Deck 1: Adult

Question 1

Nurse Jennifer is caring for an adult patient in the intensive care unit who needs arterial line monitoring. Suddenly, the patient develops sepsis and tenderness at the insertion site. Aside from antibiotics administration, Nurse Jennifer should:

A)Exchange the arterial line and catheter with the seldinger technique
B)Remove the catheter and replace it with a new one, utilizing a different site
C)Replace the continuous flush, transducer, and pressure tubing
D)Apply Povidone iodine at the puncture site

Answer 1

Remove the catheter and replace it with a new one, utilizing a different site

Question 2

An electrician was brought to the Emergency room by his coworkers and was admitted with a possible myocardial infarction. The patient is experiencing severe chest pain. He is diaphoretic and his pulse is 115 beats per minute. The nurse should immediately:

A)Notify the doctor and administer morphine as ordered
B)Give the ordered nitroglycerine until pain subsides
C)Obtain blood pressure and get the electrocardiogram
D)Administer oxygen at 4-6 L/min

Answer 2

Notify the doctor and administer morphine as ordered

Question 3

The nurse at the unit is assessing a patient. She alerted the attending physician that the patient is in cardiogenic shock. Which of the following is an indication that a patient suffers from this condition?

A)Decreased urine output
B)Increased body temperature
C)Decreased heart rate
D)Increased blood pressure

Answer 3

Decreased urine output

Question 4

A 36-year-old male admitted to the hospital with a diagnosis of sub-arachnoid hemorrhage presents symptoms like aphasia and hemiparesis. The nurse is aware that these neurologic deficits, which may be present immediately after a sub-arachnoid hemorrhage, are primarily due to:

A)Electrolyte imbalances
B)Tissue necrosis
C)Vascular spasms
D)Profound blood loss

Question 5

A nurse is observing a patient with a pulmonary artery catheter in place. On the second day, the nurse observes a right ventricle waveform from the distal catheter port. What would be the most appropriate nursing action?

A)Switch monitoring lines to the proximal port of the catheter
B)Inflate the balloon with 1.5 ml air and advance the catheter
C)Advance the catheter 10 cm with the balloon deflated
D)Leave in right ventricle, you can still get pulmonary artery systolic pressure from right ventricle

Question 6

Nurse Jenny suspects that one of the admitted patients suffers from an organic heart murmur. Nurse Jenny is aware that the murmur is probably a defect in the:

A)Mixing of blood
B)Coronary arteries
C)Action of the valves
D)Heart conduction system

Question 7

Kelly, a 32-year-old college professor, was seen at the clinic. The doctor said that she is probably suffering from torsade des pointes. A 12-lead ECG tracing showed that she has a prolonged QT interval. During history taking, the nurse learns that she has a history of family deafness, previously had hypokalemia, and has likely used what medication?

A)Anti arrhythmics
B)Anti diabetic agents
C)Anti tubercular
D)Anti anemic medications

Question 8

Nurse Betty is caring for an adult patient who is admitted with a spinal cord injury. Betty is aware that a patient is developing autonomic dysreflexia if the patient has:

A)Absence of sweating
B)Pyrexia and shock
C)Flaccid paralysis and numbness
D)Bradycardia and paroxysmal hypertension

Question 9

Channing, a 34-year-old farmer who experiences severe chest pain, is brought to the emergency room. When assessing the ECG tracing, the nurse concludes that Channing is experiencing premature ventricular contractions. Which of the following abnormalities would support this conclusion?

A)Regular rhythm; >100 beats per minute; normal P wave; normal QRS complex
B)Irregular rhythm; absent P wave; wide and distorted QRS complex
C)Regular rhythm; 100-250 beats per minute; absent P wave; wide and distorted QRS complex
D)Regular rhythm; abnormally shaped P wave; normal QRS complex

Question 10

An electrocardiogram is ordered for Marilyn, a 42-year-old customer service representative who is complaining of chest pain. What would be an early finding in the lead over an infarcted area?

