MSH
36. Pt has an acute MI, what do you start them on?
ACE inhibitor
21: Degenerative joint disease
Achieve satisfaction pain control
9. Collaborative care for patient?
Administer meds
29. Nursing care with higher priority when giving care.
Altered tissue perfusion.
4: Acquired aplastic anemia
Bone marrow transplant
44: Mother of a child with cerebral palsy (CP)
Brain Damage with CP is not progressive
28: V -Fib
CPR
13. Pt has central line with Flolan running and gets interrupted, what will you do?
Call the Dr immediately
5. Pt taking digoxin has nausea and difficulty breathing, what should you teach him?
Call your HCP
12.Three months after Dx of T2DM pt and nocompliance to Tx regimen.....
Check A1c.
25.Client with Blood glucose of 50mg/dl, before action.
Check level of consciousness. (ALOC).
32. Pain in back and when urinating
Check temp and Pulse
42. Which person gets seen first?
Chest pain with diaphoresis
43. Vomiting hit head
Complete Neuro assessment
21. Nurse assisting PD client ambulate in hallway.
Confirm that this is an effective technique.
11: Blood transfer reaction
Count measure vital sign increase in 30 mins
17. CHF with coughing, increased BP, increased respirations, what should RN do?
Assess for acute congestive heart failure manifestations
22. Pt says they feel as if something gave way, what will you do first?
Assess for serosanguinous drainage
16. Fracture of left femur + fixation complain of pain.
Assess peripheral pulse.
19. Patient w/ COPD having SOB
Assist to a sitting position
20. 2hrs Post op laparoscopy client demanding for food.
Auscultate bowel sound in all 4 quadrant.
49: Warfarin and the diet in food
Avoid the Food rich in Vitamin K
39. Megaloblastic anemia -
B12 injection (Meglaoblastic anemia: The defect in red cell DNA synthesis is most often due to hypovitaminosis, specifically vitamin B12 deficiency or folate deficiency.)
13. AIDS pt classification for bacterial endocarditis -
B2 (what is it?)
52. Test for CHF?
BNP
19. Beta blocker (coreg) for 12 weeks, what sign is of most concern -
BP 88/42
50. 76 year old lady with osteoporosis, what is the best exercise?
Bike (swimming also good choice, right?)
9.COPD patient with ABGs and elevated CO2
- the value is normal, document it
55. Oliguria phase has 250 ml of emesis and 150 ml of urine, how much fluid will you give them?
1000 ml - 500 for what they lost plus an extra 500 for sensible loss
44. Calcium intake -
1500 mg (postmenopause)
45: A math Question:
200mg/250mg * 2 mL = 1.6 mL
33. Nausea and vomiting, dehydration action -
250 ml/hr of Normal Saline
a client with cirrhosis of the liver is admitted with complications related to end stages liver disease, which interventions should the nurse implements? (STAT) A: monitor abdominal girth B: increase oral fluid intake to 1500 ml daily C: report serum albumin and globulin levels D: provide diet low in phosphorus E: note signs of swelling and edemas
A, C, E (monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about about the progression of disease related complication. in advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels. which cause third spacing that results in generalized....)
4. Pt with swollen leg and suspected DVT, what do you do?
Infuse isotonic solution
28. Hospice incontinence -
Insert foley for comfort
18: Anaphylactic shock
Intravenous vasoconstricty shock
31. Pt with potassium level of 6.0, med to give.
Kayaxalate (used to lower hyperkalamia)
23. Laryngectomy and tracheostomy expectorate copious purulent secretion.
Leave the old ties in place till the new one is secured.
11. What will you assess for in an elderly pt that is malnourished?
Depression, tooth problems, transportation, check labs
48: Stiffness in Right Knee
Destruction of joint cartilage
12: Boy 7 years old is in suicidal risk
Determine patient's wishes
24. Client with emphysema and HF has edema, coughing and SOB. BNP is elevated.
Furosemide.
21. Most effective way to assess the elderly?
Geriatric assessment tool
38. Woman comes to the ER with bruises on upper arms and face, what do you do?
Get the forensic nurse to examine her
9. Client is about to go to physical therapy but before that is having a wound debridement(whirlpool therapy)? What should the nurse do?
Give analgesic.
13. Client with SIADH complains of dry mouth and thirsty....
Give hard candy.
30. Bone cancer client with constipation complain of pain of 8 on 1-10 scale.
Give opioid and non opioid simultaneously.
42. Expressive aphasia
Give visual pics
15. Pt with multiple transplant reaction to report to HCP (healthcare prosional)
Lower back pain and hypotension.
