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The nurse is providing care for several patients that arrived at the convenient care at the same time. Which patient will the nurse assess first? A) 15 year old with a severe headache, stiff neck, and high temp. [meningitis] B) 27 year old with a fever, vomiting, abdominal cramping, and diarrhea. [dehydration] C) 62 year old with arthritis and having severe pain. D) 43 year old with dysuria, severe burning with urination and fever. [UTI] - Correct answer A Paramedics call the charge nurse. They are coming in with 4 patients involved in a motor vehicle accident. Which patient does the nurse plan to see first based on the report? A) A 26 year old screaming of pain. Has a visible right knee deformity and weak lower extremity pulses. [circulation] B) A 22 year old female who is responsive to painful stimuli, pulse rate 118 beats per minute with no visible traumas or injuries. [intracranial hemorrhage] C) A 6 year old boy with a visible deformity to the forearm and crying. D) an 8 year old girl with a cut on the forehead, crying intensely with a pulse rate of 126 beats per minute. - Correct answer B - Patient might be experiencing internal hemorrhage and go into a hypovolemic shock The nurse provides care for a patient with diabetes insipidus. Which nursing diagnosis is most appropriate? A) Fluid volume deficit related to excess urine output. B) Hyponatremia related to high sodium excretion. [not a Nanda nursing diagnoses] C) Risk for fluid volume overload related to decreased urine output [ deficit not overload]
D) Hyperglycemia is related to reduced insulin and cortisol production. [diabetes mellitus] - Correct answer A - DI is deficiency of secretion of antidiuretic hormone or decreased response to ADH. This results in massive water excretion. Thus, fluid volume deficit A patient right after post hypophysectomy. He is thirsty and has frequent urination. Which action does the nurse take first? A) Check the glucose in urine B) Encourage drinking water C) Check urine specific gravity D) Call the surgeon - Correct answer C -Post-op, diabetes insipidus can temporarily occur due to low ADH Which Outcome indicates that the intervention for a patient with syndrome of inappropriate antidiuretic hormone {SIADH} has been effective? A) Decreased serum osmolality B) Serum sodium is decreased C) Increased urine output D) Increased urine osmolality - Correct answer C- Increased urine output - sign that treatment is effective The nurse performs a newborn assessment. Which finding does the nurse report to the physician? A) Pink patch on the back of the neck B) Bluish skin over the sacral gluteal area C) A rectal temperature of 98*F D) A respiratory rate of 24 breaths per minute - Correct answer D: normal resp rate ~ 30-60; Pink patch ~ {stork bite} normal, bluish skin ~ {mangolian spots} normal;, Newborn 0-2yr old, Infants <1 yr old The oncology nurse is giving a teach about risk factors and demographics of lung cancer at a gathering at the local community clinic. Which group of individuals has the highest risk for lung cancer? A)African Americans B) Caucasians C) South East Asians
D) Aspirin- EC - Correct answer D- Aspirin EC {enteric coated} should not be crushed The nurse provides pre-op teaching for a patient. Which kind of anesthesia alters the level of consciousness? (Select all that apply} A) General anesthesia B) Topical anesthesia C) Regional anesthesia D) local anesthesia E) conscious sedation - Correct answer A,E The nurse provides care for a patient who had an unexpected death during a night shift. The patient has many tubes and drains in place. The nurse is performing postmortem care of the deceased patient. Which action by the nurse is appropriate when managing the tubes prior to a scheduled autopsy? A) Discontinue tubes and drains and send to autopsy with the body B) Discontinue tubes and drains and put them in biohazardous bags C) Keep all tubes and drains in place in the patient's body D) Keep Iv tubes in place but remove drains. - Correct answer C -If an autopsy is to be performed, any tubes or drains will be left in place to be assessed and cultured, then removed by the medical examiner The nurse auscultates a patient's bowel sounds. Which finding is most important for the nurse to report to the physician? A) Bruit sound over the abdominal aorta B) Irregular bowel sounds C) Uninterrupted bowel sounds over the ileocecal area D) Absent bowel sounds for a whole 1 minute - Correct answer A- burit signifies a turbulence ~ Abdominal Aortic Aneurysm {AAA} - emergent; Listen for 3-5 minutes, small bowel sounds are continuous {fluid}, bowel are not "regular" A patient is scheduled to receive an IV antibiotic q 8 hours, next dose is at 2p.m. The patient is prescribed peak and trough blood levels. At which time does the nurse schedule the trough level to be drawn?
