NCLEX practice Questions
15. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response? A. Electrical energy fields B. Spinal column manipulation C. Mind-body balance D. Exercise of joints
B. Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.
15. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? A. Slow pulse rate B. Weight gain C. Decreased systolic pressure D. Irregular WBC lab values
B. Weight gain Weight gain due to fluid accumulation is associated with heart failure and congenital heart defects.
A 17-year old girl and her mother are both in the exam room for the girl's school physical. Before asking the girl about her sexual history, which statement should the nurse make? a) "Mother, I'm going to ask you step out, so I can complete the health history." b) "Do you think your mother should leave the room now?" c) "The two of you seem so close. I'll ask questions about sexual history now." d) "Mother, do you think your daughter is sexually active?"
a) "Mother, I'm going to ask you step out, so I can complete the health history."
A 10-month old baby with a fractured right femur is admitted to the pediatric unit. Which action should the nurse take first? a) Ask the parents how the fracture occurred. b) Do a quick physical assessment. c) Administer pain medication. d) Ask the hospital social worker to come to the unit.
a) Ask the parents how the fracture occurred. In case of injury, especially among babies and children, it is very important that the nurse should first assess possible abuse. Reported suspected abuse is the responsibility of all healthcare professionals.
A patient presents to the emergency department with a blood pressure of 180/130 mmHg, headache, and confusion. Which additional finding is consistent with a diagnosis of hypertensive emergency? A) Retinopathy B) Bradycardia C) Jaundice D) Urinary retention
A) Retinopathy It may cause hypertensive retinopathy, resulting in hemorrhages, exudates, and/or papilledema. Other consequences of a hypertensive emergency include stroke, heart attack, aortic dissection, kidney damage, and pulmonary edema.
A female patient complains of abdominal discomfort. Watery stool has been leaking from her rectum. This could be a sign of... A) Bowel incontinence B) fecal impaction C) diarrhea D) constipation
*Fecal impaction* Fecal impaction can be serious. When constipation is not resolved, stool becomes hardened and unable to pass. Liquid stool may pass around the impaction. Patients may complain of feeling bloated; having the urge to push; nausea or vomiting; not wanting to eat. The impaction may need to be manually removed. Patient education should include increasing liquids and fiber, as well as regular physical activity.
A patient reports smoking 10 cigarettes per day for 40 years. How will the healthcare provider document this patient's smoking habit in terms of pack years? 5 pack years 10 pack years 4 pack years 20 pack years
20 pack years A pack contains 20 cigarettes. Calculate pack years by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 1 pack-year is equal to smoking 20 cigarettes (1 pack) per day for 1 year.
When performing chest percussion on a child, which of the following techniques should the nurse use? A Firmly but gently striking the chest wall to make a popping sound. B. Gently striking the chest wall to make a slapping sound. C Percussing over an area from the umbilicus to the clavicle. D Placing a blanket between the nurse's hand and the child's chest.
A Firmly but gently striking the chest wall to make a popping sound. The nurse should firmly yet gently strike the chest wall with the hand cupped to make a hollow popping sound. A slapping sound indicates that an incorrect technique is being used. The area over the rib cage is percussed to loosen mucus from the underlying lung passages. The child should wear a thin piece of clothing (T-shirt) over the chest area to protect the skin without diminishing the effect of the percussion.
A patient with a diagnosis of lung cancer is receiving chemotherapy and reports nausea and loss of appetite resulting in decreased food intake. What should the healthcare provider recommend to promote adequate nutrition? Advise the patient to... A) Eat small meals throughout the day B) Eat only favorite foods to increase appetite C) Eat only when feeing hungry D) Eat large meals but less frequently throughout the day
A) Eat small meals throughout the day
When assessing a patient diagnosed with osteoarthritis (OA), the healthcare provider looks for which characteristic of this condition? A) Joint crepitus B) Bilateral joint swelling C) Decreased grip strength D) Waddling gait
A) Joint crepitus
26. When you are taking a patient's history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking? A. Amitriptyline (Elavil) B. Calcitonin C. Pergolide mesylate (Permax) D. Verapamil (Calan)
A. Amitriptyline (Elavil) Amitriptyline (Elavil) is a tricyclic antidepressant and used to treat symptoms of depression. Option B: Calcitonin is used to treat osteoporosis in women who have been in menopause. Option C: Pergolide mesylate (Permax) is used in the treatment of Parkinson's disease. Option D: Verapamil (Calan) is a calcium channel blocker.
32. A nurse if reviewing a patient's chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition? A. Borrelia burgdorferi B. Streptococcus pyogenes C. Bacillus anthracis D. Enterococcus faecalis
A. Borrelia burgdorferi Option B: is linked to Rheumatic fever Option C: is linked to Anthrax Option D: is linked to Endocarditis.
2. A nurse is reviewing a patient's past medical history (PMH). The history indicates the patient has photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select all that apply: A. Ciprofloxacin (Cipro) B. Sulfonamide C. Norfloxacin (Noroxin) D. Sulfamethoxazole and Trimethoprim (Bactrim) E. Isotretinoin (Accutane) F. Nitro-Dur patch
A. Ciprofloxacin (Cipro) B. Sulfonamide C. Norfloxacin (Noroxin) D. Sulfamethoxazole and Trimethoprim (Bactrim) E. Isotretinoin (Accutane)
Which finding(s) is (are) of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A. Cramping with bright red spotting B. Extreme tenderness of the breast C. Lack of tenderness of the breast D. Increased amounts of discharge E. Increased right-side flank pain
A. Cramping with bright red spotting C. Lack of tenderness of the breast E. Increased right-side flank pain (A and C) are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. (E) could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. (B and D) are normal signs during the first trimester of a pregnancy.
A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply. A. Excessive alcohol use. B. Gallstones. C. Abdominal trauma. D. Hypertension. E. Hyperlipidemia with excessive triglycerides. F. Hypothyroidism.
A. Excessive alcohol use. B. Gallstones. C. Abdominal trauma E. Hyperlipidemia with excessive triglycerides. Pancreatitis, a chronic or acute inflammation of the pancreas, is a potentially life-threatening condition. Excessive alcohol intake and gallstones are the greatest risk factors. Abdominal trauma can potentiate inflammation. Hyper-lipidemia is a risk factor for recurrent pancreatitis. Hypertension and hypothyroidism are not associated with pancreatitis.
