PHYSIOLOGIC INTEGRITY
( CARDIO/ENDO)
( CARDIO/ENDO)
Which type of insulin works in 24-hour period?
1. Metformin
2. Glipizide
3. Glargine
4. Rosiglitazone
ANSWER: 3
After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, “You are incompetent!” Which is the nurse’s best response?
1. “Do you believe that I was the cause of your blood test being canceled?”
2. “I see that you are upset, but I feel uncomfortable when you swear at me.”
3. “Have you ever thought about ways to express anger appropriately?”
4. “I'll give you some space. Let me know if you need anything.”
Answer 2 - 2. “I see that you are upset, but I feel uncomfortable when you swear at me.”
Nurse Priscilla is preparing to examine a Hispanic child who was brought by the mother for his first physical check-up. While assessing the child, the nurse would avoid doing which of the following?
1. Weighing the client.
2. Asking the mother questions about the child.
3. Having an interpreter if necessary.
4. Admiring the child.
Answer: 4
During the administration of chemotherapy agents, Nurse Fredgie observed that the IV site is red and swollen when the IV is touched Stacy shouts in pain. The first nursing action to take is:
1. Notify the physician
2. Flush the IV line with saline solution
3. Immediately discontinue the infusion
4. Apply an ice pack to the site, followed by warm compress.
Answer: 3. Immediately discontinue the infusion
You are caring for a patient with Unstable Ventricular Tachycardia. Which management should you provide?
1. Defibrillation
2. Pacemaker
3. Cardioversion
4. Maze procedure
ANSWER: 3
A client on an inpatient psychiatric unit tells the nurse, “I should have died because I am totally worthless.” In order to encourage the client to continue talking about feelings, which should be the nurse’s initial response?
1. “How would your family feel if you died?”
2. “You feel worthless now, but that can change with time.”
3. “You've been feeling sad and alone for some time now?”
4. “It is great that you have come in for help.”
Answer 3 - “You've been feeling sad and alone for some time now?”
The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?
1.Reinforce pursed-lip breathing
2. Make a nursing care regimen that gradually increases activity intolerance
3. Assist the patient with activities of daily living
4. Consult with the physical therapy department about reconditioning exercises
Answer: 1. Reinforce pursed-lip breathing
A 15-year-old male client arrives at the emergency department. He is conscious, coherent and ambulatory, but his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration?
1. “He’s a diabetic, so he needs attention right away.”
2. “There was a lot of blood and we used three bandages.”
3. “The stick was really dirty and covered with mud.”
4. “He pulled the stick out, just now, because it was hurting him.”
Answer 4
Patient X was diagnosed with Cushings disease. As a nurse taking care of this patient, you know that Patient X will have the following conditions. Select all that apply (SATA)
1. Easy bruising
2. Pimple
3. Thin hair
4. Prone to osteoporosis
5. Darkening of skin folds including the neck and groin
6. Increased cortisol level
ANSWER: ALL
Which nursing statement is a good example of the therapeutic communication technique of offering self?
1. “I think it would be great if you talked about that problem during our next group session.”
2. “Would you like me to accompany you to your electroconvulsive therapy treatment?”
3. “I notice that you are offering help to other peers in the milieu.”
4. “After discharge, would you like to meet me for lunch to review your outpatient progress?”
Answer 2 - 2. “Would you like me to accompany you to your electroconvulsive therapy treatment?”
The charge nurse is making assignments for the next shift. Which patient should be assigned 4 the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit?
1. A 58-year old on airborne precautions for tuberculosis (TB)
2. A 68-year old just returned from bronchoscopy and biopsy
3. A 72-year old who needs teaching about the use of incentive spirometry
4. A 69-year old with COPD who is ventilator dependent
Answer: 3. A 72-year old who needs teaching about the use of incentive spirometry
Nurse Winchel is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best?
1. Ask the other nurse if she needs help.
2 Assess the client and let the other nurse know what should be done.
3. Ask the client if he is satisfied with his care.
4. Contact the nursing supervisor to address the situation.
Answer: 4. Contact the nursing supervisor to address the situation.
You are caring for a patient diagnosed with Pericarditis. What are the expected signs and symptoms of this condition? Select all that apply (SATA)
1. Pericardial friction rub
2. Pain upon inhalation
3. Pain occurs when lying supine
4. Muffled heart sound
5. Murmurs
6. Osler’s nodules
ANSWER: 1 2 3
A nursing measure to promote sleep in school-age children is to:
1. Make sure the room is dark and quiet
2. Encourage evening exercise
3. Encourage television watching
4. Encourage quiet activities prior to bedtime
Ans. 4 - Encourage quiet activities prior to bedtime
Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?
1. Evaluating the patient’s complaint of chest pain
2. Monitoring laboratory values for changes in oxygenation
3. Assessing for symptoms of respiratory failure
4. Auscultating the lungs for crackles
Answer 4 Auscultating the lungs for crackles.
A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following?
1. “What was the initial first aid done?”
2. “Where did the incident happen?”
3. “What direction did the bullet enter into the body?”
4. “How long ago did the incident occur?”
Answer: 3. “What direction did the bullet enter into the body?”
A client’s ECG revealed the following condition: P wave is normal, QRS complex is 0.07 seconds, PR interval is 0.12 seconds, Rate is 40bpm and the Rhythm is regular. Based on the following results, what management will you provide? Select all that apply (SATA)
1. Beta Adrenergic Blocker
2. Calcium Channel Blocker
3. Atropine
4. Adenosine
5. CPR
6. Defibrillation
ANSWER: 3
What are the manifestations of alcohol withdrawal? select all that apply (SATA)
1. Hypotension
2. Sweating
3. Tremors
4. Constipation
5. Lethargy
6. Delirium
Answer - 2, 3, 6
You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant?
1. Teaching the patient about the importance of adequate of fluid intake and hydration.
2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
4. Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.
Answer: 3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
Cham works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last.
1. A 50-year-old female with moderate abdominal pain and occasional vomiting.
2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity.
3. An ambulatory dazed 25-year-old male with a bandaged head wound.
4. An irritable infant with a fever, petechiae, and nuchal rigidity.
1. 1, 2, 3, 4
2. 2, 1, 3, 4
3. 4, 3, 1, 2
4. 3, 4, 2, 1
Answer 3