417 Final Question Practice
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. give the PRN diphenhydramine b. Send a urine specimen to the lab c. administer PRN acetaminophen (tylenol) d. draw blood for a new type and crossmatch
C: administer PRN acetaminophen (tylenol)
A 19-year-old says their heart is skipping beats. An ECG shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse do next? a. start an IV catheter for emergency use b. start supplemental o2 at 2-3 L/min via nasal cannula c. ask patient about current stress level and caffeine use d. have the patient taken to nearest ED
C: ask patient about current stress level and caffeine use in a patient with a normal heart, occasional PVCs is a benign finding. The timing of PVCs indicates stress or caffeine as possible etiologic factors. The patient is hemodynamically stable, so there is no reason for oxygen, an IV or being seen in the ED.
A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's: a. blood glucose b. urine osmolality c. serum creatinine d. serum potassium
C: serum creatinine
The nurse understands that as preload increases: a. CO decreases b. CO stays the same c. CO increases d. CO and Stroke volume increase
D: CO and stroke volume increase
A patient with acute kidney injury (AKI) has longer QRS intervals on the ECG than were noted on the previous shift. Which action should the nurse take first? a. notify the patient's health care provider b. document the QRS interval measurement c. review the chart for the patient's current creatinine level d. Check the medical record for the most recent potassium level
D: check the medical record for the most recent potassium level
The nurse expects which of the following to be ordered for a client with heart failure who needs intervention to decrease afterload: select all that apply a. Furosemide b. Propanolol c. Digoxin D. Penicillin
a & b: Furosemide & Propanolol
The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) a. Fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus
a, b, d, e fever oriented to name only dilated right pupil > left pupil decorticate posturing to painful stimulus
A 34-year-old female patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups. A.2 B.3 C.4 D.5
a. 2
The nurse is assessing a 31-year-old female patient with abdominal pain. The nurse, who notes that there is ecchymosis around the area of umbilicus, will document this finding as a.Cullen sign. b.Rovsing sign. c.McBurney sign. d.Grey-Turner's sign
a. Cullen sign
Which of the following should be a priority in the client's care plan who is receiving TPN? a. daily weights b. I&Os c. E-panel d. compression stockings
a. Daily weights
The nurse knows that the Hemodynamic Parameter for Left Ventricular Preload is: a. PAWP b. CVP c. SV d. CO
a. PAWP
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxic chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest
a. Paradoxic chest movement
a patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most likely to result in postponing the SBT? a. new ST segment elevation is noted on the cardiac monitor b. enteral feedings are being given through an orogastric tube c. scattered rhonchi are heard when auscultating breath sounds d. hydromorphone (dilaudid) is being used to treat postoperative pain
a. a new ST segment elevation is noted on the cardiac monitor
A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.
a. auscultate the patient's lung sounds
A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30
a. blood pressure 156/60, pulse 55, respirations 12
The nurse will anticipate preparing an older patient who is vomiting "coffee-ground" emesis for a. Endoscopy. b. Angiography. c. barium studies. d. gastric analysis.
a. endoscopy
A Nurse is working in the ED when a client is admitted via helicopter for 3rd degree frostbite. What is the nurses priority actions? a. Immersion of the affected regions in circulating water bath (temp around 98.6 to 104) b. Elevation of effected extremity c. Obtaining IV access d. Tetanus and Antibiotic Prophylaxis
a. immersion of the affected regions in circulating water bath (temp around 98.6 to 104)
An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees. b. Position the patient with the knees and hips flexed. c. Encourage coughing and deep breathing to improve oxygenation. d. Cluster nursing interventions to provide uninterrupted rest periods.
a. keep the head of the bed elevated to 30 degrees
The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath
a. oxygen saturation is 88%
A female patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a.Position patient with the knees flexed. b.Avoid use of opioids or sedative drugs. c.Offer frequent small sips of clear liquids. d.Assist patient to breathe deeply and cough.
