Daytona Beach Community College

Department of Nursing
NUR 2744 Practice Exam ANSWERS/Rationale
2744 ANSWERS and RATIONALE
1. A (these signs and symptoms may be applied to several problems.
Obtaining a client history
would assist with establishing the cause of the problem).
n B—the first thing to do is speak with the patient before invasive procedures

although you
will likely obtain serum electrolytes at a later time
n C—as with patients with SIADH, peripheral edema may not be present if

fluid is in
intracellular spaces also we do not yet know how much weight gain over
how long.
n D—The patient presents with no GI symptoms save for nausea. More

information is
needed to determine cause.
2. D—the patient has had surgery known to cause DI. The question states DI
is present.
Appropriate treatment is to notify the physician of the increased urine output
and anticipate
replacement of vital fluids.
n A-- Urine has already been assessed for 2 hours, to assess for a longer

period delaying
fluid replacement may be harmful to the patient.
n B—The patient will most likely show changes in urine osmolality and

sodium. Urine
Acetone is not important in the DI patient. These changes will not affect
treatment and
waiting for results to treat may be harmful
n C—the patient will most likely show changes in serum electrolytes and

osm. These
changes will not affect treatment and waiting for results may be harmful to
the patient.
3. D—In a patient with cardiogenic shock, you should anticipate initial
administration of IV Fluids
or fluid volume expanders such as plasmanex (normal serum albumin) to
increase cardiac output
by increasing myocardial muscle fiber stretch which increases contractility.
n A—you should discontinue nitrates or other drugs that reduce blood
volume, preload, or
myocardial fiber stretching.
n B—You should not administer Metoprolol (lopressor) because it may

decrease
contractility and may worsen shock. This drug also lowers blood pressure.
n C—Morphine decreases preload hence decreasing contractility.

4. B—This statement avoids inflammatory accusations and reinforces

positive behavior. It also
communicates the team leader’s expectation that everyone will follow the
floating requirement.
n A—This statement is inflammatory and ‘never’ is usually an exaggeration.

n C—This statement is apologetic and confrontational.

n D—This statement offers a false promise when floating requests are likely

to occur again,
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this statement may destroy a trusting relationship with the team leader.
5. C—the halo’s wrench and tool kit should be available at all times and
should be visible in the
room in case the chest plate must be removed for CPR
n A—Logrolling the patient is no longer necessary as the halo traction device

stabilizes the
fracture with movement.
n B—Keeping the HOB at 30 to 45 degrees is not necessary for patients in

halo traction
devices.
n D—The stem of the question identifies no risks for aspiration hence this

invasive
procedure is not necessary and could cause harm.
6. B—Recurring chest pain 12 hours post MI indicates extension of the MI.
To verify, the nurse
should obtain a 12 lead EKG and notify the physician of a change in
condition
n A—recurring chest pain is not a sign of reperfusion

n C—administration of a thrombolytic would require a physician’s order as

does the heparin.

n D—While morphine sulfate may increase oxygen delivery and decrease

sensation of pain,
it requires an order and nothing in the stem indicates that an order for
lidocaine is
warranted.
7. D—Bladder distention or other similar stimuli are the trigger for this
spinal cord response after
spinal shock. Monitoring the Foley cath for patency can prevent an episode
from occurring.
n A—chloral hydrate is a sedative which is not indicated for this patient

n B—laboratory findings will not predict an event as it is caused by a

physical stimulus
n C—the patient should be repositioned every 2 hours to prevent skin lesions,

keeping the
patient in trendelenberg position will not help prevent an episode and may
potentially be
harmful.
8. C—The fundamental problem with pulmonary edema is that the patient’s
lungs are fluid
overloaded making exchange of gasses at the alveolar level very difficult if
not impossible. If the
patient is not breathing he will die making this the highest priority diagnosis
n A—The problem is at the alveolar level and makes the exchange of gasses

impossible.
Changing the breathing pattern will not help, we must get to the fundamental
problem.
n B—While the patient would definitely have a nursing diagnosis of anxiety,

this is not the

priority at this time
n D—The patient has a fluid volume overload, not deficit.

