NUR 221 EXAM 1 QUESTIONS AND ANSWERS 100% VERIFIED
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Course
NUR 221
Institution
NUR 221
NUR 221 EXAM 1 QUESTIONS AND ANSWERS 100% VERIFIEDNUR 221 EXAM 1 QUESTIONS AND ANSWERS 100% VERIFIEDNUR 221 EXAM 1 QUESTIONS AND ANSWERS 100% VERIFIED
The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 m...
NUR 221 EXAM 1 QUESTIONS AND
ANSWERS 100% VERIFIED
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 - 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. - ANSWER-A. Implement droplet
precautions upon admission.
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. - 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?" - 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?
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." - 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 - 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 - ANSWER-B. Early in the recovery stage
A patient with progressively deteriorating lower extremity motor and sensory function is
having a lumbar puncture. What finding suggests that this patient has Guillain-Barré
syndrome (GBS)?
A. Elevated protein level
B. Elevated glucose level
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