NUR 2571 / NUR2571 Professional Nursing II / PN 2 LATEST Final Exam QUESTIONS AND ANSWERS, Exams of Nursing

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NUR 2571 / NUR2571 Professional Nursing II / PN 2 LATEST Final Exam QUESTIONS AND ANSWERS | ALREADY GRADED A+ RASMUSSEN COLLEGE A client has a tracheostomy tube in place. When the nurse suctions the client,food particles are noted. What action by the nurse is best? b. Measure and compare cuff pressures.ANS: B

2. A nurse assesses a client after an open lung biopsy. Which assessment findingis matched with the correct intervention? c. Client has reduced breath sounds. Nurse calls physician immediately.ANS: C
3. A nurse assesses a clients respiratory status. Which information is of highestpriority for the nurse to obtain? d. Occupation and hobbiesANS: D
4. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? a. Cardiac rate and rhythmANS: A
5. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? a. Assess clients rate, rhythm, and depth of respiration.

7. A nurse is assessing a client who is recovering from a lung biopsy. Whichassessment finding requires immediate action? b. Absent breath soundsANS: B
8. A nurse is caring for a client who has just experienced a 90- second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula.
9. A nurse is caring for a client who is scheduled to undergo a thoracentesis.Which intervention should the nurse complete prior to the procedure? d. Validate that informed consent has been given by the client.ANS: D

9. A nurse assesses a client after a thoracentesis. Which assessment findingwarrants immediate action? d. The trachea is deviated toward the opposite side of the neck.ANS: D 1.A nurse is caring for a client who has just had a central venous access lineinserted. Which action should the nurse take next? b. Ensure an x-ray is completed to confirm placement.ANS: B
10. A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include inthis clients teaching? a. Avoid carrying your grandchild with the arm that has the central catheter.ANS: A 5.A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention fromthe nurse? b. Report of headache and stif f neckANS: B 7.A nurse is assessing clients who have intravenous therapy prescribed. Whichassessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate

attention? d. Upper extremity swelling is noted.ANS: D 13.A nurse teaches a client who is prescribed a central vascular access device.Which statement should the nurse include in this clients teaching? c. Ask all providers to vigorously clean the connections prior to accessing the device.

ANS: C

14.A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? b. Place warm compresses on the site.ANS: B 17.A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin witha concentration of 100 units/mL. Which of the syringes shown below should the nurse use to draw up and administer the heparin? ANS: D (10-mL syringe picture) 2.A nurse assesses a client who has a peripherally inserted central catheter(PICC). For which complications should the nurse assess? (Select all that apply.) a. Phlebitis c. Thrombophlebitis ANS: A, C

11. While assessing a client who has facial trauma, the nurse auscultates stridor.The client is anxious and restless. Which action should the nurse take first?

a. Contact the provider and prepare for intubation.ANS: A 8.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above thesite. Which action should the nurse take next? d. Stop the infusion of intravenous fluids.

3. A nurse assesses a client who has facial trauma. Which assessment findingsrequire immediate intervention? (Select all that apply.) a. Stridor d. Ecchymosis behind the earANS: A, D

12. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Whichprovider order should the nurse expect to receive? b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W
13. A nurse assesses clients on the medical-surgical unit. Which client is atgreatest risk for development of obstructive sleep apnea? c. A 55-year-old woman who is 50 pounds overweightANS: C
14. A nurse cares for a client who is experiencing epistaxis. Which action shouldthe nurse take first? a. Initiate Standard Precautions.ANS: A 2.A client is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) should thenurse set the infusion to ANS: 16 drops/min 1.A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate shouldthe nurse set the pump (mL/hr) to deliver this infusion? ( Record your answer using a whole number. ) mL/hr ANS:42--1000 mL 24 hours = 41.6 mL/hr. (42 is the answer)
15. A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? Howshould the nurse respond? c. This medication will promote daytime wakefulness.ANS: C

2. A nurse assesses a client who has developed epistaxis. Which conditions inthe clients history should the nurse identify as potential contributors to this problem? (Select all that apply.) b. Hypertension c. Leukemia d. Cocaine useANS: B, C, D
3. After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statementindicates the client comprehends the teaching?

c. I will take this medication every morning to help prevent an acute attack.ANS: C

