75 RN Practice Questions

8/11/2019 75 RN Practice Questions

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75 Practice Question

Incorrect...

The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. Afterbeing told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessmentfinding?

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Increase in Forced Vital Capacity (FVC)

A narrowed chest cavity

Clubbed fingers

An increased risk of cardiac failureSubmit

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Increase in Forced Vital Capacity (FVC)

Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPDwould have a decrease in FVC.

A narrowed chest cavity

A patient with COPD often presents with a barrel chest, which is seen as a widened chest cavity.

Clubbed fingers

Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels .

An increased risk of cardiac failure

Although a patient with these conditions would indeed be at an increased risk for cardiac failure, this is apotential complication and not an assessment finding.

The nurse is taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer. After beingtold the patient is complaining of epigastric pain, the nurse expects to note which assessment finding?

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Melena

Nausea

Hernia


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Hyperthermia

Submit

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Melena

Correct Melena is the finding that there are traces of blood in the stool. This is a common manifestation ofDuodenal Ulcers, since the Duodenum is further down the gastric anatomy .

Nausea

Nausea may be present, but is a generalized symptom and by itself doesnt indicate a Duodenal Ulcer

Hernia

A Hernia is a protrusion of a segment of the abdomen through another abdominal structure. It is not associatedwith an Ulcer and is a condition, not an assessment finding.

Hyperthermia

Hyperthermia, a high temperature, is not an assessment finding of a Duodenal Ulcer

A nurse is providing discharge teaching for a patient with severe Gastroesophogeal Reflux Disease. Which ofthese statements by the patient indicates a need for more teaching?

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Im going to limit my meals to 2 -3 per day to reduce acid secretion.

Im going to make sure to remain upright after meals and elevate my head when I sleep

I wont be drinking tea or coffee or eating chocolate any more.

Im going to start trying to lose some weight.

Submit

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Im going to limit my meals to 2 -3 per day to reduce acid secretion.

Correct Large meals increase the volume and pressure in the stomach and delay gastric emptying. Itsrecommended instead to eat 4-6 small meals a day .

Im going to make sure to remain upright after meals and elevate my head when I sleep

Incorrect This is a correct verbalization of health promotion for GERD.

I wont be drinking tea or coffee or eating chocolate any more.


Im going to start trying to lose some weight.


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The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing labresults, the nurse finds that the patients blood pressure is 95/60, pulse is 110 beats per minute, and the patientreports epigastric pain. What is the priority intervention?

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Start a large-b ore IV in the patients arm

Ask the patient for a stool sample

Prepare to insert an NG Tube

Administer intramuscular morphine sulphate as ordered

Submit

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Start a large- bore IV in the patients arm

Correct The nurse should suspect that the patient is haemorrhaging and will need need a fluid replacementtherapy, which requires a large bore IV.

Ask the patient for a stool sample

Incorrect While this is useful in the diagnosis and assessment of Peptic Ulcer Disease, it is not the priorityintervention.

Prepare to insert an NG Tube

Incorrect While this intervention may be used in the later stages of Peptic Ulcer Disease, it is not the first andpriority intervention.

Administer intramuscular morphine sulphate as ordered

Incorrect While this is an important intervention to manage pain, it is not the priority intervention.

A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to thephysician immediately?

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Hemoglobin 11 g/dl

Platelet of 150,000

INR of 2.5

Potassium of 2.7 mEq/L

Submit


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Hemoglobin 11 g/dl

This is below normal, but a normal female hemoglobin is 12-14. There is a more critical lab result.

Platelet of 150,000

This is also below the normal values, but is not the most critical lab result.

INR of 2.5

This is a therapeutic range for a patient who is taking an anticoagulant for atrial fibrillation

Potassium of 2.7 mEq/L

Correct A potassium imbalance for a patient with a history of dysrhythmia can be life-threatening and canlead to cardiac distress.

While receiving normal saline infusions to treat a GI bleed, the nurse notes th at the patients lower legs have

become edematous and auscultates crackles in the lungs. What should the nurse do first?

