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1. A client receives an autologous blood transfusion. The nurse should assess the client for which of the following? 1) Low back pain, headache and hematuria. 2) Urticaria, pruritus, and bronchospasm. 3) Tachycardia, chills, and fever. 4) Flushing, palpitations, and nausea.

2. A patient is brought to the emergency room with a compound fracture of the left femur. The patient’s vital signs are BP 80/60, pulse 120, respirations 26, temperature 99.0 degrees Fahrenheit (37.2 Degrees Cel.). Which of the following fluids, if ordered by the physician, should the nurse question? 1) Lactate Ringer’s 2) .45% NaCl. 3) .9% NaCl. 4) Hetastarch 3. The physician orders an IV with 5% dextrose in water (D5W) started for an 86-year-old patient on an acute care medical unit. Which of the following actions by the nurse is BEST? 1) Instruct the patient to breathe slowly and deeply through the mouth during auscultation of the posterior chest. 2) Apply the tourniquet 1 to 2 inches above the IV insertion site. 3) Apply a blood pressure cuff above the IV site insertion and inflate the cuff to the same level as the systolic blood pressure. 4) Start the IV using the dorsal veins of the patient’s forearm on the nondominant side. 4. The nurse cares for a patient receiving parenteral nutrition (TPN) through a subclavian triple lumen catheter. It is MOST important for the nurse to take which of the following actions?

1. Remove the old dressing over the insertion site, moving against the direction the catheter is inserted. 2. Clean the insertion site with an alcohol swab, moving from the outside to the inside in a circular pattern. 3. Flush the unused catheter lumens with heparinized saline. 4. Use clean gloves to reapply an occlusive dressing to the insertion site. 5. The nurse cares for a client who is receiving hetastarch (Hespan) intravenously. It is MOST important for the nurse to assess which of the following? 1. Pretibial ederma 2. Hourly urine output 3. Client’s weight.

4. Client’s lung sounds. 6. The nurse teaches a client about lorazepam (Ativan). Which of these statements by the client requires an intervention by the nurse? 1. “If the dose of Ativan is increased, I may feel more sleepy than usual.” 2. “I should follow my regular diet when taking this medication.” 3. “I may feel dizzy when I take this medication.” 4. “It is possible to get addicted to this medication after I take it for one week”

7. The nurse cares for the clients in the family planning clinic. A client using oral contraceptives for birth control is placed on a 7-day course of ampicillin. The nurse determines that teaching is successful if the client makes which of the following statements? 1. “I should take ampicillin with meals” 2. “Oral contraceptives will cause fluid retention.” 3. “I should use a barrier method of birth control for the rest of my cycle.” 4. “I should stop taking the oral contraceptives while taking ampicillin.” 8. A client diagnosed with a bacterial infection has a known allergy to penicillin and sulfa. Which of the following medications, if ordered by the physician, should the nurse question?

1. 2. 3. 4.

Tetracycline hydrochloride (Tetracyn) Sulfisoxazole (Gantrisin) Azithromycin (Zithromax) Ciprofloxacin (Cipro)

9. The nurse instructs a client about taking doxycycline calcium (Vibramycin). The nurse should intervene if the client makes which of the following statements? 1. “I should wear a hat and use sunscreen when I am outside” 2. “I should take this medication 1 hour before meals.” 3. “I should drink more fluids when taking this medication.” 4. “I should take this medication at bedtime.” 10. The nurse prepares to administer carbamazepine (Tegretol) 200 mg to a client. The nurse should assess which of the following prior to administration of the medication? 1. Serum platelet levels and hemoglobin. 2. Blood urea nitrogen and creatinine. 3. Aspartate aminotransferase (AST) and alanine aminotranserase (ALT). 4. C-reactive protein and creatinine kinase (CK) 11. The nurse cares for a client receiving propranolol (Inderal). It is MOST important for the nurse to observe for which of the following? 1. Dry cough. 2. Pulse rate less than 60 bpm. 3. Increased urinary output. 4. Difficulty sleeping. 12. The nurse cares for the clients on an acute-care neuroscience unit. Which of the following medications should the nurse administer FIRST? 1. Prednisone (Deltasone) 60 milligrams orally for a client diagnosed with multiple sclerosis reporting increased muscle weakness and fatigue. 2. Pyridostigmine (Mestinon) 75 mg orally for a client diagnosed with myasthenia graves reporting increased difficulty swallowing oral secretions. 3. Benztropine (Cogentin) 1 mg orally for a client diagnosed with Parkinson’s disease who is drooling. 4. Heparin 5,000 units subq for a client diagnosed with a thrombotic stroke 48 hours ago. 13. An elderly client using clonidine hydrochloride (Catapres-TTS) transdermal patches daily comes to be outpatient clinic for monitoring. Which of the following statements, if made by the client to the nurse, indicates further teaching is required? 1. “When I get out of bed in the morning, I move slowly so I don’t get dizzy.” 2. “One time I put adhesive patch on my right arm, and the next time I put it on my left arm.”

