CHII exam 4
Put into order the steps for blood administration: 1. get the blood from the blood bank 2. verify all patient information with a second RN 3. draw a blood sample for type and cross 4. ensure the IV access is 18 or 20 gauge 5. set up with 0.9% NS and filtered Y-tubing 6. begin the infusion and set the pump to infuse at a slow rate 7. check the patient's vital signs 8. stay with the patient for the first 15 minutes and monitor for a transfusion reaction 9. check the patient's vital signs again 10. make sure you have a consent form and provider orders
10,3,4,1,7,2,5,6,8,9
What does SNS stand for in the emergency resources context?
Strategic National Stockpile
blood products are transfused with which of the following IV fluids? a. 0.9% NS b. 0.45% NS c. Lactated Ringer's d. 10% dextrose
a. 0.9% NS
The nurse is establishing a plan of care for a client with newly diagnosed pelvic inflammatory disease (PID). Which problem does the nurse place as the client's highest priority? a. Infection b. Infertility c. Reduced sexual drive d. Reduced self-esteem
a. infection
Which nursing intervention helps to reduce the incidence of osteomyelitis for a client receiving hemodialysis? a. Instructing the client to brush teeth after every meal b. Maintaining clean dressing change technique for long-term IV catheters c. Using clean technique d. Using Standard Precautions
a. instruct the client to brush their teeth after every meal
A 54-year-old patient is on the surgical unit after a radical abdominal hysterectomy. Which finding is most important to report to the health care provider? A) Urine output of 125 mL in the first 8 hours after surgery B) Decreased bowel sounds in all four abdominal quadrants C) One-inch area of bloody drainage on the abdominal dressing D) Complaints of abdominal pain at the incision site with coughing
a. minimal UO (abnormal)
A 32-year-old woman who is diagnosed with Chlamydia tells the nurse that she is very angry because her husband is her only sexual partner. Which response should the nurse make first? A) "You may need professional counseling to help resolve your anger." B) "It is understandable that you are angry with your husband right now." C) "Your feelings are justified and you should share them with your husband." D) "It is important that both you and your husband be treated for the infection."
b. (validate feelings before giving information)
The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site. a. 2,4,3,1 b. 3,4,1,2 c. 1,4,3,2 d. 4,3,2,1
b. 3,4,1,2 (breathing first = ABCs, then examine site before applying direct pressure, and placing it above the client's heart)
Due to bacterial contamination risks related to blood transfusions, you must administer the blood product within how much time of receiving it from the blood bank? a. 15 minutes b. 30 minutes c. 4 hours d. 8 hours
b. 30 minutes (to give it within 4.5 hours total)
How quickly should you run a blood transfusion (300 mL)during the first 15 minutes (in mL/hr)? a. 15 mL/min b. 60 mL/min c. 100 mL/min d. 125 mL/min
b. 60 mL/hr (or 1 mL/min)
A 48-year-old woman is scheduled to have a bilateral salpingo-oophorectomy (BSO) and total abdominal hysterectomy (TAH) using a traditional open procedure for ovarian cancer. Her oncologist told her that after she recovers from surgery, she may need to have adjuvant chemotherapy to destroy any remaining cancer cells. She is married with a teenage daughter who is in the 12th grade. The patient tells you as her nurse that she is devastated that she "may not live to see her daughter go to the prom and graduate from high school." Will she experience a medical menopause? a. Yes, her fallopian tubes were removed during the surgery. b. Yes, her ovaries were removed during surgery. c. Yes, her uterus was removed during the surgery. d. No, she will still have her period and the chance to get pregnant.
b. Yes b/c her ovaries were removed
The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What electrolyte imbalance would the nurse monitor for after the blood transfusion? a. Hyponatremia b. Hyperkalemia c. Hypercalcemia d. Hypomagnesemia
b. hyperkalemia
After a nearby explosion, patients are being brought into your ED. Which of the following injuries is a secondary injury? a. ruptured eardrum b. lacerations from debris c. broken bone from another victim's impact d. exacerbation of asthma
b. lacerations from debris
A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse's best initial action? a. Remove the splint to reduce skin pressure. b. Perform a neurovascular assessment. c. Report the client's concern to the primary health care provider. d. Inspect the skin under the elastic bandage.
b. neurovascular check (for compartment syndrome)
When a patient with a BKA (below the knee amputation) is discharged home, their wound is usually left: a. in its original surgical dressing b. open to air c. in a compression wrap d. in a wet to dry dressing
b. open to air
A client had an anterior and posterior colporrhaphy (cervical) procedure this morning. What is the nurse's current priority assessment when caring for this client? a. Monitoring for urinary incontinence b. Determining pain level c. Checking for bowel sounds d. Inspecting the sternal incision
b. pain level (should have a foley in place post op, bowel sounds will be assessed but not the priority, there is no sternal incision)
A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse's best initial action? A. Remove the splint to reduce skin pressure. B. Perform a neurovascular assessment. C. Report the client's concern to the primary health care provider. D. Inspect the skin under the elastic bandage.
