ICP
The nurse is monitoring a client with increased ICP. Which neurological assessment finding should the
nurse report immediately?
a) Sluggish pupillary response
b) Unequal pupil size
c) Decreased level of consciousness
d) Numbness and tingling in the extremities
c) Decreased level of consciousness
Which patient problem places the client at highest risk for septic shock?
a. Heart failure
b. Cirrhosis
c. Burns covering 45% TBSA
d. 2nd trimester pregnancy
c. Burns covering 45% TBSA
A nurse is working on a telemetry floor and watching the telemetry monitor. The nurse
recognizes which of the following is a characteristic of supraventricular tachycardia
(SVT)?
a. Absent p-waves
b. Heart rate less than 100 beats/min
c. Ventricular tachycardia with a “twisting of points”
d. Narrow QRS complex
d. Narrow QRS complex
A nurse is caring for a patient with COVID-19 and C-diff infection. Which precautions
should the nurse place on the patient?
a. Standard precautions
b. Aerosol contact precautions
c. Droplet and contact precautions
d. Contact precautions
b. Aerosol contact precautions
A client arrives in the ED with chest pain, shortness of breath, and diaphoresis. An ECG shows ST elevation in leads I, II, and III. What coronary artery does the nurse suspect is being
occluded?
A) Left Anterior Descending Artery
B) Right Coronary Artery
C) Circumflex Artery
D) Left Coronary Artery
A) Left Anterior Descending Artery
A new grad nurse is caring for a patient with increased intracranial pressure (IICP). Which
action by the new grad nurse requires intervention by the charge nurse?
A. Preparing the patient for a lumbar puncture
B. Elevating the head of the bed to 35 degrees
C. Assessing neurological status for changes
D. Administering antiemetics to avoid patient vomiting
A. Preparing the patient for a lumbar puncture
A lumbar puncture is contraindicated for a person experiencing increased intracranial pressure.
A nurse is caring for a patient diagnosed with sepsis. Which assessment finding is most concerning and
requires immediate intervention?
a. POC Glucose 180mg/dL
b. Serum lactate level 4.2 mmol/L
c. HR 110 bpm
d. Warm, flushed skin
b. Serum lactate level 4.2 mmol/L
A client reports to the ED with diaphoresis and feeling weak and dizzy. The EKG shows an irregular rhythm with normal QRS complexes but no discernable P or T waves. The heart rate is 180BPM. What orders would the nurse expect? SATA
A) Diltiazem loading dose 10mg IVP, once
B) Diltiazem drip 5mg/hr. increase by 5mg/hr every 15min until rate maintains under 110.
C) Continuous heart monitoring
D) BP every 2 hours
E) Nitroglycerine 0.4mg sublingual tablet, once
A) Diltiazem loading dose 10mg IVP, once
B) Diltiazem drip 5mg/hr. increase by 5mg/hr every 15min until rate maintains under 110.
C) Continuous heart monitoring
You are teaching a patient on how to prevent getting infected with COVID-19. What are some of the preventions? Select all that apply:
a. Handwashing
b. Wearing gloves when out in public
c. Cover cough and sneeze
d. Disinfect surfaces
e. Get a COVID-19 vaccination
a. Handwashing
c. Cover cough and sneeze
e. Get a COVID-19 vaccination
A nurse is providing discharge teaching to a 68-year-old female client who has recently had a permanent pacemaker implanted. Which of the following statements by the client indicates a need for further teaching?
A) "I should avoid lifting my arm above my shoulder on the side where the pacemaker was implanted for the first 4-6 weeks."
B) "I need to wear a medical alert bracelet that identifies me as having a pacemaker."
C) "I can go through security at the airport without informing the security officers about my pacemaker."
D) "If I feel dizzy, lightheaded, or have a rapid heartbeat, I should immediately call my healthcare provider."
C) "I can go through security at the airport without informing the security officers about my pacemaker."
The nurse is caring for a client with a head injury and monitoring them for signs of increased intracranial pressure. Which of the following are late signs of IICP? Select all the apply.
a. Confusion
b. Sluggish pupils
c. Widened pulse pressure
d. bradycardia
e. Slurred Speech
b. Sluggish pupils
c. Widened pulse pressure
d. bradycardia
A nurse is caring for a client who has been diagnosed with sepsis. The client is exhibiting signs of hypoperfusion, including decreased blood pressure, tachycardia, and cool extremities. The nurse understands that early intervention is crucial in managing sepsis. Which of the following actions should the nurse prioritize in the care of this client?
A) Administering broad-spectrum antibiotics as ordered
B) Encouraging deep breathing and relaxation exercises
C) Withholding intravenous fluids until blood cultures are drawn
D) Monitoring the client's urine output every 8 hours
A) Administering broad-spectrum antibiotics as ordered
A client arrives at the emergency department with severe chest pain, shortness of breath, and diaphoresis. The healthcare provider suspects a STEMI (ST-Elevation Myocardial Infarction). Which of the following interventions should the nurse prioritize to manage this client's condition?
A) Administer aspirin as prescribed
B) Encourage the client to walk around to reduce anxiety
C) Initiate oxygen therapy at 6 L/min via nasal cannula
D) Administer nitroglycerin as prescribed if blood pressure allows
E) Wait for laboratory results before administering aspirin
A) Administer aspirin as prescribed
C) Initiate oxygen therapy at 6 L/min via nasal cannula
D) Administer nitroglycerin as prescribed if blood pressure allows
A client with COVID-19 is receiving oxygen therapy via nasal cannula. Which nursing intervention is essential to prevent complications associated with oxygen therapy?