7. Amrinone (Inocor) is used for short term therapy for CHF and acts by which of the following mechanisms? A. Increasing stroke volume and heart rate B. Slowing ventricular rate and increasing cardiac output C. Vasodilating and increasing peripheral vascular resistance D. Increasing cardiac output and enhancing renal perfusion
A. Increasing stroke volume and heart rate The action of amrinone (Inocor) is to increase stroke volume, ejection fraction, and heart rate. Lanoxin, not amrinone, slows ventricular rate and increases cardiac output. The vasodilator effect of amrinone decreases peripheral vascular resistance. Any increase in cardiac output will enhance renal perfusion; this is not just specific to amrinone.
12. A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient? A. Onset of pulmonary edema B. Metabolic alkalosis C. Respiratory alkalosis D. Parkinson's disease type symptoms
A. Onset of pulmonary edema Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development. Early symptoms of aspirin poisoning also include tinnitus, hyperventilation, vomiting, dehydration, and fever. Late signs include drowsiness, bizarre behavior, unsteady walking, and coma. Abnormal breathing caused by aspirin poisoning is usually rapid and deep. Pulmonary edema may be related to an increase in permeability within the capillaries of the lung leading to "protein leakage" and transudation of fluid in both renal and pulmonary tissues. The alteration in renal tubule permeability may lead to a change in colloid osmotic pressure and thus facilitate pulmonary edema (via Medscape).
36. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? A. Apply dressing using sterile technique B. Improve the client's nutrition status C. Initiate limb compression therapy D. Begin proteolytic debridement
B. Improve the client's nutrition status The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help
1. A nurse is reviewing a patient's medication during shift change. Which of the following medications would be contraindicated if the patient were pregnant? Select all that apply: A. Warfarin (Coumadin) B. Finasteride (Propecia, Proscar) C. Celecoxib (Celebrex) D. Clonidine (Catapres) E. Transdermal nicotine (Habitrol) F. Clofazimine(Lamprene)
A. Warfarin (Coumadin) B. Finasteride (Propecia, Proscar) Option A: Warfarin (Coumadin). Has a pregnancy category X and associated with central nervous system defects, spontaneous abortion, stillbirth, prematurity, hemorrhage, and ocular defects when given anytime during pregnancy and a fetal warfarin syndrome when given during the first trimester. Option B: Finasteride (Propecia, Proscar). Also has a pregnancy category X which has a high risk of causing permanent damage to the fetus. Option C: Celecoxib (Celebrex). Large doses cause birth defects in rabbits; not known if the effect on people is the same. Option D: Clonidine (Catapres). Crosses the placenta but no adverse fetal effects have been observed. Option E: Transdermal nicotine (Habitrol). Nicotine replacement products have been assigned to pregnancy category C (nicotine gum) and category D (transdermal patches, inhalers, and spray nicotine products). Option F: Clofazimine (Lamprene). Clofazimine has been assigned to pregnancy category C.
The Emergency Department notifies the pediatric unit of an admission of a 10-year old with bacterial meningitis. What type of isolation should be implemented? a) Droplet precautions b) Contact precautions c) Airborne precautions d) Standard precautions
a) Droplet precautions Bacterial meningitis is caused by exposure to through respiratory droplets. The droplets are heavy, and fall within 3 feet of the patient. Droplet precaution, in addition to standard precaution, requires a mask when giving direct care or coming into close vicinity of the patient. Standard precautions are general precautions taken with all patients.
8. George, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the nurse that George needs to continue taking the salicylates he had received at home? A. Chorea. B. Polyarthritis. C. Subcutaneous nodules. D. Erythema marginatum.
B. Polyarthritis. Chorea is the restless and sudden aimless and irregular movements of the extremities suddenly seen in persons with rheumatic fever, especially girls. Polyarthritis is characterized by swollen, painful, hot joints that respond to salicylates. Subcutaneous nodules are nontender swellings over bony prominences sometimes seen in persons with rheumatic fever. Erythema marginatum is a skin condition characterized by nonpruritic rash, affecting trunk and proximal extremities, seen in persons with rheumatic fever.
The healthcare provider prepares to administer a corticosteroid to a patient with a diagnosis of asthma. What is the rationale for administering this drug to this patient? A) Promote bronchodilation B) Decrease airway swelling C) Prevent respiratory infections D) Promote expectoration of mucus
B) Decrease airway swelling Corticosteroids and other anti-inflammatory drugs work by reducing inflammation, swelling, and mucus production in the airways of a person with asthma. As a result, the airways are less inflamed and less likely to react to asthma triggers. Inhaled corticosteroids are the primary treatment for asthma.
25. A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal? A. 11-year-old male: 90 BPM, 22 RPM, 100/70 mmHg B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg C. 5-year-old male: 102 BPM, 24 RPM, 90/65 mmHg D. 6-year-old female: 100 BPM, 26 RPM, 90/70 mmHg
B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg
11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A. Trichomoniasis B. Chlamydia C. Staphylococcus D. Streptococcus
B. Chlamydia Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.
A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted? A. If MSAFP (maternal serum alpha-fetoprotein) and estriol levels are high and the human chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal defect. B. If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. C. If MSAFP are within normal limits, there is a guarantee that the baby is free of all structural anomalies. D. If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal findings.
B. If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample are indications of possible chromosomal defects (B). High levels of MSAFP and estriol in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as spina bifida and anencephaly, not chromosomal defects (A). One of the limitations of the multiple marker screening is that any defects covered by skin will not be evident in the blood sampling (C). After 15 weeks of gestation, there will be traces of MSAFP, estriol, and hCG in the blood sample (D).
Which of these assessment findings should the healthcare provider expect to identify as an early clinical characteristic of multiple sclerosis (MS)? A) Muscle atrophy B) dementia C) vision loss D) clonus
C) vision loss MS is an inflammatory demyelinating disease of the central nervous system. Demyelination will cause slowed conduction and eventually loss of function. Vision loss and eye pain (optic neuritis) are early symptoms of MS due to inflammation of the optic nerve. Dementia is uncommon and found only in severely affected patients. Clonus (rhythmic contractions when a muscle is stretched) is a sign of nerve damage which may be seen as MS progresses. Muscle atrophy is also a later sign of MS which is caused by disuse of a muscle group.
The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign? A. 3 B. 4 C. 5 D. 8
C. 5 The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0 and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5 (C). (A, B, and D) are not accurate.
