Question

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Administer an antiemetic.

Rationale :

🟦 Opioids like morphine commonly cause nausea and vomiting by stimulating the chemoreceptor trigger zone and slowing GI motility.

🟦 Giving an ordered antiemetic treats the symptom promptly, improves comfort, and helps prevent aspiration risk in a postoperative client.

🟦 Controlling nausea also supports better pain control, because untreated vomiting can lead clients to avoid using the PCA and then experience uncontrolled pain.

🟦 Post-op nausea can worsen fluid/electrolyte imbalance, so treating it early supports recovery and oral intake tolerance.

🟦 This is the most direct, evidence-based nursing response when nausea/vomiting is linked to opioid analgesia and there is no evidence of bowel obstruction in the stem.

Insert a nasogastric tube.

🟦 An NG tube is not first-line for opioid-related nausea and is typically reserved for bowel obstruction/ileus or severe gastric decompression needs.

🟦The scenario describes expected opioid side effects rather than a GI emergency.

Encourage use of the incentive spirometer.

🟦Incentive spirometry helps prevent atelectasis, but it does not treat nausea and vomiting.

🟦It’s appropriate postoperative care, just not the priority response to the current symptom.

Auscultate bowel sounds.

🟦 Assessing bowel sounds can be helpful overall, but it does not relieve the client’s active nausea/vomiting.

🟦 The immediate need is symptom control to reduce discomfort and prevent aspiration.

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Answer 2

Correct Answers:

Apply cool compresses to the affected Iimb every 6 hr.

Rationale :

🟦 Early after a total knee replacement, swelling and pain are expected due to tissue trauma and inflammation.

🟦 Applying cold therapy helps reduce edema, decreases inflammatory response, and can lower pain by reducing nerve conduction in the area.

🟦 Cooling also helps minimize postoperative bleeding/oozing and promotes functional recovery by improving comfort for early mobility.

🟦 Scheduled cold application supports better participation in physical therapy and helps prevent stiffness from guarding.

🟦 This intervention is safe, noninvasive, and directly targets the expected postoperative problem of swelling and pain in the first 24 hours.

Place a pillow under the affected limb.

🟦Placing a pillow directly under the knee can encourage flexion contracture and limit extension, which is harmful after a knee replacement.

🟦The goal is to promote full extension unless otherwise prescribed.

Promote bed rest for 5–7 days.

🟦Extended bed rest increases risk for DVT, pneumonia, constipation, and delayed functional recovery.

🟦Early mobilization and therapy are standard to prevent complications.

Encourage increased fluid intake.

🟦Hydration is beneficial, but it is not the most targeted priority for the immediate post-op knee concerns compared with swelling management.

🟦 The question focuses on an action specific to knee replacement recovery, where cold therapy is more direct.

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Answer 3

Correct Answers:

Encourage fluid intake at and between meals.

Rationale :

🟦 Spinal cord injuries can cause neurogenic bladder, leading to incomplete emptying and urinary stasis, which increases UTI risk.

🟦 Encouraging adequate fluid intake promotes regular urine production, helping flush bacteria from the urinary tract and reducing colonization.

🟦 Better hydration also reduces urine concentration, which lowers irritation and helps maintain healthier bladder conditions.

🟦 This intervention is noninvasive and supports long-term prevention, especially for clients who may need intermittent catheterization schedules.

🟦 In addition, increased fluids can improve overall elimination patterns and decrease complications tied to prolonged urine retention.

Offer the client the bedpan every 2 hr.

🟦Bedpans support toileting, but they do not address neurogenic bladder emptying effectively in many SCI clients.

🟦Preventing UTIs depends more on effective bladder emptying and urine flow, not bedpan frequency.

Obtain a prescription for an indwelling urinary catheter.

🟦Indwelling catheters increase UTI risk by providing a direct pathway for bacteria and causing biofilm formation.

🟦When catheterization is needed, intermittent catheterization is generally preferred to reduce infection risk.

Cleanse the perineum from back to front.

🟦This technique increases contamination risk by moving organisms from the anus toward the urethra.

🟦 Correct hygiene is front to back to reduce bacterial transfer and lower UTI risk.

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Answer 4

Correct Answers:

Administer oxygen via nasal cannula.

Rationale :

🟦 A sucking chest wound is an open pneumothorax that can rapidly impair ventilation and oxygenation, evidenced by RR 40/min and tachycardia.

🟦 Immediate oxygen supports improved oxygen delivery while other emergency interventions are initiated.

🟦 Early supplemental oxygen is a key stabilization step because hypoxia can worsen shock and tissue perfusion quickly.

🟦 This client shows signs of respiratory compromise and possible evolving shock (weak pulse, HR 118), so supporting oxygenation is urgent.

🟦 While definitive management includes an occlusive dressing and chest tube setup, oxygen is an immediate measure to reduce hypoxemia during rapid response actions.

