Cumulative Practice Questions
A client is having frequent premature ventricular contractions (PVCs). A nurse would place a priority on the assessment of which of the following items? A. Blood pressure and peripheral perfusion B. Sense of chest palpitations C. Causative factors such as caffeine or drug use D. Precipitating factors such as infection
A
A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Increase in urine output B. Pupils measuring 8mm and nonreactive C. Systolic BP remaining at 179 D. Normal BUN and Creatinine levels
A
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the 12 lead EKG? A. Sinus tachycardia B. Ventricular Fibrillation C. Supraventrical Tachycardia D. Atrial fibrillation
A
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following orders by the provider should the nurse clarify? A. MRI B. CT Scan C. Daily 12 lead EKGs D. Physical Therapy
A
A nurse is caring for a patient who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take? A. Verify the most recent serum calcium level B. Verify the most recent serum sodium level C. Obtain a 12 lead EKG D. Administer a muscle relaxer
A
A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization? A. QT interval B. QRS complex C. U wave D. PR interval
A
A nurse is preparing to defibrillate a patient in ventricular fibrillation. After placing the paddles/pads on the patient's chest and before delivering the shock, what should be done? A. Confirm the rhythm is ventricular fibrillation B. Ensure the patient is intubated C. Set the mode to "synchronize" D. Administer lidocaine hydrochloride
A
A nurse is teaching a patient with a new diagnosis of diabetes insipidus. Which of the following statements indicates the patient needs further teaching? A. "It's important that I monitor my blood sugar before all meals and before bed" B. "I need to drink a lot of water to stay hydrated" C. "This condition is likely temporary but can be lifelong condition" D. "I have to take all medication as prescribed and not skip doses"
A
A nurse takes on the "med nurse" role during a code blue. The leader instructs to prepare for administration of 6mg of Adenosine IV push. The nurse knows this medication is used to treat the following rhythm: A. Supraventrical Tachycardia (SVT) B. Ventricular Tachycardia without a pulse C. Atrial fibrillation (A-fib) D. Ventricular Tachycardia with a pulse
A
A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which action should the nurse take first? A. Call 911 B. Lay the woman flat on her back and tell her to lay still C. Call her emergency contact listed in her cell phone D. Give the women a baby aspirin pill
A
A patient presents in the emergency department after a syncopal episode. Their EKG shows Sinus Bradycardia with a HR of 34. The patient is reporting dizziness and lightheadedness, although they seem confused at times. What drug does the nurse anticipate to be ordered? A. Atropine B. Amiodarone C. Adenosine D. Diltiazem
A
A patient with CKD missed two hemodialysis treatments this week. They present to the ED with complaints of chest pain and heart palpitations. An EKG shows multifocal PVCs. The nurse anticipates which of the following as a potential cause: A. Hyperkalemia B. Hypokalemia C. Fluid overload D. Hyperphosphatemia
A
A patient with Crohn's Disease is taking Methylprednisolone (solumedrol), which is a corticosteroid, for a flare up. The patient is complaining of extreme thirst, polyuria, and blurred vision. What is your next nursing action? A. Check the patient's blood glucose B. Check the patient's hemoglobin A1C C. Assess bowel sounds and time of last BM D. Prepare an ampule of Dextrose 50% for administration
A
A patient with a confirmed ischemic stroke is admitted to the neuro unit. What action should the nurse take first upon arrival? A. Implement aspiration precautions B. Initiate an ambulation schedule C. Educate on the signs and symptoms of a stroke D. Perform range of motion exercises
A
The RN is reviewing an EKG rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and the QRS complex measures 0.06 seconds. The overall ventricular heart rate is 64 beats per minute. Which of the following is the correct interpretation based on these characteristics? A. Normal Sinus Rhythm B. Sinus Bradycardia C. Sinus Arrythmia D. Sinus Tachycardia
A
The heart monitor is showing erratic heart rates jumping from 50 to 125 bpm. You notice irregularity between R waves. What is the most accurate way to assess the patient's HR? A. Listen to an apical HR for 1 minute B. Use the six second method C. Take a radial pulse for 15 seconds and multiply by 4 D. Use the R to R method
A
The nurse is educating the patient on potential complications for their 3rd colon resection related to Crohn's disease. Which phrase is the most accurate? A. "As more colon is removed, there is risk for short bowel syndrome" B. "This surgery is usually curative for this disease" C. "You will have a colostomy bag for life following this surgery" D. "You will have an ileostomy bag temporarily following this surgery"
