Med/Surg

A patient has a NG tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the pt demonstrates: A) Passage of flatus and feces through the colostomy B) Absence of N&V C) Passage of mucus from the rectum

A) Passage of flatus and feces through the colostomy

During the emergent stage of burn management for a patient with burns of 30% of the body the nurse should assess the patient for which of the following? Select all that apply A) Hyperkalemia B) Fever spikes C) Hypoglycemia D) Increased hematocrit E) Hyponatremia

A, B, D, and E

The nurse is teaching the pt with an ileal conduit how to prevent a UTI. Which of the following measures would be most effective? A) Avoid people with respiratory infections B) Maintain a daily fluid intake of 2000-3000 ml C) Use sterile technique to change the appliance D) Irrigate the stoma daily

B) Maintain a daily fluid intake of 2000-3000 ml

You are the home care nurse who is visiting her patient with a history of worsening CHF. The patient is unable to lie flat in bed. This condition is known as: A) Nocturnal dyspnea B) Orthopnea C) Palpitations D) Shortness of breath

B) Orthopnea

The best strategy to achieve the goal of integrated and cost effective care is: A) The adoption of team nursing B) The adoption of self-managed care C) The implementation of case management D) The reduction of the administrative work force

C) The implementation of case management

A patient with Crohn's disease is admitted with fever, leg cramping, diarrhea, frequent premature contractions, and abdominal pain. The nurse reviews the patients lab data and determines immediate intervention is required when the results identify which of the following? A) Hypoalbuminemia B) Leukocytosis C) Increased Erythrocyte sedimentation rate D) Hypokalemia

D) Hypokalemia

An adolescent who has a nasogastric tube in place following surgery for a ruptured appendix reports feeling nauseated. What is the most appropriate action by the nurse? A) Provide oral hygiene B) Measure the gastric drainage C) Assess serum electrolytes D) Irrigate the tube

D) Irrigate the tube

A patient with partial-thickness burns on both lower extremities and portions of the trunk requires immediate fluid resuscitation. Which IV fluid would the nurse plan to administer first? A) Albumin B) NS with 20 mEq of K per 1000 mL C) Dextrose 5% in water (D5W) D) Lactated Ringers Solution

D) Lactated Ringers Solution

Which respiratory change would a nurse see most often in a patient with increased intracranial pressure? A) Nasal flaring and retractions B) Rapid, deep respiration's C) Paradoxical chest movements D) Slow, irregular respiration's

D) Slow, irregular respiration's

Mr. Pelletier, 54 years old, was diagnosed with leukemia 2 years ago. Recently he has become more fatigued and he constantly feels "run down". After a thorough assessment and appropriate blood work, Mr. Pelletier's doctor advises him that his hemoglobin is 74 and that he will require blood transfusions. Within 5 minutes of initiating a blood transfusion, Mr. Pelletier complains of fever, chills, and back pain. What should you do first? A) Auscultate the lungs and monitor for itchy, raised rash B) Obtain BP, pulse, and temp C) Report to charge nurse and stop the infusion D) Stop the infusion and start 0.9% NS to keep the vein open

D) Stop the infusion and start 0.9% NS to keep the vein open

Which of the following indicates the patient with ulcerative colitis has attained an expected outcome of nursing care? A) The patient accepts that an ileostomy will be necessary B) The patient verbalizes the importance of restricting fluids C) The patient experiences decreased frequency of constipation D) The patient maintains an ideal body weight

D) The patient maintains an ideal body weight

The patient who abused alcohol for more than 20 years is diagnosed with cirrhosis of the liver. The nurse determines that teaching about the disease has been successful when the patient makes which statement? A) "If I decide to stop drinking, I won't kill myself" B) "If I watch my BP, I should be okay" C) "If I take vitamins, I can undo some liver damage" D) "If I use nutritional supplements, I won't have problems"

A) "If I decide to stop drinking, I won't kill myself"

The correct landmark for obtaining an apical pulse is the: A) Left fifth intercostal space, midclavicular line B) Left seventh intercostal space, midclavicular line C) Left second intercostal space, midclavicular line D) Left fifth intercostal space, midaxillary line

A) Left fifth intercostal space, midclavicular line

A patient with a productive cough, chills, and nigh sweats is suspected of having active TB. The most important intervention by the nurse would be? A) Maintain the patient on respiratory isolation B) Prepare the patient to be discharged on bedrest C) Administer tuberculin test ordered by the physician D) Administer the isoniazid ordered by the physician immediately before discharge

A) Maintain the patient on respiratory isolation

A nurse is assessing a patient with a history of substance abuse who has pinpoint pupils, a HR of 56 beats/min, a respiratory rate of 6 breaths/min, and a temp of 35.5 degrees C. The nurse determines that which is the most likely cause of the patients symptoms? A) Opioids B) Amphetamines C) Cannabis D) Alchohol

A) Opioids

When positioned properly, the tip of a central venous catheter should lie in the: A) Superior vena cava B) Basalic vein C) Subclavian vein D) Jugular vein

A) Superior vena cava

A patient with partial-thickness and full thickness burns is assess in the ED to have 15% of his total body burned. The nurse assesses his vital signs as 100/50 mm Hg, HR 130 beats/min, and respiratory rate of 26 breaths/min. Which nursing interventions are appropriate for this patient? Select all that apply A) Administering 6 mg of morphine IV B) Covering the burns with saline soaked towels C) Starting and IV infusion of lactated ringers solution D) Placing ice directly on the burn areas E) Administering tetanus prophylaxis as ordered F) Cleaning the burns with hydrogen peroxide

A, C, and E

Immediately after giving an injection, a nurse is accidentally stuck with the needle. The nurse is aware that testing for HIV antibodies should occur: A) Immediately and then again in 6 weeks B) Immediately and then again in 3 months C) In 2 weeks and then again in 6 months D) In 2 weeks and then again in 1 year