b. perform a neurovascular assessment
20 % of patients with a hip fracture due to which of the following complications? a. hip dislocation b. pneumonia c. recurrent falls d. recurrent infections
b. pneumonia
What are the 4 P's of hourly rounds for fall risks? a. Position, pain, placement, personality b. position, pain, placement, personal needs c. position, painting, placement, personal needs d. position, pain, place, personal needs
b. position, pain, placement, personal needs
Sarin is an example of a chemical nerve agent which can cause signs and symptoms including which of the following? a. loss of consciousness b. pulmonary edema c. loss of sight d. loss of sensation
b. pulmonary edema
Your patient with chronic osteomyelitis is at risk for contractures, what is the priority nursing intervention? a. give her pain medication b. put her foot into a brace c. immobilize the area d. get her ready for surgery
b. put her foot into a brace
A patient comes into the ER with symptoms of dark urine, muscle pain, weakness, nausea, and vomiting. What do you anticipate the diagnosis will be? a. rheumatoid arthritis b. rhabdomyolysis c. myopathy d. septic arthritis
b. rhabdomyolysis
What is the treatment for HIT? a. decrease the heparin infusion b. stop the heparin infusion c. start coumadin d. blood transfusion
b. stop the heparin (HIT= heparin-induced thrombocytopenia)
Your patient with a CHF exacerbation has labs that come back with the following results: WBC - 10k, Hgb - 6.9, Hct - 43%, Plt - 150k. Which of the following provider orders would you anticipate? a. replace platelets with 1 unit of serum STAT b. transfuse 1 unit of PRBCs within 4 hours c. transfuse 1 unit of whole blood within 8 hours d. transfuse 1 unit of whole blood within 4 hours
b. transfuse 1 unit of PRBCs w/in 4 hours
What is the difference between closed and open reductions? (SATA) a. closed reductions require surgery b. open reductions can be done at the bedside c. closed reductions can be done at the bedside d. open reductions require surgery e. closed reductions can be done by a RN
c,d
In the ER, you receive a patient with a tylenol overdose. Which patient answer means that they can receive activated charcoal? (SATA) a. "I got the antidote in the ambulance on the way here." b. "I took the pills about 3 1/2 hours ago." c. "I took the pills about 30 minutes ago." d. "I did not get the antidote in the ambulance on the way here." e. "I already got activated charcoal in the ambulance."
c,d (less than 1 hour and no antidote given already)
Which action will the nurse include in the plan of care for a patient with right arm lymphedema? A) Check blood pressure (BP) on both right and left arms. B) Avoid isometric exercise on the right arm. C) Assist with application of a compression sleeve. D) Keep the right arm at or below the level of the heart.
c.
For compressive devices in the plan of care for a patient with a hamstring strain, which of the following indicates a need for further teaching? a. "I will wear my compression brace for 30 minutes at a time" b. "I will take my compression brace off for 15 minutes at a time" c. "I will wear my compression brace at all times during the day" d. "I will wear my compression brace intermittently until my doctor says it's okay to discontinue use"
c. "wear it at all times"
Which of the following is the IV fluid of choice for burn victims? a. 0.9% NS b. 0.45% NS c. Lactated Ringer's d. 10% Dextrose
c. LR
Which antidote would you give for a tylenol (acetaminophen) overdose? a. naloxone b. flumazenil c. acetylcysteine d. Vitamin K
c. acetylcysteine (usually a nasal decongestant)
The nurse performs an assessment on a newly admitted client with thrombocytopenia. Which assessment finding requires immediate intervention by the nurse? a. Reports of pain b. Increased temperature c. Bleeding from the nose d. Decreased urine output
c. bleeding from the nose
After a nearby explosion, patients are being brought into your ED. Which of the following injuries is a tertiary injury? a. ruptured eardrum b. lacerations from debris c. broken bone from another victim's impact d. exacerbation of asthma
c. broken bone from another victim's impact
The night shift nurse reports that a client admitted with a femur fracture was just put into a cast, and gives you her sheet without any further report. She wrote "CMS check" to what is she referring to possibly? a. Cardiovascular, muscular, sensation check b. circulation, muscular, sensation check c. circulation, movement, sensation check d. cardiovascular, movement, sensation check
c. circulation,movement,sensation check
What is the treatment for hemophilia? a. heparin b. coumadin c. clotting factor replacement d. methotrexate
c. clotting factor replacement
A patient comes into the ED with suspected mustard gas exposure and is in the red zone. What is the priority nursing intervention? a. Assess vital signs and lung sounds b. place the patient in an isolation room c. decontaminate the patient d. assess airway and level of consciousness
c. decontaminate (needs to be in green or cold zone before assessment!)
A client had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. The staff nurse notes that the urinary drainage is pink-tinged and clear. What is the nurse's best action? a. Notify the charge nurse as soon as possible. b. Increase the rate of the bladder irrigation. c. Document the assessment in the medical record. d. Prepare the patient for a blood transfusion.
c. document (normal finding)
Which is more life-threatening, heat exhaustion or heat stroke, and why? a. Heat stroke because it is a prolonged exposure to heat b. Heat exhaustion because it is a failure of hypothalamic thermoregulation c. heat stroke because it is a failure of hypothalamic thermoregulation d. heat exhaustion because it is a prolonged exposure to heat
c. heat stroke because it is a failure of hypothalamic thermoregulation
Cast syndrome occurs mainly with which type of cast? a. upper extremity b. lower extremity c. hip spica d. bilateral lower extremities
c. hip spica (cast syndrome AKA mesenteric artery syndrome --> bowel necrosis.)
