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2025/2026 NURS 258 ACUTE CARE FINAL EXAM |ACTUAL Qs&As|100% VERIFIED|A+GRADE
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A nurse is observing the closed chest drainage system of a client who is 24 hours post
thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. What
action should the nurse take?
- Continue to monitor the client’s respiratory status - (slow steady bubbling in the suction control chamber is an expected finding)
A nurse is caring for a client who is 5 hours postoperative following a transurethral resection
of the prostate (TURP). The nurse notes that the patients indwelling catheter has not drained
in the past hour. What action would the nurse take first?
- Check the tubing for kinks - (Use the least restrictive intervention first)
A nurse in monitoring a client who was admitted with a severe burn injury and is receiving IV
fluid resuscitation therapy. The nurse should identify a decrease in which of the following
findings as an indication of adequate fluid replacement?
- Heart rate - (When a clients circulating fluid volume is low, the heart rate increases to maintain
adequate blood pressure. Therefore the nurse should identify a decrease in heart rate
as in indication of adequate fluid replacement.
A nurse in caring for a client who has cancer and a new prescription for odansetron tp treat
chemotherapy induced nausea. Which of the following adverse effects should the nurse
monitor?
- Headache - (This is a common adverse effect of this medication)
A nurse is caring for a client who has active pulmonary TB and is to be started on intravenous
rifampin therapy. The nurse should instruct the client that this medication can cause which of the
following adverse effects?
- Body secretions turning a red orange color - (Rifampin is used in combination with other medicines to treat TB. Rifampin will cause
the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-
brown.)
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a
fractured tibia. Which of the following is the priority action for the nurse to take?
- Perform a neurovascular assessment - (The greatest risk to the client is neurovascular injury. Therefore, the priority action is
to perform a neurovascular assessment. This consists of assessing the involved
extremity (the lower leg) at the most distal point (the foot) for circulation (color),
motion (movement), and sensation, and can be remembered by the acronym "C-M-S
check.")
A nurse is caring for a client who is 1 day postop following a subtotal thyroidectomy. The client
reports a tingling sensation in the hands, the soles of the feet and around the lips. For which of
the following should the nurse assess the client?
- Chvostek’s sign - The nurse should suspect that the client has hypocalcemia, a possible complication
following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness
and tingling in the hands, the soles of the feet, and around the lips, typically appearing
between 24 and 48 hr after surgery. To elicit Chvostek's sign, the nurse should tap the
client's face at a point just below and in front of the ear. A positive response would be
twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular
excitability due to hypocalcemia.
A nurse is caring for a client who was admitted with bleeding esophageal varices and has a
esophagogastric balloon Tamponade with sengstaken-blakeore tube to control the bleeding.
What action should the nurse take?
- Provide frequent oral and nares care - A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If the
client is alert, the nurse should encourage the client to spit saliva into a tissue or basin.
If the client is not alert, gentle suctioning of the oral cavity and nares might be required
to remove secretions.
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of
clear drainage coming from the client’s right nostril. Which of the following actions should
the nurse take first?
- Test the drainage for glucose - This is the priority nursing action. Because of the high risk of cerebral spinal fluid
(CSF) leak in clients with basal skull fractures, the nurse should realize there is a
possibility that the clear fluid coming from the client's nostril is CSF, which will test
positive for glucose.
A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several
treatments, the client reports fatigue. Which of the following actions should the nurse take?
- Check the results of the clients most recent CBC - The client might have anemia as a result of myelosuppression (bone marrow
suppression) from the chemotherapy. If so, she might require treatment for the anemia
(transfusion, medication) and the provider might have to delay further chemotherapy
until her blood counts are higher.
A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client
asks the nurse several questions about what the provider might be planning to do. Which of the
following nursingresponses should the nurse make?
- Encourage the client to write down questions to ask the provider. - The nurse does not know the answers to the client's questions, so helping the client
to prepare questions for the provider addresses the client's needs.
A nurse is teaching the partner of a client who had an acute MI about the reason blood was
drawn from the client. Which of the following statements should the nurse make regarding
cardiac enzyme studies?
- Test tests help to determine the degree of damage to the heart tissues - Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the
degree of damage to the myocardium. The enzymes most commonly measured are CPK
and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It
may take 4 hr or more after the onset of manifestations for the test to become abnormal
and up to 24 hr for the level to peak. Eventually, the levels in the blood fall back to
normal. Consequently, serial blood tests must be taken from the client to document and
evaluate enzyme levels.
A nurse is caring for a client who has returned from the surgical suite following surgery for a
fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture.
laryngeal cancer. The nurse should anticipate that the client will report that her earliest
manifestation was?
- Hoarseness - Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long
exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks
is the earliest manifestation of cancer of the larynx because the tumor impedes the
action of the vocal cords during speech. The voice may sound harsh and lower in
pitch than normal.