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Stop the saline infusion immediately

Notify Physician

Elevate the patients legs

Continue the infusion, since these are normal findings

Submit

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Stop the saline infusion immediately

Correct, the patient has a fluid volume overload as a result of overly rapid fluid replacement. The nurse shouldstop the infusion and notify the physician .

Notify Physician

This is not the first action the nurse should take.

Elevate the patients legs

This would help with the edema, but is not a priority

Continue the infusion, since these are normal findings

This is not a normal finding

The nurse is working in a support group for clients with HIV. Which point is most important for the nurse tostress?


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They must inform household members of their condition

They must take their medications exactly as prescribed

They must abstain from substance use

They must avoid large crowdsSubmit

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They must inform household members of their condition

Incorrect Each patient has a right to privacy of their medical condition. It is their choice whether they informhousehold members.

They must take their medications exactly as prescribed

Correct Antiretrovirals must be taken exactly as prescribed to prevent drug-resistant strains. Even misseddoses can reduce the effectiveness of future treatment .

They must abstain from substance use

Incorrect While substance use should be discouraged, using safe practices with needles can preventtransmission of HIV.

They must avoid large crowds

Incorrect Avoiding large crowds to prevent infection is a priority in the later stages of HIV, when the patienthas AIDS.

A nurse finds a 30-year-old woman experiencing anaphylaxis from a bee sting. Emergency personnel have beencalled. The nurse notes the woman is breathing but short of breath. Which of the following interventions shouldthe nurse do first?

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Initiate cardiopulmonary resuscitation

Check for a pulse

Ask the woman if she carries an emergency medical kit

Stay with the woman until help comes

Submit

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Initiate cardiopulmonary resuscitation

Incorrect CPR is premature at this point, and there is another action that can be taken first.


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Check for a pulse

This is the first step when initiating CPR, but not the best and first course of action.

Ask the woman if she carries an emergency medical kit

Correct Many patients who have a known history of anaphylaxis carry epi-pens in their pockets orbelongings. This is the best way to stop a hypersensitivity reaction before it becomes life-threatening .

Stay with the woman until help comes

Incorrect While this should be done, its not the best and first course of action.

A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity whenhe notices which of these assessment findings?

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The patient states he had a manic episode a week ago

The patient states he has been having diarrhea every day

The patient has a rashy pruritis on his arms and legs

The patient presents as severely depressed

The patients lithium level is 1.3 mcg/L

Submit

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The patient states he had a manic episode a week ago

Incorrect Having a manic episode is not an indication of lithium toxicity. This finding indicates that the lithiumis not effective or is not at a therapeutic level.

The patient states he has been having diarrhea every day

Correct Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity .

The patient has a rashy pruritis on his arms and legs

Incorrect This is not a symptom of lithium toxicity

The patient presents as severely depressed

Incorrect Having a depressive episode is not an indication of lithium toxicity. This finding indicates that thelithium is not effective or is not at a therapeutic level.

The patients lithium level is 1.3 mcg/L

This is within the therapeutic range of lithium

A 65 year old man is prescribed Flomax (Tamsulosin) for Benign Prostatic Hyperplasia. The patient lives in anupstairs apartment. The nurse is most concerned about which side effect of Flomax?


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Hypotension

Tachycardia

Back Pain

Difficulty UrinatingSubmit

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Hypotension

Correct Hypotension can lead to dizziness and a risk for injury to the patient.

Tachycardia

Tachycardia can be a side effect of Flomax, but is not an immediate safety risk, nor is it a common side effect.

Back Pain

Back Pain can be a side effect of Floma, but is not a safety risk

Difficulty Urinating

Dysuria is a symptom of Benign Prostatic Hyperplasia, not a side effect of Flomax

A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-timecaretaker. The nurse is most concerned about which side effect of heparin?

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Back Pain

Fever and Chills

Risk for Bleeding

Dizziness

Submit

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Back Pain

Incorrect Back pain, while it can occur, is not an immediate concern

Fever and Chills

Incorrect Fever and Chills, while it can occur, is not an immediate concern

Risk for Bleeding


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Induce vomiting

Incorrect This may be warranted for a severe lithium toxicity, but would be premature at this point.