B) Immediately and then again in 3 months

When a central venous catheter dressing becomes moist or loose, what should a nurse do first? A) Notify the physician B) Remove the dressing, clean the site, and apply a new dressing C) Remove the catheter, check for catheter integrity, and send the tip for culture D) Draw a circle around the moist spot and note the date and time

B) Remove the dressing, clean the site, and apply a new dressing

A nurse is caring for a patient recovering from cocaine abuse. The priority intervention for this patient would be? A) Skin care B) Suicide precautions C) Frequent orientation D) Nutrition consultation

B) Suicide prevention

A patient has the following arterial blood gas values: pH 7.52; PaO2 50 mm Hg; PaCO2 28mm Hg; HCO3 24 mEq/L. Based upon the patients PaO2, which of the following conclusions would be accurate? A) The patients PaO2 level is within normal range B) The patient is severely hypoxic C)The oxygen level is low but poses no risk for the patient D) The patient requires oxygen therapy with very low oxygen concentrations

B) The patient is severely hypoxic

Mr. Singh requires a blood transfusion. Which of the following statements is correct about blood administration? A) The nurse stays with pt for the first 20 minutes as this is when reactions are most likely to occur B) Two nurses are required to check the pts blood bag, chart, and ID band prior to administration of the blood product C) Vital signs must be checked before and after blood administration and during administration if there are any untoward reactions D) SIgns of a febrile reaction are hives, wheezing, pruritus, and joint pain

B) Two nurses are required to check the pts blood bag, chart, and ID band prior to administration of the blood product

A patient with cirrhosis is jaundiced and edematous. He is experiencing severe itching and dryness and asks the nurse if anything can be done for his skin. What is the best intervention by the nurse? A) Put mitts on his hands B) Use alcohol free body lotion C) Lubricate the skin with body oil D) Wash the skin with soap and water

B) Use alcohol free body lotion

Joe Smith, age 16, is evaluated for a closed head injury following a snowboarding accident. Which of the following assessments would be of priority concern to the RN? A) Headache B) Vomiting C) Tinnitus D) Diplopia

B) Vomiting

The family of an adolescent who smokes marijuana asks the nurse if the use of weed leads to abuse of other drugs. What is the most appropriate response by the nurse? A) "Use of weed is a stage your child will go through" B) "Many people use weed and don't use other street drugs" C) "Use of weed can lead to abuse of more potent substances" D) "It is difficult to answer that question as I don't know your child"

C) "Use of weed can lead to abuse of more potent substances"

A patient with TB who has been on combined therapy with rifampin and isoniazid asks the nurse how long he will have to take those medications. The nurse should tell the pt that: A) Medication is rarely needed after two weeks B) He will need to take the medication for the rest of his life C) The course of therapy if usually six months D) He will be reevaluated in one month to see if further medication is needed

C) The course of therapy if usually six months

A patient diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the patient, the nurse explains that one advantage of a catheter is that it can be used: A) For one week before being replaced B) To administer only blood products and IV fluids C) To provide long term access to central veins D) In patients with infections in the blood

C) To provide long term access to central veins

A nurse is caring for a patient with a central line who is receiving IV solutions. THe pt suddenly develops tachycardia and dyspnea. Cyanosis is noted, and the nurse suspects air embolism. Which of the following actions are most appropriate? A) Slow the IV rate B) Provide emotional support to the patient C) Turn the patient on the left side and lower the head of the bed D) Elevate the head of the bed and monitor vital signs

C) Turn the patient on the left side and lower the head of the bed

The nurse provides care for a patient with AIDS. Which lab test is the best indicator of effective treatment with antiviral medications? A) T4 lymphocyte count B) CD4 count C) Viral load D) Absolute neutrophil count

C) Viral load Rationale: The viral load is an actual count of viral presence and is the best test

When a patient is in the emergent phase of burn management, the nurse should assess for: A) Hypernatermia B) Hemodilution C) Hyperkalemia D) Metabolic alkalosis

C)Hyperkalemia Rationale: Due to the massive cellular destruction that occurs in burns, potassium is released into the extracellular fluid, which leads to hyperkalemia

The nurse is teaching a client about the method of HIV transmission that carries the most risk. The patient demonstrates understanding of exposure risks by making which of the following statements? A) "I can have routine teeth cleaning at the dentist's office" B) "I may have intercourse with my spouse" C) "I may engage in unprotected, nonrestrictive sexual contact" D) "I should not engage in intercourse with a new partner without a condom"

D) "I should not engage in intercourse with a new partner without a condom"

A patient with an ileostomy asks how long to wear the pouch before changing it. The nurse performing teaching of how to care for an ileostomy should tell the patient which of the following? A) "It depends on your activity level and your diet" B) "The pouch is changed only when it leaks" C) "You should change the pouch every evening before bedtime" D) "You can wear the pouch for about 4-7 days"

D) "You can wear the pouch for about 4-7 days"

Using the Rule of Nines, determine the total body surface area that has been burned in a patient with partial-thickness and full-thickness burns to left arm, left anterior leg, and anterior trunk: A) 27% B) 30% C) 18% D) 36%

D) 36%

A 72 year old male with cirrhosis is admitted to the hospital in a hepatic coma. What is the most important nursing intervention? A) Perform neuro checks B) Complete the patient admission C) Orient the patient to his environment D) Check airway, breathing, and circulation

D) Check airway, breathing, and circulation

If a patients central venous catheter accidentally becomes disconnected from the IV line, what should the nurse do first? A) Apply a dry sterile dressing to the site B) Tell the patient to take and hold a deep breath C) Call the physician D) Clamp the catheter

