Question 1

The nurse provides discharge instructions to a client with a graft site on the right leg. Which statement, if made by the client, would indicate the need for further instruction?

Accepted Answer

The graft site must be free from pressure and should be immobilized; therefore, weight bearing must be avoided. The graft site must also be protected from harsh materials or ingredients and sunlight.

Question 2

A 20-year-old male client with a BMI of 33 has been admitted for recurrent chest pains and difficulty breathing. During the assessment, it is found that his father and mother have both suffered from myocardial infarction before the age of 50. Which of the following nursing actions is the first step to prevent the client from developing myocardial infarction?

Accepted Answer

A sedentary lifestyle and poor diet are associated with obesity and myocardial infarction; however, the client must be willing and committed to participate in a weight reduction program. Therefore, assessment of interest in reducing weight is the most critical step in prevention of these diseases.

Question 3

The nurse is reviewing the goals of the treatment plan for a new patient admitted with Septic Shock with a nursing student. What is the best summary of the priorities of care for the patient with Septic Shock?

Accepted Answer

The best way to summarize the priority of care for the patient with Septic Shock is to identify and treat the infecting pathogen (infectious organism). Treatment goals will include maintaining the oxygenation, perfusion and hemodynamic body systems otherwise known as the circulatory system.

Question 4

The nurse is preparing to transfer the patient to a telemetry unit after treatment for a new diagnosis of Atrial Fibrillation and Status Post Mechanical Valve. The patient will be on long term Warfarin Therapy. What is the goal International Normalized Ratio (INR) for this patient?

Accepted Answer

The International Normalized Ratio (INR) goal for a patient who has Status Post Mechanical Valve surgery is 3.0 to 4.0. If the patient just was on Warfarin, a medication taken to prevent the blood from clotting and to treat blood clots and overly thick blood for Atrial Fibrillation (Abnormal or irregular heart rhythm), he would have an International Normalized Ratio (INR) goal of 2.0 to 3.0.

Question 5

A patient has been transferred to the intensive care unit after being diagnosed with Diabetes Ketoacidosis. The nurse would expect to see the following signs and symptoms:

Accepted Answer

In a patient with Diabetes Ketoacidosis the nurse would expect to see severe dehydration, rapid and deep breathing (also known as Kussmaul's respirations) and abdominal cramps. Polyuria, polydipsia, and polyphagia are signs and symptoms of Diabetes Mellitus. Extreme thirst, nocturia, hypotension and tachycardia are symptoms of Diabetes Insipidus.

Question 6

The nurse is taking care of a 51 year old with Acute Lymphocytic Leukemia (ALL) with a White Blood Cell count of 6.0. What would the nurse NOT do when preventing infection from occurring in the patient?

Accepted Answer

When working to prevent an infection in a patient with Acute Lymphocytic Leukemia (ALL) with a White Blood Cell count of 6.0, the nurse would avoid inserting a Foley Catheter or any other non-critical device that would increase the risk of a patient obtaining an infection. The nurse should take vital signs every 2 to 4 hours; check the patient's mouth often to assess for mouth ulceration and give antibiotic therapy quickly.

Question 7

A patient has second and third degree burn injuries to his anterior chest and abdomen, anterior left arm, anterior right arm and left anterior leg. Using the Rule of Nines, what percentage of the body surface area (BSA) is affected?

Accepted Answer

Using the Rule of Nines, a method of estimating the extent of body surface that has been burned in an adult, dividing the body into sections of 9 per cent or multiples of 9 per cent; the percentage of the body surface area (BSA) of the patient is 36%. The various percentages of affected area would be 18% for the anterior chest and abdomen, 4.5% for the anterior left arm, 4.5% for the anterior right arm and 9% for the anterior left leg.

Question 8

When working the family of the patient in critical care, a nurse should use this kind of Therapeutic Communication:

Accepted Answer

When working with the family of the patient in critical care, the nurses' best method of Therapeutic Communication to use is to consider the family to be an integral part of the team and engage them in the patient's care. Therapeutic Communication involving the family as part of the team can ease anxiety, tension and frustration on the part of the family helping ensure better patient outcomes and family satisfaction.

Question 9

A patient is beginning IV Phenytoin for diagnosis of a new onset of Seizures. What adverse effects would the nurse asses for after administering the medication?

Accepted Answer

After administering Phenytoin for a diagnosis of new onset of Seizures, the adverse effects the nurse would assess for include slurred speech, thrombocytopenia, and Stevens-Johnson syndrome. Hemorrhage, prolonged clotting time and thrombocytopenia are adverse effects of Heparin. Gastrointestinal bleeding, acute renal insufficiency and liver dysfunction are adverse reactions of Aspirin. Fosphenytoin may cause increased Intracranial Pressure (ICP), cerebral edema and somnolence.

