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NUR 325 Exam 3 | Questions & Answers 100% Verified Correct| Latest Update
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NUR 325 Exam 3 | Questions & Answers 100% Verified Correct| Latest Update
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NUR 325 Exam 3 | Questions & Answers 100%Verified Correct| Latest Update
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees
no electrocardiogram complexes on the screen. The first action of the nurse is to:
a. Check the client status and lead placement
b. Press the recorder button on the electrocardiogram console
c. Call the physician
d. Call a code blue - ✔✔A (Sudden loss of electrocardiogram complexes indicates ventricular
asystole or possible electrode displacement. Accurate assessment of the client and equipment
is necessary to determine the cause and identify the appropriate intervention.)
Which assessment is indicated to evaluate a patients' leg circulation?
a. Carotid arteries for bruits
b. Pedal and tibial pulses for presence and quality
c. Orthostatic blood pressure readings - ✔✔B
A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of
the following findings should the nurse expect?
a. Thin, pliable toe nails
b. Leg pain at rest
c. Hairy legs
d. Flushed/ warm legs - ✔✔B (In the initial stages of PAD, clients might experience
intermittent claudication. As the disease progresses, the client will experience pain even at rest
due to ischemia of the distal extremities. The client might describe this pain as a persistent
burning or aching pain that often awakens the client at night. A client who has PAD will have
,thickened toenails. They will also have shiny, dry skin on the legs with sparse hair growth, and
they will have skin that is cool or cold to the touch.)
A nurse is caring for an older adult client. The nurse informs the client that straining while
defecating can cause which of the following?
a. Dilated pupils
b. Dysrhythmias
c. Diarrhea
d. Gastric ulcer - ✔✔B (Dysrhythmias can result from straining while defecating. When the
client contracts the abdominal muscles and holds their breath while bearing down then the
client exhales, there is a sudden release of intraabdominal pressure against the closed airway,
which can result in cardiac dysrhythmias and elevated blood pressure.)
A nurse is caring for a client who returns to the nursing unit from the recovery room after a
sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative
bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic
shock?
a. Decrease in RR from 20 to 16/min.
b. Decrease in urinary output from 50 mL to 30mL per hour.
c. Increase in the temp from 99.5 fahrenheit to 101.5 fahrenheit.
d. Increase in the HR from 88 to 110/min. - ✔✔D (Hypovolemic shock is a condition in which
the heart is unable to supply enough blood to the body because of blood loss or inadequate
blood volume. In an effort to compensate for this, the HR increases steadily. In the first stage of
shock, the HR is >100/min. As shock progresses, the HR continues to accelerate to more than
150/min. Hyperthermia is seen in septic shock, one of the classic signs of shock is cool, moist
skin. A client experiencing shock would have an increased RR.)
While performing an admission assessment for a client, the nurse notes that the client has
varicose veins with ulcerations and lower extremity edema with a report of a feeling of
,heaviness. Which of the following nursing diagnoses should the nurse identify as being the
priority in the client's care?
a. Impaired tissue perfusion
b. Alteration in body image
c. Alteration in activity tolerance
d. Impaired skin integrity - ✔✔A (When using the airway, breathing, and circulation priority
framework, the nurse should identify impaired perfusion of tissues as the priority finding.)
A nurse is giving a presentation to a community group about preventing atherosclerosis. Which
of the following should the nurse include as a modifiable risk factor for this disorder? (Select all
that apply.)
a. Genetic predisposition
b. Hypercholesterolemia
c. Hypertension
d. Obesity
e. Smoking - ✔✔B C D E
A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The
nurse should identify which of the following medications as the case of the client's low
potassium level?
a. Furosemide
b. Nitroglycerin
c. Metoprolol
d. Spironolactone - ✔✔A (Furosemide is a loop diuretic that inhibits the reabsorption of
sodium and chloride and results in diuresis, which decreases potassium levels through excretion
in the distal nephrons. Hypokalemia is an adverse effect of furosemide. Spironolactone is a
, potassium-sparing diuretic medication, therefore, hyperkalemia is an adverse effect of this
medication.)(reg potassium=3.5-5.0)
A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse
should recognize that this sound represents which of the following heart conditions?
a. Atrial gallop
b. Ventricular gallop
c. Closure of mitral valve
d. Closure of the pulmonic valve - ✔✔B (S3 indicates a ventricular gallop caused by a rush of
blood into a ventricle that is stiff or dilates. This can be a finding of heart failure and
hypertension.) An S4 sound represents an Atrial Gallop. Closure of the mitral valve is
represented by the S1 sound, and closure of the pulmonic valve is represented by the S2 sound.
A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping
because of cold feet. Which of the following nursing actions should the nurse take to promote
the client's comfort?
a. Obtain a pair of slipper-socks for the client
b. Rub the client's feet briskly for several minutes
c. Increase the client's oral fluid intake
d. Place a moist heating pad under the client's feet - ✔✔A (In cold weather or when the
client's feet are cold, he should wear extra socks or slipper socks to help provide warmth and
increase his level of comfort. Massaging the legs or feet can cause a clot to break loose in the
bloodstream. Impairment of arterial or venous circulating to a lower extremity is a
contraindication for massage and heating pads. If there is co-existing sensory involvement, the
client might not be able to feel a burn and be prone to serious injury)
While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2
heart sounds. The nurse should document this finding as which of the following?
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