A) Assessing oxygen saturation every 4 hours
B) Increasing oxygen flow rate as needed
C) Ensuring humidification of oxygen
D) Encouraging deep breathing exercises
C) Ensuring humidification of oxygen
The telemetry nurse is reviewing an EKG of a patient suspected of having atrial fibrillation (A-Fib). What characteristic EKG findings would the nurse expect to observe in a patient with atrial fibrillation?
a. P waves with a consistent and normal morphology
b. Absence of QRS complexes
c. Regular R-R intervals
d. Irregularly irregular rhythm with fibrillatory waves
d. Irregularly irregular rhythm with fibrillatory waves
A nurse is caring for a patient who suffered a complete spinal cord injury between L4-L5. The nurse awakens the patient from sleep to assess their vitals. Vital signs read: 160/98 BP, HR 50, TEMP 99.2F, SpO2 95%, and respirations 22. What should the nurse do first?
a. Assess patient for sweating below injury
b. Bladder scan the patient
c. Sit patient up in semi-fowler or high fowler position
d. Assist the patient to the restroom
c. Sit patient up in semi-fowler or high fowler position
A med-surg nurse is assuming care of an elderly client with a UTI. This patient has a history of inpatient hospital admission due to UTI and pneumonia. During morning assessment she notes patient confusion, flushed warm skin, and has a temperature of 101.8F, respirations of 28, SPO2 is 94%, BP 88/56 and HR 122. The HCP suspects sepsis. What intervention should the nurse prioritize?
a. Administer antipyretics
b. Obtain lactate and blood cultures
c. Encourage patient to increase fluid intake orally
d. Administer oxygen
b. Obtain lactate and blood cultures
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. A nurse is
most concerned with this dysrhythmia because:
a) It is uncomfortable for the client, giving a sense of impending doom.
b) It produces a high cardiac output that quickly leads to cerebral and myocardial
ischemia.
c) It is almost impossible to convert to a normal sinus rhythm.
d) It can develop into ventricular fibrillation at any time
d) It can develop into ventricular fibrillation at any time
A nurse in the med surg unit is caring for a group of clients, some of which are suspected of having Covid-19 infections. Which priority action by the
nurse demonstrates proper infection control to prevent the transmission of the virus to uninfected patients on the unit?
a. Wearing a surgical mask when interacting with suspected Covid positive
patients.
b. Reusing the same gown for suspected Covid positive patients to reduce
waste.
c. Using specially designated equipment for each suspected Covid positive
patient.
d. Ensuring proper donning and doffing of PPE for each patient encounter
e. Placing the suspected Covid positive patients on contact precautions.
c. Using specially designated equipment for each suspected Covid positive
patient.
d. Ensuring proper donning and doffing of PPE for each patient encounter
A 60-year-old female client is scheduled for elective cardioversion to treat her persistent atrial fibrillation. The nurse is preparing the client for the procedure. Which of the following assessments is the nurse's priority prior to cardioversion?
A) Verify the client’s level of anxiety and provide reassurance as needed.
B) Ensure that the client has a patent intravenous (IV) line for medication administration.
C) Check the client's international normalized ratio (INR) to assess for adequate anticoagulation.
D) Confirm that the client is NPO for at least 8 hours prior to the procedure.
C) Check the client's international normalized ratio (INR) to assess for adequate anticoagulation.
Prior to elective cardioversion, it is essential to assess the client’s anticoagulation status (INR) to ensure that the client is at an appropriate level of anticoagulation. This reduces the risk of thromboembolism and stroke, which can occur if a clot is dislodged during the procedure.
A 72 year old at urgent care with daughter with worsening confusion and memory loss. Pt
doesn’t know where they are or why they’re there. Pt is agitated that they don’t remember and that their headache won’t go away. Daughter is concerned about dementia because of family hx and patient fell last week. Which diagnosis will the nurse expect?
A) New onset dementia
B) Early stage Alzheimers
C) Subdural hematoma
D) Epidural hematoma
C) Subdural hematoma
Which are signs of EARLY signs and symptoms of sepsis/septic shock select all that apply:
a. Low to normal BP
b. Cool, pale, edematous skin
c. Oliguria to anuria
d. Nausea, vomiting, diarrhea
e. Baseline but anxious mentation
f. Rapid, deep respirations
a. Low to normal BP
d. Nausea, vomiting, diarrhea
e. Baseline but anxious
f. Rapid, deep respirations
Which of the following medications should the nurse anticipate administering to help manage the client’s dysrhythmia?
A) Lisinopril
B) Diltiazem
C) Furosemide
D) Digoxin
B) Diltiazem
Rationale:
Diltiazem is a calcium channel blocker that helps control the heart rate in atrial fibrillation with a rapid ventricular response. It slows the conduction through the AV node and decreases the heart rate.
A patient has been recently diagnosed with COVID-19 and admitted to the hospital. What is the
best positioning for your patient?
A. Supine with the head of the bed elevated
B. Sidelying with the arm abducted and flexed overhead
C. Prone
D. Trendelenburg
C. Prone
A client is having frequent premature ventricular contractions. The nurse should place priority
on assessment of which item?
a. Sensation of palpitations
b. Causative factors, such as caffeine
c. Precipitating factors, such as infection
d. Blood pressure and oxygen saturation
d. Blood pressure and oxygen saturation