A
The nurse is preparing to defibrillate a patient. Which rhythm did the nurse observe to make this decision? A. Ventricular Fibrillation B. Ventricular Tachycardia with a pulse C. Asystole D. Rapid A Fib
A
The nurse should assess for an important early indicator of acute pancreatitis, which is an elevated level of __________ in the first 24 hours of inflammation onset: A. Serum amylase B. Serum lipase C. Serum glucose D. ALT & AST
A
You receive report on the following patients on the neurology unit. Which patient should be assessed first? A. A patient with a recent subarachnoid hemorrhage who has become increasing difficult to arouse. B. A patient who experienced an ischemic stroke 3 days ago and has complained about a mild headache C. A patient who experienced a hemorrhagic stroke 10 days ago who is scheduled to be discharged to a rehabilitation center today. D. A patient who received tPA 48 hours ago for an ischemic stroke who has residual hemiparesis
A
You're caring for a 45 year old patient who is admitted with reports of extreme mid-epigastric pain that radiates to the back. The patient states the pain started last night after eating fast food. As the nurse, you know the two most common causes of pain like this is: A. Gallstones and alcohol abuse B. Alcohol abuse and obesity C. Diabetes and smoking D. High cholesterol and alcohol abuse
A
A patient with carcinoma of the lung develops Syndrome of Inappropriate Antidiuretic Hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? (select all that apply) A. Chemotherapy B. Radiation therapy C. Serum sodium levels D. Decreased oral sodium intake E. Medication that is antagonistic to antidiuretic hormone F. Increased fluid intake
A, B, C, E
The nurse is caring for a patient admitted to the hospital with acute pancreatitis. Which of the following interventions would the nurse expect to be ordered for this patient? (select all that apply) A. Administer anticholinergics as prescribed B. Give pain medicine as prescribed C. Give small, frequent, high calorie meals D. Maintain the patient in a supine, flat position E. Encourage coughing and deep breathing F. Administer antacids as prescribed
A, B, E, F
The nurse is assessing a patient who has experienced a left hemisphere stroke. Which neurological deficits would the nurse anticipate? (Select all that apply) A. Aphasia B. Impulsive behavior C. Left sided hemiparesis D. Depression E. Left sided homonymous hemianopsia
A, D
A 36-year-old patient's lab work show anti-HAV and IgG present in the blood. As the nurse you would interpret this blood work as? A. The patient is in the icteric phase of viral Hepatitis. B. The patient has recovered from a previous Hepatitis A infection and is now immune to it. C. The patient has an active infection of Hepatitis A. D. The patient is in the preicetric phase of viral Hepatitis.
B
A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis? A. Lower dose of antithyroid medication B. Avoid administering IV contrast for a CT scan C. Make the patient NPO D. Lowering the temperature of the room
B
A nurse is assisting a client who has hypothyroidism with meal planning. Which of the following foods should the nurse recommend that the client add to her diet? A. Dairy products B. Whole grains and fiber C. Foods high in sodium D. Lean meats
B
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? A. Symptoms that come and go B. A sudden onset of symptoms with an associated headache C. Gradual onset of symptoms D. Symptoms that occur quickly but resolve on their own
B
A nurse is caring for a client who is on Warfarin (Coumadin) therapy for atrial fibrillation. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer? A. Atropine B. Vitamin K C. Protamine sulfate D. Adenosine
B
A nurse is caring for a patient after a hypophysectomy. The nurse notices clear nasal drainage from the patient's nostril. The initial nursing action would be to: A. Continue to observe the drainage B. Test the drainage for glucose C. Lower the head of the bed D. Instruct the patient to blow their nose
B
A patient has developed hepatitis A after eating contaminated oysters. The nurse assesses the patient for which of the following symptoms? A. Dark Stools B. Left upper quadrant pain C. Weight gain D. Malaise
D
A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter? A. Flush the lumen with sterile water after use B. Use a 10mL syringe to flush the catheter C. Reuse alcohol containing caps on all access points D. Use clean technique when accessing the line
B
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history? a. COPD b. Gallstones c. Diabetes Mellitus d. Hypolipidemia
B
A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: A. Sinus tachycardia B. Ventricular tachycardia C. Ventricular fibrillation D. Premature ventricular contractions
