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NUR 213 NUR213 - FINAL EXAM _Q&A/NUR 213 - FINAL EXAM
2 _Q& QUESTIONS AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2025 Excelsior College
- What is the primary purpose of the nursing process? Assessment, diagnosis, planning, implementation, and evaluation of patient care The nursing process provides a systematic framework for delivering individualized patient care.
- Which vital sign change is most concerning in a postoperative patient? Increased respiratory rate and decreased oxygen saturation These changes may indicate respiratory compromise or hypoxia requiring immediate attention.
- What is the best method to prevent hospital-acquired infections? Proper hand hygiene Hand hygiene is the most effective way to prevent transmission of pathogens in healthcare settings.
- Which patient is at highest risk for developing pressure ulcers? An immobile elderly patient with diabetes Immobility and poor circulation increase the risk for skin breakdown and pressure ulcers.
- What is the normal range for adult blood pressure? 120/80 mmHg This range is considered normal for healthy adults without hypertension.
- Which lab result indicates dehydration? Increased hematocrit Dehydration causes hemoconcentration, resulting in elevated hematocrit levels.
- What is the priority nursing intervention for a patient experiencing chest pain? Administer oxygen and assess vital signs immediately Oxygen helps improve tissue oxygenation; prompt assessment identifies life- threatening conditions.
- What is the best way to verify nasogastric tube placement? Check gastric pH and confirm with X-ray pH testing and radiographic confirmation ensure correct tube placement to prevent complications.
- Which electrolyte imbalance is indicated by muscle twitching and paresthesia? Hypocalcemia Low calcium levels increase neuromuscular excitability, causing twitching and numbness. 10.What should a nurse do if a patient refuses medication? Explain the benefits and document the refusal
17.What is the appropriate gauge needle size for intramuscular injections in adults? 21 - 23 gauge This size is commonly used to administer IM injections safely. 18.Which lab value indicates risk for bleeding in a patient on warfarin? INR of 4. An INR above 3 indicates increased bleeding risk and need for intervention. 19.What is the correct sequence for donning personal protective equipment (PPE)? Gown, mask, goggles, gloves This sequence prevents contamination and ensures proper PPE use. 20.What assessment finding indicates fluid overload? Jugular vein distention JVD reflects increased central venous pressure seen in fluid overload. 21.Which intervention helps reduce postoperative deep vein thrombosis risk? Encouraging early ambulation Movement promotes circulation and reduces venous stasis. 22.What is the earliest sign of hypoxia? Restlessness and anxiety The brain is sensitive to low oxygen, causing neuro changes like anxiety. 23.What is the normal urine output for an adult per hour? 30 mL/hr or more This indicates adequate kidney function and hydration status.
24.Which medication class is commonly used to treat hypertension? ACE inhibitors ACE inhibitors help relax blood vessels, lowering blood pressure. 25.What is the primary goal of diabetic foot care education? Prevent ulcers and infections through proper hygiene and footwear Diabetes increases risk of foot complications; prevention is key. 26.What is the best method to assess pain in a nonverbal patient? Use a validated pain assessment tool like the FLACC scale Behavioral scales help evaluate pain in patients unable to communicate verbally. 27.Which sign indicates worsening heart failure? Increased peripheral edema Edema reflects fluid retention and declining cardiac function. 28.How often should a patient using a PCA pump be assessed for sedation level? Every 1-2 hours Frequent monitoring prevents overdose and respiratory depression. 29.What is the appropriate response if a fire breaks out in a patient room? Remove patients, activate alarm, contain fire, extinguish if safe (RACE) Following RACE protocol ensures safety and fire control. 30.Which symptom is an early indicator of hypoglycemia? Sweating and shakiness These neurogenic symptoms appear early in low blood sugar episodes.
38.What is a common sign of hypokalemia? Muscle weakness and arrhythmias Low potassium affects muscle and cardiac function. 39.Which assessment finding indicates adequate pain control? Patient reports pain at a manageable level (usually below 4/10) Effective analgesia is indicated by tolerable pain reports. 40.How often should turning and repositioning occur to prevent pressure ulcers? Every 2 hours Frequent repositioning reduces pressure and improves circulation. 41.What is the first step in performing cardiopulmonary resuscitation (CPR)? Check for responsiveness and call for help Ensures safety and mobilizes emergency assistance. 42.What type of diet is recommended for a patient with heart failure? Low sodium diet Reducing sodium decreases fluid retention and workload on the heart. 43.Which symptom requires immediate intervention in a postoperative patient? Sudden drop in blood pressure and increased heart rate These may signal hemorrhage or shock. 44.What is the expected finding in a patient with dehydration? Dry mucous membranes and decreased skin turgor These are classic signs of fluid volume deficit.