A) 1430
B) 1500
C) 1330
D) 1400 - Correct answer C - a trough level is drawn approximately 30 minutes before the next scheduled dose Patient is getting gentamicin IV every 8 hours. The provider ordered a gentamicin peak. If the medication is administered at 10 am over one hour, at which time should the nurse draw the gentamicin peak? A) 10 am just before giving the dose B) 12 noon C) 11:30 am D) 5:30 pm just before the next due dose - Correct answer C - peak occurs 30 minutes after to completion of IV drug The nurse provides care to a new admission. Which action is the best example of culturally appropriate nursing intervention? A) Assign the family members to most of the patients personal care B) Take a permission before touching the patient for the physical assessment C) Keep a personal space of 3 feet when assessing the patient D) Keep in mind the patient's ethnicity as the most important factor in planning care - Correct answer B - many cultures consider it disrespectful to touch a patient without asking permission; in a NEW admission, the ethnicity is not the most important factor The nurse provides care for a patient with acute anxiety. What is most important for the nurse to assess the patient for? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis - Correct answer A - anxiety causes hyperventilation, which results in a loss of carbon dioxide. Respiratory alkalosis is caused by decreased carbon dioxide in the blood A patient who had gastric surgery 2 days ago has an NGT attached to intermittent suction. The patient had a large amount of secretions in the last
A) High hematocrit B) Slow heart rate C) Elevated blood pressure D) Increased urinary output - Correct answer A - a large fluid shift will occur from intravascular to interstitial What is the single most important act the preceptor should emphasize on while orienting a new nurse on a burn unit? A) Put on PPE including head and shoe covers B) Make sure medical equipment is not shared between patient rooms C) Put patients with infection in private negative pressure rooms D) Wash hands thoroughly and consistently during your shift - Correct answer D- hand washing is the single most important act to prevent transmission of infection on a burn unit The nurse provides care for a 16-year old patient who is diagnosed with meningitis. The provider ordered intravenous and oral hydration. The nurse closely monitors the patient's fluid intake. Which serious complication does the nurse monitor for this patient? A) Heart failure B) Hypovolemic shock C) Cerebral edema D) Pulmonary edema - Correct answer C- because of the inflammation of the meninges, the patient is vulnerable to developing cerebral edema and increased intracranial pressure. Patient had a car accident, she is oriented to self but not to time and place. The patient complains of a severe headache and is restless. Which action does the nurse take first? A) Help the patient remember the current location and time of the day B) Put the patient in a vest restraint C) Neurological assessment every 15 minutes D) Give the patient PRN morphine and lorazepam - Correct answer C- Remember ADPIE, increased ICP is suspected. Confusion, restlessness, pupillary changes, and altered level of consciousness are the earliest signs
A patient experiences a fever, headache, photophobia, and neck stiffness. Which transmission-based precaution will the nurse implement for this patient? A) Contact B) Airborne C) Droplet D) Standard - Correct answer C- the patient's symptoms are consistent with N. meningitis and droplet precautions should be used A patient had a car accident, is unconscious from a severe head injury and a back fracture. The patient has no ID on him, but needs emergency surgery. Which action is best for the nurse to take when obtaining informed consent for the surgery? A) Ask the ED provider to sign the informed consent B) Get an urgent court order for the surgery C) Transport the patient to the OR for surgery D) Request the police to locate the family and identify the patient - Correct answer C- Informed consent of an adult is not needed when in emergency situation, and delaying treatment could cause death of patient The nurse assess distended neck veins in a patient reporting shortness of breath and chest pain. Which problem is causing the Jugular Vein Distention? A) Dehydration B) Brain mass C) Fluid overload D) Electrolyte imbalance - Correct answer C- fluid overload causes increase of blood volume. This increase causes the veins to distend, most obviously in the neck veins. The RN is reviewing how to prevent medication error with a nursing student. Which response by the nursing student indicates that additional teaching is required? (Select all that apply) A) Preparing medications for patients independently B) Checking the MAR against the drug level at least two times prior to administering the medication
