NURS 213 REAL EXAM QUESTIONS AND
VERIFIED ANSWERS 2024-2025 LATEST
UPDATE WITH RATIONALE/ GRADED A+
1.A client has an AV fistula in the right upper arm for hemodialysis treatments. When
planning care for this client, which measure should the nurse implement to promote
client safety?
A) Take blood pressures only on the right side to ensure accuracy
B) Use the fistula for all venipunctures and IV infusions
C) Ensure that small clamps are attached to the fistula dressing at all times
D) Assess the fistula for the presence of a bruit and a thrill every 4 hours - answers-D)
Assess the fistula for the presence of a bruit and a thrill every 4 hours
2.A client is scheduled for hydrotherapy for a burn dressing change. Which action
should the nurse take to ensure that the procedure is most tolerable for the client?
A) Ensure the client has a robe and slippers
B) Administer an analgesic 20 mins before therapy
C) Send dressing supplies with the client to hydrotherapy
D) Administer an IV antibiotic 30 mins prior to therapy - answers-B) Administer an
analgesic 20 mins before therapy
3.A client with Myasthenia Gravis is admitted to the hospital, and the nursing history
reveals that the client is taking pyridostigmine. When assessing the client for the side
effects of this medication, the nurse should ask the client about the presence of which
occurance?
A) Mouth ulcers
B) Muscle cramps
C) Feelings of depression
D) Unexplained weight gain - answers-B) Muscle Cramps
Rationale: Pyridostigmine is an anticholinesterase inhibitor used to treat myasthenia
gravis. Muscle cramps and small muscle contractions are common side effects and
occur as a result of overstimulation of neuromuscular receptors.
4.The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac
monitor. Which action should the nurse take?
A) Prepare for defibrillation
B) Continue to monitor the rhythm
C) Notify the HCP
,D) Prepare to administer lidocaine hydrochloride - answers-B) Continue to monitor the
rhythm
Rationale: As an isolated occurance, a PVC is not life threatening. The nurse should
continue to monitor the patients rhythm. Frequent PVCs, however, maybe precursors of
a more life-threatening rhythm such as vtach or vfib.
5.A client was admitted to the hospital 24 hours ago after sustaining blunt force trauma
to the chest. Which earliest clinical manifestations of acute respiratory distress
syndrome (ARDS) should the nurse monitor for?
A) Cyanosis and pallor
B) Diffuse crackles and rhonchi on chest auscultation
C) Increase in respiratory rate from 18 to 30 breaths per minute
D) Haziness or "white out" appearance of lungs on chest X-ray - answers-C) Increase
in respiratory rate from 18 to 30 breaths per minute
Rationale: ARDS usually develops within 24-48 hrs after an initiating event, such as
chest trauma. In most cases tachypnea and dyspnea are the earliest clinical
manifestations as the body compensates for mild hypoxemia through hyperventiliation.
Cyanosis and pallor are usually late signs of severe hypoxemia. In ARDS lung sounds
are initially clear but progress to crackles and rhonchi as pulmonary edema occurs.
Xrays will shouw a "white out" appearance much later in the progression of ARDS.
6.A client has developed atrial fibrillation and has a ventricular rate of 150 beats per
minute. The nurse should assess the client for which effects of this cardiac occurrence?
A) flat neck veins
B) nausea and vomiting
C) hypotension and dizziness
D) hypertension and headache - answers-C) hypotension and dizziness
The home care nurse is making a follow-up visit to a client after a renal transplant. The
nurse should assess the client for which manifestations of acute graft rejection?
A) hypotension, graft tenderness, and anemia
B) hypertension, oliguria, thirst, and hypothermia
C) fever, hypertension, graft tenderness, and malaise
D) fever, vomiting, hypotension, and copious amounts of dilute urine output - answers-
C) fever, hypertension, graft tenderness, and malaise
7.A client with a burn injury recieves a prescription for a regular diet. Which is the best
meal for the nurse to provide to the client to promote wound healing?
