Ca Ii.docx

DIRECTIONS: Choose the best answer. CLIENT WITH HEAD INJURY (INCREASED INTRACRANIAL PRESSURE) 1. A two y/old child who experienced a head trauma and receiving mechanical ventilation suddenly develops increase intracranial pressure. Which of the following actions would a nurse take first? a. Suction the endotracheal tube b. Position the child in Trendelenburg c. Increase the oxygen concentration d. Hyperventilate the child 2. Which of the following statement a nurse include discharge instructions of the patient of an eight y/old boy has been diagnosed with concussion? a. “Call your healthcare provider if your child has repeated episodes of vomiting” b. "Don't give your child any nonprescription analgesics for 48 hours” c. “Limit your child diet to clear liquids for 24 hours" d. “Keep your child in a quiet and darkened room while he is recovering” 3. A patient who has returned to the neurosurgery unit following a frontal craniotomy has all the following order in the chart. Which orders should a nurse question? a. Provide oxygen at two liters per minute b. Administered Dexamethasone (DECADRON) 4 mg every 6 hours c. Infuse IVF at 50 - 60 ml per hour d. Elevate head of the bed 30 degrees 4. Which of the patient outcomes should indicate to a nurse that treatment with mannitol (Osmitrol) has been effective for a patient who has increased ICP? a. Decrease level of consciousness b. Increased urinary output c. Elevate body temperature d. Slowed papillary response 5. Following an automobile accident, a young woman is admitted to the hospital with head injuries. To determine if her condition is deteriorating, the nurse should assess her to the: a. Escalation of her discomfort

b. Quality of her respiration c. Narrowing of her pulse pressure d. Rapidly of her heart rate 6. An elderly client who lives alone is admitted to hospital after a syncopal event. Serum level of albumin are found to be 2.0 g/dl. Which of the following is a nursing priority for this patient? a. Potential alteration in comfort b. Potential alteration in elimination c. Potential alteration in skin integrity d. Potential alteration in mobility 7. A patient is suspected of having a subarachnoid hemorrhage. A nurse should prepare that patient for which of the following diagnostic tests: a. Cerebral arteriogram b. Intravenous pyelogram c. Gallium scan d. Carotid Doppler study 8. Which of the following actions would a nurse take when caring for a patient who is brought to the emergency department with a potential spinal cord injury? a. Taping the patient's eyelids closed b. Elevating the head of the patient's bed c. Placing the patient in a side-lying position d. Maintaining the patient's neck in extension 9. When planning care for a patient who has a diagnosis of increase ICP, a nurse should give priority to which of the following measures? a. Limiting environmental stimuli b. Increasing fluid intake c. suctioning nasotracheally every hour d. keeping the patient in a recumbent position 10. The nurse caring for a patient who has had a subarachnoid hemorrhage should be aware that Increasing pressure is manifestation by: a. widening pulse pressure b. an increased heart rate c. decreased blood pressure d. decreased body temperature

11. Which of the following measures would a nurse include in the care plan of the patient who has a cerebellar tumor? a. Keep the room darkened b. Speak slowly and clearly c. Provide memory aid d. Ambulate with assistance 12. A nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client ask for a snack and something to drink. The nurse determines that the most appropriate choice for this client to meet the nutritional needs is: a. A. Hot herbal tea with graham crackers b. Iced coffee with peanut butter and crackers c. Vanilla wafers and milk d. Cocoa with honey and toast 13. A nurse is assessing the corneal reflex on an unconscious client. The nurse would use which of the following as the safest stimulus to touch the client's cornea? a. Wisp of cotton b. Sterile drop of saline solution c. Sterile glove d. Tip of a 1ml syringe with the needle removed 14. A nurse is caring for a client who had a craniotomy. When assessing the client for major postoperative complications, the nurse monitors for: a. Restlessness b. Bleeding c. Hypotension d. Bradycardia 15. A nursing instructor has thought a student about increased intracranial pressure (ICP). The student ask about the three types of noncompressive cranial contents. The student responds correctly by stating this that includes the: a. Ventricles blood volume and the subarachnoid space b. Cerebrospinal fluid, brain, and the foramen ovale c. Semisolid brain, cerebrospinal fluid, and the intravascular blood d. Gray matter, white matter, and the extrapyramidal tract

16. An adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. A nurse assess for which of the following values that should be negative if the CSF is normal? a. Protein b. Glucose c. White blood cells d. Red blood cells 17. A nurse is caring for a client with left sided Bell's Palsy. Which statement requires further exploration by the nurse? a. "My left eye is tearing a lot." b. "I have trouble closing my left eyelid" c. "I can't taste anything on the left side" d. “I don't know how I'll live with the effects of this stroke for the rest of my life" 18. A nurse is monitoring the intracranial pressure (ICP) of a client with a head injury. The cerebrospinal fluid pressure (CSF) Is averaging 25mmHG. The nurse analyzes the result as: a. Normal b. Compensation, indicating adequate brain adaptation c. Borderline in elevation, indicating the initial stage of compensation d. Increased, indicating a serious compromise in cerebral perfusion 19. Which of the following actions should the nurse include in the plan of care who has bacterial meningitis? a. Restraining the client in bed b. Increasing the client's fluid intake c. Keeping the client in supine position d. Reducing the client's environmental stimuli 20. Presbycusis is hearing loss primarily caused by - which of the following etiologies? a. Trauma b. Congenital c. Conductive d. Sensorineural

Situation: After an abdominal surgery, the circulating and scrub nurse have critical responsibility about sponge and instrument count. 21. Counting is performed thrice: During the preincision phase, the operative phase, and closing phase. Who counts the sponge and instrument count. a. The scrub nurse only b. The circulating nurse only c. The surgeon and the assistant surgeon d. The scrub nurse and the circulating nurse 22. The layer of the abdomen is divided into 5, arrange the following from the first layer going to the deepest layer: 1. Fascia 2. Muscle 3. Peritoneum 4. Subcutaneous/Fat 5. Skin a. 5,4,3,2,1 b. 5,4,2, 1,3 c. 5.4,1,3,2 d. 5.4,1,2,3 23. When the first sponge instrument count reported? a. Before closing the subcutaneous layer b. Before peritoneum is closed c. Before closing the skin d. Before the fascia is sutured 24. Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any discrepancy of the counts so that immediate and appropriate action is instituted? a.