Rank the following nursing activities in the correct order from first activity to last activity. Elevate the head of the bed to 90% 2. The nurse begins the transfusion at 5mil/min-4 3. The nurse cares for a patients several hours after insertion of a central venous line. The nurse assesses a client receiving cyclophosphamide(Cytoxan-anti cancer drug-attack dividing cell in normal and abnormal cell too). Continue the treatment plan.3 * must go slowly 17. The nurse determines that the pt weighs 48kg (106lb).-1 4.help breath better…but do one thing when I go home.what will be the outcome Answer: 1 18. 3.0%NaCl is infusing through the line at 75ml/h. has consptiation been a problem for you? Answer: 3 16. The nurse should take which of the folling actions FIRST? 1.” 14. have you noticed any hair loss? 2. *pneumothorax. An IV of . a patient diagnosed with mania becomes depressed. The nurse administers packed cells to a client. 4. Monitor the patient for suicidal behavior. Have you had any nausea and vomiting? 4. Check the IV flow rate and insertion site. reassure the patient that everything will be ok.. Explore with the patient the reasons the patient appears depressed.” 4. The Dr. obtain equipment forinsertion of a chest tube 4. The pt become restless and apprear short of breath. It is MOST important for the nurse to take which of the following actions?” 1.3. Have you loss any weight? May vomiting and nausea 3. After 2 weeks of receiving lithium therapy. so I take a short nap. The nurse obtains the blood product from the blood bank. How many milligrams of amoxicillin should the nurse administer for each dose?____mg? . The nurse obtains a history of transfusion reactions. 3. “Sometimes the medicine makes me feel sleepy in the middle of the day. orders amoxicillin trihydrate(Amox) 20mg/kg PO q8hrs for a 12 years old pt. the nurse starts an IV with a 19-guauge needle-2 2. 2. “I remove the adhesive patch before I take a shower in the morning and replace it with a new one each evening. 1. 15.. Contact the physician to discuss the addition of an antidepressant. It is most important for the nurse to ask which of the following questions? 1.

Amoxil 21.The nurse instructs a client taking clopidogrel (plavix) 75mg daily. Did you use a new bath soap? 2. The nurse receives a phone call from a client taking Cipro 250mg po bid for the past 3 days. I can continue to take ibuprofen pills for my arthritis pain while taking plavix 2. I will need to take a daily muiltivit pill every day while taking plavix Answer:3 if you deal w/ ginko. The RN is aware that careful monitoring of the pt’s blood sugar is necessary if the pt receives which of the following meds?which med increase blood sugar 1. captopril (capoten)-PRIL -ACE inhibitor-control blood pressure 3. Which of the following response by the nurse is BEST? 1. When do you take the medication? 4. The nurse cares for a client receiving cisplatin(Platino-AQ)-It is most important for the nurse to follow up on which of the following client statements? 1. Prednisone (deltasone)-SONE –steroid-increase blood sugar 2. it will be necessary for me to have blood test monitoring done when take plav 3. My family thinks I ignore them when they are talking to me Platinol is an anti-cancer drug (can have bone marrow suppression) Answer: 4 . indicaties understading about the instructions? Plavix-antiplatelet 1. The nurse admits a pt with a hx of breast cancer and type 1 diabetes. 3. Nifedipine(procardia)4. Call me back if the rash gets worse. I take antiemetics after receiving Platinol-Aq 4. I now use a soft toothbrush 3. I cannot continue to take ginko for my memory problems while taking plavix 4.Answer: 20x48=960mg **and if given for each dose (single dose) or in 24 hr: 960mgx3 19. Which of the following statements. I drink 8-10 glasses of water every day 2. stop taking the meds. Answer: 4…pt has a sensitivity of CIPRO 20. if make by the client to the nurse. The client tells the nurse while bathing this morning he noticed a fine macular rash on his body. garlic and herbal –might be interaction because this is an antiplatelet agent herbal meds interaction w/ meds 22.

Give your childr one-half the prescribed dose every other day during the next week. I take a dialy multivit 2. I practivc tai chi dialy 3. which of the following patient's medication does not cause urine discoloration? . If you believe this change is due to medication.5mg bentropine(cogentin) for a client who has a hx of glaucoma and Type 2 diabetes. A patient tells you that her urine is starting to look discolored. The nruse cares for a client receiving carbidopa/levodopa (sinemet). It will be necessary to give your child high-calorie nutritious foods while take Ritalin Think: appetite and Med? Answer: 3 1. withhold the benztropine and contact the doctor 2. I eat several small meals a day Carbidopa/levodopa –anti parkingson agent (will decrease to effect If take w/ large amount of perodoxin) normal is ok Concern about herbal (kava-decrease anxiety. assess the client’s blood sugar prior to the first dose of the medications 3. Think: interaction w/ other meds Benztrophine did not effect blood sugar but contraindication w/ glaucoma Answer:1 24. You need to contact your health care provider today? 4. Inform the client that benztropine may cause urinary retention. Which of the following actions whould the nurse take FIRST? 1.23. I take kava for insomnia 4. It is most important for the nurse to make which of the following statements? 1. The RN receives an order for . 3. What has the child been eating during the last two week? 2. The nurse is MOST concerned if the client states which of the following? Most concern is mean something goes wrong 1. restlessness and insomnia) Answer:3 25. tell the client that the beneficial effects of the med will decrease over time 4. The nurse receives a phone call from a mother of an 8 years old taking Ritalin who says that her child has lost 4 lbs in the last two weeks.

