EXAM WITH CORRECT SOLUTIONS.

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NUR 221 EXAM 1

EXAM WITH CORRECT SOLUTIONS.

The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5° F.The patient is lethargic, responds to voice but falls asleep readily when not stimulated.Which nursing action is most important to include in this patient's plan of care?

• Frequent neurological assessments
• Side to side position changes
• Range of motion to extremities
• Frequent oropharyngeal suctioning - correct answer- A.

Frequent neurological assessments

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis.To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse?

• Implement droplet precautions upon admission. 1 / 3

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• Wash hands thoroughly before leaving the room.
• Scrub the hub of all central line ports prior to use.
• Dispose of all bloody dressings in biohazard bags. - correct

answer- A. Implement droplet precautions upon admission.

The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO 2 ) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5° F.What is the priority nursing action?

• Elevate the head of the bed 30 degrees.
• Keep lights dim at all times.
• Implement seizure precautions.
• Maintain bed rest at all times. - correct answer- C.

Implement seizure precautions.

A patient seeks treatment for progressively deteriorating motor and sensory function. What question is essential for the nurse to ask when completing this patient's health history?

• "Have you been around any small children?" 2 / 3

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• "When was the last time you had anything to eat?"
• "When was the last time you traveled out of the country?"
• "Have you recently experienced any lung or stomach

infections?" - correct answer- D. "Have you recently experienced any lung or stomach infections?"

A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the nurse respond about the pathophysiology of the disorder?

• "An infection eats away at the nerve endings."
• "An infection enters the spinal cord and erodes the nerves at

the roots."

• "The nerves are killed by infiltration of your body's white

blood cells used to fight an infection."

• "After an infection your immune system created antibodies

that affect the covering of the nerves." - correct answer- D."After an infection your immune system created antibodies that affect the covering of the nerves."

A patient is experiencing bilateral symmetrical muscle weakness and sensory changes of both feet and legs. What should the nurse expect to assess that determines the presence of Guillain-Barré syndrome (GBS)?

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