Nur 202 Final Questions With Complete Solutions
An emergency department nurse is caring for a trauma patient.
Which interventions does the nurse perform during the primary
survey? (Select all that apply.)
A. Foley catheterization
B. Needle decompression
C. Initiating IV fluids
D. Splinting open fractures
E. Endotracheal intubation
F. Removing wet clothing
G. Laceration repair
B. Needle decompression
C. Initiating IV fluids
E. Endotracheal intubation
F. Removing wet clothing
An elderly client who has fallen from a roof is transported to the
emergency department by ambulance. The client was
unconscious at the scene but is conscious on arrival and is
triaged as urgent. What is the priority assessment the nurse
includes during the primary survey of the patient?
A. A full set of vital signs
B. Cardiac rhythm
C. Neurologic status
D. Client history
C. Neurologic status
,A client with a stroke has damage to Brocas area. What
intervention to promote communication is best for this client?
A. Assess whether or not the client can write.
B. Communicate using yes-or-no questions.
C. Reinforce speech therapy exercises.
D. Remind the client not to use neologisms.
A. Assess whether or not the client can write.
An emergency department nurse cares for a middle-age
mountain climber who is confused, ataxic, and exhibits impaired
judgement. After administering oxygen, which intervention
would the nurse implement next?
A. Administer dexamethasone.
B. Complete a mini mental state examination.
C. Prepare the client for computed tomography of the brain.
D. Request a psychiatric consult.
A. Administer dexamethasone.
A nurse is caring for a dying client. The client's spouse states, "I
think he is choking to death." How would the nurse respond?
A. "Do not worry. The choking sound is normal during the
dying process."
B. "I will administer more morphine to keep your spouse
comfortable."
C. "I can ask the respiratory therapist to suction secretions out
through his nose."
,D."I will have another nurse assist me to turn your spouse onto
the side."
D."I will have another nurse assist me to turn your spouse onto
the side."
An intensive care nurse discusses withdrawal of care with a
client's family. The family expresses concerns related to
discontinuation of therapy. How will the nurse respond?
a."I understand your concerns, but in this state, discontinuation
of care is not a form of active euthanasia."
b. "You will need to talk to the primary health care provider
because I am not legally allowed to participate in the withdrawal
of life support."
c. "I realize this is a difficult decision. Discontinuation of
therapy will allow the client to die a natural death."
d. "There is no need to worry. Most religious organizations
support the client's decision to stop medical treatment."
c. "I realize this is a difficult decision. Discontinuation of
therapy will allow the client to die a natural death."
A client is receiving IV alteplase and reports a sudden severe
headache. What is the nurse's first action?
A. Perform a comprehensive pain assessment.
B. Discontinue the infusion of the drug.
C. Conduct a neurologic assessment.
D. Administer an antihypertensive drug.
B. Discontinue the infusion of the drug.
, After a craniotomy, the nurse assesses the client and finds dry,
sticky mucous membranes, acute confusion, and restlessness.
The client has IV fluids running at 75 mL/hr. What action by the
nurse would the nurse take first?
A. Assess the client's urinary output.
B. Assess the client's serum sodium level.
C. Increase the rate of the IV infusion.
D. Provide oral care every hour.
B. Assess the client's serum sodium level.
10. A clients mean arterial pressure is 60 mm Hg and
intracranial pressure is 20 mm Hg. Based on the clients cerebral
perfusion pressure, what should the nurse anticipate for this
client?
A. Impending brain herniation
B. Poor prognosis and cognitive function
C. Probable complete recovery
D. Unable to tell from this information
B. Poor prognosis and cognitive function
A nurse is teaching a wilderness survival class. Which
statements would the nurse include about the prevention of
hypothermia and frostbite? (Select all that apply.)
A. "Wear synthetic clothing instead of cotton to keep your skin
dry.
B. "Drink plenty of fluids. Brandy can be used to keep your
body warm."
