Many older clients have sensory loss. To help prevent
disorientation, facilities often allow older clients to keep their
eyeglasses on and hearing aids in until the start of anesthesia.
The other actions are appropriate for all operative clients.
A circulating nurse wishes to provide emotional support to a
client who was just transferred to the operating room. What
action by the nurse would be best?
a. Administer anxiolytics.
,b. Give the client warm blankets.
c. Introduce the surgical staff.
d. Remain with the client. Correct Answers ANS: D
The nurse can provide emotional support by remaining with the
client until anesthesia has been provided. An extremely anxious
client may need anxiolytics, but not all clients require this for
emotional support. Physical comfort and introductions can also
help decrease anxiety.
A client asks the nurse if eating only preservative- and dye-free
foods will decrease cancer risk. What response by the nurse is
best?
a. Maybe; preservatives, dyes, and preparation methods may be
risk factors.
b. No; research studies have never shown those things to cause
cancer.
c. There are other things you can do that will more effectively
lower your risk.
d. Yes; preservatives and dyes are well known to be
carcinogens. Correct Answers ANS: A
Dietary factors related to cancer development are poorly
understood, although dietary practices are suspected to alter
cancer risk. Suspected dietary risk factors include low fiber
intake and a high intake of red meat or animal fat. Preservatives,
preparation methods, and additives (dyes, flavorings,
sweeteners) may have cancer- promoting effects. It is correct to
say that other things can lower risk more effectively, but this
does not give the client concrete information about how to do so,
and also does not answer the clients question.
,A client comes to the family medicine clinic and reports joint
pain and stiffness. The nurse is asked to assess the client for
Heberdens nodules. What assessment technique is correct?
a. Inspect the clients distal finger joints.
b. Palpate the clients abdomen for tenderness.
c. Palpate the clients upper body lymph nodes.
d. Perform range of motion on the clients wrists. Correct
Answers ANS: A
Herberdens nodules are seen in osteoarthritis and are bony
nodules at the distal interphalangeal joints. To assess for this
finding, the nurse inspects the clients distal fingertips. These
nodules are not found in the abdomen, lymph nodes, or wrists.
A client had a surgical procedure with spinal anesthesia. The
nurse raises the head of the clients bed. The clients blood
pressure changes from 122/78 mm Hg to 102/50 mm Hg. What
action by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Lower the head of the bed.
d. Nothing; this is expected. Correct Answers ANS: C
A client who had epidural or spinal anesthesia may become
hypotensive when the head of the bed is raised. If this occurs,
the nurse should lower the head of the bed to its original
position. The Rapid Response Team is not needed, nor is an
increase in IV rate.
A client has a continuous passive motion (CPM) device after a
total knee replacement. What action does the nurse delegate to
, the unlicensed assistive personnel (UAP) after the affected leg is
placed in the machine while the client is in bed?
a. Assess the distal circulation in 30 minutes.
b. Change the settings based on range of motion.
c. Raise the lower siderail on the affected side.
d. Remind the client to do quad-setting exercises. Correct
Answers ANS: C
Because the clients leg is strapped into the CPM, if it falls off
the bed due to movement, the clients leg (and new joint) can be
injured. The nurse should instruct the UAP to raise the siderail
to prevent this from occurring. Assessment is a nursing
responsibility. Only the surgeon, physical therapist, or specially
trained technician adjusts the CPM settings. Quad-setting
exercises are not related to the CPM machine.
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 provider to request more analgesia.
b. Demonstrate how to splint the incision.
c. Have the client take shallower breaths.
d. Tell the client 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
some pain is normal and expected after surgery, but that answer
alone does not provide any interventions to help the client.
