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Nur 245 Finale - Nursing Concepts of Nursing Care of the Adult II (Hondros College of Nu, Exams of Nursing

Massachusetts College of Pharmacy and Health SciencesNursing

Nur 245 Finale - Nursing Concepts of Nursing Care of the Adult II (Hondros College of Nursing)

Typology: Exams

2023/2024

Available from 02/19/2025

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Nur 245 Finale - Nursing
Concepts of Nursing Care of the Adult II
(Hondros College of Nursing)
1. A client attending a free screening for coronary artery disease reports taking Simvastatin daily for
the last yr. the low-density lipoprotein is 170 mg. What instruction should be important for the
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Nur 245 Finale - Nursing

Concepts of Nursing Care of the Adult II

(Hondros College of Nursing)

  1. A client attending a free screening for coronary artery disease reports taking Simvastatin daily for the last yr. the low-density lipoprotein is 170 mg. What instruction should be important for the

nurse to include? a. Encourage 60 mins of exercise daily b. Continue current plan of regular diet and exercise c. Discuss finding with your healthcare provider d. Drink 8 oz of milk daily

  1. An elderly male client is diagnosed with slabio, chronic angina and prescribed nitroglycerin sublingual, which question would be most important for the nurse to ask the client. a. Do you have daily bowel movement? b. Do you get yearly chest x rays? c. Are you sexually active? d. Have you had any weight changes recently?
  2. A nurse is administering meds to a client on telemetry unit. which medication would the nurse question? a. Furosemide IV push to a pt with potassium level 3.6? b. Digoxin orally to a pt with rapid atrial fibrillation? c. Enalapril orally to a pt with a BP of 88/64, HR 65? d. Morphine IV push to a pt c/o chest pain and is diaphoretic?
  3. A nurse understand which complication occurs during the fibrotic stage of acute resp distress synd? a. Fibrosis tissue forms a scarring, decreased lung complication, increased work of breathing? b. Fluids shift into the alveoli, bronchi collapse and further decreased in lung compliance? c. Intrapulmonary shunting develops because alveoli fill with fluid and blood? d. The lung attempts to repair itself so the patient will get worse or continue to decline
  4. The nurse has received shift report, which pt should be seen first? a. The pt diag with a myocardial infarction c/o severe ingestion? b. The pt diag with CHF that has 3+ pitting edema? c. The pt diag with atrila fibrillation who’s apical pulse is 100 and irregular? d. The pt diag with sinus bradycardia who is c/o constipation?
  5. A pt who is in hypovolemic shock has the following clinical signs, HR 120, BP 80/50, urine output 20ml/hr. after administrating IV fluid bolus, which sign noticed by a nurse is the best indication of improved perfusion? a. Right aterial pressure? b. Systolic BP increases to 85 mm/hg c. HR drops to 100 bpm d. output increase to 100ml/hr
  6. A client with a diag with gastrointestinal bleeding. Which of the would suggest the client is in compensatory stage of shock? a. Change in LOC b. Decreased HR c. Hyperactive bowel sounds d. Increased urine output

d. UTI

  1. A pt with a cerebral aneurysm exhibits signs of ICP, what nursing intervention could be most appropriate for this pt. a. Bed rest in a quiet non stimulating environment b. Encourage independence with ADL’s to promote recovery c. Early initiation of physical therapy d. Range of motion exercises to prevent contractors
  2. A burn pt is admitted to the ED, the nurse assessment includes dry mucous membranes, weak thready pedal pulses, blood BP 88/42, resp rate 28, and pulse 110. What is the priority action for the nurse? a. Obtain a chest xray b. Draw a CBC and BMP c. Insert 2 large bore IV’s d. Apply ice to groin and axillae
  3. The nurse is caring for a pt with increase ICP, what intervention cold the nurse plan? SATA a. Place pt in supine position b. Use stool softeners c. Early enteral feeding d. Provide care over a long period of time e. Suction pt frequently
  4. A health care provider orders for a pt who was admitted with acute subdermal chest pain, which actions are appropriate to adding to an experienced LPN? SATA a. Attach cardiac monitor leads b. Give Heparin 5000 units IV push c. Obtain a 12 lead ekg d. Asking the pt about pertinent medical hx e. Having the pt chew and swallow aspirin 325mg
  5. A pt comes to the ED c/o of chest pain, what is the first action the nurse should take? a. Auscultate heart and lung sounds b. Attach a cardiac monitor c. Obtain a BP d. Access pain characteristics
  6. A pt returns from a percutaneous coronary intervention for an acute myocardial infarction, what is the most appropriate to report to the health care provider? a. An increase in cardiac enzymes b. A decrease in the ST segment c. Capillary refill of 3 sec in the affected limb d. No change in the pts chest pain.
  7. A nurse is caring for a pt with pneumonia, the nurse understands which of the following are certain criteria for sepsis? SATA a. Temp of 101 b. Pain with coughing c. WBC of 15, d. BP 80/

