Nursing Guide; Brain Flex – Flashcards
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A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client? a. Taking hourly blood pressures with mechanical cuff b. Encouraging fluid intake of at least 200mL per hour c. Position in high Fowler's with knee gatch raised d. Administering Tylenol as ordered
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(B) is correct. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.
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A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client? a. Side-lying with knees flexed b. Knee-chest c. High Fowler's with knees flexed d. Semi-Fowler's with legs extended on the bed
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(D) is correct. Placing the client in semi-Fowler's position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect.
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The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside? a. A tracheotomy set b. A padded tongue blade c. An endotracheal tube d. An airway
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(A) is correct. The client who has recently had a thyroidectomy is at risk for tracheal edema. A padded tongue blade is used for seizures and not for the client with tracheal edema, so answer B is incorrect. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem, so answers C and D are incorrect.
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A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use? a. Body temperature of 99°F or less b. Toes moved in active range of motion c. Sensation reported when soles of feet are touched d. Capillary refill of < 3 seconds
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(D) is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.
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The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by: a. Cats b. Dogs c. Turtles d. Birds
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(D) is correct. Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or turtles. Therefore, answers A, B, and C are incorrect.
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Which task should be assigned to the nursing assistant? a. Placing the client in seclusion b. Emptying the Foley catheter of the preeclamptic client c. Feeding the client with dementia d. Ambulating the client with a fractured hip
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(C) is correct. Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. Only an RN or the physician can place the client in seclusion, so answer A is incorrect. The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable, making answer B incorrect. A nurse or physical therapist should ambulate the client with a fractured hip, so answer D is incorrect.
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A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to: a. Douche after intercourse b. Void every 3 hours c. Obtain a urinalysis monthly d. Wipe from back to front after voiding
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(B) is correct. Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Douching is not recommended and obtaining a urinalysis monthly is not necessary, making answers A and C incorrect. The client should practice wiping from front to back after voiding and bowel movements, so answer D is incorrect.
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The nurse has a pre-op order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to: a. Administer the medications together in one syringe b. Administer the medication separately c. Administer the Valium, wait 5 minutes, and then inject the Phenergan d. Question the order because they cannot be given at the same time
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(B) is correct. Valium is not given in the same syringe with other medications, so answer A is incorrect. These medications can be given to the same client, so answer D is incorrect. In answer C, it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic.
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A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should: a. Be injected into the deltoid muscle b. Be injected into the abdomen c. Aspirate after the injection d. Clear the air from the syringe before injections
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(B) is correct. Lovenox injections should be given in the abdomen, not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection. Therefore, answers A, C, and D are incorrect.
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The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a non-stress test can be ordered for this client to: a. Determine lung maturity b. Measure the fetal activity c. Show the effect of contractions on fetal heart rate d. Measure the well-being of the fetus
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(B) is correct. A non-stress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological well-being, making answers A, C, and D incorrect.
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The infant is admitted to the unit with tetrology of falot. The nurse would anticipate an order for which medication? a. Digoxin b. Epinephrine c. Aminophyline d. Atropine
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(A) is correct. The infant with Tetralogy of Fallot involves four heart defects: A large ventricular septal defect (VSD), Pulmonary stenosis, Right ventricular hypertrophy and, An overriding aorta. He will be treated with digoxin to slow and strengthen the heart. Epinephrine, aminophyline, and atropine will speed the heart rate and are not used in this client; therefore, answers B, C, and D are incorrect.
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The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will: a. Tire easily b. Grow normally c. Need more calories d. Be more susceptible to viral infections
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(A) is correct. The toddler with a ventricular septal defect will tire easily. He will not grow normally but will not need more calories. He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children. Therefore, answers B, C, and D are incorrect.
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The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to: a. Turning the client to the left side b. Milking the tube to ensure patency c. Slowing the intravenous infusion d. Notifying the physician
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(D) is correct. The output of 300mL is indicative of hemorrhage and should be reported immediately. Answer A does nothing to help the client. Milking the tube is done only with an order and will not help in this situation, and slowing the intravenous infusion is not correct; thus, answers B and C are incorrect.
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The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to: a. Apply the new tie before removing the old one. b. Have a helper present. c. Hold the tracheotomy with the nondominant hand while removing the old tie. d. Ask the doctor to suture the tracheostomy in place.
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(A) is correct. The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Answer C is not the best way to prevent the client from coughing out the tracheotomy. Asking the doctor to suture the tracheotomy in place is not appropriate.
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The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid: a. Using oil- or cream-based soaps b. Flossing between the teeth c. The intake of salt d. Using an electric razor
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(B) is correct. The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor; therefore, answers A, C, and D are incorrect.
