Nursing Tasks, Procedures, and Patient Care, Exams of Nursing

Download Nursing Tasks, Procedures, and Patient Care and more Exams Nursing in PDF only on Docsity! NCLEX -Practice questions with 100% correct answers. The nurse is providing care for several patients that arrived at the convenient care at the same time. Which patient will the nurse assess first? A) 15 year old with a severe headache, stiff neck, and high temp. [meningitis] B) 27 year old with a fever, vomiting, abdominal cramping, and diarrhea. [dehydration] C) 62 year old with arthritis and having severe pain. D) 43 year old with dysuria, severe burning with urination and fever. [UTI] - Correct answer A Paramedics call the charge nurse. They are coming in with 4 patients involved in a motor vehicle accident. Which patient does the nurse plan to see first based on the report? A) A 26 year old screaming of pain. Has a visible right knee deformity and weak lower extremity pulses. [circulation] B) A 22 year old female who is responsive to painful stimuli, pulse rate 118 beats per minute with no visible traumas or injuries. [intracranial hemorrhage] C) A 6 year old boy with a visible deformity to the forearm and crying. D) an 8 year old girl with a cut on the forehead, crying intensely with a pulse rate of 126 beats per minute. - Correct answer B - Patient might be experiencing internal hemorrhage and go into a hypovolemic shock The nurse provides care for a patient with diabetes insipidus. Which nursing diagnosis is most appropriate? A) Fluid volume deficit related to excess urine output. B) Hyponatremia related to high sodium excretion. [not a Nanda nursing diagnoses] C) Risk for fluid volume overload related to decreased urine output [ deficit not overload] D) Hyperglycemia is related to reduced insulin and cortisol production. [diabetes mellitus] - Correct answer A - DI is deficiency of secretion of antidiuretic hormone or decreased response to ADH. This results in massive water excretion. Thus, fluid volume deficit A patient right after post hypophysectomy. He is thirsty and has frequent urination. Which action does the nurse take first? A) Check the glucose in urine B) Encourage drinking water C) Check urine specific gravity D) Call the surgeon - Correct answer C -Post-op, diabetes insipidus can temporarily occur due to low ADH Which Outcome indicates that the intervention for a patient with syndrome of inappropriate antidiuretic hormone {SIADH} has been effective? A) Decreased serum osmolality B) Serum sodium is decreased C) Increased urine output D) Increased urine osmolality - Correct answer C- Increased urine output - sign that treatment is effective The nurse performs a newborn assessment. Which finding does the nurse report to the physician? A) Pink patch on the back of the neck B) Bluish skin over the sacral gluteal area C) A rectal temperature of 98*F D) A respiratory rate of 24 breaths per minute - Correct answer D: normal resp rate ~ 30-60; Pink patch ~ {stork bite} normal, bluish skin ~ {mangolian spots} normal;, Newborn 0-2yr old, Infants <1 yr old The oncology nurse is giving a teach about risk factors and demographics of lung cancer at a gathering at the local community clinic. Which group of individuals has the highest risk for lung cancer? A)African Americans B) Caucasians C) South East Asians A) 1430 B) 1500 C) 1330 D) 1400 - Correct answer C - a trough level is drawn approximately 30 minutes before the next scheduled dose Patient is getting gentamicin IV every 8 hours. The provider ordered a gentamicin peak. If the medication is administered at 10 am over one hour, at which time should the nurse draw the gentamicin peak? A) 10 am just before giving the dose B) 12 noon C) 11:30 am D) 5:30 pm just before the next due dose - Correct answer C - peak occurs 30 minutes after to completion of IV drug The nurse provides care to a new admission. Which action is the best example of culturally appropriate nursing intervention? A) Assign the family members to most of the patients personal care B) Take a permission before touching the patient for the physical assessment C) Keep a personal space of 3 feet when assessing the patient D) Keep in mind the patient's ethnicity as the most important factor in planning care - Correct answer B - many cultures consider it disrespectful to touch a patient without asking permission; in a NEW admission, the ethnicity is not the most important factor The nurse provides care for a patient with acute anxiety. What is most important for the nurse to assess the patient for? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis - Correct answer A - anxiety causes hyperventilation, which results in a loss of carbon dioxide. Respiratory alkalosis is caused by decreased carbon dioxide in the blood A patient who had gastric surgery 2 days ago has an NGT attached to intermittent suction. The patient had a large amount of secretions in the last day down in the suction bottle. Which ABGs result will the nurse expect to see? A) pH - 7.23, PaCO2 - 48 mmHG B) pH - 7.39, PaCO2 - 38 mmHg C) pH - 7.49, HCO - 30 mmol/L D) pH- 7.28, HCO - 20 mmol/L - Correct answer C - this ABG reflect metabolic alkalosis A patient states "I feel ugly because I lost my hair" after receiving chemotherapy for ovarian cancer. Which statement does the nurse say to help the patient cope with those feelings? A) "Lets see how you look with a shawl or hat" B) "Your hair will grow back 3-4 months after you finish treatment" C) "Some women shave their heads when this starts to happen" D) "Just think how it makes you not brushing your hair every day" - Correct answer A- the patient has feelings of a distrubed body image and low self esteem because of hair loss. The nurse needs to say something to improve those feelings. Suggesting a scarf or hat is appropriate. It will offer an immediate solution to the patient. C-Telling the pt that shaving her head will not help her cope with her current feelings right away , B dodges the empathy needed with this situation, D- is almost sarcastic The nurse provides care for a patient with facial, and neck burns. What is the best position for the patient? A) Prone with a rolled sheet under the head B) Supine with padding on the affected side C) Supine without pillows or padding D) Prone without extra padding around the head - Correct answer C- a supine position minimizes pressure and irritation to the burned areas, but burned areas may stick to pillows or padding. Pillows may cause contraction in patients with neck burns. While frying chicken, the hot oil fell on the patient's abdomen and thighs. Patient was diagnosed with 3rd degree burns while in the ED. Which finding will the nurse expect to observe during the emergent phase of the burn injury? A) High hematocrit B) Slow heart rate C) Elevated blood pressure D) Increased urinary output - Correct answer A - a large fluid shift will occur from intravascular to interstitial What is the single most important act the preceptor should emphasize on while orienting a new nurse on a burn unit? A) Put on PPE including head and shoe covers B) Make sure medical equipment is not shared between patient rooms C) Put patients with infection in private negative pressure rooms D) Wash hands thoroughly and consistently during your shift - Correct answer D- hand washing is the single most important act to prevent transmission of infection on a burn unit The nurse provides care for a 16-year old patient who is diagnosed with meningitis. The provider ordered intravenous and oral hydration. The nurse closely monitors the patient's fluid intake. Which serious complication does the nurse monitor for this patient? A) Heart failure B) Hypovolemic shock C) Cerebral edema D) Pulmonary edema - Correct answer C- because of the inflammation of the meninges, the patient is vulnerable to developing cerebral edema and increased intracranial pressure. Patient had a car accident, she is oriented to self but not to time and place. The patient complains of a severe headache and is restless. Which action does the nurse take first? A) Help the patient remember the current location and time of the day B) Put the patient in a vest restraint C) Neurological assessment every 15 minutes D) Give the patient PRN morphine and lorazepam - Correct answer C- Remember ADPIE, increased ICP is suspected. Confusion, restlessness, pupillary changes, and altered level of consciousness are the earliest signs spread of organisms that are acquired from direct or indirect contact, especially multidrug-resistant organisms such as MRSA A new NAP is on the unit, the nurse delegates finger-stick glucose check and then discovers that the NAP has never done this task before, and changes the assignment. Why did the nurse change the assignment? A) It is not the right supervision B) It's not the right person C) It's not the right circumstance D) It's not the right direction - Correct answer B- it is not the right person. Choosing the correct personnel to complete the task {nerve done it before}; Supervision {appropriate monitoring, intervention and follow up}, circumstance{using appropriate pt & setting to determine if it is right}, direction{giving the right direction for a task} The nurse delegates ambulating a patient 4 days after surgery to a nursing assistive personnel (NAP). Which type of delegation is the nurse following? A) Supervision B) Circumstance C) Person D) Communication - Correct answer B - the person is stable 4 days post op The nurse delegates tasks to a nursing assistive personnel for the first time. Which actions are appropriate for the nurse to implement? (Select all that apply) A) Explain to the NAP which tasks will be delegated B) Explain to the NAP how to report task completion C) Permit the NAP to decide which patient changes to report D) Allow the NAP to decide when tasks will be completed E) Explain to the NAP the expected task outcomes - Correct answer A,B,E The nurse reviews care needed for a patient 2 days post-operation.Which would the nurse delegate to nursing assistive personnel (NAP)?(Select all that apply) A) Apply T.E.D. stockings B) Measure height and weight and document it C) Educate on performing breathing exercise D) Check for urinary retention using a bladder ultrasound E) Assist in wearing a leg prosthesis - Correct answer A,B,E Which tasks can be delegated to a UAP? A) Inserting a foley catheter B) Measuring and recording the patient's output through a Foley catheter C) Teaching a patient how to care for a catheter after discharge D) Assessing for symptoms of a urinary tract infection? - Correct answer B- falls w/i the implementation phase of the nursing process and does not require nursing judgement. Evaluation of the intake & output must be done by the nurse The nurse is getting a 22 year old patient ready before surgery. What would the nurse delegate to the nursing assistive personnel? (SATA) A) Getting a clean catch urinalysis B) Taking vital signs C) Assess lung sounds D) Put on T.E.D. stockings E) Educate patient on correct technique to use incentive spirometer - Correct answer A,B,D The nurse provides care for multiple patients. Which tasks does the nurse delegate to the nursing assistive personnel?