If you found the following drug in the refrigerator it should be removed from the refrigerator's contents? A. Multiple sclerosis B. Immediately see a social worker B. You are responsible for reviewing the nursing unit's refrigerator. Autonomic neuropathy D. Phenolphthalein D. Start prophylactic Pentamide treatment D. Atherosclerosis B. Systemic sclerosis . Which of the following is the most important action that nursing student should take? A. Which of the following would you most likely suspect? A.A. Anorexia nervosa C. You are taking the history of a 14 year old girl who has a (BMI) of 18. Aspirin 2. Somatic neuropathy 6. Sulfasalazine B. Start prophylactic AZT treatment C. Epogen (injection) 3. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Diabetic nephropathy C. Corgard B. Which of the following would you most likely suspect? A. Urokinase D. IgD C. IgG 4. induced vomiting and severe constipation. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb? A. Seek counseling 5. The girl reports inability to eat. IgE D. She has also recently discovered that she is pregnant. Humulin (injection) C. Levodopa C. A 34 year old female has recently been diagnosed with an autoimmune disease. IgA B. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Bulimia D.

Which of the following would you most likely suspect? A. A 24 year old female is admitted to the ER for confusion. A fifty-year-old blind and deaf patient has been admitted to your floor. Hypercalcaemia C. and polyuria. Onset of pulmonary edema B. Which of the following statements made by a nurse is not correct regarding PKU? A. Mental deficits are often present with PKU. intense abdominal pain. Which of the following would be the best instruction for this patient? A. Metabolic alkalosis C. RH negative. A patient has taken an overdose of aspirin. RH positive B. D. A patient is getting discharged from a SNF facility. Let others know about the patient's deficits B. Rho gam is most often used to treat____ mothers that have a ____ infant. Deep breathing techniques to increase O2 levels. A new mother has some questions about (PKU). Irritable bowel syndrome 8. Continuously update the patient on the social environment. 12. Provide a secure environment for the patient. A. Hypocalcaemia D. RH positive. RH negative C. . B. Decrease CO2 levels by increase oxygen take output during meals. Respiratory alkalosis D. Diverticulosis B. RH positive D. Cough regularly and deeply to clear airway passages. B. Cough following bronchodilator utilization D. The effects of PKU are reversible. C. RH negative 9. A Guthrie test can check the necessary lab values. constipation. Parkinson's disease type symptoms 11. The patient has a history of severe COPD and PVD. C. This patient has a history of a myeloma diagnosis. D.7. As the charge nurse your primary responsibility for this patient is? A. RH positive. The urine has a high concentration of phenylpyruvic acid C. RH negative. The patient is primarily concerned about their ability to breath easily. Communicate with your supervisor your concerns about the patient's deficits. 10. Which of the following should a nurse most closely monitor for during acute management of this patient? A.

The life span of RBC is 60 days. Simian crease B. A. Hypotonicity 15. Streptokinase B. B. Which of the following clinical signs would most likely be present? A. C. Brachycephaly C. A patient has recently experienced a (MI) within the last 4 hours. A patient asks a nurse. . D. A nurse is putting together a presentation on meningitis. Yellow vegetables and red meat C. difficile 18. Green vegetables and liver B.13. Which of the following characteristics is not associated with Down's syndrome? A. Which of the following medications would most like be administered? A. You will be assigned to care for the child at shift change. Carrots D. The life span of RBC is 90 days. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. H. What type of foods contain folic acids?” A. Milk 17. Coumadin 16. influenza C. N. The patient asks how long to RBC's last in my body? The correct response is. The life span of RBC is 45 days. Oily skin D. meningitis D. A nurse is administering blood to a patient who has a low hemoglobin count. Weight gain C. The life span of RBC is 120 days. Irregular WBC lab values 14. Which of the following microorganisms has noted been linked to meningitis in humans? A. pneumonia B. Slow pulse rate B. Atropine C. S. A mother has recently been informed that her child has Down's syndrome. Cl. “My doctor recommended I increase my intake of folic acid. Decreased systolic pressure D. Acetaminophen D.

Trust vs. 5 year old male. 90/65 mm Hg D.. According to Erickson which of the following stages is the adult in? A.p. When does the discharge training and planning begin for this patient? A. 6 year old female. mistrust B. 90/70mm Hg 24.p. Which of the following conditions would a nurse not administer erythromycin? . isolation 21.19. guilt C.p.p. A young adult is 20 years old and has been recently admitted into the hospital.m. When you are taking a patient's history. Pergolide D. 100/70 mm Hg B. A toddler is 16 months old and has been recently admitted into the hospital. 26 resp/min.m. 22 resp/min.. isolation 22. Elavil B. Preoperative discussion 20..102 b. Trust vs. mistrust B. shame D..m. guilt C. shame D. A nurse is making rounds taking vital signs. guilt C. she tells you she has been depressed and is dealing with an anxiety disorder. Autonomy vs. Upon admit C. Following surgery B. Which of the following medications would the patient most likely be taking? A. mistrust B. Trust vs. Initiative vs. 13 year old female – 105 b.100 b. isolation 23. Initiative vs. 11 year old male – 90 b. A child is 5 years old and has been recently admitted into the hospital. Which of the following vital signs is abnormal? A. Verapamil 25. shame D. According to Erickson which of the following stages is the toddler in? A.. A 65 year old man has been admitted to the hospital for spinal stenosis surgery. Within 48 hours of discharge D. Autonomy vs. Intimacy vs. 105/60 mm Hg C.. Intimacy vs. Autonomy vs. According to Erickson which of the following stages is the child in? A. 22 resp/min. Intimacy vs. Calcitonin C.m. 24 resp/min. Initiative vs.

