The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5° F. The patient is lethargic,
responds to voice but falls asl...
NUR 221 EXAM 1 STUDY GUIDE
QUESTIONS WITH ANSWERS 2024
The nurse admits a patient to the critical care unit following a motorcycle crash.
Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate
58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5° F. The
patient is lethargic,
responds to voice but falls asleep readily when not stimulated. Which nursing
action is most important to include in this patient's plan of care?
A. Frequent neurological assessments
B. Side to side position changes
C. Range of motion to extremities
D. Frequent oropharyngeal suctioning -Correct Answer ✔A. Frequent neurological
assessments
The nurse has just received a patient from the emergency department with an
admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial
infections to other patients, what is the best action by the nurse?
A. Implement droplet precautions upon admission.
B. Wash hands thoroughly before leaving the room.
C. Scrub the hub of all central line ports prior to use.
D. Dispose of all bloody dressings in biohazard bags. -Correct Answer ✔A.
Implement droplet precautions upon admission.
NUR 221 EXAM 1
,NUR 221 EXAM 1
The nurse is caring for a patient admitted with bacterial meningitis. Vital signs
assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110
beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO 2 ) 95% on
supplemental oxygen at 3 L/min, and a temperature 103.5° F. What is the priority
nursing action?
A. Elevate the head of the bed 30 degrees.
B. Keep lights dim at all times.
C. Implement seizure precautions.
D. Maintain bed rest at all times. -Correct Answer ✔C. Implement seizure
precautions.
A patient seeks treatment for progressively deteriorating motor and sensory
function. What question is essential for the nurse to ask when completing this
patient's health history?
A. "Have you been around any small children?"
B. "When was the last time you had anything to eat?"
C. "When was the last time you traveled out of the country?"
D. "Have you recently experienced any lung or stomach infections?" -Correct
Answer ✔D. "Have you recently experienced any lung or stomach infections?"
A patient with Guillain-Barré syndrome (GBS) asks how the illness develops.
What should the nurse respond about the pathophysiology of the disorder?
NUR 221 EXAM 1
, NUR 221 EXAM 1
A. "An infection eats away at the nerve endings."
B. "An infection enters the spinal cord and erodes the nerves at the roots."
C. "The nerves are killed by infiltration of your body's white blood cells used to
fight an infection."
D. "After an infection your immune system created antibodies that affect the
covering of the nerves." -Correct Answer ✔D. "After an infection your immune
system created antibodies that affect the covering of the nerves."
A patient is experiencing bilateral symmetrical muscle weakness and sensory
changes of both feet and legs. What should the nurse expect to assess that
determines the presence of Guillain-Barré syndrome (GBS)?
A. Areflexia
B. Hyporeflexia
C. Hyperreflexia
D. Hyperanalgesia -Correct Answer ✔A. Areflexia
A patient with Guillain-Barré syndrome (GBS) loses respiratory function three
weeks into the acute phase. When should the nurse expect respiratory function to
return in this patient?
A. During the plateau phase
B. Early in the recovery stage
C. At the end of the plateau stage
D. At the end of the recovery stage -Correct Answer ✔B. Early in the recovery
stage
NUR 221 EXAM 1
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller PossibleA. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $14.49. You're not tied to anything after your purchase.
