NUR 1023 FINAL EXAM – SEVERAL COMBINED
1. Which surgical procedure should the nurse anticipate the client with
myasthenia gravis undergoing to help prevent the signs/symptoms of the
disease process?
A thymectomy.
2. Which ocular or facial signs/symptoms should the nurse expect to assess for
the client diagnosed with myasthenia gravis?
Ptosis and diplopia.
3. The client diagnosed with myasthenia gravis is being discharged home.
Which intervention has priority when teaching the client’s significant others?
Discuss ways to help prevent choking episodes.
4. Which assessment data should the nurse assess in the client diagnosed with
Guillain-Barré syndrome?
Progressive ascending paralysis of the lower extremities and numbness.
5. Which statement by the client supports the diagnosis of Guillain-Barré
syndrome?
“I had a really bad cold just a few weeks ago.”
6. The client diagnosed with Guillain-Barré syndrome asks the nurse, “Will I ever
get back to normal? I am so tired of being sick.” Which statement is the best
response by the nurse?
“You should make a full recovery within a few months to a year.”
7. The client diagnosed with an acute exacerbation of multiple sclerosis is placed
on high-dose intravenous injections of corticosteroid medication. Whichnursing
intervention should be implemented?
Monitor the client’s serum blood glucose levels frequently.
8. The client diagnosed with ALS asks the nurse, “I know this disease is going to
kill me. What will happen to me in the end?” Which statement by the nurse
would be most appropriate?
“Most people with ALS die of respiratory failure.”
9. The client with ALS is admitted to the medical unit with shortness of breath,
dyspnea, and respiratory complications. Which intervention should the nurse
implement first?
1. Elevate the head of the bed 30 degrees.
2. Administer oxygen via nasal cannula. 3. Assess the client’s lung sounds.
,4. Obtain a pulse oximeter reading.
10. The client is to receive a 200-mL intravenous antibiotic over 30 minutes via
an intravenous pump. At what rate should the nurse set the IV pump?
400ml
11. The client is diagnosed with ALS. As the disease progresses, which
intervention should the nurse implement?
Assist the client to prepare an advance directive.
12. The client is in the terminal stage of ALS. Which intervention should the
nurse implement?
Perform passive ROM every two (2) hours.
13. The health-care provider wants an SvO2 level on a patient with a pulmonary
artery catheter. From where should this sample be taken?
Distal lumen
14. The nurse is preparing to obtain a pulmonary artery wedge pressure (PAWP)
on a patient. What action should be taken to ensure for the patient’s safety? Inflate
the balloon 1.5 mL
15. The nurse wants to evaluate a patient’s right heart preload. Which approach
should be used to obtain this measurement
Measure the central venous pressure
16. The nurse suspects that a patient is experiencing a complication from a
pulmonary artery catheter. What findings did the nurse use to make this clinical
determination? Select all that apply.
Bleeding
Elevated body temperature
Acute onset of shortness of breath
Development of a cardiac dysrhythmia
17. The nurse is preparing to determine a patient’s left heart afterload. What
measurements are needed to make this calculation? Select all that apply
Cardiac output
Mean arterial pressure
Central venous pressure
1. The client asks about ways to prevent carbon monoxide poisoning. Which
teaching will the nurse provide?
a. “You can see black smoke when carbon monoxide is in the air.”
,b. “If you are experiencing carbon monoxide poisoning, your skin will begin
turning blue.”
c. “The only way to get poisoned from carbon monoxide gas is if you are in the
presence of a fire.”
d. “It is important to have carbon monoxide detectors in your home, because
this is an odorless gas.”
1. Which assessment finding does the nurse interpret as demonstrating a
client’s fluid resuscitation adequacy?
a. Decreased skin turgor
b. Decreased pulse pressure
c. Decreased core body temperature
d. Decreased urine specific gravity
1. Which nursing intervention(s) decrease(s) the risk for cross-contamination in
the client with a severe burn injury? (Select all that apply.)
a. Place client in isolation.
b. Encourage multiple visitors to support client.
c. Ensure that no plants or flowers are in the client’s room.
d. Teach family members not to bring fresh fruits and vegetables to the client.
e. Change gloves after cleaning and dressing of one wound area, before
cleaning and dressing another.