Hold the next dose of Lithium

Correct Lithiums therapeutic range is 0.5 -1.5mcg/L, and begins toxicity at 1.5mcg/L

Administer an anti-emetic

Incorrect While minor toxicity can cause vomiting and nausea, this is not a priority action

Give the next dose of Lithium

Incorrect Lithiums therapeu tic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L

A patient asks the nurse why they must have a heparin injection. What is the nurses best response?

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Heparin will dissolve clots that you have.

Heparin will reduce the platelets that make your blood clot

Heparin will work better than warfarin.

Heparin will prevent new clots from developing.

Submit

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Heparin will dissolve clots that you have.

Incorrect Heparin does not do this.

Heparin will reduce the platelets that make your blood clot

Incorrect Heparin does not do this

Heparin will work better than warfarin.

Incorrect Heparin has a different mechanism of action than warfarin, and a different route of administration,but achieve similar results.

Heparin will prevent new clots from developing.

Correct -This is a correct statement .

The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab resultsshow that the troponin I value is a 5.3 ng/mL. Which of these intervention, if not completed already, would takepriority over the others?

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Put the patient in a 90 degree position

Check whether the patient is taking diuretics

Obtain and attach defibrillator leads

Check the patients last ejection fract ion

Submit

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Put the patient in a 90 degree position

Incorrect This position is optimal for helping a patient breathe, but is not the priority action in an emergencysituation.

Check whether the patient is taking diuretics

Incorrect Diuretics play a role in CHF by decreasing fluid volume, but this patient is likely having an acute

myocardial infarction.

Obtain and attach defibrillator leads

Correct Ventricular Fibrillation is the cause of death in most cases of deaths due to sudden cardiac arrest. Defibrillation is the most important action to take to prevent death.

Check the patients last ejection fraction

Incorrect Ejection fraction is a test used to gauge the severity of CHF, not an emergency cardiac arrest.

A nurse is caring for a patient undergoing a stress test on a treadmill. The patient turns to talk to the nurse.Which of these statements would require the most immediate intervention?

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Im feeling extremely thirsty. Im going to get some water after this.

I can feel my heart racing.

My shoulder and arm is hurting.

My blood pressure reading is 158/80

Submit

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Im feeling extremely thirsty. Im going to get some water after this.

Incorrect This does not require immediate intervention. This is a common response to exercise and activity.

I can feel my heart racing.

Incorrect This does not require immediate intervention. This is a common response to exercise and activity.


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My shoulder and arm is hurting.

Correct Unilateral arm and shoulder pain is one of the classic symptoms of myocardial ischemia. The stresstest should be halted.

My blood pressure reading is 158/80

Incorrect This does not require immediate intervention. Moderate elevation in blood pressure is a common

response to exercise and activity.

The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab resultsshow that the BNP (B-type Natriuretic Peptide) value is a 615 pg/ml. What would the nurse take as the priorityaction?

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Call a cardiac code and implement emergency measures

Check the patients oxygen saturation

Inform the physician that the patient has Congestive Heart Failure

Encourage the patient to limit activity

Submit

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Call a cardiac code and implement emergency measures

Incorrect There is no evidence that the patient is undergoing a cardiac arrest.

Check the patients oxygen saturation

Correct An elevated BNP indicates that there is decreased cardiac output. A priority intervention would beto ensure proper oxygenation after an assessment .

Inform the physician that the patient has Congestive Heart Failure

Incorrect Although BNP suggests Congestive Heart Failure, it is not used in itself to diagnose CHF. An elevatedBNP can also be caused by dysrhythmias or renal disease.

Encourage the patient to limit activity

Incorrect This is an intervention that can help treat CHF, but not a priority action at this time.

A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistantwould most require the nurses immediate intervention?