9. A nurse is teaching a client who has cystic fibrosis (CF). Which statementshould the nurse include in this clients teaching? c. Eat a well-balanced, nutritious diet.ANS: C
10. While assessing a client who is 12 hours postoperative after a thoracotomyfor lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? b. Cover the insertion site with sterile gauze.ANS: B
11. A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nursetake? d. Administer pain medication and encourage the client to take deep breaths.ANS: D
12. A nurse cares for a client who has a chest tube. When would this client be athighest risk for developing a pneumothorax? d. When the tube becomes disconnected from the drainage systemANS: D
13. The nurse is caring for a client who is prescribed a long- acting beta2 agonist.The client states, The medication is too expensive to use every day. I only use my inhaler when I have an attack. How should the nurse respond? d. It is important to use this type of inhaler every day. Lets identify potentialcommunity services to help you. ANS: D

5. A nurse assesses a client who has a chest tube. For which manifestationsshould the nurse immediately intervene? (Select all that apply.) b. Tracheal deviation c. Sudden onset of shortness of breathANS: B, C
6. A nurse is caring for a client using oxygen while in the hospital. What assessment findingindicates that goals for a priority diagnosis are being met? b. Intact skin behind the ears

10.A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink ofwater. Which action should the nurse take next? c. Assess the clients gag reflex before giving any food or water. client has been diagnosed with tuberculosis (TB). What action by the nursetakes highest priority? a. Educating the client on adherence to the treatment regimenANS: A 12.A nurse has educated a client on isoniazid (INH). What statement by theclient indicates teaching has been effective? c. I will take this medication on an empty stomach.ANS: C

3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation.ANS: A
4. A client has been hospitalized with tuberculosis (TB). The clients spouse is fearful of entering the room where the client is in isolation and refuses to visit.What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in

further detail.ANS: A

16. A client is being discharged on long-term therapy for tuberculosis (TB). Whatreferral by the nurse is most appropriate? d. Visiting Nurses for directly observed therapyANS: D

1. A nurse assesses a client who has appendicitis. Which clinical manifestationshould the nurse expect to find? a. Severe, steady right lower quadrant painANS: A
2. A nurse cares for an older adult client who has Salmonella food poisoning. Theclients vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first? b. Administer intravenous fluids.ANS: B
3. A nurse assesses a client who is hospitalized with an exacerbation of Crohnsdisease. Which clinical manifestation should the nurse expect to find? c. High-pitched, rushing bowel sounds in the right lower quadrantANS: C
4. After teaching a client who is prescribed adalimumab (Humira) for severeulcerative colitis, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? b. I will take this medication with my breakfast each morning.ANS: B
5. A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The clientstates that he no longer enjoys going out with his friends. How should the nurse respond?
6. A nurse assesses a client who has ulcerative colitis and severe diarrhea.Which assessment should the nurse complete c. Share any thoughts and feelings that cause you to limit social activities. d. Friends can be a good support system for clients with chronic disorders.

first? c. Heart rate and rhythmANS: C

16. A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appearsthin and disheveled. Which question should the nurse ask first? c. Do you experience shortness of breath with basic activities?
17. A nurse cares for a client with ulcerative colitis. The client states,” I feel like Iam tied to the toilet.” This disease is controlling my life. How should the nurse respond?

a. Lets discuss potential factors that increase your symptoms.ANS: A

10. A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, I am having trouble swallowing this pill.Which action should the nurse take? c. Ask the health care provider to prescribe the medication as an enema instead.ANS: C
11. A nurse assesses a client with ulcerative colitis. Which complications arepaired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding Erosion of the bowel wall b. Abscess formation Localized pockets of infection develop in the ulceratedbowel lining d. Nonmechanical bowel obstruction Paralysis of colon resulting from colorectalcancer ANS: A, B, D
12. The student nurse studying stomach disorders learns that the risk factors foracute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids e. Nonsteroidal anti-inflammatory drugs (NSAIDs)ANS: A, B, C, E
13. A client is recovering from an esophagogastroduodenoscopy (EGD) andrequests something to drink. What action by the nurse is best? b. Assess the clients gag

reflex.ANS: B

19. A nurse teaches a client who is at risk for colon cancer. Which dietaryrecommendation should the nurse teach this client? c. Add vegetables such as broccoli and cauliflower to your new diet.ANS: C
20. A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins e. Skeletal muscle weaknessANS: A, B, E

15.A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complicationof this therapy should the nurse assess this client? d. Infection ANS: D

4. A nurse has conducted a community screening event for oral cancer. Whatclient is the highest priority for referral to a dentist? b. Client who smokes and drinks dailyANS: B
5. A client is having a temporary tracheostomy placed during surgery for oralcancer. What action by the nurse is best to relieve anxiety? a. Agree on a postoperative communication method.ANS: A
6. A client had an oral tumor removed this morning and now has atracheostomy. What action by the nurse is the priority? c. Place the client in a high-Fowlers position.ANS: C
7. A nurse studying cancer knows that job-related risks for developing oralcancer include which occupations? (Select all that apply.) a. Coal miner c. Metal worker d. Plumber e. Textile workerANS: A, C, D, E

d. Peppermint

8. A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up intothe lower part of the clients neck. What action by the nurse takes priority? oxygenation.ANS: A 6.A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Selectall that apply.)