Anesthesiologists

b. Surgeon c. OR nurse supervisor d. Circulating nurse 25. Which of the following are the 2 interventions of the surgical team when an instrument was confirmed missing a. MRI and Incidence report b. CT Scan, MRI, Incidence report c. X-RAY and Incidence report d. CT Scan and Incidence report Heart Failure

26. The nurse is assessing a 59 y.o. male patient with CHF who was just admitted on the Medical-Surgical Unit. Which of the following is not a manifestation of LVF: a. Difficulty breathing b. Sharp pain on the Upper Abdomen c. Patient experiences sensation of suffocation d. Patient assumes tripod position 27. A 35 y.o. patient with RVF was assigned to the nurse, which would be the priority assessment of the nurse? a. Abdominal pain b. Anorexia c. Weight gain d. Fatigue 28. The nurse is caring for a 75 y.o. client with LVF. The nurse should be alerted when the patient experiences: a. crackles b. confusion c. pallor d. tachycardia 29. The patient is receiving Digoxin to treat CHF. The nurse should monitor for the ff. laboratories. Which is a priority? a. BUN levels b. Magnesium levels c. Creatinine levels d. Potassium levels 30. The nurse monitors the patient closely to prevent Digoxin toxicity. Which of the ff. patients is at high risk of developing toxicity? a. a patient with serum K=3.3 mEq/L and Digoxin level=1.8 nglml b. a patient with serum K=3.8 mEq/L and D1goxin level= 1.9 nglml c. a patient with serum K=3 5 mEq/L and Digoxin level=1.9 ng/ml d. a patient with serum K=3.4 mEq/L and Digoxin level=2.0 nglml ENDO ADDISON'S I CORTICOSTEROID THERAPY 31. A 69 y.o. patient with Addison's was placed under the care of the nurse. The patient asked what could have caused the development of this disease. In response to this, the nurse will tell the patient that the most common cause is:

a. Idiopathic b. Sudden cessation of Steroids use c. Autoimmune d. Chronic Steroids use 32. The nurse reviews the laboratories of the patient with Addison's. Which of the following findings is the priority of the nurse? a. Glucose 90 mg/dl b. K 5.6 mEq/L c. Sodium 148 mEq/L d. Calcium 9 mg/dl 33. The nurse reviews the chart of the patient with Addison's admitted for 4 days. Which of the following assessment would the nurse expect to find? a. Hypocalcemia b. Hypophosphatemia c. Hyperkalemia d. Hypertension 34. Which among the statements made by the patient indicates the need for further teaching regarding corticosteroid therapy? a. “I will eat foods high in calcium & vitamin D” b. "I will need to avoid crossing-legs” c. "I need to take low calories, low protein, low sodium foods” d. “I need to have regular eye-check ups” 35. A nurse was given order to administer Solu-Cortef to a patient with Addison's disease. The nurse knows that the best time to give the medicine is when? a. Early morning, at about 7:00 a.m. b. After dinner, at 7:00 p.m. c. Before going to bed at 10:00 p.m. d. After lunch, 12:30 p.m. Situation : P. Cruz, 65 years old, was admitted in the Telemetry because of signs and symptoms of acute myocardial infarction. You are expected to recognize electrocardiographic readings on the cardiac monitor. 36. Which of the following appear abnormal on an EKG when ischemia and injury occur in the myocardium? a. QRS interval

b. ST segment and T wave c. QRS complex d. PR interval 37. From and ECG reading, a QRS complex represents: a.

Ventricular depolarization

b. Ventricular repolarization c. End of ventricular depolarization d. Atrial depolarization 38. Which of the following represents ventricular repolarization? a. T wave b. ST segment c. QRS complex d. PR interval 39. It is important that the nurse measures intervals of ORS complex. Which of the following represent the normal interval of the QRS complex? a. Greater than 20 seconds b. 20 seconds c. 10 seconds d. 12 seconds to 20 seconds 40. Later in the acute phase of myocardial infarction, which of the following typically appears as the first sign of the death? a. ST segment suppression b. Short T wave c. Prolonged PR interval d. Pathologic Q wave 41. During an eight-hour shift a client drink two 6- ounce cups of tea and vomits 125 ml of fluid. Intravenous fluids absorbed equaled the urinary output. During this eight-hour period the client's fluid has lost is: a. 235 ml b. 250 ml c. 255 ml d. 360 ml

42. A patient who has had a total gastrectomy is given instructions on measure to prevent the developing of dumping syndrome. Which of the following statements, if made by the patient, would indicate a correct understanding of the instructions? a. “I will have a bedtime snack” b. "I will rest one hour before each meal" c.

"I will avoid concentrated sugar"

d. "I will include high-fiber foods in my diet” 43. Which of the following findings, if identified in a patient in the immediate postoperative period following coronary artery bypass grafting (CABG), would indicate the need for immediate follow-up by the nurse? a. Chest tube drainage of 75 ml/hr b. Urinary output of 100 ml/hr c. Blood pressure of 124/60 mmHg d. Oxygen saturation of 92% 44. Which of the following nursing interventions is most appropriate in the care of a patient who has peripheral venous insufficiency? a. Elevating the legs b. Increasing the fluid intake c. Limiting the activity level d. Massaging the extremities 45. Which of the following conditions if reported in a patient's history, should a nurse recognize as a contributing factors to the development of metabolic alkalosis? a. Chronic obstructive pulmonary disease (COPD) b. Type I Diabetes Mellitus c. Cushing’s syndrome d. Reynaud's syndrome 46. Which of the following conditions would a nurse recognize as contributing to the development of respiratory alkalosis? a. Chronic obstructive pulmonary disease (COPD) b. Episodes hyperventilation c. Frequent loose stools d. Hiatal Hernia 47. Which of the following symptoms would a nurse expect to identify when assessing a patient who has chronic obstructive pulmonary disease (COPD)?

a. Increase anterior-posterior chest diameter b. Decreases residual lung volume c. Bronchovesicular breath sounds d. Kussmauls respirations 48. Which of the following comments, if made by a Mrs. Hanes who is administered phenazophyridine hydrochloride (Pyridium), would indicate to a nurse that the medication is effective? a. "There is no swelling in my ankles" b. "It does not hurt me to urinate” c. “I do not have diarrhea" d. "My head is not spinning" 49. When instructing a patient who needs to restrict potassium intake, which of the following foods would the nurse identify as being the lowest in potassium? a. Raisins b. Grapes c. Spinach d. Potato 50. A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. A nurse immediately assesses the client for other signs and symptoms of: a. Myocardial Infarction b. Pneumonia c. Pulmonary embolism d. Pulmonary edema 51. The physician inserts a central venous catheter the nurse should assist Mr. Jeff to assume which of the following positions? a.

Supine

b. Trendelenburg's c. Reverse Trendelenburg's d. High-Fowlers 52. Mr. Ferdie asks the nurse what may have contributed to the development of his detached retina. The nurse explains that the client at greatest risk for development of a retinal tear usually has: a.