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A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for: a. Allergies to pineapples and bananas b. A history of streptococcal infections c. Prior therapy with phenytoin d. A history of alcohol abuse
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(B) is correct. Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. There is no reason to assess the client for allergies to pineapples or bananas, there is no correlation to the use of phenytoin and streptokinase, and a history of alcohol abuse is also not a factor in the order for streptokinase; therefore, answers A, C, and D are incorrect.
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The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to: a. Perform the Valsalva maneuver as the catheter is advanced b. Turn his head to the left side and hyperextend the neck c. Take slow, deep breaths as the catheter is removed d. Turn his head to the right while maintaining a sniffing position
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(A) is correct. The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. Answers B, C, and D will not facilitate removal.
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A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to: a. Have a Protime done monthly b. Eat more fruits and vegetables c. Drink more liquids d. Avoid crowds
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(A ) is correct. Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting, so answer B is incorrect. Drinking more liquids and avoiding crowds is not necessary, so answers C and D are incorrect.
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The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating: a. Fruits b. Salt c. Pepper d. Ketchup
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(C) is correct. Pepper is not processed and contains bacteria. Answers A, B, and D are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed.
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A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the: a. Head of the pancreas b. Proximal third section of the small intestines c. Stomach and duodenum d. Esophagus and jejunum
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(A) is correct. During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer B is incorrect because the proximal third of the small intestine is not removed. The entire stomach is not removed, as in answer C, and in answer D, the esophagus is not removed.
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A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain? a. "The pain will go away in a few days." b. "The pain is due to peripheral nervous system interruptions. I will get you some pain medication." c. "The pain is psychological because your foot is no longer there." d. "The pain and itching are due to the infection you had before the surgery."
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(B) is correct. Pain related to phantom limb syndrome is due to peripheral nervous system interruption. Answer A is incorrect because phantom limb pain can last several months or indefinitely. Answer C is incorrect because it is not psychological. It is also not due to infections, as stated in answer D.
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A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? a. The client should be placed in a room with negative pressure. b. Infection requires close contact; therefore, the door may remain open. c. Transmission is highly likely, so the client should wear a mask at all times. d. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.
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(D) is correct. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. The door should remain closed, but a negative-pressure room is not necessary, so answers A and B are incorrect. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask, so answer C is incorrect.
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A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by: a. Passing water through a dialyzing membrane b. Eliminating plasma proteins from the blood c. Lowering the pH by removing nonvolatile acids d. Filtering waste through a dialyzing membrane
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(D) is correct. Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. It does not pass water through a dialyzing membrane nor does it eliminate plasma proteins or lower the pH, so answers A, B, and C are incorrect.
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The primary reason for rapid continuous rewarming of the area affected by frostbite is to: a. Lessen the amount of cellular damage b. Prevent the formation of blisters c. Promote movement d. Prevent pain and discomfort
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(A ) is correct. Rapid continuous rewarming of a frostbite primarily lessens cellular damage. It does not prevent formation of blisters. It does promote movement, but this is not the primary reason for rapid rewarming. It might increase pain for a short period of time as the feeling comes back into the extremity; therefore, answers B, C, and D are incorrect.
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A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB? A. Chest x-ray B. Mantoux test C. Breath sounds examination D. Sputum culture for gram-negative bacteria
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(B) The Mantoux is the most accurate test to determine the presence of TB.
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A nurse teaching a patient with COPD pulmonary exercises should do which of the following? A. Teach purse-lip breathing techniques. B. Encourage repetitive heavy lifting exercises that will increase strength. C. Limit exercises based on respiratory acidosis. D. Take breaks every 10-20 minutes with exercises.
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(A) Purse lip breathing will help decrease the volume of air expelled by increased bronchial airways.
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A patient that has TB can be taken off restrictions after which of the following parameters have been met? A. Negative culture results. B. After 30 days of isolation. C. Normal body temperature for 48 hours. D. Non-productive cough for 72 hours.
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(A) Negative culture results would indicate absence of infection.
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A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The nurse should do which of the following first? A. Check the patient's chest x-ray results. B. Retake vitals including blood pressure. C. Perform a neurological screen on the patient. D. Request the physician on-call assess the patient.
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(B) Dizziness can be a sign of hypotension, that may a contraindication with Morphine.
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A 64 year-old male who has been diagnosed with COPD, and CHF exhibits an increase in total body weight of 10 lbs. over the last few days. The nurse should: A. Contact the patient's physician immediately. B. Check the intake and output on the patient's flow sheet. C. Encourage the patient to ambulate to reduce lower extremity edema. D. Check the patient's vitals every 2 hours.
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(B) Check the intake and output prior to making any decisions about patient care.