C 9. What type of precaution is used with persons that have Cytomegalovirus infection? A. D 4. Care for pt 3). D The proper sequence of precautions for taking care of a pt on Infection Control Precautions are as follows : 1) Wash hands upon completion 2). D 10. A 25. Campylobacterial infection B. B 7. Pneumonia D. A 22. B 20. B 24. Multiple Sclerosis Answer Key 1. B 21. A 17. Don mask/gown/gloves 4). D 23. Legionnaire's disease C. B 5. Remove mask/gown/gloves 7. D 2. A 3. Droplet precautions D. Contact precautions C. D 11. Standard precautions B. Enter Room 5). Airborne precautions . B 14. C 6. C 13. C 15. D 19. D 12. A 16.A. D 18. B 8.

Tuberculosis B. What illness/disease process requires the use of disposable dishware according to the center for disease control guidelines? Choose all that apply: A. As per Standard Precautions. Which of the following nursing action should take priority? A. Cough F. and the patient's environment. or has diarrhea or a draining wound. Change gloves between distinctive tasks (e. Check all that apply: 1.g. perineal care. Meningitis D. Wear a disposable gown for direct contact with the patient or the environment if the patient is incontinent. When caring for someone on “Contact Isolation”. . Sneezing D. The following is true. Gowns are removed and placed in a special container for next use. Cloth gowns may be substituted if there is no risk of splash 3. the patient's bedside equipment. A patient arrives at the emergency department complaining of mid-sternal chest pain. b. 2. suctioning).8. C. Chicken pox 9. a. C. wear a mask and protective eyewear when performing procedures that generate aerosols (Standard Precautions) 1. An electrocardiogram. Fever B. Wear gloves for all contact with the patient. MRSA (methicillin-resistant Staphylococcus aureus). Chest exam with auscultation. Careful assessment of vital signs. Gloves must always be removed before leaving the room. What are the symptoms of Acinetobacter infection caused by pneumonia? Check all that apply: A. Congestion E. A complete history with emphasis on preceding events. wound care. Runny Nose 10. B. 2 part answers must be entirely correct. Chills C. a. b. D.

D. Which of the following statements by the nurse is correct? . A one-week postoperative coronary bypass patient. B. B.2. keep the other bed in the room unassigned to provide privacy and comfort to the family. Which of the following actions should the nurse take? A. 4. 3. A post-operative valve replacement patient who was recently admitted to the unit because all surgical beds were filled. D. If possible. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed. A patient with unstable angina being closely monitored for pain and medication titration. A suspected myocardial infarction patient on telemetry. Which misunderstanding by the family indicates the need for more detailed information? A. Contact the physician to report the unusual rituals and activities. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. The patient should resume a normal diet with emphasis on nutritious. C. A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. B. D. The charge nurse on the cardiac unit is planning assignments for the day. healthy foods. A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. The patient should continue use of the incentive spirometer to keep airways open and free of secretions. Restrict visiting hours and ask the family to limit visitors to two at a time. The patient may resume normal home activities as tolerated but should avoid physical exertion and get adequate rest. C. C. A patient has been hospitalized with pneumonia and is about to be discharged. The physician has prescribed Glucagon for emergency use. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery? A. 5. The mother asks the purpose of this medication. just admitted from the Emergency Department and scheduled for an angiogram. A nurse provides discharge instructions to a patient and his family. who is being evaluated for placement of a pacemaker prior to discharge. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved.

A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation. B. Patch the eye. bowel sounds will be louder and higher pitched. Place fluorescein drops in the eye. The nurse performs an initial abdominal assessment on a patient newly admitted for abdominal pain. A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal. Which of the following choices indicates the correct placement of the conductive gel pads? A. 8. C. In the presence of intestinal obstruction. Irrigate the eye repeatedly with normal saline solution. The advanced cardiac life support team prepares to defibrillate. Glucagon prolongs the effect of insulin. The frequency and intensity of bowel sounds varies depending on the phase of digestion. B. B. Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after injection. Test visual acuity. D. Glucagon treats lipoatrophy from insulin injections. 7. 9. Glucagon treats hypoglycemia resulting from insulin overdose. Right of midline below the bottom rib and the left shoulder. allowing fewer injections. The left clavicle and right lower sternum. C. C. D. D. B. The nurse hears what she describes as "clicks and gurgles in all four quadrants" as well as "swishing or buzzing sound heard in one or two quadrants." Which of the following statements is correct? A. C. 6. All of the above. The nurse should be most concerned about which of the following findings? . Which of the following nursing actions is a priority? A. The upper and lower halves of the sternum. A nurse is caring for a patient who has had hip replacement. D. The right side of the sternum just below the clavicle and left of the precordium.A.

headache.52. PCO2 40 mm Hg.A. pH 7. A patient who is unable to bear weight on the left foot. PCO2 54 mm Hg. Notify the physician. A patient is admitted to the hospital with a calcium level of 6.7 C). 12. Restrain the patient's limbs.8 F (38. Hypoactive bowel sounds. 13. B. C.42. B. with swelling and bruising following a running accident. A nurse cares for a patient who has a nasogastric tube attached to low suction because of a suspected bowel obstruction. B. C. Which of the following symptoms would you NOT expect to see in this patient? A. spicy meal. B. C. pH 7. Which of the following patients should be assigned the highest priority? A. D. The admitting physician writes orders for actions to be taken in the event of a seizure. Numbness in hands and feet. Complaints of pain following physical therapy. A nurse working the evening shift is presented with four patients at the same time. Muscle cramping. D. Which of the following arterial blood gas results might be expected in this patient? A. C. Emergency department triage is an important nursing function. 10. Temperature of 101. Complaints of pain during repositioning. and myalgias for the past 72 hours. 11. A patient with low-grade fever. . Position the patient on his/her side with the head flexed forward. D. Positive Chvostek's sign. Administer rectal diazepam. A child is admitted to the hospital with an uncontrolled seizure disorder. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed. Scant bloody discharge on the surgical dressing. D. B. Which of the following actions would NOT be included? A.0 mg/dL. A patient with abdominal and chest pain following a large.

