Medications
Prioritization
Critical Thinking
Skills
Wild Card
100
A 12 y/o boy injured his right knee yesterday playing soccer and is brought to the outpatient clinic by his mom. His knee is painful, swollen, bruised. He has a history of hemophilia Which medication is BEST for this patient? a. oxycodone terephthalate (percodan) b. ibuprofen c. enteric coated aspirin d. codeine phosphate
d. analgesic used for moderate to severe pain and does not affect bleeding disorder
100
The triage nurse has just returned to the desk and has four phone messages to return.Which of the following messages should she return FIRST? a. a woman in her first trimester of pregnancy c/o heartburn b. a man c/o of heartburn that radiates to his jaw c. a woman c/o hotflashes and difficulty sleeping d. a boy c/o knee pain after playing basketball
b. indicates chest pain, needs to seek medical attention immediately.
100
You are monitoring the fluid status of a 63 y/o woman receiving IV fluids following surgery. Which of the following symptoms suggests she has fluid volume overload? a. temperature 101, BP 96/60, pulse 96 and thready b. cool skin, respiratory crackles, pulse 86 and bounding c. c/o HA, abdominal pain, lethargy d. urine o/p 700 cc/24 hr, CVP of 5, nystagmus
b. bounding pulse, elevated BP, JVD, edema, HA, polyuria, diarrhea, liver enlargement
100
When using restraints for an agitated patient, which of the following statements should NOT influence the nurse's actions during this intervention? a. The restraints/seclusion policies set forth by the institution b. the patient's competence c. the patient's voluntary/involuntary status d. the patient's nursing care plan
c. the need for restraints is based on patient's behavioral status and condition, not the voluntary/involuntary status
100
You are the admitting nurse for a patient with cystic fibrosis. Which of the following orders would you NOT expect to receive? a. to maintain contact isolation b. to maintain a 1500 cc fluid restriction daily c. IV cefepime d. chest physiotherapy
b. a fluid restriction would not be ordered because CF patients are at increased risk of kidney stone development- they should drink plenty of fluids
200
The physician orders ranitidine hydrochloride (zantac) 150 mg PO qday for a client. The nurse should advise the client the BEST time to take this medication is a. before breakfast b. with dinner c. with food d. at HS
d. best results when taking once a day. absorption not affected by food.
200
The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time? a. confirm that all staff understand and comply with the treatment plan. b. establish mutually agreed upon realistic goals c. ensure that the potent reinforces (rewards) are important to the client d. establish a fixed interval schedule for reinforcement
a. all staff need to be included in program development, consistency and follow through is important to prevent the level of manipulation by staff during program implementation
200
The nurse is caring for clients on a med-surg unit. What would be the MOST appropriate action for the nurse to take after noting that a client who had surgery earlier today suddenly developed a fixed and dilated pupil? a. reassess in 5 minutes b. check the patient's visual acuity c. lower the HOB d. contact the physician
d. fixed and dilated pupil represents a neurological emergency
200
You prepare to administer an injection of haloperidol decanoate (Haldol D). Which nursing action is MOST appropriate? a. massage the injection site b. give deep IM in large muscle c. use a 2 inch 25 gauge needle d. administer the med in divided doses
B. give deep IM in large muscle- medication is irritating to subQ tissue
200
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol? a. steadily increasing VS b. mild tremors and irritability c. decreased respirations and disorientation d. stomach distress and inability to sleep
a. client is approaching delirium tremens
300
M.C. is given 6 mg morphine IVP for postoperative pain. Following administration, you observe: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate? a. allow him to rest undisturbed b. administer 02 via facemask or NC c. adminiser naloxone (narcan) d. place epinephrine 1:1,000 at the bedside.
c. narcan should be given to reverse respiratory depression- RR 8 is too low and requires intervention
300
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body? a. counseling regarding problems with body image b. maintain airborne precautions c. maintain aseptic technique during procedures d. encourage peers to visit regularly
c. he is at high risk for infection so this is a patient safety concern. Think Maslows hierarchy of needs
300
On a medical surgical unit, you are admitting a 75 y/o woman with CHF exacerbation. During your admission assessment you learn she is on a low-sodium diet, has been on chlorothiazide (diuril) 500 mg PO daily for 6 months. Diagnostics show: Na 127, K 3.8, glucose 110, normal CXR. The signs and symptoms the nurse would expect the client to exhibit include: a. sticky mucous membranes, decreased urine output, firm tissues b. cool moist skin, hand tremors, confusion c. HA, apprehension, lethargy d. SOB, chest pain, anxiety
c. hyponatremia s/sx also include muscle twitching, convulsions, diarrhea.
