Signs/Symptoms
A nurse is assessing her 86 year old patient and notes the patient is flushed, confused, and irritable. Her latest set of vitals are BP 154/87, HR 90, R 16, and 02 97%. The nurse anticipates which of the follow lab values:
A- K 3.5
B- Na 155
C- Mg 1.5
D- Phos 5
B- Na 155
Hypernatremia s/s- flushed, confusion, irritability, and elevated BP
A nurse is caring for a patient admitted to the unit for a chest pain, palpitations, and SOB. After receiving the patients most recent labs, the nurse notes a potassium level of 6. Which of the following interventions would the nurse anticipate?
A- Administering Spironolactone
B- Diet with leafy green vegetables
C- Administer Potassium Chloride
D- continuous cardiac monitoring (ECG)
Answer- D
Rationale: Spironolactone is a potassium-sparing diuretic, diet should limit potassium rich foods, Potassium Chloride is given in hypokalemia.
An ED nurse is caring for a 89 year old female patient who presented with confusion and abdominal pain. The nurse notes which of the following is used to confirm a UTI?
A- UA positive for leukocytes
B- Abdominal X-ray
C- Low Na
D- Low WBC
Answer- A UA positive for leukocytes
Rationale: UA positive for leukocytes confirms a present infection in the urine. Low WBC and low Na would not indicate a UTI. Abdominal X-ray would not show signs of a UTI.
A nurse is caring for a patient with a history of DM type 2. When administering the patients morning medications, the nurse notes a morning glucose check of 253. According to the sliding scale below, how much short acting insulin would the nurse administer?
Glucose Units
150-200 2 units
200-250 4 units
250-300 6 units
300-350 8 units
350-400 10 units
A- 10 units
B- 2 units
C- 6 units
D- 4 units
Answer- C- 6 units
Rationale: For a glucose of 253, the nurse should administer 6 units as per the sliding scale.
A nurse is coming in for their shift and received report on their patients. After receiving report, the nurse knows which of the following patients should be seen first?
A- A patient with a productive cough and temp of 100.8 F
B- A patient with pneumonia reporting increased shortness of breath and RR 32/min
C- A patient post-op day 2 with mild incisional pain
D- A patient receiving a blood transfusion with no current complications
Answer: B
A patient is admitted to the ED with a history of IBS. Which of the following would the nurse anticipate assessing in the patient?
A- Fever
B- Abdominal pain
C- Bloody stool
D- Sudden weight loss
B- Abdominal Pain
Rationale: IBS s/s relate to malfunction vs IBD (Chron's, UC, etc) relate to inflammatory response- fever, sudden weight loss, bloody stool
A patient presents to the ED with a chief complaint of pain rated a 10/10 in the LLQ. While waiting for her CT results, the patient states the pain has stopped. Upon further assessment, she states she felt a pop followed by relief. How should the nurse respond?
A- Express happiness that she has some relief
B- Administer PRN Tylenol
C- Immediately call the doctor
D- Let the patient know you're still waiting for the CT results and you'll be back as soon as they're in
Answer- C
Rationale: A popping sensation followed by relief indicates appendix rupture. Expressing happiness in her relief and waiting for CT results doesn't acknowledge her change in status, and administering Tylenol in appropriate as she reports no pain.
A nurse is caring for a patient with anemia. After reviewing the patients morning labs, the doctor has placed an order to administer 1 unit of RBC. After administering the blood, what lab values would the nurse expect to confirm the 1 unit of RBC was effective?
A- Hct 36
B- Hgb 7.2
C- Platelet 46,000
D- RBC 4.0
Answer- B Hgb 7.2
Rationale: A hgb 7.2 shows the blood transfusion was effective. Hct 36, platelet 46,000 , and RBC 4.0 are low and could indicate another transfusion is needed.
A nurse is caring for a patient with glaucoma. After administering the patients scheduled Timolol, the nurse anticipates which of the following:
A- lower BP
B- blurry vision
C- fatigue
D- loss of appetite
Answer- A lower BP
Rationale: Timolol is a beta-blocker that works to reduce the pressure in the eye causing a reduction in the patients BP. Blurry vision and fatigue are side effects of alpha antagonists, and loss of appetite is a side effect of carbonic-anhydrase inhibitor.