B. A hematoma is visible in the area of the IV insertion site.4%. D. dyspneic and uncomfortable. 17. The IV solution is infusing too slowly. B. crackles are heard in the bases of both lungs. D. A nurse is performing routine assessment of an IV site in a patient receiving both IV fluids and medications through the line. C. pH 7. Total serum protein 7. probably indicating that the patient is experiencing a complication of transfusion. particularly in a patient scheduled for surgery. C. Which of the following results are abnormal? Note: More than one answer may be correct. A. Draw a blood sample for type and crossmatch and request blood from the blood bank.4 g/dL.C. PCO2 36 mm Hg. A nurse enters the room to find the patient sitting up in bed. The follow lab results are received for a patient. Which of the following complications is most likely the cause of the patient's symptoms? . Administer vitamin K.0 g/dL. the nurse anticipates which of the following actions? A. C. Total cholesterol 340 mg/dL. D. A hospitalized patient has received transfusions of 2 units of blood over the past few hours. warm. 16. Included in the list of current medications is Coumadin (warfarin) at a high dose. 14. particularly when the limb is elevated. Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) level. D. The area proximal to the insertion site is reddened. PCO2 25 mm Hg. The patient complains of pain on movement.38.25. Cancel the surgery after the patient reports stopping the Coumadin one week previously. Glycosylated hemoglobin A1C 5. Which of the following would indicate the need for discontinuation of the IV line as the next nursing action? A. Hemoglobin 10. pH 7. B. A patient is admitted to the hospital for routine elective surgery. Concerned about the possible effects of the drug. On assessment. and painful. 15.

The procedure is usually painless and is followed by a gush of amniotic fluid. including decreased urinary output and changes in skin turgor.A. Allergic transfusion reaction. The FHR (fetal heart rate) will be followed closely after the procedure due to the possibility of cord compression. at least every 2-4 hours. Continue to breastfeed frequently. Watch for signs of dehydration. Follow up with the infant's physician within 72 hours of discharge for a recheck of the serum bilirubin and exam. The infant should be restrained in an infant car seat facing forward or rearward in the back seat. and place the bassinet in a dimly lit area. The infant should be restrained in an infant car seat. A nurse is giving discharge instructions to the parents of a healthy newborn. A patient in labor and delivery has just received an amniotomy. Which of the following instructions by the nurse is NOT correct? A. The infant should be restrained in an infant car seat. Keep the baby quiet and swaddled. C. 18. D. Acute hemolytic reaction. Contractions may rapidly become stronger and closer together after the procedure. D. B. A. Answer Key . B. Which of the following instructions should the nurse provide regarding car safety and the trip home from the hospital? A. D. C. Febrile non-hemolytic reaction. 20. the parent may sit in the back seat and hold the newborn. C. A nurse is counseling the mother of a newborn infant with hyperbilirubinemia. Which of the following is correct? Note: More than one answer may be correct. Fluid overload. properly secured in the front passenger seat. properly secured in the back seat in a rear-facing position. For the trip home from the hospital. C. 19. B. B. D. Frequent checks for cervical dilation will be needed after the procedure.

1. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. including onset of symptoms. 4. In the case of antibiotics. . as well as a nutritious diet. Answer: A The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. it is important that the dying be surrounded by loved ones and not left alone. Answer: C It is always critical that patients being discharged from the hospital take prescribed medications as instructed. it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. B. Answers A. and D are incorrect because they create unnecessary conflict with the patient and family. Traditional rituals and foods are thought to ease the transition to the next life. In the Vietnamese culture. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. Continued use of the incentive spirometer after discharge will speed recovery and improve lung function. A thorough medical history. When possible. will be necessary and it is likely that an electrocardiogram will be performed as well. Answer: C When a family member is dying. 3. allowing the family privacy for this traditional behavior is best for them and the patient. chest exam with auscultation may offer useful information after vital signs are assessed. A post-operative patient also requires close monitoring and cardiac experience. 2. but these are not the first priority. The patient who is one-week post-operative and nearing discharge is likely to require routine care. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. Answer: C The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. The patient should resume normal activities as tolerated. Similarly. a full course must be completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection.

Following irrigation. Some pain during repositioning and following physical therapy is to be expected and can be managed with analgesics. nor is patching the eye. Answer: D Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of neurovascular complications and the development of infection. Answer: D All of the statements are true. Options A. A small amount of bloody drainage on the surgical dressing is a result of normal healing. A temperature of 101. Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat. Answer: A Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline.5. The irrigation should be continued for at least 10 minutes. Following Glucagon administration. B. . and should always be considered abnormal. which vary with the phase of digestion. Answer: D One gel pad should be placed to the right of the sternum. visual acuity will be assessed. To defibrillate. Glucagon reverses rather than enhances or prolongs the effects of insulin. 7. just below the clavicle and the other just left of the precordium. for example. the paddles are placed over the pads. The gurgles and clicks described in the question represent normal bowel sounds. Fluorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash. The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurism. as indicated by the anatomic location of the heart. the patient should respond within 15-20 minutes at which time oral carbohydrates should be given.8 F (38. 8. 6. Answer: B Glucagon is given to treat insulin overdose in an unresponsive patient. 9. Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. and C are not consistent with the position of the heart and are therefore incorrect responses.