9. A—post intubation, it is most important to assess for bilateral breath

sounds first. The
endotracheal tube may have been inserted too far and traveled down the
right main stem
bronchus where it could cause a tension pneumothorax.
n C-D—while all of these are relative to the intubated patient, it is most

important to assess
breath sounds before doing any of these.
10. C—while some of the other tests are certainly indicative of DIC, the
FDP and D-Dimer are
specific to DIC and these levels would indicate a positive finding of DIC.
n A, B, D—while these could indicate DIC, they are less specific for DIC
11. B—Propofol is a lipid solution. This patient is receiving a 10% lipid
solution in addition to the
propofol. This is more than the body’s fat requirement.
n A--The patient is on propofol, a medication that will assist with reducing

anxiety. While
this may be an appropriate diagnosis it is not the priority at this time.
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n C—We do not have information regarding patient weight trends, intake and
output. This
information would be required to determine if the patient is receiving too
much fluid.
n D—While being on TPN places the patient at a greater risk for infection,

this is not the

priority (it is a risk not an actual problem).
12. B—When the pacemaker fires but the heart produces no response, this is
considered a failure to
capture.
n A—this condition occurs when the pacemaker does not fire producing

pauses. Note that

the patient does not have this condition when the pacer does not fire for the
heart’s natural
rhythm.
n C—This condition occurs when the pacemaker ignores the underlying

rhythm producing
pacer spikes throughout the pqrs.
n D—This condition occurs when the pacemaker does not fire and the heart

does not
produce a rhythm…a lack of any electrical activity.
13. D—The nurse should first check the written physician order to ensure
that no transcription error
has taken place regardless of the actual orders…suspicion should be aroused
by the order for
heparin sodium for a hemorrhagic stroke patient.
n A—The nurse must check the written order against the medication

administration record
before signing her name indicating that the orders are correct.
n B—Heparin sodium could be dangerous to the hemorrhagic stroke patient

causing further
intracranial bleeding
n C—The nurse should ensure that the order was transcribed correctly before
calling the
physician to question the order. This should be done if the written order is
correct (refer
to B).
14. B—Even though it is important to give the medication quickly, the nurse
should never use broken
equipment as it could harm either the nurse or the patient. This step can be
taken quickly by
delegating another staff member to pick up the pump or by going to central
supply to obtain the
pump. Less that 10 minutes would be lost.
n A—never use a broken piece of electrical equipment it could cause

electrocution.
n C—Never use a broken piece of electrical equipment it could cause

electrocution. Fixing
the problem with tape may not work.
n D—The nursing supervisor will not be able to obtain the appropriate

equipment more
quickly. Notification of this authority is not necessary.
15. A—These signs and symptoms indicate a negative reaction to the
transfusion and the patient
could quickly deteriorate. Observing for theses signs and symptoms during
the first 15 minutes
of the transfusion takes priority in this situation.
n B—This patient information is nice but not essential…transfusions also

may take up to 4
hours.
n C—Documentation is certainly important but takes lower priority than

observation for a
transfusion reaction
n D—Assessment of vital signs at the END of the transfusion is important

but the priority

would be from start to finish.
16. C—The patient with a chest tube is likely to avoid coughing and deep
breathing due to the
discomfort caused by the chest tube. This may lead to many complications
therefore it is very
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important for the nurse to take an active role in pulmonary toilet.
n A—fluctuation in the suction chamber even in a wet chest drainage system

is
unimportant. You are thinking about the water seal chamber which should
have
fluctuations but no bubbling.
n B—Nursing requires an order to clamp a chest tube. Clamping negates the

function of the
chest drainage system.
n D—While the nurse may milk the tubing if there is a large amount of

drainage, the stem

of the question does not indicate this condition so C&DB would take
priority.
17. D—Modified trendelenberg allows full respiratory excursion by slightly
elevating the head and
increasing venous return by elevating the feet. Full respiratory excursion is
crucial to assume
maximum ventilation capacity. The client going into shock needs all the air
he can get.
n A&B—Promote respiratory excursion but do not improve venous return

n C—Promotes venous return but does not aid respiratory excursion.

18. B—to prevent atmospheric air from rushing into the thoracic cavity, the
nurse should instruct the
client to take a deep breath then hold it.
n A&C would allow air to enter the thoracic cavity.

n D the valsalva maneuver is helpful when removing the chest tube.