1. A Nurse is panning care for a client who has prerenal acute kidney injury
(AKI) Following abdominal aortic aneurysm repair. Urinary output is
60mLin the past 2hr and blood pressure is 92/58mm Hg. The nurse
should expect which of the following interventions?
Prepare to administer a challenge
2. A Nurse is assessing a client who has prerenal acute kidney injury (AKI)
which of the following findings should the nurse expect? Select all that
apply
Elevated creatinine/ reduced urine output
3. In providing an educational in-service to the nursing staff about peritoneal
dialysis, which information does the nurse include in this presentation?
The peritoneum acts as a semipermeable membrane through which
wastes move by diffusion and osmosis.
4. Which statement by the family member of a client who has a Sengstaken-
Blakemore tube placed to threat complications of liver disease indicates
, understanding of this treatment modality?
The tube provides compression to stop esophageal bleeding
5. A client with chronic kidney disease is experiencing manifestations of
anemia. Based on this date, which statement does the nurse anticipatefor
this client?
Administer erythropoietin (epoetin) injections
6. The nurse is assessing a client in the ER with the following signs and
symptoms; painful mid-epigastric pain felt in the back, elevated glucose,
fever, and vomiting. During the head-to-toe assessment, you notice bluish
discoloration around the umbilicus. The RN recognizes this as which sign?
Cullen’s sign
7. The nurse is caring for a client receiving hourly peritoneal dialysis
exchanges. During a one-hour exchange, the nurse infuses 2,000mL of
dialysate and 1,900 mL of outflow is returned. During the exchange, the
client drinks 8oz of apple juice, 2 cups of water and voids 150mL of urine.
Calculate and record the client’s intake in millimeters and use numerical
values only.
820
8. On which scientific rationale should a nurse base the response when a
client asks, what does an elevated PSA test mean?
An elevated PSA can result from several different causes
9. A client had a transurethral resection of the prostate (TURP) with
continuous bladder irrigation yesterday. The staff nurse notes that the
1. Which surgical procedure should the nurse anticipate the client with
myasthenia gravis undergoing to help prevent the signs/symptoms of the
disease process?
A thymectomy.
2. Which ocular or facial signs/symptoms should the nurse expect to assess for
the client diagnosed with myasthenia gravis?
Ptosis and diplopia.
3. The client diagnosed with myasthenia gravis is being discharged home.
Which intervention has priority when teaching the client’s significant others?
Discuss ways to help prevent choking episodes.
4. Which assessment data should the nurse assess in the client diagnosed with
Guillain-Barré syndrome?
Progressive ascending paralysis of the lower extremities and numbness.
5. Which statement by the client supports the diagnosis of Guillain-Barré
syndrome?
“I had a really bad cold just a few weeks ago.”
6. The client diagnosed with Guillain-Barré syndrome asks the nurse, “Will I ever
get back to normal? I am so tired of being sick.” Which statement is the best
response by the nurse?
“You should make a full recovery within a few months to a year.”
7. The client diagnosed with an acute exacerbation of multiple sclerosis is placed
on high-dose intravenous injections of corticosteroid medication. Whichnursing
intervention should be implemented?
Monitor the client’s serum blood glucose levels frequently.
8. The client diagnosed with ALS asks the nurse, “I know this disease is going to
kill me. What will happen to me in the end?” Which statement by the nurse
would be most appropriate?
“Most people with ALS die of respiratory failure.”
9. The client with ALS is admitted to the medical unit with shortness of breath,
dyspnea, and respiratory complications. Which intervention should the nurse
implement first?
1. Elevate the head of the bed 30 degrees.
2. Administer oxygen via nasal cannula. 3. Assess the client’s lung sounds.
,4. Obtain a pulse oximeter reading.
10. The client is to receive a 200-mL intravenous antibiotic over 30 minutes via
an intravenous pump. At what rate should the nurse set the IV pump?
400ml
11. The client is diagnosed with ALS. As the disease progresses, which
intervention should the nurse implement?
Assist the client to prepare an advance directive.