Answer B is a normal blood gas. who should be notified of the seizure. blocking the airway. The patient with the foot injury may have sustained a sprain or fracture. nursing actions should focus on securing the patient's safely and curtailing the seizure. respiratory distress. Of the answers given. Patients with trauma. Rectal diazepam may be a treatment ordered by the physician. he also may be having an acute myocardial infarction and require urgent attention. The patient with fever. Increased gastric motility. Answer: B During a witnessed seizure. Answer: A . Answer: C Normal serum calcium is 8. 12. Numbness in hands and feet and muscle cramps are also signs of hypocalcemia. 11. headache and muscle aches (classic flu symptoms) should be classified as non-urgent. or acute neurological changes are always classified number one priority. chest pain. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn. A side-lying position with head flexed forward allows for drainage of secretions and prevents the tongue from falling back. Answer: A A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric fluid. only answer A (pH 7. Answer C represents respiratory acidosis. Answer D is borderline normal with slightly low PCO2. 14. The child's chin laceration may need to be sutured but is also non-urgent. abdominal cramping and diarrhea is an indication of hypocalcemia. The patient is hypocalcemic.10 mg/dL. and the limb should be x-rayed as soon as is practical. PCO2 54 mm Hg) represents alkalosis. Answer: C Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care.52.10. but the damage is unlikely to worsen if there is a delay. 13. Restraining the limbs is not indicated because strong muscle contractions could cause injury. Positive Chvostek's sign refers to the sustained twitching of facial muscles following tapping in the area of the cheekbone and is a hallmark of hypocalcemia. resulting in hyperactive (not hypoactive) bowel sounds.5 .

16 g/dL. 17. The next step is to check the PT and INR to determine the patient's anticoagulation status and risk of bleeding. causing fluid leak into the lungs. itching. If lab results indicate an anticoagulation level that would place the patient at risk of excessive bleeding. the surgeon may choose to delay surgery and discontinue the medication. Answer: B An IV site that is red. The procedure itself is painless and results in the quick . rapid respirations. Total serum protein of 7. The FHR is assessed immediately after the procedure and followed closely to detect changes that may indicate cord compression. It is the most serious adverse transfusion reaction and can cause shock and death. Symptoms of allergic transfusion reaction would include flushing. Preparation for transfusion.4% are both normal levels. 15. Pain on movement should be managed by maneuvers such as splinting the limb with an IV board or gently shifting the position of the catheter before making a decision to remove the line. is only indicated in the case of significant blood loss.0-g/dL and glycosylated hemoglobin A1c of 5. as described in option C. and a generalized rash. 16. Febrile non-hemolytic reaction results in fever. Vitamin K is an antidote to Coumadin and may be used in a patient who is at imminent risk of dangerous bleeding. painful and swollen indicates that phlebitis has developed and the line should be discontinued and restarted at another site.The effect of Coumadin is to inhibit clotting. Answer: B. warm. Total cholesterol levels of 200 mg/dL or below are considered normal. An IV line that is running slowly may simply need flushing or repositioning. and discomfort as in the patient described. C. 18. and D Uterine contractions typically become stronger and occur more closely together following amniotomy. Answer: D Fluid overload occurs when then the fluid volume infused over a short period is too great for the vascular system. Answer: A and B Normal hemoglobin in adults is 12 . Symptoms include dyspnea. A hematoma at the site is likely a result of minor bleeding at the time of insertion and does not require discontinuation of the line. Acute hemolytic reaction may occur when a patient receives blood that is incompatible with his blood type.

Signs of dehydration. Answer: A All infants under 1 year of age weighing less than 20 lbs. 20. She is alert and sitting on her mother s lap. Following amniotomy. Frequent feedings will help to metabolize the bilirubin. and has increased work of breathing. cervical checks are minimized because of the risk of infection 19. Infants should always be placed in an approved car seat during travel. and respirations of 48 breaths/min. Infant car seats should never be placed in the front passenger seat. D. Assessment reveals that she has warm. including decreased urine output and skin changes. flushed skin. You should immediately determine whether the patient has: A.expulsion of amniotic fluid. delayed capillary refill time. 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. the ability to tolerate oral feedings. She has a blood pressure of 88/66 mm Hg. C. A recheck of the serum bilirubin and a physical exam within 72 hours will confirm that the level is falling and the infant is thriving and is well hydrated. stridor. even on that first ride home from the hospital. indicate inadequate fluid intake and will worsen the hyperbilirubinemia. B. a pulse of 128 beats/min. weak pulses. . should be placed in a rear-facing infant car seat secured properly in the back seat. Answer: D An infant discharged home with hyperbilirubinemia (newborn jaundice) should be placed in a sunny rather than dimly lit area with skin exposed to help process the bilirubin. is using her abdominal muscles to breathe.