e. AMS

  1. A pt was exposed to a powdered substance at work, the pt presents to the ED nurse and is unsure of what the chemical is called. What action should the nurse take first? a. Obtain vital signs b. Perform a focused assessment c. Place the pt in the shower d. Attach a cardiac monitor
  2. 4 victims of a car accident are being transported to the ED, what order should the victims be assessed? 1, a 70 yr old with a 6-10 abd pain 2. A 25 yr old with multiple trauma injuries to face and jaw 3. A 68 yr old with obvious fracture to the LLL with intact pulses 4. a 53 yr old with c/o racing heartbeat and chest pain a. 4,2,1, b. 2,4,1, c. 1,4,3, d. 2,1,3,
  3. The nurse is performing a primary survey on a pt involved in a motorcycle accident, the nurse is assessing that the pt, he is awake but not talking. Which action should the nurse take next? a. Check for loose teeth b. Check the cap refill c. Check bilateral carotid pulses d. Assess lung sounds
  4. The nurse is assessing a pt that comes into the ED after being at a constructions site for 8 hrs and in 100* heat, the nurse is assessing the pt for heat stroke, which findings will show that the pt is having a heat stroke? SATA a. A HR of 110 b. Hot dry skin c. Oral temp of 100* F d. AMS e. Perfused sweating
  5. A student nurse is being questioned by the nurse health coordinator about health care coordination, the nurse educator knows the students understands the healthcare delivery when which statement is being made? a. Is adequately meeting the needs of the homeless population b. Is available for everyone c. Needs are best meet with a collaborative effort d. Is available to people with disabilities or chronic conditions
  6. A nurse is caring for a pt in the ICU with DIC, which of these conditions will the nurse recognize as risk factors for DIC? SATA a. Septicemia b. Hemolytic blood transfusion reaction c. DM type 2 d. CAD e. Extensive burns in trauma
  1. The nurse is caring with a pt with ICP, The nurse recognizes which symptoms is the earliest sign of increased ICP? a. BP decreased to 100/ b. New findings of decreased LOC c. HR decreased to 58 d. Urine output of 20ml in the past hr
  2. The nurse is caring for a pt with ICP. Which action is considered to be unsafe? a. Elevate HOB to 30 * b. Provide stool softeners c. Align the head with the body d. Cluster many nursing activities when performing care
  3. A pt with full thickness burns over 50% of the body arrives to the ED. The pt weighs 70kg, using parkland formula, circulate the amount of fluid replacement that the nurse should give in the first 8 hrs? a. 3500 ml b. 7000 ml c. 10,500 ml d. 14,000 ml
  4. The nurse is caring for a burn pt in the emergent phase. The nurse understands the nutritional needs during this phase. The nurse understands that the pt needs which type of diet? a. High protein, high carb diet b. Decreased caloric intake by three times their normal c. Eat at least 1500 calories per day in small frequent meals d. Gluten free diet