C. "Remove your hat when exercising to prevent overheating."
An emergency department nurse is caring for a trauma patient.
Which interventions does the nurse perform during the primary
survey? (Select all that apply.)
A. Foley catheterization
B. Needle decompression
C. Initiating IV fluids
D. Splinting open fractures
E. Endotracheal intubation
F. Removing wet clothing
G. Laceration repair
B. Needle decompression
C. Initiating IV fluids
E. Endotracheal intubation
F. Removing wet clothing
An elderly client who has fallen from a roof is transported to the
emergency department by ambulance. The client was
unconscious at the scene but is conscious on arrival and is
triaged as urgent. What is the priority assessment the nurse
includes during the primary survey of the patient?
A. A full set of vital signs
B. Cardiac rhythm
C. Neurologic status
D. Client history
C. Neurologic status
,A client with a stroke has damage to Brocas area. What
intervention to promote communication is best for this client?
A. Assess whether or not the client can write.
B. Communicate using yes-or-no questions.
C. Reinforce speech therapy exercises.
D. Remind the client not to use neologisms.
A. Assess whether or not the client can write.
An emergency department nurse cares for a middle-age
mountain climber who is confused, ataxic, and exhibits impaired
judgement. After administering oxygen, which intervention
would the nurse implement next?
A. Administer dexamethasone.
B. Complete a mini mental state examination.
C. Prepare the client for computed tomography of the brain.
D. Request a psychiatric consult.
A. Administer dexamethasone.
A nurse is caring for a dying client. The client's spouse states, "I
think he is choking to death." How would the nurse respond?
A. "Do not worry. The choking sound is normal during the
dying process."
B. "I will administer more morphine to keep your spouse
comfortable."
C. "I can ask the respiratory therapist to suction secretions out
through his nose."
,D."I will have another nurse assist me to turn your spouse onto
the side."
D."I will have another nurse assist me to turn your spouse onto
the side."
An intensive care nurse discusses withdrawal of care with a
client's family. The family expresses concerns related to
discontinuation of therapy. How will the nurse respond?
a."I understand your concerns, but in this state, discontinuation
of care is not a form of active euthanasia."
b. "You will need to talk to the primary health care provider
because I am not legally allowed to participate in the withdrawal
of life support."
c. "I realize this is a difficult decision. Discontinuation of
therapy will allow the client to die a natural death."
d. "There is no need to worry. Most religious organizations
support the client's decision to stop medical treatment."
c. "I realize this is a difficult decision. Discontinuation of
therapy will allow the client to die a natural death."
A client is receiving IV alteplase and reports a sudden severe
headache. What is the nurse's first action?
A. Perform a comprehensive pain assessment.
B. Discontinue the infusion of the drug.
C. Conduct a neurologic assessment.
D. Administer an antihypertensive drug.
B. Discontinue the infusion of the drug.
, After a craniotomy, the nurse assesses the client and finds dry,
sticky mucous membranes, acute confusion, and restlessness.
The client has IV fluids running at 75 mL/hr. What action by the
nurse would the nurse take first?
A. Assess the client's urinary output.
B. Assess the client's serum sodium level.
C. Increase the rate of the IV infusion.
D. Provide oral care every hour.
B. Assess the client's serum sodium level.
10. A clients mean arterial pressure is 60 mm Hg and
intracranial pressure is 20 mm Hg. Based on the clients cerebral
perfusion pressure, what should the nurse anticipate for this
client?
A. Impending brain herniation
B. Poor prognosis and cognitive function
C. Probable complete recovery
D. Unable to tell from this information
B. Poor prognosis and cognitive function
A nurse is teaching a wilderness survival class. Which
statements would the nurse include about the prevention of
hypothermia and frostbite? (Select all that apply.)
A. "Wear synthetic clothing instead of cotton to keep your skin
dry.
B. "Drink plenty of fluids. Brandy can be used to keep your
body warm."
C. "Remove your hat when exercising to prevent overheating."