B
A patient admitted from a nursing home has a history of frequent, drug resistant UTIs. They begin showing early signs of acute hepatitis. What is the most likely cause? a. Hepatitis E from contaminated water b. Frequent antibiotic use c. Autoimmunity d. High risk lifestyle behaviors
B
A patient is having asymptomatic changes to their cardiac rhythm. Which action should the nurse take first? A. Limit the patient's activity until they return to normal sinus rhythm B. Check the patient's most recent electrolyte panel C. Check the patient's most recent hemoglobin level D. Notify the provider
B
A patient new to hemodialysis is scheduled for placement of an HD cath in Interventional Radiology. Which lab is most important to check prior to the procedure? A. Potassium B. PT & INR C. Hemoglobin & Hematocrit D. BUN & Creatinine
B
A patient with Crohn's disease is scheduled to receive an infusion of infliximab (Remicade). What intervention by the nurse will determine the effectiveness of treatment? A. Monitoring the leukocyte count for 2 days after infusion B. Checking the frequency and consistency of bowel movements C. Checking for occult blood in the stool after infusion D. Checking serum liver enzymes before and after the infusion
B
A patient with a recent history of a total thyroidectomy presents to the Emergency Department with complaints of dizziness and syncope. He admits to not taking his daily medications regularly. The nurse anticipates which cardiac rhythm? A. Ventricular Tachycardia B. Sinus Bradycardia C. Sinus Tachycardia D. Normal Sinus Rhythm
B
A patient with severe dehydration is ordered continuous IV fluids. Due to poor peripheral vasculature, a midline catheter is placed by ultrasound. The next day it's found the patient has a UTI and is ordered IV vancomycin. What is the most appropriate next action by the nurse? A. Evaluate for new peripheral IV access B. Tell the provider the patient needs a central line in order to administer the Vanco safely C. Administer the Vanco through the midline D. Call pharmacy and ask to change the Vanco to po
B
In planning care for the patient with Crohn's disease, the nurse recognizes that the major difference between ulcerative colitis and Crohn's disease is that Crohn's disease: A. Is manifested by rectal bleeding and anemia more than UC B. Often recurs after surgery, while UC is curable with surgery C. Causes fewer nutritional deficiencies than UC D. Often results in toxic megacolon
B
Jordin is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client? a. Monitor LFTs daily b. Keeping the client's fingernails short and smooth c. Administer sleep aids prn d. Monitor cardiac rhythm
B
The RN knows this test provides the most accurate and complete visual of the cardiac rhythm? A. 5 lead EKG B. 12 lead EKG C. 3 lead EKG D. 24 hour EEG
B
The nurse is caring for a patient recent diagnosed with hypothyroidism and started on levothyroxine. What information reported by the patient requires immediate action by the nurse? A. Fatigue B. Chest pain and palpitations C. Weight loss D. Decreased appetite
B
The nurse is reviewing the record of a patient with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the chart? A. Fluffy and clay colored B. Loose, watery C. Dark, tarry stools D. Constipation
B
What is the rationale for permissive hypertension in an ischemic stroke patient? a. Maintain homeostasis for patient's with prior hypertension B. Encouraging blood flow through a tighter space to increase perfusion C, Decrease intracranial pressure D. Prevents another stroke from occurring
B
When a pacemaker fires and doesn't result in myocardial activation, this is called: A. Failure to pace B. Failure to capture C. Demand pacing D. Failure to sense
B
Which abnormal lab value is expected for a patient with chronic hepatitis C? A. Na+ 127 B. INR 1.9 C. K+ 5.5 D. Creatnine 4.4
B
Which aspect of the heart's action does the QRS complex on the EKG represent? A. Repolarization of ventricles B. Depolarization of ventricles C. SA node firing D. Depolarization of atria
B
Which of the following signs and symptoms is NOT expected with Diabetes Insipidus? A. Polyuria B. Polyphagia C. Polydipsia D. Extreme thirst
B
A patient is experiencing symptomatic tachycardia that is not responsive to vagal maneuvers. Which med order would the nurse question? A. Diltiazam (Cardizem) IV titration, 1mg/hr increasing by 0.5mg/hr until achieving a HR < 110 B. Atropine 0.5mg IV push C. Labetalol 20 mg IV push prn for HR > 120, hold for SBP <110 D. NSS 1 L bolus IV over 1 hour
B atropine for sinus brady
After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the ED. He's unconscious and his pupils are nonreactive. Which interventions would be contraindicated for this patient? Select all that apply A. Assess for nuchal rigidity B. Administer Lorazepam (Ativan) for seizure prevention C. Elevate the HOB D. Administer 1 L bolus of 0.45% NSS E. Administer Ondansetron (Zofran) Q6 hours IV