a. position patient with the knees flexed
A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What should the nurse plan for when this patient has ordered a computed tomography (CT) scan? a. shut the feeding off 30 to 60 minutes before the scan b. ask the health care provider to reschedule the CT scan c. connect the feeding tube to continuous suction during the scan d. send the patient to CT scan with oral suction in case of aspiration
a. shut the feeding off 30 to 60 minutes before the scan
a 48-year-old man who has just been started on tube feedings of full-strength formula at 100 mL/hr has 6 diarrhea stools the first day. Which action should the nurse plan to take? a. slow the infusion rate of the tube feeding b. check gastric residual volumes more frequently c. change the enteral feeding system and formula every 8 hours d. discontinue water administration through the feeding tube
a. slow the infusion rate of the tube feeding
which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. the patient is alert and oriented b. the patient denies nausea or anorexia c. the patient's bilirubin level decreases d. the patient has a least one stool daily
a. the patient is alert and oriented
When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patient's pulse is slightly irregular. c. The patient's blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.
a. the patient is more difficult to arouse
When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.
a. the patient takes warfarin (Coumadin) daily
The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider? a. Urine output of 800 mL in the last hour b. Intracranial pressure of 16 mm Hg when patient is turned c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg
a. urine output of 800 mL in the last hour
The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic and vital sign assessment. Which assessments will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)? A. Judgment B. Eye opening C. Abstract reasoning D. Best verbal response E. Best motor response F. Cranial nerve function
b, d, e eye opening, best verbal response, best motor response
A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.
b. 11
After a change-of-shift report, which patient should the nurse assess first? a.40-year-old male with celiac disease who has frequent frothy diarrhea b.30-year-old female with a femoral hernia who has abdominal pain and vomiting c.30-year-old male with ulcerative colitis who has severe perianal skin breakdown d.40-year-old female with a colostomy bag that is pulling away from the adhesive wafer
b. 30 year old female with a femoral hernia who has abdominal pain and vomiting
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site
b. 400 mL of blood in the collection chamber
A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patient's GCS score as a. 6 b. 7 c. 9 d. 11
b. 7
the nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement? a. I can expect yellow-green drainage from the incision for a few days b. I can remove the bandages on my incisions tomorrow and take a shower c. I should plan to limit my activities and not return to work for 4 to 6 weeks d. I will need to maintain a low fat diet for life because I no longer have a gallbladder
b. I can remove the bandages on my incisions tomorrow and take a shower
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes d. A 35-year-old patient who was admitted the previous day with
b. a 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
Which patient should the nurse assess first? a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who is scheduled for a dressing change d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr
b. a patient with smoke inhalation who has wheezes and altered mental status
to detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor: a. bilirubin levels b. ammonia levels c. potassium levels d. prothrombin time
b. ammonia levels
Which nursing action has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Administration of low-molecular-weight heparin d. Application of pneumatic compression devices to legs
b. assessment of respiratory rate and effort
The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP
b. decreased pulse, irregular respirations, increased pulse pressure
A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. Keep the head of the bed flat b. Elevate the HOB by 30 degrees c. Maintain pt on the left side with the head supported on a pillow d. Use a continuous rotation bed to continuously change patient position
b. elevate the HOB by 30 degrees
when caring for a 63-year old woman with a soft, silicone nasogastric tube in place for enteral feedings, the nurse will: a. avoid giving medications through the feeding tube b. flush the tubing after checking for residual volumes c. administer continuous feedings using an infusion pump d. replace the tube every three days to avoid mucosal damage
b. flush the tubing after checking for residual volume
The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock? a. Involuntary and spastic movement b. Hypotension and warm extremities c. Hyperactive reflexes below the injury d. Lack of sensation or movement below the injury
b. hypotension and warm extremities
A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a.Insert a urinary catheter to drainage. b.Infuse metronidazole (Flagyl) 500 mg IV. c.Send the patient for a computerized tomography scan. d.Place a nasogastric (NG) tube to intermittent low suction.
b. infuse metronidazole (Flagyl) 500 mg IV
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.
b. notify the health care provider
A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a.Auscultate the bowel sounds. b.Prepare the patient for surgery. c.Check the patient's oral temperature. d.Obtain information about the accident.
b. prepare the patient for surgery
The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. the patient complains of right upper-quadrant pain with palpation b. the patient's hands flap back and forth when the arms are extended c. the patient has ascites and a 2 kg weight gain from the previous day d. the patient's abdominal skin has multiple spider-shaped blood vessels
b. the patient's hands flap back and forth when the arms are extended
The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants b. The patient's lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient's blood pressure (BP) has increased to 142/84 mm Hg
b. the patient's lungs have crackles audible to midchest
A 33-year-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a.Stool will be expelled from both stomas. b.This type of colostomy is usually temporary. c.Soft, formed stool can be expected as drainage. d.Irrigations can regulate drainage from the stomas.