D) Clamp the catheter

Mr. Fonda and his wife live in a seniors apartment complex with 24 hour nursing service. Mr. Fonda falls and fracures his hip. After treatment in hospital, he is ready to go home. The patient must be assessed in maintaining hip precautions. How can the discharge nurse best ensure continuity of his rehabilitation? A) Send a pamphlet that outlines hip precautions to the nurse on site and at the complex B) Telephone the nurse on site at the complex and give a complete report C) Ensure the hospital physiotherapist has reviewed hip precautions with the patient and his wife D) Complete a referral to the community physiotherapist and arrange for a home visit

D) Complete a referral to the community physiotherapist and arrange for a home visit

The home care agency requests that the nurse caring for her patient perform a new IV procedure on him. The nurse does not have the policy that accompanies this procedure. What should the nurse do? A) Contact the nursing practice consultant of the provincial nurses association (CARNA) B) Check the IV policies at the local hospital C) Carry out the procedure but document that no policy existed D) Discuss the situation with the immediate supervisor

D) Discuss the situation with the immediate supervisor

Which nursing action is essential when providing continuous enteral feeding? A) Positioning the patient on his left side B) Adding methylene blue to the enteral feeding to detect aspiration C) Warming the formula before administering it D) Elevating the head of the bed

D) Elevating the head of the bed Rationale: Reduces the risk of aspiration and allows the formula to flow into the patients intestines

Immediately after surgery to create an ileostomy, which goal has the highest priority? A) Assisting the patient with self care activities B) Providing relief from constipation C) Minimizing odor formation D) Maintaining fluid and electrolyte balance

D) Maintaining fluid and electrolyte balance

A nurse is assessing a patient with a history of cocaine abuse. The nurse is aware that the assessment may include which of the following findings? A) Glossitis B) Pharyngitis C) Bilateral ear infections D) Perforated nasal septum

D) Perforated nasal septum

The nurse is assisting the physician with the removal of a chest tube. The nurse should instruct the patient to take which action? A) Exhale slowly B) Stay very still C) Inhale and exhale quickly D) Perform the Valsalva Maneuver

D) Perform the Valsalva Maneuver

A patient presents to the ER with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the patients current health problem? A) Gastroesophageal reflux disease B) Appendicitis C) Hypertension D) Ulcerative Colitis

D) Ulcerative Colitis

The student nurse is assigned an HIV positive patient. The student asks the staff nurse what precautions are necessary when taking the patients BP. The nurse instructs the student to: A) Wear gloves B) Wear a gown C) Use contact precautions D) Wash hands

D) Wash hands

A nurse is caring for a pt with AIDS who is receiving Retrovir (zidovudine). The pt asked the nurse, "how does this drug work?" The nurse determines that teaching was effective when the pt makes which statement? A) "It kills the HIV virus" B) "It suppresses the HIV virus" C) "I won't infect anyone else when I am taking this drug" D) "It is the only drug for HIV I need to take"

B) "It suppresses the HIV virus"

A nurse is caring for a patient with a central venous catheter and notices redness and tenderness at the catheter insertion site. Which assessment finding would indicate possibel systemic infection? A) BP of 112/78 mm Hg B) Temp of 36.3 degrees C C) Resp rate of 32 breaths/min D) HR of 55 beats/min

C) Resp rate of 32 breaths/min

In order for organ donation to proceed, the nurse needs to be aware of the criteria for brain death. Which of the following are findings which indicate brain death? 1. Coma or unresponsiveness 2. Absence of brainstem reflexes 3. Apnea 4. Presence of decorticate positioning Select One: a) 1 and 3 b) 1, 2, and 3 c) 2 and 3 d) All of the above

b) 1, 2, and 3

Which of the following statements indicates the patient with Crohn's disease understands nutritional modifications? A) "A diet high in vitamins and protein is important" B) "I am allowed to have two to three glasses of wine weekly" C) "I can enjoy peanuts for an evening snack" D) "I may have cola drinks with my meals"

A) "A diet high in vitamins and protein is important"

A patient has been recently started on clopidogrel (Plavix) after recently experiencing a myocardial infarction. The nurse should develop a teaching plan that includes which of the following points? Select all that apply: A) The patient should report unexpected or prolonged bleeding B) The patient may bruise more easily and experience bleeding gums C) Plavix works by preventing platelets from sticking together and forming a clot D) The patient should drink a glass of water after taking Plavix E) The patient should always take Plavix with food

A, B, and C Rationale: Plavix is generally well absorbed and may be taken with or without food; it should be taken at the same time every day. While food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of Plavix; the patient must understand the importance of reporting any unexpected, prolonged, or excessive bleeding, including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of Plavix; the patient should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in patients who have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking Plavix.

Which of the following interventions should the nurse include when developing a plan of care for a patient with Chron's disease, who is receiving TPN? Select all that apply A) Weighing the patient daily B) Monitoring vital signs once a shift C) Taping all IV tubing connections securly D) Monitoring the IV infusion rate hourly E) Changing the central venous line dressing daily

A, C, and D

Following the formation of an ileal conduit, the nurse notes that the patients urinary drainage appliance contains pale yellow urine with large amounts of mucus. How should the nurse interpret this date? A) The pt is developing an infection of the urinary tract B) The mucus is caused by elevated levels of glucose in the urine C) These findings are normal for a pt with an ileal conduit D) There is irritation of the stoma

C) These findings are normal for a pt with an ileal conduit

A nurse is assessing a patient admitted with deep-partial thickness and full-thickness burns on the face, arms, and chest. Which assessment finding is the nurse most concerned with? A) Rectal temp of 38 degrees celcius B) Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg C) Urine output of 20 ml/hr D) White pulmonary secretions

C) Urine output of 20ml/hr

Which signs and symptoms would indicate that your patient is experiencing circulatory overload as a complication of blood administration? A) Bounding pulse B) Chills C) Dry Cough D) Hypotension

