The nurse is caring for a client who has returned to post-surgical suite after postanesthetic recovery from a nephrectomy. The nurse's most recent assessment reveals increased sedation, shortness of breath, hypotension, and low urine output over the last 2 hours. What is the nurse's best response? ...
Nurs 370 Final Exam Questions and
Correct Answers
The nurse is caring for a client who has returned to post-surgical suite after
postanesthetic recovery from a nephrectomy. The nurse's most recent assessment
reveals increased sedation, shortness of breath, hypotension, and low urine output over
the last 2 hours. ✅What is the nurse's best response?
Assess the client for signs of bleeding and inform the primary care provider.
The highest priority for intervention during the first 30 minutes in treating an acute
myocardial infarction including the following(s). Select All That Apply ✅Oxygen therapy
Morphine administration
Nitroglycerin (NTG)
Aspirin (ASA)
A nurse on a busy medical unit provides care for many client who requires indwelling
urinary catheter at some points during their hospital care. ✅The nurse should
recognize a heightened risk of injury associated with indwelling catheter are in which
client?
A client who has Alzheimer disease and who is acutely agitated
While auscultating the heart of a patient admitted for complications following a
myocardial infarction three weeks ago, the nurse notes the presence of a new S3 heart
sounds. ✅Based on this finding, what is the nurse's best action at this time?
Assess symptoms of left-sided heart failure
A patient hospitalized for worsening renal failure suddenly becomes restless and
agitated. Your assessment reveals tachycardia, hypertension, and crackles bilaterally
scattered throughout the lung fields. ✅What do these symptoms suggest?
The patient is developing pulmonary edema
A client with advanced venous insufficiency is confined to bedrest following orthopedic
surgery. How can the nurse best prevent skin breakdown in the client's lower
extremities? ✅Ensure the client's heels are supported and protected.
A nurse has a client with a spinal cord injury and is tailoring the care plan to prevent the
major cause of death for this client. The nurse's care plan includes assisted coughing
techniques, applied sequential compression device, and prevented pressure injuries.
✅Which are the most likely
possible causes of death for this client? Pneumonia, pulmonary embolism, and sepsis
After a sudden decline in cognition, a 77-year-old client who has been diagnosed with
vascular dementia is receiving care at home. To reduce this client's risk of future
, infarcts, which action should the nurse most strongly encourage? ✅Rigorous control of
the client's blood pressure and lipid levels.
The nurse is caring for a 78-year-old client who has had an outpatient cholecystectomy.
The nurse is getting the client up for the first walk postoperatively. ✅To decrease the
potential of orthostatic hypotension and consequent falls, what should the nurse have
the client do?
Sit in a chair for 10 minutes prior to ambulating.
The nurse is administering medication to a client through a feeding tube. Which action
should the nurse take? ✅Flush with 50 mL of water between each medication.
A patient with ischemic brain attack (stroke) is susceptible to post stroke complications.
Which complications are sensitive to nursing care? Select all that apply. ✅Extremity
contractures
Urinary tract infection
Impaired skin integrity
Which of the following should be included in an interprofessional symptom management
care plan for patients undergoing intravenous chemotherapy for a malignancy? Select
all that apply. ✅Mucositis
Neutropenia
Thrombocytopenia
Anemia
Pruritis
A client has become legally blind as a result of macular degeneration. When attempting
to meet this client's psychosocial needs, what nursing action is most appropriate?
✅Assess and promote the client's coping skills during interactions with the client.
A client has recently received a diagnosis of gastric cancer; the nurse is aware of the
importance of assessing the client's level of anxiety. Which of the following actions is
most likely to accomplish? ✅The client is encouraged to express fears openly.
A nurse is caring for a client who has a diagnosis of gastrointestinal (GI) bleed. During
shift assessment, the nurse finds the client is tachycardiac and hypotensive, and the
client has an episode of hematemesis while the nurse is in the room. ✅In addition to
monitoring the client's vital signs and level of consciousness, what would be a priority
nursing action for this client?
Notify healthcare provider
A nurse is providing palliative care to a client with a diagnosis of end-stage chronic
obstructive pulmonary disease (COPD). What is the primary goal of this nursing care?
✅To improve the client's and family's quality of life.
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