A thirty-five-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect? A. Atherosclerosis B. Diabetic nephropathy C. Autonomic neuropathy D. Somatic neuropathy
C. Autonomic neuropathy Autonomic neuropathy (also known as Diabetic Autonomic Neuropathy) affects the autonomic nerves, which control the bladder, intestinal tract, and genitals, among other organs. Paralysis of the bladder is a common symptom of this type of neuropathy. Option B: Diabetic nephropathy (DN) is typically defined by macroalbuminuria—that is, a urinary albumin excretion of more than 300 mg in a 24-hour collection—or macroalbuminuria and abnormal renal function as represented by an abnormality in serum creatinine, calculated creatinine clearance, or glomerular filtration rate (GFR). Clinically, diabetic nephropathy is characterized by a progressive increase in proteinuria and decline in GFR, hypertension, and a high risk of cardiovascular morbidity and mortality
10. Rhogam is most often used to treat____ mothers that have a ____ infant. A. RH positive, RH positive B. RH positive, RH negative C. RH negative, RH positive D. RH negative, RH negative
C. RH negative, RH positive Rhogam prevents the production of anti-RH antibodies in the mother that has a Rh positive fetus.
A 26-year-old gravida 2, para 1 client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate? A. Drowsiness and paroxysmal bradycardia B. Depressed reflexes and increased respirations C. Tachycardia and a feeling of nervousness D. A flushed warm feeling and dry mouth
C. Tachycardia and a feeling of nervousness Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness (C). (A) is not a side effect. (B and D) are side effects of magnesium sulfate.
14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working? A. The client complains of discomfort at the IV insertion site B. The client states "I just can't get relief from my pain." C. The level of drug is 100 ml at 8 AM and is 80 ml at noon D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon
C. The level of drug is 100 ml at 8 AM and is 80 ml at noon
18. Ms.Clark has hyperthyroidism and is scheduled for a thyroidectomy. The physician has ordered Lugol's solution for the client. The nurse understands that the primary reason for giving Lugol's solution preoperatively is to: A. decrease the risk of agranulocytosis postoperatively. B. prevent tetany while the client is under general anesthesia. C. reduce the size and vascularity of the thyroid and prevent hemorrhage. D. potentiate the effect of the other preoperative medication so less medicine can be given while the client is under anesthesia.
C. reduce the size and vascularity of the thyroid and prevent hemorrhage. Doses of over 30 mg/day may increase the risk of agranulocytosis. Lugol's solution does not act to prevent tetany. Calcium is used to treat tetany. The client may receive iodine solution (Lugol's solution) for 10 to 14 days before surgery to decrease vascularity of the thyroid and thus prevent excess bleeding. Lugol's solution does not potentiate any other preoperative medication.
11. Which of the following is least likely to influence the potential for a client to comply with lithium therapy after discharge? A. The impact of lithium on the client's energy level and lifestyle. B. The need for consistent blood level monitoring. C. The potential side effects of lithium. D. What the client's friends think of his need to take medication
D. What the client's friends think of his need to take medication The impact of lithium on the client's energy level and lifestyle are great determinants to compliance. The frequent blood level monitoring required is difficult for clients to follow for a long period of time. Potential side effects such as fine tremor, drowsiness, diarrhea, polyuria, thirst, weight gain, and fatigue can be disturbing to the client. While the client's social network can influence the client in terms of compliance, the influence is typically secondary to that of the other factors listed.
9. Johanna has ventricular ectopy, which of the following drugs is the first line used to treat her condition? A. quinidine (Cardioquin) B. digoxin (Lanoxin) C. procainamide ( Pronestyl) D. lidocaine (Xylocaine)
D. lidocaine (Xylocaine) Lidocaine is the only choice used to treat ventricular ectopy. A and C are class IA antiarrhythmics. Digoxin is a cardiac glycoside.
The healthcare provider is caring for a patient who has an implanted permanent pacemaker due to complete heart block and severe bradycardia. Which of the following should the healthcare provider assess first to determine pacemaker functioning? a) Electrocardiogram (EKG) b) Blood pressure c) Apical pulse d) Pacemaker insertion site
a) Electrocardiogram (EKG) An apical pulse within normal range will give some indication that the pacemaker is functioning, but it will not specifically show how often the pacemaker is firing. An EKG is the best way to determine pacemaker function because the actual pacing is determined by pacer artifact which can be seen on the EKG strip.
According to the CDC, when removing personal protective equipment (PPE) which item is removed first? a) Gloves b) Goggles c) Mask d) Gown
a) Gloves The Centers for Disease Control and Prevention recommends removing PPE in an order that minimizes contamination from pathogens. Since gloves are the "dirtiest," they are removed first. To make it easy to remember, remove the PPE in alphabetical order: gloves, goggles, gown, masks.
A nurse in the Neonatal ICU administers adult-strength digitalis (Digoxin, Lanoxin) to a 3-pound infant. As a result, the neonate experiences permanent heart and brain damage. The nurse can be charged with a) Negligence b) Malpractice c) Assault d) Tort
b) Malpractice The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose, even if accidental, is malpractice. Negligence is failing to perform the proper standard of care for a patient; a tort is a wrongful act committed on the patient or the patient's belongings; and assault is a violent physical or verbal attack.
5. The therapeutic drug level for digoxin is: A. 0.1-2.0 ng/mg B. 1.0-2.0 ng/mg C. 0.1-0.5 ng/mg D. 0.5-2.0 ng/mg
D. 0.5-2.0 ng/mg
34. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication? A. Weight gain of 5 pounds B. Edema of the ankles C. Gastric irritability D. Decreased appetite
D. Decreased appetite Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias.
31. A nurse if reviewing a patient's chart and notices that the patient suffers from conjunctivitis. Which of the following microorganisms is related to this condition? A. Yersinia pestis B. Helicobacter pylori C. Vibrio cholerae D. Haemophilus aegyptius
D. Haemophilus aegyptius A - plague b - stomach ulcers c - cholera
5. A 34-year-old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb? A. IgA B. IgD C. IgE D. IgG
D. IgG IgG is the only immunoglobulin that can cross the placental barrier. Option A: IgA antibodies protect body surfaces that are exposed to outside foreign substances. Option B: IgD antibodies are found in small amounts in the tissues that line the belly or chest. Option C: IgE antibodies cause the body to react against foreign substances such as pollen, spores, animal dander.