A) peanut butter & jelly sandwich, apple, tea
B) chicken breast, broccoli, strawberries, milk
, C) veal chop, boiled potatoes, jell-o, orange juice
D) pasta with tomato sauce, garlic bread, ginger ale - answers-B) chicken breast,
broccoli, strawberries, milk
Rationale: the meal with the best potential to promote wound healing includes nutrient-
rich food choices including protein, such as chicken and milk, and vitamin c, such as
strawberries and broccoli. The remaining food options include one or more items with
low nutritional value, especially the jell-o, tea, jelly, and ginger ale.
8.An adult client arrives in the emergency department with burns to both entire legs and
the perineal area. Using the rule of nines, the nurse could determine that approximately
what percentage of the clients body surface area has been burned? - answers-37%
Rationale: Each leg is 18% and the perineum is 1% (18+18+1 = 37)
9.A client who is unresponsive and pulseless and has a possible neck injury is brought
into the emergency department after a motor vehicle crash. What should the nurse do to
open the clients airway?
A) Insert an oropharyngeal airway
B) Tilt the head and lift the chin
C) Place in the recovery position
D) Stabilize the skull and push up the jaw - answers-D) Stabilize the skull and push up
the jaw
Rationale: the healthcare team uses the jaw thrust maneuver to open the airway until an
xray confirms that the cervical spine is stable in order to prevent potential aggravation of
the cervical spine injury.
10.The nurse assesses the water seal chamber of a closed chest drainage system and
notes fluctuations in the chamber. What does this finding indicate?
A) The tubing is kinked
B) An air leak is present
C) The lung has reexpanded
D) The system is functioning as expected - answers-D) The system is functioning as
expected
Rationale: Fluctuations (tidaling) in the water seal chamber is normal during inhalation
and exhalation.
The nurse plans care for the client diagnosed with end stage renal disease (ESRD).
Which findings does the nurse expect to find in the clients medical record? Select all
that apply:
A) Edema
VERIFIED ANSWERS 2024-2025 LATEST
UPDATE WITH RATIONALE/ GRADED A+
1.A client has an AV fistula in the right upper arm for hemodialysis treatments. When
planning care for this client, which measure should the nurse implement to promote
client safety?
A) Take blood pressures only on the right side to ensure accuracy
B) Use the fistula for all venipunctures and IV infusions
C) Ensure that small clamps are attached to the fistula dressing at all times
D) Assess the fistula for the presence of a bruit and a thrill every 4 hours - answers-D)
Assess the fistula for the presence of a bruit and a thrill every 4 hours
2.A client is scheduled for hydrotherapy for a burn dressing change. Which action
should the nurse take to ensure that the procedure is most tolerable for the client?
A) Ensure the client has a robe and slippers
B) Administer an analgesic 20 mins before therapy
C) Send dressing supplies with the client to hydrotherapy
D) Administer an IV antibiotic 30 mins prior to therapy - answers-B) Administer an
analgesic 20 mins before therapy
3.A client with Myasthenia Gravis is admitted to the hospital, and the nursing history
reveals that the client is taking pyridostigmine. When assessing the client for the side
effects of this medication, the nurse should ask the client about the presence of which
occurance?
A) Mouth ulcers
B) Muscle cramps
C) Feelings of depression
D) Unexplained weight gain - answers-B) Muscle Cramps
Rationale: Pyridostigmine is an anticholinesterase inhibitor used to treat myasthenia
gravis. Muscle cramps and small muscle contractions are common side effects and
occur as a result of overstimulation of neuromuscular receptors.
4.The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac
monitor. Which action should the nurse take?
A) Prepare for defibrillation
B) Continue to monitor the rhythm
C) Notify the HCP
,D) Prepare to administer lidocaine hydrochloride - answers-B) Continue to monitor the
rhythm
Rationale: As an isolated occurance, a PVC is not life threatening. The nurse should
continue to monitor the patients rhythm. Frequent PVCs, however, maybe precursors of
a more life-threatening rhythm such as vtach or vfib.