(SATA) A) Assess patient's pain level B) Teach patient how to perform crutches use C) Hand meal trays D) Give bath to a patient with a surgical site E) Get standard vital signs - Correct answer C,D,E The nurse is looking to prevent venous thromboembolism. Which action does the nurse delegate to the NAP? (SATA) a) Change the patient's position every 2 hours B) Help the patient ambulate as needed C) Give the patient education materials on venous thromboembolism D) Apply sequential compression devices E) Apply compression stockings - Correct answer A,B,D,E Which activity does the nurse delegate to nursing assistive personnel? (SATA) A) Teach the patient how to self-administer a small enema B) Take vital signs of a patient with contact precautions C) Take the patient's vital signs at 10 minutes from the blood transfusion start D) Reinforce the dressing of a pressure ulcer E) Help a patient with poor eyesight to get to the bathroom - Correct answer B,E The nurse provides care for an elderly patient with no past medical history.The nurse evaluates the patient's immunization status. Which of the patient's immunizations are up-to-date? (SATA) A) Receive his tetanus booster at age 60 B) Did not get the hepatitis A vaccine yet C) Last herpes zoster vaccine at age 60 D) Did not get the hepatitis B vaccine yet E) Got flu shot this season - Correct answer A,C,E - the pt has no medical history {not at risk does not need hep vaccine} The nurse provides care for the patient receiving radiation therapy for lung cancer. Which patient statement indicates to the nurse that further intervention is needed due to the side effects of radiation? (SATA) A) "I'm having difficulty swallowing" B) "I am missing days at work recently" C) "I haven't had a bowel movement in 4 days" D) "I have rash on my arm pits" E) "My hair is falling out in clumps" - Correct answer A,B,D - Radiation to lungs could be affecting tissues around the throat {airway}, the patient is fatigued, radiation therapy can cause rashes → deodorant is an irritant; constipation and alopecia is usually found in CHEMO pts When do you administer the Herpes live vaccine? A) 40-50 years A) Swaddle the newborn in a flexed position B) Maintain the newborn in a prone position C) Frequently feed the newborn a high-calorie formula D) Station the newborn in a quiet area on the unit E) Dimmed light around newborn's crib provides a more peaceful environment - Correct answer A,D,E - swaddling the pt will comfort them {similar to when they were in utero} and in a flexed position will prevent startle, place newborn in a quiet, dimmed lighting area to prevent agitation; You do not place an infant prone unattended → SIDS, it is not necessary to frequently feed the newborn What potential long-term effects of fetal alcohol syndrome does the nurse include in teaching for pregnant women about alcohol consumption during pregnancy? (SATA) A) Delayed physical growth B) Facial deformities C) Respiratory depression D) Learning disabilities E) Hypotension - Correct answer A,C,D The nurse provides care to a newly diagnosed patient with schizophrenia who is prescribed chlorpromazine 25 mg PO TID. Which patient statement indicates a correct understanding of taking the medication? (SATA) A) I'll brush my teeth three times a day B) It will take 4-6 weeks for my medication to start working C) I may have a glass of wine each night because it is good for the heart D) I can drive myself to work on Monday E) I have to get blood levels regularly for a couple of months F) I will not worry about pink urine - Correct answer A,B,E,F - Chlorpromazine has a side effect of extremely dry mouth so oral hygiene is very important, phenothiazines take 4-6 weeks to see signs of improvement,chlorpromazine has an effect on white blood cells and can cause leukocytopenia, this medication is known to cause pink tinged urine; no alcohol, no heavy machinery {cars} on an antipsychotic, The nurse provides care to a patient diagnosed with C.diff. Which precaution will the nurse take? (SATA) A) Wear a protective gown when entering the patient's room B) Wear a surgical respirator mask while administering medications C) Wear gloves when handling the food tray D) Patients visitors should wear a mask while in the patient's room E) Don surgical gloves with removing surgical dressing - Correct answer A,B - C. Diff is contact precautions, gown & gloves; respirator is for airborne, a mask is not necessary, to remove a surgical dressing wear disposable gloves and then put on surgical gloves to clean dressing The nurse assesses the new admission. What indicates that the patient is at risk for having a latex allergy? (SATA) A) Patient has a current avocado allergy B) Patient received packed red blood cells C) The patient has a history of arthritis D) Patient has a history of multiple surgical procedures E) Patient is a health care worker - Correct answer A,D,E - avocados and banana allergies are linked to latex allergy, if a pt has multiple surgical procedures they are exposed to latex a good bit this increases their risk for allergy, a health care worker wears latex gloves constantly, this can increase the risk. A healthy patient is being treated for localized herpes zoster (shingles). What observations indicate to the nurse that care is appropriate? (SATA) A) Applied airborne precautions B) Prescribed oral acyclovir C) Keep patient's room closed at all times D) Nurse assigned to care for patient has history of chickenpox E) Perform pursed lip breathing exercises - Correct answer B,D,E - Herpes zoster (shingles) is contact precautions, Acyclovir should be prescribed, nurse w a hx of chickenpox is immune to virus, pursed lip breathing can help the pt cope with the discomfort of shingles {does not affect oxygenation or respiratory system} The nurse instructs parents on the sudden infant death syndrome (SIDS). Which statements require the nurse to act? (SATA) A) My baby sleeps in a supine position B) My baby sleeps in his car seat on my way to child care C) I always cover my baby from chest to toe during sleep D) I like to put a small pillow under my baby's head when he sleeps E) I let my baby nap on my waterbed - Correct answer B,C,D,E - An infant has no control over their neck muscles, if they fall asleep in the car seat with their head leading forward it could obstruct or close their airway, A blanket and pillow could cover their face and cause suffocation, an infant should sleep on a firm surface, soft surfaces could cause neck flexion or suffocation ;Supine is an appropriate position to sleep in Disseminated Herpes zoster is airborne precaution. A) True B) False - Correct answer True A patient is diagnosed with CHF. Which information about self- management at home will the nurse include in the teaching? (SATA) A) Set a regular time for your medication B) Drop down the sodium intake to 4 grams a day. C) Avoid taking ibuprofen for headaches D) Inform symptoms of shortness of breath to your physician E) Report weight gain of more than 3 pounds per week to your physician - Correct answer A,C,D,E - Adhere to medication regime, avoid NSAIDS {retain salt & fluids}, weight gain and SOB are both exacerbations of CHF ;Pts w CHF need to drop their sodium intake to less than 2 grams per day Which statement by a patient diagnosed with CHF raises concerns for the nurse? A) When I wake up my ankles are normal, but are swollen at night B) I have hard time catching my breath after I make my bed in the morning C)I feel bloated most of the time D) Every time I cough, I experience chest pain - Correct answer B- Pulmonary edema is more concerning fluid passes from the pulmonary capillaries to the alveoli causing SOB, and respiratory depression, dyspnea can become worse with physical exertion; Chest pain caused by coughing is a sign of pericarditis and can be treated with antibiotics, Swollen ankles and the feeling of bloatedness are expected signs for right sided HF A) I will include more of broccoli and bananas in my diet B) I will be monitoring my blood pressure at least once a week C) I will take my medication every day in morning D) I will use salt substitute with my meals E) I will move slowly from a sitting position to a standing position - Correct answer A,D - ACE inhibitors can cause potassium retention so a diet that stays away from high potassium is encouraged, salt substitute causes potassium retention The patient is scheduled for surgery the next morning. The order states NPO without mentioning medication. Which medication causes the nurse to question its administration prior to surgery? (SATA) A) Atenolol 25 mg for hypertension B) Midazolam 5 mg to prevent seizures C) Aldosterone 25 mg for hypertension D) Dexamethasone 4 mg for COPD E) Clopidogrel 75 mg given daily for a-fib F) Alprazolam 2.5 mg given at bedtime for insomnia - Correct answer C, E - You don't hold antihypertensives before surgery unless it is a diuretic (aldosterone), give midazolam so that the levels are not messed up and cause seizures, clopidogrel is a blood thinner Roles and responsibilities of the nurse manager position include: (SATA) A) Monitoring the professional practice model on the unit B) Coordinating the patient discharge care C) Empower the nursing staff at the administration's meetings D) Following up on patient's and family complaints E) Following up on the root cause analysis of incident reports - Correct answer A,C,D A patient is being transfused 1 unit of packed RBCs. The patient complains of burning at the IV site. The nurse assesses the site and edema is present. Which action does the nurse take first? A) Stop the transfusion B) Flush the IV cannula with pre-filled normal saline C) Remove the IV cannula and apply pressure to the site D) Raise the extremity above the heart level - Correct answer A - Burning and edema are signs of infiltration, stop the infusion, assess and raise above heart level; do not apply pressure to the sight,Never flush an IV that has edema The patient calls the nurse and complains about pain at the IV insertion site. He has dobutamine infused via peripheral intravenous catheter. After stopping the infusion, which action does the nurse take next? A) Apply cold compresses to the IV site B) Call the doctor C) Mark around the affected skin D) Position and support the extremity - Correct answer B- signs of extravasation should be reported right away to start treatment before losing any tissue, Never apply cold compresses to dobutamine; marking the area and supporting the extremity comes after treatment is initiated Which of the following is not a side effect of ACE inhibitors? A) Proteinuria B) Neutropenia C) Tachycardia D) Skin rash - Correct answer C - tachycardia is a side effect of calcium channel blockers The nurse assesses a patient in labor. Which assessments indicate that the patient is in the active phase of the first stage of labor? (SATA) A) Her contractions are 2 to 3 minutes apart B) Her contractions are irregular C) Her contractions are 30-40 seconds long D) There is an extensive amount of blood gush E) The patient is doubtful of ability to control pain - Correct answer A,E In true labor, contractions are stronger, longer & wider apart. True False - Correct answer False- contractions become stronger, longer & shorter apart Which is an indicator that the patient had an effective intervention to treating her mild pre-eclampsia? A) Blood pressure of 146/82 mm Hg B) Periorbital edema C) Deep tendon reflexes of 2+ D) Proteinuria of 3+ - Correct answer C - indicates that the intervention is working The patient came for her 16 week gestation visit and asked the nurse how her baby looks. Which is an accurate response by the nurse? A) Extremities are just starting to show and you can hear a heartbeat now B) Lungs and ear are functional now C) He would be sucking on his thumb right now D) We can tell the sex of your baby today - Correct answer D- sex determintion is possible, Extremities are formed & a heart rate is heard by 8 weeks, lungs aren't functional, sucking on his thumb would occur around 20 weeks Nursing report was given to the night shift nurse about four pregnant patients in active labor. Which patient does the nurse assess first? A) A nulliparous patient 10 cm dilation and 100% effacement B) A nulliparous patient with fetus in transverse lie and FHR of 155 BPM C) A multipara patient at 8 cm dilation with the presenting fetal part at 2+ station D) A multipara patient at 0 station with fetus in breech presentation - Correct answer C-most multipara women have very fast transition phase; D - the fetus is still in breech position, B - the fetus is stable and in transverse lie; A- even though they are fully dilated and effaced, nulliparous women take longer to transition The nurse creates a dietary teaching plan for a pregnant patient. Which information will the nurse include? A) Protein requirements will double B) Increase calories by 800 