32. The nurse practicing in a maternity setting recognizes that the postmature fetus is at risk due to A. Excessive fetal weight B. Low blood sugar levels C. Depletion of subcutaneous fat D. Progressive placental insufficiency
D. Progressive placental insufficiency The placenta functions less efficiently as the pregnancy continues beyond 42 weeks. Immediate and long-term effects may be related to hypoxia.
26. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to: A. Achieve harmony B. Maintain a balance of energy C. Respect life D. Restore yin and yang
D. Restore yin and yang For followers of Chinese medicine, health is maintained through the balance between the forces of yin and yang.
8. Before giving milrinone (Primacor) by an IV infusion to a client with symptoms of CHF, which of the following nursing actions is necessary? A. Record sodium level. B. Administer loading dose over 15 minutes. C. Assess CV status. D. Review medication regimen to identify if client is on IV furosemide(Lasix).
D. Review medication regimen to identify if client is on IV furosemide(Lasix). Milrinone (Primacor) is incompatible with IV furosemide (Lasix), and many clients with CHF are taking furosemide. Assessing potassium, not sodium, is essential. Choice B is not done before administration but during administration. Assessment of CV status is not specific for milrinone and is indicated for any drug that affects the circulatory system.
20. A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC's last in my body? The correct response is. A. The life span of RBC is 45 days. B. The life span of RBC is 60 days. C. The life span of RBC is 90 days. D. The life span of RBC is 120 days.
D. The life span of RBC is 120 days.
When assigning tasks to unlicensed assistive personnel (UAP), the nurse can ask them to do all the following EXCEPT a) Report signs of skin breakdown b) Provide patient and family education c) Assist a patient who is choking d) Measure intake and output
b) Provide patient and family education
While caring for a patient following a laryngectomy, the patient suddenly becomes pale and nonresponsive, with a BP of 90/40. The initial action should be to... a) Increase the infusion of Dextrose in normal saline (D5NS) b) Move the emergency cart to the bedside c) Place the client in Trendelenburg position d) Administer atropine intravenously
a) Increase the infusion of Dextrose in normal saline (D5NS) D5NS infusion is hypertonic, so it will draw fluid into the circulation. Trendelenburg position could compromise the airway in a patient who has had head or neck surgery. Atropine could cause hyponatremia and further hypotension. Moving the emergency cart to the bedside is not necessary at this time.
When caring for a patient with a cardiac dysrhythmia, which laboratory value is a priority for the healthcare provider to monitor? a) Na+, K+, Ca+2 b) PT and INR c) Hgb and Hct d) BUN and Cr
a) Na+, K+, Ca+2
A staff nurse is walking to lunch in the main corridor of the hospital when the code for infant abduction is announced. What should the staff nurse do? a) Observe people in the area who are carrying oversized coats or large bags. b) Contact the charge nurse of the nursery to obtain details. c) Go directly to the obstetrics unit to offer assistance as required. d) Quickly move to the hospital entrance and check each person who leaves.
a) Observe people in the area who are carrying oversized coats or large bags.
A mother tells the nurse that her 8-year old doesn't eat as much as her toddler or teenager. The nurse should explain that school-age children have a lower... Activity level Hormone level Growth rate Metabolic rate
Growth rate
The healthcare provider is teaching a patient with emphysema pursed-lip breathing. Pursed lip breathing helps patients with emphysema because it... Helps the patient achieve maximum inhalation. Helps keep the small airways open and prevents air trapping. Increases the respiratory rate and oxygenation. Creates negative pressure in the airways.
Helps keep the small airways open and prevents air trapping. Pursed lip breathing (PLB)is one of the best ways to control shortness of breath. It improves ventilation by keeping the small airways open and releases air that is trapped in the lungs. It also extends the expiratory phase, which slows the breathing rate. Because patients with emphysema have less elastic recoil in their lungs, airways can collapse during expiration, air gets trapped, and exhalation is difficult. Cleveland Clinic suggests the following method to teach PLB: 1. Relax neck and shoulder muscles. 2. Inhale slowly through the nose for two counts, keeping the mouth closed. Don't take a deep breath; a normal breath will do. It may help to count silently: inhale, one, two. 3. Pucker or "purse" the lips as if whistling. 4. Exhale slowly and gently through the pursed lips for four counts.
The nurse plans to instruct parents of a 4-year old with cystic fibrosis (CF) about the child's nutritional needs. Which should be included during teaching? High calorie Low carbohydrate High fat Low protein
High calorie Children with cystic fibrosis require a high calorie, high protein diet in order to avoid failure to thrive syndrome. Other CF therapies include pancreatic enzyme replacement, fat-soluble vitamins, and supplemental feedings (gastrostomy or parental) if nutritional needs can't be met by eating.
After educating a 19-year old client about possible adverse effects of her oral contraception, which of the client's concerns shows a lack of understanding? Headaches Ovarian cancer Nausea Weight gain
Ovarian cancer
A 32-year old client refuses to have any analgesia or anesthesia during her birth experience. As the nurse assists her during the second stage of her labor, which position should she use to begin pushing? Lithotomy position with high stirrups Squatting with her body curved into a "C" position Lying on her left side in the Sims' position Knee-chest position with head elevated
Squatting with her body curved into a "C" position Squatting helps enlarge the pelvic outlet and allows gravity to assist. The most efficient position is for the mother to squat with her body curved over her knees in a "C" position. Squatting can open the pelvis by 10%.
When caring for an elderly client who has visual and hearing impairments, which of the following should the nurse assess? Cognitive decline Sensory overload Confusion and anger Social isolation
Social isolation Sensory impairments can lead to social isolation for older adults. Confusion and anger can be part of cognitive decline, which is a separate concern, unrelated to diminished vision or hearing. Sensory overload very unlikely.
A clinician is providing education to a patient with a recent diagnosis of a transient ischemic attack (TIA). Which of the statements by the patient indicates that the patient understands the information? a) "I should seek medical attention immediately if I experience these symptoms again, because I could be having a stroke." b) "Transient ischemic attacks (TIAs) are often caused by small bleeds in the brain that resolve on their own." c) "TIAs are usually caused by large bleeds in the brain that resolve on their own." d) "Because TIAs don't cause permanent damage, I do not need to worry if I have another one."
a) "I should seek medical attention immediately if I experience these symptoms again, because I could be having a stroke."
