NUR 211 Final Assessment

Question 1

A nurse is caring for a client who has sickle cell anemia. The client asks, “Why do I feel so tired and fatigued all of the time?” Which of the following information should the nurse provide?

• “You have fewer red blood cells.”
• “You have a low ferritin level.”
• “You have an autoimmune disease.”
• “You have had a gastrointestinal bleed.”

Question 2

The nurse is caring for a client who is post-thoracentesis. Which 3 findings require immediate follow-up?

• Decreased breath sounds
• Decreased lung sounds
• Heart rate 110/min and regular
• Subcutaneous emphysema
• Blood pressure 128/84 mm Hg
• Productive cough

Question 3

The nurse is caring for a client with a suspected cardiac tamponade. Which diagnostic test should the nurse anticipate the provider to order first?

• Echocardiogram
• Chest X-ray
• Electrocardiogram
• Cardiac catheterization

Question 4

A nurse is providing teaching to the partner of a client who is being discharged with a new tracheostomy. Which of the following actions by the partner indicates a readiness for the client’s discharge?

• Stating they are ready to take the client home
• Performing the procedure independently
• Asking questions about the procedure
• Observing the nurse perform the procedure

Question 5

A nurse is assessing a client who has a deep vein thrombosis (DVT) in the right lower leg. Which of the following manifestations should the nurse expect? (Select All that Apply.)

• Warmth
• Erythema
• Swelling
• Cyanosis
• Absence of pulse

Question 6

A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following is an appropriate nursing action?

• Withhold food and liquids until the client’s gag reflex returns.
• Encourage the client to cough and deep breathe every 4 hours.
• Keep the client in a supine position for 2 hours.
• Monitor for bright red hemoptysis.

Question 7

A nurse is teaching a group of newly licensed nurses about acute respiratory distress syndrome (ARDS). The nurse should identify that which of the following is the most common cause of ARDS?

• Sepsis
• Pneumonia
• Aspiration
• Near-drowning

Question 8

A nurse is caring for a client who has a suspected pulmonary embolism (PE). Which of the following diagnostic tests should the nurse expect? (Select All that Apply.)

• D-dimer blood test
• CT scan
• Lung ventilation and perfusion scan (VQ scan)
• Chest X-ray
• Arterial blood gases

Question 9

A nurse is prioritizing care for four clients. Which of the following clients should the nurse assess first? NUR 211 Final Assessment

• Reports pain as 5 on a scale of 0 to 10
• Scheduled for a routine procedure in 1 hour
• Requesting assistance with a bath
• Needing a dressing change

Question 10

The nurse is reviewing the assessment of a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? NUR 211 Final Assessment

• Increased heart rate
• Decreased blood pressure
• Increased respiratory rate
• Decreased oxygen saturation

Question 11

A client is admitted with a 2-day history of headache, muscle aches, fever, and sore throat. Diagnostic results show the client is positive for influenza B. Which of the following actions should the nurse take? (Select all that apply.)

• Place the client in a private room.
• Wear a mask when caring for the client.
• Encourage the client to increase fluid intake.
• Initiate airborne precautions.
• Administer antibiotics.

Question 12

A nurse is developing a plan of care for a community health fair regarding prostate screening. Which of the following information should the nurse include? NUR 211 Final Assessment

• Prostate cancer mortality is more than double for Black American males than for men in every other group.
• All men should begin annual screening at age 40.
• A PSA level of 2 ng/mL is considered elevated.
• Digital rectal exams are the only necessary screening tool.

Question 13

A nurse is assessing a client who has a chest tube in place following a pneumothorax. Which of the following findings is an indication of a tension pneumothorax?

• Movement of the trachea toward the unaffected side
• Constant bubbling in the water seal chamber
• Sudden decrease in drainage amount
• Presence of tidal movement in the tubing

Question 14

A nurse is caring for a client who is postoperative following a lobectomy. Which of the following assessments should the nurse give highest priority to?

• Arterial blood gases
• Urinary output
• Pain level
• Surgical dressing

Question 15

A client who is being treated for a life-threatening condition tells the nurse they want to leave the facility against medical advice (AMA). Which of the following actions should the nurse take?

• Explain the risk the client faces if she leaves the facility.
• Restrain the client to prevent them from leaving.
• Call security to block the exit.
• Refuse to provide the client with their personal belongings.

Question 16

A nurse is providing teaching for a client who is newly diagnosed with pulmonary tuberculosis (TB). Which of the following information should the nurse include in the teaching?