Abdominal breathing in this patient should be viewed as a: A. A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. a pulse of 128 beats/min. C. D. deliver bag-valve-mask ventilations.2. is using her abdominal muscles to breathe. 4. administer a nebulizer treatment with a beta-agonist medication. and respirations of 44 breaths/min. is using her abdominal muscles to breathe. suction the oropharynx for secretion. flushed skin. compensatory mechanism to increase the volume of air inhaled and respiratory rate. and has increased work of breathing. She is alert and sitting on her mother s lap. He has a blood pressure of 74/62 mm Hg. normal finding for a toddler. deformed left thigh. and respirations of 48 breaths/min. 3. She is alert and sitting on her mother s lap. a pulse of 128 beats/min. D. What do these findings tell you about the patient s condition? A. Assessment reveals abrasions to his left shoulder and back and a swollen. a pulse of 152 beats/min. B. flushed skin. C. without increased work of breathing. and respirations of 48 breaths/min. and has increased work of breathing. sign of decreased perfusion to the respiratory center. sign of impending respiratory failure. He is unresponsive and his skin is cool because of a low body . A 6-year-old boy who was struck by a car while he was riding his bicycle is unresponsive and has pale. She has a blood pressure of 88/66 mm Hg. Assessment reveals that she has warm. cool skin. administer humidified oxygen via blow-by method. Assessment reveals that she has warm. The first step in treatment is to: A. A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. B. She has a blood pressure of 88/66 mm Hg.

and rapid. The appropriate initial treatment is to: A. The tachycardia in this infant is most likely due to: A. and a capillary refill time of 4 seconds. hypovolemia. He has a blood pressure of 74/60 mm Hg. respirations without increased work of breathing at 60 breaths/min. 6. administer epinephrine via an intraosseous needle. and diarrhea for the past 3 days. vomiting. swelling of the brain. and diarrhea for the past 3 days. His heart rate is fast because of pain in his shoulder and leg C. . A 3-month-old infant who is extremely lethargic has had a cough. Assessment reveals that he responds to pain. D. B. vomiting. C. a pulse of 190 beats/min. D. administer 100% oxygen by mask. perform endotracheal intubation. and rapid. He has a blood pressure of 74/60 mm Hg. His respirations are fast because the impact affected the respiratory center in his brain D. has mottled skin color. a pulse of 190 beats/min. B. A 3-month-old infant who is extremely lethargic has had a cough. Assessment reveals that he responds to pain.temperature from being outside B. and a capillary refill time of 4 seconds. pneumothorax. C. anxiety. His blood pressure is low because compensatory mechanisms for blood loss are failing 5. has mottled skin color. administer dopamine intravenously. respirations without increased work of breathing at 60 breaths/min.

An 8-year-old boy fell 7 feet out of a tree. 9. open her mouth and insert an oropharyngeal airway to maintain a patent airway. Crackles in the lungs C. He has a blood pressure of 92/74 mm Hg. the substance was ingested approximately one hour ago. The first step in caring for this patient is to: A. turn her on her side to allow any water to drain from her mouth.7. C. there is a history of abdominal surgery. Bystanders report that she was shaking all over as they pulled her out of the water. and a deformed right forearm. . stabilize her cervical spine to reduce the risk of further spinal injury. A 10-year-old girl is unresponsive when she surfaces after diving into a quarry. Which of the following findings in a 2-year-old child assists in identifying the cause of a grand mal seizure? A. a pulse of 128 beats/min. elevate her head to reduce the risk of aspiration. multiple abrasions on his right shoulder and hip. Activated charcoal is contraindicated in a patient who has ingested a toxic substance if: A. Cardiac dysrhythmia 8. D. the substance was corrosive. landing on his right arm and falling to his right side. He is crying and appears agitated. there is a history of diarrhea or vomiting. 10. warm skin. C. D. Abdominal tenderness D. B. Fever B. B. Assessment reveals that he has pale. and respirations of 32 breaths/min.

and a deformed right forearm. He is crying and appears agitated. warm skin. Exposing only those areas currently being assessed and then covering them C. cover him with blankets to prevent heat loss. place him in a position of comfort to decrease anxiety. multiple abrasions on his right shoulder and hip. and respirations of 32 breaths/min. B. Asking him what hurts the most and begin by assessing that area of the body 11.What is the best approach to conducting the assessment of this patient? A. Assessment reveals that he has pale. the first step in caring for this patient is to: A. a pulse of 128 beats/min. Assessment reveals that he has pale. C. multiple abrasions on his right shoulder and hip. D. An 8-year-old boy fell 7 feet out of a tree. landing on his right arm and falling to his right side. Asking him if it is okay to listen to his lungs and touch his chest and stomach D. manually stabilize the cervical spine to reduce the risk of spinal injury. He has a blood pressure of 92/74 mm Hg. and respirations of 32 breaths/min. He has a blood pressure of 92/74 mm Hg. initiate hyperventilation to reduce the accumulation of acids in the body. Secondary brain injury . warm skin. 12. a pulse of 128 beats/min. Telling him he must lie still or he may become paralyzed B. What is the most likely cause for the abnormal appearance of this patient? A. An 8-year-old boy fell 7 feet out of a tree. He is crying and appears agitated. and a deformed right forearm. After completing your initial assessment. landing on his right arm and falling to his right side.