Hypertension

b. Near-sightedness c. Cranial tumors d. Sinusitis 53. A nurse is caring for a client with suspected carbon monoxide poisoning. Of the following interventions that the nurse assists in implementing, which is the highest priority? a. Requesting a building inspection at the site of the incident from the local health department b. Drawing blood for carboxyhemoglobin levels c. Frequently observing the client d. Administering 100% oxygen 54. A client with late stage of emphysema complains of an occipital headache, drowsiness and difficulty concentrating. The nurse interprets that these symptoms are indicative of which complication of emphysema? a. Encephalopathy b. Carbon dioxide narcosis c. Carbon monoxide poisoning d. Cerebral embolism 55. The client has been admitted with relapsing-remitting multiple sclerosis (MS). Which of the following should be the focus of the nursing assessment and history? a. rate of ascending paralysis b. level of consciousness c. bladder function d. evoked potentials of the optic pathways 56. In peritoneal Dialysis the inflow time to allow dialysate to flow into the peritoneal cavity is: a. 5-10mins b. 10-20mins c. 10-30 mins d. 1 hour 57. The client complains of experiencing midcalf pain when walking a block or more. The patient states that the discomfort is relieved with rest. The nurse suspects that this client may be experiencing intermittent claudication. Intermittent claudication occurs when arterial occlusion, reaches which of the following percentages?

a. 20% b. 40% c. 50% d. 100% 58. In a client with acute appendicitis, the nurse should anticipate which of the following treatments? a. Administration of enemas to clean bowel b. Insertion of nasogastric tube c. Placement of client on NPO status d. Administration of heat to the abdomen 59. A client who has Meiniere's disease is experiencing an acute attack of vertigo. Which of the following interventions should the nurse include in the care plan? a. Darken the client’s room and provide a quiet environment. b. Provide a low-sodium bland diet. c. Administer a narcotic to relieve headache. d. Encourage fluid intake to prevent dehydration. 60. Clients who are newly diagnosed with cancer have many fears and concerns. Which of the following issues is of primary concern? a. Ability to perform in usual roles b. Cost of treatments c. Prognosis d. Pain CLIENT WITH MYASTHENIA GRAVIS 61. To which of the following nursing diagnosis would a nurse give a priority in caring for a patient who has a myasthenia gravis? a.

Ineffective individual coping

b. Situational low self-esteem c. Ineffective thermoregulation d. Risk for aspiration 62. Which of the following pieces of equipment would nurse order when planning the home care needs of a patient who has myasthenia gravis? a. Suction apparatus b. Oxygen Cylinder c. Sequential compression device

d. Alternating pressure mattress 63. Which of the following findings would a nurse expect to observe when assessing a patient who has myasthenia gravis? a. tongue deviation b. intention tremors c. plantar flexion d. drooping eyelids 64. A patient who is receiving pyridostigmine bromine (Mestinon) makes all of the following statements. Which one should indicate to a nurse that the Mestinon is having a therapeutic affect? a. “My urine has no odor” b. “My headaches are gone" c. "My vision is less blurry” d. “My chewing is stronger" 65. Which of the following statements, if made by a patient who has myasthenia gravis, would indicate correct understanding of necessary adaptations to the disease? a.

"My activity tolerance will increase during the day''

b. “My diet should include high protein foods” c. “I will avoid people who have colds” d. “I can perform AOL comfortably” SITUATIONAL: PATIENTS WITH CHEST TUBES CAN BE VERY CHALLENGING TO NEW NURSES. 66. The chest tube drainage of Tirso has continuous bubbling in the water seal drainage. After an hour how you noticed that the bubbling stops. Which of the following condition is the possible cause of the malfunctioning sealed drainage? a. suction being too high b. An air leak c. A tube being too small d. A tension pneumothorax 67. While you were making your endorsements, you found out the chest tube of a client was disconnected. What would be your appropriate action? a. Assist the client back to his bed and place him on the affected side b. Cover the end of the chest tube with sterile gauze

c. Reconnect the tube to the chest tube system d. Put the end of the chest tube into a cup of sterile normal saline 68. Dr. Reyes asked you to assist him with the removal of Tirso's chest tube. You will instruct the client to: a. Continuously breath normally during the normal of the chest tube b. Take a deep breath, exhale, and bear down c. Exhale upon actual removal of the tube d. Hold breath unit the chest tube is removed 69. Chest tube diameter is measured or expressed in: a. French b. Gauge c. Millimeters d. Inches 70. When transporting clients with chest tube, the system should be: a. Disconnected b. Closed c. Placed lower than patient's chest d. Placed between the legs of the client CLIENT WITH POLYCYTHEMIA VERA SITUATION: A nursing student was assigned to take care of a client who was diagnosed of Polycythemia Vera 71. You planned the nursing care of the client together with the nursing student you asked the nursing student to enumerate the clinical manifestation of a client with polycythemia vera. You expected the nursing student to enumerate the following manifestation EXCEPT, a. Generalized pruritus b. ruddy complexion c. splenomegaly d. hepatomegaly 72. The nursing student reviews the laboratory findings and finds which blood results are elevated; a. BP WBC Hematocrit b. Bilirubin RBC platelet c. RBC WBC platelet count

d. WBC platelet and cholesterol 73. Phlebotomy was ordered as part of the therapy you instructed client and emphasized that the procedure can be repeated. The client inquired what is the primary arm of the procedure? Your APPROPRIATE response is: a. Remove excess blood and donate to patient of the same blood type b. Prevent headache dizziness c. Keep the BP reading within normal range d. Keep the hematocrit within the normal range 74. The companion ask why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be: a. Actually the patient does not need these supplement b. It is best that the client get these supplements from natural resources c. These supplements enhance the production of RBC d. The vitamins and iron can suppress bone marrow function 75. The client generalized pruritus. The following are APPROPRIATE nursing intervention EXCEPT; a. Administer routine antihistamine round the clock b. Wearing light material loose fitting camisa c. Regulate room temperature to 25 degrees or lower d. Bathe in tepid and cool water follow by cocoa based lotion application CLIENT WITH ACUTE EPISODES OF CHOLECYSTITIS SITUATION: NURSE FELY with ACUTE EPISODIC OF CHOLECYSTITIS 76. Nurse Fely did her admission assessment. She understand that the pain is characterized as: a. tenderness that is generalized in the upper epigastric area b. pain in the upper quadrant radiating to the left shoulder c. tenderness and rigidity at the left epigastric area - radiating to the back d. tenderness and rigidity of the upper right abdomen radiating to the midsternal area 77. To confirm the diagnosis of cholecystitis the attending physician ordered the procedure that can detect gallstone as small as 1 to 2 cm and inflammation Nurse fely would prepare the client for which specific procedure? a. gall bladder series b. oral cholecystogram

c. cholangiography d. ultrasonography 78. The diagnosis was confirmed as cholecystitis with gallstone. The doctor prepare client for removal of his gallbladder. The client ask the nurse how will affect my digestion? The nurse's MOST correct response would be: a. The removal of the gallbladder usually interferes with digestion but can be dietary modification b. The removal of the gallbladder does not usually interfere with digestion c. Your body system will adjust in due time d. The removal of the gallbladder would significally interfere only with digestion food 79. Reviewing the laboratory finding of the client the nurse found which finding are elevated? 1. WBC count 4. RBC count 2. Total serum bilirubin 5. Cholesterol 3. Alkaline phosphate 6. Serum amylase a. 2, 3,4 b. 1,2,3 c. 3,5,6 d. 1, 2, 6 80. At T-tube was inserted and the doctor ordered to monitor amount color consistency and odor drainage which of the following procedure can be the nurse perform without the doctors order? a. Clamping b. Aspirating c. Irrigating d. Emptying the drainage CLIENT WITH DIABETES MELLITITUS SITUATION: MARINA a newly hired staff nurse in the medical surgical unit was assigned who work with senior nurse. A female client was admitted with a diagnosis of diabetic foot gangrene left toe type 2 diabetes. Marina dssisted the senior nurse during admission of the client. 81. From the nursing history obtained from the - client which information is MOST likely related to the development of gangrene on the clients left toe? a. accidental cut on big toe while cutting toenails