What is the treatment for ITP? a. heparin b. coumadin c. methotrexate d. aspirin
c. methotrexate (b/c immunosuppressant)
A client undergoes a surgical amputation of a lower extremity after a motor vehicle crash. The client's vital signs are stable. What is a priority nursing action in the early postoperative period to help prevent complications in this client? a. Fitting the client with a prosthetic device b. Inspecting the limb stump daily for signs of skin breakdown c. Positioning and range-of-motion of the affected extremity d. Teaching the client and family how to apply shrinker stockings
c. positioning and ROM exercises (not B b/c will wait for stump to heal)
What is the nurse's priority intervention when working with a patient that is post op after an amputation? a. assess wound healing b. assess infection manifestations c. preventing contractures d. recognizing phantom limb pain
c. preventing contractures (all are correct but contractures are non-reversible)
DMARDs are slow acting drugs for which of the following diseases? a. myopathy b. septic arthritis c. rheumatoid arthritis d. osteoarthritis
c. rheumatoid arthritis
During a mass casualty situation, which of the following patients would be considered a "green tag?" a. Abdominal evisceration b. Open fracture of the left forearm c. Sprained ankle d. Sucking chest wound
c. sprained ankle (green tag = "walking wounded")
An older man comes into the ER with flu-like symptoms including fever, chills, body aches, and nausea. Upon further assessment you find that he has an odd looking rash on his hands and feet. What disease process do you anticipate based on this assessment? a. chlamydia b. gonorrhea c. syphilis d. HPV
c. syphilis (secondary stage)
A client comes to the emergency department covered with coagulated blood and a white powder. The client is hysterical and fears that it is anthrax. What does the nurse do first? a. Administers antibiotics b. Provides emotional support c. Takes the client to the decontamination room d. Triages the client
c. takes the client for decontamination
When the nurse is working in the women's health care clinic, which action is appropriate to take? A) Teach a healthy 30-year-old about the need for an annual mammogram. B) Discuss scheduling an annual clinical breast examination with a 22-year-old. C) Explain to a 60-year-old that mammography frequency can be reduced to every 3 years. D) Teach a 28-year-old with a BRCA-1 mutation about magnetic resonance imaging (MRI).
d.
The nurse is teaching a 19-year-old female with genital warts about her condition. Which client statement requires the need for further education from the nurse? a. "There is no known treatment that will cure genital warts." b. "The warts may actually disappear or resolve without any treatment at all." c. "Genital warts may reappear at the same site." d. "Wart remover treatment from the drugstore will help me get rid of them."
d. OTC wart remover will help me get rid of them (false, all the rest are true)
Leslie is now in the ER after her brother knocked over pan of boiling water from the stove. Leslie is now 9 months old and has burns on her back, neck, and right arm. After the Leslie's respiratory and circulatory status is assessed, the next most important intervention would be to assess what? a. urinary retention b. cardiac monitoring c. supplemental O2 administration d. monitor for signs of compartment syndrome in the R arm
d. compartment syndrome on R arm
Typically a person with a core body temperature of less than 78 degrees F will present with what manifestation? a. stupor b. obtunded c. comatose d. dead
d. dead (coma is < 82.4 F)
A client has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon? a. Swelling of the right lower extremity b. 1+ to 2+ bilateral palpable pedal pulses c. Pain of right lower extremity on movement d. Decreased sensation of right lower extremity
d. decreased sensation of the right lower extremity (abnormal finding - call HCP)
Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? a. Increased skin turgor b. Decreased pulse pressure c. Decreased core body temperature d. Decreased urine specific gravity
d. decreased urine specific gravity (indicates more water in the urine and skin turgor is not as accurate)
What is the treatment for Von Willebrand's Disease? a. heparin b. coumadin c. methotrexate d. desmopressin
d. desmopressin (synthetic WV factor replacement)
After a nearby explosion, patients are being brought into your ED. Which of the following injuries is a quaternary injury? a. ruptured eardrum b. lacerations from debris c. broken bone from another victim's impact d. exacerbation of asthma
d. exacerbation of asthma
A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? a. "The pain will go away after the swelling decreases." b. "That's phantom limb pain and every amputee has that." c. "Your foot has been amputated, so it's in your head." d. "On a scale of 0 to 10, how would you rate your pain?"
d. how would you rate your pain?
A patient with severe rheumatoid arthritis is visiting the clinic for a follow up. You know that which of the following drugs is a disease-modifying antirheumatic drug? a. clonidine b. lisinopril c. methicillin d. methotrexate
d. methotrexate
Which of the following provider orders would need to be addressed with the HCP for a patient with thrombocytopenia? a. implement bleeding precautions b. transfuse 1 unit of whole blood c. give docusate senna once daily d. refer to Gastroenterology for a rectal exam
d. refer to gastro for rectal exam (no rectal exams/probes/meds as a bleeding precaution)
During a mass casualty, which injury is considered a "red tag?" a. Abdominal evisceration b. Open fracture of the left forearm c. Sprained ankle d. Sucking chest wound
d. sucking chest wound
Which of the following medications would you administer for a patient experiencing priapism? (SATA) a. vasodilator b. vasoconstrictor c. smooth muscle relaxer d. skeletal muscle relaxer
a,c
What are the signs and symptoms that your patient has developed a fat embolism after their fracture? (SATA) a. chest petechiae b. ↓ RR c. ↑ HR and BP d. decreased LOC e. ARDS symptoms f. chest pain and elevated troponins
a,c,d,e (↑RR and chest pain - the troponins)
You're calculating the true urine output of a patient with a CBI foley at the end of your 12 hour shift. Today, his intake included 8 oz. of coffee, 12 oz of water with lunch, an IV infusing 0.9% NS at 100mL/hr, and 3 L of irrigant fluid. His output was about 5800 mL via the foley catheter. What is his true urine output? Is it normal?