Raise the foot of the bed to a 90° angle.

🟦 This is not an appropriate positioning strategy and can worsen respiratory mechanics by compromising diaphragmatic movement.

🟦The client’s priority issue is breathing, not aggressive foot elevation.

Prepare to insert a central line.

🟦A central line is not the first step in managing an open pneumothorax with acute respiratory distress.

🟦Immediate priorities are airway and breathing support, then definitive chest management.

Remove the dressing to inspect the wound.

🟦Removing a dressing can allow more air entry and worsen the pneumothorax.

🟦The priority is maintaining coverage and supporting breathing rather than exposing the wound unnecessarily.

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Answer 5

Correct Answers

Muscle movements [ Parkinson Disease ]
Ambulation pattern [ Parkinson Disease ]
Speech [ Parkinson Disease ; Stroke ]
Orientation status [ Parkinson Disease ; Stroke ]
Facial rigidity [ Parkinson Disease ]

Rationale :

Muscle movements (resting tremors, generalized stiffness) → Parkinson disease

🟦 Parkinson disease classically causes resting tremor because of dopamine deficiency in the basal ganglia, especially the substantia nigra.

🟦 The tremor often begins unilaterally (like the right arm on Day 1) and progresses over time to become bilateral, matching the 6-month follow-up.

🟦 Parkinson also causes rigidity and increased muscle tone, which is why the client later has generalized stiffness in addition to tremors.

🟦 These motor changes are typically chronic and progressive, not sudden, which helps separate Parkinson from an acute stroke presentation.

🟦 Multiple sclerosis can cause weakness or spasticity, but resting tremor with progressive rigidity is far more consistent with Parkinson’s disease.

Ambulation pattern (slow, rigid gait) → Parkinson disease

🟦 A hallmark of Parkinson disease is bradykinesia, which leads to a slow gait and difficulty initiating movement.

🟦 The description of the gait being slow and rigid aligns with muscle rigidity and reduced automatic movements seen in Parkinson.

🟦 Parkinson gait often progresses toward a shuffling pattern with decreased arm swing, reflecting impaired motor control from basal ganglia dysfunction.

🟦 This is typically a gradual decline, which matches the timeline (worsening over 6 months).

🟦 Stroke-related gait changes are usually more sudden and often show unilateral weakness, while MS gait changes often fluctuate with relapses rather than steadily progressing this way.

Speech (slow → slow and slurred) → Parkinson disease (also can be seen in stroke)

🟦 In Parkinson disease, speech is often slow, soft, and monotonous due to bradykinesia affecting facial, tongue, and laryngeal muscles.

🟦 Over time, reduced muscle coordination can lead to dysarthria, which explains the progression to slow and slurred speech at 6 months.

🟦 Parkinson speech changes tend to be progressive, matching the shift from slow speech to slow/slurred speech.

🟦 Stroke can also cause slurred speech, but stroke speech deficits are typically sudden onset and often accompanied by other acute focal neurologic signs.

🟦 Since this client shows progressive bilateral Parkinsonian motor features (tremor, rigidity, facial masking), the speech changes most strongly support Parkinson disease as the primary condition.

Orientation status (initially oriented → later disoriented to date/time) → Parkinson disease (possible cognitive progression)

🟦 Parkinson disease can progress beyond motor symptoms and affect cognition, especially as the disease advances, leading to Parkinson-related cognitive impairment.

🟦 Being disoriented to date and time suggests decline in attention, executive function, and memory, which can occur in later stages.

🟦 The key clue is the gradual change over 6 months, which is consistent with a progressive neurologic condition rather than a sudden event.

🟦 Stroke can cause orientation problems, but that usually follows an acute neurologic insult and is often more abrupt and associated with other focal deficits.

🟦 MS may cause cognitive issues, but the client’s dominant pattern is classic Parkinson motor progression, making Parkinson the best fit for the orientation change in this clinical picture.

Facial rigidity and drooling → Parkinson disease

🟦 Facial rigidity is a classic Parkinson feature and appears as a mask-like face due to decreased facial expressiveness from bradykinesia and rigidity.

🟦 Drooling occurs because swallowing becomes less frequent and less coordinated, not because saliva production increases—this reflects impaired motor control.

🟦 These findings strongly support Parkinson because they reflect progressive involvement of cranial and facial muscle control.

🟦 Stroke can cause facial droop or asymmetry, but facial rigidity with drooling is more characteristic of Parkinsonian facial masking than acute focal weakness.

🟦 MS can affect swallowing, but the combined pattern of resting tremor + rigidity + facial masking + drooling is most consistent with Parkinson disease.

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Answer 6

Correct Answers:

Bladder infection

Rationale :

🟦 Bladder infection (cystitis) can cause hematuria because inflammation irritates the bladder mucosa, making small vessels fragile and prone to bleeding.