32. Hemorrhaging esophageal varicies, what is highest priority?
Maintenance of airway
8. Pt asks nurse about heart transplant, what do you tell him?
Many factors go in to choosing candidate.
46: ICP
Measure blood pressure
7. Pt on 2 g sodium diet, what do they need to avoid?
Milk products
50: Acute Renal Failure (ARF)
Monitor PT Cardiac Activity
31. Abscess drainage
Monitor WBC's
TEST II 1. Pt comes in with frostbite and husband used hand warmers and rubbed them, what will this cause?
More tissue damage
6. Effective teaching for HAART therapy?
Multiple drugs lower the viral load
41. ALC
Muscle weakness
43. HIV med Sustiva is an -
NNRTI
17 cirrhosis disease, exacerbation
NPO (nothing by mouth)
18 Bowel rest
NPO (nothing by mouth)
41: Viral HCP, complaining of weakness and fat
New onset of purple skin lesions
29: Pt willing to have a living will
Notify the MD
27. Who to assess first?
Pt that had severe abdominal pain that suddenly stops
2. Pt had near drowning in lake, what do you watch for?
Pulmonary edema
54. Pt's hands hard, white and numb -
Put in warm water, move extremeties 55. Math problem - 2.5 tabs
25. Pt has bowel evisceration, what will you do first?
Put on a sterile dressing
12. Elderly pt is combative, what do you do first?
Reorient and talk calmly (Combative: adj. 好战的；好事的)
37. Highest priority for acute pancreatitis?
Respiration
15. MVA pt bleeding profusely from abdomen, what's your first action?
Start 18 gauge IV and hang NS
37. Nurse is taking a pt's history, what is of most concern?
States that their shoes fit tighter
20. Elderly pt he can't learn things like he used to, what do you do?
Stay with the pt longer
49. Pt exposed to HIV has negative test at 1 week, what would be the rationale for the negative test?
Still in primary phase and viral load is not showing up
12. Who is going to be assessed first?
Sucking chest wound
1: If a pt has Moderate Alzheimer's disease
Suggest adult day care
22. Xenograft for a Jewish clent with burn.
Taken from nonhuman source.
39. Alcoholic dad in ER, what do you do?
Talk calmly and lowly
1. Man worried about getting osteoporosis like his wife -
Tell him he should get a bone density test.
19. What do you do to prevent drug/drug interactions?
Tell pt to bring all OTC, supplements and med with them to dr'sappt
14. Pt on 2nd round of chemo that finished 3 days ago and calls and says he has lots of hematuria
call physician
46. How to minimize infection in an AIDS pt -
change IV tubing daily
42. Stab wound -
check BP and pulse (stab wound cause large amount of blood loss)
11 Hypothyroidism
check level of consciousness
40. Lethargic and difficult to arouse -
check level of consciousness
6. Which pt do you give a new graduate nurse at the end of 3 month training?
colostomy
34: NGT pt with nausea what is the first thing to do
connect the tube to suction
35. Zantac -
decreased irritation of esophageal varicies (Zantac is Antacid and antihistamine It can treat and prevent heartburn. it can also treat stomach ulcers, gastroesophageal reflux disease (GERD), and conditions that cause too much stomach acid)
20. Ejection fraction 38% -
decreased tissue perfusion
6. a client with newly diagnosed crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?
describe the use of an elimination diet to find trigger foods (Crohn disease is an inflammatory bowel disease marked by patchy areas of full-thickness inflammation anywhere in the gastrointestinal tract, from mouth to the anus.)
3. After a colon resection for colon cancer, a male client is moaning while being transported to unit (PACU). Which intervention should the nurse implement first?
determine clients pulse, blood pressure, and respirations
version 2 1. In teaching a client newly diagnosed with multiple sclerosis (MS), which approach should the nurse emphasize as most likely to prevent an exacerbation of symptoms?
develop preplanned mechanisms to avoid or minimize the effects of triggers
34. Pt has lung cancer and has a liver scan, you tell them the reason for the scan is because -
different treatment is needed if the cancer has metastasized to the liver
19 patient with respiratory infection, AIDS
diminished lung sounds
16. During disaster, media wants info -
direct them to disaster command post
3. A client is recovering from a transurethral prostectomy. Which activity should be limited until after the first postoperative visit with his healthcare provider/;
driving a car
6. a client admitted to a surgical unit is being evaluated for an intestinal obstruction . the healthcare prescribed nasogatric tube(NGT) to be inserted and placed to intermittent low wallsuction. Which intervention -to facilitate proper tube placement?
