Nursing
During IV antibiotic therapy, a patient complains of burning at the site. What is the priority nursing action?
Notify the physician
Pause the infusion and assess the IV site
Document the complaint
Administer pain medication
Answer:
B) Pause the infusion and assess the IV site
Which of the following is the most accurate way to measure core body temperature?
A. Axillary
B. Oral
C. Rectal
D. Temporal
C) Rectal
A patient with a brain injury has difficulty regulating body temperature. Which brain structure is affected?
A. Cerebellum
B. Hypothalamus
C. Medulla oblongata
D. Thalamus
Answer:
B) Hypothalamus
A nurse is assessing breath sounds and hears high-pitched musical wheezes. This indicates:
A. Fluid in the lungs
B. Airway constriction (asthma)
C. Pneumothorax
D. Normal breath sounds
Answer:
B) Airway constriction (asthma)
Which patient requires airborne precautions?
A. MRSA
B. Tuberculosis
C. C. difficile
D. Influenza
Answer:
B) Tuberculosis
The nurse notes a patient’s oxygen saturation is 86% on room air. The priority action is to:
A. Recheck in 15 minutes
B. Apply supplemental oxygen
C. Document and notify respiratory therapy later
D. Encourage coughing and deep breathing only
B) Apply supplemental oxygen
When applying PPE, the correct sequence is:
A. Gown, mask, goggles, gloves
B. Mask, gown, gloves, goggles
C. Gloves, goggles, gown, mask
D. Gown, gloves, goggles, mask
Answer:
A) Gown, mask, goggles, gloves
A nurse suspects increased intracranial pressure (ICP). Which assessment supports this?
A. Decreased blood pressure, increased HR
B. Headache, vomiting, unequal pupils
C. Rapid breathing and high temperature
D. Clear speech and calm demeanor
B) Headache, vomiting, unequal pupils
A nurse finds a small fire in a patient’s room. The first step is to:
A. Extinguish the fire
B. Rescue the patient
C. Close the door
D. Pull the alarm
B) Rescue the patient
(RACE: Rescue, Alarm, Contain, Extinguish)
The nurse enters a patient’s room and observes that the patient is pale, diaphoretic, and restless. Vital signs show BP 78/46, HR 124, RR 28, O₂ sat 90%. What should the nurse do first?
A. Call a rapid response
B. Raise the head of the bed
C. Recheck vital signs
D. Document and continue assessment
A) Call a rapid response
Rationale: These findings suggest shock; immediate intervention and team response are necessary.