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NUR 213 Final exam Questions and Correct detailed Answers with rationales|already Graded A+
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NUR 213 Final exam Questions and Correctdetailed Answers with rationales|already
Graded A+
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 -
CORRECT ANSWERS D) Assess the fistula for the presence of a bruit and a
thrill every 4 hours
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 - CORRECT ANSWERS
B) Administer an analgesic 20 mins before therapy
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 - CORRECT ANSWERS B) Muscle Cramps
,NUR 213 Final exam Questions and Correct
detailed Answers with rationales|already
Graded A+
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.
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 - CORRECT 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.
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 - CORRECT
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
,NUR 213 Final exam Questions and Correct
detailed Answers with rationales|already
Graded A+
pulmonary edema occurs. Xrays will shouw a "white out" appearance much later in
the progression of ARDS.
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 - CORRECT 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 -
CORRECT ANSWERS C) fever, hypertension, graft tenderness, and malaise
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 - CORRECT ANSWERS B)
chicken breast, broccoli, strawberries, milk
, NUR 213 Final exam Questions and Correct
detailed Answers with rationales|already
Graded A+
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.
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? -
CORRECT ANSWERS 37%
Rationale: Each leg is 18% and the perineum is 1% (18+18+1 = 37)
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 - CORRECT 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.
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
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