B (give Keppra or Dilantin) Ativan is CNS depressant D avoid hypotonic solutions
A patient arrives to the Emergency Department unresponsive. The cardiac monitor shows no electrical activity, CPR is initiated but the patient later dies. The patient's family sues the hospital for malpractice for "not shocking him when he flat lined". What key info is the family missing? Select all that apply A. The patient wasn't adequately anticoagulated B. Defibrillation is not the proper treatment for asystole C. You cannot "jump start" a heart with no electricity D. The staff should have initiated an emergency cardioversion E. The patient likely needed a pacemaker for months
B, C
The nurse is caring for a patient with suspected hyperparathyroidism. Which clinical manifestations would represent the expected electrolyte imbalance? (select all that apply) A. Hyperactive bowel sounds B. Lethargy and weakness C. Kidney stones D. Seizures E. Nausea and vomiting
B, C, E
A patient is diagnosed with hepatitis, even though their viral hepatitis testing all came back negative. The nurse knows that non-infectious hepatitis can occur due to: (select all that apply) A. Consuming contaminated food or water B. Drug overdoses C. Unprotected sex D. A diet high in fat and carbs E. Autoimmune causes
B, E
A 12 lead EKG shows a rhythm with rapid atrial contractions, a narrow QRS, and hidden p waves in the preceding complex. The nurse recognizes this rhythm as: A. Sinus Tachycardia B. Atrial Flutter C. Supraventrical Tachycardia D. Atrial fibrillation
C
A 36 year old male patient is admitted for post op care following a cholecystectomy. While sleeping his HR ranges between 44-48. Which piece of information from his past medical history could explain this? A. A family history of diabetes and stroke B. A diagnosis of mild anxiety and depression C. A vigorous cardiovascular exercise regimen D. Use of antiemetics during the intra-op phase of care
C
A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate? A. Provide multiple options when asking the patient questions B. Speak in a higher tone of voice C. Use nonverbal cues in conversation D. Use language consistent with a 3rd grade level of understanding
C
A patient has experienced persistent atrial fibrillation (a-fib) with occasional rapid ventricular response (RVR) for the past 3 days. In addition to administering an antidysrhythmic medication, the nurse anticipates which of these orders? A. Prepare for defibrillation B. Prepare for immediate cardioversion C. Initiate a Heparin infusion D. Administer Atropine IV push
C
A patient is admitted with a brain tumor. Which of the following presenting signs and symptoms are most likely the result of increased intracranial pressure? A. Tremors B. Increased thirst C. Headache and vomiting D. Aphasia
C
A patient is wearing a continuous cardiac monitor which begins to alarm. The RN sees no cardiac activity on the screen. Which of the following should be the first action the nurse takes? A. Begin CPR B. Call a Code Blue C. Check the patient and lead placement D. Notify the Physician
C
A patient who was NPO for 2 days is now allowed to advance their diet. So far, chicken broth and juice have been tolerated. Which food choice is now most appropriate? A. Pancakes with syrup B. Plain Yogurt C. Dry Toast D. Milkshake
C
A patient with adrenal hyperplasia is returning from surgery following an adrenalectomy. The nurse should monitor the patient for what immediate post operative complication? A. Infection B. Thromboembolism C. Rapid changes in blood pressure D. Nausea and vomiting
C
A patient with known a-fib presents to the pre-op area for their elective cardioversion. Which statement is most concerning for the nurse and warrants reporting to the provider? A. "I felt like I was going to pass out when I was bowling last week!" B. "I want this taken care of- I don't want to have another mini stroke" C. "I had a nose bleed two weeks ago so I took a break from my blood thinner" D. "The palpitations and fluttering is my chest is really impacting my ability to exercise regularly"
C
A patient's EKG shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds. The R-R interval is regular is and there is a regularly occurring p-wave for every QRS. What is the correct interpretation? A. Normal Sinus Rhythm B. Sinus Dysrhythmia C. Sinus Tachycardia D. Atrial fibrillation
C
A patient's family member is upset that the care team didn't shock the patient when he "flat lined". The RN knows this is a common misunderstanding and that the only shockable rhythms are: A. Torsaddes de Points and Ventricular fibrillation B. Supraventrical Tachycardia and Ventricular Fibrillation C. Ventricular fibrillation and pulseless ventricular tachycardia D. Ventricular fibrillation and sinus tachycardia
C
