Fundamentals
A patient is having dyspnea. what would the nurse do first?
A. elevate the head of the bed
B. elevate the foot of the bed
C. take BP
D. remove pillows from under the head
A. elevate the head of the bed
Name three anticoagulant medications
Lovenox
Heparin
Eliquis
Coumadin
Xarelto
Pradaxa
A doctor has ordered cardiac enzymes on a patient being admitted with chest pain. You know that _____________ levels elevate 2-4 hours after injury to the heart and is the most regarded marker by providers.*
A. Myoglobin
B. CK-MB
C. CK
D. Troponin
D. Troponin
While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?
A. Stop the saline infusion immediately
B. Notify Physician
C. Elevate the patient's legs
D. Continue the infusion, since these are normal findings
A. Stop the saline infusion immediately
The nurse assesses patient's breath sounds. Which one requires immediate medical attention? A patient who has:
A. Crackles
B. Rhonchi
C. Stridor
D. Wheezes
C. Stridor
The doctor orders an IV weight-based medication to be infused at 12 mg/kg. The patient weighs 115 lbs. You are supplied with a bag of the IV medication that reads 100 mg/2mL. How many mL/hr will you administer?
A. 24 mL/hr
B. 3 mL/hr
C. 12.5 mL/hr
D. 1.5 mL/hr
C. 12.5 mL/hr
A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately?
A. Hemoglobin 11 g/dl
B. Platelet of 150,000
C. INR of 2.5
D. Potassium of 2.7 mEq/L
D. Potassium of 2.7 mEq/L
What are the three ways to confirm NG tube placement?
1. Chest Xray
2. Syringe Test
3. pH test
What is the EKG rhythm?
A. Normal Sinus rhythm
B. Sinus Bradycardia
C. First degree AV block
D. Second degree AV block
C. First degree AV block
Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)?
A. Hepatitis B
B. Occasional alcohol use
C. Allergy to aspirin
D. Gastric irritation with bleeding
A. Hepatitis B
What type of fluid would a patient with severe hyponatremia most likely be started on?
A. Hypotonic
B. Hypertonic
C. Isotonic
D. Colloid
B. Hypertonic
You have a new admission. While performing a head-to-toe assessment on your patient, you note the following wound on the patient’s right heel. You document this as a:
A. Stage 1 Pressure Injury
B. Stage 3 Pressure Injury
C. Unstageable
D. Deep-Tissue Injury
E. Stage 2 Pressure Injury
F. Stage 4 Pressure Injury
E. Stage 2 Pressure Injury
Which of the following patients is experiencing an abnormal change in vital signs? A patient whose (select all that apply):
A. BP was 132/80 sitting and is 120/60 upon standing
B. Rectal temperature is 97.9°F in the morning and 99.2°F in the evening
C. Heart rate was 76 before eating and is 60 after eating
D. Respiratory rate was 14 when standing and is 22 after walking
A. BP was 132/80 sitting and is 120/60 upon standing
C. Heart rate was 76 before eating and is 60 after eating
You are performing discharge teaching with a patient who is going home on Synthroid. Which statement by the patient causes you to re-educate the patient about this medication?
A. “I will take this medication at bedtime with a snack.”
B. “I will never stop taking the medication abruptly.”
C. “If I have palpitations, chest pain, intolerance to heat, or feel restless, I will notify the doctor.”
D. “I will not take this medication at the same time I take my Carafate.”
A. “I will take this medication at bedtime with a snack.”
A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?
A. Monitor for fever every 4 hours.
B. Require visitors to wear respiratory masks and protective clothing.
C. Consider transfusion of packed red blood cells.
D. Check for signs of bleeding, including examination of urine and stool for blood.
D. Check for signs of bleeding, including examination of urine and stool for blood.
Patient diagnosed with CHF, +2 bilateral extremities edema, crackles lung sounds, on Lasix IV push BID. Which of the following options below will you include as nursing interventions for this patient?
A. Keep patient’s legs below heart level daily.
B. Weigh patient every morning on standing scale.
C. Monitor potassium levels daily.
D. Maintain a daily fluid restriction of no more than 4 L of fluid per day.
E. Strictly monitor intake and output daily.
F. Educate the patient daily about the importance of asking for help before ambulating.
B. Weigh patient every morning on standing scale.
C. Monitor potassium levels daily.
E. Strictly monitor intake and output daily.
F. Educate the patient daily about the importance of asking for help before ambulating.
The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes mellitus?
A. A 48-year-old woman with a hemoglobin A1C of 8.4%
B. A 58-year-old man with a fasting blood glucose of 111 mg/dL
C. A 68-year-old woman with a random plasma glucose of 190 mg/dL
D. A 78-year-old man with a 2-hour glucose tolerance plasma glucose of 184 mg/dL
A. A 48-year-old woman with a hemoglobin A1C of 8.4%
A patient is prescribed Metoprolol. Which statement by the patient requires the nurse to re-educate the patient on how to take the medication properly?
A. “After I stop taking this medication I will let my physician know.”
B. “I take this medication with my breakfast every morning.”
C. “I will change positions slowly while I’m taking this medication.”
D. “While I’m taking this medication I will monitor my heart rate.”
A. “After I stop taking this medication I will let my physician know.”
The nurse provides 3% NS to serum the serum sodium level 120 mEq/L. A routine BMP the next morning shows the sodium has increased to 150 mEq/L. Based on these results, what is the priority nursing intervention?
A. Continue to monitor; no intervention needed at this time
B. Administer sodium tablets as scheduled on the MAR
C. Notify the provider; call rapid response to perform a detailed neuro assessment
D. Notify the provider; provide more hypertonic saline until desired level is achieved
C. Notify the provider; call rapid response to perform a detailed neuro assessment
The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST?
A. A client with an IV of normal saline infusing at 125 ml per hour complaining of slight swelling at the IV insertion site.
B. A client 3 days post right knee replacement complaining of right calf pain with movement.
C. A client with a respiratory rate of 24 and an oxygen saturation of 94% on room air.
D. A client 12 hours after a hysterectomy complaining of nausea.
B. A client 3 days post right knee replacement complaining of right calf pain with movement.