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NUR 325 Exam 3 Questions With Complete Solutions
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NUR 325 Exam 3 Questions With Complete Solutions
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NUR 325 Exam 3 Questions With Complete SolutionsA 45-year-old male client with leg ulcers and arterial
insufficiency is admitted to the hospital. The nurse understands
that leg ulcers of this nature are usually caused by:
a. Decreased arterial blood flow secondary to vasoconstriction
b. Decreased arterial blood flow leading to hyperemia
c. Atherosclerotic obstruction of the arteries
d. Trauma to the lower extremities Correct Answers A
(Decreased arterial flow is a result of vasospasm. The etiology is
unknown. It is more problematic in colder climates or when the
person is under stress. Hyperemia occurs when the vasospasm is
relieved.)
A 45-yr-old man with asthma is brought to the emergency
department by automobile. He is short of breath and appears
frightened. During the initial nursing assessment, which clinical
manifestation might be present as an early manifestation during
an exacerbation of asthma?
a. Anxiety
b. Cyanosis
c. Bradycardia
d. Hypercapnia Correct Answers A (decreased CO2 because
hyperventilating)
A 57-year-old client with a history of asthma is prescribed
propranolol (Inderal) to control hypertension. Before
administered propranolol, which of the following actions should
the nurse take first?
,a. Monitor the apical pulse rate
b. Instruct the client to take medication with food
c. Question the physician about the order
d. Caution the client to rise slowly when standing Correct
Answers C (Propranolol and other beta-adrenergic blockers are
contraindicated in a client with asthma, so the nurse should
question the physician before giving the dose. The other
responses are appropriate actions for a client receiving
propranolol, but questioning the physician takes priority. The
client's apical pulse should always be checked before giving
propranolol; if the pulse rate is extremely low, the nurse should
withhold the drug and notify the physician.)
A 60-year-old male client comes into the emergency department
with complaints of crushing chest pain that radiates to his
shoulder and left arm. The admitting diagnosis is acute
myocardial infarction. Immediate admission orders include
oxygen by NC at 4L/minute, blood work, chest x-ray, an ECG,
and 2 mg of morphine given intravenously. The nurse should
first:
a. Administer the morphine
b. Obtain a 12-lead ECG
c. Obtain the lab work
d. Order the chest x-ray Correct Answers A (Although
obtaining the ECG, chest x-ray, and blood work are all
important, the nurse's priority action would be to relieve the
crushing chest pain.)
,A 72-year-old man presents to the emergency room. The patient
appears diaphoretic and anxious, and has noted peripheral
edema. The patient's vital signs are blood pressure of 100/40,
heart rate of 130 and irregular, and respiratory rate of 26. How
does the nurse interpret these findings?
a. The patient is having a myocardial infarction.
b. The patient has impaired central perfusion.
c. The patient has a virus.
d. Pain medication should be administered to this patient.
Correct Answers B (This patient has the classic symptoms of
impaired central perfusion. Central perfusion occurs when
cardiac output is optimal and blood is pumped to all of the
organs and tissues from the arteries, through the capillaries, and
then back to the heart through the veins. The nurse needs to
administer oxygen. Chest pain is often present with myocardial
infarction, along with elevated blood pressure readings and
electrocardiogram changes. Viral illness commonly presents
with other symptoms such as body ache or gastrointestinal
issues, and typically has little or no effect on the heart rate. Pain
management is not indicated for patients who do not present
with pain. Also, the question is asking what assessment the
nurse has made, and is not asking about interventions.)
A client comes to the outpatient clinic and tells the nurse that he
has had legs pains that began when he walks but cease when he
stops walking. Which of the following conditions would the
nurse assess for?
a. An acute obstruction in the vessels of the legs
b. Peripheral vascular problems in both legs
, c. Diabetes
d. Calcium deficiency Correct Answers B (Intermittent
claudication is a condition that indicates vascular deficiencies in
the peripheral vascular system. If an obstruction were present,
the leg pain would persist when the client stops walking. Low
calcium levels may cause leg cramps but would not necessarily
be related to walking.)
A client enters the ER complaining of chest pressure and severe
epigastric distress. His VS are 158/90, 94, 24, and 99*F. The
doctor orders cardiac enzymes. If the client were diagnosed with
an MI, the nurse would expect which cardiac enzyme to rise
within the next 3 to 8 hours?
a. Creatine kinase (CK or CPK)
b. Lactic dehydrogenase (LDH)
c. LDH-1
d. LDH-2 Correct Answers A (Creatine kinase (CK, formally
known as CPK) rises in 3-8 hours if an MI is present. When the
myocardium is damaged, CPK leaks out of the cell membranes
and into the bloodstream. Lactic dehydrogenase rises in 24-48
hours, and LDH-1 and LDH-2 rises in 8-24 hours.)
A client enters the ER complaining of severe chest pain. A
myocardial infarction is suspected. A 12 lead ECG appears
normal, but the doctor admits the client for further testing until
cardiac enzyme studies are returned. All of the following will be
included in the nursing care plan. Which activity has the highest
priority?
a. Monitoring vital signs
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