A)Absent P wave
B)Absent Q wave
C)Elevated ST segment
D)Flat T wave

Question 11

The physician discusses the case of a patient inside the patient's room. The doctor asks the patient if she ever had an illness that would predispose her to having a heart murmur. The nurse is aware that one of these predisposing illnesses is:

A)Mononucleosis
B)Rheumatic fever
C)Infectious hepatitis
D)Mumps

Question 12

Benita, a 65-year-old banker, was admitted to the unit due to pyrosis, dyspepsia, and difficulty swallowing. Based on the symptoms presented, the clinical nurse specialist might suspect:

A)Gastric Ulcer
B)Hiatal hernia
C)GERD
D)Esophagitis

Question 13

Ralph is a 48-year-old driver who is admitted because of mild chest pain. He is 5 feet, 9 inches tall and weighs 200 pounds. He is diagnosed with a myocardial infarction. Morphine sulfate, Diazepam, and Lidocaine were prescribed. The doctor orders 8 mg of Morphine Sulfate to be given intravenously. The vial on hand is labeled 1 ml/ 10 mg. The CNS nurse should administer:

A)10 minims
B)12 minims
C)14 minims
D)16 minims

Question 14

Mr) David, a patient with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical pulse rate is 45 bpm and he is on bed rest. The clinical nurse specialist concludes that his pulse rate is most likely the result of which of the following:

A)Cardiac glycoside
B)Vasodilator
C)Bed-rest
D)Diuretic

Question 15

Mr) Davids is admitted to the hospital with a diagnosis of left-sided congestive heart failure. During an assessment, the nurse should expect to find:

A)Dyspnea on exertion
B)Peripheral edema
C)Crushing chest pain
D)Neck vein distention

Question 16

Benita is a patient who is 48 hours post surgery for a repair of aortic aneurysm. The nurse should closely watch this patient because of what significant risk after the procedure?

A)Potential alteration in renal perfusion
B)Potential ineffective coping
C)Potential wound infection

Question 17

The clinical nurse specialist notes that patient Benita has lipid abnormalities. The nurse is aware that one of the following is a risk for developing atherosclerosis:

A)High levels of high density lipid cholesterol
B)Low concentration triglycerides
C)High levels of low density lipid cholesterol
D)Low levels of low density lipid cholesterol

Question 18

Mr) Hoffman, a firefighter, was admitted to the unit due to an accidental burn sustained after a rescue. The patient sustained thoracic burns and smoke inhalation and therefore, is at high risk for impaired gas exchange. Nursing interventions for this patient would include all of the following except for:

A)Suctioning the airway PRN
B)Repositioning from side to side every 2 hours
C)Maintaining the patient in supine position with the head of the bed elevated
D)Providing humidified oxygen as prescribed

Question 19

A clinical nurse specialist assesses the carbon monoxide level of a patient following a burn injury and notes that the level is 43%. Based on this level, which finding would the nurse expect to observe during the assessment of the patient?

A)Flushing and headache
B)Dizziness and vomiting
C)Tachycardia and tachypnea
D)Coma

Question 20

A clinical nurse specialist is caring for a hypertensive adult male patient who is admitted at the hospital. The physician ordered verapamil to decrease blood pressure. After several days of taking the medications, it is noted that the patient is experiencing toxicity. What medication should a nurse expect as an antidote?

A)Acetaminophen
B)Calcium
C)Atropine
D)Warfarin

Question 21

Larry is a 56-year-old fisherman who is admitted at the intensive care unit. It is noted that intubation is contraindicated and is not possible for this patient and an esophageal obturator airway (EOA) was considered as an option. Which of the following is true about esophageal obturator airway?

A)It rarely causes regurgitation
B)It requires visualization of the trachea before insertion
C)It should not be used with a conscious and pediatric patient
D)It can be inserted by a person who has ACLS training

Question 22

Naomi, a 40-year-old cook, returns to the recovery unit after a cholecystectomy. During the assessment, the nurse notices that Naomi's blood pressure is gradually dropping and her apical pulse is increasing. What will be the initial nursing action at this time?

A)Prepare and transfuse a unit of fresh whole blood
B)Fast drip 200 cc of present IV fluid and position the patient in Trendelenburg position
C)Immediately notify the physician and report the vital signs obtained
D)Position the patient in Sim's position

Question 23

Viva, a 25-year-old call center representative, was brought to the emergency room with chief complaint of visual disturbance that was described as double vision and flashing lights. At the time of assessment, Viva said that visual disturbances are gone, but she now has a severe pounding headache over her left eye. The nurse suspects a case of:

A)Tension headache
B)Brain tumor
C)Aura and migraine
D)Conversion reaction

Question 24

Antonio is an adult patient who is admitted due to lung cancer. The nurse learns that the patient is a cigarette smoker and has been for nearly 35 years. The nurse is aware that smoking is always associated with which type of lung cancer?