Question 10

A patient has been admitted to the intensive care unit with a diagnosis of "rule out" Guillain-Barre syndrome. The nurse is completing the admission data base and asking about the patient's history. What diagnosis might precipitate a diagnosis of Guillian-Barre syndrome?

Accepted Answer

When completing the admission data base and asking about the patient's history the diagnosis that might precipitate Gullian-Barre syndrome is mild fevers, upper respiratory infections or minor viruses. The nurse should pay particular attention to any mild infections and fevers the patient has recently had. The primary cause of Guillian-Barre syndrome is not known; however; about 50% of patients with Guillian-Barre have a recent history of infection.

Question 11

The nurse is assessing the tests of a patient with a diagnosis of acute right-sided Heart Failure. What parameter would be elevated in right-sided Heart Failure?

Accepted Answer

When looking at the parameters for a patient with a diagnosis of right-sided Heart Failure, the Central Venous Pressure (CVP) would be elevated. The Central Venous Pressure (CVP) describes the amount of blood that is returning to the heart and is a measure of the pressure of the blood in the thoracic vena cava.

Question 12

The nurse is preparing to wean a patient from mechanical ventilation. What option is NOT a method of weaning the patient from mechanical ventilation?

Accepted Answer

The option that is NOT appropriate for weaning a patient from mechanical ventilation is controlled mandatory ventilation. This method is only used when the patient is unable to take breaths on their own. Controlled mandatory ventilation is not a weaning method.

Question 13

A patient admitted with suspected renal disease and severe low back pain is preparing to go to have a Renal Arteriography test. Before going to the test, the nurse would ensure that:

Accepted Answer

Before sending a patient with suspected renal disease and severe low back pain for a Renal Arteriography test, it is important to ensure the patient is not allergic to iodine and shellfish. Allergies to iodine and shellfish may cause an adverse reaction to the dye. The lab values serum creatinine and urea nitrogen should be checked. All abnormal lab values should be reported to the attending physician.

Question 14

The nurse is assisting the physician during an Abdominal Paracentesis. What is the maximum amount of fluid that should be aspirated?

Accepted Answer

The maximum amount of fluid that should be removed during an Abdominal Paracentesis is 1,500 to 2,000 mL. Removing more than 2,000 mL of peritoneal fluid during one Paracentesis may cause an episode of Hypovolemic Shock.

Question 15

More patients are being diagnosed with Multi Organ Dysfunction Syndrome (MODS) and being treated in the Intensive Care Unit. This is because:

Accepted Answer

More patients are being diagnosed with Multi Organ Dysfunction syndrome (MODS) and being treated in the intensive care unit because of the progress of health care treatments and services being more effective resulting in a greater advancement of treatments and services. The more progress made in health care treatments and services; the greater increase in positive patient outcomes such as those with traumatic injuries and infections.

Question 16

Which gland is responsible for the release of Calcitonin?

Accepted Answer

The gland responsible for the release of Calcitonin is the Thyroid gland. Calcitonin is a hormone produced by C-cells of the thyroid gland and is responsible for reducing the levels of calcium in the blood.

Question 17

A patient has developed Acute Respiratory Acidosis, with a pH of 7.25 and a PaCO2 of 55. What is the underlying cause of Respiratory Acidosis?

Accepted Answer

The underlying cause of respiratory acidosis is that the lungs are not sufficiently ventilating. Acute Respiratory Acidosis is a sudden collapse of the body's ventilation system often resulting from central nervous system disease, drugs or toxins or Chronic Obstructive Pulmonary Disease (COPD).

Question 18

What are the signs and symptoms of patient who is in stage 3 of Hepatic Encephalopathy?

Accepted Answer

The signs and symptoms of the patient in stage 3 of Hepatic Encephalopathy are severe confusion and an inability to follow commands. Hepatic Encephalopathy results from a build up of ammonia in the body due to the inability of the liver. This is primarily due to cirrhosis of the liver.

Question 19

A patient's family begins to ask several questions about the variety of numbers on the patient's monitor. What would be the most appropriate response for the nurse to give?

Accepted Answer

The most appropriate response for the nurse to give in such a situation is "Tell me about which numbers are concerning to you." This response acknowledges the family's concerns and helps them understand the patient's condition. It is normal for families to feel helpless and powerless and the nurse has the opportunity to offer empowerment and comfort through simple but focused explanations.

Question 20

A patient is suspected of developing an Upper Gastrointestinal bleed two days after a total hip replacement. What are the most appropriate nursing actions?

Accepted Answer

The most appropriate action for a suspected diagnosis of an Upper Gastrointestinal bleed includes making the patient NPO (nothing by mouth to eat or drink) and inserting a Nasogastric tube to the intermittent suction. This will prevent any chance of increasing irritation to the suspected upper gastrointestinal bleed and allow for appropriate management.

Quiz 1: Adult