When coming back from lunch, the nurse notices a male patient walking alone in the hall. The patient is wearing non-grip socks and the colored wristband that indicates a risk for falling. What is the first thing the nurse should do? a) Walk with the client back to his room and assist him to get in bed. b) Sit the patient in a chair and find the nurse aide. c) Tell the patient to keep walking to build strength d) Instruct the patient to walk only in his room.
a) Walk with the client back to his room and assist him to get in bed. A patient who is at risk for falls should be assisted when ambulating. The nurse should accompany him back to his room and assist him to get back in bed. Asking the nurse aide to walk with him is acceptable, but the nurse should stay with the patient until the aide arrives. Walking only in his room will not build the patient's strength and stamina. Any activity that causes fatigue is not recommended.
The healthcare provider administers NPH insulin at 6:00 AM to a patient with diabetes. How soon will the patient show any signs hypoglycemia? a) 7:00 AM b) 10:00 AM c) 9:00 AM d) 8:00 AM
b) 10:00 AM NPH insulin is an intermediate-acting insulin, usually given once or twice a day. The peak effect of NPH insulin occurs 4-12 hours after administration, so the nurse should begin to monitor for signs of hypoglycemia at 10:00 AM. Hypoglycemia (blood glucose below 70mg/dl) can have a rapid onset. Signs include shakiness, dizziness, anxiety, confusion, sweating, chills, and clammy skin. The patient's pulse may increase. The patient may complain of blurred vision, headache, fatigue, hunger, or nausea.
At what age should blood test screening for lead poisoning in a low-risk child begin? a) 6 months b) 18 months c) 12 months d) 24 months
b) 18 months The screening schedule is based on CDC recommendations, based on research showing that blood lead levels increase most rapidly at 6-12 months and peak at 18-24 months. Starting at 6 months, a questionnaire should be used at routine check-ups to assess the risk of high-dose lead exposure. If risk seems low, an initial blood lead screening test can be done at 12 months. If the result is < 10 µg/dL, a second test is recommended at 24 months. If the result is higher, more frequent monitoring is indicated.
Due to a staff shortage, a nurse with only six months of experience is puled from his surgical unit to a medical unit. Which patient assignment is most appropriate for him? a) A 69-year old with COPD who is on a ventilator b) A 72 year-old who requires instruction on an incentive spirometer c) A 68-year old who has just returned from a bronchoscopy and biopsy d) A 58-year old on airborne precautions for active tuberculosis (TB)
b) A 72 year-old who requires instruction on an incentive spirometer When a nurse is pulled (or "floated" to a different unit, patients should be assigned that are compatible with the nurse's experience. The nurse should be assigned the patient who needs instruction on using an incentive spirometer. Many surgical patients are taught about coughing, deep breathing, and use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specific post-procedure care, and the ventilator-dependent patient requires a nurse who is familiar with ventilator care.
A patient who has a history of chronic bronchitis is admitted to the medical unit. The healthcare provider notes the red blood cell count is elevated. Which of these is the likely contributing factor to this lab result in this patient? a) Decreased fluid intake b) Chronic hypoxia c) Hypercapnia d) Insensible water loss
b) Chronic hypoxia Chronic hypoxia, from reduced air exchange, leads to low oxygen levels in the body. The kidneys respond to chronic hypoxia by releasing erythropoietin, which stimulates red blood cell production. The red blood cell count is elevated to compensate for the hypoxia, or low oxygen levels. More cells are available to carry and deliver the maximum amount of oxygen
When a patient refuses treatment, this is an example of a) Civil law b) Common law c) Medical law d) Statutory law
b) Common law Common law allows a mentally competent adult to refuse medical treatment, even if it hastens death. Also called case or precedent law, it's based on past cases of a similar type. Individual cases contribute to the precedence for resolving a legal conflict. The right to refuse treatment is based on U.S. cases from 1891 and 1914. The judgment of the 1914 case (Schloendorff v. Society of New York Hospital) states, "Every human being of adult years and sound mind has a right to determine what shall be done with his own body..."
A male patient with a history of type 1 diabetes is two days post-op following cholecystectomy. He has complained of nausea and can't tolerate solid foods. The nurse finds the patient confused and shaky. Which of the following most likely explains the patient's symptoms? a) Respiratory acidosis b) Hypoglycemia c) Diabetic ketoacidosis d) Hyperglycemia
b) Hypoglycemia A post-operative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia (blood glucose < 70 mg/dl). Symptoms include confusion , anxiety, sweating, chills, tachycardia, nausea, and dizziness. Respiratory acidosis is related to chronic conditions such as asthma, COPD, and neuromuscular disorders. Hyperglycemia and ketoacidosis do not cause confusion and shakiness.
The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? a) ABX to treat the underlying infection b) IV fluids to increase intravascular volume c) vasopressors to increase BP d) corticosteroids to reduce inflammation
b) IV fluids to increase intravascular volume
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST? a) Institute seizure precautions b) Initiate respiratory isolation c) Document vital signs d) Assess neurologic status
b) Initiate respiratory isolation The initial therapeutic management of acute bacterial meningitis includes standard and respiratory (droplet) isolation precautions. Initiation of antimicrobial therapy should be immediate. Nurses should take necessary precautions to protect themselves and others from possible infection. Airborne or droplet isolation measures include: 1. Wear a mask when entering the patient's room. 2. A single patient room is preferred. If not available, spatial separations of more than 3 feet and drawing the curtain between beds is especially important. 3. When the patient is transferred or leaves the room, they should wear a mask if tolerated and follow respiratory hygiene.
A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most significant action that nursing student should take? a) Seek counseling b) Start prophylactic AZT treatment c) See a social worker immediately d) Start prophylactic Pentamidine treatment
b) Start prophylactic AZT treatment Azidothymidine (AZT) treatment is the most critical intervention and should be started within 72 hours after exposure. It is an antiretroviral medication used to prevent and treat HIV/AIDS by reducing the replication of the virus. After exposure, prophylactic treatment with 2 or 3 antiretroviral medications is continued for 4 weeks. Pentamidine is an antimicrobial medication given to prevent and treat pneumocystis pneumonia. Talking to a social worker or getting counseling may be appropriate later.
For a patient who is in the late stages of chronic bronchitis, which of the following would indicate the patient has developed cor pulmonale? a) hypocapnia b) night sweats c) venous stasis ulcers d) hepatomegaly
b) night sweats Cor pulmonale, or right-sided heart failure, is the result of a lung condition, such as chronic bronchitis or COPD. The diseased lungs deliver less oxygen to the right ventricle, putting a strain on the heart from pulmonary hypertension. Over time, the right ventricle fails, causing increased venous pressure and liver enlargement (hepatomegaly). Common early symptoms include fatigue, tachypnea, shortness of breath on exertion, and a cough.