elevate head of bed 60 to 90 degrees
21 Crohns disease
elimination diet
30: Patient has dementia and is having a difficulty eating
encourage finger eating
15. AIDS pt with decreased weight and malnourished
encourage mouth care
16. Pneumonectomy -
encourage use of incentive spirometer
23. Pt with hepatitis, what are the signs and symptoms -
fatigue and diarrhea
18. Pt has DIC -
fibrinogen level is decreased
3. another SATA about diabetes
finger stick, skin, vitals
25: 10 month baby chocking
finger to the middle of breastbone
4. a client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
further decline in level of consciousness
53. Pt has fever, chills, pain at consovertebral angle -
get urine culture
52. Pt in hospital with moderate headache at base of skull bilaterally -
give Tylenol
6 patient with partial thickness burn
give narcotics
8. Which action shows a nurse understands a client's condition with CHF and diabetes that is in hospice?
give them a piece of cake
47. IBS -
have it for a long time, and learn to deal with it
16: Cleft lip baby feeding how to hold
hold upright position
36: allogratfting procedure:
human source graft require monitoring for sings of graft rejection
8.when preparing a teaching plan for a client newly diagnosed with diabetes mellitus, the nurse should describe which situation as requiring the most immediate action by the client or family?
hypoglycemic shock
45. Pt with Crohn's has brown foul smelling urine -
ileostomy is temporary assess for fistula
23 patient with BPH, TURP, clotting
increase blow bag irrigation
2. During spring break, a young adult presents at the urgent care clinic and report headache. Which intervention is most important for the nurse to implement?
initiate isolation precautions
5. A client who took a camping vacation two weeks ago in a country with a tropical climate comes symptoms and diarrhea for the past week. Which finding is most important for the nurse report?
jaundice sclera
8 indwelling catheter at home
keep bag below bladder level
10 pruritus, hives, severe itching of skin
keep nails cut short
12 something about the cervic (neck)
keep neck/head straight and in anatomical position
53. Snakebite -
keep pt still and remove restrictive clothing
45. HIV WBC lymphocyte count is decreased and viral load is increased -
lab work results
17. Pleurodesis position -
leaning forward and upright
1 pulmonary abscess
left lateral side *SATA-Diabetes 2 Questions
8. a client with chronic kidney disease is started on hemodialysis, during the first treatment the client's blood pressure 150/90 mm hg to 80/30 mm hg. Which action should the nurse take first?
lower the head of the chair and elevate feet
7. A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
measure her temperature and pulse rate
54. Pt has nuchal rigidity, positive brozinski ? sign and rash -
meningitis
38. Cirrhosis with end stage renal disease -
monitor for PSE by GI bleeding
9 patient with weakness and lethargy, what priority intervention
monitor for loss of consciousness
7 ABG question
monitor respiratory rate in depth
9. a client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse spostoperative discharge instruction?
monitor urinary stream for decrease in output
29. Collaborative care for pleural effusion -
morphine
20: Heart sound (video was shown) to figure the what kind of a sound it makes
murmur
23. 28 yo AIDS pt with dementia -
needs palliative care and pain control
39: catheter with liver lock tipped syringe
no corrective action is needed by the nurse
31. Hep B -
no treatment (there are treatment but no cure, can prevented by vaccine)
9. Pt is in hospice
nurse encourages them to tell about their life
4. Pt with terminal disease, family says they're withdrawn -
nurse says this is normal in end of life
51. Pt comes in with new onset of cluster headaches -
nurse should expect to take complete history
5. Pt's family concerned that the pt isn't eating -
nurse tells them to tell pt that food is available when they're hungry and don't force them to eat.
15. The nurse is performing an eye examination on an elderly client. The client states 'My vision is blurred, and I don't easily see clearly when I get into a dark room." The nurse best response is:
o "As one ages, visual changes are noted as part of degenerative changes. This is normal." Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision.
31. Which statement by the client indicates to the nurse that the patient understands precautions necessary during internal radiation therapy for cancer of the cervix?
o "My 7 year old twins should not come to visit me while I'm receiving treatment." Children have cells that are normally actively dividing in the process of growth. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself.
38. A nurse is directed to administer a hypotonic intravenous solution. Looking at the following labeled solutions, she should choose
o 0.45% NaCl Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and D5W are isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic with a higher tonicity thab the blood.
44. A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of the face, neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned?
o 31% Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9% - head; 9% - each upper extremity; 18%- front chest and abdomen; 18% - entire back; 18% - each lower extremity and 1% - perineum.