ANS: A, C, D, E

12. A nurse is assessing clients on a medical-surgical unit. Which client is at riskfor hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioningANS: A
13. A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How shouldthe nurse respond? c. Berries, cherries, apples, and peaches are low in potassium.ANS: C
14. A nurse cares for a client who has a serum potassium of 7. mEq/L and isexhibiting cardiovascular changes. Which prescription should the nurse implement first? c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.ANS: C
15. After teaching a client to increase dietary potassium intake, a nurse assesses theclients understanding. Which dietary meal selection indicates the client correctly understands the teaching? c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milkANS: C
16. A nurse is assessing a client who has an electrolyte imbalance related to renalfailure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.) a. Electrocardiogram changes d. Paralytic ileus e. Tomato sauce

e. Skeletal muscle weaknessANS: A, D, E

1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? a. Increased rate and depth of respirations
2. A nurse is assessing a client with hypokalemia, and notes that the clients handgrip

strength has diminished since the previous assessment 1 hour ago. Which actionshould the nurse take first? a. Assess the clients respiratory rate, rhythm, and depth.ANS: A

6. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving theclients hypokalemia? (Select all that apply.) c. Strong productive cough d. Active bowel soundsANS: C, D
7. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients careplan? (Select all that apply.) b. Use a draw sheet to reposition the client in bed. d. Provide nonslip footwear for the client to use when out of bed.ANS: B, D
8. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to preventcomplications of this therapy? d. Metabolic alkalosisANS: D
9. A nurse is caring for a client who is experiencing moderate metabolicalkalosis. Which action should the nurse take? d. Teach the client fall prevention measures.ANS: D
10. A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen.What action by the nurse is the

priority? b. Notify the provider immediately.ANS: B

10. A nurse assesses a clients oral cavity and observes the condition depicted inthe photo below: What action by the nurse is best? b. Assess the client for dysphagia.ANS: B
11. A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominalpain. Which action should the nurse take next? d. Assess the clients bowel sounds.ANS: D

1. A nurse inserts a nasogastric (NG) tube for an adult client who has a bowelobstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowlers position, withpillows behind the head and shoulders c. Checks for correct placement by checking the pH of the fluid aspirated fromthe tube e. Connects the NG tube to intermittent medium suction with an anti-refluxvalve on the air vent ANS: A, C, E
2. A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with thisdiagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L c. Abdominal pain in upper quadrants e. Serum sodium of 121 mEq/LANS: A, C, E
3. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme[ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm HgANS: A
4. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates theclient correctly understood the teaching? d. Grilled chicken breast with glazed carrotsANS: D
5. A nurse is caring for a client who has the following laboratory

results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144mEq/L. Which assessment should the nurse complete first? a. Depth of respirationsANS: A

10. A nurse evaluates the following arterial blood gas values in a client: pH 7.48,PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results? b. Anxiety-induced hyperventilationANS: B
11. After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statementindicates the client needs additional teaching?

c. I take sodium bicarbonate after every meal to prevent heartburn.ANS: C

13. A nurse is caring for a client who received benzocaine spray prior to a recentbronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next? b. Notify the Rapid Response Team.ANS: B
14. The nurse assesses the client using the device pictured below to deliver 50%O2: The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? c. Immediately increase the flow rate.ANS: C
15. A nurse assesses a client who reports waking up feeling very tired, even after8 hours of good sleep. Which action should the nurse take first? d. Ask the client if he or she has ever been evaluated for sleep apnea.ANS: D
16. A nurse assesses several clients who have a history of asthma. Which clientshould the nurse assess first? d. A 27-year-old client with a heart rate of 120 beats/min ANS: D
17. A nurse evaluates the following arterial blood gas and vital sign results for aclient with chronic obstructive pulmonary disease (COPD): Which action should the nurse take first? d. Initiate oxygenation therapy to increase saturation to 92%.ANS: D