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).
fluid is in
intracellular spaces also we do not yet know how much weight gain over
needed to determine cause.
2. D\u2014the patient has had surgery known to cause DI. The question states DI
Appropriate treatment is to notify the physician of the increased urine output
replacement of vital fluids.
Acetone is not important in the DI patient. These changes will not affect
waiting for results to treat may be harmful
changes will not affect treatment and waiting for results may be harmful to
3. D\u2014In 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.
4. B\u2014This statement avoids inflammatory accusations and reinforces
positive behavior. It also
communicates the team leader\u2019s expectation that everyone will follow the
n A\u2014This statement is inflammatory and \u2018never\u2019 is usually an exaggeration.
n C\u2014This statement is apologetic and confrontational.
n D\u2014This statement offers a false promise when floating requests are likely
this statement may destroy a trusting relationship with the team leader.
5. C\u2014the halo\u2019s 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
procedure is not necessary and could cause harm.
6. B\u2014Recurring chest pain 12 hours post MI indicates extension of the MI.
it requires an order and nothing in the stem indicates that an order for
7. D\u2014Bladder 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
patient in trendelenberg position will not help prevent an episode and may
8. C\u2014The fundamental problem with pulmonary edema is that the patient\u2019s
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
Changing the breathing pattern will not help, we must get to the fundamental
9. A\u2014post 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.
important to assess
breath sounds before doing any of these.
10. C\u2014while 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.
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