NUR 213 Final Exam Latest Update -

NUR 213 Final Exam Latest Update - Actual Exam from Credible Sources with 100 Questions and Verified Correct Answers Golden Ticket to Guaranteed A+ Verified by Professor

. A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a

• shallow breathing pattern.
• partial pressure of arterial oxygen (PaO2) of 45 mm Hg.
• partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg.

d. respiratory rate of 32/min. - CORRECT ANSWER: B

Rationale: The PaO2 indicates severe hypoxemia and that the nurse should take

immediate action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be caused by other factors, such as anxiety or pain.

• The wounded victim is unable to walk, respiratory rate is absent but when airway is

repositioned breathing is noted. The wounded victim is assigned what tag color?

• Green
• Red
• Yellow
• Black - CORRECT ANSWER: B: Red

A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg.Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated?

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• 921 mL/hr
• 938 mL/hr
• 158 mL/hr
• 789 mL/hr - CORRECT ANSWER: A: 921 mL/hr

First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The pt's weight 63 kg. BSA percentage: 58.5%...Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ......4 x 58.5 x 63 = 14,742 mL......Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL......Hourly

Rate: 7371 divide by 8 equals 921 mL/hr

A 40-year-old patient is diagnosed with end-stage liver disease. The patient began drinking alcohol heavily at 17 years of age.Which statement indicates to the nurse that the patient has alcoholic cirrhosis?

• "I seem to be sweating profusely all the time."
• "I've had a lot of abdominal pain and swelling."
• "I've been experiencing crushing chest pain."
• "I've had a low-grade fever for several weeks now." - CORRECT ANSWER: B) "I've

had a lot of abdominal pain and swelling."

Rationale: Alcoholic cirrhosis causes metabolic changes in the liver. It results in fluid buildup and pain in the abdomen caused by the shunting of blood around the liver and bleeding in the gastrointestinal tract. Pruritus, not profuse sweating, is a manifestation of alcoholic cirrhosis and occurs because of severe jaundice and bile salt deposits on the skin. Crushing chest pain and low-grade fever are not manifestations of alcoholic cirrhosis.

A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? 2 / 4

A. 63%

B. 81%

C. 72%

D. 54% - CORRECT ANSWER: A.

Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor?

• Red
• Yellow
• Green

D. Black - CORRECT ANSWER: C

Green tags are for patients who have MINOR injuries. If the patient can walk around they are tagged as green. Sometimes they are referred to as the "walking wounded".

A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing?

• Repositions the client from side to side every 2 hours
• Elevates the head of the bed to 60 degrees
• Auscultates the lung fields every 4 hours 3 / 4

D) Encourages deep breathing exercises every 2 hours - CORRECT ANSWER: B)

Elevates the head of the bed to 60 degrees

Rationale: Elevating the head of the bed enlists gravity as an aid in relieving pressure on the diaphragm. The other options are general measures in the care of a client with ascites, but the primary measure is the one that relieves diaphragmatic pressure.

A client has an AV fistula in the right upper arm for hemodialysis treatments. When planning care for this client, which measure should the nurse implement to promote client safety?

• Take blood pressures only on the right side to ensure accuracy
• Use the fistula for all venipunctures and IV infusions
• Ensure that small clamps are attached to the fistula dressing at all times
• Assess the fistula for the presence of a bruit and a thrill every 4 hours - CORRECT

ANSWER: D) Assess the fistula for the presence of a bruit and a thrill every 4 hours

A client has developed atrial fibrillation and has a ventricular rate of 150 beats per minute. The nurse should assess the client for which effects of this cardiac occurrence?

• flat neck veins
• nausea and vomiting
• hypotension and dizziness

D) hypertension and headache - CORRECT ANSWER: C) hypotension and dizziness

A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis, and the nurse prepares to perform an assessment on the client. Which findings are

associated with this inflammatory heart disease? Select all that apply:

• Fever
• Leukopenia
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