NUR 305 EXAM 1 QUESTIONS WITH COMPLETE
SOLUTIONS
5 elements of nursing process Correct Answer - Assessment
- Analysis (also called Diagnosis)
- Planning
- Implementation
- Evaluation
A client with a cardiovascular problem Correct Answer -
Monitoring blood sugar (if diabetic)
- Assessing vital signs
- Teaching about medications
- Assessing food intake (if related to dietary management of
cardiovascular issues)
A client with a gastrointestinal or genitourinary problem
Correct Answer - Performing abdominal assessments
- Assessing urine output
- Assessing food intake
- Teaching about dietary changes
A client with a musculoskeletal problem Correct Answer -
Assisting with ambulation
- Teaching about assistive devices (walker, cane, crutches)
- Implementing fall risk precautions
A client with a neurological problem Correct Answer -
Performing neurological assessments
- Assessing vital signs
,- Teaching about medications (if neurological issue is related to
medication management)
A client with a respiratory problem Correct Answer -
Administering oxygen
- Teaching about deep breathing techniques
- Oxygen saturation monitoring
- Assessing vital signs
A client with an integumentary problem Correct Answer -
Performing wound care
- Performing skin assessments
- Teaching about follow-up care
A nurse is attending to a client experiencing a cardiovascular
problem who is scheduled to receive their morning blood
pressure medications (antihypertensives). Of the nursing
interventions below, which will the nurse perform first?
a. Assess the client's blood pressure
b. Administer the blood pressure medication
c. Teach the client about dietary changes to manage the
cardiovascular problem
d. Teach the client about the medication to be administered
Correct Answer A: Assess the client's blood pressure
Rationale: Checking the current blood pressure is crucial before
administering antihypertensive medication to ensure it is safe
and appropriate to give the medication based on the client's
current blood pressure reading.
,A nurse is attending to a client experiencing a cardiovascular
problem who received their morning blood pressure medication
2 hours ago. Which finding indicates that the blood pressure
medication was effective?
a. The client's blood pressure decreased from 156/86 to 130/68
b. The client is complaining of stabbing chest pains
c. The client states that they feel well rested
d. The client states "my blood pressure feels normal" Correct
Answer A: The client's blood pressure decreased from 156/86
to 130/68
Rationale: The decrease in blood pressure to a more normal
level directly shows that the medication is working as intended.
The other options do not specifically indicate the effectiveness
of the blood pressure medication.
A nurse is caring for a 74 year-old client who currently has a
fever at 38.4C (101.1F), shortness of breath, thick
nasopharyngeal secretions and a weak cough. The client is
tachypneic with an oxygen saturation is 87% on room air. The
patient also has a history of depression and is recently widowed.
Analyze Cues: What conditions are most consistent with the
client's assessment findings? Select all that apply.
Respiratory infection
Pneumonia
Depression
Hypertension
Influenza Correct Answer - Respiratory infection (general term
that can encompass conditions like pneumonia and influenza)
, - Pneumonia (matches with fever, shortness of breath, thick
secretions, and low oxygen saturation)
- Influenza (could be a cause of fever, cough, and respiratory
symptoms)
A nurse is caring for a 74 year-old client who currently has a
fever at 38.4C (101.1F), shortness of breath, thick
nasopharyngeal secretions and a weak cough. The client is
tachypneic with an oxygen saturation is 87% on room air. The
patient also has a history of depression and is recently widowed.