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A 13 year old girl is admitted to the ER with lower right abdominal discomfort. The admitting nursing should take which the following measures first? A. Administer Loritab to the patient for pain relief. B. Place the patient in right sidelying position for pressure relief. C. Start a Central Line. D. Provide pain reduction techniques without administering medication.
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(D) Do not administer pain medication or start a central line without MD orders.
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A patient that has delivered a 8.2 lb. baby boy 3 days ago via c-section, reports white patches on her breast that aren't going away. Which of the following medications may be necessary? A. Nystatin B. Atropine C. Amoxil D. Loritab
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(A) Thrush may be occurring and the patient may need Nystatin.
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A 22 year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening? A. The patient is excited about being around family again. B. The patient's suicide plan has probably progressed. C. The patient's plans for the future have been clarified. D. The patient's mood is improving.
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(B) The suicide plan may have been decided.
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A 64 year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure? A. Secure the restraints to the bed rails on all extremities. B. Notify the physician that restraints have been placed properly. C. Communicate with the patient and family the need for restraints. D. Position the head of the bed at a 45 degree angle.
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(C) Both the family and the patient should have the need for restraints explained to them.
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A nurse has just started on the 7PM surgical unit shift. Which of the following patients should the nurse check on first? A. A 75 year-old female who is scheduled for an EGD in 10 hours. B. A 34 year-old male who is complaining of low back pain following back surgery and has an onset of urinary incontinence in the last hour. C. A 21 year-old male who had a lower extremity BKA yesterday, following a MVA and has phantom pain. D. A 27 year-old female who has received 1.5 units of RBC's. via transfusion the previous day.
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(B) The new onset of urinary incontinence may require additional medical assessment, and the physician needs to be notified.
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A nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to use a quad cane. Which of the following is the most appropriate gait sequence? A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence. B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence. C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence. D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
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(A) The cane should be placed in the patient's strong upper extremity, and left arm/right foot go together, for normal gait.
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A nurse has been instructed to place an IV line in a patient that has active TB and HIV. The nurse should where which of the following safety equipment? A. Sterile gloves, mask, and goggles B. Surgical cap, gloves, mask, and proper shoewear C. Double gloves, gown, and mask D. Goggles, mask, gloves, and gown
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(D) All protective measures must be worn, it is not required to double glove.
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A nurse is caring for a patient who has recently been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant? A. Transferring the patient to the shower. B. Ambulating the patient for the first time. C. Taking the patient's breath sounds D. Educating the patient on monitoring fatigue
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(A) Nursing assistants should be competent on all transfers.
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A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is: A. Request a private evaluation of the female's scalp from her parents. B. Contact the female's parents about your observations. C. Observe the hairline and scalp for possible signs of lice. D. Contact the student's physician.
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(C) Observation of the student's hair is the next step.
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A nurse is covering a pediatric unit and is responsible for a 15 year-old male patient on the floor. The mother of the child states, "I think my son is sexually interested in girls." The most appropriate course of action of the nurse is to respond by stating: A. "I will talk to the doctor about it." B. "Has this been going on for a while?" C. "How do you know this?" D. "Teenagers often exhibit signs of sexual interest in females."
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(D) Adolescents exhibiting signs of sexual development and interest are normal.
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A 93 year-old female with a history of Alzheimer's Disease gets admitted to an Alzheimer's unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse? A. Recommend the patient remain in her room at all times. B. Recommend family members bring pictures to the patient's room. C. Recommend a speech therapy consult to the doctor. D. Recommend the patient attempt to walk pushing the w/c for safety.
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(B) Stimulation in the form of pictures may decrease signs of confusion.
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A nurse is performing a screening on a patient that has been casted recently on the left lower extremity. Which of the following statements should the nurse be most concerned about? A. The patient reports, "I didn't keep my extremity elevated like the doctor asked me to." B. The patient reports, "I have been having pain in my left calf." C. The patient reports, "My left leg has really been itching." D. The patient reports, "The arthritis in my wrists is flaring up, when I put weight on my crutches."
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(B) Pain may be indicating neurovascular complication.
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A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions? A. Patient may have a DVT. B. Patient may be exhibiting signs of dermatitis. C. Patient may be in the late phases of CHF. D. Patient may be experiencing anxiety after surgery.
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(A) All of these factors indicate a DVT.
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A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention? A.A home health patient reports, "I am starting to have breakdown of my heels." B. A patient that received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today." C. A young female reports, "I think I sprained my ankle about 2 weeks ago." D. A middle-aged patient reports, "My knee is still hurting from the TKR."
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(B) The patient experiencing neurovascular changes should have the highest priority. Pain following a TKR is normal, and breakdown over the heels is a gradual process. Moreover, a subacute ankle sprain is almost never a medical emergency.