1000 mL/abnormal (high if normal UO is ~50 mL/hr. this is about 83 mL/hr)
If a patient is scheduled for an MRI, it will be important for the nurse to do which of the following? (SATA) a. determine a history of claustrophobia b. ask the patient if they have a pacemaker or any cardiac stents c. insert a 20 gauge IV d. hydrate them with IV fluids afterwards to remove harmful radiation e. maintain them as NPO until after the test
a,b (no radiation, no IV needed, no need for NPO)
Which of the following medications are often given before a blood transfusion? (SATA) a. benadryl b. lasix c. acetaminophen d. lisinopril e. lorazepam
a,b,c (to lessen known transfusion reaction, or decrease risk for fluid overload)
What are the main interventions for carpal tunnel syndrome? (SATA) a. splinting b. change of activity/PT c. steroid injections d. surgical interventions e. potassium replacement
a,b,c,d (K+ replacement for hypokalemic myopathy)
Which of the following STIs are bacterial? (SATA) a. chlamydia b. gonorrhea c. pelvic inflammatory disease d. syphilis e. genital herpes (HSV) f. genital warts (HPV)
a,b,c,d (PID b/c it's mostly caused by gonorrhea/chlamydia)
What additional assessment data will the nurse collect from an older Euro-American (white) woman to determine the client's risk for osteoporosis? (Select all that apply.) a. Tobacco use, especially smoking b. Alcohol use each day c. Exercise and activity level d. Dietary intake of Vitamin D e. Use of calcium supplements f. Medication history
a,b,c,d,e,f (all of them)
The community nurse is educating a client about frostbite prevention. Which factors will the nurse teach that are risk factors for developing frostbite? (Select all that apply.) a. Dehydration b. Smoking history c. Previous frostbite d. Excessive fatigue e. Smoking f. Wearing wool socks g. History of diabetes
a,b,c,d,e,g (wearing wool socks is a good prevention against frostbite, the rest are risk factors)
What are the priority nursing interventions for a patient with severe hypothermia? (SATA) a. ABCs b. warming blankets c. "bear hug" warming machine d. fluid resuscitation e. correct alkalosis f. warm IV fluids and lights
a,b,c,d,f (correct acidosis not alkalosis)
What are the signs and symptoms of acute osteomyelitis? (SATA) a. fever b. swelling c. erythema and heat d. pruritis e. throbbing bone pain f. caused by a foot ulcer
a,b,c,e
Which assessment findings will the nurse expect for a client who is suspected of having pelvic inflammatory disease? (Select all that apply.) a. Vaginal bleeding b. Fever c. Lower abdominal pain d. Constipation e. Rigid abdomen
a,b,c,e (constipation is not a finding of pelvic inflammatory disease)
What are the nursing treatments for rhabdomyolysis (SATA)? a. IV fluids b. electrolyte replacement c. treat the cause d. massage e. transfer to ICU
a,b,c,e (do not massage)
What is the priority nursing interventions for a patient coming in with hyperthermia? (SATA) a. ABCs b. cooling blankets c. IV access d. Q1 neuro checks e. ice packs to the axillae and groin f. fluid bolus of 0.9% NS g. thorazine administration
a,b,c,e,f,g (thorazine prevents shivering)
An 82-year-old client with anemia is prescribed 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? a. hypotension b. hypertension c. decreased pallor d. rapid, bounding pulse e. flattened superficial veins f. capillary refill < 3 s
a,b,d
A burn victim's priority nursing interventions include which of the following? (SATA) a. airway management b. fluid resuscitation c. cooling d. cardiac monitoring e. infection prevention
a,b,d,e
What are the priority nursing interventions of a patient coming in with an unknown overdose? (SATA) a. monitor airway and RR b. administer activated charcoal c. assess fluid retention d. administer diuretics/laxatives e. administer antidotes
a,b,d,e
Your patient is receiving 1 unit of PRBCs for low hgb and hct. Which of the following manifestations would lead you to consider a transfusion reaction is occurring? (SATA) a. ↑ RR and SOB b. tachycardia c. bradycardia d. hypertension e. hypotension f. fever/chills g. sudden anxiety h. itching/rash formation
a,b,d,e,f,g,h
Which of the following are bleeding disorders? (SATA) a. thrombocytopenia b. immune thrombocytopenia purpura (ITP) c. thrombotic thrombocytopenic purpura (TTP) d. Heparin induced thrombocytopenia (HIT) e. hemophilia f. Von Willebrand factor excess g. Von Willebrand factor deficit h. Disseminated intravascular coagulation
a,b,e,g,h (TTP, HIT, VW excess are all clotting disorders)
Which signs and symptoms does the nurse expect to find in clients with any type of anemia? (Select all that apply.) a. Exercise intolerance b. Fatigue c. Glossitis d. Jaundice e. pain f. Microcytic red blood cells g. Paresthesias of the hands and feet h. Tachycardia
a,b,e,h (not microcytic RBC, but sickled)
To prevent contractures, nurses can implement which of the following? (SATA) a. have the patient sit up for no more than 1 hour b. have the patient sit up for at least 1 hour c. have the patient lay prone d. have the patient lay supine e. have the patient in a trendelenburg position
a,c
Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? (Select all that apply.) a. Place client in isolation. b. Encourage multiple visitors to support client. c. Ensure that no plants or flowers are in the client's room. d. Teach family members not to bring fresh fruits and vegetables to the client. e. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another.
a,c,d (e decreases the risk of auto-contamination not cross-contamination)
Your patient coming from a house fire could be about to lose his airway based on which of the following assessments? (SATA) a. singed scalp, eyebrows, and eyelashes b. burns on the upper extremities c. black sputum d. wheezing auscultated e. SOB with accessory muscle use f. patient conscious during the injury g. patient in an open space of the house
a,c,d,e (also includes burns on the face, unconscious at time of injury, and in a closed space)
How will you know your patient with a hip spica cast is experiencing cast syndrome? (SATA) a. abdominal pressure b. lower extremity pain c. nausea d. vomiting e. abdominal distention f. black, tarry stool
a,c,d,e (no lower extremity pain and no black stools)
Your patient just came back from a laminectomy (spinal) surgery, what are your priority nursing interventions? (SATA) a. log rolling only b. do not move them under any circumstances c. pillow between the legs d. avoid twisting e. assume complete bed rest f. ambulate after 2 hours post op g. pain management
a,c,d,f,g
The nurse is assigned to care for a client who has undergone a modified radical right mastectomy for breast cancer. When delegating care, which statements by the nursing assistant would require further teaching by the nurse? (Select all that apply.) a. "I will irrigate the drainage tube after I empty it." b. "If the client says she is in pain, I will tell you right away." c. "It is important for me to take blood pressure on the client's right arm." d. "When helping the client walk, I'll remind her to stand straight." e. "I'll let you know if her surgical dressing is intact and dry."