55. Gregg Lohan, age 75, is admitted to the medical-surgical floor with weakness and left-sided chest pain. The symptoms have been present for several weeks after a viral illness. Which assessment finding is most symptomatic of pericarditis?
o A pericardial friction rub may be present with the pericardial effusion of pericarditis. The lungs are typically clear when auscultated. Sitting up and leaning forward often relieves pericarditis pain. An S3 indicates left-sided heart failure and isn't usually present with pericarditis.
26. An adult has just been brought in by ambulance after a motor vehicle accident. When assessing the client, the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation?
o A rapid pulse and increased RR The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for survival.
39. Which drug would be least effective in lowering a client's serum potassium level?
o Aluminum hydroxide Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. All the other medications mentioned help treat hyperkalemia and its effects.
4. The nurse includes the important measures for stump care in the teaching plan for a client with an amputation. Which measure would be excluded from the teaching plan?
o Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. The "shrinker" bandage is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow
9. Which is irrelevant in the pharmacologic management of a client with CVA?
o Aspirin is used in the acute management of a completed stroke. The primary goal in the management of CVA is to improve cerebral tissue perfusion. Aspirin is a platelet deaggregatorused in the prevention of recurrent or embolic stroke but is not used in the acute management of a completed stroke as it may lead to bleeding.
54. James King is admitted to the hospital with right-side-heart failure. When assessing him for jugular vein distention, the nurse should position him:
o Assessing jugular vein distention should be done when the patient is in semi-Fowler's position (head of the bed elevated 30 to 45 degrees). If the patient lies flat, the veins will be more distended; if he sits upright, the veins will be flat.
28. Which nursing measure would avoid constriction on the affected arm immediately after mastectomy?
o Avoid BP measurement and constricting clothing on the affected arm A BP cuff constricts the blood vessels where it is applied. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm
48. Treatment with hemodialysis is ordered for a client and an external shunt is created. Which nursing action would be of highest priority with regard to the external shunt?
o Avoid taking blood pressure measurements or blood samples from the affected arm. In the client with an external shunt, don't use the arm with the vascular access site to take blood pressure readings, draw blood, insert IV lines, or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt.
1. A client had a laminectomy and spinal fusion yesterday. Which statement is to be excluded from your plan of care?
o Before log rolling, remove the pillow from under the client's head and use no pillows between the client's legs. Laminectomy: n. [外科] 椎板切除术Following a laminectomy and spinal fusion, it is important that the back of the patient be maintained in straight alignment and to support the entire vertebral column to promote complete healing.
33. Which is an incorrect statement pertaining to the following procedures for cancer diagnostics?
o CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic fields and radio frequencies to detect tumors.
49. Assessing the laboratory findings, which result would the nurse most likely expect to find in a client with chronic renal failure?
o Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to
8. What would be the MOST therapeutic nursing action when a client's expressive aphasia is severe?
o Encourage the client to speak at every possible opportunity. Expressive or motor aphasia is a result of damage in the Broca's area of the frontal lobe. It is amotor speech problem in which the client generally understands what is said but is unable to communicate verbally. The patient can best he helped therefore by encouraging him to communicate and reinforce this behavior positively
2. A client is admitted from the emergency department with severe-pain and edema in the right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have the highest priority?
o Ensure an intake of at least 3000 ml of fluid per day. Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones.
43. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by:
o Fluid shift from intravascular space to the interstitial space This period is the burn shock stage or the hypovolemic phase. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output.
20. Chemical burn of the eye are treated with
o Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done.
19. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to:
o Force air out of the lungs The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material.
12. A client is to undergo lumbar puncture. Which is least important information about LP?
o Force fluids before and after the procedure. LP involves the removal of some amount of spinal fluid. To facilitate CSF production, the client is instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after the procedure.
42. If a client has severe bums on the upper torso, which item would be a primary concern?
o Frequently observing for hoarseness, stridor, and dyspnea Burns located in the upper torso, especially resulting from thermal injury related to fires can lead to inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a patent airway is a primary concern.
47. Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching?
o He will be pain free. Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance.
41. Contractures are among the most serious long-term complications of severe burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures?
o Helping the client to rest in the position of maximal comfort Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort. But this approach can lead to contracture deformities and other complications.
50. A female client is admitted with a diagnosis of acute renal failure. She is awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature 100.4°F (38°C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance?
o Hyponatremia The normal serum sodium level is 135 - 145 mEq/L. The client's serum sodium is below normal. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting.
27. A client suffering from acute renal failure has an unexpected increase in urinary output to 150ml/hr. The nurse assesses that the client has entered the second phase of acute renal failure. Nursing actions throughout this phase include observation for signs and symptoms of
o Hypovolemia, wide fluctuations in serum sodium and potassium levels. The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur.
