A nursing student is caring for a client that increased shortness of breath and a heart rate of 98 beats per minute, respiratory rate of 22 breaths per minute, blood pressure of 132/84 mm Hg and an oxygen saturation of 90% on room air. The student understands that which of the following nursing dia...
NSG 300 FINAL EXAM QUESTIONS AND
CORRECT ANSWERS
A nursing student is caring for a client that increased shortness of breath and a heart
rate of 98 beats per minute, respiratory rate of 22 breaths per minute, blood pressure of
132/84 mm Hg and an oxygen saturation of 90% on room air. The student understands
that which of the following nursing diagnosis for this client is the priority?
a. ineffective airway clearance
b. ineffective breathing pattern
c. impaired gas exchange
d. activity intolerance ✅c. impaired gas exchange
(The oxygen saturation of 90% reflects that there is an oxygen-carbon dioxide
imbalance.)
A nurse on a medical surgical unit is caring for a client who is receiving hydromorphone
via a patient-controlled analgesia pump. The nurses assessment finds the client to be
drowsy, temperature 36.2 C orally, pulse rate 52 bpm, blood pressure 101/58 mm Hg,
respiratory rate 11, and SpO2 93% on 3L of oxygen via nasal cannula. Which action
should the nurse take next?
a. Document the findings
b. Attempt to arouse the client
c. Contact the primary healthcare provider immediately
d. Check the medication administration history on the patient-controlled analgesia pump
✅b. Attempt to arouse the client
(The nurse needs to assess the client first.)
The nurse is caring for a young-adult patient on the medical-surgical unit. When doing
midnight checks, the nurse observes the patient awake, putting a puzzle together.
Which information will the nurse consider to best explain this finding?
a. The patient misses family and is lonely.
b. The patient was waiting to talk with the nurse.
c. The patient has been kept up with the noise on the unit.
d. The patient's sleep-wake cycle preference is late evening. ✅d. The patient's sleep-
wake cycle preference is late evening.
(This patient is awake and alert enough to do a puzzle. The individual's sleep-wake
preference is probably late evening. All persons have biological clocks that synchronize
their sleep-wake cycle. This explains why some individuals fall asleep in the early
evening, whereas others go to bed at midnight or early morning. Waiting to talk with the
nurse, being lonely, and noise on the unit may contribute to lack of sleep, but the best
explanation for the patient being awake is the biological clock.(Potter et al, 2021, p.
1038))
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