b. type 2 diabetic diagnosed 15 years ago c. Father had type 2 diabetic post above knee amputation right leg d. Preferred open sandals to close leather shoes 82. The physician ordered bilateral lower extremities Doppler UTZ. Which of the following is the physician interested to find out through this diagnostic test? a. Occlusion of large vessel and arterioles b. Distal paresthesias c. Oygenation of tissues in the lower extremities d. Isolated peripheral neuropathies 83. The senior nurse asked Manna to list nursing interventions for the nursing diagnosis Ineffective tissue perfusion peripheral. From the following list prepared by Marina, which intervention will the senior nurse consider to be CONTRAIDICATED? a. Maintain both extremities in independent position b. Encourage frequent change position c. Regular passive and active exercise of all extremities d. Keep extremities war using a foot cradle 84. When Marina checked the capillary blood glucose at the client at 6pm before meats as instructed by the senior nurse the result showed 65mg/dl. Which of the following Manna do FIRST? a.

Look for the senior nurse and report

b. Check the physician order in case CBG Is below 70 mg/dl c. Give juice as prescribed in the insulin scale pre-meals d. Re-check CBG 85. The senior nurse observes that Marina occasionally does not follow agreed upon interventions. The senior nurse report that Marina should improve in which of the following? a. Compliance to standards b. Attitude towards criticism c. Demonstration of proper decorum d. Identifying own learning needs CLIENT WITH ASTHMA 86. A client with acute asthma is prescribed short-term corticosteroids therapy. What is the rationale for the use of steroids in clients with asthma?

a. Corticosteroids promote bronchodilators b. Corticosteroids act as an expectorant c. Corticosteroids have an anti-inflammatory effect d. Corticosteroids prevent development of respiratory infections 87. The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly. Except, a.

The inhaler Is held upright

b. Head is tilted down while inhaling the medicine c. Client waits 5 minutes between puffs d. Mouth Is rinsed with water following administration 88. A client is prescribed metaproterenol (Alupent) via a meter-dose inhaler (MDI), two puffs every 4 hrs. The nurse instructs the client to report side effects. Which of the following are potential side effects of metaproterenol? a. Irregular heartbeat b. Constipation c. Pedal edema d. Decreased pulse rate 89. The client with asthma should be taught that which of the following is one of the most common precipitating factors of an acute asthma attack? a. Occupational exposure to toxins b. Viral respiratory infections c. Exposure to cigarette smoke d. Exercising in cold temperatures 90. Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma? a. Cough productive of yellow sputum b. Bilateral expiratory wheezing c. Chest tightness d. Respiratory rate of 30 breaths/minute CLIENT IN VARIOUS CLINICAL SETTINGS: 91. Jake is in the Post Anesthesia Care Unit following a colorectal reaction. He has an IV of Dextrose 5% Lactated Ringers Solution. Upon assessment you observe that

he is exhibiting sudden onset of crackles in the lungs, moist, respiration and tachypnea. Which of the following will you do FIRST? a. Notify anesthesiologist b. Increase O2 flow rate c. Place on fowler’s position d. Reduce IV rate 92. Four clients injured in an automobile accident, enter the emergency department (ED) at the same time and are immediately seen by a triage nurse. As the triage nurse, you would assign the HIGHEST priority to the client with the: a. Severe head injury and no blood pressure b. Maxillofacial injury and gurgling respirations c. Second trimester pregnancy with premature labor d. Lumbar spinal cord injury and lower extremity paralysis 93. Daniel with myeloma complains of deep bone pain. As his nurse which of the following will you do FIRST? a. Assess bone pain b. Administer prescribed analgesic c. Teach pain relief strategies d. Support position with pillow 94. You are reviewing the laboratory results of Clare who has rheumatoid arthritis. Which laboratory result should you expect to find? a. Increased platelet count b. Altered blood urea nitrogen (BUN) and creatinine levels c. Electrolyte imbalance d. Elevated erythrocyte sedimentation rate (EESR) 95. Mr. Paras is receiving total parental nutrition (TPN). If you will evaluate her nutritional status, which of the following indicators will tell you that TPN was effective? a. Laboratory work up b. Adequate hydration c. Weight gain d. Diminish episode of nausea and vomiting 96. While Jayvee, a burn patient is being transferred from the burn unit to the operating room, the IV bottle fell on Jayvee's head. He sustained laceration on his

forehead. The nurse was proven guilty of negligence. Which of the following did the nurse fail to do? a.

Hold the IV bottle

b. Check the IV stand c. Place the IV stand on the food part of the stretcher d. Restrain Jayvee 97. While Mrs. Enriquez is receiving chemotherapy, which of the following will you include in the plan of care to address her nutritional needs? a. Administer compazine before meals b. Enrich diet with red meats c. Serve hot soup and food d. Increase the amount of spice in the diet 98. During the meal, a client with hepatitis B dislodges her IV line and bleeds on the surface of the over-the-bed table. It would be the most appropriate for the nurse to instruct a housekeeper to clean the table with: a. Alcohol b. Acetone c. Ammonia d. Bleach 99. Nino is being treated with radiation therapy. What should be included in the plan of care to minimize skin damage from the radiation therapy? a. Cover the areas with thick clothing materials b. Apply a heating pad to the site c. Wash skin with water after the therapy d. Avoid applying creams and powders to the area CLIENT WITH BURNS 100.

The nurse should recognize that fluid shift in a client with a burn injury results

from an increase in the? a. Permeability of Capillary walls b. Total volume of intravascular plasma c. Total volume of circulating whole blood d. Permeability of the kidney tubules 101.

A priority nursing diagnosis category for a client with burns during the

emergent period would be?

a. Excess Fluid volume b. Imbalanced nutrition Less than Body requirements c. Risk for injury (falling) d. Risk for infection 102.

The client with a major bum injury receives total parenteral nutrition (TPN).

The primary reason for this therapy is to help? a.

Correct water and electrolyte imbalance

b. Allow the gastrointestinal tract to rest c. Provide supplemental vitamins and minerals d. Ensure adequate caloric and protein intake 103.

Endotracheal or tracheostomy tubes are placed in clients who have

experienced a.

Electrical burns of the hands and arms causing dysrhythmia

b. Thermal burns to the head, face and airway resulting in hypoxia c. Chemical burns on the chest and abdomen d. Second hand smoke inhalation 104.

The nurse is caring for a client with a burn / injury and understands that stress

reactions can result in hypersecretion of gastric acids. Therefore, the nurse must assess the client for signs and symptoms of which of the following potential complications? a. Paralytic lieus b. Gastric distention c. Hiatal Hernia d. Curling’s Ulcer SITUATIONAL: THE O.R. IS DIVIDED INTO THREE ZONES TO CONTROL TRAFFIC FLOW AND CONTAMINATION. 105.

What OR attires are worn in the restricted area?

a. Scrub suit, OR shoes, head cap b. Head cap, scrub suit, mask, OR shoes c. Mask, OR shoes, scrub suit d. Cap, mask, gloves shoes 106.