The nurse has instructed the family of a patient with a brain attack (stroke) who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines the family understands these measures when they verbalize: A. Discourage the use of eyeglasses B. Place objects in the patient's impaired field of vision C. Remind the patient to turn their head to scan the lost visual field D. Approach the patient from the impaired field of vision
C
The nurse is assigned to care for a patient with complete right-sided hemiparesis. The nurse plans care knowing that in this condition: A. The patient has lost the ability to ambulate independently but is able to feed and bath themselves without assistance B. The patient has lost the ability to move the right arm but is able to walk independently C. The patient has weakness on the right side of the body, including the face and tongue D. The patient has complete paralysis of the right arm and leg
C
The occupational health nurse is teaching staff nurses about prevention of hepatitis C. Which of the following strategies would the nurse emphasize? A. Vaccination B. Prevention of food borne illnesses C. Sharps safety D. Routine testing
C
What is the correct description of a Second Degree Heart Block Mobitz Type I? A. There is no relationship between the atrial and ventricular rhythm B. The atrial rate is regular and faster than the ventricular rate, which is irregular C. The PR interval progressively lengthens until it is not conducted D. The PR interval is longer than 0.20 seconds
C
What is the rationale behind synchronizing with the QRS during cardioversion? A. Decrease damage to heart tissue B. Less pain for patient C. Prevent arrythmia development D. Prevent clot dislodgment
C
When computing a heart rate from an electrocardiography (ECG/EKG) , the nurse counts 15 small blocks between the R waves of patient who has a regular rhythm. What does the nurse calculate the patient's heart rate to be? A. 150 B. 60 C. 100 D. 75
C
Which lab orders would the RN expect for a patient presenting with symptoms consistent with hepatitis B? A. BUN, Creatinine B. Cholesterol, Triglycerides C. ALT, AST, Bilirubin D. Bilirubin, Potassium, Sodium
C
Which part of an EKG is assessed for acute myocardial ischemia? A. QT Interval B. QRS Complex C. ST Segment D. PR Interval
C
You're providing diet teaching to a patient with ulcerative colitis about what types of foods to avoid during a "flare-up". Which foods below should the patient avoid? Select all that apply. A. Ice Cream B. Cooked carrots C. Fresh peaches & pears D. White rice E. Popcorn
C, E
A client with a bundle branch block is on a cardiac monitor. The nurse should expect to observe: A. Irregularly spaced QRS complexes B. Elevated ST segments C. QT interval > 0.48 seconds D. QRS segment > 0.12 seconds
D
A client with advanced chronic hepatitis has been diagnosed with hepatic encephalopathy. The nurse expects to assess: a. Weight loss b. Hand tremors c. Lower extremity edema d. Disorientation/confusion
D
A female patient presents to her primary care office complaining of spontaneous lactation despite having a negative pregnancy test. The nurse anticipates diagnostic testing to rule out A. Meningioma B. Glioblastoma multiforme C. Acoustic neuroma D. Pituitary adenoma
D
A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which the following laboratory findings indicate a therapeutic effect of the medication? A. Blood glucose of 99 B. Serum sodium of 147 C. Urine output over 300mL per hour D. Urine specific gravity 1.012
D
A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse? A. Pulse Oximetry reading of 95% B. WBC count of 11.2 C. BP of 132/80 from an arterial line D. ICP reading of 18 mm Hg
D
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? A. Increase isotonic IV fluid rate B. Instruct on coughing/deep breathing exercises C. Provide a brightly lit environment with music for comfort D. Position HOB at 30 degree incline
D
A nurse is planning care for a client who had a craniotomy and is restless following surgery. Which of the following interventions should the nurse include in the plan? A. Check the surgical site for signs of infection B. Administer opioid pain medication C. Apply soft restraints D. Reduce stimulation
D
A nurse is planning care for a client who is to start receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care? A. Change TPN solution every 48 hours B. Infuse lipids over 18 hours C. Change TPN tubing every 36 hours D. Use a 1.2 micron filter when infusing TPN with fat emulsions
D
A nurse is viewing the cardiac monitor in a client's room and notes that their frequent PVCs have transitioned to sustained ventricular tachycardia. The client is awake and alert, has a palpable pulse, has good skin color, and all leads are properly placed. The nurse would prepare to do which of the following? A. CPR B. Call a Code Blue C. Prepare for the administration of atropine D. Prepare for the administration of amiodarone
D