A) Bounding pulse

A patient recovering from an abdominal surgery and has a NG tube inserted. The expected outcome of using the NG tube is GI tract? A) Decompression B) Gavage C) Compression D) Lavage

A) Decompression

The nurse is caring for a patient who has a deep partial-thickness and full-thickness burns. During the emergent (resuscitative) phase of burn management, there will be a fluid shift from the: A) Intracellular to extracellular compartment B) Interstitial to the intracellular compartment C) Intravascular to the interstitial compartment D) Extracellular to intravascular compartment

C) Intravascular to the interstitial compartment

The nurse is assessing a patient who reports chest pain rated 8/10 on a 10 point visual analog scale. A 12-lead ECG is completed and reveals ST elevation in the inferior leads. Troponin levels are also elevated. What is the highest priority for nursing management of this patient at this time? A) Reduce pain and myocardial oxygen demand B) Monitor daily weights and urine output C) Permit unrestricted visitation by family and friends D) Provide patient education on medications and diet

A) Reduce pain and myocardial oxygen demand

A child is receiving TPN. During TPN therapy, the most important nursing action is: A) Providing a daily bath B) Elevating the head of the bed 60 degrees C) Monitoring the blood glucose level closely D) Assessing vital signs every 30 minutes

C) Monitoring the blood glucose level closely Rationale: Most TPN solutions contain a high glucose content, placing the pt at risk for hyperglycemia.

A nurse notes that a patient, who experienced a head injury 24 hours ago has returned to the ED with slurred speech and is disoriented to time and place. The first nursing action should be to? A) Report the change to the physician B) Continue to assess hourly as ordered C) Repeat a neurological assessment in 15 minutes D) Notify the operation room of the need for surgery

A) Report the change to the physician

An 18 year old patient is admitted with a closed head injury sustained in a MVC. His intracranial pressure shows an upward trend. Which intervention should the nurse perform first? A) Reposition the patient to avoid neck flexion B) Administer 1g of Mannitol IV as ordered C) Increase the ventilators respiratory rate to 20 breaths/minute D) Administer 100mg of pentobarbital IV as ordered

A) Reposition the patient to avoid neck flexion

The nurse is caring for the client immediately after the removal of the endotracheal tube. The nurse should immediately report which sign if experienced by the patient? A) Stridor B) Occasional pink-tinged sputum C) Respiratory rate of 24/min D) A few basilar lung crackles on the right side

A) Stridor

A patient with Crohn's disease experiences 20 watery stools a day. When assessing the patient, the nurse would anticipate which finding? A) Tenting skin turgor B) Decreased HR C) Dilute urine D) Elevated BP

A) Tenting skin turgor

A community health nurse is working with a family whose elderly parent lives in the home with the married child and two dependent children. As caregivers to the parent, the clients voice concerns over the recent and suden behavior changes they've noticed (forgetfulness, confusion, and weakness). The nurse, using knowledge of the elderly population should respond: A) "What kind of medication is your parent taking?" B) "Confusion is a normal sign of aging" C) "Does Alzheimer's Disease run in your family?" D) "Do you pay attention to how much liquid your parent takes in 24 hours?"

A) "What kind of medication is your parent taking?"

A patient involved in a MVC presents to the ER with severe internal bleeding. The patient is unresponsive and hypotensive. Which IV solution will most likely be ordered to increase intravascular volume, replace immediate blood loss and increase blood pressure? A) 5% Dextrose in Lactated Ringers B) 0.33% Sodium Chloride (1/3 NS) C) 0.225% Sodium Chloride (1/4 NS) D) 0.45% Sodium Chloride (1/2 NS)

A) 5% Dextrose in Lactated Ringers

The nurse should instruct the patient with an ileostomy to report which of the following immediately? A) Absence of drainage from the ileostomy for 6 or more hours B) Passage of liquid stool from the stoma C) Temp of 37.7 degrees Celsius D) Occasional presence of undigested food in the effluent

A) Absence of drainage from the ileostomy for 6 or more hours

Some benefits of case management include: 1. Better coordination of care 2. Assistance in navigating through a complex health care system 3. Reduced cost of care 4. Better communication among community agencies Select one: A) All of the above B) 1, 3, and 4 C) None of the above D) 2 and 3

A) All of the above

An elderly pt with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurses priority should be the potential for: A) Fluid volume excess B) Aspiration C) Constipation D) Hyperglycemia

A) Aspiration

When considering the option of respite care for the patient, the home care nurse must: A) Be knowledgeable of the community resources available B) Wait until the caregiver specifically asks for this service C) Ask for payment from the family prior to authorizing a service D) Ensure that even reluctant family members are "doing their part" in caring for the patient

A) Be knowledgeable of the community resources available

The ED nurse is caring for a client with a head injury secondary to a snowmobile collision who in response to painful stimuli, assumes decerebrate posturing. Which data would indicate the clients condition is improving? A) The patient has purposeful movements when the nurse rubs the sternum B) The patient extends upper and lower extremities in response to painful stimuli C) The patient is flaccid when the nurse applies painful stimuli D) The client has a Glasgow Coma Scale Rating of 4

A) The patient has purposeful movements when the nurse rubs the sternum

The emergency department physician has determined electrocardiogram changes for a patient with severe angina pectoris. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering: A) Troponin B) Myoglobin C) Lactate dehydrogenase D) Creatine kinase

A) Troponin Rationale: This patient exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level. Creatine kinase, lactate dehydrogenase and myoglobin tests can show evidence of muscle injury, but they're less specific indicators of myocardial damage than troponin.