  5. The nurse caring with a pt with major burns. Which of the following indicates that fluid resuscitation is effective during the first 24 hrs of care? a. Urine output of 30-50 ml/hr b. Resp rate of 18 c. HR of 130 d. BP of 96/
  6. A pt received a deep partial thickness burn to the anterior trunk, perineum, and left anterior and posterior arm. What is the total body surface area burned? a. 18% b. 28% c. 35% d. 40%
  7. The nurse is caring for a pt in the ED with ARDS. Which findings requires the most rapid intervention by the nurse? a. Pts Pa02 is 45 b. Pts Pao2 is 33 c. Pts resp are shallow d. Pts HR is 92
  1. A pt with Cirrhosis is becoming confused. The nurse should plan a dietary consultation to limit the amount of which ingredient in the pts diet? a. Proteins b. Calories c. Minerals d. Carbs
  2. Which Instructions should the nurse include when providing discharge instructions to a pt diag with PAD? a. Encourage using a heating pad on lower extremities b. Instruct the pt to wear elastic support hose at all times c. Instruct the pt to walk daily for at least 30 mins d. Encourage pt to check both the feet for red areas at least once a week
  3. A nurse is providing care for a pt with acute coronary syndrome. The pt is receiving nitro IV conts infusion and begins to develop chest pain. What action will the nurse take before increasing the infusion rate? a. Auscultate heart and lung sounds b. Initiate IV fluids of 0.9 N.S at 50 ml/hr c. Take vital signs d. Administer hydralazine 25 mg IV push
  4. After initiating Heparin for the pt diag with a DVT in the left lower extremity, the nurse noted a platelet count of 100,000. Which action would the nurse take next? a. Discontinue the infusion and call provider b. Cont to monitor the vital signs hourly c. Assess the pt for any signs of bleeding d. Administer oxygen 2L per N.C
  5. A pt who suffered a P.E is ready to be discharged and is prescribed warfarin (coumadin) which assessment finding is most concerning to the nurse? a. Multiple ecchymotic areas on the fore (cant make this work out) b. Bleeding for 10 sec from a venipuncture site from a lab draw c. An INR of 1. d. The pt eats a green leafy salad every day
  6. A nurse is caring for a pt admitted to cardiac care unit for a STEMI that received TPA, which assessment finding concerns the nurse? a. Blood oozing from around the IV site b. Intermittent premature ventricular contractions c. Somnolence d. Bleeding from the lungs
  7. The nurse is caring for a 50 yr old pt with Laennec’s cirrhosis. The pts abd girth has increased by 3 inches over the past 24 hrs. the pts resp are shallow at a rate of 40 breaths per min. The physician decides to perform a paracentesis. What is the nurses highest priority for the pt? a. Frequent monitoring the pt BP and pulse during the procedure b. Gathering all the appropriate sterile supplies c. Positioning the pt in a tripod position d. Accurately labeling the abd fluid devices