a,c,e (E only because CNAs cannot properly assess as an RN)
Which of the following STIs are asymptomatic at some point? (SATA) a. chlamydia b. gonorrhea c. pelvic inflammatory disease d. syphilis e. genital herpes (HSV) f. genital warts (HPV)
a,d,f (syphilis latent phase is asymptomatic)
A client has undergone transurethral resection of the prostate (TURP). Which interventions does the nurse incorporate in this client's postoperative care? (SATA) a. Administer antispasmodic medications. b. Encourage the client to urinate around the catheter if pressure is felt. c. Perform intermittent urinary catheterization every 4 to 6 hours. d. Place the client in a supine position with his knees flexed. e. Assist the client to mobilize as soon as permitted.
a,e (ambulate asap just like any other surgery)
After returning from transurethral resection of the prostate, the client's urine in the continuous bladder irrigation system is a burgundy color. Which client needs does the nurse anticipate after the surgeon sees the client? (SATA) a. Antispasmodic drugs b. Emergency surgery c. Forced fluids d. Increased intermittent irrigation e. Monitoring for anemia
a,e (no need to increase intermittent irrigation, sanguineous urine is expected post op.)
What are the signs and symptoms of chronic osteomyelitis? (SATA) a. localized pain b. fever c. swelling d. erythema and heat e. drainage from the area f. caused by a foot ulcer
a,e,f (no systemic S+S in chronic osteomyelitis)
Your patient with a BKA following a serious case of osteomyelitis is in spiritual distress after seeing how much of him limb was removed. His wife is trying her best to help and is with him constantly. It is post op day 2 and she insists on keeping his stump elevated on a pillow. What is the most appropriate response as the nurse? a. "Thank you for helping, but now we should really let his leg rest without the pillow to prevent contractures." b. "Thank you for helping, keep elevating his leg as much as possible." c. "Thank you for helping, but I can take it from here." d. "Thank you for helping, you should go and get some rest."
a. (after 24 hours, remove the pillow under the amputated leg to prevent contractures)
For the fluid resuscitation stage of a patient with severe burns, the HCP orders 2 L of lactated ringer's to be administered within 24 hours. What is the rate (in mL/hr) the nurse would set the initial bag (1L) for in the first 8 hours? a. 125 mL/hr b. 84 mL/hr c. 250 mL/hr d. 999 mL/hr
a. 125 mL/hr (because we want half ot the 24 hr order given in the first 8 hours, therefore 1000mL/8 hours = 125 mL/hr)
A patient comes into the ER with active tuberculosis. The recommended PPE is level: a. A b. B c. C d. D
a. A (most protective since airborne)
PRICE stands for which of the following? a. Protection, Rest, Ice, Compression, Elevation b. Pulses, Rest, Ice, Compression, Elevation c. Protection, Rest, Ice, Controlling pain, Elevation d. Pulses, Rest, Ice, Controlling pain, Elevation
a. Protection (don't hit it again), Rest, Ice(20/20 for the first 24 hrs --> heat after), Compression, Elevation
The nurse is assessing several clients who are receiving transfusions of blood components. Which assessment finding requires immediate action by the nurse? a. Respiratory rate of 36 breaths/min in a client receiving red blood cells b. Temperature of 99.1°F (37.3°C) for a client with a platelet transfusion c. Sleepiness in a client who received diphenhydramine (Benadryl) as a premedication d. A partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh-frozen plasma (FFP)
a. RR of 36
A young black woman who has sickle cell disease (SCD) comes to the emergency department with severe joint and back pain, a cough, a temperature of 102.2°F (39°C), and shortness of breath. She appears anxious and states "I have never felt this way before." The health care provider prescribes 3 mg of morphine IV and a stat chest X-ray. Should oxygen be started even though it has not yet been prescribed? Why or why not? a. Yes, O2 will help with sickle cell disease regardless b. Yes, O2 will decrease her pain c. No, O2 is a medication and needs provider orders d. No, she will be fine.
a. Yes (O2 is a staple in managing SCD)
The nurse is teaching a group of young men about sexually transmitted diseases. What does the nurse tell them to look for in the primary stage of syphilis? a. a painless chancre b. genital rash c. scrotal swelling d. weeping discharge
a. a painless chancre (chancres = syphillis)
The RN working in the hospital emergency department is assigned to care for these four clients. Which client does the nurse attend to first? a. Adolescent with an erection for "10 or 11 hours" who is reporting severe pain b. Young adult with a swollen, painful scrotum who has a recent history of mumps infection c. Middle-aged adult discharged 2 days ago after a transurethral resection of the prostate who has increased hematuria d. Older adult with a history of benign prostatic hyperplasia and palpable bladder distention
a. adolescent w/ priapism
A patient was out with friends at a concert, and was exposed to Sarin (nerve agent) along with at least 100 other people at the concert. You are the nurse at one of the hospitals helping with the triage. Once in the cold zone, Dawn is evaluated for symptoms. She has developed difficulty breathing, blurred vision, nausea and vomiting, and rhinorrhea. Her BP is 188/92, HR is 112, RR is 32, O2 Sat is 88%, and she is afebrile. What would be the priority nursing intervention? a. Airway management b. lower her BP c. supplemental O2 d. administer the antidote to sarin
a. airway management (sarin causes pulmonary edema --> SOB and O2 sat ↓)
What is the treatment for DIC? a. heparin b. coumadin c. enoxaparin d. bleeding precautions
a. heparin (fix the cause, which is over clotting)
A client had an orchiectomy and laparoscopic radical retroperitoneal lymph node dissection this morning. What assessment finding will the nurse report to the primary health care provider? a. The client's pain level is a 10 on a 0 to 10 pain scale after pain medication. b. The client's urinary catheter is draining clear yellow urine. c. The client is concerned about his ability to have an erection. d. The client's blood pressure is 132/82 in a sitting position.