A)Bronchoalveolar carcinoma
B)Undifferentiated carcinoma
C)Squamous cell carcinoma
D)Adenocarcinoma

Question 25

The nurse is caring for a patient with a prolapsed mitral valve. The nurse is aware that it is a benign cardiac condition that can be associated with atypical chest pain. The nurse is also aware that the chest pain is possibly due to:

A)Dysfunctional left ventricle
B)Arrhythmias
C)Papillary muscle ischemia and dysfunction
D)Ventricular ischemia

Question 26

A nurse caring for an adult male patient who sustained a high-voltage electrical injury analyzes the patient's test results. Which finding would the nurse interpret as increasing the patient's risk of developing acute tubular necrosis?

A)Carbonaceous sputum
B)Hyperkalemia and hyponatremia
C)Presence of myoglobin in the urine
D)Cloudy cerebrospinal fluid

Question 27

Corrine is a 48-year-old mother who is admitted to the hospital with a diagnosis of ruled out mitral stenosis. She signed the consent for surgery to correct her stenosed valve because of unbearable signs and symptoms. She is complaining of difficulty breathing, coughing up blood, orthopnea, and paroxysmal dyspnea. The nurse is aware that these symptoms are the result of:

A)Right heart failure
B)Thickened pericardium
C)Left ventricular hypertrophy
D)Pulmonary hypertension

Question 28

A nurse is caring for Mrs. Holiday, who was diagnosed with chronic renal failure. During the end of shift endorsement, the nurse said that she was able to observe which of the following?

A)Ruddy skin complexion
B)Anorexia, weakness, and pruritus
C)Polyuria, polydipsia, and polyphagia
D)Fruity-smelling breath

Question 29

Erick is a 50-year-old patient who had an abdominal surgery. An hour after the surgery, Erick develops internal hemorrhage. During further assessments, the nurse would expect that the patient will exhibit:

A)Tachycardia
B)Hypertension
C)Polyuria
D)Bradypnea

Question 30

A clinical nurse specialist notes that a patient is demonstrating signs and symptoms of blood transfusion reaction. The nurse immediately stops the blood transfusion and then does what??

A)Hangs a bag of normal saline using a new IVF tubing
B)Sends a urine specimen to the laboratory
C)Obtains blood pressure in both arms
D)Monitor intake and output every 15 minutes

Question 31

Tamica is a female adult patient who is admitted due to esophageal varices, with chief complaint of hematemesis. The physician ordered 3 "u" of blood to be transfused after proper typing and crossmatching. The nurse administers the first unit of blood and after 30 minutes, the patient complains of severe flank pain. What would be the initial nursing action?

A)Obtain vital signs
B)Monitor hourly urinary output
C)Stop the transfusion
D)Assess the pain further

Question 32

A patient is scheduled for kidney transplant surgery. The physician ordered preoperative medications of azathioprine, cyclosporine, and prednisone. The nurse is aware that these medications will:

A)Prevent iatrogenic reactions
B)Stimulate leukocytosis
C)Provide passive immunity
D)Reduce antibody production

Question 33

A patient with diabetic ketoacidosis has a potassium level of 5.5mEq/L. When monitoring the electrocardiogram tracing, the clinical nurse specialist would expect to observe:

A)Prolonged ST segment with abnormal Q wave
B)Increased number of T wave with peaked P wave
C)Wide QRS complex with peaked T wave
D)Abnormal P wave and T wave

Question 34

Hypoinsulinism is a long term complication of pancreatoduodenectomy. An adult patient is already aware of it since the physician discussed it with him during the doctor's morning rounds. To validate the understanding of the teaching, the nurse asks the patient when to seek medical supervision and treatment. The patient must state that he should call if he experiences:

A)Abnormal increase in thirst
B)Increase in weight
C)Oliguria
D)Anorexia

Question 35

A nurse is assessing a patient who is on his 24-hours post-surgery for correction of an abdominal hernia. The nurse would like to determine if the patient's peristalsis has returned in order to start the diet because the patient's husband reported that the patient is asking for glass of water. What would be the first indicator that the nurse should expect?