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A nurse is working in an outpatient orthopedic clinic. During the patient's history the patient reports, "I tore 3 of my 4 Rotator cuff muscles in the past." Which of the following muscles cannot be considered as possibly being torn? A. Teres minor B. Teres major C. Supraspinatus D. Infraspinatus
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(B) Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis make up the Rotator Cuff.
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Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site? A. Thoroughly irrigate the wound before collecting the specimen. B. Use a sterile swab and wipe the crusty area around the outside of the wound. C. Gently roll a sterile swab from the center of the wound outward to collect drainage. D. Use a sterile swab to collect drainage from the dressing.
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(C) Rolling a swab from the center outward is the right way to obtain a culture specimen from a wound. Irrigating the wound washes away drainage, debris, and many of the colonizing or infecting microorganisms. The outside of the wound and the dressing may be colonized with microorganisms that haven't affected the wound, so specimens from these sites could give inaccurate results.
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A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids is given first? A. Albumin. B. D5W. C. Lactated Ringer's solution. D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml.
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(C) Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not primary fluid replacement. Dextrose isn't given to burn patients during the first 24 hours because it can cause pseudodiabetes. The patient is hyperkalemic from the potassium shift from the intracellular space to the plasma, so potassium would be detrimental.
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Patients with Type 1 diabetes mellitus may require which of the following changes to their daily routine during periods of infection? A. No changes. B. Less insulin. C. More insulin. D. Oral diabetic agents.
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(C) During periods of infection or illness, patients with Type 1 diabetes may need even more insulin to compensate for increased blood glucose levels.
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Adequate fluid replacement and vasopressin replacement are objectives of therapy for which of the following disease processes? A. Diabetes mellitus. B. Diabetes insipidus. C. Diabetic ketoacidosis. D. Syndrome of inappropriate antidiuretic hormone secretion (SIADH).
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(B) Maintaining adequate fluid and replacing vasopressin are the main objectives in treating diabetes insipidus. An excess of antidiuretic hormone leads to SIADH, causing the patient to retain fluid. Diabetic ketoacidosis is a result of severe insulin insufficiency.
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Which of the following potentially serious complications could occur with therapy for hypothyroidism? A. Acute hemolytic reaction. B. Angina or cardiac arrhythmia. C. Retinopathy. D. Thrombocytopenia.
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(B) Precipitation of angina or cardiac arrhythmia is a potentially serious complication of hypothyroidism treatment. Acute hemolytic reaction is a complication of blood transfusions. Retinopathy typically is a complication of diabetes mellitus. Thrombocytopenia doesn't result from treating hypothyroidism.
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After a liver biopsy, place the patient in which of the following positions? A. Left side-lying, with the bed flat. B. Right side-lying, with the bed flat. C. Left side-lying, with the bed in semi-Fowler's position. D. Right side-lying, with the bed in semi-Fowler's position.
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(B) Positioning the patient on his right side with the bed flat will splint the biopsy site and minimize bleeding. The other positions won't do this and may cause more bleeding at the site or internally.
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Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis? A. Nutrition management. B. Fluid and electrolyte balance. C. Management of hypoglycemia. D. Pain control.
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(B) Acute pancreatitis is commonly associated with fluid isolation and accumulation in the bowel secondary to ileus or peripancreatic edema. Fluid and electrolyte loss from vomiting is a major concern. Therefore, your priority is to manage hypovolemia and restore electrolyte balance. Pain control and nutrition also are important. Patients are at risk for hyperglycemia, not hypoglycemia.
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After surgical repair of a hip, which of the following positions is best for the patient's legs and hips? A. Abduction. B. Adduction. C. Prone. D. Subluxated.
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(A) After surgical repair of the hip, keep the legs and hips abducted to stabilize the prosthesis in the acetabulum.
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When giving intravenous (I.V.) phenytoin, which of the following methods should you use? A. Use an in-line filter. B. Withhold other anticonvulsants. C. Mix the drug with saline solution only. D. Flush the I.V. catheter with dextrose solution.
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(C) Phenytoin is compatible only with saline solutions; dextrose causes an insoluble precipitate to form. You needn't withhold additional anticonvulsants or use an in-line filter.
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Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma? A. Bradycardia. B. Large amounts of very dilute urine. C. Restlessness and confusion. D. Widened pulse pressure.
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(C) The earliest sign of increased ICP is a change in mental status. Bradycardia and widened pulse pressure occur later. The patient may void a lot of very dilute urine if his posterior pituitary is damaged.
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Which of the following nursing interventions should you use to prevent footdrop and contractures in a patient recovering from a subdural hematoma? A. High-top sneakers. B. Low-dose heparin therapy. C. Physical therapy consultation. D. Sequential compressive device.