🟦 With an indwelling urinary catheter, bacteria can ascend into the bladder, increasing risk for a catheter-associated UTI (CAUTI).

🟦 Blood-tinged urine is often accompanied by other UTI signs such as cloudy/foul-smelling urine, suprapubic discomfort, or fever, so this finding should raise concern for infection.

🟦 The catheter also causes mechanical irritation, but hematuria in this context is clinically treated as suspicious for infection until ruled out.

🟦 Recognizing blood in urine as a possible infection sign is important because untreated cystitis can progress to pyelonephritis or sepsis, especially in vulnerable clients.

Pernicious anemia:

🟦Pernicious anemia causes vitamin B12 deficiency leading to macrocytic anemia and neurologic symptoms, not blood in urine.

🟦It does not directly irritate the urinary tract to cause hematuria.

Prostate enlargement:

🟦BPH commonly causes urinary retention, weak stream, and hesitancy, not typically blood-tinged urine as the primary sign.

🟦Hematuria can occur but is less direct than infection when the client has a catheter and new blood-tinged output.

Dehydration:

🟦Dehydration usually produces concentrated, dark amber urine, not true hematuria.

🟦 It can worsen irritation, but it does not directly cause blood to appear in the urine.

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Answer 7

Correct Answers:

Establish a regular sleep pattern.

Rationale :

🟩 A core management strategy for fibromyalgia is improving sleep quality, because poor sleep worsens pain sensitivity, fatigue, and cognitive “fog.”

🟩 Establishing a consistent sleep-wake routine supports better restorative sleep, which can reduce symptom flares over time.

🟩 Fibromyalgia is strongly linked to altered pain processing in the CNS, and sleep disruption amplifies central sensitization, making pain feel more intense.

🟩 Regular sleep habits also support better daily function by improving energy levels, mood stability, and ability to participate in activity pacing.

🟩 This intervention is realistic, sustainable, and one of the most evidence-supported lifestyle steps for long-term symptom control alongside gentle exercise and stress reduction.

Avoid exercise during flare-ups

🟩Total avoidance can lead to deconditioning, which worsens pain and fatigue over time.

🟩During flares, the goal is gentle movement and pacing, not complete inactivity unless instructed for another condition.

Increase calcium intake

🟩Calcium intake is not a primary strategy for fibromyalgia symptom control because fibromyalgia is not caused by calcium deficiency.

🟩Nutrition matters for general health, but it does not specifically target widespread musculoskeletal pain in fibromyalgia.

Try jogging or running between flare-ups

🟩High-impact exercise may trigger symptom flares and increase pain in many clients.

🟩Fibromyalgia management favors low-impact aerobic activity (like walking, swimming, cycling) started gradually.

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Answer 8

Correct Answers:

Headache

Rationale :

🟪 A post–dural puncture headache is a known complication of spinal anesthesia caused by CSF leakage through the puncture site.

🟪 This lowers CSF pressure and produces a positional headache that worsens when upright and improves when lying flat.

🟪 It may also be associated with neck stiffness, nausea, dizziness, or auditory symptoms, making it an important complication to recognize early.

🟪 Identifying this complication matters because persistent CSF leak can require interventions such as hydration, caffeine, analgesics, or an epidural blood patch if severe.

🟪 Unlike expected numbness or temporary urinary changes, headache is a key red-flag finding that indicates a true anesthesia-related complication.

Hiccoughs

🟪Hiccoughs are not a typical spinal anesthesia complication and are usually benign or related to gastric irritation.

🟪They do not indicate CSF leakage or neurologic compromise in this setting.

Numbness in the legs

🟪Temporary sensory and motor block in the lower extremities is an expected effect of spinal anesthesia.

🟪It becomes concerning only if it persists longer than expected or worsens unexpectedly.

Absence of urge to void

🟪Reduced bladder sensation can occur temporarily after spinal anesthesia due to autonomic blockade.

🟪It is monitored, but by itself it is not the hallmark complication the question is targeting.

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Answer 9

Correct Answers

Blank 1 Correct Option: photosensitivity
Blank 2 Correct Option: chronic fatigue

Rationale :

Photosensitivity

🟦 Clients with systemic lupus erythematosus (SLE) commonly develop photosensitivity, meaning UV light triggers or worsens skin inflammation.

🟦 Your client already has a butterfly (malar) rash and cutaneous plaques on the scalp/face/neck, which are classic skin patterns that often flare with sun exposure.

🟦 UV exposure can activate immune responses in SLE, leading to more rash, hyperpigmentation, and plaque worsening, even when the client feels “fine” otherwise.

🟦 Photosensitivity is clinically important because it increases risk for frequent flares, persistent skin injury, and worsening visible lesions that affect quality of life and self-image.