kcal/day C) Need to increase iron C) 3x the baby's birth weight D) Palpable posterior fontanel - Correct answer B- sit up without support is a realistic expectation; Pincer grasp appears at 9 months, 3x birth weight by the age of one, posterior fontanel closes at 2 months The nurse observes a student assess neonates in the newborn nursery. Which action by the student nurse requires immediate intervention by the nurse? A) Documenting a negative red light reflex in a 2 day old neonate B) Testing the tonic neck reflex by lying the neonate supine and turning the head to one side C) Testing the rooting reflex by stroking the corner of the neonate's mouth D) Documenting a positive Babinski reflex in a 1-day old neonate - Correct answer A - a negative red light reflex indicates a severe neurological deficit, possibly caused by increased intracranial pressure. It must be evaluated immediately The nurse is dropping a urine specimen to the lab. Which nursing action is necessary? A) Always put the urine container in a biohazard ziplock bag B) Deliver by hand to the lab within 1 hour of obtaining the specimen C) Deliver the urine specimen through the tubing system D) Label the urine container with the room number - Correct answer A- biohazard bags are necessary for all specimens; delivering by hand in 1 hour is not as necessary The nurse is giving discharge instructions to a 10 year old boy with a fractured radius bone. Which observation requires the nurse to refer the patient to home health? A) The boy didn't go to the playroom during the hospital stay B) The father works night shifts C) The boy's mother has bruises around her neck D) The mother is anxious to leave the unit - Correct answer C - bruises around the neck could be signs of abuse at home. Violence in the family is a rsik factor for child abuse An enema is given to a patient with impacted bowel. The patient's heart rate drops from 80-50 beats per minute once the nurse starts introducing the enema. Which action does the nurse take first? A) Withdrawal the rectal tube B) Reduce the flow rate of the enema C) Stop the enema D) Position the patient on his left side - Correct answer C - first step is to stop what is causing the vagal stimulation, then put patient on his left side, remove the tube and reassess. Later you may be able to try again at a slower rate. A patient is admitted after a MVA, the patient has a body mass index of 17. Which assessment will the nurse identify as a health problem? A) Hydromorphone allergies B) Arthritis C) Pressure sore injury D) Low blood pressure - Correct answer C - underweight patient would negatively impact wound healing, {bony prominences} A COPD patient diagnosed with emphysema. The patient starts getting anxious and confused. What is the first action the nurse should take? A) Raise the oxygen flow rate from 2 to 4 liters per minute B) Help patient perform breathing exercises C) Check the patient's serum sodium D) Assess the patient's blood pressure - Correct answer B - this prevents the collapse of the alveoli and helps the patient control the depth and rate of breathing The nurse taking care of multiple patients. Which patient will the nurse assess first? A) Patient with CHF and reports retrosternal pain B) Patient who had laparoscopic abdominal surgery 2 hours ago and is sleeping C) Patient who had a left lung lobectomy 15 hours ago and is positioned on the right side D) Patient who had an appendectomy 10 hours ago with vesicular lung sounds on the lower lobes - Correct answer A - patient w/ CHF reporting signs of MI. Patients with chest pain will be considered in myocardial infarction until proven otherwise. The nurse provides care for a patient diagnosed with type 2 diabetes. The health care provider has ordered exenatide for the patient. When will the nurse administer this medication? A) Twice a day within 1 hour before morning and evening meals B) Once a day before bedtime C) Twice a day within 2 hours before morning and evening meals D) Twice a day within 1 hour after morning and evening meals - Correct answer A - exenatide stimulates the pancreas to secrete insulin when blood sugar levels are high. It should be administered twice a day within 1 hour before the morning and evening meals Patient is prescribed glimepiride for his type 2 diabetes mellitus. The nurse is reconciling the patient's medication, which entry in the patient's medication list causes the nurse to question the glimepiride prescription? (SATA) A) Atenolol B) Gemfibrozil C) Ginkgo biloba D) Ginseng E) Ibuprofen F) Valerian - Correct answer A,B,D,E -Atenolol (Beta blocker) mask side effects of hypoglycemia, Gemfibrozil (cholesterol med) ^ hypoglycemic effect , Ginseng ^ hypoglycemia effect of sulfonylureas, Ibuprofen ^ hypoglycemic effects A home care nurse taking care of a patient receiving tube feeding. Thich care objective will the nurse identify as a priority for this patient? A) Education B) Counseling C) Screening D) Case management - Correct answer A - education and health promotion are the primary objectives of home care contraindication is if the pt is immunocompromised, taking antiviral medication or has MMR allergy A patient is at 11 weeks gestation. Which finding does the nurse expect to observe? A) Can feel the fundus at the umbilicus B) Can listen to the fetal heart rate using a doppler C) Can palpate the fetal movement D) Can see colostrum - Correct answer B - the nurse should be able to hear the fetal heart rate of 110-160 bpm with doppler around 8-12 weeks gestation; at this time the fundus will be at the symphysis pubis, fetal movement is felt around 18-20 weeks, colostrum is seen at 16 weeks A student nurse is supervised by the RN while taking BP of an adult patient with a small sized cuff. What instruction does the RN express to the student? A) Reliable readings of BP B) Shows a false low reading C) The high cuff pressure will cause brachial nerve damage D) Shows a false high reading - Correct answer D - the small cuff will not read brachial artery measurements unless it is extremely inflated, when it is it will show a false high reading The RN is educating the patient on the use of an incentive spirometer. Which instructions does the nurse include? A) Maintain spirometer at 45 degrees angle while breathing in B) Blow into the spirometer for 3 full seconds C) Deeply inhale through spirometer and hold your breath for 3 seconds D) Maintain the spirometer straight up to allow the aerosols to drop into the lungs - Correct answer C - deep inhalation and holding breath for 3 seconds prevent atelectasis; should be eye level so that they can watch the level of intake, spirometer does not have aerosol - thats an inhaler A psychiatric patient on the unit continuously tells the nurse that his stomach is missing. Which response by the nurse is appropriate? A) Losing weight should not be a problem for you then B) When do you think it went missing C) Sounds like you feel very lonely here D) I will do whatever it takes to help you get better - Correct answer C - delusions often reflect the patient's underlying emotion. The nurse should first respond to emotions then orient the patient to reality. Don't encourage the delusions A patient has autonomic dysreflexia. What is the next step after elevating the head of the bed? A) Give antihypertensives B) Remove restrictive clothing C) Insert urinary catheter D) Call the doctor - Correct answer B The charge nurse observes the nurse delegate a dressing change for a patient with fever, neutropenia, and hypotension to the LPN. Which action will the charge nurse do next? A) Allow the LPN to complete the assigned task B) Ask another experienced LPN who is more comfortable with dressing changes to complete the task C) Explain to the nurse that the dressing change can not be delegated to the LPN D) Ensure that the nurse follows up with the LPN if the task was done - Correct answer C - the patient is not stable and the nurse should complete the dressing change instead The charge nurse is distributing the assignment for the nurses on the night shift. Which patient is most appropriate to be assigned to the LPN? A) A psychotic patient B) A patient undergoing chemotherapy administration C) A patient who has right leg skin traction D) A patient undergoing blood transfusion - Correct answer C - the most stable patient with expected outcomes; Things to ask: Is this pt stable? Does this pt have outcomes (are they high risk)? The night shift psychiatric nurse on the unit is going out of the patient's room and notices a bipolar patient experiencing an episode of mania at the nurse's station. Which intervention would promote therapeutic interaction with the patient? A) Approaching the patient and assertively ask him to abide by acceptable behaviors B) Redirect the patient to his room and minimize trigger of his behavior C) Reminding the patient of the limits and isolating the patient to his room D) Going over the unit rules and the patient's rights, then encourage the patient to go to his room and sleep because it is late - Correct answer B - effective strategies include redirecting the patient and reducing environmental trigger Can LPN cosign a unit of packed RBCs? A) Yes B) No - Correct answer B - No,you need two RN's to cosign a blood transfusion The nurse supervisor is rounding on the psychiatric unit at the beginning of a night shift. What situation requires the supervisor to give immediate attention? A) The UAP removes the dinner tray of a patient diagnosed with major depression. The tray is still complete & untouched by the patient. B) The UAP is changing the bed linen while a bipolar patient is trimming his beard with an electric razor C) The LPN gets loud trying to convince a patient with bipolar disorder to take his medication D) The UAP puts some cologne on an Alzheimer patient after giving him a bed bath, places the cologne on the food table while patient is getting ready to eat dinner and goes to the dirty utility room to drop the used towels - Correct answer D - personal care items impose choking risk for the patient with dementia The doctor prescribes sulindac 150 mg PO twice a day for 10 days. Which symptoms should the patient report immediately to the doctor? A) Anorexia B) Double vision C) Ecchymosis of the lower limbs A patient with crutches at the top of the stairs leaning his weight on his good leg and the crutches. What does the patient do next? A) Go ahead to the first step placing down both crutches first B) Bring both the crutches and the unaffected leg down to the first step C) Bring both the crutches and the affected leg down the first step D) Move down the stairs with the good leg first and the crutches follow - Correct answer A - the patient goes down the stairs with the crutches first A patient with a right tibial wound is prescribed negative- pressure wound therapy. Which is the most important action for the nurse to take prior to applying the wound vac? A) Draw serum protein level B) Assess motor power in the right leg C) Check for capillary refill of the thumb D) Check white blood cell count - Correct answer A - protein is important for wound healing, if the albumin is low → give albumin to increase wound healing effects During physical assessment, the nurse checks the patient's back and sees small pinpoint hemorrhagic dots. What does the nurse document in her chart? A) Extravasation B) Cyanosis C) Melanoma D) Petechiae - Correct answer D A patient posts an open- reduction internal fixation (ORIF) for a fractured right femur. The Nurse can't palpate the pedal pulse in the right leg. Which action should the nurse take next? A) Check the pain score using a numeric scale B) Assess the right foot for redness C) Assess for acute compartment syndrome D) Put the patient in a supine position and raise the right leg on a pillow - Correct answer C - absence of pedal pulse indicates acute compartment syndrome What are the 5 P's of compartment syndrome? (SATA) A) Pain B) Paresthesia C) Parotitis D) PE E) Pulselessness F) Pallor G) Peritonitis H) Paralysis - Correct answer A, B, E, F, H The nurse just finished getting a shift report. Which patient will the nurse see first? A) 24 hours post appendectomy patient B) 4 hours post cataract repaired patient C) A patient with an esophagogastric tube inserted during the morning shift D) A patient 2 days post spinal fusion surgery - Correct answer C- Monitor BP & Hr to assess for hypovolemic shock. Esophagogastric/Blakemore tube is indicated for gastric bleeding especially with Cirrhosis How will the nurse put the trochanter roll into position for an unconscious patient? A) Trochanter to the knee B) Lateral side of the hip to the middle of the thigh C) Middle of the thigh to the knee D) Medial part of the hip to the mid part of the calf - Correct answer B - this prevents the legs from rolling outwards when the patient is in supine position. If patella is directed upwards, this means that the position of the roll is correct and effective. The nurse received an admission from the PACU. The patient had a left total hip replacement. 