b. this type of colostomy is usually temporary
Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a.Restrict fluid intake to prevent constant liquid drainage from the stoma. b.Use care when eating high-fiber foods to avoid obstruction of the ileum. c.Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d.Change the pouch every day to prevent leakage of contents onto the skin.
b. use care when eating high-fiber foods to avoid obstruction of the ileum
The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient a.inserts the irrigation tubing 4 to 6 inches into the stoma. b.hangs the irrigating container 18 inches above the stoma. c.stops the irrigation and removes the irrigating cone if cramping occurs. d.fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.
b.hang the irritating container 18 inches above the stoma
Which hemodynamic parameter best reflects the effectiveness of drugs the nurse give to reduce a patient's left ventricular afterload? a. Mean arterial pressure (MAP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)
b: systemic vascular resistance (SVR)
The newly licencesed nurse shows adequate ability to calculate CPP following an educational meeting when they say: a. CPP is calculated the same was as BMI b. CPP is calculated by taking the CO and subtracting the ICP c. CPP is calculated first taking the DBP then adding ⅓ of SBP - DBP and THEN taking that number and subtracting the ICP d. CPP is calculated by multiplying the DBP by 2
c. CPP is calculated first taking the BDP then adding 1/3 of SCP - DBP and then taking that number and subtracting the ICP
An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the health care provider when arterial blood gas measurement results reveal a a. pH of 7.43 b. SaO2 of 94% c. PaO2 of 50 mm Hg d. PaCO2 of 30 mm Hg
c. PaO2 of50 mm Hg
An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48-year-old with a simple fracture of the lower leg
c. a 26 year old male who has pale, cool, clammy skinftvg
during change of shift report, the nurse learns about the following four patients. which patient requires assessment first? a. a 40 year old patient with chronic pancreatitis who has gnawing abdominal pain b. a 58-year old who has compensated cirrhosis and is complaining of anorexia c. a 55-year-old with cirrhosis and ascites who has an oral temperature of 102 F (38.8 C) d. a 36 year old patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain
c. a 55-year old with cirrhosis and ascites who has an oral temperature of 102 F (38.8 C)
Which patient should the nurse assess first after receiving change-of-shift report? a. A patient with nausea who has a dose of metoclopramide (Reglan) due b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 92/58 mm Hg d. A patient admitted yesterday with gastrointestinal (GI) bleeding who has melena
c. a patient with esophageal varices who has a blood pressure of 92/58 mm Hg
A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed antiemetic. c. Assess the blood pressure (BP). d. Notify the health care provider.
c. assess the BP
To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level ? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist in planning a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.
c. assist in planning a prescribed bowel program
A 19-year-old female is brought to the emergency department with a knife handle protruding from the abdomen. During the initial assessment of the patient, the nurse should a.remove the knife and assess the wound. b.determine the presence of Rovsing sign. c.check for circulation and tissue perfusion. d.insert a urinary catheter and assess for hematuria.
c. check for circulation and tissue perfusion
A 19-year-old female is brought to the emergency department with a knife handle protruding from the abdomen. During the initial assessment of the patient, the nurse should a.remove the knife and assess the wound. b.determine the presence of the Rovsing sign. c.check for circulation and tissue perfusion. d.insert a urinary catheter and assess for hematuria.
c. check for circulation and tissue perfusion
When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.
c. decorticate posturing
The earliest signs of increased ICP the nurse should assess for include a. Cushing's triad b. unexpected vomiting c. decreasing level of consciousness (LOC) d. dilated pupil with sluggish response to light
c. decreasing level of consciousness (LOC)
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light
c. extremity movement
a patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action including the dysrhythmia protocol should the nurse do? a. obtain a 12-lead ECG b. notify theHCP of change in rhythm c. give supplemental o2 at 2-3 L/min via nasal cannula d. assess the patient's vital signs including o2 saturation
c. give supplemental o2 at 2-3L/min via nasal cannula because patient has dyspnea and chest pain in association with new rhythm, the nurse's actions should be to address airway, breathing, and circulation starting with o2 administration
A patient has a systemic blood pressure of 120/60 and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? A. High blood flow to the brain B. Normal intracranial pressure C. Impaired blood flow to the brain D. Adequate autoregulation of blood flow
c. impaired blood flow to the brain
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours. b. Continuing to monitor the laboratory results. c. Increasing the rate of the ordered IV solution. d. Typing and crossmatching for a blood transfusion.
