1. A 55-year-old patient with a history of hypertension is admitted with complaints of severe
headache, blurred vision, and epistaxis. The patient’s blood pressure is 220/120 mm Hg. What is the
priority nursing action?
• A) Administer oral antihypertensive medication
• B) Obtain an elec...
NUR 164 Exam 2, HONDROS complete solutions and explanations
2023/2024
1. A 55-year-old patient with a history of hypertension is admitted with complaints of severe
headache, blurred vision, and epistaxis. The patient’s blood pressure is 220/120 mm Hg. What is the
priority nursing action?
• A) Administer oral antihypertensive medication
• B) Obtain an electrocardiogram (ECG)
• C) Administer intravenous antihypertensive medication
• D) Elevate the head of the bed and monitor closely
Answer: C) Administer intravenous antihypertensive medication
Explanation: The patient is experiencing a hypertensive crisis, which requires immediate administration
of IV antihypertensive medication to rapidly reduce blood pressure and prevent end-organ damage.
2. A nurse is caring for a patient with acute kidney injury (AKI) who is oliguric and has a potassium
level of 6.8 mEq/L. What is the most appropriate intervention?
• A) Administer a potassium-sparing diuretic
• B) Prepare the patient for hemodialysis
• C) Encourage the patient to drink more fluids
• D) Monitor the patient’s cardiac rhythm and administer a sodium polystyrene sulfonate enema
Answer: B) Prepare the patient for hemodialysis
Explanation: A potassium level of 6.8 mEq/L is dangerously high and can lead to life-threatening cardiac
dysrhythmias. Hemodialysis is necessary to rapidly reduce potassium levels in severe cases of
hyperkalemia.
3. A 68-year-old patient with a history of type 2 diabetes and peripheral arterial disease (PAD)
presents with a non-healing ulcer on the left foot. The wound is pale with a black eschar. What is the
best treatment approach?
• A) Debride the wound and apply a moist dressing
• B) Apply a dry sterile dressing and monitor
• C) Use compression therapy to improve circulation
• D) Administer broad-spectrum antibiotics and schedule a vascular consult
, Answer: D) Administer broad-spectrum antibiotics and schedule a vascular consult
Explanation: The presence of a non-healing ulcer with eschar in a patient with PAD suggests poor
circulation, potentially complicated by infection. Broad-spectrum antibiotics and a vascular consult are
needed to address both the infection and underlying vascular issues.
4. During the assessment of a patient with chronic obstructive pulmonary disease (COPD), the nurse
notes paradoxical chest wall movement and the patient’s trachea is deviated to the left. What should
the nurse suspect?
• A) Tension pneumothorax
• B) Pleural effusion
• C) Pulmonary embolism
• D) Atelectasis
Answer: A) Tension pneumothorax
Explanation: Paradoxical chest wall movement and tracheal deviation are classic signs of a tension
pneumothorax, a life-threatening condition that requires immediate intervention to release trapped air
and re-expand the lung.
5. A nurse is caring for a patient with cirrhosis who has developed hepatic encephalopathy. Which of
the following medications is most appropriate to lower ammonia levels in the patient’s blood?
• A) Spironolactone
• B) Lactulose
• C) Neomycin
• D) Rifaximin
Answer: B) Lactulose
Explanation: Lactulose is a non-absorbable sugar that helps reduce ammonia levels in patients with
hepatic encephalopathy by trapping ammonia in the colon and promoting its excretion.
6. A patient with a history of heart failure presents with dyspnea, orthopnea, and pink, frothy sputum.
On auscultation, crackles are heard throughout both lung fields. Which of the following interventions
should be initiated first?
• A) Administer intravenous diuretics
• B) Initiate high-flow oxygen therapy
• C) Perform a chest X-ray
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Aguider. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.49. You're not tied to anything after your purchase.