• A typical course of treatment involves 6 to 9 months of consistent medication use.
• The client will need to be in isolation for the duration of treatment.
• The medication can be stopped once symptoms resolve.
• TB is transmitted through contaminated surfaces.

Question 17

A nurse is teaching a client who has peripheral arterial disease (PAD) about a walking program. Which of the following instructions should the nurse include?

• Walk until the point of pain, stop and rest, and then resume walking once the pain has subsided.
• Walk only on flat surfaces to avoid strain.
• Stop walking as soon as any discomfort is felt and do not resume.
• Wear heavy boots to provide support during the walk.

Question 18

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

• Notify the x-ray department that the client requires airborne precautions.
• Have the client wear a mask.
• Ask the x-ray technician to come to the client’s room to obtain a portable x-ray.
• Wear a filtration mask and gloves during transport.

Question 19

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

• Differences between oral and axillary temperatures.
• Different blood pressures in the upper limbs.
• Different apical and radial pulses.
• Differences in upper and lower lung sounds.

Question 20

A nurse is providing discharge teaching for a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching? NUR 211 Final Assessment

• Use an electric razor while on this medication.
• Increase fiber intake to reduce the adverse effect of constipation.
• If a dose of the medication is missed, double the dose at the next scheduled time.
• Mild nosebleeds are common during initial treatment.

Question 21

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

• Disconnect the chest tube from the drainage system during transport.
• Keep the drainage system below the level of the client’s chest at all times.
• Empty the collection chamber prior to transport.
• Clamp the chest tube prior to transferring the client to a wheelchair.

Question 22

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

• Encourage the client to ambulate frequently.
• Encourage coughing and deep breathing.
• Encourage the client to increase fluid intake.
• Encourage regular use of the incentive spirometer.

Question 23

A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider?

• WBC 2300/mm³
• RBC 5 million/mm³
• Hemoglobin 12 g/dL
• Platelets 155,000/mm³

Question 24

A nurse is providing nutritional teaching to a client who has fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend that the client include in their diet?

• 1.5 oz raisins
• 8 oz whole milk
• 8 oz black tea
• 1 cup canned black beans

Question 25

A nurse is caring for a client who has a positive Mantoux test. Which of the following diagnostic tests should the nurse expect the provider to prescribe to confirm the diagnosis of active pulmonary tuberculosis?

• Sputum culture for acid-fast bacillus
• Chest x-ray
• Sputum smear
• Repeat Mantoux test

Question 26

A nurse is evaluating the effectiveness of tracheostomy suctioning for a client. Which of the following findings should the nurse identify as an indication that the procedure was effective?

• Increased respiratory rate
• Stable oxygen saturation
• Brisk capillary refill
• Clear breath sounds

Question 27

A nurse is teaching a client who has a new diagnosis of atrial fibrillation. Which of the following statements should the nurse make to describe this condition?

• “The heart’s electrical signals are slow and steady.”
• “The heart’s electrical signals are blocked at the ventricles.”
• “The heart’s electrical signals are rapid, chaotic, and irregular.”
• “The heart’s electrical signals are originating from a single point in the atrium.”

Question 28

A nurse is assessing a client who has hyponatremia. Which of the following findings should the nurse expect?

• Seizures
• Hyporeflexia
• Hypertonicity
• Bounding peripheral pulses

Question 29

A nurse is providing discharge teaching for a client who is postoperative following a kidney transplant. Which of the following instructions should the nurse include?

• “You can stop taking your immunosuppressant medications if you feel well.”
• “Avoid crowds.”
• “Expect a fever for the first week after surgery.”
• “Check your weight once a week.”

Question 30

A nurse is caring for a client who is 24 hr postoperative following a thoracotomy and has a chest tube connected to a wet suction drainage system. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

• Check the suction control outlet on the wall.
• Check the tubing connections for leaks.
• Clamp the chest tube.
• Continue to monitor the client’s respiratory status.

Question 31

A nurse is teaching the parents of a toddler who has a new diagnosis of cystic fibrosis. Which of the following instructions should the nurse include? NUR 211 Final Assessment

• Provide a low-calorie diet.
• Keep a thermometer in the toddler’s room.
• Administer pancreatic enzymes 2 hr after meals.
• Restrict the toddler’s physical activity.

Question 32

A nurse is assessing a client who survived acute respiratory distress syndrome (ARDS). Which of the following long-term changes should the nurse expect? (Select all that apply.)

• Muscle wasting
• Cognitive loss
• Functional impairment
• Fat accumulation
• Weight gain

Question 33

A nurse is caring for a client who has hemophilia A and is scheduled for wisdom tooth extraction. Which of the following medications should the nurse anticipate the provider prescribing prior to the procedure?