6. Which nursing diagnosis is of the highest priority when caring for a client with myasthenia gravis?
o Ineffective airway clearance related to muscle weakness Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. This leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation.
34. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of the ff. statements about chemotherapy is true?
o It affects both normal and tumor cells Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow, thus the effect of bone marrow depression.
11. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Nursing care of the client includes the following EXCEPT
o Kept the extremity used as puncture site flexed to prevent bleeding. Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the procedure. Ice bag can be applied intermittently to the puncture site.
29. Which of the following interventions would be included in the care of plan in a client with cervical implant?
o Low residue diet It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions
21. Which initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest?
o Palpable carotid pulse Presence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of CPR. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be noted after
23. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following?
o Pericardial tamponade Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above norm
3. A 70-year-old female comes to the clinic for a routine checkup. She is 5 feet 4 inches tall and weighs 180 pounds. Her major complaint is pain in her joints. She is retired and has had to give up her volunteer work because of her discomfort. She was told her diagnosis was osteoarthritis about 5 years ago. Which would be excluded from the clinical pathway for this client?
o Place items so that it is necessary to bend or stretch to reach them. Patients with osteoarthritis have decreased mobility caused by joint pain. Over-reaching and stretching to get an object are to be avoided as this can cause more pain and can even lead to falls. The nurse should see to it therefore that objects are within easy reach of the patient
30. High uric acid levels may develop in clients who are receiving chemotherapy. This is caused by:
o Rapid cell catabolism One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction of large number of tumor cells. . Intracellular contents are released, including potassium and purines, into the bloodstream faster than the body can eliminate them. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. They can precipitate in the kidneys and block the tubules causing acute renal failure
53. The nurse is interviewing a slightly overweight 43-year-old man with mild emphysema and borderline hypertension. He admits to smoking a pack of cigarettes per day. When developing a teaching plan, which of the following should receive highest priority to help decrease respiratory complications?
o Smoking cessation should receive highest priority when trying to reduce risk factors for respiratory complications. Losing weight and decreasing salt and caffeine intake can help to decrease risk factors for hypertension.
13. Which of the following indicates poor practice in communicating with a hearing-impaired client?
o Speak clearly in a loud voice or shout to be heard Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. It is enough for the nurse to speak clearly and slowly
5. The client has clear drainage from the nose and ears after a head injury. How can the nurse determine if the drainage is CSF?
o Test for glucose The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result with the drainage indicate CSF leakage.
52. What is the ratio of chest compressions to ventilations when one rescuer performs cardiopulmonary resuscitation (CPR) on an adult?
o The correct ratio of compressions to ventilations when one rescuer performs CPR is 15:2 Smoking should receive highest priority when trying to reduce risk factors for with respiratory complications. Losing weight and decreasing salt and caffeine intake can help to decrease risk factors for hypertension
51. When assessing a patient for fluid and electrolyte balance, the nurse is aware that the organs most important in maintaining this balance are the:
o The lungs and kidneys are the body's regulators of homeostasis. The lungs are responsible for removing fluid and carbon dioxide; the kidneys maintain a balance of fluid and electrolytes. The other organs play secondary roles in maintaining homeostasis.
24. A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock. The best indicator of adequate fluid balance during this period is
o Urine output of 30 to 50 ml/hr. Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue perfusion to the different organs of the body. Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Normal renal perfusion should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance
22. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following except
o administering an irritant that will stimulate vomiting Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its absorption. For corrosive poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric lavage and the administration of activated charcoal to absorb the poison. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is swallowed.
7. A client with head injury is confused, drowsy and has unequal pupils. Which of the following nursing diagnosis is most important at this time?
o altered cerebral tissue perfusion The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage
36. Maria Sison, 40 years old, single, was admitted to the hospital with a diagnosis of Breast Cancer. She was scheduled for radical mastectomy. Nursing care during the preoperative period should consist of
o assessing Maria's expectations and doubts Assessing the client's expectations and doubts will help lessen her fears and anxieties. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed
25. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. When she arrives in the RR she is still in shock. The nurse's priority should be
o assessing her VS especially her RR Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications.
40. An adult is receiving Total Parenteral Nutrition (TPN). Which of the following assessment is essential?
o fluid and electrolyte monitoring Total parenteral nutrition is a method of providing nutrients to the body by an IV route. The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and sterile water based on individual client needs. It is intended to improve the clients nutritional status. Because of its composition, it is important to monitor the clients fluid intake and output including electrolytes, blood glucose and weight.