a. Gastrointestinal bleed b. Severe vomiting c. Third spacing d. Diabetes insipidus

  1. The nurse understands that which of the following condition puts a pt at risk for ARDS? SATA a. Drug reaction b. Head injury c. Pancreatitis d. Sepsis e. High altitudes
  2. The nurse is caring for a pt who presents with hypotension, poikilothermia and paralysis. The nurse understands theses are clinical manifestations of which type of shock? a. Neurogenic shock b. Anaphylactic shock c. Hypovolemic shock d. Cardiogenic shock
  3. Then nurse is caring for a pt with a BP of 84/40, urine output of 20ml hr, and HR of 115, the nurse understands that this pt is in which stage of shock? a. Progressive b. Initial c. Final d. Refractory
  4. A pt is admitted to the ED and diag with pneumonia, the nurse administers the first dose of Cefipine 2g IVPG, in 10 mins after the infusion is started, the pt c/o difficulty breathing and lung swelling. The nurse would anticipate the provider to order which of the following meds? SATA a. Dopamine b. Epinephrine c. Rantidine d. Diphenhydramine e. Penicillin
  5. The nurse is caring for a client with multiple organ dysfunction. Which assessment findings are most accurate to determine adequate tissue perfusion? a. BP, Pulse, and respirations b. Breathing sounds, BP, temp c. Pulse pressure, LOC, Pupillary response d. LOC, urine output, skin color, temp
  6. An elderly pt is admitted to the ED after having being diag with UTI several days ago, the pt now presents with a temp of 102*f, HR 135, skin is warn and flushed, BP 80/42, after receiving a 1000 ml bolus of 0.9 N/S, which order will the nurse anticipate next? a. Sodium bicarbonate b. Nor-epinephrine c. Epinephrine d. Nitroglycerine
  1. An elderly pt has been receiving tx at home for viral pneumonia. The pt is now being admitted to the ICU, with a diag of Acute resp failure, while reviewing lab result, the nurse notes ABD’s ph 7.48, Pao2 55, Paco2 38, which assessment finding of ARF will the nurse expect to see with this pt? SATA a. Diminished pedal pulse b. Change In mental status c. Headaches d. Tachycardia e. Use of accessory muscles
  2. A 70 yr old has developed age spots and is concerned about skin cancer. Which of the following would the nurse educate the pt to be concerned about? a. Change in the dryness of the skin b. Monitor spots that change color c. Increase in pruritus’ d. Increase of number of age spots
  3. A nurse is working at a health fair and is asked about ways to prevent skin cancer, the nurse educates on which of the following? SATA a. Wear long sleeves and long pants when in the sun b. Apply sunscreen on at least on hr before going outside c. Wear a large hat d. Avoid activities outdoor between 10am – 4pm e. Spend no more than 20 mins in a tanning bed
  4. An emergency nurse is taking care of a homeless pt in the winter who presents with AMS, the nurse is concerned that the pt is hypothermic, which assessment findings would the nurse notice that confirms hypoxia conditions. SATA a. Hypoventilation b. Shivering c. Areflexia d. Diaphoresis e. Hypotension
  5. The nurse is caring for a pt who experiences a near drowning accident, the pt is alert and oriented. Resp rate is 30, Spo2 89%, HR 100, BP 100/60. Which action would be most important for the nurse to take next? a. Assess for orientation b. Auscultate lung sounds c. Monitor urine output d. Check temp
  6. A pt is admitted to the ED after receiving multiple bee stings to the left l hand. The left hand is beginning to become edematous, which action should the nurse take first? a. Apply ice pack to left hand b. Administer Benadryl 25 mg orally c. Start an IV d. Remove ring on left hand
  1. A mother is talking to a community nurse concerning her adult daughter who is mentally challenged and who is not able to live on her own. The mother is concerned about her daughter’s welfare when she is no longer able to care for her. Which is the best response by the nurse? a. You have raised your daughter well and she should be alright on her own b. Let us Investigate community resources that are available to assist you c. There are no group home that mentally adults can live in d. Is there any family that you can contact to take over her care.
  2. A pt diag with acute resp distress synd is restless and has a sat level of 88%, the pt conts to become increasing restless and sats conts to drop to 86% on 15L non-rebreather. Which will the nurse anticipate the provider to order? a. Administer a large dose of lasixs IV push b. Increase the liters of oxygen the pt is on c. Assist with intubation d. Schedule the pt for pulmonary surgery
  3. Which is the primary tool used for colon cancer screening? a. Occult blood test b. Abd xray c. Serum hemoglobin d. Serum electrolytes
  4. A pt suspected of developing acute resp failure is experiencing anxiety and agitation due to increased hypoxemia and dyspnea. The nurse would implement which of the following intervention to improve oxygenation and provide comfort to the pt? a. Administer small amounts of propofol b. Assist the pt up to the chair c. Force fluids for the next 24 hrs d. Position the pt in the tripod position
  5. A pt is seen in the ED after sustaining injuries from a MVA the nurse is performing a head to toe assessment, which part of the survey is this? a. Tertiary b. Initial c. Primary d. Secondary
  6. The nurse understands that which of the following can cause systemic inflammatory response syndrome? SATA a. Pancreatitis b. End stage renal disease c. Pulmonary emboli d. Tibia fx e. Sepsis
  7. The nurse is caring for a pt on a ventilator in the ICU, the nurse includes which of the following intervention on the plan of care to prevent ventilator associated pneumonia? SATA a. Brush teeth with a soft tooth brush every shift b. Swab lips and oral mucosa q 2 hrs

c. Avoid suctioning to prevent dehydration d. Move the endotracheal tube to the opposite of the mouth daily e. Place the pt into the supine position