19. A—restlessness and increased respirations may indicate hemorrhage

n B—introducing water into the stomach may cause metabolic alkalosis from

the loss of
chloride or hydrogen ions
n C—the balloon holds the tube in place and should not be deflated before

removal
n D—the balloon controls esophageal bleeding and should be kept inflated at

all times even

though pressure checks should be included in the plan of care.
20. B—angioedema is a severe allergic reaction which should be reported to
the physician
immediately.
n A—while angioedema can cause edema of the larynx and difficulty

breathing, the first

action should be to notify the physician and request orders to treat the
condition
n C—nothing in the stem of the question gives information noting that the

patient is
experiencing cardiac arrest. CPR on a patient with adequate vital signs will
cause harm to
the patient
n D—While the nurse may anticipate giving epinephrine to the patient to

counteract the
allergic reaction, a physician’s order is needed for this action and 2 ampules
is a nonspecific
dose.
21. B—the client’s blood gas results and slight fever indicate postoperative
hypoventilation and
atelectasis. Vigorous deep breathing can correct these problems
n A—administration of oxygen is not helpful because the client is

hypoventilating, not
hypoxic
n C—Sputum analysis will not help the client’s respiratory status at this time

but may be
helpful in diagnosing any respiratory infections if coughing and deep
breathing do not
work.
n D—is not warranted because the blood gas results do not indicate

respiratory acidosis.
22. B—Peanut butter provides the protein and fat needed by the burn patient
with raisins providing
the iron required by the burn patient
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n A--provides adequate nutrients but too much fat
n C&D—do not provide enough protein or iron

23. B—shock causes tissue hypoxia. The first action should be to start the
oxygen to promote tissue
oxygenation.
n A—is appropriate after oxygen therapy is initiated

n C—the nurse would need further data before implementing

n D—is important but does not take precedence over starting oxygen.

24. C—Mannitol is an osmotic diuretic which causes increased urine output.

n A, B, D—none of these are side effects of mannitol.
25. D—An elevated serum potassium level (hyperkalemia) is common in
acute renal failure putting
the client at risk for life-threatening cardiac arrythmias.
n A—although hypocalcemia may occur in acute renal failure it does not

cause tetany due to

the acidosis that occurs with renal failure keeping calcium in its ionized
form
n B—Damaged renal tubules cannot conserve sodium

n C—this option suggests shock which is not identified as a complication of

ARF
26. A—an assessment is vital before intervention can be planned
n B—After the assessment it would be important to find out the client’s

anxiety level
n C—After the assessment it would be important to analyze what triggered

the event
n D—This intervention would be a part of long term planning

27. D—by decreasing sodium ions, holding onto hydrogen ions and
secreting nahco3, the kidneys
regulate pH
n A-C—these answers are wrong or incomplete.

28. D—Hemorrhage or blood in the CSF within the brain, ventricles or

subarachnoid space is
irritating to the meninges and causes headache and nuchal rigidity.
n A-C—the signs and symptoms in the stem do not indicate any of these

conditions
specifically.
29. A—Kidney diseases such as acute renal failure interfere with the
metabolism and excretion of
Quinidine resulting in higher drug concentrations in the body. These higher
levels of the drug
can depress myocardial excitability causing cardiac arrest. The nurse should
withhold the drug
and call the physician to clarify the order.
n B—with the threat of cardiac arrest, the nurse should not administer the

medication just
because it was ordered
n C—the second dose would be too early to measure quinine levels in the

blood
n D—bradycardia and cardiac arrest are more likely than hypotension in this

case but
hypotension may follow prolonged periods of severe bradycardia.
30. B—A halo or ring will appear around the blood if drainage from the nose
or ear of a head injured
patient contains cerebrospinal fluid.
n A&C—the collection of any type of culture or laboratory value using a

swab or suction is
contraindicated because brain tissue may be inadvertently removed at the
same time or
other tissue damage may result.
n D—packing the nose is not indicated if CSF is present in the drainage. The

nurse should
first check the drainage before other action and await physician orders after
notification of
result.
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31. B—Hypercapnia causes vasodilation which will increase intracranial
pressure.
n A&C-- Vigorous coughing or suctioning when not necessary will cause a

rise in the
intracranial pressure.
n D—keeping the head of the bed flat will raise intractainial pressure by not

permitting free
flow of venous return out of the intracranial cavity.
32. A—A restrictive band 2-3 inches above the bite is most effective in
containing the venom and
minimizing lymphatic and superficial venous return.
n B-D--Elevation or immobilization of the limb would not be effective.