A patient has just been admitted to the hospital for observation. Based on the laboratory results, what is the patient's primary problem? Hematocrit 45\% Hemoglobin 15g/dl (150g/L) Platelets 50 x 10\^9/L. a) productive cough b) recurrent nosebleeds c) RUQ pain d) DVT
b) recurrent nosebleeds Platelets (thrombocytes) are important for blood clotting. The normal range for platelets is 150,000-400,000mcL (150-400 x 10^9/L). Platelets are decreased in this patient. This will lead to impaired hemostasis which could explain the patient's recurrent nosebleeds.
When evaluating the arterial blood gases (ABGs) of a patient with a 20 year history of chronic bronchitis, which of these would the healthcare provider expect? a) met. acidosis uncompensated b) resp. acidosis, compensated c) resp. alkalosis, uncompensated d) ret. alkalosis, compensated
b) resp. acidosis, compensated Chronic bronchitis diminishes airflow during expiration, trapping carbon dioxide (CO2) in the lungs. The increased CO2 lowers the arterial pH, causing respiratory acidosis. The kidneys compensate for the chronic acidosis by conserving bicarbonate. This keeps the pH in a low-normal range, resulting in compensated respiratory acidosis.
Mrs. J is in the adult ICU on a ventilator. The nurse caring for her recognizes that her endotracheal tube needs suctioning. Based on the nurse's understanding of this procedure, what level of pressure should the nurse apply while suctioning? a. 70-80 mmHg b. 100-120 mmHg c. 150-170 mmHg d. 200 mmHg
b. 100-120 mmHg When suctioning the endotracheal tube of an adult client, the nurse should set the suction apparatus at a level no higher than 150 mmHg, with a preferable level between 100 and 120 mmHg. Suction pressure that is too high can contribute to the client's hypoxia. Alternatively, too low of suction pressure may not clear adequate amounts of secretions.
A nurse is advising a patient with Chronic Fatigue Syndrome on infection control procedures. Which of the following statements by the patient indicates that the patient understands the advice? a. I'm going to a basketball game tonight. b. I should avoid anyone with cold symptoms. c. I should have a blood test. d. I'm not going to attend functions with large crowds.
b. I should avoid anyone with cold symptoms.
The healthcare provider auscultates the lungs of an adult patient. Soft, low pitched breath sounds are heard over the posterior lower lobes. Inspiration is longer than expiration. The healthcare provider interprets this assessment data as a) Bronchovesicular sounds usually heard b) Bronchial breath sounds normally heard in this location c) Vesicular breath sounds normally heard in this location d) Mixed bronchial and bronchovesicular sounds
c) Vesicular breath sounds normally heard in this location Vesicular breath sounds are low-pitched, rustling sounds heard over the peripheral lung fields, with inspiration being 2-3 times longer than expiration. Smaller components of the lungs produce softer sounds than bronchial breathing.
The healthcare provider is evaluating effectiveness of discharge teaching for a male patient following an abdominal aortic aneurysm (AAA) repair. Which of these statements made by the patient indicates the teaching has been successful? a) "I will be able to resume my usual work-out at the gym." b) "I should avoid being around people who are sick." c) "It is possible that I may experience some sexual dysfunction." d) "I will take my radial pulse each day and keep track of the rate."
c) "It is possible that I may experience some sexual dysfunction." Male patients often experience erectile dysfunction after AAA repair due to decreased blood flow to the pelvic area during surgery. Also, the expanding abdominal aorta can compress and damage the nerves and blood vessels of the penis. Patients are taught to palpate pulses below the level of the repair, not at the radial pulse. The strength and quality of the pulse is more important than the rate. Exercise is slowly increased; the surgeon will advise the patient about activity. Avoiding communicable infections can be discussed, but is not the priority of discharge teaching.
When assessing gross motor skills, for which infant should the nurse request a developmental referral? a) A 6-month old who does not creep. b) A 4-month old who is unable to sit without support. c) A 9-month old who is unable to stand while holding on. d) A 2-month old who does not roll over.
c) A 9-month old who is unable to stand while holding on. Over 90% of infants who are 9-months old can stand if they have something to hold onto. Rolling over should occur between 4-6 months; sitting without support is expected at 6 months. Creeping is normal at about 9 months.
When caring for a patient with Meniere's disease, which is the most appropriate safety consideration? a) Maintain contact isolation measures. b) Raise the side rails on the patient's bed. c) Assist the patient to and from the bathroom. d) Restrict caffeine intake after breakfast.
c) Assist the patient to and from the bathroom.
A patient is taking daily low-dose aspirin and experiences prolonged bleeding from a superficial cut. Which of the following lab results would be expected for this patient? a) Platelets 150 x 10^9/L b) Activated partial thromboplastin time (aPTT) 30 seconds c) Bleeding time of 8 minutes d) Prothrombin time (PT) 14 seconds
c) Bleeding time of 8 minutes During primary hemostasis, a platelet plug is formed. Clotting factors are involved in secondary hemostasis (coagulation). Both aPTT and PT measure the coagulation pathways. Aspirin inhibits cyclooxygenase (COX) which promotes the synthesis of TXA_2. Because TXA_2 is necessary for platelet aggregation, primary hemostasis is inhibited. This is measured by bleeding time. Platelet activity is affected, but not the number of platelets.
A patient has recently been diagnosed with leukemia. Which of the following symptoms would a health care professional expect to see given this diagnosis? a) Dyspnea, malaise, and hypotension b) Bradycardia, hypotension, and palpitations c) Bruising, fatigue, and bone pain d) Paresthesia, facial rash, and abdominal pain
c) Bruising, fatigue, and bone pain Because the bone marrow is not making an adequate amount of red blood cells and platelets, the patient will experience fatigue due to anemia, and bruising due to decreased platelets. Bone pain is caused by the stretching of the periosteum because of the excessive white blood cells. The CBC may show increased blasts, or immature white blood cells, crowding out the normal RBCs and platelets.
The doctor orders a 24-hour ambulatory electrocardiography using a Holter monitor to a client with frequent fainting spells. To obtain the most accurate record, the nurse should instruct the client to avoid which of the following EXCEPT? a) Shaving with an electric razor. b) Using a cellular telephone. c) Eating with metal utensils. d) Standing close to a microwave.
c) Eating with metal utensils. Using electrical devices, such as electric razors and toothbrushes, may alter the data recorded with a Holter monitor. Patients are also generally advised to magnets, microwaves, electric blankets, cell phones, and MP3 players.