A)The patient has a bowel movement
B)The patient can tolerate general liquids
C)The patient has bowel sounds
D)The patient passes flatus

Question 36

Rudy is a 55-year-old patient who was diagnosed with Hepatitis A. After three weeks, the patient developed hepatic cirrhosis and ascites with an elevated serum ammonia level. What would be the priority nursing intervention, considering that the patient has high ammonia levels?

A)Oral fluid intake restrictions
B)Obtaining a daily weight
C)Observe for signs of increasing confusion
D)Measurement of urine specific gravity

Question 37

Michelle is a 27-year-old model who has just undergone a subtotal gastrectomy. Immediately after the procedure, she was brought to the post-anesthesia care unit. A clinical specialist nurse who is assigned to Michelle noticed that there are small blood clots in the gastric drainage. What would be the nurse's initial action?

A)Nothing. This is just a normal event.
B)Instill the tube utilizing a normal saline
C)Alert the physician about the finding
D)Immediately clamp the tube

Question 38

Michelle is a post-operative patient who had a subtotal gastrectomy. After 72 hours, she complained of abdominal pain that she described as severe with a pain scale of 8 to 9. The assigned nurse did an abdominal palpation and noted that it is rigid. The nurse should initially:

A)Encourage the patient to ambulate with care
B)Administer analgesics as prescribed
C)Obtain the patient's vital signs
D)Have the patient use an incentive spirometer

Question 39

Nurse Gwen is caring for a patient who had an infratentorial craniotomy. The patient is already at the intensive care unit after a discharge from the post-anesthesia care unit. After careful periodic assessments, Gwen noticed that the patient has an increasing intracranial pressure. Nurse Gwen should initially:

A)Start an osmotic diuretic
B)Elevate the head of the bed
C)Notify the physician regarding the finding
D)Set the intravenous fluid rate at KVO

Question 40

An adult patient was admitted to the emergency department after sustaining a spinal cord injury above the T6 level. Which adaptation is important for a clinical nurse specialist to monitor when concerned about spinal shock?

A)High blood pressure
B)Distended bladder
C)Hypoventilation
D)Tachycardia

Question 41

Julia, a 27-year-old patient, is admitted to the unit following a pneumonectomy. The nurse's primary concern for this patient is to maintain:

A)An intact chest tube drainage
B)Ventilatory exchange
C)Supplemental oxygenation
D)Blood replacement

Question 42

A 16-year-old female patient is admitted following a burn injury. She sustained deep-partial thickness burns on her neck, anterior chest, and entire right arm. When assessing for heat inhalation, the nurse should first observe for:

A)Abnormalities in chest X-rays
B)Nasal discharge containing carbon particles
C)Sputum tinged with blood
D)Abnormalities in ABG level that are consistent with acidosis

Question 43

An adult patient was admitted at the hospital due to a severe respiratory problem. His current respiratory status requires endotracheal intubation and positive pressure ventilation. The best immediate nursing intervention at this point is to:

A)Maintain the sterility of the ventilation system
B)Facilitate the patient's verbal communication
C)Assess the patient's response to mechanical ventilation
D)Have the parents sign the consent for an immediate surgery

Question 44

An adult patient who smokes 3 packs of cigarettes a day was admitted to the hospital with a diagnosis of pulmonary emphysema. When the nurse assessed the patient, she noticed shortness of breath and that the patient used his accessory muscles during respirations. The nurse is aware that the patient's dyspnea is due to:

A)Rapid expulsion of air from the alveoli
B)Difficulty in expelling the air trapped in the alveoli
C)Spastic bronchi which traps the air
D)Increased vital capacity of the lungs

Question 45

Mariane recently had an abdomino-perineal resection and colostomy. She accuses the nurse of being negligent during the change of dressing because she says the surgical wound looks terrible. The nurse recognizes that Mariane is using which defense mechanism?

