NURS 231 Final Exam Latest Update -

NURS 231 Final Exam Latest Update - Actual Exam 450 Questions and 100% Verified Correct Answers Guaranteed A+ Verified by Professor

"critical rescue" assessment criteria for patients experiencing stroke/TBI to detect increased intracranial pressure and/or hypertension - CORRECT ANSWER: *ABC's are priority (w/in 10 minutes); Neuro assessment , LOC/cognition, GCS, call rapid response

Early signs:

-headache -N/V -blurry vision/visual disturbances -SOB -seizures (also late) -chest pressure -change LOC

Late:

-elevated BP -bradycardia -cerebral vasodilation -seizures -cushings triad -increased systolic, widened pulse pressure -irregular resp

• The student nurse studying shock understands that the common manifestations of

this condition are directly related to which problems? (Select all that apply.)

• Anaerobic metabolism 1 / 4

• Hyperglycemia
• Hypotension
• Impaired renal perfusion

e. Increased perfusion - CORRECT ANSWER: a. Anaerobic metabolism

• Hypotension

The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.

1) What is the formula for MAP?2) What's the normal?3) What is pts MAP that has BP of 120/80?

4) What is the pts MAP that has BP of 100/65 - CORRECT ANSWER: 1) MAP=

(2xDBP)+SBP / 3 2) normal is 70-110, but trend!3) 93 4) 76

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?

• Assess for other manifestations of hypoxia.
• Change the sensor on the pulse oximeter.
• Obtain a new oximeter from central

supply.

• Tell the client to take slow, deep breath - CORRECT ANSWER: a. Assess for other

manifestations of hypoxia.

• / 4

Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

A client arrives in the emergency department after being in a car crash with fatalities.The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?

• Apply direct pressure to the bleeding.
• Ensure the client has a patent airway.
• Obtain consent for emergency surgery.
• Start two large-bore IV catheters. - CORRECT ANSWER: CORRECT ANSWER: B

Airway is the priority, followed by breathing and circulation (IVs and direct pressure).Obtaining consent is done by the physician.

A client comes to the emergency department with chest discomfort. Which action does the nurse perform first?

a) Provides pain relief medication

b) Remains calm and stays with the client

c) Obtains the client's description of the chest discomfort

d) Administers oxygen therapy - CORRECT ANSWER: c) Obtains the client's

description of the chest discomfort

*Neither oxygen therapy nor pain medication is the first priority in this situation. An assessment is needed first.

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?

• Blood pressure that is 20 mm Hg below baseline
• Oxygen saturation of 94% on room air
• Poor peripheral pulses and cool skin 3 / 4

• Urine output of 1.2 mL/kg/hr for 4 hours - CORRECT ANSWER: c. Poor peripheral

pulses and cool skin

Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as sinus bradycardia. What action by the nurse is most important?

• Assess the clients blood pressure and level of consciousness.
• Call the health care provider or the Rapid Response Team.
• Obtain a permit for an emergency temporary pacemaker insertion.

d. Prepare to administer antidysrhythmic medication. - CORRECT ANSWER:

CORRECT ANSWER: A

Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the clients hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best?

• Breathing so rapidly interferes with oxygenation.
• Maybe the client has respiratory distress syndrome.
• The blood clot interferes with perfusion in the lungs.
• The client needs immediate intubation and mechanical
• / 4