A patient has frequent PVCs and runs of ventricular tachycardia which self resolve to normal sinus rhythm. The patient is currently asymptomatic. What should the nurse be most concerned about with this arrythmia? A. It indicates extreme hypokalemia B. It indicates a structural issue with the heart valves C. If sustained this rhythm is life threatening D. It is almost impossible to convert to a normal sinus rhythm
D
A patient is found to be in paraxysmal atrial fibrillation. They are being anticoagulated using IV heparin by titration. The patient has a series of bowel movements with large amounts of bright red blood and a subsequent drop in hemoglobin. The nurse anticipates the provider to order which medication in response to this event? A. Vitamin K B. Metoprolol C. Warfarin D. Protamine sulfate
D
A patient presents to the ED in unstable SVT. When adjusting the BP cuff you notice a PICC line in the RUE, a family member tells you the patient gets IV abx at home. The provider says to prepare for administration of Adenosine IV push. Which option is most appropriate at this time? A. Prepare to push the adenosine through the PICC line B. Advocate for a CT scan of the chest C. Establish intraosseous access D. Establish peripheral access
D
A patient presents to the Emergency Department after a car accident. She is wearing a medical alert bracelet listing Addison's Disease. What should the nurse expect to be included in the care of this patient? A. Limiting IV fluid replacement B. Low sodium diet C. Hypothermia therapy D. Increased glucocorticoid replacement
D
A patient presents with symptoms consistent with a pheochromocytoma. The nurse anticipates which diagnostic test to confirm this diagnosis? A. 24 hour glucose test B. Renal ultrasound C. Biopsy D. 24 urine test
D
A patient with a recent ischemic stroke refused to work with Physical Therapy (PT). He states he is too tired and needs rest to heal. Which statement by the nurse is the best in response to the patient's decision? A. "If you don't work with PT now you will never get out of here!" B. "I respect that you don't want to be bothered today. PT will come back tomorrow" C. "I will talk to PT and get you a list of excercises to do when you're ready" D. "I understand the hospital is tiring. We will ask PT to focus on one thing that is most important to you today"
D
A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? A. "It is caused by the overproduction of parathormone by the parathyroid gland." B. "It is caused by the lack of production of insulin by the pancreas.." C. "It is caused by the overproduction of growth hormone by the pituitary gland." D. "It is caused by the lack of production of corticosteroids by the adrenal gland."
D
After several diagnostic tests, a client is diagnosed with diabetes insipidus. A nurse performs an assessment of the patient knowing that which symptom is most indicative of this disorder? A. Fatigue B. Diarrhea C. Weight gain D. Polydipsia
D
Junctional rhythms originate from what area of the heart? A. Ventricles B. SA node C. Purkinje Fibers D. AV node
D
The RN correctly interprets this rhythm as: (interval measurements provided) PR- 0.28 QRS- 0.08 QT- 0.48 A. Second Degree Heart Block Type 1 B. Third Degree Heart Block C. Normal Sinus Rhythm D. Normal sinus rhythm with a first degree heart block
D
The nurse is caring for a patient receiving high dose oral corticosteroid therapy after a kidney transplant. What side effect would the nurse monitor for as it presents the greatest risk? A. Hypoglycemia B. Hypotension C. Increased urine output D. Infection
D
The nurse notices their patient has regularly occuring p-waves and regularly occuring QRS complexes, but they do not have any relationship with each other. The nurse prepares which treatment for this rhythm? A. Defibrillation B. Electric Cardioversion C. Adenosine D. Transcutaneous Pacemaker
D
The patient has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing pain. What type of pain is consistent with this diagnosis? A. Burning and aching, located in the epigastric area and radiating to the umbilicus B. Burning and aching, located in the lower left quadrant C. Severe and unrelenting, located in the right lower quadrant with radiation to the back D. Severe and unrelenting, located in the epigastric area and radiating to the back.
D
Which is the most likely treatment for symptomatic bradycardia with an unknown cause? A. Amlodipine B. Adenosine C. Allopurinol D. Atropine
D
Defibrillation is used to treat the following rhythms. Select all that apply: A. Third Degree Heart Block B. 2nd Degree Heart Block Type 2 C. Pulseless Electrical Activity D. Ventricular Fibrillation E. Pulseless Ventricular Tachycardia F. Asystole
D, E
What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply. A. The PR interval measures 0.26 seconds B. The QRS complex measures > 0.24 seconds C. Four to eight QRS complexes occur in a six second strip D. One p wave precedes each QRS E. The R to R interval is consistent
D, E