45.What is the correct site for intramuscular injection in an adult? Ventrogluteal muscle This site is preferred for large volumes and fewer complications. 46.What should a nurse do if a patient develops a seizure? Protect the patient from injury and maintain airway patency Safety and airway protection are priorities during seizures. 47.What is the significance of decreased oxygen saturation on pulse oximetry? Indicates hypoxemia requiring oxygen therapy Low SpO2 reflects inadequate oxygenation of blood. 48.Which condition is a contraindication for administering live vaccines? Immunosuppression Live vaccines can cause disease in immunocompromised patients. 49.What is an important teaching point for patients prescribed antibiotics? Complete the full course even if symptoms improve Stopping early can cause resistance and incomplete treatment. 50.Which nursing action promotes wound healing? Maintaining a moist wound environment Moist wounds heal faster by promoting cell migration and repair. 51.What is the most important assessment before administering beta- blockers? Check the patient’s heart rate and blood pressure
58.What is the best action when a patient develops sudden chest pain and shortness of breath? Administer oxygen and notify the healthcare provider immediately These signs may indicate myocardial infarction or pulmonary embolism. 59.What is the priority nursing diagnosis for a patient with impaired gas exchange? Ineffective breathing pattern related to alveolar-capillary membrane changes Altered gas exchange results from lung pathology affecting breathing efficiency. 60.How is fluid volume overload typically treated? With diuretics and fluid restriction Diuretics promote fluid excretion; fluid restriction prevents further overload. 61.What is the purpose of a chest tube? To remove air, fluid, or blood from the pleural space Chest tubes restore negative pressure and allow lung re-expansion. 62.Which finding requires immediate intervention in a patient with a tracheostomy? Sudden respiratory distress and decreased oxygen saturation This may indicate tube obstruction or dislodgment requiring urgent action. 63.What is the priority nursing action when a patient complains of numbness and tingling after a cast application? Assess for signs of compartment syndrome and notify the physician
Nerve compression and impaired circulation can lead to serious complications. 64.Which electrolyte imbalance is common with diuretic use? Hypokalemia Many diuretics increase potassium excretion, leading to low levels. 65.What is the normal range for blood glucose in a fasting adult? 70 - 100 mg/dL This range is considered normal fasting blood sugar. 66.What is the best way to prevent falls in hospitalized elderly patients? Ensure adequate lighting and remove environmental hazards Reducing obstacles and improving visibility lowers fall risk. 67.What is the primary concern with hyperkalemia? Risk of cardiac arrhythmias Elevated potassium disrupts cardiac electrical activity causing dangerous arrhythmias. 68.How should insulin be stored? In the refrigerator but not frozen Proper storage maintains insulin potency. 69.What symptom is common in right-sided heart failure? Peripheral edema and jugular vein distention Right ventricular failure causes systemic venous congestion. 70.What is the priority nursing intervention for a patient with a seizure disorder?
77.Which medication is contraindicated in patients with asthma? Beta blockers Beta blockers may cause bronchospasm and worsen asthma symptoms. 78.What is the normal hemoglobin range for adult females? 12 - 16 g/dL This range represents adequate oxygen-carrying capacity. 79.What is the best method for assessing peripheral pulses? Palpate bilaterally and compare strength and symmetry Comparison detects circulation deficits or arterial occlusion. 80.How often should a sterile dressing be changed on a surgical wound? As ordered by the healthcare provider or when soiled Frequent changes prevent infection but unnecessary changes may delay healing. 81.What is the rationale for elevating an edematous limb? To promote venous return and reduce swelling Elevation decreases hydrostatic pressure and fluid accumulation. 82.What is the appropriate action if a patient reports sudden dizziness when standing? Assist the patient to sit or lie down and monitor vital signs Preventing falls and assessing for orthostatic hypotension is critical. 83.Which nutrient is essential for wound healing? Protein Protein is necessary for tissue repair and immune function.
84.What is a priority nursing action for a patient with hypovolemic shock? Administer intravenous fluids rapidly Fluid replacement restores circulating volume and tissue perfusion. 85.Which vital sign changes indicate pain? Increased heart rate and blood pressure Pain activates the sympathetic nervous system causing these changes. 86.What is the primary purpose of chest physiotherapy? To mobilize and clear pulmonary secretions Techniques like percussion and postural drainage help clear mucus. 87.What should the nurse do if a patient has an IV infiltration? Stop the infusion and elevate the affected limb Stopping fluid prevents further tissue damage; elevation reduces swelling. 88.What is the correct order of abdominal assessment? Inspection, auscultation, percussion, palpation Auscultation before palpation prevents altering bowel sounds. 89.Which patient is most at risk for hypothermia? An elderly patient with poor circulation Aging and circulatory problems reduce heat production and retention. 90.What is the significance of a decreased platelet count? Increased risk of bleeding Platelets are essential for clotting; low levels increase hemorrhage risk.
98.How often should oral care be performed for an unconscious patient? Every 2 hours Regular care prevents infection and maintains mucous membrane integrity. 99.Which symptom indicates increased intracranial pressure? Decreased level of consciousness and pupillary changes Rising pressure affects brain function and cranial nerves.
- What is the correct method to measure blood pressure? Place the cuff snugly on the upper arm at heart level and use appropriate cuff size Proper technique ensures accurate readings.