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The nursing assistant fills the patients pitcher with ice cold drinking water

The nursing assistant elevates the head of the bed to 60 degrees for a meal


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The nursing assistant refills the ice pack laying on the insertion site

The nursing assistant places an extra pillow under the patients head on request

Submit

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The nursing assistant fills the patients pitcher with ice cold drinking water

Incorrect It is recommended to generously hydrate after a coronary angiogram to excrete contrast medium,reducing kidney toxicity

The nursing assistant elevates the head of the bed to 60 degrees for a meal

Correct For 3-6 hours after a coronary angiogram (depending on the insertion site), the patient should havetheir bed no higher than 30 degrees and be on bedrest.

The nursing assistant refills the ice pack laying on the insertion site

Incorrect An ice pack or dressing is recommended to be placed on the insertion site to minimize risk ofbleeding.

The nursing assistant places an extra pillow under the patients head on request

Incorrect An extra pillow will not violate any post-procedural protocols for coronary angiogram.

A man is has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea.The nurse is concerned about which side effect of lisinopril?

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Vertigo

Hypotension

Palpitations

Nagging, dry cough

Submit

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Vertigo

Incorrect While this may occur, the patient is at higher risk due to another adverse effect.

Hypotension

Correct The patient is particularly at risk for hypotension due to possible dehydration from fluid loss.

Palpitations

Incorrect While this may occur, the patient is at higher risk for another adverse effect.


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Nagging, dry cough

Incorrect While this is a common side effect, the patient is at higher risk for another adverse effect..

The nurse is taking the health history of a patient being treated for sickle cell disease. After being told thepatient has severe generalized pain, the nurse expects to note which assessment finding?

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Severe and persistent diarrhea

Intense pain in the toe

Yellow-tinged sclera

Headache

Submit

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Severe and persistent diarrhea

Incorrect This is not a manifestation of sickle cell disease

Intense pain in the toe

Incorrect Gout is a manifestation of Polycythemia Vera, in which the there is an overabundance of red bloodcells

Yellow-tinged sclera

Correct Jaundice is a common clinical finding of sickle cell disease, caused by bilirubin released from damagedor destroyed RBCs

Headache

Incorrect While this may occur, it is not indicative or a classic symptom of sickle cell disease.

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A client with Multiple Sclerosis reports a constant, burning, tingling pain in the shoulders. The nurse anticipatesthat the physician will order which medication for this type of pain?

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alprazolam (Xanax)

Corticosteroid injection


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gabapentin (Neurontin)

hydrocodone/acetaminophen (Norco)

Submit

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alprazolam (Xanax)

Incorrect alprazolam is used to reduce anxiety

Corticosteroid injection

Incorrect Corticosteroid injections are used to reduce inflammation in a localized area, often due to jointbreakdown. In MS patients it is used to treat acute exacerbations (flare -ups), but the symptoms described donot constitute an acute exacerbation.

gabapentin (Neurontin)

Correct Anticonvulsants like gabapentin are often the first line of treatment for nerve pain

hydrocodone/acetaminophen (Norco)

Incorrect Opioids would not be the appropriate medication to treat nerve pain.

Which of these clients is likely to receive sublingual morphine?

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A 75-year-old woman in a hospice program

A 40-year-old man who just had throat surgery

A 20-year-old woman with trigeminal neuralgia

A 60-year-old man who has a painful incision

Submit

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A 75-year-old woman in a hospice program

Correct Sublingual morphine is often used in hospice because the patients are unable to swallow, andintravenous access can be painful and not conducive to palliative care.

A 40-year-old man who just had throat surgery

Incorrect Patients who have surgery most likely have an Intravenous line

A 20-year-old woman with trigeminal neuralgia

Incorrect Morphine would not be the first choice for nerve pain


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A 60-year-old man who has a painful incision

Incorrect Although Morphine would be an appropriate medications, there is no indication that it should beadministered sublingually

In educating clients on ways to manage pain, which topic can be appropriately delegated to a LPN/LVN who willcontinue under supervision?

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Acupuncture

Guided Imagery

Alternating Rest/Activity

Over the counter medications

Submit

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Acupuncture

Incorrect This is outside the nursing scope of practice and requires special training or education

Guided Imagery

Incorrect This also requires additional training or education

Alternating Rest/Activity

Correct This is within the nursing scope of practice and within the training and education provided to allnurses. It is safe to use and a standard treatment.