32. A post-operative complication of mastectomy is lymphedema. This can be prevented by
o frequently elevating the arm of the affected side above the level of the heart. Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling
37. A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT
o hypertension In hypovolemia, one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria.
16. A nurse is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the
o lower half of the sternum The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration
10. Which is considered as the earliest sign of increased ICP that the nurse should closely observed for?
o progression from restlessness to confusion and disorientation to lethargy The first major effect of increasing ICP is a decrease in cerebral perfusion causing hypoxia that produces a progressive alteration in the LOC. This is initially manifested by restlessness.
35. Kathy refuses to acknowledge that her breast was removed. She believes that her breast is intact under the dressing. The nurse should
o recognize that Kathy is experiencing denial, a normal stage of the grieving process A person grieves to a loss of a significant object. The initial stage in the grieving process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patient's feelings and encourage verbalization
17. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. This is given to:
o relax the bronchial smooth muscle Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles.
46. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On physical examination, the nurse should be looking for tenderness on palpation at McBurney's point, which is located in the
o right lower quadrant To be exact, the appendix is anatomically located at the Mc Burney's point at the right iliac area of the right lower quadrant.
14. Which of the following activities is not encouraged in a patient after an eye surgery?
o sexual intercourse To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP.
18. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on arrival. When his parents arrive at the hospital, the nurse should
o speak to both parents together and encourage them to support each other and express their emotions freely Sudden death of a family member creates a state of shock on the family. They go into a stage of denial and anger in their grieving. Assisting them with information they need to know, answering their questions and listening to them will provide the needed support for them to move on and be of support to one another.
45. Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge teaching should include
o telling him to avoid heavy lifting for 4 to 6 weeks The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. There is no special diet required. The fluid intake of eight glasses a day is good advice but is not a priority in this case.
16 open angle glaucoma
peripheral vision
24 stroke left side, diabetes
place blanket NEXT to feet
48. How to make a positive diagnosis of HIV -
positive ELISA and western blot tests
24. Pt who can't donate blood -
post pregnancy has 6 week old - needs to be 6 mo before donating
10. Digoxin and HCTZ together -
potassium level is 3.0 and dangerous
10. a client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood notifying the healthcare provider, what information should the nurse provide first using the SBAR (situation, background, assessment, and recommendation ) communication process?
preface the report by stating the clients name and admitting diagnosis
5. after a computer tomography (CT) scan with intravenous medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
prepare a dose of epinephrine (adrenalin)
7. Home health nurse visits at 0800, what is of most concern to her? -
pt is weaker than on her last visit.
25. Assess which pt to see first -
pt with peptic ulcer vomiting blood
15 Vital signs, BP, HR ( a lot of different results in numbers)
pulse ox
4 patient with asthma
pursed lip breathing (picture)
2. While assessing a client in a supine position, the nurse observes jugular vein distention. The client's vital signs are: heart rate 110 beats/minute, respirations 28 breaths/minute, and blood pressure 160/88. What should the nurse take?
raise the head of the bed 45 degrees
14: ELSIA test
received HIV maternal antibody transmission antihistamine
5 an image is shown with NG tube
reconnect the tube
22. Spiritual distress goal -
reconnect themselves with their higher power
22: 3 months pylorotomy yest (Select all that apply)
restlessness clenched fists, high pulse, and high respiration
7. when explaining dietary quidelines to a client with acute glomerulonepheritis (AGN) , which instruction should the nurse include in the dietary teaching ?
restrict sodium intake
4. Which nursing problem has the highest priority when planning care for a client with osteomalacia?
risk for injury
31: P.D
risk of aspiration related to M.V
30. Patient develops DIC from -
septicemia
3. Neck vein distention while pt sitting up in bed receiving blood products -
slow down the infusion
47. Prevent infection in AIDS pt -
soak toothbrush in bleach
22. Osteoarthritis
swimming
33. A pt is dying and asks if they are -
tell the truth
44. Gunshot wound -
tell them ileostomy is temporary
35. Pt teaching for compliance with hypertension meds -
tell them that hypertension eventually leads to heart failure
30. Crohn's teaching -
times of remission/exacerbations
22 patient with chemo and flu-like
tylanol (acetaminophen) every 3-4 hours
46. Appendicitis -
use ice pack
2. Giving platelets
use short infusion set with no filter.
