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NURS 420 Final Exam | Questions & Complete Solutions
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NURS 420 Final Exam | Questions &Complete Solutions
the nurse assesses a patient with a skull fracture to have a glasgow coma scale score of 3. additional
vital signs assessed by the nurse include blood pressure 100/70 mmHg, heart rate 55 beats/min,
respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3L per nasal cannula. what
is the priority nursing action:
a. monitor the patients airway patency
b. elevate the head of the patients bed
c. increase supplemental oxygen therapy
d. support bony prominences with padding - ✔✔a. monitor the patients airway patency
comparing the patient's current (home) medications with those ordered during hospitalization
and communicating a complete list of medications to the next provider when the patient is
transferred within an organization or to another setting are strategies to:
a.improve accuracy of patient identification
b.prevent errors related to look-alike and sound-alike medications
c.reconcile medications across the continuum of care
d.reduce harms associated with administration of anticoagulants. - ✔✔c.reconcile medications
across the continuum of care
which of the following assists the critical care nurse in ensuring that care is appropriate and based on
research?
a.Clinical practice guidelines
b.Computerized physician order entry
c.Consulting with advanced practice nurses
d.Implementing Joint Commission National Patient Safety Goals - ✔✔a. clinical practice guidelines
Which of the following is a National Patient Safety Goal? (Select all that apply.)
,a.Accurately identify patients.
b.Eliminate use of patient restraints.
c.Reconcile medications across the continuum of care.
d.Reduce risks of healthcare-acquired infection. - ✔✔a.Accurately identify patients.
c.Reconcile medications across the continuum of care.
d.Reduce risks of healthcare-acquired infection.
A nurse who plans care based on the patient's gender, ethnicity, spirituality, and lifestyle is said to:
a.be a moral advocate
b.facilitate learning
c.respond to diversity
d.use clinical judgment. - ✔✔c.respond to diversity
The vision of the American Association of Critical-Care Nurses is a healthcare system driven by:
a.a healthy work environment.
b.care from a multiprofessional team under the direction of a critical care physician.
c.the needs of critically ill patients and families.
d.respectful, healing, and humane environments. - ✔✔c. the needs of critically ill patients and
families.
Blood gas levels of pH:7.5 PaCO2: 25 HCO3: 25 - - ✔✔uncompensated respiratory alkosisis
The family members of a critically ill patient brings a copy of the patient living will to the hospital which
identifies the patient's wishes regarding health care. You discuss contents of the living will with the
patient's physician. This is an example of implementation of which of the AACN Standard of
Professional Performance:
a. Acquires and maintains current knowledge of practice
b. Acts ethically on the behalf of the patient and family
c. Considers factors related to safe patient care
, d. Uses clinical inquiry and integrates research findings in practice - ✔✔b. Acts ethically on the behalf
of the patient and family
Many critically ill patients experience anxiety. The nurse can reduce anxiety with which approach?
a. Ask family members to limit their visitation to 2-hour periods in morning, afternoon, and evening
b. Explain the unit routine
c. Explain procedures before and while you are doing them
d. Suction Mr. J.'s endotracheal tube immediately when he starts to cough - ✔✔c. Explain
procedures before and while you are doing them
The nurse is caring for a patient who has been declared brain dead. The patient is considered a
potential organ donor. To proceed with donation, the nurse understands that:
a. A signed donor card mandates that organs be retrieved in the event of brain death
b. After brain death has been determined, perfusion and oxygenation of organs is maintained
until organs can be removed in the operating room
c. The healthcare proxy does not need to give consent for the retrieval of organs
d. Once a patient has been established as brain dead, life support is withdrawn and organs are retrieved
- ✔✔b. After brain death has been determined, perfusion and oxygenation of organs is maintained
until organs can be removed in the operating room
In evaluating a patients nutrition, the nurse would monitor which blood test as the most sensitive
indicator of protein
a. Albumin
b. BUN
c. Prealbumin
d. triglycerides - ✔✔c. Prealbumin
In addition to residual stomach volume, what other evidence suggest feeding intolerance
a. Abdominal distention
b. Absence of tympany on percussion
c. Active bowel sounds
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