A patient is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the patient? A) "PTCA" involves passing a catheter through the coronary arteries to find blocked arteries" B) "PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter" C) "PTCA involves inserting grafts to divert blood from blocked coronary arteries" D) "PTCA involves curring away blockages with a special catheter"

B) "PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter" Rational: PTCA is best described as insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery. Cutting away blockages with a special catheter is an atherectomy. Passing a catheter through the coronary arteries to find blocked arteries is a cardiac catheterization. Inserting grafts to diert blood from blocked arteries describes coronary artery bypass graft surgery.

The nurse is performing discharge teaching with a patient who received an ileostomy as treatment for inflammatory bowel disease. During this discharge teaching, the nurse should stress the importance of: A) Taking only enteric-coated medications B) Wearing an appliance pouch only at bedtime C) Increasing fluid intake to prevent dehydration D) Consuming a low-protein, high-fiber diet

C) Increasing fluid intake to prevent dehydration

A patient has returned from receiving a cardiac catheterization. Which post-procedure intervention must the nurse now provide for this patient? A) Inform the patient that he may experience numbness or pain in his leg B) Assess the puncture site frequently for hematoma formation or bleeding C) Restrict fluids for 6 hours after the procedure D) Withhold analgesics for at least 6 hours after the procedure

B) Assess the puncture site frequently for hematoma formation or bleeding Rationale: Because the diameter of the catheter used for cardiac catheterization is large, the puncture site must be checked frequently for hematoma formation and bleeding. The nurse should administer analgesics as ordered and needed. If the femoral artery was accessed during the procedure, the patient should be instructed to report any leg pain or numbness, which indicates arterial insufficiency. Fluids should be encouraged to eliminate dye from the patients system.

A nurse assesses that a patient, who has just arrived in the emergency department, is diaphoretic and short of breath. He complains of squeezingsubsternal pain that radiates to the left shoulder and jaw, and he states he is nauseated. What should the nurse do? A) Complete the patients registration information, perform and electrocardiogram, gain IV access, and take vitals B) Attach a cardiac monitor, take vitals, administer sublingual nitroglycerin, and administer oxygen if indicated C) Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician D) Gain IV access, give sublingual nitroglycerin, and alert the cardiac cath team

B) Attach a cardiac monitor, take vitals, administer sublingual nitroglycerin, and administer oxygen if indicated Rationale: Cardiac chest pain is cause by myocardial ischemia. Therefore the nurse should administer supplemental oxygen supply, attach a cardiac monitor to help detect life threatening arrhythmias, and take vital signs to ensure that the patient isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the patient is stabilized. Alerting the cardiac cath team or the physician before completing the initial assessment is premature

The nurse admitting a patient from the ED following a fall that resulted in ICP. The nurse interprets that the patients Glasgow Coma Scale score has improved the most after making which of the following latest assessments? A) Best eye opening response 3, best motor response 8, best verbal response 6. B) Best eye opening response 4, best motor response 6, best verbal response 5. C) Best eye opening response 5, best motor response 4, best verbal response 8. D) Best eye opening response 6, best motor response 5, best verbal response 4.

B) Best eye opening response 4, best motor response 6, best verbal response 5.

You are caring for a 1-day-old infant who has an orogastric tube in place. Which initial intervention should you perform prior to feeding the infant expressed breast milk (EBM) via the orogastic tube? A) Change the tubing before each feeding B) Check for placement of the tube C) Instill 60mL of water through the tube D) Place the infant in the left lateral postition

B) Check for placement of the tube

A nurse records a patients history and discovers several risk factors for coronary artery disease (CAD). Which cardiac risk factors can the patient control? A) Diabetes, hypercholesterolemia, and heredity B) Diabetes, hypercholesterolemia, and hypertension C) Age, gender, and heredity D) Diabetes, age, and gender

B) Diabetes, hypercholesterolemia, and hypertension Rationale: Controllable risk factors for CAD include hypertension, hypercholesterolemia, obesity, lack of exercise, smoking, diabetes mellitus, stress, alcohol use, and use of hormonal contraceptives. Uncontrollable risk factors include gender, age, and heredity.

A patient comes to the ED complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? A) Widened QRS complex B) Elevated ST segment C) Absent Q wave D) Prolonged PR interval

B) Elevated ST segment Rationale: Ischemic myocardial tissue changes cause elevation of the ST segment, an inverted T wave, and pathological Q wave. A prolonged PR interval occurs with first degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normall an MI may cause significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.

Mrs. Alves has experienced massive internal bleeding and is comatose. Her husband refuses to allow transfusions of blood because their religion prohibits blood transfusions. Which of the following interventions is the most appropriate initial action by the nurse? A) Contact the physician so that a court order can be obtained to administer the blood B) Ensure that Mr. Alves understands the rationale for the transfusion and the risks of not having the transfusion C) Have Mr. Alves sign a treatment refusal form and notify the physician D) Institute the blood transfusion since the physician ordered it and Mrs. Alves survival depends on volume replacement

B) Ensure that Mr. Alves understands the rationale for the transfusion and the risks of not having the transfusion

Sue, a 15 year old female is brought to the ER with a head injury after being involved in a snow mobile accident. She is unconscious upon arrival to the ER. Which of the following considerations should the nurse give the highest priority in her care? A) Determining whether she has a neck fracture B) Establishing an airway C) Replacing blood losses D) Stopping bleeding from open wounds

B) Establishing airway

A patient has burned 40% of his body 10 hours ago and is now receiving fluid replacement with Lactated Ringers at 375 ml/hr. The nurses assessment reveals: temp 36.2, HR 122, BP 84/42, CVP 2 mm Hg, and urine output 25 ml for the last 2 hours. Using the SBAR technique for communication, the nurse calls the healthcare provider with the recommendation for: A) Dextrose 5% B) IV rate increase C) Lasix D) Fresh Frozen Plasma

B) IV rate increase Rationale: The decreased urine output, low BP, low CVP, and high HR indicate hypovolemia and the need to increase fluid volume replacement. Lasix is a diuretic that should not be given due to the existing fluid volume deficit. FFP is not indicated. It is given to patients with deficient clotting factors who are bleeding. Fluid replacement used for burns is LR solution, NS, or albumin.

