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NUR 213 Final Exam
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NUR 213 Final ExamA 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 - ANS 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 - ANS 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 - ANS 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.
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 - ANS 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 - ANS 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.
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 - ANS 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 - ANS 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 - ANS 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.
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? - ANS 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 - ANS 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
C) The lung has reexpanded
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