A 30-year-old patient with a congenital atrial septal defect has lived with the defect without significant problems until now. Which of the following is an indication that the patient is becoming hemodynamically symptomatic? a) Blood pressure 140/90 b) Bronchoconstriction and wheezing c) Exertional dyspnea d) Intermittent claudication
c) Exertional dyspnea Because blood is shunted from left to right, pulmonary blood flow is increased. Pulmonary arteries become enlarged, and increased pulmonary pressure can result in pulmonary edema which interferes with gas exchange, especially when the patient is active. Bronchoconstriction and wheezing is caused by constriction of bronchial smooth muscle and is not a hemodynamic symptom. Intermittent claudication occurs when there is decreased arterial blood to skeletal muscle.
During initial rounds on the shift, the nurse finds that a patient's TPN solution has been infusing at a slower rate than ordered. It is now 2 hours behind. What should the nurse do? a) Continue at the same rate, and adjust the next bottle to infuse faster. b) Increase the infusion rate to return to the correct amount. c) Notify the physician to receive new infusion orders. d) Double the infusion rate for 2 hours, then return to the ordered rates.
c) Notify the physician to receive new infusion orders. When TPN infusion rate changes by 10% (either increase or decrease) the patient's blood glucose level can be drastically altered. Always notify the physician to receive a new order to adjust the rate.
The healthcare provider is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The healthcare provider identifies which of the following areas as the correct stoma site? a) RUQ b) LUQ c) RLQ d) LLQ
c) RLQ A total colectomy involves the removal of the large intestine. The gastrointestinal output will occur at the terminal end of the ileum. The stoma will be located in the right lower quadrant of the abdomen. A total cholectomy is performed for intestinal inflammatory conditions such as Crohn's disease or ulcerative colitis. It may also be done for severe, chronic constipation.
The healthcare provider is preparing a patient on the medical-surgical unit for a thoracentesis. Which of the following is the most appropriate position for the patient during the procedure? a) The head of bed elevated 45 degrees with the patient lying on the affected side. b) Prone, with both arms extended above the head. c) Sitting up, leaning over a bedside table and feet supported on the ground or stool. d) The head of the bed flat with the patient lying on the unaffected side.
c) Sitting up, leaning over a bedside table and feet supported on the ground or stool.
A small plane carrying the football team from the local university crashes and survivors are being transported to the hospital. Four team members died in the crash. Before the survivors reach the hospital, what should the nurse anticipate being asked to do? a) notify the university of the crash b) call the hospital's volunteer office c) call the nearest crisis response team d) alert the local news station
c) call the nearest crisis response team fter a traumatic event, there will be a great need for support from disaster and crisis specialists. The survivors, families of the deceased team members, fellow students, and the community will need empathy and counseling. News media usually monitor emergency radio, so they will already be aware. Volunteers may be helpful, but are not experts in assisting with disasters. The university will receive information from other sources.
In the event of a fire in a client's home, your first action is to _______. a) report the fire to your agency. b) get the fire extinguisher. c) move the client to a safe place. d) turn on the fire alarm.
c) move the client to a safe place. The nurse should be familiar with exits and location of fire extinguishers. If a smoke or fire alarm sounds, your first action is to keep the client safe. Remember "R.A.C.E." to quickly act. R = Rescue/Remove the client. A = Alarm, if the alarm is not connected to the fire department, call 911 to report it. . C = Confine/Contain the fire or smoke by closing doors to prevent or slow the spread. Smoke is especially dangerous for everyone. E = Extinguish the fire if possible, using a handheld fire extinguisher. Attempt to extinguish only small fires, as long as you and the client can remain safe, and have an escape route.
A patient who recently stopped smoking asks a healthcare provider about the risks of developing lung cancer. The healthcare provider's best response is a) "If lung cancer hasn't developed yet, the ongoing risk is equivalent to a non-smoker." b) "An elevated risk of developing lung cancer compared to a non-smoker will remain constant life-long." c) "In 8 months, the risk of developing lung cancer is twice as high as a non-smoker." d) "In 15 years, the risk of developing lung cancer will be equivalent to a non-smoker."
d) "In 15 years, the risk of developing lung cancer will be equivalent to a non-smoker." Damaged cells in the lungs can be replaced by healthy cells over long periods of time. The risk of developing lung cancer for this patient will be the same as a non-smoker in 15 years. The benefits of quitting smoking begin within 20 minutes, when the heartrate returns to normal. After one month, cilia in the lungs begin to repair. At one year, risk of heart disease is half that of a smoker's.
During a staff meeting, the supervisor reports on a recent infection control audit. Which finding indicates a need for staff training? a) A lab technician puts on a mask, gown, and gloves before entering the room of a patient on strict isolation b) A certified nursing assistant does not wear gloves when feeding an elderly patient c) A patient with active tuberculosis wears a mask when going to another department for testing d) A nurse with open lesions on her hands puts on gloves before giving direct patient care
d) A nurse with open lesions on her hands puts on gloves before giving direct patient care There is no need to wear gloves when feeding a client. However, universal (standard) precautions (treating all blood and body fluids as if they are infectious) should be followed in all situations. A client with active tuberculosis should be on respiratory precautions, including wearing a mask outside his private room. Staff members with exudative lesions or weeping dermatitis should not give direct care or handle patient-care equipment until the condition resolves, even if wearing gloves. Strict isolation requires the use of mask, gown, and gloves for anyone entering the room.
The healthcare provider is performing an assessment on a patient who is taking propranolol (Inderal) for supraventricular tachycardia. Which assessment finding is an indication the patient is experiencing an adverse effect of this drug? a) Urinary retention b) Paresthesia c) Dry mouth d) Bradycardia
d) Bradycardia
Which of the following conditions does NOT require airborne contact precautions? a) Rubeola b) Tuberculosis c) Varicella zoster d) Clostrididum difficile
d) Clostrididum difficile
Which statement is true regarding medical legality? a) A nurse who becomes ill and leaves during a shift is not abandoning patients if the supervisor is notified. b) A second trimester abortion may be obtained without state involvement. c) Student nurses cannot be sued for malpractice while in a clinical class setting. d) Consent for medical treatment can be given by a minor with a sexually transmitted disease (STD).
d) Consent for medical treatment can be given by a minor with a sexually transmitted disease (STD). The HIPAA Privacy Rule allows for treatment of an STD infection without parental consent. The client is "advised" to contact sexual partners but is not "required" to give names. After age 13, permission from parents is not needed, based upon current privacy laws. A minor is considered "the individual" who can consent for STD treatment. Each state has regulations regarding the stage of pregnancy when a woman can legally obtain an abortion. Student nurses can be held liable for their actions. Leaving a patient without care is a form of negligence.