Which of the following nursing inventions should be given the highest

priority when receiving a client in the OR? a. Check for presence of dentures, jewelry, nail polish and other accessories

b. Receive the client at the semi-restricted area change his gown c. Assess level of consciousness d. Verify the identification and informed consent 107.

Conversation while in the operation is ongoing is minimized because:

a. Full concentration is demanded during the entire procedure b. It annoys the surgeon c. It is unethical to talk about the client d. It enhances the spread of microorganism to the incision site 108.

Spaulding categorized instruments according to use. Where do you classify

endoscopic instrument? a.

Decontaminated instruments

b. High level disinfected instruments c. High technology instruments d. Sterile instruments 109. a.

In the OR, "Surgical Conscience" means: Observance of Operating Room Protocol at all times

b. Use of prescribed OR attire in all areas of the OR c. Honest adherence to surgical aseptic techniques all the time d. Strict implementation of “Standard Precaution" CLIENT WITH HEMATOLOGICAL PROBLEM 110.

Which of the following nursing intervention is appropriate for a client with a

platelet count of 31,000/mm3? a. Pad sharp surfaces to avoid minor trauma when walking b. Assess for spontaneous petechiae in the extremities c. Keep the room darkened d. Check for blood in the urine 111.

The nurse evaluates that the client correctly understands how to report signs

of bleeding when she makes which of the following statements? a.

"Petechiae are large red skin bruises"

b. "Ecchymoses are large purple skin bruises" c. "Purpura is an open cut on the skin" d. "Abrasions are small pinpoint red dots on the skin" 112.

Which of the following is contraindicated for a client diagnosed with DIC?

a. Treating the underlying cause

b. Administering heparin c. Administering Coumadin d. Replacing depleted blood products 113.

Which of the following is an assessment finding associated with Internal

bleeding with DIC? a.

Bradycardia

b. Hypertension c. Increasing abdominal girth d. Petechiae 114.

During the induction stage for treatment leukemia, the nurse should remove

which items that the family has brought into the room? a. A Bible b. A picture c. A sachet of lavender d. A hairbrush SITUATION: Diabetes is a disease that can be controlled by effective health teaching particularly in the area diet activity. 115.

What is the metabolism defect responsible for the diabetes mellitus?

a. Decrease production of the glucose level b. Hypofunction at the anterior lobe of the pituitary gland c. Inadequate production of the parathyroid gland d. Inadequate secretion of the beta cells of the islets of Langerhans 116.

Metabolic defect that would cause acidosis?

a. Increase glycogenolysis in the liver b. Incomplete oxidation of fats c. Over storage of glycogen d. Increase oxidation of fats and carbohydrates 117.

Identify the symptoms that would suggest an overdose of insulin:

a. Drowsiness and fever b. Flushed skin and vomiting c. Easy fatigability and dysnea d. Sweating and anxiety 118.

A patient inquired. "What should we do, if we observe early signs of

hypoglycemia?" The nurse reply:

a. Call the doctor immediately b. Give him a drink of orange juice with sugar added c. Offer snack high in protein and low fat d. Give NPH insulin as ordered 119.

Which of the following nursing consideration must be taken into account for a

client with type I diabetes mellitus on the morning of surgery? a. The client should take half of his usual daily insulin b. The client should receive an oral antidiabetic agent c. The client should receive an I.V. insulin infusion d. The client should take his full daily insulin dose with no dextrose infusion SITUATION: Nurse Carla is assigned in the emergency unit meeting varied opportunities that developed her nursing skills. 120.

A 17-year-old is admitted following an automobile accident. He is very

anxious, dyspneic, and in severe pain. The left chest wall moves in during inspiration and balloons out when he exhales. The nurse understands these symptoms are most suggestive of: a. Hemothorax b. Flail chest c. Atelectasis d. Pleural effusion 121.

A young man is admitted with a flail chest following a car accident. He is

intubated with an endotracheal tube and is placed on a mechanical ventilator (control mode, positive measure). Which physical findings alert the nurse to an additional problem in respiratory function? a. Dullness to percussion in the 3rd to 5th intercostals space, midclavicular line b. Decrease paradoxical motion c. Louder breath sounds on the right chest d. pH of 7.36 in arterial blood gases 122.

The nurse is caring for a client who has just had a chest tube attached to a

water seal drainage system (Pleur-evac). To ensure that the system functions effectively the nurse should: a. Observe for intermittent bubbling in the water seal chamber b. Flush the chest tubes with 30 to 60 ml of NSS q4 to 6 hours c. Maintain the client in an extreme lateral position

d. Strip the chest tubes in the direction of the client 123.

The nurse enters the room of a client who has a chest tube attached to a water

seal drainage system notices the chest tube is dislodged from the chest. The most appropriate nursing intervention is to: a. Notify the physician b. Insert the new chest tube c. Cover the insertion site with new petroleum gauze d. Instruct the client to breathe deeply until help arrives 124.

A 71 -year-old is admitted to the hospital with congestive heart failure. She

has shortness of breath and a +3 -4 peripheral edema. The care plan to reduce the client's edema should include nursing strategies for: a. Establishing limits on activity b. Fostering a relax environment c. Identifying goals for self-care d. Restricting IV fluids DRUG RELATED INTERACTION 125.

You administered morphine sulfate 1 mg IV as ordered the following are

intended action of this drug EXCEPT; a. Decrease anxiety b. Reduce preload c. Relieve pain d. Improve efficacy of breathing Situation: Respiratory disorders must be addressed by the nurse early to prevent development of complications in his/her patient.

126.

An old man develops nasal flaring, cyanosis and diminished breath sounds

on one side. The diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first? a. CPR b. Insertion of chest tube c. Oxygen therapy d. Assisted ventilation

127.

The nurse is caring for a bedridden patient on mechanical ventilation. When

performing endotracheal suctioning, the nurse will avoid hypoxia by: a. Inserting a fenestrated catheter with a whistle tip without suction

b. Completing suction pass in 30 sec with pressure 150 mmHg c. Hyperoxygenating with 100% oxygen for 1-2 mins, before and after each suction pass d. Minimizing suction pass to 60 sec. while slowly rotating the lubricated catheter

128.

A father and his family were exposed to Mycobacterium tuberculosis about 2

months ago. To confirm the presence or absence of exposure to infection, it is most important for all family members to have a: a. Chest x-ray b. Blood culture c. Sputum culture d. PPD intradermal test

129.

During the beginning of the shift assessment of an adult with ásthma and is

receiving oxygen per nasal cannula at 2 LPM. The nurse would be most concerned about which unreported finding? a. Pulse oximetry reading of 89% b. Crackles at the base of the lungs on auscultation c. Rapid shallow respirations with intermittent wheezes d. Excessive thirst with a dry cracked tongue

130.