c. increasing the rate of the ordered IV solution
A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.
c. multiple options are available to maintain sexuality after spinal cord injury
The nurse in the clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10 scale d. Patient who had a craniotomy for a brain tumor who now 3 days postoperative had had continued vomiting
c. patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10 scale
Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 15 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min
c. pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg
patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Elevate the head of the patient's bed to 60 degrees. b. Document the BP and ICP in the patient's record. c. Report the BP and ICP to the health care provider. d. Continue to monitor the patient's vital signs and ICP.
c. report the BP and ICP to the health care provider
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit of 53% b. Serum sodium of 147 mEq/L c. Serum potassium of 6.1 mEq/L d. Blood urea nitrogen of 37 mg/dL
c. serum potassium of 6.1 mEq/L
Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Inspect the contact burns. b. Check the blood pressure. c. Stabilize the cervical spine. d. Assess alertness and orientation.
c. stabilize the cervical spine
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device. d. Adjust the dial on the wall regulator to decrease suction.
c. take not further action with the collection device
CN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the brainstem by a. assessing for nystagmus b. testing the corneal reflex c. testing pupillary reaction to light d. testing for oculocephalic (doll's eye) reflex
c. testing pupillary reaction to light
A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? a. the patient's heart rate is 97 beats/min b. the patient's oxygen saturation is 93% c. the patient's respiratory rate is 32 breaths/ min d. the patient's spontaneous tidal volume is 450 mL
c. the patient's respiratory rate is 32 breaths/min
a patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to: a. perform leg exercises hourly while awake b. ambulate the evening of the operative day c. turn, cough, and deep breathe every 2 hours d. choose preferred low-fat foods from the menu
c. turn, cough, and deep breathe every 2 hours
A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to: a. obtain the BP b. check the level of orientation c. administer supplemental oxygen d. obtain a 12-lead electrocardiogram
c: administer supplemental oxygen
Which patient should the nurse assess first after receiving a change-of-shift report? a.60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b.50-year-old patient with familial adenomatous polyposis who has occult blood in the stool c.40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d.30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute
d. 30 year old patient who has abdominal distention and an apical heart rate of 136 beats/minute
After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion
d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion
Which of the following medications would the nurse understand being contraindicated in the client who has AKI? a. Penicillin b. Azithromycin c. Insulin d. Metformin
d. Metformin
To determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient's: a. P wave b. Q wave c. PR interval d. QRS complex
d. QRS complex the QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, AV node, a bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Milk the chest tube gently to remove any clots. b. Clamp the chest tube momentarily to check for the origin of the air leak. c. Assist the patient to deep breathe, cough, and use the incentive spirometer. d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.
d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine. air leak is expected in the postoperative period after a thoracotomy
When analyzing the rhythm of a patient's ECG, the nurse will need to investigate further upon finding an: a. isoelectric ST segment b. PR interval of 0.18 seconds c. QT interval of 0.38 seconds d. QRS interval of 0.14 seconds
d. WRS interval 0.14 seconds PR and QT are within normal range and ST segment should be isoelectric or flat. Therefore, the QRS is out of range, being prolonged, and should be investigated by RN
the nurse has received a change of shift report about the following patients on a progressive care unit. Which patient should the nurse see first? a. a patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin due b. a patient with 2nd degree AV block, type 1, rate 60, who is dizzy when ambulating c. a patient who is in sinus rhythm, rate 98 regular, recovering from elective cardioversion 2 hours ago d. a patient whose ICD fired twice today and has a dose of amiodarone due
d. a patient whose ICD fired twice today and has a dose of amiodarone due
After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A patient whose cranial x-ray shows a linear skull fracture b. A patient who has an initial Glasgow Coma Scale score of 13 c. A patient who lost consciousness for a few seconds after a fall d. A patient whose right pupil is 10 mm and unresponsive to light
d. a patient whose right pupil is 10 mm and unresponsive to light
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses b. A patient with an open femur fracture c. A patient with bleeding facial lacerations d. A patient with paradoxical chest movement
d. a patient with paradoxical chest movement
a young adult contracts hepatitis from contaminated food. During the acute phase of the patient's illness, the nurse would expect serologic testing to reveal: a. antibody to hepatitis D b. hepatitis B surface antigen c. anti-hepatitis A virus immunogloblin G d. anti-hepatitis A virus immunoglobilin M
d. anti-hepatitis a virus immunoglobulin M
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to: a. administer oxygen therapy at a high flow rate b. obtain a urine specimen to send to the lab c. notify the health care provider about the symptoms d. disconnect the transfusion and infuse normal saline
d. disconnect the transfusion and infuse normal saline
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system
d. insertion of a chest tube with a chest drainage system
Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? a. Hematocrit b. Blood pressure c. Oxygen saturation d. Intracranial pressure
d. intracranial pressure
A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% O2using a nonrebreather mask.