A nurse is instructing a client who is newly diagnosed with pulmonary TB about the use of
antitubercular medications. Which of the following information should the nurse include in
the teaching?
- A typical course of treatment involves 6 - 9 months of consistent medication use - Pulmonary TB is a contagious bacterial infection caused by Mycobacterium
tuberculosis. Active TB is usually treated with the simultaneous administration of a
combination of medications to which the organisms are susceptible. Such therapy is
continued until the disease is controlled. A 6 - to 9-month regimen consisting of two,
and often four, different medications is used. The client should not drink alcohol
during this time.
A nurse is craing for a client who is 1 day post op following a transphenoidal 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 potential complication of hypophysectomy is cerebral spinal fluid (CSF) leakage.
Fluid leakage from the nose is a sign that this complication has occurred. The first
action the nurse should takeusing the nursing process is to assess the drainage for the
presence of glucose, which would indicate that the drainage is CSF.
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative
blood loss. The client reports chills and back pain and the clients BP is 80/64. What action
should the nurse take first?
- Stop the infusion of blood - This client is experiencing an acute intravascular hemolytic transfusion reaction. The
greatest risk to this client is injury from receiving additional blood; therefore, the first
action the nurse should take is to stop the infusion of blood.
A nurse in the ED is caring for a clinet who has a sucking chest wound resulting from a
gunshot. The BPis 100/60, pulse is 118/mon and RR of 40. What is the priority for the nurse?
- Administer oxygen via nasal cannula - The client has an increased respiratory rate and heart rate, indicating that she is
having respiratory difficulty. The sucking chest wound indicates the client has a
pneumothorax and/or ahemothorax. Administering oxygen will increase the oxygen
exchange in the lungs and the oxygen available to the tissues.
A nurse is preparing a client for surgery. Prior to administering the prescribed hydroxyzine
the nurseshould explain to the clinet that which medication is for the following indications?
**- Controlling emesis
be used to control nausea and vomiting in preoperative and postoperative clients.
Diminishing anxiety is correct. Hydroxyzine is an effective antianxiety agent that
may be used to diminish anxiety in surgical clients, as well as in clients who have
moderate anxiety.
Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine
potentiates the actions of narcotic pain medications; therefore, narcotic requirements
may be significantly reduced.
- Drying secretions is correct. Hydroxyzine, an antihistamine, commonly causes
drying of the oral mucous membranes.
A nurse is assessing a client who is receiving IV vancomycin. The nurse notes flushing of the
neck and tachycardia. Which of the following actions should the nurse make?
- Decrease the infusion rate of the IV - This client is experiencing Red man syndrome, which includes a flushing of the neck,
face, upper body, arms and back along with tachycardia, hypotension and urticaria. This
can lead to an anaphylactic reaction if the IV infusion rate is not slowed down to run
greater than 1 hour.
A nurse is caring for a clinet who has a new diagnosis of urolithiasis. Which of the following
should the nurse identify as an associated risk factor?
- Family history - Family history is strongly correlated with the formation of urolithiasis. A nurse
should assess a client who has kidney stones for familial tendencies toward stone
formation.
- "Warfarin takes several days to work, so the IV heparin will be used until
the warfarin reaches a therapeutic level."
- Heparin and warfarin are both anticoagulants that decrease the clotting ability of the
blood and help prevent thrombosis formation in the blood vessels. However, these
medications work in different ways to achieve therapeutic coagulation and must be
given together until therapeutic levels of anticoagulation can be achieved by warfarin
alone, which is usually within 1 to 5 days.When the client's PT and INR are within
therapeutic range, the heparin can be discontinued.
- Check the catheter tubing for kinks or twisting. - The nurse should check the catheter for twisting or kinks in the tubing. These
obstructions can affect the flow of urine causing pooling in the tubing that could
backflow into the bladder.
- Pantoprazole 80 mg IV bolus twice daily - The nurse should anticipate a provider's prescription for a proton pump inhibitor
to decrease gastric acid production, which ultimately decrease pancreatic
secretions.
- "I will limit my alcohol intake." - A client who has gout should limit alcohol consumption, which is known to cause a
gouty attack by inhibiting excretion of uric acid and leading to its buildup. However,
clients should be encouraged to increase their fluid intake to help prevent formation
of urinary stones.
- Regular insulin - Regular insulin is classified as a short-acting insulin. It can be given intravenously
with an onset of action of less than 30 min. This is the insulin that is most appropriate
in emergency situationsof severe hyperglycemia or diabetic ketoacidosis.
- Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. - The nurse should instruct the client to avoid activities that increase intraocular
pressure. Therefore, the nurse should instruct the client to avoid lifting anything
heavier than 4.5 kg (10 lb) for 1 week following surgery.