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(A) High-top sneakers are used to prevent footdrop and contractures in patients with neurologic conditions. A consult with physical therapy is important to prevent footdrop, but you can use high-top sneakers independently.
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Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube? A. You see a lot of drainage from the chest tube. B. Arterial blood gas (ABG) levels are normal. C. The chest X-ray continues to show the lung is 35% deflated. D. The water-seal chamber doesn't fluctuate when no suction is applied.
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(D) The chest tube isn't removed until the patient's lung has adequately reexpanded and is expected to stay that way. One indication of reexpansion is the cessation of fluctuation in the water-seal chamber when suction isn't applied. The chest X-ray should show that the lung is reexpanded. Drainage should be minimal before the chest tube is removed. An ABG test isn't necessary if clinical assessment criteria are met.
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A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed? A. Acute respiratory distress syndrome (ARDS). B. Atelectasis. C. Bronchitis. D. Pneumonia.
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(A) Severe hypoxia after smoke inhalation typically is related to ARDS. The other choices aren't typically associated with smoke inhalation.
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A 19-year-old patient comes to the ED with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should you take first? A. Take a full medical history. B. Give a bronchodilator by nebulizer. C. Apply a cardiac monitor to the patient. D. Provide emotional support for the patient.
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(B) The patient having an acute asthma attack needs more oxygen delivered to his lungs and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. The patient may not need cardiac monitoring because he's only 19 years old, unless he has a medical history of cardiac problems.
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A 20-year-old patient is being treated for pneumonia. He has a persistent cough and complains of severe pain on coughing. What could you tell him to help him reduce his discomfort? A. "Hold your cough as much as possible." B. "Place the head of your bed flat to help with coughing." C. "Restrict fluids to help decrease the amount of sputum." D. "Splint your chest wall with a pillow for comfort."
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(D) Showing this patient how to splint his chest wall will help decrease discomfort when coughing. Holding in his coughs will only increase his pain. Placing the head of the bed flat may increase the frequency of his cough and his work of breathing. Increasing fluid intake will help thin his secretions, making it easier for him to clear them.
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A patient infected with human immunodeficiency virus (HIV) begins zidovudine therapy. Which of the following statements best describes this drug's action? A. It destroys the outer wall of the virus and kills it. B. It interferes with viral replication. C. It stimulates the immune system. D. It promotes excretion of viral antibodies.
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(B) Zidovudine inhibits DNA synthesis in HIV, thus interfering with viral replication. The drug doesn't destroy the viral wall, stimulate the immune system, or promote HIV antibody excretion.
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Corticosteroids are potent suppressors of the body's inflammatory response. Which of the following conditions or actions do they suppress? A. Cushing syndrome. B. Pain receptors. C. Immune response. D. Neural transmission.
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(C) Corticosteroids suppress eosinophils, lymphocytes, and natural-killer cells, inhibiting the natural inflammatory process in an infected or injured part of the body. This helps resolve inflammation, stabilizes lysosomal membranes, decreases capillary permeability, and depresses phagocytosis of tissues by white blood cells, thus blocking the release of more inflammatory materials. Excessive corticosteroid therapy can lead to Cushing syndrome.
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A 16-year-old patient involved in a motor vehicle accident arrives in the ED unconscious and severely hypotensive. He's suspected to have several fractures of his pelvis and legs. Which of the following parenteral fluids is the best choice for his current condition? A. Fresh frozen plasma. B. 0.9% sodium chloride solution. C. Lactated Ringer's solution. D. Packed red blood cells.
answer
(D) In a trauma situation, the first blood product given is unmatched (0 negative) packed red blood cells. Fresh frozen plasma often is used to replace clotting factors. Lactated Ringer's solution or 0.9% sodium chloride is used to increase volume and blood pressure, but too much of these crystalloids will dilute the blood and won't improve oxygen-carrying capacity.
question
A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks' gestation. She's at risk for which of the following blood dyscrasias? A. Thrombocytopenia. B. Idiopathic thrombocytopenic purpura (ITP). C. Disseminated intravascular coagulation (DIC). D. Heparin-associated thrombosis and thrombocytopenia (HATT).
answer
(C) Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage. Thrombocytopenia results from decreased production of platelets. ITP doesn't have a definitive cause. A patient with abruptio placentae wouldn't get heparin and, as a result, wouldn't be at risk for HATT.
question
Which of the following positions would best aid breathing for a patient with acute pulmonary edema? A. Lying flat in bed. B. Left side-lying position. C. High Fowler's position. D. Semi-Fowler's position.