43. Pt has excessive diarrhea -
use witch hazel compresses for inflammation
32: 3 year old toilet trained
usually reassure their toileting when they leave the hospital
24. What is the best way to prevent spreading of Hep A?
wash hands
20 Question about gall bladder, bile, cholecystectomy
yellowing of skin and eyes
47: Bleeding at the injection site (Select all that apply, Put the question in sequence according to its first and last priority)
• Retract the needle into syringe • Apply an adhesives bandage over the injection site • Place syringe in a puncture - resistant container • Remove disposable exam gloves
28. Pt with nausea and vomiting for 4 days, what is of most concern?
They're lethargic and confused
47: Question regarding priority
Treat sudden Flank Pain First
14. Client with emphysema with CT drain change from green to clear liquid.
Tx is effective, document, continue to monitor pt.
51. Pt has blunt trauma to abdomen from MVA, what test will you do?
Ultrasound
41. Which pt gets a black triage tag?
Unresponsive head injury
3. Hypothermia pt getting moved, what do you need to do?
Use a cardiac monitor
19. CVA client with expressive aphasia frustrated.
Use communication board.
2: Obtain blood glucose (Select all that apply)
Varify the insulin prescribed, draw the insulin and clean the selected site
43: If a person has a Parkinson's disease
Worry about physical mobility
17: Chemotherapy patient goes to elementary school
Worry about the direct contact with children
27: Hyperparathyroidism diseases diet
Yogurt
3: Cefidinir
Yogurt and buttermilk
46. SATA ALS prevention
a. ???
21. Pt 6 hours affter surg, pt deep breath/cough:
a. Advise only deep breathe
35. Headache
a. Alcohol
4. Blind and diaphoretic
a. Assist to Bathroom
30. Shock entered left hand, exit left food
a. Cardiac monitoring
23. Pt diabetis 3 months prior
a. Check A1C
5. Gave woman insulin, has chills:
a. Check CBG again (what about glucose>??)
45. SATA furosimdie:
a. Check crackles b. Urine output C. O2 sat
17. Chin absess
a. Check for airway patency
38. Leg traction
a. Check peripheral pulse
8. After hemorrhage, bringing sacral
a. Check vitals
22. Burn pt:
a. Continue EKG monitoring
39. Pt on methadone for back pain
a. Continue same dose of methadone and treat pain PRN meds
24. Pt low Hgb and HCt
a. Diet with beef steak and broccoli
36. SIDAH
a. Eat hard candy
31. Lady talking antacids no relief:
a. Focus on st elevation
9. Vomit looks like coffee grounds
a. Get vitals
43. Pt has asthma
a. Give PRN albuterol
25. Pt with 6.7 potassium
a. Give kayexalate
14. Transurethral resection blood clots
a. Increase irrigation/flow rate
40. Arterial leg ulcer
a. Inspect feet daily
37. Pt after chemo, low neutrophils
a. Isolate
34. Trach cleaning:
a. Keep old ties in place
6. Radiation port
a. Keep out of sun
11. Start pt eating again
a. Low sodium broth, no hot tea, lemon popsicle
1. COPD,
a. Lower to 2L/ cannula
10. Lady with MS after falling
a. Neuro assess
41. TB Test
a. Normal
3. After surgery (woman) shortness of breath
a. Prepare for for intubate
18. Pt passed out in clinic AED applied
a. Read defibrillator reading
42. Surgery NPO, pt drank OJ
a. Reschedule surgery 6 hours
26. Pt before surgery inform doctor
a. Serum creatinine level 27. 1
7. Man after bypass surgery, anestomis leakage
a. Strict fluid replacement
15. Restrictions renal calculo
a. Tea and chocolate
32. Pt dark tarry stool
a. Test blood for occult
16. Prostate enlarged
a. Urinary retention
33. Newly diabetic pt what type test
a. Vision, dexterity
19. Abdominal surg pt with distention:
a. ausculate bowl sounds
20. prevent DVT
a. encourage leg exercises
44. Pt pheochromocytoisis:
a. high BP
2. Diverticulosis,
a. high fiber diet w/fluids (diverticulosis is a condition in which small, bulging pouches develop in the digestive tract) Diverticulosis: outpouching: related to low intake of dietary fiber and increased pressure in the colon needed to expel the small, low-bulk stool. It is common in older adult, though it may never produce complication, some may never have any symptoms. Diverticulitis: inflamed diverticula: inflammation of the diverticula, or outpuchings of the colon. It left untreated, lead to perforation of the intestine and can cause peritonitis. Assessment focuses on: abdominal pain, abdominal distention, flatulence, fever, rectal bleeding, alternating constipation and diarrhea. Consideration: peritonitis (can also lead to hypovolemic shock).