10 hours later, the patient is still disoriented to place, time, and situation. Which action does the nurse perform first? A) Keep an abductor pillow between the patient's legs B) Keep orienting the patient to the surrounding and situation every hour C) Place the patient on NPO until fully oriented D) Encourage the patient to perform breathing exercises to wash out the CO2 build up - Correct answer A - placing and keeping a pillow between the legs keeps the new hip joint in proper alignment and prevent accidental dislocation of the prosthesis; with orthopedic surgeries always think safety A patient who is experiencing domestic violence asks the nurse why she is continuously getting beaten. What response is best by the nurse? A) Do you remember why you are being hit? B) Let us concentrate on your healing process now C) You don't deserve the abuse, we are here for you whenever you are ready for the help D) Your boyfriend is the only one who can answer why he is beating you - Correct answer C - reinforcing the patient's worth and stating that help is available is therapeutic; A- never imply they deserved the abuse, B- do not delay emotional healing, D - is not therapeutic The patient tells the nurse he is having urinary incontinence 3 days after his prostatectomy. He is changing incontinence pads. Which action by the home health nurse is appropriate? A) Instruct the patient to drink less fluids B) Encourage the patient to use artificial sugar in his drinks C) Encourage the patient to perform pelvic muscle strengthening exercises D) Take doxazosin 2 mg PO daily - Correct answer C - performing the exercise will enhance bladder control. The exercises should be done several times a day and will see improvement in a few weeks. What is the most common complication after joint replacement surgery? A) Clots B) Nerve damage C) Infection D) Bleeding - Correct answer C The nurse is caring for a patient after a prostatectomy. The nurse is working on a nursing diagnosis of Stress urinary Incontinence related to weakened pelvic musculature. Which goal is most important for this patient? osteoporosis. ECT contract the muscles and might place the patient at risk for bone fractures A student nurse is assessing a 60 year old patient for dehydration under the supervision of the nurse. When would the nurse intervene? A) Assess orthostatic blood pressure B) Checks the trend of patient's weight over the last week C) Assess the skin turgor on the thigh D) Checks the electrolyte level - Correct answer C - in this patient population, it it best to check the skin turgor by pinching the skin on the sternum or the hand for accurate assessment The physician prescribes 1.5 grams of vancomycin to be infused over 24 hours for MRSA infection. How many milligrams per hour does the nurse administer to the patient? - Correct answer 62.5 or 63 mg/hr Do sickle cell anemia patients have a high risk for CVA? Yes No - Correct answer yes The patient is scheduled for a Pelvic ultrasound to investigate cervical cancer. What instruction does the nurse include during the pre-procedure teaching? A) NPO for 6 hours prior to the procedure B) The ultrasound transducer might cause some discomfort while examining the abdomen C) Should drink 1 liter of water before the ultrasound D) Don't worry about the pain because local anesthetic will be given - Correct answer c- Filling the bladder with water prior to the test expands the uterus, causing it to move up and out of the pelvic cavity, which improves visualization Patient is being treated with a radioactive implant for bladder cancer. The nurse will intervene when the NAP does what? A) Spends more than 30 minutes in the patient's room at a time B) Puts the morning care equipment at the bedside table C) Stands at foot of the bed, crossing the placed portable bedside shield D) Stays at least 3 feet away when speaking with the patient - Correct answer Neither NAP nor visitors should stand at the foot of bed where the shield is no longer protecting them from radiation Which action is most important for a nurse to take with a patient getting radiation through implanted seeds for his bladder cancer? A) Check the position of the seeds every 4 hours B) Put the patient on a low-residue diet to minimize bowel movement C) Instruct the patient to use the bathroom every couple of hours D) Minimize drinking fluids to increase the effect of radiation in the bladder - Correct answer B - having a bowel movement can dislodge the radioactive implant, pt may be put on stool softener; Check the seeds q 8 hours, the pt needs to stay on strict bedrest, increase fluids to wash the radiation out of the body Patients with internal seed radiation should eat with disposable utensils. True False - Correct answer True, they should use disposable utensils, remove them from the room in double bags The nurse is preparing to give a medication IV push into an established peripheral IV line. Which action does the nurse take? A) Choose the distal port to the IV cannula B) Open the IV to a free flow rate while giving the medication C) Time the medication administration process D) Explain what just happened to the patient - Correct answer C - using a watch to record the time of administration ensures safe drug infusion; Use the proximal port, use a pinch and release method on the IV line to prevent back flow and flush the drug, educate the patient before you administer meds The nurse is caring for multiple patients. Which patient will the nurse assign to the LPN? A) Patient who had an accidental pneumothorax during appendectomy B) A MVA patient with high ICP who is not easily arouse C) A patient with cellulitis on 2nd dose of antibiotics D) A patient for discharge who had a fractured fibula with an external fixator - Correct answer C - antibiotics for cellulitis is the most stable patient; LPNs can not take care of unstable patients, RNs must do admissions and discharges The school nurse is watching the kids playing during recess. Which observation requires the nurse to intervene immediately? A) Two boys fighting over a girl B) A boy pushing a girl off the swing while moving C) A 3 year old placing his palm on his ear and crying D) A 6 year old with protruding tongue and drooling - Correct answer D - signs and symptoms of acute epiglottitis {airway}, stridor, mouth breathing, drooling, hoarse voice, restlessness and cough. Patient feels better leaning forward Nurse is triaging patients. Which patient has priority to be seen first? A) A 20 year old who got out of a car accident with neck pain B) A 4 year old having hoarseness and noisy, high pitched wheezes on inspiration C) A 9 year old who got his scheduled immunization yesterday is having a fever of 101.5F D) A 45 year old patient on coumadin who fell down and has deep laceration of his tibia - Correct answer B - those signs are concerning of stridor which indicates an upper airway obstruction which is an emergency, airway is the highest priority Which organism causes epiglottis? A) MRSA B) Staphylococcus aureus C) Haemophilus influenzae D) Streptococcus pneumonia - Correct answer C A 2 year old child with failure to thrive tested positive for a sweat test. What orders does the nurse anticipate? A) Give replacement enzymes C) The patient's menstrual cycle is back to normal D) The patient reached an ideal body weight - Correct answer C - Amenorrhea is a sign of anorexia nervosa, a normal cycle shows that the pt has met goal The nurse sees another nurse don a gown, gloves and face mask before entering a patient's room. What would the nurse expect the patient's diagnosis to be? A) 1 year old with RSV B) A 6 year old with hepatitis A C) A 15 year old with C. Diff D) A 20 year old with influenza A - Correct answer D - droplet precaution is needed A patient is on peritoneal dialysis. The nurse notices that the outflow looks tinged red. Which action does the nurse take first? A) Call the doctor B) Ask the patient about her last menstrual period C) Check vital signs D) This finding is normal in peritoneal dialysis - Correct answer B - because of the hypertonicity of dialysate, blood from the uterus can be pulled through the fallopian tubes into the effluent; It should be clear in color, or tinged yellow The nurse is assigned to take care of 4 patients, after reviewing their history which patient is identified as being most at risk for developing breast cancer? A) 29 year-old nulliparous patient B) 45 year old patient with a familial history of breast cancer C) 58 year old patient with history of breast cancer at 38 D) 60 year old patient who has been menopause for 13 years - Correct answer C most at risk- age greater than 50 is at risk for developing BC especially with a positive hx; First pregnancy is at 30 years old ^ risk for breast cancer, pt with family history of BC is at risk, women over the age of 50 are at risk for breast cancer Are women with large breasts at risk for breast cancer? Yes No - Correct answer yes - They are 3x higher than women with smaller breast The nurse audits the documentation of the student's assessment of the patient's anterior chest. The student has correct documentation when the nurse sees what? A) Excursion of the diaphragm is 3 cm B) Asymmetric expansion of the chest C) Clear vesicular breath sounds over bilateral lungs D) Symmetric ribs and intercostal spaces noted - Correct answer D - appropriate inspection of the anterior chest; Excursion of the diaphragm & expansion of the chest is assessed on the posterior, breath sounds are assessed posteriorly & anteriorly A patient with HIV is experiencing a new abnormal skin tissue, the physician is suspecting a cutaneous Kaposi sarcoma. Which assessment confirms the diagnosis? A) Swelling and blockage of the lymphatic system B) Slightly elevated purple lesions all over the skin C) Swelling in the genitalia D) Punch biopsy of the lesion - Correct answer D - a punch biopsy will provide an accurate diagnosis A patient diagnosed with peripheral arterial insufficiency is ready for discharge. It is important to include which of the following in the discharge teaching? A) Soak your feet in warm water three times a day B) Keep your body warm by wearing baggy layered clothing or use blankets C) Elevate your feet whenever you are resting D) Lay down your feet on the floor for at least 4 hours a day - Correct answer B - stay warm by dressing in non-constricting layers of clothing; resting your feet on the ground is recommended but 4 hours a day is extensive The patient is currently on streptokinase for a recent stroke. Which lab value would cause the most concern? A) Serum glucose of 187 B) INR of 1.3 C) Platelet count of 85,000 D) Hemoglobin level of 8.4 - Correct answer C - low platelet count has a higher risk for bleeding The nurse manager is giving orders in terms of patient's room allocation, reviewing plan of care and assigning tasks for LPNs. Which leadership style is she practicing? A)Autocratic leadership B) Democratic leadership C) Laissez-faire leadership D) Transformational leadership - Correct answer A - autocratic leadership is like a micromanager, this is the aggressive style of leadership, democractic focuses on teamwork, Laissez-faire leadership gives a lot of freedom, transformational leadership will build you up and support the staff Which observation by the nurse requires intervention during the care of a patient with continuous NG tube feeding by a student nurse? A) Before refilling the next feeding, the nurse aspirates gastric fluid to check for proper placement B) Student nurse administers two medications at a time, then flushes properly with water C) Maintain the patient in a semi fowler position at all times D) Before refilling the next feeding the student nurse checks and measures the gastric residue - Correct answer B - Risk for NGT medication clumping and interaction; administer 1 med at a time The nurse double dosed the patient on vancomycin and the patient is at the oliguric phase of acute kidney injury. Which will the nurse expect to observe? A) Urine output of 1ml/kg/hr B) K + 5.9 C) Creatinine 1.1 The patient complains of pain at his renal biopsy site 14 hours post op which radiates to his flank and umbilical area. Which complication is suspected? A) Bleeding B) Infection C) Hypertension D) Renal colic - Correct answer A - this is the number one complication with internal organ biopsy A patient is on phenytoin for his idiopathic seizure disorder. The patient is going on a date in 2 weeks and is concerned about having an episode. Which action is the best for the nurse to take? A) Call the doctor and suggest increasing his phenytoin dose on the day of his date B) Attend the date to provide assistance C) Go over some relaxation exercises that the patient can practice on his date D) Encourage the patient to have a seizure diary - Correct answer D - having a dairy will help monitor what the triggers are and avoid those activities The patient is having status epilepticus. Which action is most appropriate for the nurse to take? A) Place a mouthpiece in the patient's mouth B) Hold the patient's arms down C) Put the side rails up D) Maintain the patient in the center of the bed - Correct answer C - Putting up the side rails The nurse wants to determine the heart rate while holding a 6 second strip. The nurse counts 7 QRS complexes. What is the heart rate? A) 88 bpm B) 70 bpm C) 80 bpm D) 32 bpm - Correct answer B - on a 6 sec strip count the QRS complexes x 10 During an active seizure, is it ok to put a pillow under the patient's head to protect from head trauma? A) True B) False - Correct answer False - Just let the patient seize, a pillow can cause neck flexion and obstruct the airway What is the treatment of unstable V-tach with a pulse? A) Defibrillation 200 J B) Amiodarone C) Sync. Cardioversion D) Cardiac Compressions - Correct answer C A medical surgical nurse calls in sick 2 hours before the beginning of the shift. The supervisor floats a nurse from the postpartum unit. Now the team consists of a nurse, a NAP, and one nurse resigned from the postpartum unit. Which patient will the charge nurse assign to the postpartum unit nurse? A) Patient with lumbar spinal cord injury required assistance to transfer to the bedside commode B) A patient with a history of MI 2 days ago who is having insomnia C) A hospice patient exhibiting gasping respirations D) A 24 hour post-craniotomy patient who is on continuous sedation - Correct answer B - the float nurse will be assigned to a stable patient A patient presented to the ED with expiratory wheezes and dyspnea. ABGs results are pH - 7.31, PaCO- 50, HCO - 24, and PaO2 - 51. The nurse puts the patient in high fowler's position and administered 1L/min of oxygen via nasal cannula. After 30 minutes, the ABG results are pH - 7.36, PaCP - 44, HCo3 - 22, and PaO2 - 68. Which action does the nurse take first? A) Bump up the oxygen to 2 liters per minute B) Start the process of admitting the patient C) Monitor the patient for another hour D) Discharge the patient home - Correct answer A - Bumping up the oxygen will improve the hypoxia; normal PaO2 = 80 -100 The nurse receives a report front eh night shift. Which patient does that nurse see first? A) A patient 3 days post CABG is getting his atrioventricular wires removed today B) Patient with diabetes mellitus type II is getting a cardiac catheterization at 12 noon C) A patient at 36 hours post surgery with a PCA for pain D) A patient awaiting heart transplant - Correct answer C - PCA is used for pain relief but can have side effects from the narcotics. The nurse should monitor hypotension, respiratory depression, nausea, bowel movement & urinary incontinence A patient is experiencing oral and esophageal mucositis after his last chemotherapy treatment. During the discharge teaching, which comment by the patient indicates successful teaching? A) I will stop by the grocery store on the way home to pick up a mouthwash for gargling B) I will swish and spit my nystatin after every meal I eat C) I will chill down this week and play with my legos D) I will drink a glass of lemon juice with black pepper every morning to help heal the lacerations in my mouth - Correct answer C - relaxation helps boost the immune system, distraction from pain is important ; ;Commercial mouthwashes contain a high concentration of alcohol & that will not help heal their mouth, the patient should swish and swallow nystatin, lemon juice is citric and is counterproductive to the healing process 30 minutes after a cystoscopy with spinal anesthesia, the patient starts to feel his toes and move the legs a little bit. Which action will the nurse take next? A) Check vital signs B) Auscultate abdominal sounds C) Assess if legs are warm D) Auscultate lung sounds - Correct answer A - this indicates the motor blockage from the anesthetic is wearing off. However, patients are still at risk for hypotension. BP and vital signs are important to assess for hypotension A 45 year old patient with insulin dependent diabetes mellitus. The patient is asking if he should take the yearly flu vaccine. Which response by the nurse is appropriate? A) Only healthcare providers need to get the flu vaccine every year B) The influenza vaccine is required every other year for a patient with chronic medical illness C) The inactivated influenza vaccine should be taken yearly D) Stay away from the influenza vaccine because it might give you the flu - Correct answer C - an annual or yearly influenza immunization is recommended for everyone over the age of 6 months especially a patient with chronic illness Should bisphosphonates be taken on an empty stomach first thing in the morning with 8 oz of water. True False - Correct answer True -- they should be NPO for 1 hour after too The spouse of a patient with depression is stating that the patient doesn't complete activities of daily living. What is an appropriate intervention for the nurse to suggest? A) Give the patient his medication before planning activity B) Allow the patient extra time to finish scheduled activities C) Help the patient with dressing and grooming D) Force the patient to complete morning ADLs - Correct answer B - communicating clear, calm expectations and giving the patient time to complete activities are useful and will benefit the patient to complete his activities; Depression medication take 2-4 weeks to give a therapeutic effect, some medication can also cause drowsiness A 55 year old patient was ordered dexamethasone 4 mg BID for nausea and vomiting. Which patient statement causes the nurse to be concerned? A) I will take my medication with meals B) I have this wound on my toes that won't heal C) I have to get consistent workouts D) I will avoid crowds from september till march - Correct answer B - corticosteroids suppresses the immune system → this will affect the healing process, can cause infection The student nurse is performing a dressing on a PICC line while the preceptor is supervising him. After removing the dressing, which action by the student requires the preceptor to intervene? A) Use the Iodine to clean the catheter insertion site B) Cover the catheter with a 4X4 gauze to get his sterile field ready C) Using a circular motion, he cleans the catheter site from the outside towards the insertion site D) Place an occlusive dressing and marking the date on it - Correct answer C - the cleaning motion is circular from the inside to the outside Alzheimer's patient is currently 48 hours post infection appendectomy. The patient messed with the IV fluid rate and opened the regulator to free flow. When the nurse discovered the incident, the patient already received 500 ml of normal saline. Which assessment indicates fluid volume overload? A) Fine crackles upon auscultation with elevated blood pressure B) Tachycardia and orthostatic hypotension C) Flushed face and warm dry skin D) Thready pulse and increased rate and depth of respirations - Correct answer A - These symptoms can cause the pt headache and SOB, these are signs of fluid overload The patient's wife who is diagnosed with Alzheimer asks if the new medication will improve the patient's dementia. Which response is appropriate by the nurse? A) The patient will be able to live independently B) The progression of Alzheimer will stop C) It will help improve the short term memory D) It will control symptoms of dementia but will not improve it - Correct answer D - dementia is irreversible What is a proper presentation of dementia? A) Sudden onset & reversible B) Slow progressive & irreversible C) Sudden onset & irreversible D) Slow progressive & reversible - Correct answer B A 56 year old patient was transferred to the ED after wandering away from home. The patient was found confused and restless. Which action is important to include in the patient's plan of care? A) Accept patient's behavior B) Give the patient's time to get used to the nurses C) Maintain a stable and consistent environment D) Make decisions on behalf of the patient until his confusion is gone - Correct answer C - this is the most beneficial to reduce anxiety of the new space The nurse arrived at their night shift and received a report on four patients. Which assessment finding does the nurse immediately report to the on call doctor? A) A patient with Afib reports halos in his vision B) A patient diagnosed with meningitis complains of headaches C) A patient who is 6 hours post open cholecystectomy, has negative bowel sounds D) Patient reports 2 episodes of diarrhea after he had his CT scan in the afternoon - Correct answer A -should be reported right away, side effects of Digoxin or Amiodarone are halos or blurred vision; B- headaches are expected finding; C - after 72 hours no bowels sounds would be concerning; D - contrast dye will have laxatives in them A patient is newly diagnosed with iron deficiency anemia, the nurse is giving discharge dietary instructions. Which meal option indicates that the patient had a good understanding if selected? A) Grounded beef with whole wheat pasta and cheese B) Chicken broth with coffee C) Boiled egg and pickles with orange juice D) White toast with tuna salad - Correct answer A - Beef is a very high source of iron; Coffee has tannin and will prevent absorption of iron, C has a lot of calcium in it & will help with asportion but there is no iron is this food selection, D is low in iron B) I have noticed a greenish vaginal discharge C) I will take my doxycycline pill at 11 am and 11 pm D) My boyfriend uses condoms for birth control E) I will complete taking all the pills prescribed to me F) I will take my antacid at bedtime - Correct answer B,C,F - B - dox. Has a risk to increase superinfection, C - it is taken at least 1 hour before because it causes esophageal irritation, F antacids should be taken 1-3 hours from dox administration, A - Doxycycline causes photosensitivity, sunscreen is suggested. D - it interferes with oral contraceptives, E correct information A 50 years old patient who had a hysterectomy, 48 hours later the patient notices a grayish foul-smelling vaginal discharge. What would