spread of organisms that are acquired from direct or indirect contact, especially multidrug-resistant organisms such as MRSA A new NAP is on the unit, the nurse delegates finger-stick glucose check and then discovers that the NAP has never done this task before, and changes the assignment. Why did the nurse change the assignment? A) It is not the right supervision B) It's not the right person C) It's not the right circumstance D) It's not the right direction - Correct answer B- it is not the right person. Choosing the correct personnel to complete the task {nerve done it before}; Supervision {appropriate monitoring, intervention and follow up}, circumstance{using appropriate pt & setting to determine if it is right}, direction{giving the right direction for a task} The nurse delegates ambulating a patient 4 days after surgery to a nursing assistive personnel (NAP). Which type of delegation is the nurse following? A) Supervision B) Circumstance C) Person D) Communication - Correct answer B - the person is stable 4 days post op The nurse delegates tasks to a nursing assistive personnel for the first time. Which actions are appropriate for the nurse to implement? (Select all that apply) A) Explain to the NAP which tasks will be delegated B) Explain to the NAP how to report task completion C) Permit the NAP to decide which patient changes to report D) Allow the NAP to decide when tasks will be completed E) Explain to the NAP the expected task outcomes - Correct answer A,B,E The nurse reviews care needed for a patient 2 days post-operation.Which would the nurse delegate to nursing assistive personnel (NAP)?(Select all that apply) A) Apply T.E.D. stockings
B) Measure height and weight and document it C) Educate on performing breathing exercise D) Check for urinary retention using a bladder ultrasound E) Assist in wearing a leg prosthesis - Correct answer A,B,E Which tasks can be delegated to a UAP? A) Inserting a foley catheter B) Measuring and recording the patient's output through a Foley catheter C) Teaching a patient how to care for a catheter after discharge D) Assessing for symptoms of a urinary tract infection? - Correct answer B- falls w/i the implementation phase of the nursing process and does not require nursing judgement. Evaluation of the intake & output must be done by the nurse The nurse is getting a 22 year old patient ready before surgery. What would the nurse delegate to the nursing assistive personnel? (SATA) A) Getting a clean catch urinalysis B) Taking vital signs C) Assess lung sounds D) Put on T.E.D. stockings E) Educate patient on correct technique to use incentive spirometer - Correct answer A,B,D The nurse provides care for multiple patients. Which tasks does the nurse delegate to the nursing assistive personnel?(SATA) A) Assess patient's pain level B) Teach patient how to perform crutches use C) Hand meal trays D) Give bath to a patient with a surgical site E) Get standard vital signs - Correct answer C,D,E The nurse is looking to prevent venous thromboembolism. Which action does the nurse delegate to the NAP? (SATA) a) Change the patient's position every 2 hours B) Help the patient ambulate as needed C) Give the patient education materials on venous thromboembolism
B) 50-60 years C) > 60 years - Correct answer C A patient, who takes medication for hypertension, complaints of a dry cough. Which medication will the nurse suspect is causing the cough? A) Amlodipine B) Lisinopril C) Verapamil D) Propranolol - Correct answer B - ACE inhibitors most common side effect is a non-productive cough During a patient education seminar about colorectal cancer. Which patient does the nurse identify as being at higher risk for colorectal cancer? A) A 20 year old patient who exercises regularly B) A 56 year old patient who follows a high fat diet C) A 32 year- old adult who has an uncle with colon cancer D) A 45 year old female who had hysterectomy 2 years ago - Correct answer B - the patient has a couple of risk factors, age >50 years old, and following a high fat diet; familial history of 1st degree relatives {parents, siblings} is a risk factor not an uncle. The nurse assesses a patient diagnosed with colorectal cancer. What symptoms does the nurse ask the patient during admission assessment? (SATA) A) Instant abdominal bloating B) Severe spasmodic abdominal pain C) Ribbonlike stools D) Rectal bleeding E) Diarrhea and/or constipation - Correct answer C,D,E - these are symptoms of colorectal cancer. Patients with colon cancer, especially those with cancer on right colon may experience colics, cramping and pain, left of colon {colorectal cancer}will not; Instant abdominal bloating is a sign for obstruction A patient with B-cell leukemia is getting high dose methotrexate. Which statement by the patient shows understanding of appropriate precautions? (SATA)
