IPC
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 c/o 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.
This lactate level would indicate lactic acidosis
What is >4mmol/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. Sharing facemask
c. Cover cough and sneeze
d. Disinfect surfaces
e. Travel
a. Handwashing
c. Cover cough and sneeze
e. Travel
What should the patient avoid after ICD placement?
lifting arm on ICD side above shoulder
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 concerned for a patient with sepsis that they may be displaying signs of septic
shock. Identify the EARLY signs of septic shock.
A: Shallow Breathing
B: Warm and flushed skin
C: Cool and pale skin
D: Rapid deep breathing
E: Normal to low BP
F: Hypotension
B: Warm and flushed skin
D: Rapid deep breathing
E: Normal to low BP
The telemetry nurse is reviewing a rhythm strip for a client with a 2nd degree type II heart block. The nurse notes a QRS complex of 0.16 seconds, no measurable PR interval, and a regular R to R and P to P interval. The nurse assesses the client and determines the client is responsive but dizzy with a pulse rate of 50bpm. Which action by the nurse is correct?
a. Continue to monitor
b. Prepare the client for pacemaker insertion
c. Have the client perform a vagal maneuver
d. Call a code blue
b. Prepare the client for pacemaker insertion
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 (AFib). 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
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
When the nurse evaluates a client's response to cardioversion, which observation would be of the
highest priority to the nurse?
A-Blood pressure
B-Status of airway
C-Oxygen flow rate
D-Rapid Respiration Rate
C-Oxygen flow rate
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 s/s of sepsis/ septic shock:
1. Low to normal BP
2. Cool, pale, edematous skin
3. Oliguria to anuria
4. Nausea, vomiting, diarrhea
5. Baseline but anxious mentation
6. Rapid, deep respirations
7. Shallow, dyspneic respirations
8. Tachycardia, possible dysrhythmias
9. Normal urinary output
10. Warm, dry, flushed skin
11. Altered mental status
12. Increased, thready pulses
13. Increased body temperature with chills and slight weakness
14. Normal to low body temperature
Low to normal BP
Nausea, vomiting, diarrhea
Baseline but anxious
Rapid, deep respirations
Normal urinary output
Warm, dry, flushed skin
Increased, thready pulses
Increased body temperature with chills
and slight weakness
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 for drainage
D. Trendelenburg
C. Prone for drainage
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