Although you may

lay the victim supine to counteract effects of shock, this would not be
effective in
minimizing tissue damage.
33. D—Nervous control of the diaphragm (phrenic nerve) occurs at level C 3
or C 4.
34. C—Crutchfield tongs are a form of traction to hyperextend the neck and
decompress the spine.
During their use, the cervical spine is very unstable. It is important to
continue to turn the patient
to avoid the complications of immobility but turning should be no greater
than a 15 degree
elevation while supporting the back and neck to avoid twisting movement.
n A—the weights on the traction make it impossible for the client to sit up.

Instability of
the cervical spine places the client at risk for further injury to the spinal cord.
n B—The head of the bed should be no more than 30 degrees with the use of

the Crutchfield
tongs
n D—this places the client at risk for impaired skin integrity and ineffective

airway
clearance.
35. D--In the post operative course of care the nurse should assess for
complications, bleeding having
the highest priority. To evaluate for bleeding the nurse should assess the area
for frank blood,
and assess for tachycardia.
n A—This is an important part of the plan of care but does not include the

life threatening
component of airway, breathing, and circulation
n B—This is an important part of the plan of care but while the patient may

require
treatment for pain, it does not outweigh potential hemorrhage in importance.
n C—This will be a part of the plan of care to determine evidence of

infection throughout
the client’s hospital course but it does not take priority over potential for
hemorrhage.
36. A—frequent walks are permissible but strenuous activity should be
avoided for a few weeks until
the client has consent from the physician.
n Brisk walking is a strenuous activity which should be avoided for a few

weeks until the

client has permission from the health care provider
n Eating is contraindicated before activity shunting blood to the GI tract

precluding
adequate blood flow to the legs and heart
n Nitroglycerine is a medication only used for active chest pain and must be

ordered by the
physician.
37. A—furosemide is a loop diuretic which increases potassium excretion in
the distal loop.
Hypokalemia is a cause of toxic reactions in the person taking digoxin.
Potassium loss is
exacerbated with the concomitant use of both drugs. Orange juice increases
potassium levels
while the other foods do not.
38. A—the swishing sound or ‘bruit’ heard indicates that blood is flowing
through the graft and is
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expected.
n B—the arm with the graft should never be used for blood pressure checks

or drawing
blood
n C—This is not indicated for this normal finding

n D—the graft is patent, further testing is not required.

39. B—it is important to support the client prior to and during any
procedures to allay anxieties.
n A—the nurse has an order, the hemoglobin falls within the range. No

further order check

is warranted at this time
n C—this step is important but will be done by 2 RN’s once the blood is

obtained from the

laboratory
n D—the laboratory would notify the nurse upon receiving the order if no

blood of the
patient’s type were available
40. D—the client who has expressive aphasia knows what he wants to say
but cannot verbalize the
appropriate words. Pictures of common objects and needs gives him an
opportunity to indicate
what he would like
n A—speaking above normal voice level is not indicated as the patient’s

hearing is not
damaged
n B—supplying the correct words readily will decrease the patient’s

motivation to regain
normal speech
n C—correcting speech may frustrate the patient and make them unwilling to

try to speak.
Many times the patient is unaware of involuntary use of profane or vulgar
language and is
embarrassed.
41. D—The symptoms this patient is complaining about are similar to lupus
erythematosus and are
seen in patients who have been on large doses for over one year. The patient
should notify the
physician immediately.
n A—the dosage would not routinely be increased

n B—while aspirin may relieve some of the symptoms, it is not the nurse’s

role to make this

recommendation. It would not solve the problem, only mask it.
n C—this situation needs immediate attention and the symptoms are unlikely

to subside.
42. C—after a heavy meal, blood is diverted to the GI tract. Increased
cardiac workload increases
the risk of underperfusion of the coronary arteries.
n A—the client should lie on their back while the partner kneels to take some

of the weight
from the client and reduce myocardial oxygen demand
n B—This is not an appropriate recommendation for this client.

n D—Uncomplicated MI patients may usually resume sexual activity in

about 5-8 weeks.