300
Your patient on a surgical unit has a diagnosis of rule out intestinal obstruction and you are preparing to insert a salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure? a. HOB elevated 30-45 degrees b. HOB elevated 60-90 degrees c. sidelying with head elevated 15 degrees d. lying flat with head turned to the left side
b. facilitates swallowing and movement of tube through GI tract
300
An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after fracture. It is MOST important for the nursing care plan to include that the client: a. eat a high protein low-residue diet b. lie on her unoperated side c. exercise her arms and legs d. cough and deep breathe
d. prevents respiratory complications due to immobility following surgery
400
A young adult is brought to the ED s/p a MVA with a closed head injury and suspected subdural hematoma. He c/o severe HA, but is A&0 x 4. The nurse would question which order? a. promethazine (phenergan) 25 mg IM q 3 h b. morphine sulfate 4-10 mg IM q 3 h c. docusate sodium (colace) 50 mg PO BID d. ranitidine (zantac) 50 mg iVPB q 12h
B. Morphine- narcotic analgesic, causes CNS and respiratory depression contraindicated in head injury and masks signs of ICP
400
A woman is admitted to L&D in a sickle cell crisis. Which nursing action is of HIGHEST priority? a. administer O2 b. turn her to her right side c. provide adequate hydration d. start antibiotics
c. adequate hydration is the priority for a patient in sickle cell crisis- dehydration will worsen the vaso-occlusive crisis and also with hyponatremia less 02 is free (more is bound to RBC) contributing to hypoxia.
400
You are caring for a postcholecystecomy client who had his T-tube removed this AM. 2 hours after removal of the T-Tube you note the 4X4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which action? a. remove the dressing adn replace with a more absorbent dressing b. collect a culture of the drainage c. observe for dehiscence d. reinforce the dressing with an 8 x10 dressing
a. expect the wound will continue to drain until it heals, keep it clean and dry
400
After abdominal surgery, a client has a NG tube attached to low intermittent suction. The client becomes nauseated and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate? a. Irrigate the tube with distilled water b. call for KUB to confirm placement c. administer an antiemetic medicine d. insert a new NG tube
b. confirm placement is the first intervention to perform
400
A client in the ICU is given procainamide HCL slow IVP. The nurse should withhold the next dose if which of the following was observed? a. presence of premature ventricular contractions b. occurence of severe hypotension c. recurring paroxysmal atrial tachycardia d. a sedimentation rate of 10
b. bradycardia or severe hypotension is an adverse reaction
500
You are monitoring a client's EKG strip and note a few coupled premature ventricular contractions (greater than 10/minute). The nurse should prepare to administer which medication? a. atropine sulfate (Atropine) IV b. isoproterenol (Isuprel) IV c. verapamil (Calan) IV d. lidocaine hydrochloride (Xylocaine) IV
D. Lidocaine- antiarrythmic used with frequent PVCs or Vtach.
500
The nurse is caring for clients on a medical/surgical unit and determines several situations need to be addressed. Which should she attend to FIRST? a. an angry daughter is threatening to sue the hospital because her mother fell out of bed earlier that day. b. the nursing assistant is 30 minutes overdue from a dinner break for the third time this week c. the physician call the unit to ask the nurse to obtain a client's most recent electrolyte results from lab d. the husband of a patient reports that his wife's nose is bleeding after she returned from radiation therapy.
d. should assess the client regarding the amount and cause of bleeding
500
After sustaining a closed head injury and numerous facial lacerations, a 20 year old is admitted to your unit. He is minimally responsive to noxious stimuli. Which of the following assessments if observed 3 hours later should be reported to the physician? a.The client has slight edema to the eyelids b. There is clear fluid draining from the right ear c. There is some bleeding from the lacerations d. He withdraws in response to painful stimuli
b. indicates meningeal rupture and presents potential complication of meningitis
500
During a first aide class, the nurse instructs clients on the emergency care of second-degree burns. Which of the following interventions for second-degree burns of the chest and arms will BEST prevent infection? a. wash the burn with an antiseptic soap and water b. remove clothing and wrap the victim in a clean sheet c. leave the blisters intact and apply an ointment d. take no action until the victim arrives in a burn unit
b. after the fire is out, remove clothing and cover the victim
500
You are caring for a patient following an appendectomy. The patient takes a deep breath, coughs and then winces with pain. Which of the following statements is the BEST to say? a. "take 3 deep breaths hold your incision and then cough b. "that was good. do that again and soon it won't hurt as much." c. "it won't hurt as much if you hold your incision when you cough" d."take another deep breath, hold it, and then cough deeply"
a. this is the most effective way- dilates airways and expands lung surface area
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