The healthcare provider is reviewing the arterial blood gas report for a child with severe, persistent asthma. The blood gas is: pH = 7.28, PaCO2 = 50 mmHg, HCO3 = 25. Which of these assessments are consistent with this child's arterial blood gas? a) Slow respirations, nausea, and vomiting b) Kussmaul respirations and muscle twitching c) Rapid, deep respirations and paresthesia d) Disorientation, headache, and flushed face
d) Disorientation, headache, and flushed face The patient has respiratory acidosis. The normal ranges for ABGs: pH is 7.35-7.45; PaCO2 is 35-45 mm Hg; HCO3 is 20-24eEq/L.. The increased acid has a depressant effect on the central nervous system, causing disorientation. The increased carbon dioxide also causes vasodilation of the cerebral and peripheral vasculature, causing headache and facial flushing. Other signs of respiratory acidosis include lethargy and shortness of breath.
When caring for a patient who has a pneumothorax, which of these actions should the healthcare provider include in the patient's plan of care? a) Empty the drainage chamber every shift and record the amount. b) Vigorously massage the tube every 2 hours to promote drainage. c) Change the insertion site dressing daily using aseptic technique. d) Encourage the patient to breathe deeply and cough regularly.
d) Encourage the patient to breathe deeply and cough regularly. Regular deep breathing and coughing will help re-expand the collapsed lung. The dressing is changed per protocol or as needed when it becomes soiled. Routine massage (milking) of the chest tube may excessively increase intrapulmonary pressures and may damage the lung. Tracking the amount of drainage each shift is accomplished by marking on the collection chamber.
With a stroke patient, what is the best position for insertion of a nasogastric (NG) tube? a) Supine b) Trendelenburg c) Low Fowler's d) High Fowler's
d) High Fowler's High Fowler's position is the best position to avoid aspiration. Have an emesis basin and suction equipment nearby, since tube insertion can cause temporary nausea.
The healthcare provider is assessing a patient admitted with a diagnosis of hemorrhagic stroke affecting the right cranial hemisphere. Which assessment finding is consistent with this diagnosis? a) Bilateral Babinski's sign b) Kernig's sign c) Right-sided spasticity d) Left-sided flaccidity
d) Left-sided flaccidity A patient who has sustained damage to the right cranial hemisphere will experience loss of motor function on the left side of the body. Kernig's sign is an indication of meningeal irritation and is not an expected finding. Spasticity is muscle tightness and loss of control over the muscles. Flaccidity is low muscle tone. Flaccid paralysis, a complete lack of voluntary movement, often occurs immediately after the stroke.
After an argument with her mother, an adolescent female takes an overdose of Tylenol (acetaminophen). The health care provider knows to watch for complications in which organ? a) Kidney b) Pancreas c) Heart d) Liver
d) Liver
The healthcare provider is caring for a patient with a diagnosis of first-degree atrioventricular (AV) block. Which of these waveform patterns identified on the cardiac monitor is consistent with this arrhythmia? a) No association between the P waves and QRS complexes b) QRS complexes are dropped randomly c) Significant shortening of the PR interval d) Slowed conduction through the AV node
d) Slowed conduction through the AV node In first degree AV block, there is a delay in impulse conduction through the AV node. The PR interval represents the time it takes for the impulse to travel through the atria to the AV node, to the His-Purkinje system, and through the ventricles. If the impulse is delayed at the AV node, as with first-degree heart block, the PR interval will be prolonged. In a normal heart rhythm, the PR interval is .12-.20 seconds.
The healthcare provider on pediatric unit has received her assignments for the day. Which of the following patients should the healthcare provider assess first? a) The 6-year-old with bronchitis with an intravenous (IV) antibiotic infusing at 30mL/hour. b) The 3-year-old with asthma who has an oxygen saturation of 94% on room air. c) The 11-year-old with pneumonia waiting for discharge instructions. d) The 17-year-old with a left pleural effusion complaining of chest pain 9 on a 0 - 10 scale.
d) The 17-year-old with a left pleural effusion complaining of chest pain 9 on a 0 - 10 scale.
A patient with a fractured hip has been placed in Buck's traction. Which statement is true regarding this treatment? a) Kirschner wires are inserted. b) Is used primarily to heal fractured hips. c) It utilizes a Steinman pin. d) The purpose is to immobilize the leg(s).
d) The purpose is to immobilize the leg(s). Buck's traction is one of the most common orthopedic mechanisms used for temporary immobization of a hip/femur until surgery can be performed. It exerts traction on one or both legs by using a system of ropes, weights, and pulleys. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur. Kirschner wires are used to stabilize small bones such as fingers and toes. Buck's traction is not intended for healing.
The healthcare provider is caring for a patient with a history of fatigue, dyspnea, and dark stools. The patient states, "My stools are very smelly." The patient's complete blood count (CBC) reveals a hemoglobin of 7g/dL (70g/L). Based on this patient' history, the healthcare provider anticipates an order to prepare the patient for a(an)... a) Computed tomography (CT) scan b) Bone marrow aspiration c) Comprehensive dietary inventory d) Upper gastrointestinal endoscopy
d) Upper gastrointestinal endoscopy Dark, smelly stools (melena) refers to the black "tarry" feces that are associated with upper gastrointestinal bleeding. The black color results from the iron in hemoglobin being mixed with the chemicals and intestinal bacteria of the digestive tract. Bleeding can be confirmed by endoscopy. Causes of upper-GI bleeding include peptic ulcers, gastritis, esophageal varices, cancer, and a Mallory-Weiss tear.
The earliest identifying sign for a developing pressure sore is a localized _______. a) edema b) coolness to touch c) loss of sensation d) change in color
d) change in color When pressure over a bony prominence is not relieved, the result is ischemia and damage to underlying tissue. In the earliest stage (Stage 1) skin remains intact, but appears red. The area does not blanch when touched. Skin temperature may be warmer.
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