Recognize Cues: What assessment findings require immediate
follow up by the nurse? Correct Answer - Oxygen saturation of
87% on room air (indicates hypoxemia and requires prompt
intervention to ensure adequate oxygenation)
- Shortness of breath (suggests respiratory distress that needs
urgent attention)
- Tachypnea (elevated respiratory rate indicating a possible
respiratory issue)
A nurse is caring for a patient recently admitted after a fall at
home. The nurse is reviewing the client's most recent assessment
findings. Highlight or underline the abnormal findings that
require follow up by the nurse:
Heart rate 125bpm
Blood pressure 105/66 Urine output 50mL/hr
Temperature 38.6C (101.5F) Bowel sounds normoactive Alert
and oriented x4
Complaint of dizziness Bright red stool White blood cell count
22,000
SOLUTIONS
5 elements of nursing process Correct Answer - Assessment
- Analysis (also called Diagnosis)
- Planning
- Implementation
- Evaluation
A client with a cardiovascular problem Correct Answer -
Monitoring blood sugar (if diabetic)
- Assessing vital signs
- Teaching about medications
- Assessing food intake (if related to dietary management of
cardiovascular issues)
A client with a gastrointestinal or genitourinary problem
Correct Answer - Performing abdominal assessments
- Assessing urine output
- Assessing food intake
- Teaching about dietary changes
A client with a musculoskeletal problem Correct Answer -
Assisting with ambulation
- Teaching about assistive devices (walker, cane, crutches)
- Implementing fall risk precautions
A client with a neurological problem Correct Answer -
Performing neurological assessments
- Assessing vital signs
,- Teaching about medications (if neurological issue is related to
medication management)
A client with a respiratory problem Correct Answer -
Administering oxygen
- Teaching about deep breathing techniques
- Oxygen saturation monitoring
- Assessing vital signs
A client with an integumentary problem Correct Answer -
Performing wound care
- Performing skin assessments
- Teaching about follow-up care
A nurse is attending to a client experiencing a cardiovascular
problem who is scheduled to receive their morning blood
pressure medications (antihypertensives). Of the nursing
interventions below, which will the nurse perform first?
a. Assess the client's blood pressure
b. Administer the blood pressure medication
c. Teach the client about dietary changes to manage the
cardiovascular problem
d. Teach the client about the medication to be administered
Correct Answer A: Assess the client's blood pressure
Rationale: Checking the current blood pressure is crucial before
administering antihypertensive medication to ensure it is safe
and appropriate to give the medication based on the client's
current blood pressure reading.
,A nurse is attending to a client experiencing a cardiovascular
problem who received their morning blood pressure medication
2 hours ago. Which finding indicates that the blood pressure
medication was effective?
a. The client's blood pressure decreased from 156/86 to 130/68
b. The client is complaining of stabbing chest pains
c. The client states that they feel well rested
d. The client states "my blood pressure feels normal" Correct
Answer A: The client's blood pressure decreased from 156/86
to 130/68
Rationale: The decrease in blood pressure to a more normal
level directly shows that the medication is working as intended.
The other options do not specifically indicate the effectiveness
of the blood pressure medication.
A nurse is caring for a 74 year-old client who currently has a
fever at 38.4C (101.1F), shortness of breath, thick
nasopharyngeal secretions and a weak cough. The client is
tachypneic with an oxygen saturation is 87% on room air. The
patient also has a history of depression and is recently widowed.
Analyze Cues: What conditions are most consistent with the
client's assessment findings? Select all that apply.
Respiratory infection
Pneumonia
Depression
Hypertension
Influenza Correct Answer - Respiratory infection (general term
that can encompass conditions like pneumonia and influenza)
, - Pneumonia (matches with fever, shortness of breath, thick
secretions, and low oxygen saturation)
- Influenza (could be a cause of fever, cough, and respiratory
symptoms)
A nurse is caring for a 74 year-old client who currently has a
fever at 38.4C (101.1F), shortness of breath, thick
nasopharyngeal secretions and a weak cough. The client is
tachypneic with an oxygen saturation is 87% on room air. The
patient also has a history of depression and is recently widowed.
Recognize Cues: What assessment findings require immediate
follow up by the nurse? Correct Answer - Oxygen saturation of
87% on room air (indicates hypoxemia and requires prompt
intervention to ensure adequate oxygenation)
- Shortness of breath (suggests respiratory distress that needs
urgent attention)
- Tachypnea (elevated respiratory rate indicating a possible
respiratory issue)
A nurse is caring for a patient recently admitted after a fall at
home. The nurse is reviewing the client's most recent assessment
findings. Highlight or underline the abnormal findings that
require follow up by the nurse:
Heart rate 125bpm
Blood pressure 105/66 Urine output 50mL/hr
Temperature 38.6C (101.5F) Bowel sounds normoactive Alert
and oriented x4
Complaint of dizziness Bright red stool White blood cell count
22,000