A)Intellectualization
B)Reaction formation
C)Sublimation
D)Projection

Question 46

Susan is a 34-year-old female patient who had profuse vaginal bleeding. The physician ordered blood transfusion of 2 "u" PRBC type "AB" with preblood transfusion of acetaminophen. Before administering the blood, the priority nursing intervention would be:

A)Monitor hemoglobin and hematocrit level
B)Let the blood reach room temperature
C)Obtain a baseline vital signs
D)Determine proper typing and crossmatching of blood

Question 47

A patient who is admitted with a diagnosis of diabetes type 1 was placed on an insulin pump. When teaching the patient on how to control diabetes, the short-term goal should be: "The patient will ­_____...."

A)…adhere to the medical regimen."
B)…demonstrate the correct use of the pump."
C)…state self-care activities that are necessary in order to control diabetes."
D)…have a normal glucose level within the next 3 weeks."

Question 48

A 40-year-old patient with chronic atrial fibrillation was placed on an oral anticoagulant therapy. Nurse Victoria is preparing to administer the medication, but she decided to withhold it because she noted that the patient has:

A)An elevated erythrocyte sedimentation rate
B)International normalized ratio between 6 and 7
C)Apical rate of 52 bpm
D)Partial thromboplastin time of 25 sec

Question 49

A 28-year-old patient was admitted with a diagnosis of Hepatitis A. The doctor ordered contact precautions. In addition to the standard precautions, what isolation procedures should be strictly implemented?

A)All people who enter the patient's room should wear a mask, gown, and gloves
B)Gowns and mask should be worn only when a person handles the patient's soiled linen and other utensils
C)The patient should be isolated in a private room with the door always kept closed
D)Gown and mask should be worn whenever a person will come in contact with a contaminated body fluids and feces

Question 50

Nurse Dolly was walking in the hallway of the unit when she noticed a patient having a tonic-clonic seizure. Nurse Dolly's priority should be to:

A)Protect the patient's head from any injury
B)Transfer the patient to a soft surface
C)Firmly hold the patient's upper extremities
D)Insert an airway between the patient's teeth

Question 51

Nurse Jenna is making a short-term goal for an adult male patient who is on his first week of admission following a spinal cord injury at the T3 level. What is an appropriate short-term goal that Jenna should identify?

A)"The patient will know his limitations"
B)"The patient will perform ambulation independently"
C)"The patient will carry out his hygiene activities"
D)"The patient will consider changes in his lifestyle"

Question 52

A morbidly obese adult patient who smokes 2 packs of cigarettes daily was admitted for a major abdominal surgery. Postoperatively, the most appropriate laboratory value that a clinical nurse specialist should monitor that would reflect the patient's respiratory status is the:

A)O2 saturation
B)PO2
C)Hemoglobin
D)PCO2

Question 53

An adult patient who was diagnosed with chronic obstructive pulmonary disease (COPD) has an acute COPD exacerbation episode. He experiences dyspnea and is anxious. In order to decrease the dyspnea, the nurse's initial action is to:

A)Set the oxygen at 6L/min
B)Teach and encourage the patient to do rhythmic breathing
C)Assess the vital signs especially the blood pressure
D)Encourage the patient to breathe using a paper bag

Question 54

Antonio is a patient who is on his first day following a right pneumonectomy. After the morning rounds, he suddenly sits straight up in bed. He has labored breathing; he is making a crowing sound; and his skin is pale, moist, and cool to touch. The nurse should immediately:

A)Auscultate the left lung
B)Call the physician
C)Assess the operative site for bleeding
D)Check the patency of the chest tube

Question 55

After a thoracic surgery, a male adult patient was transported to the unit. He has a chest tube connected to a water-seal drainage attached to suction. The nurse noticed that there is excessive bubbling in the water-seal chamber. The nurse should:

A)Assess the bottle system for air leaks
B)Strip the chest tube catheter
C)Do nothing because it is expected
D)Decrease the amount of suction pressure

Question 56

A male adult patient who has history of chronic renal failure is hospitalized. In order for early detection signs related to renal insufficiency, the nurse should assess the patient for signs that include:

A)Edema and pruritus
B)Dribbling after urination
C)Facial flushing
D)Decreased forced of urine stream

Question 57

An adult female patient with acute renal failure moves into the diuretic phase after 1 week of therapy. During this phase, the patient must be assessed for signs of developing:

A)Hypovolemia
B)Hyperkalemia
C)Renal failure
D)Metabolic acidosis

Question 58

In a critical situation, a physician orders the nurse to administer a dose of a drug that the nurse knows would constitute an overdose for the patient. Which statement by the nurse is most appropriate?