A) Brushing and flossing my teeth twice a day is very important B) Visitors to my room should not bring flowers C) I will bring my own pillow and blanket from home because I can't sleep without them D) I will only shave with my personal electric razor E) I will only allow visitors who have a cold into my room if they wear a mask - Correct answer B,D- Methotrexate is a chemotherapy drug. Patients receiving chemo are recommended to use soft toothbrushes or sponges, never floss {high tendencies to bleeding}; flowers are a high medium for bacterial growth, pt are at high risk of infection The nurse provides care for the patient diagnosed with esophageal cancer. Which goal does the nurse establish in the plan of care? (SATA) A) Patient will be in complete remission of his cancer B) Patient will be able to eat without aspirating C) Patient's pain will be controlled D) Patient will maintain his baseline weight E) patient will consider hospice care - Correct answer B,C,D - these are appropriate goals for the nursing plan of care While administering blood for a patient, which action will the nurse take to maintain safety? (SATA) A) Verify patient's identification with at least two identifiers B) Give the blood unit as soon as it arrives on the unit C) Administer the blood unit within 2 hours for increased benefit D) During the first 15 minutes, stay with the patient E ) Get a PRN order for 1-2 liters of oxygen during the transfusion time - Correct answer A,B,D - verify identification with at least 2 identifiers, The RN should check vital signs every 5 minutes for the first 15 minutes, Blood should be administered within the first 30 minutes of the blood leaving the blood bank; blood should be given over 2-4 hours to reduce the risk of fluid overload, o2 is not routinely administered during blood transfusion The nurse provides care for a patient diagnosed with neonatal abstinence syndrome. A newborn is having drug withdrawal symptoms. What nursing interventions would the nurse include in the plan of care? (SATA)
A) Wear a protective gown when entering the patient's room B) Wear a surgical respirator mask while administering medications C) Wear gloves when handling the food tray D) Patients visitors should wear a mask while in the patient's room E) Don surgical gloves with removing surgical dressing - Correct answer A,B - C. Diff is contact precautions, gown & gloves; respirator is for airborne, a mask is not necessary, to remove a surgical dressing wear disposable gloves and then put on surgical gloves to clean dressing The nurse assesses the new admission. What indicates that the patient is at risk for having a latex allergy? (SATA) A) Patient has a current avocado allergy B) Patient received packed red blood cells C) The patient has a history of arthritis D) Patient has a history of multiple surgical procedures E) Patient is a health care worker - Correct answer A,D,E - avocados and banana allergies are linked to latex allergy, if a pt has multiple surgical procedures they are exposed to latex a good bit this increases their risk for allergy, a health care worker wears latex gloves constantly, this can increase the risk. A healthy patient is being treated for localized herpes zoster (shingles). What observations indicate to the nurse that care is appropriate? (SATA) A) Applied airborne precautions B) Prescribed oral acyclovir C) Keep patient's room closed at all times D) Nurse assigned to care for patient has history of chickenpox E) Perform pursed lip breathing exercises - Correct answer B,D,E - Herpes zoster (shingles) is contact precautions, Acyclovir should be prescribed, nurse w a hx of chickenpox is immune to virus, pursed lip breathing can help the pt cope with the discomfort of shingles {does not affect oxygenation or respiratory system} The nurse instructs parents on the sudden infant death syndrome (SIDS). Which statements require the nurse to act? (SATA) A) My baby sleeps in a supine position B) My baby sleeps in his car seat on my way to child care
C) I always cover my baby from chest to toe during sleep D) I like to put a small pillow under my baby's head when he sleeps E) I let my baby nap on my waterbed - Correct answer B,C,D,E - An infant has no control over their neck muscles, if they fall asleep in the car seat with their head leading forward it could obstruct or close their airway, A blanket and pillow could cover their face and cause suffocation, an infant should sleep on a firm surface, soft surfaces could cause neck flexion or suffocation ;Supine is an appropriate position to sleep in Disseminated Herpes zoster is airborne precaution. A) True B) False - Correct answer True A patient is diagnosed with CHF. Which information about self- management at home will