the nurse suspect? A) Dehiscence B) Fistula C) Keloid D) Hemorrhage - Correct answer B - A leakage from the rectum to the vagina is suspected A 24 year old patient just gave birth and was transferred to the unit. Upon arrival, she asked the nurse for 20 pads and at least 15 diapers. What response by the nurse would be best? A) I will be right back with what you asked for B) You will be discharged in 4 hours, why don't you stop by the store on the way home. C) That's too many supplies D) Just tell me what items you need for the next hour - Correct answer D - is a professional response that is still getting to the patient's needs but in a cost effective way The patient is diagnosed with sleep apnea and requires a CPAP at night. While relaying the discharge teaching, which statement by the patient indicates that additional teaching is needed? A) The mask will cover my nose and mouth B) The air is pressured to my upper airway to keep it open C) I will step out to the balcony to have my smoke D) My CPAP will be my companion during vacations - Correct answer C - CPAP uses room air not oxygen, and is not combustible Which question is most important for the nurse to ask when screening a patient for sleep apnea? A) Do you frequently wake up at night? B) Do you struggle to sleep? C) Does your partner complain of your snoring? D) How many naps so you get during the day? - Correct answer C - first sign of sleep apnea is snoring The son of an Alzheimer patient decided to take his father in to live with him and his wife. Which observation concerns the nurse? A) Electrical extension cords properly attached to the walls B) There is an analog clock on the hallway wall C) There is a blow-dryer hooked in the bathroom D) Locks are present on the top of the doors - Correct answer C - any electrical devices should be secured to prevent a safety risk to the patient A patient was just put on mechanical ventilation for respiratory distress. Which is the highest priority parameter for the nurse to check after putting the patient on the machine? A) Respiratory rate B) Tidal volume C) Blood pressure D) Alarm parameters on the ventilator - Correct answer C - decreased cardiac output is a complication of mechanical ventilation due to positive pressure within the chest. The RR, tidal volume and alarms are preset on the ventilator before putting the pt on. What is the cause of high airway pressure alarms on a mechanical ventilator? A) Cuff leak B) Tachypnea C) Decreased lung compliance D) Self extubation - Correct answer C - decreased lung compliance; Cuff leak and self extubation will cause low exhaled volume/ pressure airway, tachypnea will set off the high minute ventilation alarm. The nurse is screening against skin cancer. Which observation most concerns the nurse? A) A firm red nodule with an irregular surface and multiple colors B) A non-palpable pink lesion C) A circular lesion filled with fluids D) A red and shiny lesion - Correct answer A - looks like a malignant melanoma, {Asymmetry Border Color Diameter Edges} A patient with generalized anxiety disorder had been attending therapy programs to help with his anxiety. 3 months into therapy, which statement by the patient indicates to the nurse that progress took place? A) I got rid of my nail biting habit B) When I get overwhelmed with life stuff, I just go to my room C) I get some anxiety episodes every now and then, but they don't last long D) I am getting at least 6 hours of sleep with pleasant dreams - Correct answer D - sleeping & drawing indicate a well being of the body and a major resolution of anxiety A patient recently diagnosed with non Hodgkin's lymphoma gains 3.5 kg (7.7 lbs) in 2 days. The doctor ordered labs which shows, Na - 126, K - 4.2, Cl - 104, BUN - 18, creatinine - 1.2, Hgb - 10.2, ANC - 2.4K. Which reason does the nurse identify to explain the weight gain? A) SIADH B) Chemotherapy C) Acute kidney failure D) Anemia - Correct answer A - SIADH this results in increased water absorption & delusional hyponatremia; you wouldn't consider acute kidney failure because BUN and creatinine are normal The nurse is taking care of a patient with third degree burns. While planning for the dressing change of the burn, the nurse gives priority to which action? A) Get all the necessary medical supplies and bring them to bedside B) Perform a proper debridement to the wound before collecting the specimen C) Make sure to collect the oozing of the drainage once the old dressing is removed D) Flush the exudate with sterile water before obtaining the specimen - Correct answer D - the exudate has microorganisms from the wound and the environment. It would not provide an adequate analysis of the organism causing the infection. To ensure that the wound is properly cultured, the exudate should be flushed from the wound prior to taking a swab of the wound bed A 20 year old man looking for a gift idea for his father who is diagnosed with Parkinson. What would be the best option? A) Hair product and grooming clippers B) A key chain for the home keys C) Swivel utensils for food D) A modern foam mattress - Correct answer C - useful assistive devices for Parkinson patients may include utensils with large, rubber grips, swivel utensils that are designed to counterbalance to the patients' tremor and spill proof cups Paramedics just brought in a patient with facial fractures due to a car accident. What is the most important assessment for the nurse to do? A) Vital signs B) Airway assessment C) Lung sounds D) Wound assessment - Correct answer B a 52 year old patient had a fever and sore throat for three days. After a throat culture, the patient was diagnosed with a strep throat. Urinalysis shows protein 2+ and moderate RBCs. The patient was started on amoxicillin 875 mg for 10 days. Patient stated that he is leaving on a mini vacation in 5 days for 3 weeks. What would the nurse recommend? A) Check for penicillin allergy B) Schedule the patient for an office visit before his vacation C) Where is he going on vacation D) Ask the patient to present his airfare ticket - Correct answer B- the pt is experiencing a strep throat. One adverse effect of this bacterial infection is acute glomerulonephritis, which affects the kidney's ability to function appropriately. Patient should be seen before and after his vacation The doctor recommended therapeutic massage for the patient to help with his leg pain. The patient later on asks the nurse to explain therapeutic massage. What would be the best response by the nurse? A) It helps with fluid retention B) It prevents blood clot formation C) Im improves blood pressure readings D) It enhances circulation and muscle tone - Correct answer D - therapeutic massage helps return blood flow to the heart A 70 year old patient admitted to the med-surg unit. What would the nurse monitor in the patient's fluid and electrolyte balance? A) Hyponatremia B) Hyperkalemia C) decreased oncotic pressure D) Decreased insensible fluid loss - Correct answer A - with aging ADH increases while renin, and aldosterone decreases, leading to a decreased sodium reabsorption, water retention & hyponatremia; potassium balance is not r/t age. Older patients will have increased oncotic pressure and increased insensible fluid loss The home care nurse draws blood work for a patient diagnosed with schizophrenia. The patient is on Fluoxetine daily. The next morning the results come back with Na+ 127. Which action should the nurse take? A) Transfer to the hospital and initaite suicide precaution B) Get ready to start IV hydration of 0.9% NS C) One on one observation and initiate seizure precautions D) Do a thorough neurological assessment & report to doctor - Correct answer C - critically low levels of sodium require immediate evaluation due to the risk of seizures A patient was admitted to the med-surg unit after being exposed to radiation which resulted in a burn. The nurse checks on the patient who looks anxious and complains of abdominal cramps. Which action does the nurse take first? A) Assess the abdominal cramps B) Ask the patient to calm down C) Obtain a physician order of antispasmodic D) Initiate decontamination process - Correct answer A - the nurse should evaluate the assessment finding and then determine the best course of action The triage nurse gets a message about a patient diagnosed with Parkinson. The patient is having difficulty with his speech. What should the nurse be thinking about? A) Initiate facial muscle exercise B) Depression among Parkinson patients leads to speech issues C) Will require to change his medication regimen because of disease progression D) This finding puts the patient at risk for aspiration - Correct answer D - Because the muscles for speaking are the same as those used swallowing, the nurse determines that this patient may be at risk for aspiration The mother of a 3 year old asks the pediatric nurse about suggestions to get her boy to bed without a fuss every night. Which suggestion by the nurse is best? A) Ask your boy, "Are you ready to go to sleep?" B) Tell your boy, "we are going to read your book and then get to sleep" C) Be assertive and tell your boy, "C'mon, it is time to sleep" D) Hand your boy his favorite stuffed toy and walk him to bed - Correct answer B - The child must learn bedtime limits and have a preparatory transition to bedtime Which of the following electrolyte imbalances can cause seizures? A) Hypernatremia B) Hyponatremia C) Both - Correct answer Both can cause seizures - values that are not within normal range of 135-145 A) Anorexia, difficulty concentrating, depression B) High SGOT, cirrhosis on abdominal ultrasound C) Tremors, hyperthermia, leg cramping, generalized pain D) Headache, runny nose, night sweats, hyperthermia - Correct answer C - these are symptoms associated with an alcohol-related problem {A} symptoms are signs r/t mood disorders; {B} can be caused by alcohol use but is not an indication of alcohol use {D} can be signs of withdrawal of narcotics not alcohol What is the primary reason for an amputation? A) PVD B) Tumor C) Infection - Correct answer A- 80% are because of PVD, 75% of those are due to diabetes mellitus The charge nurse is auditing a student nurse performing physical examination of the patient. Which action by the student requires immediate intervention by the charge nurse? A) The nurse asks the patient to say 99 and assess for tactile fremitus B) The nurse opens the patient's mouth and a tongue blade is used to depress the tongue C) The nurse utilizes a stethoscope to palpate the patient's abdomen with the fingers D) After the nurse completed palpating the chest he starts chest inspection - Correct answer D - physical examination of the chest goes with this sequence: inspection, palpation, percussion, and auscultation The triage nurse comes back from her break to find four messages on her patient's to call back list. Which is the priority message to take care of? A) Patient diagnosed with lymphoma is not in the mood for chemotherapy and wants to skip today's treatment. B) A patient inquiring about his abdominal stitches C) A patient with chronic arthritis is complaining of pain and stiff elbows D) Home care nurse stating that the depressed patient is refusing to bathe today - Correct answer A - this is time sensitive & the patient should be aware of the consequences. Interrupting chemotherapy or postponing a day can change the entire cell cycle The nurse's updating the plan of care of a patient who had a hysterectomy. Which intervention should the nurse include in the plan of care? {SATA} A) Repositioning every 2 hours B) Assess for adequate urine output C) Fasting for 16 hours D) Assess for vaginal bleeding E) Schedule periods for walking and leg extensions - Correct answer A,B,D,E A 10 year old boy was having chest tightness and dizziness. The ECG reveals paroxysmal supraventricular tachycardia. What should the nurse do if the boy experiences the same symptoms at a later stage? A) Ask the patient to sleep on his back with both hand above the head B) Sit in a knee to