A nurse is reviewing a stroke patients chart and recognizes what as a likely contributor to stroke? Select All That Apply
A- History of atrial fibrillation
B- BP 180/95
C- Hgb- 14
D- Smokes 1 pack a day
E- Drinks water frequently
F- Diagnosed with DM Type 2
Answer- A, B, D, and F
A nurse is documenting on a patients sacral wound. Which of the following would be signs of a Stage 2 pressure ulcer?
A- Eschar
B- Non-blanching erythema
C- Partial thickness
D- Sloughing
C- Partial thickness
Rationale: Eschar (Unstageable), Non-blanching erythema (Stage 1), Sloughing (Stage 3)
A nurse is caring for a patient who is 2 hours post-op for a BKA. When assessing the patient, the nurse notes the surgical dressing to be saturated with blood. What interventions are appropriate? Select All That Apply.
A- Remove the saturated dressing and apply a dry one
B- Place a chucks pad under the limb and explain some post op bleeding is normal
C- Reinforce the dressing with more gauze
D- Apply a tourniquet to the limb
E- Call the doctor
Answer- C & E
Rationale: Some post-op bleeding is to be expected however it should not saturate the dressing. Reinforcing the surgical dressing and notifying the doctor is best. Removing the surgical dressing, rationalizing a saturated dressing is "normal post op bleeding", and applying a tourniquet are not safe interventions and could result in harm to your patient.
An ED nurse is caring for a patient with a history of DM type 2. The nurse understands that which of the following indicates the client is in DKA?
A- Glucose 300
B- Dry mouth
C- UA positive for ketones
D- Excessive thirst
Answer- C- UA positive for ketones
Rationale: The confirmation sign for DKA is a positive ketone presence. Glucose of 300 and excessive thirst are signs of hyperglycemia however not DKA. Dry mouth is a symptom of hypoglycemia.
A nurse is administering a patients scheduled pantoprazole (Protonix). The nurse knows this medication is intended to treat what disorder?
A- Celiac disease
B- IBS
C- Pancreatitis
D- GERD (Gastroesophageal Reflux Disease)
Answer- D GERD
Rationale: Pantoprazole is a proton pump inhibitor intended to treat GERD
A nurse is reviewing orders for a newly admitted older adult patient who was diagnosed with confusion and dehydration. Which medication orders should the nurse question? Select All That Apply
A- Furosemine 40 mg IV push
B- Diphenhydramine 50 mg PO at bedtime
C- Acetaminophen 500 mg PO q 6 hr PRN
D- Lorazepam 2 mg IV q 6 hr PRN
E- Docusate sodium 100 mg PO daily
F- 0.9% NS @ 100 mL/hr
Answer: A, B, and D
Rationale: Furosemide is a diuretic and may worsen dehydration. Diphenhydramine and lorazepam put the patient at high risk for confusion, falls, and sedation.
A nurse is caring for a patient experiencing respiratory difficulty. Upon assessment, the nurse notes decreased lung sound in the lower lobes bilaterally. Which is the following would indicate a positive pneumonia diagnosis?
A- Green mucus
B- Chest x-ray with infiltrates
C- Nasal Cannula @ 2L
D- Increased appetite
B- Chest x-ray with infiltrates
Rationale- Chest x-ray with infiltrates confirms the presence of fluid in the lungs. Green mucus could be sinusitis, nasal cannula indicates need for oxygen support but does not confirm pneumonia. Increased appetite is not relevant.
When caring for a patient with a newly casted tibial fracture, the nurse notes the distal portion of the affected limb feels cold to touch and is beginning to look blueish and swollen. The nurse recognized the patient is experiencing what?
A- Compartment Syndrome
B- DVT (Deep Vein Thrombosis)
C- CHF (Congestive Heart Failure)
D- Hypothermia
Answer- Compartment Syndrome
Rationale: DVT and CHF can cause edema in the lower legs but do not explain the blueish appearance. Hypothermia would not explain why the one leg is affected.
A nurse is caring for a patient who is newly diagnosed with kidney failure. While reviewing the patients labs, the nurse notes the patients most recent GFR is 16 which indicates which stage of kidney failure?