A patient has full thickness burns to upper torso. Which of the following nursing diagnosis should take highest priority when planning care for this patient? A) Impaired physical mobility RT the disease process B) Risk for infection RT breaks in the skin C) Ineffective airway clearance RT edema of the respiratory passages D) Disturbed sleep pattern RT facility environment

C) Ineffective airway clearance RT edema of the respiratory passages

Angela King is caring for her mother who is in the late stages of Alzheimer's disease at home. Her mother was recently admitted to hospital with pneumonia. As the nurse caring for Mrs. King, you know that it is also important to assess Angela's level of wellbeing because: A) You notice that Angela is overweight and you see her eating fast foods everyday B) Long-term caregivers often become emotionally burdened, isolated and are at an increased risk of developing severe depression and suicidal ideation C) Angela may also be developing pneumonia due to her close proximity while caring for her mother D) Angela tells you that she does not have a family physician

B) Long-term caregivers often become emotionally burdened, isolated and are at an increased risk of developing severe depression and suicidal ideation

John, a 20 year old male is admitted to the hospital following a MVC. He has spinal and head injuries and is experiencing increasing ICP. John becomes very agitated and confused. Which of the following nursing interventions is most appropriate? A) Keep John restrained at all times B) Pad the side rails C) Place the bed in a low position with the side rails down D) Place the bed in high position to prevent John from getting out of bed

B) Pad the side rails

Mr. White is started on heparin (Hepalean) therapy. What blood test results does the nurse need to monitor closely? A) International normalized ratio (INR) B) Partial thromboplastin time (PTT) C) Blood urea nitrogen (BUN) D) Prothrombin time (PT)

B) Partial thomboplastin time (PTT)

The infusion rate of TPN is tapered before being discontinued. This is done to prevent which of the following complications? A) Malnutrition B) Rebound hypoglycemia C) Dehydration D) Essential fatty acid deficiency

B) Rebound hypoglycemia

When assessing a patient who reports recent chest pain, the nurse obtains a thorough history.Which patient statement most strongly suggests angina pectoris? A) "The pain resolved after I ate a sandwhich" B) "The pain lasted about 45 minutes" C) "The pain occurred while I was mowing the lawn" D) The pain got worse when I took a deep breath"

C) "The pain occurred while I was mowing the lawn"

The nurse is providing a verbal report to the flight crew who will be transferring the client to the tertiary center. Which of the following information is included in the report: 1. Clients name and age 2. Clients religion and diet requests 3. Medical Diagnosis and referring physician 4. Progress report and current health status A) 1 and 2 B) 1 and 3 C) 1, 3, and 4 D) All of the above

C) 1, 3, and 4

A nurse is teaching an adolescent with inflammatory bowel disease about treatment with corticosteroids. Which adverse effects are concerns for this patient? Select all that apply: 1. Growth spurts 2. Acne 3. Adrenal suppression 4. Osteoporosis 5. Hirsutism 6. Mood swings Select one: A) 1, 2, 3 B) 1, 3, 4, 6 C) 2, 3, 4, 5, 6 D) 2, 5, 6

C) 2, 3, 4, 5, 6

Following several snowmobile collisions in the RMWB involving teenagers not wearing helmets and intoxicated, the Community Health Nurse has been asked to address the risks involved with these activities to the students at a local high school. How would the nurse address this to have the most positive impact on the students? A) Ask the RCMP to speak to the students about the laws, fines and charges that could be laid in the event that teenagers were caught participating in these activities B) Set up booths in the cafeteria at lunch time with information for the students to pick up C) Ask a teenager who was involved in a serious snowmobile collision to speak to the students about the experience, consequences and ongoing impact D) Send pamphlets to all parents advising them of the risks involved in these activies

C) Ask a teenager who was involved in a serious snowmobile collision to speak to the students about the experience, consequences and ongoing impact

A patient with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the patients stoma appears dusky. How should the nurse interpret this finding? A) The ostomy bad should be adjusted B) An intestinal obstruction has occurred C) Blood supply to the stoma has been interrupted D) This is a normal finding 1 day after surgery

C) Blood supply to the stoma has been interrupted

Which nursing intervention should the nurse perform for a patient receiving enteral feedings through a gastrostomy tube? A) Maintain the head of the bed at a 15 degree elevation continuously B) Maintain the patient on bed rest during the feedings C) Change the tube feeding administration set at least every 24 hours D) Check the gastrostomy tube for position every 2 days

C) Change the tube feeding administration set at least every 24 hours

During a figure-skating practice, 11-year-old Kelly Lewis falls and hits her head. A computerized tomography (CT) scan of the head shows a collection of blood between the skull and the dura matter. Which type of head injury does this finding suggest? A) Sub-dural hematoma B) Subarachnoid hemorrhage C) Epidural hematoma D) Contusion

C) Epidural hematoma

A patient who has recently had a significant small and large bowel resection, is currently taking nothing by mouth. The physician has prescribed TPN. The nurse should: A) Designate a peripheral intravenous (IV) site for TPN administration B) Auscultate for bowel sounds prior to administering TPN C) Handle TPN using strict aseptic technique D) Administer TPN through a nasogastric or gastrostomy tube

C) Handle TPN using strict aseptic technique

A patient is admitted with a MI and atrial fibrilation. While auscultating the heart, the nurse notes and irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as? A) Heart rate irregular with aortic regurgitation B) Heart rate irregular with mitral stenosis C) Heart rate irregular with S3 D) Heart rate irregular with S4

