NUR 305 Exam Review Questions
A nurse is developing a plan of care for a client who is 12hr postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?
Splint the incision to support coughing every 1-2 hr
A nurse is assessing a client who is 48hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision
A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching?
You may experience a small amount of bleeding around the stoma
The nurse is caring for a client with increasing intracranial pressure following a stroke. Which evidence based nursing action are indicated for this client?
- Hyperoxygenate before and after suctioning - Avoid sudden or extreme hip or neck flexion - Provide oxygen to maintain an SaO2 of 95% or greater - Maintain HOB elevated at 30 degrees
A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse would prompt immediate action to prevent acute kidney injury?
- Urine output of 100mL in 4 hours - Amber, odorless urine - BP of 90/60
Ultrasonography is most reliable for diagnosis of kidney transplant rejection
22:59
What is the nurse's best first action when a client who had a craniotomy develops periorbital edema and ecchymosis?
Apply cold compresses
Why does the health care provider prescribe a ventilator setting to maintain PaCO2 between 35-38mmHg for a client with increased ICP?
Carbon dioxide is a vasodilator that can cause increased ICP
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?
Check the drainage for glucose
A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take?
Cover the wound with a sterile saline-soaked dressing
A patient is being discharged home after a large myocardial infarction and subsequent CABG surgery. The patient's sternal wound has not yet healed. What statement by the patient most indicates a higher risk of developing sepsis after discharge?
D 24:24
The nurse is caring for a post intracranial surgery client hemorrhagic stroke. Which assessment finding is the earliest sign of increasing ICP for this client?
Decreased level of consciousness
A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2500ml in the past 6hrs. Which of the following electrolyte imbalances should the nurse monitor the client for?
Decreased potassium level
What should the nurse suspect when hourly assessment of urine output on a client post-craniotomy exhibits a urine output from a catheter of 1500ml for two consecutive hours?
Diabetes insipidus
A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?
Document that the stoma appears healthy and well perfused
A client has recently been admitted to the orthopedic unit following total hip arthroplasty. The client has a closed suction device in place and the nurse has determined that there were 320ml of output in the first 24 hours. How should the nurse best respond to this assessment finding?
Document this as an expected assessment finding
A nurse is caring for a client who has increased ICP. Which of the following interventions should the nurse take?
Elevate the HOB 30 degrees
A nurse is developing a teaching plan for a client who had an ileostomy and will require stoma care. Which of the following information should the nurse include?
Empty the pouch when it is 1/3-1/2 full
A client is schedule for the creation of a continent ileostomy. What dietary guidelines should the nurse encourage during the weeks following surgery?
High intake of strained fruits and vegetables
A client was brought to the ED after a fall. The client is taken to the OR to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize?
Make sure you don't bring your knees close together
A client who underwent a gastric resection 3 weeks ago is having her diet progressing on a daily basis. Following her latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action?
Monitor the client closely for further signs of dumping syndrome
A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?
Oliguria 23:03
A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?
Paralytic ileus
The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's MAP is 60mmHg with an ICP of 20mmHg. What is the nurse's most appropriate action?
Participate in interventions to increase cerebral perfusion pressure (CPP=MAP-ICP)
A nurse in a one-day surgery center is providing discharge teaching for a client who is postoperative TKA. Which of the following instructions should the nurse include?
Perform setting, ankle, and calf-pumping exercises
A nurse is preparing to administer an osmotic diuretic IV to a client with increased ICP. Which of the following should the nurse identify as the purpose of the medication?
Reduce edema of the brain
A nurse cares for a patient who had an ileostomy 2 weeks ago. The patient states "the stool in my pouch is still liquid." How would the nurse respond?
The stool will always be liquid with ileostomy
A nurse is teaching a client who is preoperative for a colectomy. The client asks the nurse why he needs a large bore NG tube. Which of the following statements should the nurse make?
The tube will remove gas and fluid from your stomach
What is the nurse's best interpretation when a post intracranial surgery client develops severe hypertension with widened pulse pressure and bradycardia?
This is a late sign of increased ICP and death is imminent (Cushing's triad)
Following CABG surgery, a client's body temperature is below 96.8F. What measures should the nurse take to rewarm the client?
Use lights and thermal blankets to slowly warm the client
A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?
Pasta
A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hrs. The client also reports worsening nausea. What is the nurse's priority action?
Report signs and symptoms of obstruction to the care provider
What does the nurse expect nephrology health care provider to prescribe when a post kidney transplant client develops oliguria, elevated temperature of 100F, increased BP, and signs of fluid retention 9 days after the surgery?
21:09
A client on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurse's most recent assessments indicate that the client is producing copious quantities of dilute urine. What is the nurse's most appropriate response?
21:57
A client who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. What aspect of health education should the nurse prioritize in anticipation of discharge?
23:12
A cardiac surgery client's new onset of s/s is suggestive of cardiac tamponade. As a member of the interdisciplinary team, what is the nurse's most appropriate action?
25:22
How would the critical care nurse assess for postoperative bleeding in a client who just had CABG surgery?
26:18F
A nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24hr output totals indicates oliguria?
380ml
After teaching a patient who is recovering from a colon resection, the nurse assesses the patient's understanding. Which statements by the patient indicate a correct understanding of the teaching?
-I will use warm water and a soft washcloth to clean around the stoma - I should size the skin barrier appropriately to hug the stoma and not to expose peristomal skin
Which action does the nurse use to prevent harm by further increasing ICP when an intubated post intracranial surgery client needs to be suctioned?
13:56
What is the nurse's best action when caring for a client after craniotomy and finding the dressing is saturated and the Hemovac drainage is 100ml over 8hrs?
15:37
The nurse is caring for a client who is postoperative following a craniotomy. WHen writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What is the nurse's most appropriate intervention for this diagnosis?
16:55
A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
18:36
Why will the nurse immediately notify the nephrology health care provider if a client develops hypotension and diuresis postoperatively after a kidney transplant?
20:07
The nurse is caring for a client postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize?
Assessment of the quantity of the client's urine output 22:14
A patient is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result would the nurse report to the surgeon immediately?
INR 4.2
