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NUR 211 NUR211 - Final Exam_ Q&A/NUR 211 - Final Exam_ Q&A Questions And Correct Answers, Exams of Nursing

Excelsior CollegeNursing

NUR 211 NUR211 - Final Exam_ Q&A/NUR 211 - Final Exam_ Q&A Questions And Correct Answers (Verified Answers) Plus Rationales Excelsior College

Typology: Exams

2024/2025

Available from 06/28/2025

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NUR 211 NUR211 - Final Exam_
Q&A/NUR 211 - Final Exam_ Q&A
Questions And Correct Answers (Verified
Answers) Plus Rationales Excelsior College
1. What is the primary purpose of performing a nursing assessment?
To gather comprehensive data about the patient’s health status
This is the foundation of the nursing process and guides care planning.
2. Which intervention is the most appropriate when a patient is experiencing
shortness of breath?
Elevate the head of the bed
This position helps improve lung expansion and oxygenation.
3. When auscultating bowel sounds, which finding requires immediate
attention?
Absent bowel sounds for more than 5 minutes
This may indicate bowel obstruction or paralytic ileus.
4. What is the best method to prevent the spread of infection in the hospital
setting?
Hand hygiene
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Download NUR 211 NUR211 - Final Exam_ Q&A/NUR 211 - Final Exam_ Q&A Questions And Correct Answers and more Exams Nursing in PDF only on Docsity!

NUR 211 NUR211 - Final Exam_

Q&A/NUR 211 - Final Exam_ Q&A

Questions And Correct Answers (Verified

Answers) Plus Rationales Excelsior College

  1. What is the primary purpose of performing a nursing assessment? To gather comprehensive data about the patient’s health status This is the foundation of the nursing process and guides care planning.
  2. Which intervention is the most appropriate when a patient is experiencing shortness of breath? Elevate the head of the bed This position helps improve lung expansion and oxygenation.
  3. When auscultating bowel sounds, which finding requires immediate attention? Absent bowel sounds for more than 5 minutes This may indicate bowel obstruction or paralytic ileus.
  4. What is the best method to prevent the spread of infection in the hospital setting? Hand hygiene

Handwashing is the single most effective way to reduce infection transmission.

  1. Which vital sign change is an early indicator of hypovolemia? Increased heart rate Tachycardia compensates for decreased blood volume.
  2. What does a Glasgow Coma Scale score of 8 indicate? Severe brain injury Scores less than 8 reflect severe impairment of consciousness.
  3. What is the most important nursing action when administering a blood transfusion? Monitor for signs of transfusion reaction Early detection can prevent serious complications.
  4. Which laboratory value is the best indicator of kidney function? Serum creatinine Creatinine levels reflect glomerular filtration rate more accurately.
  5. What is the normal range for adult respiratory rate? 12 - 20 breaths per minute This range reflects normal adult ventilation at rest.
  6. What is the priority nursing diagnosis for a patient with impaired gas exchange? Ineffective airway clearance This directly affects oxygen and carbon dioxide exchange.
  1. What does a positive Babinski reflex in an adult indicate? Neurological damage This reflex is normal in infants but abnormal in adults.
  2. How do you calculate intake and output (I&O)? Subtract total output from total intake This helps evaluate fluid balance.
  3. What is the expected finding in a patient with left-sided heart failure? Pulmonary congestion Left-sided failure causes blood to back up into the lungs.
  4. When performing wound care, what is the most important infection prevention measure? Use sterile technique Sterile technique reduces risk of introducing pathogens.
  5. What does the presence of crackles in lung auscultation suggest? Fluid in the alveoli Common in conditions like pneumonia or heart failure.
  6. Which electrolyte imbalance is characterized by muscle weakness and irregular pulse? Hyperkalemia Excess potassium disrupts muscle and cardiac function.
  7. What is the appropriate action if a patient is having a seizure? Protect the patient from injury

Prevent trauma without restraining or putting objects in the mouth.

  1. How is pain intensity most accurately assessed? Using a standardized pain scale Self-report is the most reliable measure of pain.
  2. Which intervention promotes venous return in a postoperative patient? Leg elevation and compression stockings These measures reduce venous stasis and risk of clots.
  3. What is the normal range for adult blood pressure? 120/80 mmHg Represents average healthy adult BP.
  4. Which symptom is a classic sign of hypoxia? Cyanosis Bluish discoloration indicates inadequate oxygenation.
  5. How often should blood glucose be monitored in a patient with newly diagnosed diabetes? Before meals and at bedtime Helps maintain glycemic control throughout the day.
  6. What is the main goal of patient education? Promote self-care and independence Empowers patients to manage their health.
  7. Which finding in a post-operative patient suggests deep vein thrombosis (DVT)?

Increased urine output Diuretics promote fluid elimination.

  1. Which condition requires monitoring for potassium loss? Use of loop diuretics Loop diuretics cause potassium excretion.
  2. What does the presence of edema indicate? Fluid retention in interstitial spaces Common in heart failure, kidney disease.
  3. What is the priority nursing action for a patient with a suspected stroke? Activate emergency response system Rapid treatment is essential to minimize brain damage.
  4. How do you assess for orthostatic hypotension? Measure blood pressure lying, sitting, and standing Changes in BP with position indicate orthostatic hypotension.
  5. What is a common side effect of opioid analgesics? Constipation Opioids slow gastrointestinal motility.
  6. Which symptom is most indicative of infection at a surgical site? Redness and warmth around incision Classic signs of inflammation and infection.
  7. What is the appropriate action for a patient experiencing hypothermia?