answer
(C) High Fowler's position facilitates breathing by reducing venous return. Lying flat and side-lying positions worsen breathing and increase the heart's workload.
question
Which of the following interventions should be your first priority when treating a patient experiencing chest pain while walking? A. Have the patient sit down. B. Get the patient back to bed. C. Obtain an ECG. D. Administer sublingual nitroglycerin.
answer
(A) The initial priority is to decrease oxygen consumption by sitting the patient down. Administer sublingual nitroglycerin as you simultaneously do the ECG. When the patient's condition is stabilized, he can be returned to bed.
question
In which of the following types of cardiomyopathy does cardiac output remain normal? A. Dilated. B. Hypertrophic. C. Obliterative. D. Restrictive.
answer
(B) Cardiac output isn't affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. Dilated cardiomyopathy, obliterative cardiomyopathy, and restrictive cardiomyopathy all decrease cardiac output.
question
Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? A. Abdominal pain. B. Absent pedal pulses. C. Chest pain. D. Lower back pain.
answer
(D) Lower back pain results from expansion of the aneurysm. The expansion applies pressure in the abdomen, and the pain is referred to the lower back. Abdominal pain is the most common symptom resulting from impaired circulation. Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Chest pain usually is associated with coronary artery or pulmonary disease.
question
What's the first intervention for a patient experiencing chest pain and an 5p02 of 89%? A. Administer morphine. B. Administer oxygen. C. Administer sublingual nitroglycerin. D. Obtain an electrocardiogram (ECC)
answer
(B) Administering supplemental oxygen to the patient is the first priority. Administer oxygen to increase SpO2 to greater than 90% to help prevent further cardiac damage. Sublingual nitroglycerin and morphine are commonly administered after oxygen.
question
A patient receiving an anticoagulant should be assessed for signs of: a. Hypotension b. Hypertension c. An elevated hemoglobin count d. An increased number of erythrocytes
answer
(A) Hypotension. A major side effect of anticoagulant therapy is bleeding, which can be identified by hypotension (a systolic blood pressure under 100 mm Hg). Anticoagulants do not result in the other three conditions.
question
The difference between an 18G needle and a 25G needle is the needle's: a. Length b. Bevel angle c. Thickness d. Sharpness
answer
(C) Thickness. Gauge is a measure of the needle's thickness: The higher the number the thinner the shaft. Therefore, an 18G needle is considerably thicker than a 25G needle.
question
The best way to instill eye drops is to: a. Instruct the patient to lock upward, and drop the medication into the center of the lower lid b. Instruct the patient to look ahead, and drop the medication into the center of the lower lid c. Drop the medication into the inner canthus regardless of eye position d. Drop the medication into the center of the canthus regardless of eye position
answer
(A) Instruct the patient to lock upward, and drop the medication into the center of the lower lid. Having the patient look upward reduces blinking and protects the cornea. Instilling drops in the center of the lower lid promotes absorption because the drops are less likely to run into the nasolacrimal duct or out of the eye.
question
All of the following parts of the syringe are sterile except the: a. Barrel b. Inside of the plunger c. Needle tip d. Barrel tip
answer
(A) Barrel. All syringes have three parts: a tip, which connects the needle to the syringe; a barrel, the outer part on which the measurement scales are printed; and a plunger, which fits inside the barrel to expel the medication. The external part of the barrel and the plunger and (flange) must be handled during the preparation and administration of the injection. However, the inside and trip of the barrel, the inside (shaft) of the plunger, and the needle tip must remain sterile until after the injection.
question
When explaining the initiation of I.V. therapy to a 2-year-old child, the nurse should: a. Ask the child, "Do you want me to start the I.V. now?" b. Give simple directions shortly before the I.V. therapy is to start c. Tell the child, "This treatment is for your own good" d. Inform the child that the needle will be in place for 10 days
answer
(B) Give simple directions shortly before the I.V. therapy is to start. Because a 2-year-old child has limited understanding, the nurse should give simple directions and explanations of what will occur shortly before the procedure. She should try to avoid frightening the child with the explanation and allow the child to make simple choices, such as choosing the I.V. insertion site, if possible. However, she shouldn't ask the child if he wants the therapy, because the answer may be "No!" Telling the child that the treatment is for his own good is ineffective because a 2-year-old perceives pain as a negative sensation and cannot understand that a painful procedure can have position results. Telling the child how long the therapy will last is ineffective because the 2-year-old doesn't have a good understanding of time.
question
Which human element considered by the nurse in charge during assessment can affect drug administration? a. The patient's ability to recover b. The patient's occupational hazards c. The patient's socioeconomic status d. The patient's cognitive abilities
answer
(D) The patient's cognitive abilities. The nurse must consider the patient's cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient's ability to recover, occupational hazards, and socioeconomic status do not affect drug administration.