- Hemolytic - A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react
to foreign blood cells introduced by the transfusion. The antibodies bind to the
foreign cells and destroy them in a process known as hemolysis. The destroyed cells
are excreted by the kidneys (hemoglobinuria), causing the red-tinged urine.
Hemolytic transfusion reactions can result in acute renal injury, disseminated
intravascular coagulation, and circulatory collapse.
- Alendronate - The client must take alendronate first thing in the morning on an empty stomach and
wait at least 30 minutes before eating, drinking, or taking other medications.
- Pinch the tube prior to attaching the medication syringe. - After detaching the NG tube from the suction tubing, the nurse should pinch or kink
the tube to prevent distention from air entering the tube.
- WBC 2300/mm
3
- This WBC finding is below the expected reference range. Chemotherapy treatment
can cause leukopenia; the nurse should report this finding to the provider and
implement precautions to protect the client from infection.
- "I need something for the pain in my eye. I can't stand it. - Following cataract surgery, the client should expect only mild pain and should
immediately report any pain, decrease in vision, or increase in discharge from the eye.
Severe eye pain after surgery might indicate increased intraocular pressure or
hemorrhage.
- "Monitor for muscle pain." - This medication can cause rhabdomyolysis. The client should monitor and report muscle
pain.
- Lower the height of the solution container. - If nausea or cramping occurs, the flow of water should momentarily be slowed or
stopped by lowering the device or clamping the tubing. This allows the intestinal
spasm to pass while leaving the catheter in place. The nurse should then continue
administering the enema at a slower rate once the cramping has passed.
- Offer the child a choice of taking the medication with juice or water. - While taking the medicine is not a choice, the child can decide what kind of fluid to
take with the medication. This gives the preschool-aged child a sense of control over a
stressful situation and increases the child's ability to cope.
- "I will be sure to take the albuterol before taking the cromolyn." - The client should always use the bronchodilator (albuterol) prior to using the
leukotriene modifier (cromolyn). Using the bronchodilator first allows the airways to
be opened, ensuring that the maximum dose of medication will get to the client's
lungs.
- Airway patency - When using the airway, breathing, circulation approach to client care, the nurse
determines that the priority assessment is airway patency. After head and neck
surgery, a major, life-threateningcomplication is airway obstruction. The priority
actions involve airway maintenance and gas exchange.
- During transport, the drainage system should be kept below the level of the
client's chest toprevent air and drainage fluid from re-entering the thoracic cavity.
- Remove the catheter and insert another into a different site - It is possible that the catheter is up against a valve or near a nerve and is causing more
pain than an IV catheter insertion should. The nurse should remove the source of the
pain and establish peripheral IV access elsewhere.
- Amylase - Amylase is an enzyme that changes complex sugars into simple sugars that can be used
by the body. It is produced by the pancreas and salivary glands and released into the
mouth, stomach, and intestines to aid in digestion. The amylase level of a client who has
acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3
days.
- Combing her hair - Abduction of the arm is the most difficult, and usually the last, type of movement to
be regained by a client following a mastectomy.
- Measure the circumference of both upper arms. - The first action the nurse should take using the nursing process is to assess the client.
The nurse should measure the arm and compare the result with the circumference of the
other arm. If the arm is swollen, the nurse should notify the provider who inserted the
PICC line. Swelling could indicate formation of a clot above the site or even catheter
rupture.
-
pH 7.25, HCO 3
- 19 mEq/L, PaCO 2
30 mm Hg
- The nurse should expect a client who has renal failure to have metabolic acidosis, which
is
characterized by a low HCO 3
reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO 3
to 28 mEq/L, and PaCO 2
to 45 mm Hg.
- BUN 55 mg/dL - This BUN level is above the expected reference range (10-20 mg/dL). Amphotericin
B is nephrotoxic and is contraindicated if BUN is > 40mg/dL. The nurse should
report this laboratory value to the provider before initiating the medication.
said but is unable to communicate verbally. However, this does not necessarily mean
that a client is unable to reliably report pain. Evidence-based practice indicates the
nurse should first attempt to obtain the client’s self- report of pain. When assessing a
client for pain, the nurse should utilize the hierarchy of pain measures which begins with
self-report. It is always better to use a subjective method,
such as a client report, instead of an objective method, such as something that is
observable by the nurse, which is much less reliable.
- "I will make a list of my favorite beverages." - The nurse should work with the client to develop a schedule for fluid restrictions,
and should attempt to include the client’s favorite beverages when possible to
promote satisfaction.
- Yellow-green drainage on the surgical incision - Thick yellow-green drainage is indicative of an infection and should be reported
immediately.