Over the counter medications

Incorrect This is outside the nursing scope of practice. A healthcare provider (doctor, nurse practitioner, orphysicians assistant) should be consulted before taking over the counter medications.

The nurse assesses a patient suspected of having an asthma attack. Which of the following is a common clinicalmanifestation of this condition?

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Audible crackles and orthopnea

An audible wheeze and use of accessory muscles

Audible crackles and use of accessory muscles

Audible wheeze and orthopnea

Submit


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A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for thenurse to make?

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Assess the patient for nuchal rigidity

Determine the patients past exposure to infectious organisms

Check the patients WBC lab values

Monitor for increased lethargy and drowsiness

Submit

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Assess the patient for nuchal rigidity

Incorrect Although neck stiffness can be a symptom of Meningitis, it is not used to define meningitis, neither is

it a sign of further neurological deterioration.

Determine the patients past exposure to infectious org anisms

Incorrect Although this is an important part of the history gathering process, and meningitis is most oftencaused by a viral or bacterial infection, it is not the priority assessment.

Check the patients WBC lab values

Incorrect Although WBCs do rise during an infection like Mengingitis, it is not the priority assessment.

Monitor for increased lethargy and drowsiness

Correct Lethargy and drowsiness indicate a decreased level of consciousness, which is the cardinal sign ofincreased ICP (Intracranial Pressure), which can be life-threatening.

The nurse is caring for clients in the pediatric unit. A 6-year patient is admitted who has 2nd and 3rd degreeburns on his arms. The nurse should assign the new patient to which of the following roommates?

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A 4-year old with sickle-cell disease

A 12-year old with chickenpox

A 6-year old undergoing chemotherapy

A 7-year old with a high temperature

Submit

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A 4-year old with sickle-cell disease


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Acyclovir (Zovirax)

Mannitol (Osmitrol)

Lactated Ringers

Phenytoin (Dilantin)

Submit

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Acyclovir (Zovirax)

Incorrect- Acyclovir is a common antiviral drug for the treatment of viral encephalitis

Mannitol (Osmitrol)

Incorrect Mannitol is a hyperosmolar drug that helps reduce Intracranial Pressure by acting as a diuretic anddecreasing fluid in the body.

Lactated Ringers

Correct Lactated Ringers solution is often used in fluid replacement therapy, which is not warranted if apatient is at risk for high ICP.

Phenytoin (Dilantin)

Incorrect Phenytoin is an anticonvulsant and is often used to prevent seizures, which can complicate andworsen a patients neurological state.

The nurse is treating a patient who has Parkinsons Disease. Which of these practices would not be included inthe care plan?

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Decrease the calorie content of daily meals to avoid weight gain

Allow the patient extra time to respond to questions and do ADLs

Use thickened liquids and a soft diet

Encourage the patient to hold the spoon when eating

Submit

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Decrease the calorie content of daily meals to avoid weight gain

Correct Calorie content should be increased for patients with Parkinsons Disease because of dysphagia(difficulty swallowing), as well as calories burned due to muscle rigidity.

Allow the patient extra time to respond to questions and do ADLs


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Incorrect This is a best practice when working with PD patients.

Use thickened liquids and a soft diet

Incorrect This is often used to reduce the risk of aspiration

Encourage the patient to hold the spoon when eating

Incorrect The patient should be encouraged to perform ADLs as independently as possible.

A 45-year old woman is prescribed ropinirole (Requip) for Parkinsons Disease. The patient is living at home withher daughter. The nurse is most concerned about which side effect of ropinirole?

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Slurred speech

Sudden dizziness

Masklike facial expression

Stooped Posture

Submit

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Slurred speech

Incorrect Slurred speech is a common symptom of PD, not a side effect of this drug.

Sudden dizziness

Correct Dizziness and orthostatic hypotension are serious adverse effects of this drug that can lead to anincreased risk of falls. Ropiniroles drug class is a dopamine agonist, which mimic dopamine in the brain (PD ischaracterized by a lack of dopamine).