5.A client was admitted to the hospital 24 hours ago after sustaining blunt force trauma
to the chest. Which earliest clinical manifestations of acute respiratory distress
syndrome (ARDS) should the nurse monitor for?
A) Cyanosis and pallor
B) Diffuse crackles and rhonchi on chest auscultation
C) Increase in respiratory rate from 18 to 30 breaths per minute
D) Haziness or "white out" appearance of lungs on chest X-ray - answers-C) Increase
in respiratory rate from 18 to 30 breaths per minute
Rationale: ARDS usually develops within 24-48 hrs after an initiating event, such as
chest trauma. In most cases tachypnea and dyspnea are the earliest clinical
manifestations as the body compensates for mild hypoxemia through hyperventiliation.
Cyanosis and pallor are usually late signs of severe hypoxemia. In ARDS lung sounds
are initially clear but progress to crackles and rhonchi as pulmonary edema occurs.
Xrays will shouw a "white out" appearance much later in the progression of ARDS.
6.A client has developed atrial fibrillation and has a ventricular rate of 150 beats per
minute. The nurse should assess the client for which effects of this cardiac occurrence?
A) flat neck veins
B) nausea and vomiting
C) hypotension and dizziness
D) hypertension and headache - answers-C) hypotension and dizziness
The home care nurse is making a follow-up visit to a client after a renal transplant. The
nurse should assess the client for which manifestations of acute graft rejection?
A) hypotension, graft tenderness, and anemia
B) hypertension, oliguria, thirst, and hypothermia
C) fever, hypertension, graft tenderness, and malaise
D) fever, vomiting, hypotension, and copious amounts of dilute urine output - answers-
C) fever, hypertension, graft tenderness, and malaise
7.A client with a burn injury recieves a prescription for a regular diet. Which is the best
meal for the nurse to provide to the client to promote wound healing?
A) peanut butter & jelly sandwich, apple, tea
B) chicken breast, broccoli, strawberries, milk
, C) veal chop, boiled potatoes, jell-o, orange juice
D) pasta with tomato sauce, garlic bread, ginger ale - answers-B) chicken breast,
broccoli, strawberries, milk
Rationale: the meal with the best potential to promote wound healing includes nutrient-
rich food choices including protein, such as chicken and milk, and vitamin c, such as
strawberries and broccoli. The remaining food options include one or more items with
low nutritional value, especially the jell-o, tea, jelly, and ginger ale.
8.An adult client arrives in the emergency department with burns to both entire legs and
the perineal area. Using the rule of nines, the nurse could determine that approximately
what percentage of the clients body surface area has been burned? - answers-37%
Rationale: Each leg is 18% and the perineum is 1% (18+18+1 = 37)
9.A client who is unresponsive and pulseless and has a possible neck injury is brought
into the emergency department after a motor vehicle crash. What should the nurse do to
open the clients airway?
A) Insert an oropharyngeal airway
B) Tilt the head and lift the chin
C) Place in the recovery position
D) Stabilize the skull and push up the jaw - answers-D) Stabilize the skull and push up
the jaw
Rationale: the healthcare team uses the jaw thrust maneuver to open the airway until an
xray confirms that the cervical spine is stable in order to prevent potential aggravation of
the cervical spine injury.
10.The nurse assesses the water seal chamber of a closed chest drainage system and
notes fluctuations in the chamber. What does this finding indicate?
A) The tubing is kinked
B) An air leak is present
C) The lung has reexpanded
D) The system is functioning as expected - answers-D) The system is functioning as
expected
Rationale: Fluctuations (tidaling) in the water seal chamber is normal during inhalation
and exhalation.
The nurse plans care for the client diagnosed with end stage renal disease (ESRD).
Which findings does the nurse expect to find in the clients medical record? Select all
that apply:
A) Edema
