Exam 3: NUR242/ NUR 242 (Latest 2023/ 2024) Medical-Surgical Nursing Exam | Questions and Verified Answers with Rationales| 100% Correct| Grade A- Galen
Exam 3: NUR242/ NUR 242 (Latest 2023/
2024) Medical-Surgical Nursing Exam |
Questions and Verified Answers with
Rationales| 100% Correct| Grade A
Q: The nurse is assessing a patient with a chest tube following a pneumonectomy. Which
assessment finding requires intervention?
A. Bandage around the posterior tube is loose.
B. 2 cm of water is in the second chest tube chamber.
C. The water in the water seal chamber rises and falls with inhalation/exhalation.
D. Bubbling present in the water seal chamber when the patient coughs.:
Answer:
A
After lung surgery, two tubes, anterior and posterior, are used. Dressings around the wound
should not be loose. The wounds should be covered with airtight dressings.
Q: A home health patient with a history of asthma is having shortness of breath. The nurse
discovers that the peak flowmeter indicates a peak expi- ratory flow (PEF) reading that is in the
red zone. What is the priority nursing action?
A. Call 911 immediately.
B. Take the patient’s vital signs. C. Notify the patient’s prescriber.
D. Repeat the PEF reading to verify the results.:
Answer:
A
A PEF reading in the red zone indicates a range that is 50% below the patient’s personal best PEF
reading and indicates serious respiratory obstruction requiring
911 or rapid response. Offer medications and stay with the patient. Repeating the PEF reading
and taking vital signs are also important, but doing so first delays the administration of the rescue
drugs and physician notification.
Q: The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on
the unit. Results are as follows:
BG—239 mg/dL BP—138/88 mm Hg
HR—128 RR—36 breaths/min
O2 saturation—88% (room air) Temperature—101.6º F
Which vital sign or test result requires the nurse’s immediate attention? A. Blood pressure
B. Respiratory rate
C. Temperature
D. Blood glucose:
Answer:
B
All of the patient’s vital signs are abnormal. However, the most important one to report
immediately is her increased respirations (and decreased oxygen saturation). Even though a
diagnosis has not been confirmed, it is very important to address these problems. The patient is
experiencing tachypnea.
Q: After consulting with the provider, the following orders are received: Full liquid diabetic
diet
IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures × 3 and
urinalysis
Tylenol grain × every 4 hour for temperature above 101º F Cefazolin (Ancef) 1 g IVP every 8
hour
Which of the provider’s orders should the nurse implement first? A. IV fluids 1000 mL .9 NS at
60 mL/hr
B. Oxygen at 2 L per nasal cannula
C. Blood cultures and urinalysis
D. Cefazolin (Ancef) 1 g IVP every 8 hour:
Answer:
B
All of the provider’s orders are very important. However, the most important one is oxygen
therapy. Hypoxia is often seen with pneumonia, so it is very important that supplemental oxygen
is started as soon as possible. IV fluids should be started
to enhance pulmonary toileting, and the laboratory should be notified to draw the needed blood
cultures. UAP can obtain the specimen for urinalysis. The blood cultures and the UA should be
obtained before the IVP Ancef is administered.
Q: The nurse understands that which of the following is the most common symptom of
pneumonia in the older adult patient?
A. Fever
B. Cough
C. Confusion
D. Weakness:
Answer:
C
The older adult with pneumonia often has weakness, fatigue, lethargy, confusion, and poor
appetite. Fever and cough may be absent, but hypoxemia is usually present. The most common
manifestation of pneumonia in the older adult patient is confusion from hypoxia rather than fever
or cough.
Q: Which assessment finding for an older adult patient does the nurse ascribe to the natural
aging process?
A. Tightening of the vocal cords
B. A decrease in residual volume
C. A decrease in the anteroposterior diameter
D. A decrease in respiratory muscle strength:
Answer:
D
As a person ages, vocal cords become slack, changing the quality and strength of the voice; the
anteroposterior diameter increases; respiratory muscle strength decreases; and the residual
volume increases.
•
Q: The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will
have what percent of oxygen dissociate from the hemoglobin molecule?
A. 25% B. 50% C. 75%
D. 100%:
Answer:
B
Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse
tissues. Under normal conditions, 50% of hemoglobin molecules completely dissociate their
oxygen molecules when blood perfuses tissues that have an oxygen tension (concentration) of 26
mm Hg. This is considered a “normal” point at which
50% of hemoglobin molecules are no longer saturated with oxygen.
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