Masklike facial expression

Incorrect Masklike facial expression is a common symptom of PD, not a side effect of this drug.

Stooped Posture

Incorrect Stooped Posture is a common symptom of PD, not a side effect of this drug.

The nurse is taking the health history of a patient being treated for Parkinsons Disease. After being told thepatient has classic symptoms of Parkinsons, the nurse expects to note which assessment finding?

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Tremors

Low Urine Output


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Exaggerated arm movements

Risk for Falls

Submit

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Tremors

Correct Tremors is one of four cardinal signs of PD: the other three are rigidity, bradykinesia (slowmovements), and postural instability

Low Urine Output

Incorrect This is not a relevant symptom to PD

Exaggerated arm movements

Incorrect A symptom of PD would be rigidity and slow arm movements, rather than exaggeration of armmovements

Risk for Falls

Incorrect This is not an assessment finding. This is a nursing diagnosis.

A nurse enters a patients room and finds them unconscious with a rhythmic jerking of all four extremities. Thepatient is foaming heavily at the mouth. The patient was on seizure precautions and the bedrails are up andpadded. What is the nurses priority a ction?

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Administer Lorazepam (Ativan)

Turn the patient to his/her side

Call the physician

Suction the patient

Submit

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Administer Lorazepam (Ativan)

Incorrect If a seizure lasts more than 5 minutes, it is called Status epilepticus and can be life-threatening.Physicians will often order anxiolytics or sedatives to treat this condition. However, at this point it would not beappropriate for the nurse to administer this drug.

Turn the patient to his/her side

Correct Turning the patient to the side will keep the airway open, which is the first priority

Call the physician


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Incorrect This would be a priority action after ensuring the patients safety, or in the case of Status epilepticus

Suction the patient

Incorrect This intervention is warranted, but after an assessment of the patients airway, since forcing asuction catheter into a patients mouth is a last resort.

A nurse is giving a discharge education to a patient who has been diagnosed with epilepsy. Which of these

teachings would she stress the most?

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Avoid doing alcohol and drugs

Follow up with the neurologist, physician, or other health care provider as prescribed

Do not stop taking anticonvulsants, even if seizures have stopped

Wear a medical alert bracelet or carry an ID card indicating epilepsy

Submit

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Avoid doing alcohol and drugs

Incorrect Although this is a general teaching that would be applied to any hospital discharge situation, it is notthe priority to be stressed.

Follow up with the neurologist, physician, or other health care provider as prescribed

Incorrect Although this is correct to include in discharge education, following this instruction is not directlycontributing to their safety, so is not the priority.

Do not stop taking anticonvulsants, even if seizures have stopped

Correct Following this instruction is essential for their safety, since stopping anti-epileptic drugs suddenly cancause seizures and an increased chance of status epilecticus

Wear a medical alert bracelet or carry an ID card indicating epilepsy

Incorrect Although this is correct to include in discharge education, following this instruction is not directlycontributing to their safety, so is not the priority.

The nurse is caring for a patient in the ICU who has had a spinal cord injury. She observes that his last bloodpressure was 100/55, and his pulse is 48. These have both trended downwards from the baseline. What shouldthe nurse expect to be the next course of action ordered by the physician?

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Assess the patient for decreased level of consciousness

Administer Normal Saline

Insert an NG Tube


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Connect and read an EKG

Submit

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Assess the patient for decreased level of consciousness

Incorrect An assessment has already been made, and an intervention is warranted.

Administer Normal Saline

Correct The patient is entering neurogenic shock. Normal saline will replace fluid volume, treating thehypotension and bradycardia symptomatically. Atropine sulfate is also commonly used to increase the heartrate.

Insert an NG Tube

Incorrect An NG tube would not be relevant in this situation.

Connect and read an EKG

Incorrect An EKG would not be needed in this situation.

A nurse is caring for a patient who is suspected to have sustained a spinal cord injury. What best describes theoverarching principles used to guide the care for this type of condition?