question
A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written? a. Within 1 month b. Within 3 months c. Within 6 months d. Within 12 months
answer
(C) Within 6 months. In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written.
question
The nurse uses a stethoscope to auscultate a male patient's chest. Which statement about a stethoscope with a bell and diaphragm is true? a. The bell detects high-pitched sounds best b. The diaphragm detects high-pitched sounds best c. The bell detects thrills best d. The diaphragm detects low-pitched sounds best
answer
(B) The diaphragm detects high-pitched sounds best. The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.
question
To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test? a. Red blood cell count b. Sputum culture c. Total hemoglobin d. Arterial blood gas (ABG) analysis
answer
(D) Arterial blood gas (ABG) analysis. All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test evaluates gas exchange in the lungs, providing information about patient's oxygenation status.
question
The nurse in charge measures a patient's temperature at 102 degrees F. what is the equivalent Centigrade temperature? a. 39 degrees C b. 47 degrees C c. 38.9 degrees C d. 40.1 degrees C
answer
(C) 38.9 degrees C. To convert Fahrenheit degrees to centigrade, use this formula: C degrees = (F degrees - 32) x 5/9 C degrees = (102 - 32) 5/9 + 70 x 5/9 38.9 degrees C
question
The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per millilitre. The nurse should anticipate giving how much heparin for each dose? a. ¼ ml b. ½ ml c. ¾ ml d. 1 ¼ ml
answer
(C) ¾ ml. The nurse solves the problem as follows: 10,000 units/7,500 units = 1 ml/X 10,000 X = 7,500 X= 7,500/10,000 or ¾ ml
question
A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do? a. Leave the medication at the patient's bedside b. Tell the patient to be sure to take the medication. And then leave it at the bedside c. Return shortly to the patient's room and remain there until the patient takes the medication d. Wait for the patient to return to bed, and then leave the medication at the bedside
answer
(C) Return shortly to the patient's room and remain there until the patient takes the medication. The nurse should return shortly to the patient's room and remain there until the patient takes the medication to verify that it was taken as directed. The nurse should never leave medication at the patient's bedside unless specifically requested to do so.
question
A scrub nurse in the operating room has which responsibility? A. Positioning the patient B. Assisting with gowning and gloving C. Handling surgical instruments to the surgeon D. Applying surgical drapes.
answer
(C) Handling surgical instruments to the surgeon. The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.
question
A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient's anxiety? A. "Everything will be fine. Don't worry." B. "Read this manual and then ask me any questions you may have." C. "Why don't you listen to the radio?" D. "Let's talk about what's bothering you."
answer
(D) "Let's talk about what's bothering you." Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient's feeling and block communication, they would not reduce anxiety.
question
A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role? A. Manager B. Educator C. Caregiver D. Patient advocate.
answer
(B) Educator. When teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patient's wishes known to the doctor.
question
When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects? A. Faster drug clearance B. Aging-related physiological changes C. Increased amount of neurons D. Enhanced blood flow to the GI tract.
answer
(B) Aging-related physiological changes. Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases.
question
Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient's medication drawer. What should the nurse in charge do? A. Discard the syringe to avoid a medication error B. Obtain a label for the syringe from the pharmacy C. Use the syringe because it looks like it contains the same medication the nurse was prepared to give D. Call the day nurse to verify the contents of the syringe.
answer
(A) Discard the syringe to avoid a medication error. As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
question
A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction? A. Asking frequently if the patient understands the instruction B. Asking an interpreter to replay the instructions to the patient. C. Writing out the instructions and having a family member read them to the patient D. Demonstrating the procedure and having the patient return the demonstration.
answer
(D) Demonstrating the procedure and having the patient return the demonstration. Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.
question
The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer? A. Position the head of the bed flat B. Helps the patient dangle the legs C. Stands behind the patient D. Places the chair facing away from the bed.
answer
(B) Helps the patient dangle the legs. After placing the patient in high Fowler's position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.
question
A female patient with a terminal illness is in denial. Indicators of denial include: A. Shock dismay B. Numbness C. Stoicism D. Preparatory grief.
answer
(A) Shock dismay. Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.
question
Which of the following planes divides the body longitudinally into anterior and posterior regions? A. Frontal plane B. Sagittal plane C. Midsagittal plane D. Transverse plane.
answer
(A) Frontal plane. Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.
question
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal? A. A palpable radial pulse B. A palpable ulnar pulse C. Cool, pale fingers D. Pink nail beds.
answer
(C) Cool, pale fingers. A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
question
The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data? A. Vital signs B. Laboratory test result C. Patient's description of pain D. Electrocardiographic (ECG) waveforms.