C) Heart rate irregular with S3

What is the leading cause of preventable mortality and morbidity in youth in Canada? A) Cancer B) Asthma C) Injuries D) Congenital anomalies

C) Injuries

The Emergency Department (ED) in a small rural hospital has received a phone call reporting a collision between two all terrain vehicles (ATVs). The ambulances are at the scene and will be transporting the victims shortly. Their ETA is 30 minutes. Which action should the ED nurse implement first? A) Contact the local blood bank to report the incident B) Call nurses who are off-duty to come into work C) Notify the charge nurse of the incident D) Instruct staff to check the supplies in the ED

C) Notify the charge nurse of the incident

Which of the following should be a priority focus of care for a pt experiencing an exacerbation of Chrohn's disease? A) Decreasing episodes of rectal bleeding B) Maintaining current weight C) Promoting bowel rest D) Encouraging regular ambulation

C) Promoting bowel rest

The physician ordered 200ml of tube feeding every 4 hours for an unconscious pt. Prior to administering the next scheduled feeding, the nurse checks for the pts gastric residual and obtains 45 ml of gastric residual. The nurse should: A) Delay feeding the pt for 1 hour and then recheck the residual B) Withhold the tube feeding and notify the physician C) Re-administer the residual to the pt and continue with the feeding D) Dispose of the residual and continue with the feeding

C) Re-administer the residual to the pt and continue with the feeding Rationale: Gastric residuals are checked before administering feedings to determine whether gastric emptying is delayed. A residual of less than 50% of the previous feeding volume is usually considered acceptable. In this case, the amount is not excessive and the nurse should reinstill the aspirate through the tube and then administer the feeding. If the amount of gastric residual is excessive, the nurse should notify the physician and withhold the feeding. Disposing of the residual can cause electrolyte and fluid losses.

A patient has the following arterial blood gas values: pH 7.30; PaO2 89 mm Hg; PaCO2 50 mm Hg; and HCO3 26 mEq/L. Based on these values, the nurse should expect which condition? A) Metabolic alkalosis B) Respiratory alkalosis C) Respiratory acidosis D) Metabolic acidosis

C) Respiratory acidosis Rationale: This patient has a below normal blood pH value and an above normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate values are below normal. In metabolic alkalosis, the pH and HCO3 values are above normal.

What are the emergency nursing actions for a patient with a head injury due to a fall from a third floor roof? A) Assess respirations, assess circulation, and assess level of consciousness B) Stabilize C-spine, determine responsiveness, and begin chest compressions C) Stabilize C-spine, assess airway, and assess respirations D) Assess airway, assess respirations, and assess circulation

C) Stabilize C-spine, assess airway, and assess respirations

The nurse is caring for a female patient who sustained a closed head injury 8 days ago due to a MVC. Which signs/symptims would alert the nurse to a complication of a head injury? A) The patient reports having trouble sleeping due to having nightmares about the wreck B) The patient tells the nurse she has a stuffy nose and green nasal discharge C) The patient complains of extreme thirst and has an increased urine output D) The patient informs the nurse that she has started her menstrual period

C) The patient complains of extreme thirst and has an increased urine output

A patient with a history of a myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/min, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5ml over the past hour. The nurse anticipates preparing the patient for transfer to the intensive care unit and pulmonary artery catheter insertion because: A) The patient shows signs of aneurysm rupture B) The patient is in the early stage of right-sided heart failure C) The patient is going into cardiogenic shock D) The client is experiencing heart failure

C) The patient is going into cardiogenic shock Rationale: This patients findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin, and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this patient has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.

The physician has prescribed nitroglycerin 0.3 mg sublingual as an initial step in treating a patient with angina. This drug's principal effects are produced by: A) Improved conductivity in the myocardium B) Causing an increased myocardial myocardial oxygen demand C) Vasodilation of peripheral vasculature D) Antispasmodic effects on the pericardium

C) Vasodilation of peripheral vasculature Rationale: Nitro produces peripheral vasodilation which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitro decreases myocardial oxygen demand. Nitro does not have an effect of pericardial spasticity or conductivity in the myocardium

A patient with chest pain doesn't respond to Nitro. When he's admitted to the ER, the health care team obtains and electrocardiogram and administers IV morphine. The physician also considers administering TNK. This thrombolytic agent must be administered how soon after onset of MI symptoms? A) Within 24 to 48 hours B) Within 5 to 7 days C) Within 6 hours D) Within 12 hours

C) Within 6 hours Rationale: For the best chance of salvaging the patients myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after and MI. Physicians initiate IV heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.

Which set of arterial blood gas (ABG) results require further investigation? A) pH 7.38, PaCO2 33 mm Hg, PaO2 95 mm Hg, HCO3 24 mEq/L B) pH 7.44, PaCO2 43 mm Hg, PaO2 99 mm Hg, HCO3 26 meq/L C) pH 7.35, PaCO2 40 mm Hg, PaO2 91 mm Hg, HCO3 22 meq/L D) pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, HCO3 18 meq/L

D) pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, HCO3 18 meq/L Rationale: The ABG results pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, HCO3 18 meq/L indicate respiratory alkalosis. The pH level is increased and the bicarb and PaCO2 levels are decreased. Normal values are pH 7.35-7.45; PaCO2 35-45 mm Hg; HCO3 22-26 mEq/L

A patient with inflammatory bowel disease is receiving TPN. The basic component of the pts TPN solution is most likely to be: A) A colloidal dextrose solution B) A hypotonic dextrose solution C) An isotonic dextrose solution D) A hypertonic dextrose solution

D) A hypertonic dextrose solution Rationale: The TPN solution is usually a hypertonic dextrose solution. The greater the concentration of dextrose in solution, the greater to tonicity. Hypertonic dextrose solutions are used to meet the bodys calorie demands in a volume of fluid that will not overload the cardiovascular system. An isotonic dextrose solution (ex D5W) or a hypotonic dextrose solution will not provide enough calories to meet metabolic needs. Colloids are plasma expanders and blood products are not used in TPN.