the nurse include in the teaching? (SATA) A) Set a regular time for your medication B) Drop down the sodium intake to 4 grams a day. C) Avoid taking ibuprofen for headaches D) Inform symptoms of shortness of breath to your physician E) Report weight gain of more than 3 pounds per week to your physician - Correct answer A,C,D,E - Adhere to medication regime, avoid NSAIDS {retain salt & fluids}, weight gain and SOB are both exacerbations of CHF ;Pts w CHF need to drop their sodium intake to less than 2 grams per day Which statement by a patient diagnosed with CHF raises concerns for the nurse? A) When I wake up my ankles are normal, but are swollen at night B) I have hard time catching my breath after I make my bed in the morning C)I feel bloated most of the time D) Every time I cough, I experience chest pain - Correct answer B- Pulmonary edema is more concerning fluid passes from the pulmonary capillaries to the alveoli causing SOB, and respiratory depression, dyspnea can become worse with physical exertion; Chest pain caused by coughing is a sign of pericarditis and can be treated with antibiotics, Swollen ankles and the feeling of bloatedness are expected signs for right sided HF
A patient diagnosed with asthma is prescribed long-term corticosteroids medication therapy. When the nurse assesses the patient, which manifestations of Cushing syndrome are noticed? (SATA) A) Na++ - 152 mEq/L B) Blood pressure 84/42 mmHg C) High blood sugar D) K+ = 3 mmol/L E) Metabolic alkalosis - Correct answer A,C,D,E - Cushing syndrome is caused by high concentration of cortisol. Hypokalemia and hypernatremia are common, metabolic alkalosis is also caused by ectopic ACTH production. Hyperglycemia can be caused by long-term corticosteroid use. The nurse is giving dietary education to a patient diagnosed with Cushing syndrome. Which statements by the patient cause the nurse to take action? (SATA) A) I should follow a low protein diet B) I will double my carbohydrate intake C) I will include bananas and broccoli with every meal D) I should use a salt substitute with my meals E) I should increase my total daily calories - Correct answer A,B,E Before a site survey, the nurse manager tells the charge nurse to deny any knowledge of any sentinel events {an unexpected death} if asked by the surveyor. What decision will the charge nurse make? A) Inform the supervisor B) Inform the chief medical director C) Confront the nurse manager and tell her, I'm uncomfortable lying to the surveyor D) Inform the surveyor, the charge nurse was given instructions to not speak to them. - Correct answer A - always follow the direct chain of command. Nurses have a legal, professional and ethical obligation to tell the truth under any circumstances.; the chief medical director is over the entire facility, start w chain of command; in this situation, confronting the nurse manager will just cause more issues Patient on perindopril. The nurse determines that further teaching is needed when the patient makes which statements? (SATA)
A) I will include more of broccoli and bananas in my diet B) I will be monitoring my blood pressure at least once a week C) I will take my medication every day in morning D) I will use salt substitute with my meals E) I will move slowly from a sitting position to a standing position - Correct answer A,D - ACE inhibitors can cause potassium retention so a diet that stays away from high potassium is encouraged, salt substitute causes potassium retention The patient is scheduled for surgery the next morning. The order states NPO without mentioning medication. Which medication causes the nurse to question its administration prior to surgery? (SATA) A) Atenolol 25 mg for hypertension B) Midazolam 5 mg to prevent seizures C) Aldosterone 25 mg for hypertension D) Dexamethasone 4 mg for COPD E) Clopidogrel 75 mg given daily for a-fib F) Alprazolam 2.5 mg given at bedtime for insomnia - Correct answer C, E
- You don't hold antihypertensives before surgery unless it is a diuretic (aldosterone), give midazolam so that the levels are not messed up and cause seizures, clopidogrel is a blood thinner Roles and responsibilities of the nurse manager position include: (SATA) A) Monitoring the professional practice model on the unit B) Coordinating the patient discharge care C) Empower the nursing staff at the administration's meetings D) Following up on patient's and family complaints E) Following up on the root cause analysis of incident reports - Correct answer A,C,D A patient is being transfused 1 unit of packed RBCs. The patient complains of burning at the IV site. The nurse assesses the site and edema is present. Which action does the nurse take first? A) Stop the transfusion B) Flush the IV cannula with pre-filled normal saline C) Remove the IV cannula and apply pressure to the site
