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NR 226 EXAM 1 2024 ACTUAL EXAM AND STUDY GUIDE 180 QUESTIONS WITH VERIFIED ANSWERS (100% CORRECT) A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse t

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nr 226 exam 1 2024 actual exam and study guide 180

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NR 226 EXAM 1 2024 ACTUAL EXAM AND STUDY GUIDE 180
QUESTIONS WITH VERIFIED ANSWERS (100% CORRECT)
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft.
Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood
pressure and heart rate. The nurse should recognize this response as which part of the general
adaptation syndrome (GAS)?
Exhaustion stage
A. Resistance stage
B. Alarm reaction
C. Recovery reaction C. Alarm reaction

A nurse is caring for a client who has left sided hemiplegia resulting from a cerebrovascular accident. The
client works as a carpenter and is now experiencing a situational role change based on physical
limitations. The client is the primary wage earner in the family. Which of the following describes the
client's role problem?
Role conflict
A. Role overload
B. Role ambiguity
C. Role strain

A. Role conflict

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following
nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate
at this time? (Select all that apply):
Suggest coping skills for the client to use in this situation
A. Allow the client to provide input in the treatment plan
B. Assist the client with time management, and address the client's priorities.
C. Provide extensive instructions on the client's treatment regimen
D. Encourage the client in the expression of feelings and concerns

B. Allow the client to provide input in the treatment plan
C. Assist the client with time management, and address the client's priorities. E. Encourage
the client in the expression of feelings and concerns

We have an expert-written solution to this problem!

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family
assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to
the family?
Allowing the client to function independently will strengthen her muscles and promote hearing
A. The client needs to be given privacy at all times for self-reflecting and organizing her life

,B. The client's sense of loss can be lessened through retaining control of certain areas of her life D.
Performing ADLs is required prior to discharge from an acute facility

C. The client's sense of loss can be lessened through retaining control of certain areas of her life

A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge
resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if i
Could just live long enough to attend my daughter's wedding." Based on Kubler-Ross' model, which
stage of grief is the client experiencing?
Anger
A. Denial
B. Bargaining
C. Acceptance

C. Bargaining

A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The
partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by
the nurse successfully facilitate mourning for the grieving partner?

A. "Would you like me to contact the chaplain to come speak to you?"
B. "You will feel better soon. You have been expecting this for a while now."
C. "Let's talk about your children and how they are going to react."
D. "You know, it is quite normal to feel anger toward your husband at this time."
E. "Tell me more about how you are feeling."

A. "Would you like me to contact the chaplain to come speak to you?"
D. "You know, it is quite normal to feel anger toward your husband at this time."
E. "Tell me more about how you are feeling."

A nurse is caring for a client who has a terminal illness. Death is expected within 24hr. The client's family
is at the bedside and asks the nurse about anticipated findings at this time. Which of the following
findings should the nurse include in the discussion?

A. Regular breathing patterns
B. Warm extremities
C. Increased urine output
D. Decreased muscle tone

D. Decreased muscle tone

A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view
the body. Which of the following findings should the nurse include in this discussion? (Select all that
apply):

A. "I will remove the dentures from the body."
B. "I will make sure the body is lying completely flat."
C. "I will apply fresh linens and place a clean gown on the body."

,D. "I will remove all equipment from the bedside."
E. "I will dim the lights in the room

C. "I will apply fresh linens and place a clean gown on the body."
D. "I will remove all equipment from the bedside."
E. "I will dim the lights in the room
F.
A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and
diarrhea. The nurse should expect which of the following findings? (Select all that apply):
Distended neck veins
A. Hyperthermia
B. Tachycardia
C. Syncope
D. Decreased skin turgor

C. Tachycardia
D. Syncope
E. Decreased skin turgor

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of
the following clients is at risk for hypovolemia?

A. A client who has nasogastric suctioning
B. A client who has chronic constipation
C. A client who has syndrome of inappropriate antidiuretic hormone
D. A client who took an overdose of sodium bicarbonate antacids

A. A client who has nasogastric suctioning

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse
should recognize which of the following findings is a manifestation of dehydration? (Select all that
apply):

A. Hematocrit 55%
B. Serum osmolarity 260 mOsm/kg
C. Serum sodium 150 mEq/L
D. Urine specific gravity 1.035
E. Serum creatinine 0.6 mg/dL

A. Hematocrit 55%
C. Serum sodium 150 mEq/L
D. Urine specific gravity 1.035

A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients
should the nurse anticipate a prescription for fluid restriction?

A. A client who has a new diagnosis of adrenal insufficiency

, B. A client who has heart failure
C. A client who is receiving treatment for diabetic ketoacidosis
D. A client who has abdominal ascites

B. A client who has heart failure
A nurse is planning care for a client who has dehydration. Which of the following actions should the
nurse include?

A. Administer antihypertensive on schedule
B. Check the client's weight each morning
C. Notify the provider of a urine output greater than 30 mL/hr
D. Encourage independent ambulation four times a day

B. Check the client's weight each morning

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the
nurse anticipate including in the plan of care?

A. Infuse hypotonic IV fluids
B. Implement a fluid restriction
C. Increase sodium intake
D. Administer sodium polystyrene

A. Infuse hypotonic IV fluids

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify
which of the following findings as risk factors for the development of this electrolyte imbalance?

A. Crohn's disease
B. Postoperative following appendectomy
C. History of bone cancer
D. Hyperthyroidism

A. Crohn's disease

A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When
notifying the provider, the nurse should anticipate which of the following actions?

A. Starting an IV infusion of 0.9% sodium chloride
B. Consulting with dietitian to increase intake of potassium
C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage

C. Initiating continuous cardiac monitoring

A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of
glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply):

A. Hyperreflexia

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Exam (elaborations)

NR 226 EXAM 1 2024 ACTUAL EXAM AND STUDY GUIDE 180 QUESTIONS WITH VERIFIED ANSWERS (100% CORRECT) A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse t

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