An index of readiness is the ability to walk up two flights of stairs without
becoming
dyspneic.
43. D—apple juice is low in phosphorous, sodium, potassium and protein
which are nutrients that the
damaged kidney cannot clear.
n A—bananas are high in potassium causing dangerous levels

n B—Redmeats contain protein and phosphorus

n C—Legumes contain phosphorus

44. B—Nausea, warmth, facial flushing, nd a salty taste in the mouth are all
expected sensations.
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n A—Severe dyspnea could indicate a beginning anaphylactic reaction or
perforation of the
vessels, heart or lungs by the catheter
n C—generalized itching is a sign of allergic reaction to the dye
n D—The client who is cool and clammy may be experiencing hypovolemic
shock,
neurogenic shock, or anxiety
45. B—cyclosporine is an immunosuppresant that is a t-lymphocyte
inhibitor
n A—acyclovir is an antiviral agent

n C—hydromorphone is a narcotic analgesic

n D—Megestrol is a hormone to treat breast or endometrial cancer

46. C—vigorous bubbling in the water seal chamber indicates an air leak
between the patient and the
water seal. The first intervention would be to check all connections for any
potential air leaks.
n A—This would have no impact on the water seal chamber

n B—This may be done later after the problem is found or cannot be

corrected
n D—this would be performed after the leak in the system is corrected

47. D—a major priority during seizure activity is to protect the airway. The
sidelying position
promotes drainage of secretions and prevents aspiration during the seizure
n A—Restraints may cause additional injury and are not indicated

n B—In this scenario the seizure has already begun. It will not be possible to

force a tongue
blade into the client’s mouth and the nurse would risk personal injury or
injury to the
client if attempted.
n C—holding the client down may cause additional injury and is not

indicated.
48. A—the appropriate action to combat the antibody response is to stop the
transfusion of foreign
protein in the form of the red blood cells.
n B—while you may do this quickly in the regime of treatment, this requires

a physician
order
n C—It will be important to send the blood and a patient blood sample to the

lab and to fill

out transfusion reaction paperwork but it is not your priority. You must first
stop the
transfusion
n D—You will notify the physician but not before stopping the transfusion
49. B—the seventh cranial nerve closes the eyelid. Without a patch, the
cornea is subject to damage.
n A—suction is not necessary to prevent complication

n C—Water temperature does not make a difference.

n D—The client need not remain in high fowlers position although the head

of the bed
should remain at 30 degrees promote cerebral blood flow.
50. B—Edema is due to insufficient nitrogen for synthesis. When this occurs
it leads to a change in
the body’s osmotic pressure resulting in oozing of fluids out of the vascular
space. This
phenomena results in the formation of edema in the abdomen and flanks.
51. B—The nurse is responsible for supervision of all tasks delegated to the
unlicensed Assistive
personnel.
n A—this statement is not true because the unlicensed personnel require

supervision
n C—While supervision is required, uap’s are accountable for their own

actions
n D—UAP’s receive varied degrees of education before they are permitted to

work with
clients on the nursing unit.
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52. D—administration of a stool softener prevents straining at stool which
may cause the patient to
use the valsalva’s maneuver. Intra abdominal pressure such as that used
when defecating
increases intracranial pressure.
n A—this intervention is questionable but according to the stem of the

question there is no
evidence of dehydration and this is not a common side effect post SDH
evacuation
n B—Suctioning is directly contraindicated as it raises ICP

n C—Increasing the head of bed to ninety degrees will cause an increase in

ICP
53. C—Until the cervical x-rays indicate a spinal injury, the patient should
be treated as though
spinal injury has occurred. To prevent twisting, turning or increased injury,
the patient should be
kept supine with the head of bed flat. Logrolling the patient all in one
motion is acceptable.
54. D—all of these findings are normal. The most significant for a patient
with guillian barre` is
respiration. These patients lose muscular control in a progressive fasion so
the nurse must be
diligent in assessing respiration.
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