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Immobilize the cervical area to prevent further injury

Monitor the patients level of consciousness to prevent neurol ogic deterioration

Help the patient with activities of daily living and provide emotional and physical support to help themadjust to their injury

Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing

Submit

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Immobilize the cervical area to prevent further injury

Incorrect While this is an essential part of caring for a spinal cord injury, it does not adequately describeguiding principles for a complete plan of care

Monitor the patients level of consciousn ess to prevent neurologic deterioration

Incorrect While this is an essential part of caring for a spinal cord injury, it does not adequately describeguiding principles for a complete plan of care

Help the patient with activities of daily living and provide emotional and physical support to help them adjust totheir injury


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A 40-year old female who has high cholesterol and uses oral contraceptives

A 65-year old female who is African American, has sickle cell disease and smokes cigarettes.

Submit

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A 60-year old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past.

Correct Common risk factors for developing stroke include: Atrial fibrillation, arteriosclerosis, previous strokeor ischemic attack, heart surgery, valvular heart disease, diabetes, smoking, substance abuse,obesity, sedentarylifestyle, oral contraceptive use, genetic tendency, migraines, older age, male, AfricanAmerican/Hispanic/American Indian, Sickle Cell Anemia, and brain trauma. This man has the greatest risk basedon these risk factors.

a 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic.

Incorrect See Common Risk Factors for Developing a Stroke.

A 40-year old female who has high cholesterol and uses oral contraceptives


A 65-year old female who is African American, has sickle cell disease and smokes cigarettes.


A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be mostconcerned about which of these assessment findings?

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INR is 3 seconds long

Heart rate is 110 beats per minute

Intracranial Pressure is 22 mm/Hg

Blood pressure is 140/80

Submit

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INR is 3 seconds long

Incorrect This is actually within a therapeutic range for clotting times for patients with coagulation risks. Anormal INR is .9-1.2 seconds, while a therapeutic INR can be as high as 3.5 seconds.

Heart rate is 110 beats per minute

Incorrect While tachycardia is a concern, general tachycardia without other associated symptoms would notpose an immediate danger, and is not of greater priority than the next answer.


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Intracranial Pressure is 22 mm/Hg

Correct The patient is at greatest risk for an increased ICP resulting from edema 72 hours after a stroke. Atarget ICP should be less than or equal to 15-20 mm/Hg

Blood pressure is 140/80

Incorrect Blood pressure is often kept higher than usual following a stroke to maintain perfusion. Systolic BP

higher than 180, or diastolic BP higher than 105, would be the upper limit and required intervention. 140/80would not pose an immediate danger to t he patients health.

A nurse is caring for a patient scheduled to have cataract surgery. The patient asks why they developed cataractsand how they can prevent it from happening again. What is the nurses best response?

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Age is the biggest factor contributing to cataracts.

Unprotected exposure to UV lights can cause cataracts

Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.

Unfortunately, there is really nothing you can do to pr event cataracts, but they are amongst the mosteasily treated eye conditions.

Submit

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Age is the biggest factor contributing to cataracts.

Incorrect While true, this answer leaves out many other contributing factors to cataracts and does not addressprevention.

Unprotected exposure to UV lights can cause cataracts

Incorrect While true, this answer is not complete

Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.

Correct This answer covers the most common contributing factors for cataracts and includes preventable riskfactors.

Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easilytreated eye conditions.

Incorrect While most cataracts are age-related cataracts, there are still ways to prevent eye damage andcataract development.

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27/50

A nurse is educating a patient about bimatoprost (Lumigan) eyedrops for the treatment of Glaucoma. Which ofthe following indicates that the patient has a correct understanding of the expected outcomes followingtreatment?

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I should be experiencing less blurriness in my central field of vision

This medication wont help my vision at all, but will keep it from getting worse.

My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so.

This medication will help my eye restore intraocular fluid and increase intraocular pressure

Submit

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I should be experiencing less blurriness in my central field of vision

Incorrect Cataracts cause blurriness in the central field of vision, while Glaucoma presents as loss of the field ofvision peripherally.

This medication wont help my vision at all, but will keep it from getting worse.

Correct Glaucoma cannot be cured, just treated. Treatment revolves around preventing further deterioration.

