NURS 320 ACTUAL EXAM 150 QUESTIONS AND CORRECT

NURS 320 ACTUAL EXAM 150 QUESTIONS AND CORRECT

ANSWERS LATEST UPDATE//ALL YOU NEED TO PASS

NURS 320 EXAM//GRADED A+

A patient is now in the recovery room after having vaginal surgery. Due to the positioning of the procedure, you would want to assess for what while the patient is in recovery?

• Bowel Sounds
• Dysrhythmia
• Homan's Sign
• Hemoglobin Level - C

After surgery your patient is semicomatose with vital signs within normal limits. As the nurse, what position would be best for this patient?

• Semi-Fowlers
• Prone
• Low-Fowlers
• Side positioning preferably on the left side - D

After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do

FIRST?*

• Apply warm blankets & continue oxygen as prescribed
• Take the patient's rectal temperature
• Page the doctor for further orders
• Adjust the thermostat in the room - A

The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention?*

A. BP 100/80

• 24-hour urine output of 300 ml
• Pain rating of 4 on 1-10 scale
• Temperature of 99.3' F - B 1 / 4

The nurse enters a woman's room to administer 10mg Valium PO, the ordered pre-op medication for her hysterectomy. During the conversation, the client tells the nurse that she and her husband are planning to have another child in the coming year. The best action for the nurse to take is which of the following?

1.) Do not administer the pre-op medication. NOtify the nursing supervisor and the physician.

2.) Go ahead and administer the medication as ordered.

3.) Check to see if the client has signed a surgical consent.

4.)Send the client to the OR without the medication. - 1.)no client should be administered the per-op med until the informed consent has been obtained. Even if the consent form is signed, the nurse should withhold sedating meds because this client clearly does not understand the planned procedure.

The nurse administers 10mg IM morphine as a pre-op medication, and then discovers that there is

no signed operative permit. The best action for the nurse to take is to:

1.) Send the client to surgery as scheduled.

2.) notify the nursing supervisor, the OR, and the physician.

3.) cancel surgery immediately 4.) obtain the needed constent. - 2.)is a narcotic, sedative, or tranquilizing drug has been administered before signing of the consent, the drug's effects must be allowed to wear off before consent can be given.

An adult received atropine sulfate (Atropine) as a pre-op medication 30 minutes ago and is now complaining of dry mouth and her pulse rate is higher than before the medication was administered.

The nurse's best interpretation of these findings is that:

1.) The client is having an allergic reaction to the drug.

2.) the client needs a higher dose of this drug 3.) this is a normal side effect of Atropine 4.) the client is anxious about the upcoming surgery. - 3.) These are normal side effects of an anticholinergic drug; adverse side effects would include ECG changes, constipation, and urinary retention.

• / 4

An adult with COPD is scheduled for surgery and the physician has recommended an epidural anesthetic. The nurse should know that general anesthesia was not recommended for this client

because:

1.)there is too high a risk for pressure sores to develop 2.) there is less effect on the respiratory system with epidural anesthesia.

3.) CNS control of the vascular constriction would be affected with general anesthesia.

4.) there is too high a risk of lacerations to the mouth, bruising of lips, and damage to teeth. - 2.) Epidural anesthesia does not cause resp. depression, but general anesthesia can. especially in a client with COPD.

An adult had a bunion removed under an epidural block. In the immediate Post-op period the nurse plans to assess the client for side effects of the epidural block that include which of the following:

1.) headache 2.) hypotension, bradycardia, nausea, vomiting 3.)hypertension, muscular rigidity, fever, and tachypnea.

4.) urinary retention - 2.) hypotension, bradycardia, nausea and vomiting are all symptoms of sympathetic nervous system blockade, so the client should be closely monitored for these.

An adult has just arrived on the general surgery unit from the PACU. Which of the following needs to be the initial intervention the nurse takes?

1.) assess the surgical site, noting the amount and character of drainage.

2.) assess for amount of urinary output and the presence of any distention.

3.) allow the family to visit with the client to decrease the anxiety of the client.

4.)take vital signs, assessing the first for a patient airway and the quality of respirations. - 4.) a specific assessment priority is the evaluation of a patent airway and respiratory and circulatory adequacy.

In the Per-op phase, a physicial orders a patient taken off of Coumadin (warfarin) and put on IV

heparin. This change in medication will:

1.) Help the patient be more relaxed before her surgical procedure. 3 / 4

2.) Prevent blood clots.

3.) be more quickly reversible during surgery if needed.

4.) shortens the length of recovery time for post-op patients. - 3.) Heparin is quickly reversible in the event of hemorrhage with Protamine sulfate, (Coumadin can be reversed with Vitamin K, but the results are much slower than with the heparin/protamine reversal)

The nurse obtains a diet history from a pregnant 16-year-old girl. The girl tells the nurse that her typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a cheeseburger, milk shake, fries, and salad for dinner. Which of the following is the MOST accurate nursing diagnosis based on this data?

1. Altered nutrition: more than body requirements related to high-fat intake

2. Knowledge deficit: nutrition in pregnancy

• Altered nutrition: less than body requirements related to increased nutritional

demands of pregnancy

4. Risk for injury: fetal malnutrition related to poor maternal diet - 3

A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take?

• Immobilize the affected limb with a splint and ask him not to move.
• Make a thorough assessment of the circumstances surrounding the accident.
• Put him in semi-Fowler's position for comfort.
• Check the pedal pulse and blanching sign in both legs. - 1

A child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought to the recovery room. Which of the following actions should the nurse include in the child's plan of care?

• Institute measures to minimize crying.
• Perform postural drainage every 2 hours.
• Cough and deep-breathe every hour.
• Give ice cream as tolerated. - 1

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care?

• / 4