chest position for 30 seconds C) Perform paced breathing exercises D) Pinch his nose and blow the cheeks - Correct answer D is valsalva maneuver for vagal stimulation to lower the heart rate Which immunoglobulins cross from the mother to the child through the breastmilk? A) IgA B) IgE C) IgD D) Immunoglobulin M - Correct answer A - the newborn's immature immune system is "boosted" by receiving IgA via breast milk. Therefore, helping to prevent the development of infections or disease The nurse is assessing a 2 month old newborn for a regular visit, which finding would the nurse consider normal? A) Gibson's murmur B) Head circumference of 42 cm C) Tense anterior posterior fontanel when baby is sleeping D) Extrusion reflex - Correct answer D - the extrusion reflex causes a baby to push something in his mouth out with his tongue. That instinct tends to diminish around four months of age; gibson's murmur is found in patent ductus arteriosus, the normal head circumference is 33-35 cm at this age, the fontanels should be soft while baby is sleeping The pediatric nurse is taking care of a 3 year old baby. The nurse is using play therapy to distract the child. Which toy or activity is most age- appropriate? A) Playground materials such as a playhouse B) Housekeeping toys like a cleaning trolley C) Stuffed animals D) Coloring books - Correct answer C - the nurse should always be aware of patient's safety & carefully screen toys for safety concerns ; the other options are those for a preschool age child The radiation oncology nurse is educating a newly diagnosed patient with cervical cancer about insertion of radiation seeds. Which statement by the patient indicates a need for further teaching? A) I will not be needing to have a bowel movement during treatment B) The implantation period with last 1-3 days C) I will have bathroom privileges D) I would have thought twice about pursuing treatment if I was not a mother with two toddlers - Correct answer C - The patient will be on strict bedrest during the radiation implants. The patient will have a urinary catheter in place, and will get an enema before inserting the implant The nurse at a community center is screening people for gastric cancer. What is the appropriate question for the nurse to include in the screening survey? A) Any history of ulcerative colitis? B) How often do you have energy drinks? C) Any history of Helicobacter pylori infection? D) Are you into wine drinking? - Correct answer C - the presence of H. pylori in the stomach increases the risk for gastric cancer. H.pylori causes peptic ulcer disease; ulcerative colitis puts the pt at risk for colon cancer A 7 year old boy has been recurrently admitted to the ED for asthmatic attacks. The doctor prescribes Albuterol and Beclomethasone via metered dose inhaler. Which statement by the mother indicates a good understanding of the medication administration instructions? A) I will give my oy Albuterol as needed for shortness of breath, and inhale the Beclomethasone daily in the morning as a preventative measurement B) I will take both inhalers in the morning starting with albuterol C) I will only give beclomethasone when I hear noisy lung sounds D) I will give my boy the albuterol in the morning and the beclomethasone before physical activity - Correct answer A - albuterol is a rapid-acting bronchodilator used to treat acute asthma attacks. Beclomethasone is an anti inflammatory corticosteroid inhaled form used in the long-term management of asthma A patient with chronic bronchitis and emphysema is admitted to the ICU for treatment. The patient receives IV aminophylline continuous infusion into a central catheter. Which adverse effects should the nurse be aware of and monito during the infusion? A) Bradycardia and hypertension B) Hypoactive bowel sounds & constipation C) Seizure activity & heart arrhythmias D) Dysuria - Correct answer C - assess for hypotension, arrhythmias, and convulsions until aminophylline serum levels stabilize within therapeutic range The nurse on a med surg unit is giving discharge teaching for a patient treated for Clostridium Difficile. Which instructions does the nurse highlight as "call your doctor immediately category"? {SATA) A) Develop dry skin B) Increased heart rate > 105 bpm C) Stomach cramps D) Clammy limbs E) Polydipsia - Correct answer A,B,D,E - these are signs of dehydration; {C} you will have cramps if diarrhea occurs A sickle cell patient is admitted to the hematology oncology unit for a blood transfusion. Which fluid is the solution of choice to go with packed red blood cell transfusion? A) LR B) 0.9 % NS C) D5% in 45% NS D) 0.45% NS - Correct answer B - it is isotonic and does not mess with the hemostasis of the blood A patient is presented to the ED with loss of consciousness. The patient is diagnosed with DKA. The ABGs results are pH - 7.22, PaCO -37, HCO - 19, and SpO2 - 88. Which order by the doctor requires questioning? A) Oxygen 2 liters/ minute via nasal cannula B) Glucose finger stick check Q 1 hour C) Give sodium bicarbonate 100 mEq over 2 hours D) Repeat ABG's in 1 hour - Correct answer C - The current algorithm in the management of DKA recommends giving sodium bicarbonate if the pH is below 6.9 A new mother on the maternity unit tells the nurse that she would like to exclusively breastfeed. The nurse provides breastfeeding education to the new mother. Which statements by the mother indicate that further teaching is required? {SATA} A) I don't want my baby to get any bacteria. I'm going to wash my nipple with soap and water after each feeding B) I will massage my breast to help with the engorgements C) I will apply ice to my nipples for comfort D) I will apply lanolin to my dry or cracked nipples E) If my nipples are leaking milk, I will apply pressure and use nursing pads with plastic lining - Correct answer A,E - these require further teaching; soap and water will cause nipples to become dry and cracked, a plastic lining on leaking nipples will promote moisture and yeast A newly diagnosed patient with left breast cancer post mastectomy is given discharge teaching by the nurse. Which statement by the patient indicates proper understanding of the instructions? A) Applying a heating pad under the left shoulder to help with the pain at night B) Apply a sling to your left arm during post op recovery C) Attend the breast cancer support group daily D) Measure the blood pressure with your right arm only D- potentially circulatory impairment or infection could exist due to alterations in lymphatic flow {A} it is not recommended to put a heating pad on or near the operative site, {B} the arm should not be at rest, they should use passive ROM daily, {C} attendance depends on the patient - Correct answer D- potentially circulatory impairment or infection could exist due to alterations in lymphatic flow {A} it is not recommended to put a heating pad on or near the operative site, {B} the arm should not be at rest, they should use passive ROM daily, {C} attendance depends on the patient A 28 year old patient has been having nausea and vomiting for a couple of weeks now. The nurse performed a pregnancy test and it came back positive. By calculating the last menstrual cycle, the patient is 10 weeks pregnant. Which assessment finding does the nurse expect to see? A) Linea nigra on the belly B) Chloasma On the forehead C) Leg cramps D) Hypertrophy of mammary glandular tissue - Correct answer D - enlargement of the breasts is caused by hormonal stimulation during the start of the pregnancy After a head trauma, the patient becomes malnourished due to confusion and disorientation. What act indicates to the nurse that the patient is getting better? A) The patient is aware that he has lost some weight B) The patient recognises the different foods on the menu C) The patient states, "I'm thirsty, I want some water please". D) The patient responds to the nurses request when she asks him to eat his food tray - Correct answer D - this reflects a positive outcome and improvement in nutrient consumption The charge nurse is planning an assignment for the night shift team. The team consists of an RN, an LPN, and a NAP. Which patient does the nurse assign to LPN? {SATA} A) Polydipsia B) Sweating C) Polyuria D) Tachycardia E) Polyphagia - Correct answer A,C,D,E - these are signs of hyperglycemia Azithromycin is a macrolide and should be given with meals to prevent gastric irritation. True False - Correct answer False - they do not cause any irritation, you give them on an empty stomach A patient with Burkitt's lymphoma is diagnosed with spinal cord compression and is being treated for a neurogenic bladder. The patient was started on chemotherapy ang the compression was resolved. The plan is to retrain the bladder. Which medication does the nurse expect to be ordered? A) Diphenhydramine B) Lorazepam C) Dicyclomine D) Bethanechol - Correct answer C - Dicyclomine is an anticholinergic medication that promotes urinary retention; {A} is an antihistamine, {B} is an antianxiety med, {D} has a cholinergic effect that promotes urination The night shift psychiatric nurse receives reports on four patients. Which patient does the nurse see first? A) A patient going through divorce and depression, after she gave birth to a baby with growth retardation B) An ex convict with a history of post traumatic stress disorder {PTSD} after having physical abuse in prison admitted with agoraphobia after someone called the cops on him C) A business owner who is diagnosed with severe anxiety because he shut down his business and filed bankruptcy D) A dancer admitted for depression and anxiety after her sister committed suicde and her mother was recently diagnosed with ovarian cancer - Correct answer B - patients with agoraphobia have a tendency for violence to self and/or others The charge nurse is rebooting mid-day and is coordinating care for patients on a med-surg unit. What activities can the nurse delegate to the NAP? {SATA} A) Assign room placement for patients coming from the ED B) Deliver a patient to the radiology unit for an abdominal ultrasound C) Remove a patient's peripheral IV D) Assist the doctor with a patient's vaginal exam E) Prepare the equipment needed for a peripheral IV insertion F) Explain to the patient that his chest pain needs to be assessed immediately in the ED - Correct answer B,D Which of the following patients with skin disorders can benefit from ultraviolet {UV} light therapy? A) A 33 year old pregnant woman with eczema B) A mania patient with Alibert-Bazin syndrome C) A 22 year old Crohn's disease patient with psoriasis D) A patient post intraocular lens replacement surgery with skin cancer - Correct answer C - UV light therapy is not contraindicated with Crohn's disease; {A} UV light therapy is contraindicated w pregnancy, {B} these patients are usually on antipsychotic meds which can cause photosensitivity, {D} UV light therapy is contraindicated with lens replacement At a community meet up, the nurse is giving education about testicular cancer screening. Which is an accurate statement on testicular self- examination? A) I will examine my testicles on a monthly basis right after I finish my shower B) I will examine my private parts every 3 months C) I will examine each testicle independently by rolling it between my fingers D) I will watch out for any pea sized lump on my testicles - Correct answer A - it is best to be assessed after a shower because scrotal skin is relaxed and smooth; It should be performed monthly, by examining each testical independently between a thumb & finger, assess for any swelling, or abnormal lumps of any size Which item does the nurse use to test the oculomotor nerve? A) Coffee B) Cotton C) Torch D) Salt & vinegar - Correct answer C - assess PEARL - pupil size, equality, accommodation reflex, and reactivity to light; {A} coffee is smelled to test the olfactory CN1, {B} cotton is touched to cheek to assess trigeminal nerve CN5, {D} salt & vinegar checks taste the CN7 facial nerve What is a straight violation to the EMTALA {Emergency Medical Treatment and Active Labor Act}? {SATA} A) Failure to provide advanced directive information B) Patient is denied for medical screening after few visit to the ER complaining of the same flank pain which doctors couldn't find a diagnosis to in the previous assessments C) A nurse shares the patient's medical health information with a family member who is not on his PHI {patient health information} access list D) A patient is selling his kidney after his business failed E) Transferring a patient to another facility before stabilizing his condition - Correct answer B,E ; {C} violates HIPAA, {D} violates the NOTO A patient with peripheral arterial disease complains during his clinical office visit that he is experiencing leg pain during long walks. Which statement will indicate that the patient understands proper interventions? A) I will lie down on my back and elevate my feet when I experience the pain B) I will apply a heating pad to my legs when I experience the pain C) I will walk until I experience pain. I will rest, and then resume my walk D) I will perform dynamic stretching of my muscles for 10 minutes before and after the walk - Correct answer C - working the muscle will demand additional flow of blood to the muscle to provide oxygen and remove the wastes The trigeminal nerve is responsible for chewing. A medical surgical nurse admitted a newly diagnosed patient with DVT. The provider prescribed warfarin 20 mg BID for the first 15 days of therapy. While collecting the initial assessment history, which statement would warrant the nurse to hold warfarin and contact the provider immediately? {SATA} A) Patient had a bilateral cataract 2 weeks ago B) Recent endoscopy revealed gastric ulcer C) Patient is a daily alcohol consumer D) Patient is on a baby aspirin daily for the past 5 years E) Recently colonoscopy revealed multiple polyps - Correct answer B,C,D - warfarin have an increased risk for bleeding and are contraindicated w alcohol & aspirin The patient is admitted from the ED complaining of headache. The patient's BP - 188/102. The patient is known to have a history of hypertension. The nurse should assess the patient's medication adherence. Which statement made by the patient indicates proper medication adherence? A) If my blood pressure is high in the morning, I do take another dose before bedtime B) I usually take my blood pressure medication just after breakfast at the same time every morning. Never missed a dose. C) I monitor my blood pressure every morning, if my blood pressure is normal I skip the dose D) On the weekends, I hike. I take my medication after the hike on the weekends. - Correct answer B The patient is broke. The patient calls the nurse to ask if he can substitute the prescribed Pantoprazole with an over the counter antacid with a cheaper price. Which response by the nurse is appropriate? {SATA} A) Let us try the antacids for a week and will give you a follow up call then to see how you feel. B) Let me check with the pharmacy about the cost C) Pantoprozole is a selective "proton pump inhibitor", a medicine which reduces the amount of acid produced in your stomach. It is used for treating acid-related diseases of the stomach and intestine D) Caffeinated beverages can also help in the ulcer healing process E) I will email educational videos about smoking cessation F) Call the clinic if you experience black tarry stools - Correct answer B,C,E,F The nurse is planning a teaching for a 61 year old patient with a history of recurrent lung infections. Which instruction does the nurse include in the teaching? A) Avoiding cardio exercises B) Don't go outdoors during the winter season C) Limit fluid intake to 500 ml daily D) Don't forget to get your flu shot on a yearly basis - Correct answer D - this is a preventive method A 54 year old patient, with a long history of cigarette smoking was diagnosed with laryngeal cancer and had laryngectomy done. The home care nurse instructs the patient's daughter on how to suction the patient's laryngectomy tube. Which observation indicates effective teaching? A) The daughter asks her mother to take several deep breaths before starting the suctioning process B) The daughter uses a Yankauer to suction the patient's laryngectomy tube C) The daughter applies suction while both introducing the catheter to the tube and out of the tube D) The daughter suctions the corners of the mouth from saliva and then the laryngectomy tube - Correct answer A - hyperventilation prevents anoxia during suctioning A 15 year old patient fractured his radius bone during gymnastics. During the follow up visit, the patient asks about measures to relieve itching under the cast. Which response by the nurse is accurate? A) Using a blow-dryer, apply cool air under the cast B) Wrap a sterile gauze on a tongue depressor and scratch the itchy area C) Apply ice chips under the cast whenever it itches D) Put hydrocortisone cream on a sterile gauze and apply on the area that itches - Correct answer A - is very effective After being in a long term care facility for a month due to rehabilitation from a back injury. A 62 year old patient asks the nurse about exercises to improve and maintain optimal musculoskeletal function. Which response by the nurse is best? A) Do not perform weight bearing exercises B) Perform resistance training C) Putting on muscle in older adults is an unrealistic goal D) Older adults should stick to walking as a form of exercise to maintain activity - Correct answer B - it helps maintain optimal function in older adults For effective suctioning, advance the catheter 10-15 cm & only suction while withdrawing the catheter. True False - Correct answer False -Only advance until you feel resistance, then suction on the way out for only 10-15 seconds Rumors on the med surg unit suspect that the new hired nurse is using cocaine. Which observations are suggestive of that accusation? A) Sneezing & headache B) Diarrhea & nausea C) Fatigue and mydriasis D) Lack of sleep, runny nose, and facial pain - Correct answer D - signs of inhaled cocaine; {A} are signs of a viral infection or rhinitis, {B} - can be signs of withdrawal from a substance, {C} not r/t cocaine use A patient with CHF is prescribed to infuse 500 ml of NS from 6:00 am until 13:00 in the afternoon. The tubings on the unit have a drop factor of 20 gtt/ml. Which rate per minute will the nurse calibrate the infusion to deliver to the patient? A) 22 gtt/min B) 24 gtt/min C) 48 gtt/min D) 62 gtt/min - Correct answer B A 64 year old patient with DM type 1 is admitted to a new nursing home but forgets to bring his prescribed medication with him. The patient states that A) At 4 months of age, I will start mixing baby cereal in the milk bottle to give my baby girl B) I will throw away any breast milk in my freezer that is more than 4 months old C) I will introduce baby cereal at 3 months of age to help with the growth D) My baby girl has enough iron stores from my breast milk that will last her 4 months - Correct answer D - one nutrient that is present in breast milk is iron ; {A} baby cereal will not mix in the milk bottle, {B} breast milk can last up to 6 months in the freezer, {C} introduce the baby to solid food around 4- 6 months An alcoholic patient is diagnosed with liver cirrhosis. Which intervention is most helpful for the patient's situation? A) IV albumin B) Kayexalate enemas C) Placement of Blakemore tube D) Low-protein, high carbohydrate diet - Correct answer D - this reduces the risks of hepatic coma by reducing the level of ammonia that result from the breakdown of proteins; {A} is only used in cases of ascites {B} hyperkalemia is not noted, {C} Blakemore tube is used in cases of esophageal varices and bleeding A patient diagnosed with liver cirrhosis is admitted to the med-surg unit with ascites. Which treatment will the nurse expect the doctor to order? A) Albumin B) Spironolactone C) Nabumetone D) Fresh frozen plasma - Correct answer A - Albumin is a hyperosmotic protein solution, it pulls fluid back into the bloodstream During a wellness child visit of an 8 month old baby. The nurse is to perform a physical assessment on the infant. What is a good technique for the nurse to use? A) Don't wake the infant to auscultate the heart sounds B) Fully undress the infant to do the physical assessment C) Ask the mother to hold the infant during the physical exam D) Start the physical with assessing the nose and throat - Correct answer C - The infant may be fearful of the nurse and equipment, the mother will bring the infant comfort ; {A} you want the infant sleeping {B} leave the infant dressed, undress to assess certain areas toward the end of the assessment {D} start with the least invasive assessments to last The nurse calls the mother of a patient diagnosed with antisocial personality disorder to follow up on the patient's progress with therapy. The mother states that her child looks way better and is accepting greater responsibilities. Which response by the nurse is best? A) That is awesome, I am happy to hear that B) Statistics show that children with antisocial disorders do not drastically change C) Continue the medication and therapy even if you see improvement D) Walk me a little bit through the new responsibilities your child has been taking - Correct answer D - open ended statements give the opportunity to further assess the situation A 66 year old patient has been diagnosed with Diabetes Mellitus type 1 for 10 years. The patient is at risk for left big toe amputation. What is the best goal the nurse would set for the patient's plan of care? A) Normalized cholesterol levels B) Take safety measures while riding his motorcycle C) Maintain good glycemic control D) Perform daily range of motion exercises - Correct answer C - peripheral vascular disease is prevented with optimal serum glucose control Rifaximin can cause severe constipation in liver cirrhosis patients and might cause bowel obstruction. True False - Correct answer false -It causes diarrhea The nurse provides care to a patient diagnosed with COPD. Which goal is most appropriate to include on the care plan for this patient? A) Improve gas exchange B) Perform activities of daily living without dyspnea C) Obtain flu & pneumonia vaccinations D) Sleep for 8 hours without interruption - Correct answer A) — Gas exchange is a priority for this client. B) Performing activities of daily living without dyspnea may be appropriate after gas exchange is improved. C) Vaccinations would be appropriate after gas exchange is improved. D) Sleep needs vary. This may not be realistic for this client. The nurse provides care to a client diagnosed with second- and third- degree burns on the anterior thorax and legs. Which finding will the nurse expect to observe during the emergent phase of the burn injury? A) Elevated hematocrit B) Decreased heart rate C) Increased blood pressure D) Increased urinary output - Correct answer A) CORRECT— An elevated hematocrit occurs because of hemoconcentration that takes place as the result of the large fluid shifts from intravascular to interstitial spaces during the emergent phase of a burn injury. B) Heart rate increases as a result of fluid shifts. C) Blood pressure decreases as a result of fluid shifts. D) Urinary output decreases because blood is shunted away from the kidneys, and renal perfusion and glomerular filtration is decreased. The nurse provides care to a client diagnosed with acute pancreatitis. Which intervention will the nurse include in the client's care plan? (Select all that apply.) A) Monitor signs of hypocalcemia B) Observe for manifestations of respiratory infection C) Provide a diet low in carbohydrates D) Position side lyding with the head elevated 45 degrees E) Provide a diet high in fats - Correct answer A, B, D, - {C} The diet should be high in carbohydrates because carbohydrates are less stimulating to the pancreas, {E}The diet should be restricted in fats because fat stimulates the release of cholecystokinin, which can aggravate an irritated pancreas.