A- Stage 1
B- Stage 2
C- Stage 3
D- Stage 4
Answer- D Stage 4
Rationale: Kidney Disease is broken down into 5 stages based on the patients GFR result. Stage 1 (90 or higher), Stage 2 (60-89), Stage 3 (30-59), Stage 4 (15-29), and Stage 5 (less than 15).
A nurse is caring for a patient with a history of CAD. While administering the patients medications, the nurse knows which of the following is NOT an ACE inhibitor drug?
A- enalapril (Vasotec)
B- lisinopril (Zestril)
C- metoprolol (Lopressor)
D- ramipril (Altace)
Answer- C metoprolol (Lopressor)
Rationale: Metoprolol (Lopressor) is a beta-blocker
A 65 year old patient presents with dizziness and black, tarry stools. Patient has a history of Peptic Ulcer Disease.
Vitals are: BP 88/58, P 112, RR 22, and O2 96% RA
Labs are: Hgb 7.5, BUN 30, and Creatinine 1.3
Which actions should the nurse take first?
A- Notify provider
B- Start IV line in preparation for fluid administration
C- Request stool sample to test for occult blood
D- Recheck BP in 15 min
Answer: B
Which of the following signs and symptoms indicate anemia in a patient? Select All That Apply
A- Hgb 8
B- Brittle nails
C- RBC 10
D- HR 55
E- Craving ice
F- Hyperhidrosis
Answers- A, B, E
Rationale: RBC would be low, tachycardia, and extremities would feel cold
A daytime nurse is caring for a patient who has a history of DM Type 2. The patients diet was changed to NPO at midnight the night prior in preparation for her surgery today. While making your morning rounds you find her in bed and difficult to arouse. You perform a finger stick glucose check and the results are 40. Which of the following interventions would you anticipate?
A- Get her some peanut butter and graham crackers to eat
B- Administer Glucagon IV
C- Give her some orange juice to drink
D- Administer Metformin PO
Answer- B Administer Glucagon IV
Rationale: If a patient is NPO- the hypoglycemic protocol deems it appropriate to respond with IV route medications. IV Glucagon will raise her glucose rapidly. PO interventions such as peanut butter, graham crackers and orange juice are not recommended as she's already hard to arouse and they will take longer to be effective. Metformin PO is a medication for hyperglycemia.
A nurse is caring for a patient with a history of HIV who is non-compliant with his medications. Upon reviewing the patients labs, which lab would indicate the patients HIV has now progressed into AIDS?
A- RBC 7
B- Platelets 400,000
C- CD4 count <200
D- ALT 38
Answer- C CD4 could <200
Rationale: When HIV progresses into AIDS, the CD4 count depletes below 200 indicating the patients immune system is severely depleted and they're at risk for secondary infections. An RBC of 7 and Platelets of 400,000 are WNL and an ALT of 38 is slightly elevated but not enough to display liver damage from the disease.
A nurse is administering pain medication for a new patient admitted directly from surgery. The patient is NPO with orders to advance as tolerated and reports a pain score of 10/10. During report from PACU, you note that the received Fentanyl 50 mcg IV push 2 hours ago. Which of the following pain medications would be appropriate to give?
A- Hydrocodone acetaminophen (Norco) 5/325 PO q 4-6 hr
B- Morphine (MS Contin) 15 mg PO q 4 hr
C- Hydromorphone (Dilautid) 1 mg IV q 2-3 hr
D- Fentayl (Sublimaze) 12 mcg transdermal patch q 12 hr
Answer- Hydromorphone (Dilautid) 1 mg IV q 2-3 hr
Rationale: IV medications are ideal with this patient for this scenario. A patient who is NPO directly after surgery needs to gradually tolerate ice chips, sips, then liquids before taking any PO medications, A patch would be slow absorbing and not appropriate for post-op pain 10/10.
A nurse is caring for a patient with hyponatremia (Na- 124). Which of the following interventions are appropriate? Select All That Apply
A- Implement seizure precautions
B- Encourage oral water intake
C- Monitor for confusion and lethargy
D- Restrict fluids as ordered
E- Administer 3% sodium chloride IV push
F- Assess daily weights and I&O’s
Answer: A, C, D, and F