A former horseback rider with spinal cord injury complains of a pounding

headache. He is sitting in a wheelchair watching TV. Further assessment by the nurse reveals excessive sweating, a splotchy rash, goosebumps, facial flushing, nasal congestion and a HR of 50 bpm. The nurse should do which action next? a. Take the patient's RR, BP, T and papillary response b. Place the patient into the bed and administer the ordered prn analgesic c. Check the patient for bladder distention and the patient's urinary catheter for kinks d. Turn the TV off then assist the patient to use relaxation techniques

131.

The nurse is caring for a male with Parkinson's disease. He spends over 1

hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation? a. Ask family members to dress the patient b. Encourage the patient to dress more quickly c. Allow the patient the time needed to dress d. Demonstrate methods on how to dress more quickly

Situation: The nurse is caring for patients with varied neurosensory problems.

132.

Which of the following conditions assessed by the nurse would

contraindicate the use of benztropine (Cogentin)? a. Neuroleptic Malignant Syndrome b. Acute Extrapyramidal Syndrome c. Glaucoma, prostatic hypertrophy d. Parkinson's disease, atypical tremors

133.

When teaching a patient with Meniere's diseasę, the nurse should explain

that the patient should avoid foods high in: a. Calcium b. Fiber c. Sodium d. Carbohydrates

134.

To assist a male patient with trigeminal neuralgia about his nutrition needs,

the nurse should a. Offer small meals of high calorie soft food b. Assist the patient to sit in a chair for meals c. Provide additional servings of fruits and raw vegetables d. Encourage the patient to eat fish liver and chicken

135.

During seizure activity, which observation is the priority to enhance further

direction of treatment? a. Observe the sequence or type of movement b. Note the time from beginning to end c. Identify the pattern of breathing d. Determine if loss of bowel or bladder control occurs

136.

A patient is unconscious following a tonic clonic seizure. What should the

nurse do first? a. Check the pulse b. Administer Valium c. Place the patient in a side-lying position d. Place a tongue blade in the mouth Situation: Nurse Vicky is caring for patients with renal disorders.

137.

Mang Rico is admitted with a distended bladder due to the inability to void.

Nurse Vicky obtains an order to catheterize Mang Rico knowing that gradual emptying is preeferred over complete emptying because it reduces:

a. The potential for renal collapse. b. The potential for shock. c. The intensity for bladder spasms d. The risk for bladder atrophy

138.

Which of the following should Nurse Vicky implement to prepare Andrea for

KUB radiograph test? a. She must be on NPO before the test b. Enema is to be administered before the test c. Furosemide (Lasix) 20 mg IV is given 30 mins before the test d. No special ordered are necessary for this examination

139.

Andrew is admitted to the ER department with renal calculi is complaining of

severe pain and nausea. His temperature is 100.8F. The priority nursing goal for Andrew is: a. Maintain fluid and electrolyte balance b. Control nausea c. Manage pain d. Prevent UTI

140.

Nurse Vicky is caring for a Lolo Tunying with benign prostatic hypertrophy

Which of the following assessments would the Nurse Vicky anticipate finding? a. Large volume of urinary output with each voiding b. Involuntary voiding with coughing and sneezing c. Frequent urination d. Urine is dark and concentrated

141.

The primary teaching for Tin following an extracorporeal shockwave

lithotripsy (ESWL) procedure is: a. Drink 3-4 L of fluid each day for 1 month b. Limit fluid intake to 1 L of fluid for 1 month c. Increase intake of citrus fruits to 3 servings/day d. Restrict milk and dairy products for 1 month Situation: Caring for Patients with Gastrointestinal Disorders

142.

Mariah has undergone esophagogastroduodenoscopy. The nurse places

highest priority on which of the following items as part of the Mariah's care plan? a. Assessing for the return of the gag reflex b. Giving warm gargles for a sore throat c. Monitoring the temperature

d. Monitoring complaints of heartburn

143.

The nurse has taught Kaite about an upcoming endoscopic retrograde

cholangiopancreatography procedure. The nurse determines that Kate needs further information if she makes which of the following statements? a. "I know I must sign the consent form” b. "I'm glad I don't have to lie still for this procedure” c. "I'm glad some IV meds will be given to relax me." d. "I hope the throat spray keeps me from gagging”

144.

Rogel being seen in the doctor's office has just been scheduled for a barium

swallow the next day. The nurse writes down which of the following instructions for Rogel to follow before the test? a. Fast for 8 hrs before the test b. Eat a regular supper and breakfast c. Continue all oral meds as scheduled d. Monitor own bowel movement pattern for constipation

145.

The nurse is preparing to administer an enteral feeding to Inat via

nasogastric feeding tube. The most important action of the nurse is: a. Verify correct placement of the tube b. Check that the feeding solution matches the dietary order c. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach d. Ensure that feeding solution is at room temperature

146.

The nurse is caring for John with liver cirrhosis and ascites. When

instructing nursing assistants in the care of John, the nurse should emphasize that John: a. Should remain on bed rest in a semi-Fowler's position b. Should alternate ambulation with bed rest with legs elevated c. May ambulate and sit in chair as tolerated d. May ambulate as tolerated and remain in semi Fowler's position in bed Situation: Nurse Gina should be prepared to triage patients in the event of a disaster to save more lives within the shortest possible time.

147.

Nurse Gina is assigned to triage patients arriving to the emergency room for

treatment on the evening shift. She would assign highest priority to which of the following patients: a. Rocky with chest pain who states that he just ate pizza that was made with a very spicy sauce

b. Allyson with a minor laceration on the index finger sustained while cutting an eggplant c. Myrna complaining of muscle aches, headache and malaise d. Rudy who twisted his ankle when he fell while rollerblading

148.

Nurse Gina is working on a medical nursing unit during an external disaster

is called to assist with care for patients coming into the emergency room. Using principles of triage, she initiates immediate care for a patient with which of the following injuries? a. Bright red bleeding from a neck wound b. Penetrating abdominal injury c. Fractured tibia d. Open massive head injury in deep coma

149.

A typhoon is forecasted to make a landfall in 48 hours, The ER at a local

hospital is advised to prepare for the event of potential casualties. If any casualties occur, they will immediately be brought to the ER. Nurse Gina who received the telephone call regarding this warning would take which initial action? a. Supply the triage rooms with additional equipment b. Call the hospital maintenance department to secure the building from the storm c. Activate the agency disaster plan d. Increase the number of nursing staff for the day that the typhoon is expected

150.

Nurse Gina is working with older residents involved in a recent flood. Many

of the residents were emotionally despondent and refused to leave their homes for days. In planning for the rescue and relocation of these older residents, what is the first item Nurse Gina needs to consider? a. Attending to the emotional needs of the older residents b. Attending to the nutritional status and basic needs of the older residents c. Contacting the older residents families d. Arranging for ambulance transportation for the older residents

151.

An external disaster has occurred in the town. Nurse Gina from the

emergency department is transported to the site and assigned to triage the injured. Which of these patients would Nurse Gina tag as "to be seen last"? a. An infant with bilateral fractured lower legs

b. A middle-aged person with deep abrasions that are over,90% of the body c. A teenager with small amount of bright red blood dripping out of the nose d. An elderly person with an open bright red blood dripping out of the nose fracture of the left arm Situation: The nurse serves a first-aider whenever necessary, even in burn injuries.