• Fresh frozen plasma
• Recombinant clotting factor
• Packed red blood cells
• Prophylactic antibiotics

Question 34

A nurse is teaching a client about the most common location for breast cancer to occur. Which of the following locations should the nurse identify?

• Lower inner quadrant
• Lower outer quadrant
• Upper inner quadrant
• Upper outer quadrant

Question 35

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

• Immediate sodium and fluid retention
• Increased clotting factors
• Progressive increase in platelet production
• Excessive thrombosis and bleeding

Question 36

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

• Monitor the mouth for signs of xerostomia.
• Examine the skin for generalized urticaria.
• Observe for signs of infection.
• Review laboratory test results for low hemoglobin.

Question 37

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

• anti-inflammatory
• analgesic
• antiplatelet aggregate
• antipyretic

Question 38 (Select All that Apply)

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as possible risk factors for iron deficiency anemia?

• The client eats red meat daily.
• The client has had gastric bypass surgery.
• The client has had treatment for gastrointestinal cancer.
• The client eats mostly prepackaged, processed foods.
• The client has ulcerative colitis.

Question 39

A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?

• Fever
• Ecchymosis
• Fatigue
• Elevated WBC

Question 40

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin’s effects?

• Protamine sulfate
• Vitamin K
• Deferasirox
• Acetylcysteine

Question 41

A nurse is providing teaching to a client who has coronary artery disease. Which of the following statements should the nurse include in the teaching to explain the correlation between hypertension and coronary artery disease?

• “Hypertension causes a decrease in the workload of the left ventricle.”
• “Hypertension leads to a decrease in the amount of oxygen the heart needs.”
• “Hypertension can cause injury to the arterial walls, which leads to plaque formation.”
• “Hypertension prevents the buildup of cholesterol in the arteries.”

Question 42

A nurse is analyzing a client’s electrocardiogram (ECG) strip and identifies the following information: NUR 211 Final Assessment

• Heart rate: 92/min
• Rhythm: Irregular
• P wave: Unable to identify
• PR interval: Unable to measure
• QRS duration: 0.10 seconds

Based upon this information, the nurse should interpret the client’s rhythm as indicating which of the following?

• First-degree heart block
• Atrial fibrillation
• Supraventricular tachycardia
• Sinus bradycardia

Question 43

A nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm³. Which of the following interventions should the nurse include in the plan?

• Limit visitors to healthy adults.
• Take the client’s rectal temperature each day.
• Increase raw produce in the client’s diet.
• Instruct the client to floss his teeth daily.

Question 44

A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

• Continuous bubbling in the water-seal chamber
• Fluid-level fluctuations in the water-seal chamber
• Constant bubbling in the suction-control chamber
• Bloody drainage in the collection chamber

Question 45 (Select All that Apply)

A nurse manager is providing an in-service for a group of nurses about thromboembolism. Which of the following conditions should the nurse manager include as life-threatening?

• Deep vein thrombosis
• Myocardial infarction
• Ischemic stroke
• Hematoma
• Pulmonary embolism

Question 46

A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?

• The client has hypertension and anuria
• The client has metabolic alkalosis and warm extremities
• The client develops bradycardia and bradypnea
• The client has hypotension and is confused

Question 47

A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. The client’s most recent complete blood count (CBC) is shown: WBC 1,400/mm³, RBC 4.3 x 10¹²/L, Hgb 12.1 g/dL, Hct 36.5%, Platelets 170,000/mm³, Albumin 4.5 g/dL. It is important for the nurse to consider which of the following for the client?

• The client should receive an erythropoiesis stimulating agent.
• The client has an increased risk of infection.
• The client should receive a diet with increased protein.
• The client has an increased risk for bleeding.

Question 48

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, “I can feel the congestion in my lungs, and I certainly cough a lot, but I can’t seem to bring anything up.” Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?

• Helping the client select a low-salt diet
• Encouraging the client to drink 2 to 3 L of water daily
• Maintaining a semi-Fowler’s position as often as possible
• Administering oxygen via nasal cannula at 2 L/min

Question 49

A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

• Neutropenic
• Bleeding
• Droplet
• Contact

Question 50

A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client’s three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

• Continue to monitor the client as this is an expected finding.
• Verify that the suction regulator is on and check the tubing for leaks.
• Add more water to the suction control chamber of the drainage system.
• Milk the chest tube and dislodge any clots in the tubing that are occluding it.