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NUR 130 Exam One Questions With Complete Solutions
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NUR 130 Exam One Questions With Complete Solutions
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NUR 130 Exam One Questions With Complete Solutions9. A nurse delegates the ambulation of an older adult client to an
unlicensed nursing assistant (UAP). Which statement should the
nurse include when delegating this task? Correct Answers sit
client on the edge of the bed and let their legs dangle before
ambulation
9.While assessing a clients peripheral IV site, the nurse observes
a streak of red along the vein path and palpates a 4-cm venous
cord. How should the nurse document this finding? Correct
Answers Grade 3 phlebitis at IV site - presence of a red streak
and palpable cord indicates grade 3 phlebitis.
A circulating nurse has transferred an older client to the
operating room. What action by the nurse is most important for
this client? Correct Answers Allow the client to keep hearing
aids in until anesthesia begins
A circulating nurse wishes to provide emotional support to a
client who was just transferred to the operating room. What
action by the nurse would be best? Correct Answers remain
with the client - provide emotional support by remaining with
the client until anesthesia has been provided.
A client at risk for developing hyperkalemia states, I love fruit
and usually eat it every day, but now I cant because of my high
potassium level. How should the nurse respond? Correct
Answers berries, cherries, apples, and peaches are low in
potassium
,A client had a surgical procedure with spinal anesthesia. The
nurse raises the head of the clients bed. The clients blood
pressure changes from 122/78 mm Hg to 102/50 mm Hg. What
action by the nurse is best? Correct Answers lower the head of
the bed - epidural or spinal anesthesia may become hypotensive
when the head of the bed is raised.
A client has a great deal of pain when coughing and deep
breathing after abdominal surgery despite having pain
medication. What action by the nurse is best? Correct Answers
demonstrate how the splint the incision - extra support during
coughing and activity and helps decrease pain
A client has arrived in the postoperative unit. What action by the
circulating nurse takes priority? Correct Answers Participating
in hand-off report
A client has been given hydroxyzine (Atarax) in the
preoperative holding area. What action by the nurse is most
important for this client? Correct Answers raise the side rails
on the bed
A client has received intravenous anesthesia during an
operation. What action by the postanesthesia care nurse is most
important? Correct Answers Assist with administering muscle
relaxants to the client - Intravenous anesthetic agents have the
potential to cause respiratory and circulatory depression.
A client in the operating room has developed malignant
hyperthermia. The clients potassium is 6.5 mEq/L. Which action
by the nurse takes priority? Correct Answers Administer 10
,units of regular insulin - this will force potassium back into the
cells rapidly.
A client in the preoperative holding room has received sedation
and now needs to urinate. What action by the nurse is best?
Correct Answers give the client a bed pan or urinal to use -
A client is clearly uncomfortable and anxious in the preoperative
holding room waiting for emergent abdominal surgery. What
actions can the nurse perform to increase comfort? (Select all
that apply.) Correct Answers Allow the client to assume a
position of comfort, allow family to remain at bedside, provide
warm blankets and cool wash cloths, pull curtains to provide
privacy
A client is experiencing pain after leg surgery but cannot yet
have more pain medication. What comfort interventions can the
nurse provide? (Select all that apply.) Correct Answers Apply
stimulation to the contralateral leg, Assess the clients
willingness to try meditation, elevate the clients leg and apply
ice, reduce the noise level in the clients room
A client is having robotic surgery. The circulating nurse
observes the instruments being inserted, then the surgeon
appears to break scrub when going to the console and sitting
down. What action by the nurse is best? Correct Answers
document the time the robotic portion of the procedure began
A client is having shoulder surgery with regional anesthesia.
What actions by the nurse are most important to enhance client
safety related to this anesthesia? (Select all that apply.) Correct
, Answers Assessing distal circulation to the operative arm after
positioning, Padding the clients shoulder and arm on the
operating table
A client is having surgery. The circulating nurse notes the
clients oxygen saturation is 90% and the heart rate is 110
beats/min. What action by the nurse is best? Correct Answers
Assess the clients end-tidal carbon dioxide level - The triad of
early signs include decreased oxygen saturation, tachycardia,
and elevated end-tidal carbon dioxide (CO2) level.
A client is in stage 2 of general anesthesia. What action by the
nurse is most important? Correct Answers Being prepared to
suction the airway - (excitement, delirium), the client can vomit
and aspirate.
A client is on the phone when the nurse brings a preoperative
antibiotic before scheduled surgery. The circulating nurse has
requested the antibiotic be started. The client wants the nurse to
wait before starting it. What response by the nurse is most
appropriate? Correct Answers explain the rational for giving
the medication now - preoperative antibiotic must be given
within 60 minutes of the surgical start time to ensure the proper
amount is in the tissues when the incision is made.
A client is scheduled for a below-the-knee amputation. The
circulating nurse ensures the proper side is marked prior to the
start of surgery. What action by the nurse is most appropriate?
Correct Answers Facilitate marking the site with the client and
surgeon
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