Fundamentals
A nurse is caring for a patient diagnosed with active TB. Which elements of transmission based precautions are required for the nurse when providing care to this patient? SATA
1. Gown
2. Goggles or face shield
3. Hand Hygiene
4. N59 mask
5. Surgical mask
3 (Hand Hygiene) and 4 (N95 mask)
What is the cranial nerve responsible for vision?
What is the hormone responsible for stimulating uterine contractions during labor?
Oxytocin
What is the neurotransmitter commonly associated with the "fight or flight" response and may increase during anxiety or stress?
Norepinephrine
What is the normal resting heart rate range for a toddler at rest?
1. 60-100
2. 80-140
3. 130-160
4. 160-200
2. 80-140
The nurse is caring for a patient who has been treated with gastric suctioning for 4 days. Which of the following acid-base imbalances is the patient experiencing?
pH 7.50
CO2 45
O2 90
HCO3 32
Metabolic alkalosis, uncompensated
What laboratory test is most commonly used to diagnose a myocardial infarction and rises within a few hours of cardiac muscle damage?
Troponin
A nurse is assessing a newborn shortly after birth. Which of the following findings are considered normal newborn characteristics? SATA
1. Acrocyanosis of hands and feet
2. Heart rate of 130
3. Temperature of 98.6
4. Immediate ability to hold head up
1. Acrocyanosis of hands and feet
2. Heart rate of 130
3. Temperature of 98.6
A nurse is caring fro a patient experiencing generalized anxiety disorder. Which of the following might the nurse expect? SATA
1. Restlessness
2. Excessive worry
3. Difficulty concentrating
4. Elevated mood
5. Muscle tension
1. Restlessness
2. Excessive worry
3. Difficulty concentrating
5. Muscle tension
Which of the following findings are consistent with moderate to severe dehydration in a child? SATA
1. Sunken fontanel
2. Tachycardia
3. Moist mucous membranes
4. Decreased urine output
5. Delayed capillary refill
1. Sunken fontanel
2. Tachycardia
4. Decreased urine output
5. Delayed capillary refill
The accuracy of a pulse oximetry reading can be affected if the client is currently experiencing which of the following?
1. Fever
2. Tachycardia
3. Hypotension
4. Tachypnea
3. Hypotension
A nurse is caring for a patient who developed reflex tachycardia while taking isosorbide mononitrate to treat chronic stable angina. Which of the following should the nurse anticipate the provider to prescribe?
1. Furosemide
2. Captopril
3. Ranolazine
4. Metoprolol
4. Metoprolol
A pregnant patient at 32 weeks of gestation reports sudden painless vaginal bleeding. What condition should the nurse expect?
Placenta previa
A client states "Everyone would be better off without me." This statement should alert the nurse that the patient is at risk for which of the following?
1. Risk for self harm
2. Suicidal ideation
3. Ineffective coping
4. Social isolation
2. Suicidal ideation
A nurse is caring for a 3 year old admitted with epiglottitis. The child is drooling, sitting in a tripod position, and has stridor. Which of the following is the nurse's priority action?
1. Obtain a throat culture
2. Encourage oral fluids
3. Prepare for intubation
4. Place the child in a supine position
3. Prepare for intubation
Using Parkland formula, calculate the IV fluid resuscitation for a patient with patient thickness burns covering 40% of the total body surface area. The patient weighs 85kg.
How many Liters of IV fluids should the patient receive during the first 8 hours?
6.8 Liters in the first 8 hours.
The nurse is assessing a patient with hyperkalemia. Which of the following ECG changes may be present? SATA
1. Peaked T waves
2. Flattened T waves
3. ST elevation
4. Ventricular dysrhythmias
5. Widened QRS complex
1. Peaked T waves
4. Ventricular dysrhythmias
5. Widened QRS complex
A nurse is caring for a patient with preeclampsia. Which assessment findings are consistent with this condition? SATA
1. Proteinuria
2. Severe headache
3. Hypertension
4. Hypotension
5. Visual disturbances
1. Proteinuria
2. Severe headache
3. Hypertension
5. Visual disturbances
A patient states "I don't think I can handle life anymore." Which response by the nurse demonstrates therapeutic communication?
1. You shouldn't feel that way. Things aren't that bad.
2. Why would you say something like that?
3. Tell me more about what you are feeling right now.
4. You should think more positively.
3. Tell me more about what you are feeling right now.
A nurse is caring for a child with suspected meningitis. Which of the following should the nurse expect? SATA
1. Fever
2. Nuchal rigidity
3. Petechial rash
4. Increased appetite
5. Photophobia
1. Fever
2. Nuchal rigidity
3. Petechial rash
5. Photophobia
Which of the following statements about palliative care are correct? SATA
1. Palliative care focuses on quality of life and can be provided at any time
2. Palliative care is only possible with a terminal diagnosis of < 6 months
3. Palliative care is provided by a multidisciplinary team
4. Palliative care is another term for hospice care
5. Palliative care provides relief from symptoms associated with chronic illness
1. Palliative care focuses on quality of life and can be provided at any time
3. Palliative care is provided by a multidisciplinary team
5. Palliative care provides relief from symptoms associated with chronic illness
Which of the following would a nurse observe in a patient with a pulmonary embolism? SATA
1. Sudden shortness of breath
2. Tachycardia
3. Chest pain that worsens with breathing
4. Bradycardia
5. Decreased oxygen saturation
1. Sudden shortness of breath
2. Tachycardia
3. Chest pain that worsens with breathing
5. Decreased oxygen saturation
A nurse suspects the patient is experiencing postpartum hemorrhage. Which findings support this suspicion? SATA
1. Saturating a perineal pad in 15 minutes
2. Boggy uterus on palpation
3. Firm uterus at the umbilicus
4. Blood pressure of 88/54
5. Saturating a perineal pad every 1.5 hours
1. Saturating a perineal pad in 15 minutes
2. Boggy uterus on palpation
4. Blood pressure 88/54
A nurse is caring for a patient who is actively experiencing hallucinations. Which of the following nursing interventions are appropriate? SATA
1. Acknowledge the patients experience without validating the hallucination
2. Tell the patient the hallucination is real
3. Reorient the patient to reality
4. Encourage the patient to describe what they are seeing
5. Insist that the hallucination does not exist
1. Acknowledge the patients experience without validating the hallucination
3. Reorient the patient to reality
A nurse is assessing a 6 year old who is experiencing diarrhea caused by E. coli infection. Which of the following findings would be a priority to follow up?
1. Petechiae noted on the trunk
2. Multiple blood-streaked stools
3. Patient has resumed normal diet
4. Patient is requesting a glass of fruit juice
1. Petechiae noted on the trunk