29. peritoneal dialysis
a. peritonitis
28. pt w osteoarthritis
a. swimming as exercise
31. DIC -
abnormal clotting cascade - give FFP (Fresh Frozen Plasma)
24: Diazepam, benzodiazepam (Select all that apply)
admin slowly, monitor level of consciousness and perform ongoing respiration assessment
1. a client with stage IV bone cancer is admitted to the hospital for a 1 to 10 scale. Which intervention should the nurse implement
administer opioid and non-opioid medication simultaneously
2. family member calls and is confused...
administer orange juice, finger stick
19: Raynaud's disease
appropriate Temp at home and dress in layers in cold weather
13 heart failure, swollen feet
ask for any weight changes
32. Admission interview for elderly -
ask if they wear hearing aid or glasses
11. S3 is heard during auscultation -
assess for left heart failure
25 SATA - shingles
assess for pain, skin, stability
34. Pacemaker with fullness in the chest
assess heart sounds
26: Dysuria, urgency, urinary frustration
Perform a clean catch septic urine test
13: A 6 year old refusing incentive spirometer
Play game like blow out light bubbles
28. Nurse calling HCP for client complaining of pain, SBAR report pattern.
Preface the Client information to HCP.
15 increase elderly undergo surgical for glaucoma
Prevalence of glaucoma in post op
10: anger expression about roommate
Projection
40. Patient radiation d/c teaching
Protect from direct sunlight
30. Neutrophil
Protective Isolation
7.Patient complaining of abdominal pain
-auscultate bowel sounds
3.Patient complaining of leg pain
-check peripheral pulses
1.Patient taking ferrous sulfate
-check serum iron and ferritin
4.Emesis basin of coffee-ground vomit
-check vital signs
2.Patient complaining of pain in the back/sacrum area
-check vital signs first
8.Pt with eczema how will you know the medication is working
-the skin is being hydrated
17. Nursing care goal for preop client.
A physical and emotional preparedness.
40: viral meningitis in kindergarten school
A recent exposure to mump's at school
14. AIDS pt with PCP and leg ulcer, what nursing dx will he have?
Impaired gas exchange
35: Breast cancer
Dimple of skin (not normal)
40. Pt with AIDS yells at every nurse, what do you do?
Discuss options with the staff
28. TURP transurethral resection of the prostate:
Do not drive
50. What puts you at least risk for HIV?
Donating blood
23. Cold leg with a thready difficult to palpate pulse
Doppler
26. Pt went on a trip to Mexico and now has diarrhea, what do you tell him to do?
Drink Gatorade
11. Intermittent claudiation with leg pain...
Encourage progressive exercise.
7: leukocyte and allergic response
Eosinophil's (Parasitic warms)
21. Lady in ER feels dizzy then falls unconscious, what's your first action?
Establish patent airway
8: Fire evacuation of new born nursery
Evacuate each mother with babies In wheelchair
18. Pt with difficulty breathing, what 's your first action?
High fowler's
37: Thrombolytic with MI
History of alcohol abuse
10. Dr fills out DNR order according to pt's wishes, family wants CPR, what do you do?
Honor the DNR
26. Pt had pneumonia 3 months ago, what statement is most worrisome?
I don't go on walks like I used to
34. Crohn's pt says I can't take it anymore -
I see you're upset, I will sit and talk with you
36. What shows need for further teaching in pt with ileostomy?
I will irrigate everyday
38: Disaster intervention plan:
Identify a commend center where activities are coordinated
23: Prasugrel a platelets inhibitor
Observe color of urine
18. Iron deficiency anemia client selected food requiring further teaching.
Orange. Help in iron absorption but not reach in iron.
33: Increased ICP (Select all that apply)
PSS BP 160/70, PS0 BP 194/70, irregular respiration
27. Psoriasis
Palpate and tender (psoriasis: chronic skin disorder, which red papules and scaly silvery plaques with sharply defined borders appear on the body surface.)
5: Distal pulse rate, patient with IV R.F.A
Palpate at radial pulse site with 2-3 fingers
48. Appendicitis -
Rovsing's sig (palpation of the left lower quadrant of a person's abdomen increase the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis.)
6: What patients should be delegated to the Newly hired UAP
Schizophrenic pt, and pt who has been admitted with antipsychotic 2 weeks ago
29. Indication that pt needs pain meds after sx?
Shallow breathing
42: Nosebleed
Sitting up and lean forward
9: palpating lymph node of 18 months old
be alert of enlarged, warm, tender preauicular node.
41. NSAID use -
bleeding ulcer needs laparotomy
14 parotid gland-assess nerve damage
blink eyes, keep them shut
49. Diet high in calcium for osteoporosis -
broccoli and yogurt