- Administer an antiemetic prior to the procedure. - The nurse can help prevent nausea and vomiting by administering an antiemetic
prior to chemotherapy, and to tell the client to continue taking medication until
nausea and vomiting resolve.
-
The fourth heart sound (S 4
-
is an extra sound that is heard late in diastole just before S 1
. It occurs due to
resistance to blood flow in an enlarged ventricle.
- Recombinant - The underlying problem of hemophilia is a deficiency of clotting factors. Therefore,
clients who have hemophilia are given recombinant to replace the deficient factor as a
prophylactic measure before an invasive procedure, surgery, or when actively bleeding.
- Montgomery straps - Montgomery straps are adhesive strips that are applied to the skin on either side of the
surgical wound. The strips have holes so the two sides of the dressing can be tied
together and re-opened for dressing changes without having to remove the adhesive
strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid
dressing on either side of the wound and place the tape across the dressing onto the
hydrocolloid strips.
- Suppress respiratory effort - Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress
the client's respiratory efforts to the point of apnea, allowing the mechanical ventilator
to take over the work of breathing for the client. This therapy is especially helpful for a
client who has ARDS and poor lung compliance
- "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the
scanner."
- The nurse should instruct the client that many clients report being disconcerted
by the loud thumping and humming noises produced by the scanner, and for that
reason, earplugs are offered to reduce the discomfort.
- Basal cell carcinoma - A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent,
pearly borders.Telangiectatic vessels can also be present. As a basal cell tumor grows,
it can undergo central ulceration.
- Hypotension - Verapamil, a calcium channel blocker, can be used to control supraventricular
tachyarrhythmias. It also decreases blood pressure and acts as a coronary vasodilator
and antianginal agent. A major adverse effect of verapamil is hypotension; therefore,
blood pressure and pulse must be monitored before and during parenteral
administration.
- Abnormally prominent U wave - Although U waves are rare, their presence can be associated with hypokalemia,
hypertension and heart disease. For a client who has hypokalemia, the nurse should
monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U
wave, or ST depression.
- Apply ice to the affected area. - Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems
inside a joint. Applying ice to the affected area in the immediate postoperative period
(first 24 hr) reduces pain and swelling.
- To prevent fluid from accumulating in the wound - The purpose of a JP drain is to promote healing by draining fluid from a wound.
This prevents pooling of blood and fluid, which can contribute to discomfort, delay
healing, and provide a
medium for infection. The JP drainage tube is threaded through the skin into the wound
near the surgical incision and is held in place by sutures.
- Suction two to three times with a 60 - second pause between passes. - Copious secretions may require several passes of the suction catheter. An interval of 60
seconds should be allowed between passes to prevent hypoxia.
- Atelectasis - Atelectasis is the collapse of part or all of a lung by blockage of the air passages
(bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes
in position, ineffective coughing, and underlying lung disease are risk factors for the
development of atelectasis.
- Asthma - Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it
can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which
prevents smooth muscle relaxation.
- Decreased serum calcium level - A decreased serum calcium level is an expected finding for FES, although the
reason for this finding is unknown.
- "Large incisions will be made in the eschar to improve circulation." - An escharotomy is a surgical incision made to release pressure and improve circulation
in a part of the body that has a deep burn and is experiencing excessive swelling. Burn
injuries that encircle a body part, such as an arm or the chest, can cause swelling and
tightness in the affected area, resulting in reduced circulation. Making surgical
incisions into the burned tissue allows the skin to expand, reduces tightness and
pressure, and improves circulation.
- " You should report any tendon discomfort you experience while taking this
medication."
- The nurse should instruct the client to report any tendon discomfort as well as
swelling or inflammation of the tendons due to the risk of tendon rupture.
- Cheyne-Stokes respirations - Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the
point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of
respiration. CSR are common respiratory alterations seen in clients who are
unconscious, comatose, or moribund (approaching death).
- The client who has a nasogastric (NG) tube to suction - Hypokalemia is a low serum potassium value. An NG tube is used to decompress the
stomach. When attached to suction, an NG tube will remove gastric contents, which are
high in electrolytes, especially potassium, and this loss places the client at risk for
hypokalemia.
- It facilitates the client's deep breathing. - When using the airway, breathing, circulation approach to client care, the nurse should
identify facilitation of deep breathing as the most important desired effect of opioids
aside from pain relief. Following thoracic type surgeries, the client’s has increased pain
with moving, deep breathing and coughing. Opioid medications help minimize the
discomfort experienced with deep breathing and coughing which prevents the
development of postoperative pneumonia. The nurse should also encourage the client to
splint his incision to help minimize pain.
- Stop the infusion. - When using the airway, breathing, circulation approach to client care, the nurse should
place the priority on stopping the infusion. The client is exhibiting signs of penicillin
anaphylaxis and the first action that should be taken is to withdraw the medication.