Hypoxia C. and I couldn't wake her up. He is alert and crying. respiratory failure. "I couldn t get her to stop crying. A 6-month-old infant who is being cared for by a babysitter is unresponsive and has warm. I can't take her crying any more. pink skin and respirations without increased work of breathing." The babysitter states that she does not think that the infant has been sick recently. An 18-month-old boy who reportedly fell down the stairs earlier in the day just isn t acting right. 15. What information is important to obtain about a child with smoke inhalation? A. Position of the patient when found C. All of a sudden she got really quiet. Hypothermia 13. C. according to his caregivers. The babysitter states. B. Location in the room where the patient was found 14. The babysitter appears anxious and frustrated and explains that the infant had been crying for hours and would not stop. Assessment reveals multiple bruises on his thighs and back and a deformity of his right thigh. History of recent cold symptoms D. toxic exposure.B. seizures. Please help her. What is the best way to interact with the caregivers? . D. Pain D. I tried everything. shaken baby syndrome. Presence of windows or ventilation in the room B. The infant s altered level of consciousness is most likely due to: A..

decide whether the baby will be delivered at the scene or if there is time to transport the mother to the hospital. initiating bag-valve-mask ventilations. D. particularly if the infant is premature. The most important treatment of the newborn is to: A. assemble the correct size of equipment to care for the baby. C. 16. determine if meconium aspiration may have occurred. 17. and face. B. the delay has made the child very sick. C. Confront them by telling them you know that this injury could not have occurred from a fall. feet. copiously suction the mouth and nose. Explain that you are very concerned about the child s condition and that he needs to be examined at the hospital for a possible a broken leg. therefore. administer oxygen by nasal cannula at 4 L/min. Contact the local law enforcement agency to request that the caregiver be arrested while you transport the child. you will need to administer oxygen and establish an IV. . Ascertaining the due date of a newborn during an impending delivery helps you to: A. C. you are obligated to take him to the hospital. trunk. B. Ask them why they waited so long to call for help. A woman who is about to deliver a baby at home reports that the fluid was thick green when her bag of waters broke. D. D. calculate the APGAR score. as the labor is often shorter for these infants. Assessment of a newborn five minutes after delivery reveals cyanosis of the hands. vigorously dry and warm the baby. 18. therefore. Vital signs are pulse 160 beats/min and respirations 44 breaths/min. decide if an on-scene delivery is needed.A. B. Treatment of this newborn includes: A.

Use of abdominal muscles to breathe B. mottled skin. has cool. Switch the patient to oxygen by blow-by method because the . applying free flow oxygen by mask at 5 L/min. Crackles and decreased breath sounds D. Unequal chest rise and wheezing 21. He is on continuous oxygen. Which of the following signs suggests significant obstruction of the tracheostomy tube? A. His mother states that his breathing is getting much worse. Temperature of 37 degrees (98. reassessing the skin color in five minutes and then initiating oxygen therapy if needed. 19. what is the correct way to manage the respiratory status of a boy who is on a ventilator but also breathes on his own? A. Refuses a pacifier 20. Assessment reveals that he is lethargic. Immediately deliver bag-valve-mask ventilations because you may not be familiar with the ventilator C. performing intubation and positive pressure ventilation. D. A 3-year-old boy who has a tracheostomy has had difficulty breathing and coughing for 2 days because of increased secretions. Allow the patient to remain on the ventilator if he is not in respiratory distress B.6 F) C. A slow heart rate and poor air exchange B. and has copious secretions in the tracheostomy tube. C.B. Irregular respirations and wheezing C. During transport. An infant should be immediately evaluated by a physician if which of the following signs or symptoms are present? A. Acting fussier than normal D.

If the child is quiet the head does not need to be secured once lateral stabilization devices are applied . It will be more difficult to obtain a seal for ventilation C. What is the danger of using a mask that is too large on a child who requires ventilatory assistance? A. Auscultate the anterior chest and mid-abdominal area for the presence of bubbling or gurgling sounds D. Eye injuries may occur from the mask touching the globe B. Observe for gastric distention which indicates leakage of air around the tube in the trachea C. it may exert pressure and stimulate the vagus nerve 23.ventilator will not work in the ambulance D. Decrease the flow rate as the oxygen in the ambulance is more potent and requires a lower flow rate 22. After the body straps have been applied. Before any straps or lateral stabilization devices have been applied D. Auscultate for bubbling or gurgling sounds over the epigastrium and breath sounds at the midaxillary regions 24. Palpate for chest rise and fall over the anterior chest and abdomen B. If the mask extends across the eyes. which may cause dislocation of the mandible D. When should the child s head be secured to the spine board during the immobilization procedure? A. After the body straps and lateral stabilization devices have been applied B. More pressure will need to be applied to obtain a mask seal. but before the lateral stabilization devices to ensure that the tape is applied tightly C. What is the correct method to confirm proper placement of an endotracheal tube? A.

Informed consent must be signed and acknowledged by both the physician and the patient. . Which of the following substances can be infused via an intraosseous needle? A. but do function as the witness to informed consent. Fluids or medications that are not acidic D. Only medications and fluids that have a neutral pH _______________________________________________________________________ Informed consent is intended to facilitate appropriate. receiving specialty services and/or making any type of decision regarding health care. All medications and intravenous fluids B. All medications except sodium bicarbonate and dextrose C. knowledgeable decision making among clients who are hospitalized. nurses are no longer responsible for the information on and for obtaining informed consent.25. Informed consent should be directed toward the educational and cognitive level of the client. All possible outcomes and consequences of the procedure or treatment should be explained in as much detail as needed to ensure the client fully understands what is to be done and the potential outcomes.

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