Safe and Effective Environment
A train derails near your hospital. Over 25 people are injured and being transported to the emergency department. Which patient should be assessed first?
A) A 36-year old with a sucking chest wound
B) A 10-year old with a severe leg laceration
C) A 78-year old who has a compound fracture of the left arm
D) A 23-year old who is unresponsive and has a high spinal cord injury
A 36-year old with a sucking chest wound. Nurses must make difficult decisions about establishing priorities during an emergency. If given immediate attention, the patient with the sucking chest wound can recover. The patient with the severe leg laceration and the patient with the compound fracture can be given temporary care, then fully treated later. The patient with the spinal cord injury will not likely survive and should not be given first priority.
A client receives a PPD test. He returns to the clinic 24 hours later and shows the inoculated arm, which has no induration or redness. Which of the following statements, if made by the nurse, is a CORRECT interpretation of the results?
A) “You will need to return in another day for me to correctly assess the site.”
B) “This is a positive reaction. I will refer you for further evaluation.”
C) “This is a negative result. I will mark it in your chart.”
D) “This is a negative result. We will follow up with a chest x-ray to be sure.”
A) “You will need to return in another day for me to correctly assess the site.”
No need for a chest x-ray unless the PPD tests positive. This is neither a positive nor a negative result- PPD tests cannot be read until it has been 48 to 72 hours.
A 4-year-old child is admitted to the hospital after his family was in a car crash, where his parents died. The child keeps asking you to bring his parents back to life. The nurse knows that:
A) This is a normal reaction
B) The child is depressed
C) The child has not seen a person die before
D) The child is delusional and may have suffered a concussion as a result of the crash
A) This is a normal reaction. This is a normal reaction for a young child, who may not fully understand death. These requests are not necessarily indicative of delusion or depression.
Which assignment should not be performed by a licensed practical nurse (LPN)?
B. The LPN cannot start a blood transfusion; this assignment requires a registered nurse. Answers A, C, and D are all duties that a LPN can perform, and are therefore incorrect.
What is the presence of abnormal quantities of protein in the urine, which may indicate damage to the kidneys called?
Proteinuria
Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which of the following conditions is documented in the client's medical history?
1. Hypotension
2. Hypothyroidism
3. Diabetes mellitus
4. Peripheral vascular disease
Answer: 4
Rationale:
Methylergonovine is an ergot alkaloid used for postpartum hemorrhage. Ergot alkaloids are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications.
Test Taking Strategy:
Focus on the medication and its classification. Recalling that ergot alkaloids produce vasoconstriction will direct you to option 4.
A nurse works at an outpatient health center and receives a call from an adolescent girl who was recently prescribed the birth control pill. She describes “an awful leg cramp that turned the skin red.” Which of the following statements, if made by the nurse to the patient, is CORRECT?
A) “Has this happened before?”
B) “Do you play any sports where you could have injured yourself?”
C) “We’ll need you to come in to the clinic to be evaluated immediately.”
D) “This is a normal side effect with the pill and should go away after the first month.”
C) “We’ll need you to come in to the clinic to be evaluated immediately.”
This is a most-feared complication of birth control pills: a DVT. The girl needs immediate evaluation and treatment.
When reviewing a client's chart, the nurse sees that the doctor identified that the client is experiencing a situational crisis. An event that could cause this is:
A) Retirement
B) Abortion
C) Rape
D) Child abuse
B) Abortion. Abortion is a common cause of a situational crisis. Retirement may cause a maturation crisis, and child abuse and rape may cause an adventitious crisis.
Nurses are mandatory reporters of any suspected child abuse. The most important observation by the nurse that can be used as a basis for reporting suspected abuse is:
A. A lack of consistency indicates inappropriate injuries for the given history. When the history does not match the injury, other causes such as abuse should be suspected.
What are the 5 sequential steps in the nursing process?
Assessment, diagnosis, planning, implementation, and evaluation.
A 4 day old infant is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The nurse should plan to include which of the following in the plan of care during the home visit to the infant?
1. Apply lotions to the infant's exposed skin.
2. Assess skin integrity and fluid and electrolyte status.
3. Have minimal contact with the infant to prevent stimulation.
4. Advise the mother to limit the infant's oral intake during phototherapy.
Answer: 2
Rationale:
Assessing skin integrity and fluid and electrolyte status of the infant is an essential component of phototherapy.
Test Taking Strategy:
Use the steps of the nursing process. Note that option 2 addresses the first step of the nursing process, assessment.
Which of the following materials would the graduate nurse require to test the function of a patient’s glossopharyngeal nerve?
A) Soft cotton swab and a toothpick.
B) A stethoscope.
C) Tongue depressor.
D) A handheld mirror.
C) Tongue depressor.
The glossopharyngeal nerve can be tested for function by assessing gag reflex. The tongue depressor checks gag reflex.
A 50-year-old male client comes to the nurses’ station and asks the nurse if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the client becomes verbally abusive. Which of the following approaches by the nurse would be MOST effective?
1.Tell the client to lower his voice, because he is disturbing the other clients.
2.Ask the client what he wants from the cafeteria and have it delivered to his room.
3.Calmly but firmly escort the client back to his room.
4.Assign the nursing assistive personnel (NAP) to accompany the client to the cafeteria.
The correct answer is (3). The nurse should not reinforce abusive behavior. Clients need consistent and clearly defined expectations and limits.
Which of these actions, would best relieve a toddler’s anxiety if his parents must leave the hospital while he is hospitalized?
A. When family members are unable to stay at the hospital, the toddler will probably feel frightened and alone and may feel abandoned. If the parents leave something that belongs to them, the toddler will feel more secure.