A crucial aspect of preventing elder abuse is by: A) Screening caregivers B) Funding education C) Public health intervention D) Assessing for caregiver burnout

D) Assessing for caregiver burnout

If a client had irritable bowel syndrome ,which diagnostic test would determine if the diagnosis is Chron's disease or ulcerative colitis? A) Abdominal CT scan B) Abdominal x-ray C) Barium swallow D) Colonoscopy with biopsy

D) Colonoscopy with biopsy

While caring for the patient with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the patient for: A) Paralytic ileus B) Gastric distention C) Hiatal hernia D) Gastrointestinal ulceration

D) Gastrointestinal ulceration Rationale: GI ulceration, also known as Curling's ulcer, occurs in about half of patients suffering from severe burns. The incidence of ulceration appears proportional to the extent of the burns and is believed to be due to hyper-secretion of gastric acid and compromised GI perfusion.

Mr. Allman is an 80 year old male with congestive heart failure. He has stopped taking his medication because he believes that it is the cause of his headache. You are the nurse visiting him at home and you find him to be anxious, short of breath and edematous. The major goal of therapy for this patient would be to: A) Decrease peripheral edema B) Enhance comfort C) Improve respiratory status D) Increase cardiac output

D) Increase cardiac output

IV morphine has been ordered for a patient who is experiencing an acute myocardical infarction (MI). The nurse knows that morphine is given because it: A) Eliminates pain, reduces cardiac workload, and increases myocardial contractility B) Increases venous return, lowers resistance, and reduces cardiac workload. C) Raises the blood pressure, lowers myocardial oxygen demand, and eliminates pain D) Lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand

D) Lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand Rationale: When given to treat acute MI, morphine eliminates pain, reduces venous return to the heart, reduces vascular resistance, reduces cardiac workload, and reduces the oxygen demand of the heart. Morphine doesn't increase myocardial contractility, raise BP,or increase venous return.

The patient has been diagnosed with a stroke. The patients wife is concerned about her husbands generalized weakness. Which home medication should the nurse suggest to the wife prior to discharge? A) Obtain a rubber mat to place under the dinner plate B) Purchase a long handled bath sponge for showering C) Purchase clothes with velcro closure devices D) Obtain a raised toilet sear for the patients bathroom

D) Obtain a raised toilet sear for the patients bathroom

As the nurse is inserting a NG tube, the patient begins to gag. What action should the nuse take? A) Remove the inserted tube and notify the physician of the patients status B) Stop the insertion, allow the pt to rest, and then continue inserting the tube C) Encourage the pt to take deep breaths through the mouth while the tube is being inserted D) Pause until the gagging stops and then tell the pt to take a few sips of water and swallow as the tube is being inserted

D) Pause until the gagging stops and then tell the pt to take a few sips of water and swallow as the tube is being inserted

A home care nurse manager engages in: A) Nursing service treatments only B) Tertiary prevention activities only C) Secondary prevention activities only D) Primary, secondary, and tertiary health promotion activities

D) Primary, secondary, and tertiary health promotion activities

Which of the following would the nurse observe that would indicate that Digoxin and Lasix were effective in the treatment of congestive heart failure? A) Decreased lung congestion and concentrated urine B) Increased HR and concentrated urine C) Regular pulse and increased BP D) Slowed pulse and decreased lung congestion

D) Slowed pulse and decreased lung congestion

The family physician suggests to Mrs. Arif that she apply to have her husband placed in a long-term care facility due to his advanced state of Alzheimer's disease. She refuses and tells the nurse that it is too early to make this decision. How can the nurse advocate for Mrs. Arif? A) Call the family physician to learn the reasons for his recommendation B) Encourage Mrs. Arif to express her beliefs about her role as caregiver C) Seek help from nurses at the community health center D) Take steps with Mrs. Arif to examine all options from maintaining home care

D) Take steps with Mrs. Arif to examine all options from maintaining home care

Mr. Simons has been caring for his wife at home for the past few years. Her dementia has progressed and she is increasingly unable to care for herself. Mr Simons admits to feeling overwhelmed and alone. Which of the following would be a priority for the nurse? A) Communication between the family members B) The couples social isolation C) The family's relationship with the health professionals D) The problems with activities of daily living

D) The problems with activities of daily living

The nurse prepares to administer regularly prescribed medications: Nirtoglycerin, metoprolol (lopressor), and furosemide (Lasix) to a cardiac patient. When the nurse helps the patient out of bed for breakfast, the patient comes dizzy and asks to lie down. The nurse helps the patient lie down, puts up the side rails, and obtains the patients BP, which is 84/50 mm Hg. Which action by the nurse is best? A) Encourage the patient to sit up and eat breakfast B) Administer the nitroglycerin and metoprolol and withhold the furosemide C) Administer the medications immediately D) Withhold the medications and notify the physician

D) Withhold the medications and notify the physician

The patient with a major burn injury received total parenteral nutrition (TPN). The expected outcome is to: A) Correct water and electrolyte imbalances B) Allow the GI tract to rest C) Provide supplemental vitamins and minerals D) Ensure adequate caloric and protein intake

D) ensure adequate caloric and protein intake

The term "self-managed care" refers to: A) The patient assuming freedom to choose when the home care nurse can visit B) The use of Orem's nursing model to direct nursing care delivery of services C) Allowing patients families to choose the long-term care facility for their loved one. D) the patient assuming responsibility for obtaining support services based on assessed needs

D) the patient assuming responsibility for obtaining support services based on assessed needs