Definitions
A patient with a crush injury to her right arm calls the nurse and requests pain medicine, which the nurse administers as ordered. An hour later, the patient is still complaining of intense pain. Which of the following actions does the nurse take next?
a. Offer the patient a distraction, such as television or a magazine.
b. Tell the patient that she can have more medication in three hours.
c. Ask the patient to describe the pain in quality and intensity.
d. Tell the patient that this is to be expected with a crush injury.
ANS: C
The patient should be re-assessed because the dose of pain medication may not be enough to cover the level of pain.
Which action best indicates that learning has occurred?
a. A nurse presents information about diabetes.
b. A patient demonstrates how to inject insulin.
c. A family member listens to a lecture on diabetes.
d. A primary care provider hands a diabetes pamphlet to the patient.
B. A patient demonstrates how to inject insulin.
Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills. Complex patterns are required if the patient is to learn new skills, change existing attitudes, transfer learning to new situations, or solve problems.
When monitoring a patient who is at risk for hemorrhage, what assessment data is significant?
A. Hypertension; bounding pulse; cold and clammy skin
B. Warm, dry skin; hypotension; bounding pulse
C. Hypotension; cold, clammy skin; weak, thready pulse
D. Weak thready pulse; hypertension; warm, dry skin
ANS: C
Hypotension is correct because the reduction in blood volume during acute blood loss causes a fall in central venous pressure and cardiac filling. This leads to reduced cardiac output and arterial pressure. This also causes a weak and thread pulse and decreased circulation which causes cold and clammy skin.
A nurse is caring for a patient who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize which of the following complications is associated with long-term mechanical ventilation:
A. Elevated Blood Pressure
B. Dehydration
C. Hypernatremia
D. Stress ulcers
ANS: D
Stress ulcers are caused by elevated hydrochloric acid in the stomach due to reduced blood flow to the area. Stress ulcers increase the risk for systemic infection.
The nurse knows that a 60-year-old female client's susceptibility to osteoporosis is most likely related to:
A. Hormone disturbances
B. Lack of exercise
C. Lack of calcium
D. Genetic Disposition
ANS: A
A 60-year-old female is likely going through menopause, which happens when a woman goes through a 12 month period without a menstrual period. As ovaries age and release fewer hormones, FSH and LH can no longer perform their usual functions to regulate your estrogen, progesterone and testosterone. These inevitable changes in your hormones and natural decline of estrogen levels during menopause can significantly affect your health for years to come.
Which of the following best defines the term, "health disparities":
a. The degree to which individuals have the capacity to obtain, process, and understand health information and services needed to make appropriate health decisions
b. Any combination of planned learning experiences based on sound theories that provide the opportunity to acquire the information and skills needed to make quality health decisions
c. A goal of health education that may foster successful changes in health behavior
d. Systematic, potentially avoidable health differences that adversely affect socially disadvantaged groups
D. Systematic, potentially avoidable health differences that adversely affect socially disadvantaged groups
A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?
A. Ask the patient to lie down on the exam table.
B. Draw blood for chemistry panel and arterial blood gas (ABG).
C. Send the patient for a chest x-ray.
D. Check blood pressure.
ANS: D
High blood pressure exacerbates congestive heart failure and this may indicate that current treatments are not being effective. Untreated, this could lead to a heart attack.
A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which is the priority assessment data for this patient?
A. Restlessness
B. T3 level 215 ng/dL
C. Blood pressure 170/80 mm Hg
D. Decreased weight
ANS: C
The blood pressure reading is high, indicating that the patient is at risk for thyroid storm. All other findings are expected for someone with hyperthyroidism.
According to Erikson's stages of psychosocial development, which intervention is most appropriate for a hospitalized 16-year old?
a. Request the hospital chaplain to stop by.
b. Ask parents to assist with missed homework.
c. Encourage friends to visit at the hospital.
d. Restrict visitors to the teen's best friend.
C. Encourage friends to visit at the hospital.
In Erikson's Identity vs. Role Confusion stage, about 12-18 years old, adolescents learn a sense of self and independence. Their most significant social relationships are their peers. Parents and adults have influence, but friends, social groups, and societal trends help shape identity.
Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates an understanding of the nurse's teaching?
A. I must check placement four times per day.
B. I will report to the doctor any signs of indigestion.
C. I must flush the tube with water after feedings and clamp the tube.
D. If my father is unable to swallow, I will discontinue the feeding and call the clinic.
ANS: C
Flushing the tube with water after feedings will help to prevent clogs and build-up. Clamping the tube prevents anything from coming back out.
A nurse is preparing a client for surgery. The nurse understands that the perioperative phase that begins when the client is transferred to the surgical suite table and ends when the client is transferred to the PACU is called
A). pre-operative
B). post-operative
C). intra-operative
D). admission
ANS: Intra-operative
The intraoperative phase extends from the time the client is admitted to the operating room, to the time of anesthesia administration, performance of the surgical procedure and until the client is transported to the recovery room or postanesthesia care unit (PACU)
A nurse is teaching a culturally diverse patient about nutritional needs. What must the nurse do first before starting the teaching session?
a. Obtain pictures of food.
b. Get an interpreter.
c. Establish a rapport.
d. Refer to a dietitian.