🟦 Because the client has active cutaneous findings now, the nurse should treat sun exposure as a strong trigger and reinforce strict UV protection to reduce flare intensity and recurrence.

Chronic fatigue

🟦 The client reports progressive fatigue despite increasing rest, which strongly supports risk for chronic fatigue, a hallmark symptom of SLE.

🟦 The labs also support ongoing inflammatory disease activity: ESR 38 mm/hr indicates systemic inflammation, which commonly drives persistent fatigue.

🟦 The client’s hemoglobin 10 g/dL indicates anemia, which reduces oxygen delivery and can significantly worsen low energy and exercise intolerance.

🟦 SLE fatigue is often multifactorial, linked to immune activation, anemia, pain from joint tenderness, and medication effects—so it tends to be ongoing, not quickly fixed by rest alone.

🟦 Recognizing chronic fatigue early helps guide planning for energy conservation, pacing, and monitoring for complications like worsening anemia or organ involvement.

Hypoglycemia

🟦 SLE does not inherently cause hypoglycemia, and nothing in the history/labs suggests low blood glucose episodes.

🟦 Low-dose prednisone is more associated with increased blood glucose, not hypoglycemia, especially if dose rises.

Weight loss

🟦 While some chronic illnesses can cause weight changes, this scenario provides no evidence of decreased intake, GI symptoms, or documented weight trend.

🟦 The client’s priority pattern here is skin involvement + inflammation + anemia-related fatigue, not a clinical picture centered on weight loss.

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Answer 10

Correct Answers:

Difficulty reading

Rationale :

🟦 A right-hemisphere stroke commonly affects visual-spatial processing, attention, and perceptual abilities, which can interfere with reading comprehension and scanning (especially missing the left side of text).

🟦 Many clients develop left-sided neglect, meaning they may ignore the left side of the page, skip words, or lose their place while reading.

🟦 The right hemisphere also contributes to processing nonverbal information, so clients can struggle with tasks that require spatial organization and interpreting visual patterns, both essential for reading.

🟦 Reading difficulty may occur even when speech is fluent, because the problem can be perceptual/attention-based, not language production.

🟦 This finding fits a right-sided brain injury better than classic language deficits, which are more typical of left-hemisphere strokes.

Inability to recognize family members

🟦This suggests severe agnosia or specific temporal-occipital involvement and is not the most expected baseline finding for a typical right-hemisphere stroke.

🟦Right-sided strokes more often show neglect and spatial-perceptual issues rather than global inability to recognize familiar people.

Aphasia

🟦Aphasia is most commonly associated with left-hemisphere strokes (Broca/Wernicke areas in most people).

🟦A right-hemisphere stroke more often causes impaired judgment, impulsivity, neglect, and visual-spatial deficits.

Right hemiparesis

🟦Motor deficits occur contralateral to the brain injury, so a right-hemisphere stroke would more commonly cause left hemiparesis.

🟦Right hemiparesis is more consistent with a left-hemisphere stroke.

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Assessment Findings	Parkinson Disease	Stroke	Multiple Sclerosis
Muscle movements
Ambulation pattern
Speech
Orientation status
Facial rigidity

Custom NUR213 Final Assessment FA II 2025 Assessment 1

No.

1 :
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

3 :
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

4 :
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

5 :
A nurse is caring for a client.

Correct Answers

6 :
A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

7 :
A nurse is teaching a client who has fibromyalgia about self-care strategies for managing the disorder. Which of the following information should the nurse include in the teaching?

8 :
A nurse is caring for a client immediately following a procedure that required spinal anesthesia. Which of the following findings indicates the client is experiencing a complication of the anesthesia?

9 :
A nurse in a clinic is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE).

Correct Answers

10 :
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

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Custom NUR213 Final Assessment FA II 2025 Assessment 1

No.

1 : A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

2 : A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

3 : A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

4 : A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

5 : A nurse is caring for a client.

Correct Answers

6 : A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

7 : A nurse is teaching a client who has fibromyalgia about self-care strategies for managing the disorder. Which of the following information should the nurse include in the teaching?

8 : A nurse is caring for a client immediately following a procedure that required spinal anesthesia. Which of the following findings indicates the client is experiencing a complication of the anesthesia?

9 : A nurse in a clinic is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE).

Correct Answers

10 : A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

1 :
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client 8 hr postoperative following a total knee replacement. Which of the following actions should the nurse take?

3 :
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

4 :
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

5 :
A nurse is caring for a client.

6 :
A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

7 :
A nurse is teaching a client who has fibromyalgia about self-care strategies for managing the disorder. Which of the following information should the nurse include in the teaching?

8 :
A nurse is caring for a client immediately following a procedure that required spinal anesthesia. Which of the following findings indicates the client is experiencing a complication of the anesthesia?

9 :
A nurse in a clinic is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE).

10 :
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?