A)"The dose is more than I can legally give. However, if the dose is medically indicated,please administer it yourself."
B)"This is an overdose. I'm not comfortable administering it."
C)"Please show me how you computed the dosage. I think it is incorrect."
D)"You're probably thinking of another patient and drug. This is way beyond the therapeutic dose."

Question 59

A female adult patient was admitted with a chief complaint of body weakness and was formerly diagnosed with diabetes mellitus. The physician orders 30 units of insulin to be incorporated in an IV of glucose and water. The nurse understands that the only insulin compatible to use is:

A)Humulin N
B)Humulin R
C)Lente
D)Ultralente

Question 60

Digoxin (lanoxin) is ordered for a patient with a diagnosis of heart failure. The nurse is doing a care plan including observation of digoxin toxicity; therefore, the nurse should monitor the patient for:

A)Hypokalemia
B)Constipation
C)Decreased urination
D)Blurring of vision

Question 61

Cristy is a 22-year-old patient who is admitted at the hospital. She is in hypovolemic shock and has a hematocrit level of 22%. The nurse alerted the physician and anticipates an order of which the following?

A)Serum albumin
B)Blood replacement
C)High molecular dextran
D)Lactated Ringer's solution

Question 62

The clinical nurse specialist assesses the extent of the damage to a patient's ninth and tenth cranial nerves. In order to obtain accurate data, the nurse should request the patient to:

A)Swallow
B)Shrug
C)Smell
D)Blink

Question 63

A 60-year-old patient with a right lung cancer undergoes a lobectomy. After the surgery, the patient was transported to the unit with a chest tube attached to suction. What observation would prompt a nurse to notify the physician?

A)Blood clots along the tubing during the first 24-hours
B)Bloody fluid in the drainage collection chamber in the first 24-hours
C)Diminished bubbling in the water-seal chamber after 72 hours
D)Subcutaneous emphysema during his second day

Question 64

Mr) Collins is placed on digitalis on discharge from the hospital. The nurse planning with him for his discharge should educate him as to the purpose and actions of his new medication. What should the nurse teach the patient to do at home to monitor his reaction to this medication?

A)Check his serum potassium (K) level
B)Weigh himself daily
C)Take his radial pulse for one full minute
D)Obtain his blood pressure

Question 65

A nurse is speaking to a group of diabetic adults in the OPD about eye health and the importance of visits to the ophthalmologist. The nurse decides to discuss glaucoma prevention. Which of the following diagnostic tests should these patients request from their care provider?

A)Slit lamp
B)Tonometry
C)Fluorescein stain
D)Snellen's test

Question 66

A 30-year-old patient refuses to adhere to the twice-a-day ordered sessions in physical therapy. The nurse might approach this problem by:

A)Planning a conference with the patient, the physical therapist, and the nurse present to discuss the patient's feelings
B)Being the patient's advocate and asking the physician whether therapy can be decreased to once daily
C)Assuring the patient that pain medication will be administered before the scheduled physical therapy
D)Having the patient observe the progress of a more cooperative patient with the same problem

Question 67

On the morning of Mr. Coleman's planned cholecystectomy, he awakens with a pain in his right scapular area and thinks he slept in poor position. While doing the preoperative check list, the nurse notes that on his routine hematology report, his WBC is 15,000. The nurse's responsibility at this point is to:

A)Record this finding in a prominent place on the preoperative checklist and in preoperative nurse's notes
B)Nothing. This is not an unusual finding.
C)Notify the surgeon at once; this is an elevated WBC, indicating an inflammatory reaction
D)Call the laboratory for a STAT repeat WBC

Question 68

A patient is scheduled for surgery 2 days later and is to be given atropine 0.25 mg IM and Demerol 50 mg IM one hour preoperatively. Which nursing actions follow the giving of the preoperative medication?