d. place the patient on 100% O2 using a non-rebreather mask
Which assessment should the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse
d. taking the blood pressure (BP) and pulse
A patient's vital signs are pulse 90, respirations 24, BP 128/64 mm hg, and cardiac output is 4.7 L/min. The patient's stroke volume is _____ mL. (Round to the nearest whole number.)
52 SV= CO/HR 4,700 ML / 90
An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.
72 mm Hg
Which of the following statements by the nurse indicates an understanding of the teaching on preparation for a blood transfusion? Select all that apply a. I should begin by confirming that the patient needs the blood transfusion, and has informed consent signed, RH type and crossmatch in the EHR b. If my patient already has an IV with NS running, I will now use Y-tubing c. I will set my Y-tubing up with NS, and get all my vital signs prior to the blood arriving to the unit, so that I can ensure I use the blood within the appropriate amount of time (30 minutes) d. I plan to use the same tubing that's already being used in my patient's room
A & C: I should begin by confirming that the patient needs the blood transfusion, and has informed consent signs, RH type and crossmatch in the EHR I will set my Y-tubing up with NS, and get all my vital signs prior to the blood arriving to the unit, so that I can ensure I use the blood within the appropriate amount of time (30 minutes)
the newly graduated nurse understands that which of the following are measures to decrease the risk for VAP? select all that apply a. maintaining HOB elevation of 30-45 b. PUD prophylaxis c. DVT prophylaxis d.oral care on PRN status only e. daily sedation vacations
A, B, C, E maintaining HOB elevation of 30-45 PUD prophylaxis DVT prophylaxis daily sedation vacations
A client who is post-operative from a hysterectomy is suddenly complaining of shortness of breath and says that her right calf feels really hot. Which of the following interventions are the nurses priority? a. administer oxygen therapy b. sit client up in High-Fowler's position c. Being chest compressions d. Do a full head-to-toe assessment e. request order for IV Heparin
A, B, E administer oxygen therapy sit client up in High-Fowler's position request order for IV Heparin
Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply)? a. avoid commercial salt substitutes b. restrict fluid intake to 1000 mL daily c. take phosphate binders with each meal d. choose high-protein foods for most meals e. have several servings of dairy products daily
A, C, D avoid commercial salt substitutes take phosphate binders with each meal choose high-protein foods for most meals
which of the following clinical manifestations are associated with acute respiratory distress syndrome? Select all that apply a. restlessness b. warm, pink skin c. cyanosis d. tachypnea with shallow patterns e. tremors
A, C, D, E restlessness cyanosis tachypnea with shallow patterns tremors
When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Administration of H2 receptor blockers e. Maintenance of a warm room temperature
A, C, D, E urinary catheter care continuous cardiac monitoring administration of H2 receptor blockers maintenance of a warm room temperature
The nurse is caring for a client who was in a cheerleading accident and is discussing with her collegues the clinical manifestations of spinal shock. Which of the following are true? a. Loss of deep tendon and sphincter reflexes b. Increased sensation c. Flaccid paralysis below level of injury d. Should only last 24-48 hours after accident e. Can last up to a few days or weeks
A, C, E loss of deep tendon and sphincter reflexes flaccid paralysis below level of injury can last up to a few days or weeks
A client newly diagnosed with a SCI, reports to the nurse that they are feeling "really ****ing hot" and "dizzy" and when taking their vital signs, you not hypotension, fever of 102, and bradycardia. What nursing interventions should the nurse anticipate? Select all that apply. a. IV Fluids to maintain Systolic BP > 90 b. Vasopressors (i.e. desmopressin) to maintain Systolic BP > 120 c. Fluid Restrictions d. Desmopressin IV to maintain systolic BP > 90
A, D IV fluids to maintain systolic BP > 90 desmopressin IV to maintain systolic BP > 90
A client on your med-surge tele floor just had their echocardiogram and asks what the "30%" means. Which is best for the nurse to communicate the results to the client? a. your low EF % shows that your blood is not pumping enough blood out with each beat b. Your high EF% indicates that your heart walls are more enlarged than normal c. 30% is a normal score d. I don't know
A: Your low EF% shows that your blood is not pumping enough blood out with each beat
A client with persistent ventricular tachycardia is most at risk of which of the following? a. inadequate cardiac output; leading to decreased perfusion of vital organs b. sepsis c. respiratory distress d. heart failure
A: inadequate cardia output; leading to decreased perfusion of vital organs
A patient with neurogenic shock after a spinal cord injury is to receive lactated Ringer's solution 400 mL over 20 minutes. When setting the IV pump to deliver the IV fluid, the nurse will set the rate at how many milliliters per hour?
