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1.The nurse is performing her admission assessment of a patient.

When grading arterial pulses, a 1+ pulse indicates:

a.Above normal perfusion. b.Absent perfusion. c.Normal perfusion.

d.Diminished perfusion.
Answer: D

A 1+ pulse indicates weak pulses and is associated with diminished perfusion. A 4+ is bounding perfusion, a 3+ is increased perfusion, a 2+ is normal perfusion, and 0 is absent perfusion.


2. Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnose asthma. When teaching the patient about this drug, the nurse should explain that it may cause:
Nasal congestion b. Nervousness c. Lethargy d. Hyperkalemia

Answer B. Albuterol may cause nervousness. The inhaled

form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Otther adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting and muscle cramps.

3. Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In a acute rhinitis, nasal drainage normally is:

Yellow b. Green c. Clear d. Gray

Answer C. Normally, nasal drainage in acute rhinitis is

clear. Yellow or green drainage indicates spread of the infection to the sinuses. Gray drainage may indicate a secondary infection.

4. Before administering ephedrine, Nurse Tony assesses the patients history. Because of ephedrines central nervous system (CNS) effects, it is not recommended for:

Patients with an acute asthma attack b. Patients with narcolepsy c. Patients under age 6 d. Elderly patients
patients, who are particularly susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as increased systolic blood pressure, coldness in the extremities, and anginal pain). Ephedrine is used for its bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 and older.

Answer D. Ephedrine is not recommended for elderly

5.Nurse Ryan caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:

Call the physician b. Place the tube in bottle of sterile water c. Immediately replace the chest tube system d. Place a sterile dressing over the disconnection site
end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.

Answer B. If the chest drainage system is disconnected, the