answer
(C) Patient's description of pain. Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient's opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data.
question
When examining a patient with abdominal pain the nurse in charge should assess: A. Any quadrant first B. The symptomatic quadrant first C. The symptomatic quadrant last D. The symptomatic quadrant either second or third.
answer
(C) The symptomatic quadrant last. The nurse should systematically assess all areas of the abdomen, if time and the patient's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
question
Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications? A. Decreased plasma drug levels B. Sensory deficits C. Lack of family support D. History of Tourette syndrome.
answer
(B) Sensory deficits. Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient's knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention
question
A 48 year old woman presents to the hospital complaining of chest pain, tachycardia and dyspnea. On exam, heart sounds are muffled. Which of the following assessment findings would support a diagnosis of cardiac tamponade? A. A deviated trachea B. Absent breath sounds to the lower lobes C. Pulse 40 with inspiration D. Blood pressure 140/80.
answer
(C.) Pulse 40 with inspiration. Paradoxical pulse is a hallmark symptom of cardiac tamponade. As pressure is exerted on the left ventricle from fluid, the natural increase in pressure from the right ventricle during inspiration creates even more pressure, diminishing cardiac output.
question
Nurse Shiela is teaching self-care to a client with psoriasis. The nurse should encourage which of the following for his scaled lesion? A. Importance of follow-up appointments B. Emollients and moisturizers to soften scales C. Keep occlusive dressings on the lesions 24 hours a day D. Use of a clean razor blade each time he shaves.
answer
(B.) Emollients and moisturizers to soften scales. Emollients will ease dry skin that increases pruritus and causes psoriasis to be worse. Washing and drying the skin with rough linens or pressure may cause excoriation. Constant occlusion may increase the effects of the medication and increase the risk of infection.
question
A 38 year old woman returns from a subtotal thryroidectomy for the treatment of hyperthyroidism. Upon assessment, the immediate priority that the nurse would include is: A. Assess for pain B. Assess for neurological status C. Assess fluid volume status D. Assess for respiratory distress.
answer
(D.) Assess for respiratory distress. Though fluid volume status, neurological status and pain are all important assessment, the immediate priority for postoperative is the airway management. Respiratory distress may result from hemorrhage, edema, laryngeal damage or tetany.
question
Betty Lee is a 58 year old woman who is being admitted to the medical ward with trigeminal neuralgia. The nurse anticipates that Mr. Lee will demonstrate which of the following major complaints? A. Excruciating, intermittent, paroxysmal facial pain B. Unilateral facial droop C. Painless eye spasm D. Mildly painful unilateral eye twitching.
answer
(A.) Excruciating, intermittent, paroxysmal facial pain. Trigeminal neuralgia is a syndrome of excruciating, intermittent, paroxysmal facial pain. It manifests as intense, periodic pain in the lips, gums, teeth or chin. The other symptoms aren't characteristic of trigeminal neuralgia.
question
Nurse Cynthia is providing a discharge teaching to a client with chronic cirrhosis. His wife asks her to explain why there is so much emphasis on bleeding precautions. Which of the following provides the most appropriate response? A. "The low protein diet will result in reduced clotting." B. "The increased production of bile decreases clotting factors." C. "The liver affected by cirrhosis is unable to produce clotting factors." D. "The required medications reduce clotting factors."
answer
(C.) "The liver affected by cirrhosis is unable to produce clotting factors." When bile production is reduced, the body has reduced ability to absorb fat-soluble vitamins. Without adequate Vitamin K absorption, clotting factors II, VII, IX, and X are not produced in sufficient amounts.
question
Sarah complains of a nursing sensation, cramping pain in the top part of her abdomen that becomes worse in the afternoon and sometimes awakes her at night. She reports that when she eats, it helps the pain go away but that pain is now becoming more intense. Which of the following is the best condition for the nurse to draw: A. These symptoms are consistent with an ulcer B. The client probably has indigestion C. A snack before going to bed should be advised D. The client probably developing cholelithiasis.
answer
(A.) These symptoms are consistent with an ulcer. The description of pain is consistent with ulcer pain. The pain is epigastric and is worse when the stomach is empty and is relived by food.
question
Mr. Lucas, a 63 year old, went to the clinic complaining of hoarseness of voice and a cough. His wife states that his voice has changed in the last few months. The nurse interprets that Mr. Lucas's symptoms are consistent with which of the following disorders: A. Chronic sinusitis B. Laryngeal cancer C. Gastroesophageal reflux disease D. Coronary artery disease.
answer
(B.) Laryngeal cancer. These symptoms, along with dysphagia, foul-smelling breath, and pain when drinking hot or acidic, are common signs of laryngeal cancer.