A)Reinforce preoperative teaching
B)Allow his family to be with him before the medication takes effect
C)Bring his valuables to the nursing station
D)Have him void soon after receiving the medication

Question 69

A nurse observes that a nursing assistant did not use a bag impervious to liquid for contaminated linen from a patient who is on contact precautions. The nurse's best way to handle this situation should be to:

A)Put an anecdotal summary of the behavior in the nursing assistant's personnel record
B)Place the linen in an appropriate bag
C)Write an incident report about the situation
D)Review transmission-based precautions with the nursing assistant

Question 70

One night, Nurse Carol is assigned to a patient who is receiving intermittent tube feedings. The patient insisted that he can't tolerate the intermittent feedings. Nurse carol should:

A)Change the feeding schedule to omit nights
B)Suggest an antiemetic be prescribed
C)Gather more data from the night nurse about the feeding technique used
D)Ask that the type of solution be changed

Question 71

A female adult patient who had a major abdominal surgery asks the nurse if she can return to work after discharge. The most appropriate response by the nurse would be:

A)"No, not for at least 2 weeks."
B)"What type of work do you have in mind?"
C)"Yes, but I'm sure you know what it means to take it easy?"
D)"No, because you should get plenty of rest when you get home."

Question 72

A nurse is coaching a group of student nurses about the anatomy and physiology of the head. The nurse asks one of the students what to do if she observes that there is blood coming from a patient's ear after a head injury sustained following a motor vehicle collision. The correct response by the student nurse should be:

A)Cleanse the ear with sterile gauze
B)Put sterile cotton loosely in the external ear
C)Turn the patient to the unaffected side
D)Test the drainage with dextrostix

Question 73

A patient is admitted for resection of abdominal aortic aneurysm. While waiting for the surgery, the patient suddenly develops symptoms of shock. The nurse should:

A)Give the patient nothing by mouth
B)Administer the prescribed sedative
C)Notify the physician
D)Prepare for blood transfusion

Question 74

A state's Nurse Practice Act does not allow a registered nurse to suture wounds. The physician offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. The nurse should:

A)Agree to suture wounds in the physician's presence
B)Refuse to suture wounds
C)Follow the physician's instructions
D)Report the situation to the State Board of Nursing

Question 75

A patient is scheduled for surgery. The physician discusses the case with the nurse and advices that legally, a patient may not sign the operative consent. The nurse agreed with the physician's statement if the case is that:

A)Any sedative type of medication has recently been given
B)A discussion of alternatives with two physicians has not occurred
C)A complete history and physical has not been performed and recorded
D)Ambivalent feelings are present and acknowledged

Question 76

A patient with type 2 diabetes travels frequently and asks how to plan meals during trips. The nurse's most appropriate response would be:

A)"You should plan your food ahead and carry it with you from home."
B)"Make regular food choices, wherever you are, following your food plan."
C)"You can monitor your blood glucose level frequently and can eat accordingly."
D)"You can order diabetic foods on most airlines and in restaurants."

Question 77

A nurse has just received a medication order that is not legible. Which statement best reflects assertive communication?

A)"I cannot give this medication as it is written. I have no idea what you mean."
B)"Would you please clarify what you have written so I am sure I am reading it correctly?"
C)"I am having difficulty reading your handwriting. It would save me time if you would be more careful."
D)"Please print in the future so I do not have to spend extra time attempting to read your writing."

Question 78

An ambulatory patient reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

A)"How many pillows do you use at night to sleep comfortably?"
B)"Do you smoke?"
C)"Do you become short of breath during your normal daily activities?"
D)"Have you had a recent heart attack?"

Question 79

The nurse is at the community center speaking with adult people. To which comment by one of the participants during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information?

A)"I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."
B)"I usually avoid driving at night since lights sometimes seem to make things blur."
C)"I take half of the usual dose for my sinuses to maintain my blood pressure."
D)"I take extra fiber and drink lots of water to avoid getting constipated."

Question 80

A patient with an aldosterone-secreting adenoma is scheduled for surgery to remove the tumor. The patient wonders what will happen if the surgery is canceled. The newly hired nurse doesn't know how to answer the patient, which made her consult her immediate supervisor. When the nurse comes back to the patient, she correctly responds:

A)Surgery will prevent the tumor from metastazing to other organs
B)Chemotherapy is as reliable as surgery to treat adenomas of this type
C)Radiation therapy or surgery can be just as effective if the tumor is small
D)The tumor must be removed to prevent heart and kidney damage