C. Establish a rapport
Establishing a rapport is important for all patients, especially culturally diverse patients, before starting teaching sessions. Obtaining pictures of food, getting an interpreter, and referring to a dietitian all occur after rapport is established.
The nurse plans to instruct parents of a 4-year old with cystic fibrosis (CF) about the child's nutritional needs. Which should be included during teaching?
a. High calorie
b. Low carbohydrate
c. High fat
d. Low protein
A. High calorie
Children with cystic fibrosis require a high calorie, high protein diet in order to avoid failure to thrive syndrome.
A mother tells the nurse that her 8-year old doesn't eat as much as her toddler or teenager. The nurse should explain that school-age children have a lower:
a. growth rate
b. metabolic rate
c. activity level
d. hormone level
A. Growth rate
Children between the ages of 6 -12 have a slower, but steady, growth rate. They require fewer calories, compared to toddlers or adolescents, who are both growing rapidly. Healthy school age children normally eat only as much as they need to maintain their growth.
A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?
A. report chest pain
B. take the medication with milk
C. remain upright after taking for 30 minutes
D. allow 6 weeks for optimal effects.
ANS: A
When taking Celebrax, chest pain may occur and is indicative of serious complications that should be treated immediately.
The nurse supervises a UAP (unlicensed assistive personnel) to assist a legally blind patient with their meal at dinner time. What action, if performed by the UAP, is correct?
A. The UAP tells the patient which quadrant the food is in on the plate.
B. The UAP feeds the patient and tells them “Open.” when it is time for the next bite.
C. The UAP cuts up the food for the patient and hands them the knife and fork.
D. The UAP tells the patient where each food item is located on the plate by referring to the image of a clock face.
ANS: D
Referring to the image of a clock face allows the patient to have the most independence when eating. The person may be able to feed themselves and we want to maintain that level of independence wherever possible.
When caring for an elderly client who has visual and hearing impairments, which of the following should the nurse assess?
a. Confusion and anger
b. Cognitive decline
c. Social isolation
d. Sensory overload
C. Social isolation
Sensory impairments can lead to social isolation for older adults.
The nurse is instructing a 53 year-old male client with newly-diagnosed type 2 diabetes how to care for his feet at home. Which statement indicates that the client understands?
a. "It's okay to go barefoot in my own home."
b. "I'll dry my feet very well after every shower."
c. "Every Sunday evening, I will carefully inspect my feet."
d. "If I cut my foot, I'll just apply antibiotic ointment."
B. "I'll dry my feet very well after every shower."
Diabetics should dry their feet carefully to prevent fungal infections. Feet should be inspected daily and clients should seek professional care for any foot or toe injuries. Proper footwear should be worn at all times to avoid injury and to provide support.
A 17-year old girl and her mother are both in the exam room for the girl's school physical. Before asking the girl about her sexual history, which statement should the nurse make?
a. "Mother, do you think your daughter is sexually active?"
b. "Do you think your mother should leave the room now?"
c. "Mother, I am going to ask you to step out, so I can complete the health history."
d. "The two of you seem so close. I'll ask questions about your sexual history now."
C. "Mother, I am going to ask you to step out, so I can complete the health history."
Confidentiality and privacy are critical developmental needs for the adolescent. The nurse should respect these needs in order to establish a relationship of trust with the client. A sexual history should be conducted privately with a teen.
When teaching a client who is planning to get pregnant about the need to increase folic acid, which food can the nurse suggest?
a. yogurt
b. spinach
c. apples
d. chicken
B. Spinach
Green and leafy vegetables are excellent sources of folic acid. Examples are spinach, broccoli, brussel sprouts, avocados, and asparagus.
ANS: D
This is an open-ended question that allows the client to explore what they mean without giving false promises or shutting down conversation.
At a daycare center on a summer day, 4 children return from recess with complaints. Which should the nurse see first?
A. A child diagnosed with type 1 diabetes is sweaty, pale, and shaky
B. A child w/ leukemia was stung by a bee and feels hot & itchy all over
C. A child diagnosed w/ hemophilia with slurred speech and a headache
D. A child with asthma is complaining of dizziness and a sore throat
ANS: B
These are some of the signs of anaphylactic shock which is fatal if not addressed immediately.
A nurse in an emergency dept is caring for a patient with full-thickness burns over 20% of his total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first?
A. IV fluids
B. Analgesia
C. Antibiotics
D. Tetanus Toxoid
ANS: A
IV fluids should be administered first to provide circulatory support. Burns cause severe dehydration of the body. The nurse will administer all four of these items, but the fluids are the priority.
A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessment, the nurse finds: Heart rate: 200/min, BP 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take?
A. Defibrillate the client's heart
B. Perform synchronized cardioversion
C. Begin cardiopulmonary resuscitation
D. Administer lidocaine IV bolus
ANS: B
Synchronized cardioversion is a LOW ENERGY SHOCK that uses a sensor to deliver electricity that is synchronized with the peak of the QRS complex and avoids shock during the T-wave to best treat supraventricular tachycardia.
The nurse should defibrillate the client's heart for ventricular tachycardia or ventricular fibrillation.
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client's cervix is 5 cm dilated with 75% effacement. Based on the nurse's assessment the client is in which phase of labor?
A. early
B. latent
C. transition
D. active
ANS: D
Active labor for most women starts at 5 or 6 cm dilation.