a. pain 10/10 after pain meds (needs stronger pain meds or could be a post op complication)
After a nearby explosion, patients are being brought into your ED. Which of the following injuries is a primary injury? a. ruptured eardrum b. lacerations from debris c. broken bone from another victim's impact d. exacerbation of asthma
a. ruptured eardrum
A client who is receiving a blood transfusion suddenly tells the nurse, "I don't feel right!" What is the nurse's first action? a. Stop the transfusion. b. Call the Rapid Response Team. c. Slow the infusion rate of the transfusion. d. Obtain vital signs and continue to monitor.
a. stop the transfusion
A patient coming in with a swollen, tender, and limited ROM in their back is most likely a: a. strain b. sprain
a. strain
A patient comes into the ED from a soccer game in South Florida in August. The parent of the child asks whether they are suffering from heat exhaustion or heat stroke. Which of the following vital signs indicates heat exhaustion? a. Temperature of < 104 b. Temperature of > 104 c. RR of < 12 d. RR of > 20
a. temperature < 104 (heat stroke > 104)
Your patient came in from a traumatic MVC and sustained major injuries including a femur fracture of the LLE. The orthopedic surgeon prescribed skeletal traction on the extremity. When the patient awakes they scream in terror and ask you, "Why is all this metal attached to me?!" Your best response is which of the following: a. It is traction used to reduce pain and immobilize your broken leg b. It is traction used to reduce the fracture and wait until surgery is possible c. It is traction which will help your body heal d. Don't worry about it, how is your pain level?
a. traction = reduces pain and immobilize the fracture
Your patient with a cane asks you which side of the body they should use their cane on. What is your best response? a. Your unaffected side b. your injured side
a. unaffected side (Strong side)
What is an instance in which you would NOT give activated charcoal for a patient with an overdose? (SATA) a. the patient is unconscious b. the patient has diminished bowel sounds c. the patient has a suspected paralytic ileus d. the patient has already received the antidote e. the patient has not received the antidote
b,c,d
A client has a synthetic cast placed for a right wrist fracture in the emergency room. What priority health teaching is important for the nurse to provide for this client before returning home? (Select all that apply.) a. "Keep your right arm below the level of your heart as often as possible." b. "Use an ice pack for the first 24 hours to decrease tissue swelling." c. "Move the fingers of the right hand frequently to promote blood flow." d. "Report coolness or discoloration of your right hand to your doctor." e. "Don't place any device under the case to scratch the skin if it itches."
b,c,d,e (keep arm elevated - RICE)
Hip prosthetic post op interventions include which of the following: (SATA) a. Adductor pillow b. Abductor pillow c. no bending at the waist d. no twisting e. don't flex waist past 45 degrees f. no crossing feet/legs
b,c,d,f (can't flex past 90 degrees)
The nurse is encouraging range-of-motion exercises for the client, who states, "this hurts terribly; I don't want to do this." Identify the appropriate nursing response(s). (Select all that apply.) a. "You have to do the exercises to get well." b. "Range-of-motion helps promote mobility." c. "Just visualize a beach to get your mind off of the pain." d. "Let me check when you were last given pain medication." e. "What techniques for pain management have you used in the past that were helpful?" f. "The health care provider has ordered these exercises, and it is important that you do them as instructed."
b,d,e
When your patient has a spica cast, it is important to do which of the following? (SATA) a. keep them on bedrest b. turn every 2 hours c. use the side table for repositioning d. assess for nausea and vomiting e. give small, frequent meals
b,d,e
A client with thrombocytopenia is being discharged. Which instruction would the nurse include in a teaching plan for this client? (SATA) a. "Avoid large crowds." b. "Use a soft-bristled toothbrush." c. "Drink at least 2 L of fluid per day." d. "Use an electric razor instead of a straight razor." e. "Elevate your lower extremities when sitting." f. "Avoid aspirin." g. "use stool softeners/avoid straining."
b,d,f,g
A 22-year-old patient with gonorrhea is treated with a single IM dose of ceftriaxone (Rocephin) and is given a prescription for doxycycline (Vibramycin) 100 mg bid for 7 days. The nurse explains to the patient that this combination of antibiotics is prescribed to A) prevent reinfection during treatment. B) treat any coexisting chlamydial infection. C) eradicate resistant strains of N. gonorrhoeae. D) prevent the development of resistant organisms.
b.