12. The client is in the terminal stage of ALS. Which intervention should the
nurse implement?
Perform passive ROM every two (2) hours.
13. The health-care provider wants an SvO2 level on a patient with a pulmonary
artery catheter. From where should this sample be taken?
Distal lumen
14. The nurse is preparing to obtain a pulmonary artery wedge pressure (PAWP)
on a patient. What action should be taken to ensure for the patient’s safety? Inflate
the balloon 1.5 mL
15. The nurse wants to evaluate a patient’s right heart preload. Which approach
should be used to obtain this measurement
Measure the central venous pressure
16. The nurse suspects that a patient is experiencing a complication from a
pulmonary artery catheter. What findings did the nurse use to make this clinical
determination? Select all that apply.
Bleeding
Elevated body temperature
Acute onset of shortness of breath
Development of a cardiac dysrhythmia
17. The nurse is preparing to determine a patient’s left heart afterload. What
measurements are needed to make this calculation? Select all that apply
Cardiac output
Mean arterial pressure
Central venous pressure
1. The client asks about ways to prevent carbon monoxide poisoning. Which
teaching will the nurse provide?
a. “You can see black smoke when carbon monoxide is in the air.”
,b. “If you are experiencing carbon monoxide poisoning, your skin will begin
turning blue.”
c. “The only way to get poisoned from carbon monoxide gas is if you are in the
presence of a fire.”
d. “It is important to have carbon monoxide detectors in your home, because
this is an odorless gas.”
1. Which assessment finding does the nurse interpret as demonstrating a
client’s fluid resuscitation adequacy?
a. Decreased skin turgor
b. Decreased pulse pressure
c. Decreased core body temperature
d. Decreased urine specific gravity
1. Which nursing intervention(s) decrease(s) the risk for cross-contamination in
the client with a severe burn injury? (Select all that apply.)
a. Place client in isolation.
b. Encourage multiple visitors to support client.
c. Ensure that no plants or flowers are in the client’s room.
d. Teach family members not to bring fresh fruits and vegetables to the client.
e. Change gloves after cleaning and dressing of one wound area, before
cleaning and dressing another.
1. A Nurse is panning care for a client who has prerenal acute kidney injury
(AKI) Following abdominal aortic aneurysm repair. Urinary output is
60mLin the past 2hr and blood pressure is 92/58mm Hg. The nurse
should expect which of the following interventions?
Prepare to administer a challenge
2. A Nurse is assessing a client who has prerenal acute kidney injury (AKI)
which of the following findings should the nurse expect? Select all that
apply
Elevated creatinine/ reduced urine output
3. In providing an educational in-service to the nursing staff about peritoneal
dialysis, which information does the nurse include in this presentation?
The peritoneum acts as a semipermeable membrane through which
wastes move by diffusion and osmosis.
4. Which statement by the family member of a client who has a Sengstaken-
Blakemore tube placed to threat complications of liver disease indicates
, understanding of this treatment modality?
The tube provides compression to stop esophageal bleeding
5. A client with chronic kidney disease is experiencing manifestations of
anemia. Based on this date, which statement does the nurse anticipatefor
this client?
Administer erythropoietin (epoetin) injections
6. The nurse is assessing a client in the ER with the following signs and
symptoms; painful mid-epigastric pain felt in the back, elevated glucose,
fever, and vomiting. During the head-to-toe assessment, you notice bluish
discoloration around the umbilicus. The RN recognizes this as which sign?
Cullen’s sign
7. The nurse is caring for a client receiving hourly peritoneal dialysis
exchanges. During a one-hour exchange, the nurse infuses 2,000mL of
dialysate and 1,900 mL of outflow is returned. During the exchange, the
client drinks 8oz of apple juice, 2 cups of water and voids 150mL of urine.
Calculate and record the client’s intake in millimeters and use numerical
values only.
820
8. On which scientific rationale should a nurse base the response when a
client asks, what does an elevated PSA test mean?
An elevated PSA can result from several different causes
9. A client had a transurethral resection of the prostate (TURP) with
continuous bladder irrigation yesterday. The staff nurse notes that the