A busy, harried-looking physician comes onto the floor and writes out four orders in less than one minute. He leaves, shoving over a stack of the nurse’s charting on the way out the door. Which of the following four orders should the nurse question?
A) Cold compresses and elevation for a patient whose IV infiltrated two hours ago.
B) Heating pad for a patient with rheumatoid arthritis.
C) Sitz bath for a patient recovering from an episiotomy.
D) Heating pad for a diabetic patient with a foot ulcer.
D) Heating pad for a diabetic patient with a foot ulcer.
The diabetic patient might have neuropathy and be unable to correctly sense the temperature of the heating pad, resulting in a burn.
A client with severe preeclampsia is admitted to the maternity department. Which of the following room assignments is most appropriate for this client?
1. A private room across from the elevator.
2. A semiprivate room across from the nurses' station.
3. A private room two doors away from the nurses' station.
4. A semiprivate room with a client who enjoys watching television.
Answer: 3
Rationale: A quiet room in which stimuli can be minimized is most important for the client with severe preeclampsia.
Test Taking Strategy: Patients with preeclampsia should be subject to the least about of stimuli possible.
A nurse works with four patients at an outpatient health center. Which of the patients most concerns the nurse?
A) A 50 y/o Asian female who weighs 100lbs and is 5 feet in height.
B) A 24 y/o Caucasian woman who enjoys swimming on a daily basis.
C) A 50 y/o Caucasian male who has been weight-lifting at the gym two times per week.
D) A 36 y/o African American male who has been trying to eat a healthier diet.
A) A 50 y/o Asian female who weighs 100lbs and is 5 feet in height.
Although each of the above patients is healthy, the one who is most at risk for problems in the future is the post-menopausal Asian woman who has little bone mass. She is very susceptible to osteoporosis.
Three days after admission for depression, a 54-year-old female client approaches the nurse and says, “I know I have cancer of the uterus. Can’t you let me stay in bed and have some peace before I die?” In responding, the nurse must keep in mind that
a. The client must be postmenopausal.
b. Thoughts of disease are common in depressed clients.
c. Antidepressant medications frequently cause vaginal spotting.
d. Clients suffering from depression can be demanding, making many requests of the nurse.
B. Concern with having a life-threatening disease is a common issue with depressed clients. While demanding behavior (3) may be a symptom, it is not the issue here. Whether or not the client is postmenopausal (1) is not relevant.
What is the minimal apical pulse the nurse should obtain prior to administering digoxin (Lanoxin) to a hospitalized five-year-old?
a. 60
b. 70
c. 100
d. 120
B. A five-year-old needs to have an apical pulse rate of at least a 70 before digoxin can be administered. This medication slows the heart rate, and the normal heart rate of a five-year-old is between 70 and 100 beats per minute.
The physician prescribes alprazolam (Xanax) 0.25 mg p.o. TID for a client with anxiety and physical symptoms related to work pressures. The nurse should assess the client for the most common adverse effect of this drug, which is?
A) Agranulocytosis
B) Tardive dyskinesia
C) Drowsiness
D) Bradycardia
C) Drowsiness
Benzodiazepines potentiate the action of GABA, enhance presympathetic inhibition, and inhibit spinal polysynaptic afferent pathways; drowsiness, dizziness, and blurred vision are common adverse effects.
Which of the following identifies a correct principle of surgical asepsis?
a. A sterile package that becomes wet is unsterile.
b. The nurse should hold sterile objects below waist level.
c. A 3-inch border around the edges of a sterile field are considered contaminated.
d. Prolonged exposure to air will not contaminate a sterile field as long as the client's room windows and doors are kept closed.
The answer is "a"
Note the following:
b. Any sterile object held below waist level is contaminated because it cannot be viewed at all times.
c. A 1-inch border around the edges of a sterile field are contaminated.
d. A sterile field becomes contaminated by prolonged exposure to air.
The home health nurse visits a patient with HIV who lives alone in her apartment. Which of the following observations the nurse makes while in the patient’s home is MOST concerning?
A) The dishwasher is broken and the patient complains that she has low water pressure throughout the whole apartment.
B) The patient has a bowl of fake fruit on the table.
C) There is an open container of food in the refrigerator.
D) The patient has a cat who purrs loudly.
D) The patient has a cat who purrs loudly.
The open container of food in the refrigerator needs to be addressed, but the cat is more concerning. The cat’s feces could contain toxoplasmosis, an organism dangerous to immunocompromised patients.
A 20-year old male client is admitted to the psychiatric unit with a diagnosis of schizophrenia, acute episode. He is having auditory hallucinations and seems disoriented to time and place. The nurse knows that a hallucination can be explained as a(n):
a. Distortion of real auditory or visual perception.
b. Sensory experience without foundation in reality.
c. Voice that is heard by the client but is not really there.
d. Idea without foundation in reality.
B. Hallucinations may involve any sense, and they have no basis in reality. The most common are auditory. Answer (3) is an example of an auditory hallucination. Answer (2) is an illusion; answer (4) is a delusion.
A 71-yr-old male client is recovering from a stroke and exhibits signs of unilateral neglect. Which of the following supports this suspicion?
C. The client with unilateral neglect will neglect one side of the body. Answers A, B, and D are not associated with unilateral neglect.
The nurse works on a medical/surgical unit and cares for a patient receiving Lanoxin (Digoxin) and Furosemide (Lasix). The nurse knows that which of the following, if reported by the patient, must be assessed IMMEDIATELY?
A) Vomiting and halos around lights.
B) Low blood pressure and dark urine.
C) Stomach upset and headache.
D) Night sweats and headache.
A) Vomiting and halos around lights.
Lasix causes the patient to lose potassium. Digoxin, if taken with a low potassium level, can become toxic and show signs/symptoms of nausea, vomiting, and halos around lights.