152.

A man is cooking barbecue in the lawn. Accidentally, his shirt was caught on

fire. As the nurse witness the event, the immediate instruction for the man to do is: a. Pour a pail of water over the shirt b. Remove the shirt c. Stop, drop and roll over the lawn d. Get a fire extinguisher and use it on the burning shirt

153.

A person's bathrobe ignites while cooking in the kitchen on a gas stove.

Once the flames are extinguished, it is most important to: a. Give the person sips of water b. Assess the person's breathing c. Cover the person with a warm blanket d. Calculate the extent of the person's burns

154.

A child sustains burns of the arms from a barbecue accident in the park. A

bystander emerges from the crowd and suggests to a nurse that butter be applied to the burns. An appropriate response by the nurse would be, "Thanks, but: a. Well just wait for the ambulance. b. It is better to use some first aid cream. c. I'I just use a tablecloth as a blanket for now d. We should apply ice. Could you go get me some?

155.

The leading cause of death in fire is

a. Major burns b. Minor burns c. Burn shock d. Inhalation injury

156.

What gas produced by combustion causes poisoning?

a. Carbon dioxide

b. Carbon monoxide c. Nitrogen oxide d. Oxygen Situation: GIT problems of patients must be treated promptly and the nurse has a role to ensure such efforts.

157.

The nurse is caring for Nhell with acute pancreatitis. After pain

management, which intervention should be included in the plan of care? a. Cough and deep breathe every 2 hours b. Place the patient in contact isolation c. Provide a diet high in protein d. Institute seizure precautions

158.

When planning the care for Cheng with anorexia nervosa, which of these

concerns should the nurse determine to the priority for long term mobility? a. Digestive problems b. Amenorrhea c. Electrolyte imbalance d. Blood disorders

159.

The nasogastric tube of a post-operative gastrectomy patient has stopped

draining greenish liquid. The nurse should: a. Irrigate it as ordered with distilled water b. Irrigate it as ordered with normal saline c. Place the end of the tube in water to see if the water bubbles d. Withdraw the tube several inches and reposition it

160.

The nurses on a unit are planning for stoma care for patients who have a

stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown? a. Ileostomy b. Transverse colostomy c. Ileal conduit d. Sigmoid colostomy

161.

The nurse is assessing a patient with portal hypertension. Which of the

following findings would the nurse expect? a. Expiratory wheezes b. Blurred vision c. Ascites

d. Dilated pupils Situation: Caring for Patients with Musculoskeletal Disorders

162.

What is the most important aspect to include when developing a home care

plan for a patient with severe arthritis? a. Maintaining and preserving function b. Anticipating side effects of therapy c. Supporting coping with limitations d. Ensuring compliance with meds

163.

The nurse is teaching a patient who has a hip prostheses following total hip

replacement. Which of the following should be included in the instructions for home care? a. Avoid climbing stairs for 3 months b. Ambulate using crutches only c. Sleep only on your back d. Do not cross legs

164.

The nurse is caring for a patient who had a total hip replacement 4 days

ago. Which assessment requires the nurse's immediate attention? a. "I have bad muscle spasms in my lower leg of the affected extremity." b. "I just can't catch my breath over the past few minutes and I think I am in grave danger.” c. "I have to use a bedpan to pass my water at least every 1-2 hours” d. "It seems that the pain meds is not working as well today”

165.

The nurse is preparing to care for a patient scheduled for a fasciotomy

procedure being performed on an arm with compartment syndrome. The nurse understands that the anticipated therapeutic outcome of the fasciotomy is: a. Brisk bleeding from the site b. Formation of granulation tissue c. Decreasing edema formation d. Return of the distal pulses

166.

Which is the greatest risk factor in the development of osteoporosis?

a. Aging b. Menopause c. Long-term steroid use d. Caffeine intake Situation: You are caring for Rey, 35 years old, with diagnosis of myocardial infarction

167.

The priority nursing diagnosis for Rey is:

a. Constipation b. High risk for infection c. Impaired gas exchange d. Fluid volume deficit

168.

He is complaining of chest pain radiating to the left side of the chest. The

nurse knows that pain related to MI is due to: a. Insufficient oxygenation of the cardiac muscle b. Potential circulatory overload c. Left ventricular overload d. Electrolyte imbalance

169.

Which of the following laboratory values woould be consistent with Rey's

diagnosis? a. Low serum albumin b. High serum cholesterol c. Abnormally low WBC count d. Elevated creatinine phosphokinase

170.

Which statement by Rey suggests that the problem is acute MI?

a. "My pain is deep in my chest behind my sternum." b. "When I sit up the pain gets worse." c. "As I take a deep breath the pain gets worse.” d. “The pain is right here in my stomach area.”

171.

When teaching Rey about nutrition, the nurse should emphasize:

a. Eating 3 balanced meals a day b. Adding complex carbohydrates c. Avoiding very heavy meals d. Limiting sodium to 7 g/day Situation: The nurse must monitor the patients with cardiovascular problems to prevent potential complications.

172.

Flor is receiving digoxin (Lanoxin) 0.25 mg OD. The doctor has written a

new order to give metoprolol (Lopressor) 25 mg BID. In assessing Flor prior to administering the meds, which of the following should the nurse report immediately? a. BP of 94/60 b. HR of 76 c. Urine output of 50 ml/hr

d. RR of 16

173.

Mike has been taking furosemide (Lasix) for the past week The nurse

recognizes which finding may indicate he is experiencing a negative side effect from the medication? a. Weight gain of 5 pounds b. Edema of the ankles c. Gastric irritability d. Decreased appetite

174.

The nurse is caring for Mario with potassium level of 3.5 mEq/L. The patient

is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1,000 ml of 5% dextrose in water IV. Which of the following ECG patterns indicates to the nurse that the infusion should be discontinued? a.

Narrowed QRS complex

b. Shortened PR interval c. Tall, peaked T waves d. Prominent U waves

175.

Which complication on cardiac catheterization should the nurse monitor for

the 1st 24 hours after the procedure? a. Angina at rest b. Thrombus formation c. Dizziness d. Hypotension

176.

The nurse is caring for Elma with congestive heart failure. Which finding

requires the nurse's immediate attention? a. Pulse oximetry of 85% b. Nocturia c. Crackles in the lungs d. Diaphoresis Situation: The nurse is caring for patients with endocrine disorders.

177.

Mel is admitted with low T3 and T4 levels and an elevated TSH levels. On

initial assessment, the nurse would anticipate which of the following assessment findings? a. Lethargy b. Heat intolerance c. Diarrhea d. Skin eruptions

178.

Mel has been newly diagnosed with hypothyroidism and will take

levothyroxine (Synthroid) 50 mcg/day PO. As part of the teaching plan, the nurse emphasizes that this meds: a. Should be taken in the AM b. May decrease the patient's energy level c. Must be stored in a dark container d. Will decrease the patient's HR

179.

Rio with non-insulin dependent DM should be instructed to contact the

outpatient clinic immediately if the following findings are present: a. Temperature of 37.5 C with painful urination b. An open wound on the heel c. Insomnia and daytime fatigue d. Nausea with 2 episodes of vomiting

180.