  1. The nurse is caring for a pt with chronic atrial fib who has been receiving warfarin for the past 2 yrs. The INR is 6.5, which would be the priority Intervention for the nurse? a. Initiate bleeding precautions b. Administer vitamin K c. Take the pts vital signs d. Assess the pts heart sounds
  2. Nurse reviews the med hx of a pt in the clinic, the pt takes furosemide and digoxin for a hx of CHF, the pt has c/o weakness and dizziness which of the following would the nurse anticipate the provider to also order? a. Carvedilol b. Lidocaine c. Potassium d. Nitroglycerine
  3. Nadolol is prescribed for the tx of stable angina, which change in the pt best demonstrates that Nadolol has been affected? a. Increase BP and HR b. The ability to do activity’s without chest pain c. Fewer c/o cold hands and feet d. Improvement in the quality of peripheral pulses
  4. The nurse is creating a care plan for a pt with cirrhosis and acuities, which nursing intervention should be included in the plan of care? SATA a. Monitor wt daily b. Measure abd girth c. Monitor resp status d. Place pt in the supine position e. Assist pt with reg diet
  5. Nurse is monitoring a pt receiving a conts infusion of nitro after suffering M.I, how will the nurse determine if the effectiveness of the nitro administration has been meet? a. Check BP b. Monitor pts apical pulse c. Monitor for dysrhythmias d. Assess for chest discomfort
  6. The nurse is caring for a pt who has a stroke effecting the right side of the brain, the nurse establishes which of the following nursing diag? a. Impaired physical mobility related to right hemiplegia b. Risk for injury related to denial of deficits and impulsiveness’ c. Impaired verbal communication related to speech language deficits d. Ineffective coping related to depression about disability
  7. Pt arriving at the ED has experienced frost bite to both feet, which finding would the nurse note on the assessment of the pts feet? a. Feet are pink and cool to touch
  1. the provider ordered an infusion of dopamine 3 mcg/kg/min, pt wts 175lbs the med is supplied 400 mg in 250ml D5w, what rate would the nurse set the pump at, wound to nearest temp? 8.
  2. provider orders Kefzol 1g in 50ml of N.S to infuse over 30 mins, the tubbing drip factor is 60 gtt per ml, what is the flow rate in drops per min, round to the nearest whole drop? 100
  3. provider orders Hep bolus of 80 units/kg and Hep drip started at 20 units per /kh/hr, med is supplied as Hep 25000 units/250ml of D5W, pt wts 200 lbs, what would you program the pump at for the continuous infusion? 18.
  4. provider orders Dopamin 6 mcg/kg/min for client who wts 188bs, the premix is Dopamine 400 mg/ 250 ml, what would the nurse set the infusion pump at? Round to nearest tenth 19.
  5. Provider Nipride drip was started on a pt who is experiencing a hypertensive crisis, it is to run at 2 mcg/kg/min for a pt wts 175lbs, the IV bag has a concentration of Nipride 50mg/250ml, calculate the flow rate for an IV pump, round to nearest 10 th^. 47.
  6. provider orders pt to receive Hep infusion to run at 800 units per hr, Pharmacy sends Hep 25,000/250ml, how many ml per hr should the pt receive? 8
  7. provider orders Dobutamine 4mcg/kg/min IV infusion, pt wts 178lbs, pharmacy send Dobutamine 250mg/250ml, how many ML per Hr would the pump be set to, Round to nearest 10 th. 19.

ANSWER KEY

1. C

2. C

3. C

4. A

5. A

6. D

7. A

8. D

9. B

10. D

11. C

12. A

13. C

14. B

15. A

16. C

  1. B c d
  2. A c e
  3. B
  4. D
  5. A c d e
  6. C
  7. B
  8. A
  9. A b d
  10. C
  11. A b e
  12. C
  13. A b d
  14. B c d
  15. B
  16. C
  17. C
  18. C d e
  19. B
  20. D
  21. B
  22. A
  23. A
  24. B
  25. A
  26. A
  27. C

88. C

89. C

  1. A b
  2. A
  3. C
  4. C
  6. 100
  10. 8