The nurse is educating a group of young women who have sickle cell disease (SCD). Which statement from a class member indicates further teaching is necessary? a. "The pneumonia vaccine is protection that I need." b. "Getting an annual 'flu shot' would be dangerous for me." c. "I must take my penicillin pills as prescribed, all the time." d. "Frequent handwashing is an important habit for me to develop."
b. "Getting a flu shot would be dangerous to me." (It would be fine for them)
Your patient has been recently diagnosed with myopathy and asks you to explain. What is your best answer as the nurse? a. "Myopathy is any disease of the lung." b. "Myopathy is any disease of the muscle." c. "Myopathy is caused by environmental factors." d. "Myopathy can cause hyperkalemia."
b. "Myopathy is a muscular disease" ( caused by congenital factors and hypokalemia --> acute paralysis of the muscles)
The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information would the nurse explain to the parents about the risk of a child having sickle cell disease? a. "Sickle cell disease will be inherited by your children." b. "The sickle cell trait will be inherited by your children." c. "Your children will have the disease, but your grandchildren will not." d. "Your children will not have the disease, but your grandchildren could."
b. "your children will have the sickle cell TRAIT"
A client has a continuous bladder irrigation after surgery yesterday. The amount of bladder irrigating solution that has infused over the past 12 hours is 1050 mL. The amount of fluid in the urinary drainage bag is 1825 mL. The nurse records that the client had ____ mL urinary output in the past 12 hours. a. 135 mL b. 775 mL c. 755 mL d. 875 mL
b. 775 mL
What is the difference between osteoarthritis, rheumatoid arthritis, and septic arthritis? a. osteoarthritis is wear and tear, rheumatoid arthritis is from a hematogenous cause, an septic arthritis is from an autoimmune disorder b. osteoarthritis is wear and tear, rheumatoid arthritis is from an autoimmune disorder, an septic arthritis is from a hematogenous cause
b. OA = wear and tear, RA = autoimmune, SA = hematogenous cause (blood born from an infection)
Myopathy that is caused by hypokalemia has which of the following manifestations? a. radiating pain b. acute, intermittent paralysis c. decreases with discontinuation of steroids d. treated with spironolactone
b. acute, intermittent paralysis
Your patient is experiencing DIC following an osteomyelitis infection that went septic. What is your priority nursing intervention? a. give oxygen via nasal cannula b. administer heparin as prescribed c. administer the replacement factor as prescribed d. administer antibiotics as prescribed
b. administer heparin as prescribed (circulation > oxygenation in this case, since the cause is sepsis, abx would be given if not already done so, but after heparin is administered to dissolve the many microocclusions in the body already)
On a hot summer day, an older adult is found by a neighbor lying on the floor, agitated and confused. After calling 911, the neighbor places ice bags on the client's groin area and armpits. Upon arrival at the hospital, which action does the emergency department (ED) nurse perform first? a. Administer two acetylsalicylic acid (aspirin) tablets orally. b. Check the client's airway and administer high-flow oxygen therapy. c. Monitor the client's vital signs. d. Place a cooling blanket on the client.
b. airway and administer O2 (ABCs all day)
What is the only exception when you can take off the weights associated with traction? a. To bathe the patient b. To assess the patient's skin c. To make sure the equipment is working properly d. To assess the patient's lung sounds
b. assess the patient's skin
The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat? a. Grains b. Dairy c. leafy vegetables d. starchy vegetables
b. dairy
Which antidote would you give for a benzodiazepine overdose? a. naloxone b. flumazenil c. acetylcysteine d. Vitamin K
b. flumazenil
A young woman comes into the clinic complaining of something going on "down there." Upon assessment, you notice a profuse purulent discharge coming from the vagina. What diagnosis do you expect the provider to confirm? a. chlamydia b. gonorrhea c. syphilis d. HSV
b. gonorrhea
A client returns from surgery after a laparoscopic total abdominal hysterectomy. Upon initial assessment, which finding by the nurse requires immediate intervention? a. Decreased bowel sounds in all quadrants b. Heavy vaginal bleeding with clots c. Temperature of 99°F (37.2°C) d. Client statement that pain is 4 on a scale of 0 to 10
b. heavy vaginal bleeding (was laparoscopic and not through the vagina so this is abnormal)
Bucks traction is what type of traction? a. skeletal b. skin c. lower extremity d. upper extremity
b. skin
A patient coming in with a swollen, tender, and limited ROM in their ankle is most likely a: a. strain b. sprain
b. sprain
Your patient with HSV, also known as genital herpes, is concerned about spreading the disease to their new girlfriend. What do you tell the patient about their disease process? a. "There is no cure for HSV, and you will always be contagious. It's best to always use condoms." b. "There is no cure for HSV, but we can treat your lesions with antibiotics." c. "There is no cure for HSV, but you are only contagious when lesions are present." d. "There is no cure for HSV, but you are not contagious."
c. "There is no cure for HSV, but you are only contagious when lesions are present."
The nurse gives a client an IM dose of penicillin G for primary syphilis. Which client statement indicates a need for further teaching? a. "I will wait in the clinic for 30 minutes to be sure I do not have a reaction." b. "When I get home, I will call my partner to tell him/her about my diagnosis." c. "If I have sex with someone, I do not have to worry about spreading the disease." d. "I plan to return to see my primary care provider for follow-up in 6, 12, and 24 months."
c. Syphilis will be spread via sexual contact
A client who has undergone breast surgery is struggling with issues concerning her sexuality. What is the best way for the nurse to address the client's concerns? a. Ask the client if she is using her surgery as an excuse not to have any more sexual relations with her partner. b. Remind the client to avoid sexual intercourse for 2 months after the surgery. c. Ask the client about satisfaction with sexual relations with her partner. d. Teach the client that birth control is a priority.
c. ask the client about satisfaction with sexual relations with her partner
A patient has burns over more than 20% of her body, she is at risk for nausea and vomiting due to loss of blood flow to the GI tract. For this reason, what is the nurse's priority intervention? a. administer an antiemetic b. change her diet to NPO c. insert an NG tube d. fluid resuscitation
c. insert an NG tube
Your patient with a pica cast is just starting to show manifestations of cast syndrome. What is your priority nursing intervention? a. call the HCP b. do a neurovascular check c. insert an NG tube (after getting orders) d. decrease oral food intake
c. insert an NG tube (to decrease abdominal distention)
The nurse is teaching a client who is diagnosed with gonorrhea. What does the nurse tell the client about the disease? a. "Close follow-up is required because treatment failure is common." b. "Do not engage in sexual activity until your blood tests are negative." c. "You are contagious even if you have no outward symptoms." d. "You are only infectious while the lesions are draining."
c. you are contagious even without symptoms
The nurse is caring for an older adult client with heat exhaustion. What assessment finding indicates to the nurse that the client may need hospitalization? a. Alert and oriented b. Reports nausea and weakness c. Continues to sweat while being cooled d. Mucous membranes are dry and sticky.
d.
Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need for further teaching by the nurse? a. "I am going to continue having my DXA scans as my doctor orders." b. "I will drink only a half glass of wine occasionally to help me sleep." c. "I plan to increase calcium and vitamin D foods in my diet." d. "I am going to jog every day for at least 30 minutes."
d. "I am going to jog daily for 30 minutes" (jogging is a high intensity exercise that is not recommended for people at risk for osteoporosis, something better like swimming or walking should be encouraged)
After a mass casualty event, the nurse is triaging clients in the field. Which client is correctly classified? a. 38-year-old with an open femur fracture: Black tag b. 42-year-old with multiple abrasions and contusions: Yellow tag c. 54-year-old with third-degree burns over 90% of the body: Green tag d. 61-year-old who is having difficulty breathing and wheezing: Red tag
d. 61 y/o w/ SOB = Red
The nurse is caring for four clients. Which client does the nurse recognize as having the highest risk for development of breast cancer? a. 55-year-old male with gynecomastia and obesity b. 60-year-old female whose father died from colon cancer c. 65-year-old male whose mother had ovarian cancer d. 75-year-old female who was treated for breast cancer 5 years ago
d. 75 y/o w/ previous history of breast cancer
The nurse is teaching a client about taking sildenafil for erectile dysfunction. Which statement by the client indicates a need for further teaching? a. "I should have sex within an hour after taking the drug." b. "I should avoid alcohol when on the drug or it might not work well." c. "I can expect to maybe feel flushed or get a headache when I take the drug." d. "If I have chest pain during sex, I should take a nitroglycerin tablet."
d. NTG + sildenafil = death
A sexually active 25 year old woman comes into the ER with abdominal pain and a fever. You start your shift and as you transport her to the med/surg floor, you tell her that she'll be able to take a shower if she's up to it, and hope that the doctor's figure out what's wrong with her. She then confesses, "A shower would be nice, I can't seem to hide this gross, fishy smell coming from down there." You immediately think that she might have which of the following disease processes? a. chlamydia b. gonorrhea c. syphilis d. PID
d. PID
The emergency department charge nurse is making client assignments and delegating care after a mass casualty event. Which of these clients could be deemed as a "black tag?" a. Client who has multiple left rib fractures and reports dyspnea b. Client who reports severe left anterior chest pain c. Client who has a femoral fracture with palpable distal pulses d. Client who is unconscious with massive aortic bleeding from the chest
d. client who is unconscious w/ a major bleed (most likely not going to survive)
The nurse at the gynecology clinic is examining a woman's breasts. Which assessment finding will the nurse report immediately to the primary health care provider? a. A 1-cm freely mobile rubbery mass discovered by the client b. Ill-defined painful rubbery lump in the outer breast quadrant c. Backache and breast fungal infection d. Nipple discharge and dimpling
d. nipple discharge and dimpling (most indicative of a potential malignant tumor)
The nurse performs a neurovascular assessment on a client with closed multiple fractures of the right humerus who is experiencing increased pain even with maximum ordered doses of morphine. The nurse notes distal capillary refill of 3 seconds and coolness of the hand and fingers. The client reports numbness of the hand and is unable to wiggle the thumb. Which nursing action is indicated? a. Elevate the extremity. b. Apply an ice pack to the extremity. c. Reposition the extremity and recheck in 15-20 minutes. d. Notify the provider of these findings.
d. notify the provider (S+S of compartment syndrome)
Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? a. Middle-aged adult who is frantically explaining to the nurse what happened b. Young adult who suffered burn injuries in an open space c. Adult with burns to the extremities d. Older adult with thick, black-colored sputum
d. older adult with thick, black-colored sputum (if it was closed space, it would be b)
A young black woman who has sickle cell disease (SCD) comes to the emergency department with severe joint and back pain, a cough, a temperature of 102.2°F (39°C), and shortness of breath. She appears anxious and states "I have never felt this way before." The health care provider prescribes 3 mg of morphine IV and a stat chest X-ray. What additional assessment data are most important to obtain? a. Blood glucose b. Any recent infections c. Any fatigue related to exercise d. Pulse oximetry and respiratory assessment
d. pulse O2 and respiratory assessment (pts with acute respiratory distress is a major cause of death in sickle cell disease)
The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification? a. Ask the client's name b. Check the client's armband c. Verify the client's room number d. Review all information with another registered nurse (RN)
d. review info w/ another nurse
Many patients with osteoporosis require surgical intervention, what are the priority nursing interventions post op? a. wound care b. preventing infection c. blood clot prevention d. turn, cough, and deep breathe
d. turn, cough, deep breathe
Acyclovir is the drug of choice for treating which of the following STIs? (SATA) a. chlamydia b. gonorrhea c. pelvic inflammatory disease d. syphilis e. genital herpes (HSV) f. genital warts (HPV)
e,f
What are the 6 P's of compartment syndrome?
pain, pulselessness, pressure/Poikilothermia, pallor, paresthesia, paralysis
What does TRALI stand for?
transfusion related acute lung injury