Provide warm blankets and monitor vital signs Prevent further heat loss and assess for complications.

  1. What is the normal pH range of arterial blood? 7.35-7. Maintaining this range is vital for enzymatic and cellular function.
  2. How should the nurse handle a patient’s cultural beliefs that conflict with medical treatment? Respect beliefs and seek culturally appropriate alternatives Patient-centered care includes respecting cultural values.
  3. What is the recommended action if a patient refuses medication? Assess reasons and provide education Understanding concerns can improve adherence.
  4. How is oxygen saturation measured non-invasively? Pulse oximetry Provides continuous monitoring of blood oxygen levels.
  5. What is the most important factor in wound healing? Adequate nutrition Protein and vitamins are essential for tissue repair.
  6. What is the best position to promote drainage from a patient’s chest tube? Keep the drainage system below chest level Prevents backflow of fluid and air into the pleural space.
  1. What is the significance of a positive blood culture? Presence of bacteria in the bloodstream Indicates systemic infection requiring prompt treatment.
  2. What does the term “tachypnea” mean? Increased respiratory rate A compensatory response to hypoxia or acidosis.
  3. What is the first step when a patient’s intravenous site shows redness and swelling? Stop the IV infusion Signs of phlebitis require removal to prevent complications.
  4. Which action is appropriate when a patient is scheduled for surgery and expresses anxiety? Provide information and support Education and reassurance help reduce anxiety.
  5. What is the effect of elevated blood glucose on wound healing? Delays healing process Hyperglycemia impairs immune function and tissue repair.
  6. What is the safest technique for transferring a patient from bed to chair? Use a gait belt and assist as needed Ensures patient safety and prevents falls.
  7. Which symptom is characteristic of fluid overload? Bounding pulse

Increased blood volume causes strong, forceful pulses.

  1. What does a flat neck vein indicate in a patient lying at 45 degrees? Hypovolemia Low circulating volume causes veins to collapse.
  2. Which clinical finding is most concerning in a patient with pneumonia? Confusion or altered mental status May indicate hypoxia or sepsis requiring urgent attention.
  3. What is the most common cause of hospital-acquired urinary tract infections? Indwelling urinary catheter Catheters provide a direct route for bacteria into the bladder.
  4. When teaching deep breathing and coughing exercises, when should the nurse instruct the patient to perform them? Every 2 hours Prevents atelectasis and promotes airway clearance.
  5. Which electrolyte imbalance is associated with muscle cramps and cardiac arrhythmias? Hypokalemia Low potassium disrupts muscle and heart function.
  6. What is the first action when a patient reports sudden onset of severe headache and blurred vision? Notify the healthcare provider immediately
  1. Which assessment finding indicates dehydration? Dry mucous membranes Common sign of fluid volume deficit.
  2. What is the effect of immobility on the cardiovascular system? Increased risk of thrombus formation Venous stasis and decreased cardiac output promote clots.
  3. How should the nurse respond if a patient refuses to participate in care? Explore reasons and respect patient autonomy Understanding concerns promotes trust and collaboration.
  4. Which food is highest in potassium? Bananas Bananas are a rich source of potassium.
  5. What does a positive Homan’s sign indicate? Possible deep vein thrombosis Pain in calf with dorsiflexion suggests DVT.
  6. What is the normal oxygen saturation level in a healthy adult? 95 - 100% Reflects adequate oxygenation.
  7. What is the most important intervention to prevent falls in hospitalized elderly patients? Use bed alarms and keep environment clutter-free Alerts staff and removes hazards.
  1. What is the primary symptom of hypocalcemia? Muscle twitching and spasms Low calcium increases neuromuscular excitability.
  2. What is the first nursing action if a patient experiences airway obstruction? Perform the Heimlich maneuver Clears the airway to restore breathing.
  3. What is the best way to confirm correct placement of a nasogastric tube? Check pH of aspirate and confirm with X-ray Ensures safe feeding and prevents aspiration.
  4. Which intervention reduces the risk of developing pneumonia in bedridden patients? Frequent repositioning and incentive spirometry Prevents atelectasis and improves lung expansion.
  5. What is the significance of Kussmaul respirations? Compensatory deep and rapid breathing in metabolic acidosis Body attempts to blow off excess CO2.
  6. What is the appropriate nursing intervention for a patient with constipation? Increase fiber and fluid intake Promotes bowel motility and softens stool.
  7. Which symptom is an early sign of hypoxia in infants? Restlessness

Wheezing and hypotension Severe allergic reaction causing airway constriction and low BP.

  1. How can nurses help reduce healthcare-associated infections? Follow standard precautions consistently Prevents spread of pathogens in all patient care.
  2. What is the normal urine output for an adult per hour? 30 - 50 mL Indicates adequate kidney perfusion.
  3. What is the best method to promote sleep in hospitalized patients? Establish a quiet, dark environment and consistent routine Supports natural circadian rhythms and relaxation.