Answer: 1200 mL/hr
Which of the following statements by the new nurse indicates correction from her preceptor following a teaching about the patient verification process for blood transfusions: a. I will ensure informed consent has been signed by the patient by looking through their EHR b. I can use a CNA to confirm the patient's identity with the blood bag c. I will need to have double verification with the blood product and the patient's right bands d. I need to confirm name, DOB, Rh factor, and cross-match
B. I can use a CNA to confirm the patient's identity with the blood bag
a patient's heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first? a. give epinephrine IV b. perform immediate defibrillation c. prepare for ET intubation d. ventilate with a bag-valve mask device
B. perform immediate defibrillation patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; initial action should be to defibrillate
The nurse is receiving reports from the night shift nurse on four clients; who should the nurse see first? a. a client who was admitted with DKA and is receiving an IV infusion of LR's b. A client who is receiving a blood transfusion and is reporting itchiness and dizziness 45 mins into the transfusion c. a client who is due for an IM heparin injection d. A client whose PCP just ordered a blood transfusion
B: a client who is receiving a blood transfusion and is reporting itchiness and dizziness 45 mins into the transfusion.
The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with a blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. verify the patient identification (ID) according to hospital policy b. obtain the temperature, bp, and pulse before the transfusion c. double-check the product numbers on the PRBCs with the patient ID band d. monitor the patient for SOB or chest pain during the transfusion
B: obtain the temp, bp, and pulse before the transfusion
After a change-of-shift report in the progressive care unit, who should the nurse care for first? a. patient who had an inferior myocardial infarction two days ago and has crackles in the lung base b. patient with suspected urosepsis who has a new orders for urine and blood cultures with antibiotics c. patient who has a T5 spinal cord injury one week ago and currently has a heart rate of 54 beats/minute d. patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and bp of 108/58 mm Hg
B: patient with suspected urosepsis who has a new order for urine and blood cultures with antibiotics
a 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which lab result will be most important to report to the health care provider? a. serum creatinine level of 2.1 mg/dL b. serum potassium level of 6.5 mEq/L c. White blood cell count of 11,500/uL d. blood urea nitrogen *BUN) of 56 mg/dL
B: serum potassium level of 6.5 mEq/L
A patient with a history of transfusion-related acute lung injury (TRALI) must receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI in this patient? a. infuse the PRBCs slowly over 4 hours b. transfuse only leukocyte-reduced PRBCs c. administer the scheduled diuretic before the transfusion d. Give the PRN dose of antihistamine before the transfusion
B: transfuse only leukocyte-reduced PRBCs
The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. A 74-yr-old patient with palpitations and chest pain b. A 43-yr-old patient complaining of 7/10 abdominal pain c. A 21-yr-old patient with multiple fractures of the face and jaw d. A 37-yr-old patient with a misaligned lower left leg with intact pulses
C, A, B. D
a patient born in 1955 had hapatitis a infection 1 year ago. According to centers for disease control and prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical examination? a. start the hepatitis B immunization series b. teach the patient about hepatitis A immune globilin c. ask whether the patient has been screened for hepatitis C d. test for anti-hepatitis A virus immune globulin M (Anti-HAV-IgM)
C. ask whether the patient has been screened for hepatitis C