A nurse is performing a physical assessment on Nory, with insulin

dependent DM. Which complaint calls for immediate nursing action? a. Diaphoresis and shakiness b. Reduced lower leg sensation c. Intense thirst and hunger d. Painful hematoma on thigh

181.

Which of the following would be the best strategy for the nurse to use when

teaching insulin injection techniques to Mina, a newly diagnosed patient with DM? a. Give written pre and post tests b. Ask questions during practice c. Allow another diabetic to assist d. Observe a return demonstration Situation: The nurse must show compassion in caring for patients with terminal cancer

182.

The nurse is participating in a health screening clinic and is preparing

teaching materials about colorectal cancer. The nurse plans to include which of the following in a list of risk factors for colorectal cancer? a. Age over 30 yrs b. High-fiber, low-fat diet c. Distant relative with colorectal cancer d. Personal history of ulcerative colitis or Gl polyps

183.

Lolo Jose is terminally ill, has been receiving high doses of an opioid

analgesic for the past month. As death approaches and he becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider? a. Decrease the analgesic dose by half b. Discontinue the analgesic c. Continue the same analgesic dose d. Prescribe a less potent drug

184.

The nurse observes a staff member caring for a patient with left

mastectomy. The nurse would intervene if she notices the staff member is: a. Advising patient to restrict sodium intake b. Taking the BP in the left arm c. Elevating the left arm above heart level d. Compressing the drainage device

185.

The nurse is caring for a patient who has just had a modified radical

mastectomy with immediate reconstruction. She's in her 30s and has two young children. Although she's worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping? a. Tell the patient's spouse or partner to be supportive while she recovers b. Encourage the patient to proceed with the next phase of treatment c. Recommend that the patient remain cheerful for the sake of her children. d. Refer the patient to the Cancer Society's Reach for Recovery program or another support program.

186.

Lourdes experiences alopecia resulting from chemotherapy, prompting the

nursing diagnoses of Disturbed body image and Situational low self-esteem. Which of the following actions would best indicate that she is meeting the goal of improved body image and self-esteem? a. She requests that her family bring her makeup and wig b. She begins to discuss the future with her family c. She reports less disruption from pain and discomfort d. She cries openly when discussing her disease Situation: The nurse must be able to use her knowledge of triage to save more lives

187.

The nurse has been assigned to these patients in the emergency room.

Which patient would the nurse check first? a. Anok with viral pneumonia with atelectasis

b. Michelle with spontaneous pneumothorax with RR of 38 c. Dindin with tension pneumothorax with slight tracheal deviation to the right d. Fe with acute asthma with episodes of bronchospasm

188.

Which of these patients would the triage nurse request for the physician to

examine immediately? a. A 5-month old infant who has audible wheezing and grunting b. An adolescent who has a soot over the face and shirt c. A middle-aged man with 2nd degree burns over the right hand d. A toddler with singed ends of long hair that extends to the waist

189.

After change-of-shift report, which patient should the triage nurse assess

first? a. A 42-yr old patient with rheumatoid arthritis complaining of pain b. A 64-yr old patient with osteoporosis who is waiting for discharge c. A 28-yr old patient with fracture complaining that the cast is tight d. A 56-yr old patient with left leg amputation complaining of phantom pain

190.

With an alert of an internal disaster and the need for beds, the charge nurse

is asked to list patients who are potential discharges within the next hour. Which patient should the charge nurse select? a. An elderly patient who has had type 2 DM for 20 years, admitted with DKA 24 hours ago b. An adolescent admitted the prior night with Tylenol intoxication c. A middle-aged patient with an internal automatic defibrillator with complaints of "passing out at an unknown times", admitted yesterday d. A school age child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts

191.

A client who ingested 15 maximum strength acetaminophen tablets 45

minutes ago is seen in the emergency department. Which of these orders should the nurse do first?

a. Gastric lavage PRN b. Acetylcysteine (Mucomyst) for age per pharmacy c. Start an IV Dextrose 5% with 0.33% normal saline to keep vein open d. Activated charcoal per pharmacy Situation: Caring for Patients with Burn Injuries

192.

The nurse is caring for a patient who sustained 2nd- and 3rd- degree burns

on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the emergent phase of the burn injury?

a. Decreased HR b. Increased BP c. Elevated Hematocrit levels d. Increased urinary output

193.

The nurse is caring for a patient who suffered an inhalation injury from a

wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate which of the following signs in the patient? a. Flushing b. Dizziness c. Tachycardia d. Coma

194.

The patient arrives at the ER following a burn injury that occurred in the

basement at home. An inhalation injury is suspected. Which of the following would the nurse anticipate to prescribed for the patient? a. 100% oxygen via an aerosol mask b. oxygen via nasal cannula at 15 LPM c. 100% oxygen via tight fitting, non-rebreather face mask d. d. oxygen via nasal cannula at 10 LPM

195.

Alex is admitted to the hospital after sustaining burns to the chest, abdomen

right arm and right leg. Using the rule of nines, the nurse would determine that about what percentage of the client's body surface has been burned? a. 18% b. 27% c. 45% d. 64%

196.

The nurse manager is observing a new nursing graduate caring for a burn

patient in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique? a. Using sterile sheets and linens b. Performing strict hand washing techniques c. Wearing gloves and a gown only when giving direct care to the patient d. Wearing protective garb, including a mask, gloves, cap, shoe covers, scrub clothes and plastic aprons

Situation: Prioritizing pationt's needs must be done by the nurse effectively to minimize health risks

197.

A nurse employed in an emergency department is assigned to triage

patients arriving to the emergency room for treatment on the evening shift. The nurse would assign highest priority to which of the following patients? a. A patient with chest pain who states that he just ate pizza that was made with a very spicy sauce b. A patient with a minor laceration on the index finger sustained while cutting an eggplant c. A patient complaining of muscle aches, a headache and malaise d. A patient who twisted her ankle when she fell while rollerblading

198.

The hospital has sounded the call for disaster drill on the evening shift.

Which of these patients would the nurse put first on the list to be discharged in order to make the room available for a new admission? a. A middle-aged man with a history of ventilator dependency for 7 years and now admitted with pneumonia five days ago b. A young adult with DM type 2 for 10 years now and admitted with antibioticinduced diarrhea 24 hours ago c. An elderly patient with history of hypertension, hyperlipidemia and SLE admitted that morning d. An HIV positive adolescent and admitted for acute cellulitis of the lower leg 48 hours ago

199.

A triage nurse has these 4 patients arrive in the emergency department

within 15 minutes. Which patient should the triage nurse seen first? a. A 2-month old infant with a history of rolling off the bed and has a bulging fontanels with crying b. A teenager who got a singed beard while camping c. An elderly patient with complaints of frequent brown stools d. A middle-aged patient with intermittent pain behind the right scapula

200.

A nurse enters a patient's room to discover that the patient has no pulse or

respirations. After calling for help, the first action the nurse should take is: a. Start a peripheral IV b. Initiate closed chest massage c. Establish an airway d. Obtain the crash cart