My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so.

Incorrect Glaucoma treatment does not result in restoration of vision already lost.

This medication will help my eye restore intraocular fluid and increase intraocular pressure

Glaucoma is caused by an increase in intraocular fluid. Eyedrops work in various ways to decrease IntraocularPressure, not increase it.

A patient with Glaucoma is verbalizing his daily medication routine to the nurse. He states he has two differenteyedrop medications, both every twelve hours. He washes his hands, instills the drops, closes his eyes gently,and presses his finger to the corner of his eye nearest his nose. After waiting 1 minute with his eyes closed, heinstills the other medication in the same way. What is the nurses best response?

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You should wait more than 1 minute between different medications.

Your routine is very good! Can you demonstrate it for me?

It is actually not the best practice to close your eyes after instilling eyedrops.

You should actually be pressing your finger in the other corner of the eye.

Submit

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You should wait more than 1 minute between different medications.

Correct It is recommended to wait 10-15 minutes between different eyedrop medications to give them time toabsorb an avoid one medication washing another one out.

Your routine is very good! Can you demonstrate it for me?

Incorrect There is something wrong with what the patient described as his routine. After the nurse corrects

this, a return demonstration would be appropriate.

It is actually not the best practice to close your eyes after instilling eyedrops.

You should actually be pressing your finger in the other corner of the eye.

Incorrect THis is not true.

A nurse would evaluate which of these patients as appropriate candidates for a closed MRI without contrast,based on the information given?

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A 20-year old woman who has unexplained joint pain and a low BMI.

A 35-year old woman with Multiple Sclerosis and has been trying to conceive.

A 67-year old man who has had an open-heart surgery 4 years ago.

A 40-year old woman who has been in a hypomanic state for the last 2 days.

Submit

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A 20-year old woman who has unexplained joint pain and a low BMI.

Correct MRI can be used to diagnose musculoskeletal disorders, and this patient has no contraindications to anMRI.

A 35-year old woman with Multiple Sclerosis and has been trying to conceive.

Incorrect Pregnant women, or women who have a possibility of being pregnant, are not recommended to

receive MRIs.

A 67-year old man who has had an open-heart surgery 4 years ago.

Incorrect Patients with pacemakers, stents, or implants should not have MRIs. More information would haveto be gathered about this patient before an MRI can be done.

A 40-year old woman who has been in a hypomanic state for the last 2 days.

Incorrect Hypomania is a mild form of mania, and a patient with hypomania would have a very difficult timelaying still in a supine position for up to an hour. Sedation may be required, which requires more informationand assessment of this patient.


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A nurse is caring for a patient in the cardiac care unit who is taking bumetanide (Bumex) and is diagnosed withParkinsons Dis ease. An unlicensed assistive personnel is assisting with feeding the patient. Which of these foodswould the nurse stress for the patient to eat most?

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Foods containing the least amount of salt

Foods containing the most amount of potassium

Foods containing the most amount of calories

Foods containing the most amount of fiber

Submit

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Foods containing the least amount of salt

Incorrect While this is a good practice, in light of the information given, this is not the greatest priority.

Foods containing the most amount of potassium

Correct Bumex is a loop diuretic and can cause hypokalemia. Ensuring potassium is included in the diet is apriority and can directly avoid a hypokalemic crisis.

Foods containing the most amount of calories


Foods containing the most amount of fiber


A nurse knows that which of these patients are at greatest risk for a developing osteoporosis?

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An 80-year old man who has a thin build

A 48-year old african american female who smokes cigarettes and drinks alcohol

A 55-year old female with an estrogen deficiency

A 70-year old caucasian female who takes oral corticosteroids

Submit

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An 80-year old man who has a thin build

Incorrect Age and thin build are two primary risk factors, but another patient has more.

A 48-year old african american female who smokes cigarettes and drinks alcohol


30/50

Smoking cigarettes and drinking alcohol are both primary risk factors, but being African American actuallydecreases the risk for osteoporosis

A 55-year old female with an estrogen deficiency

Incorrect Only two risk factors are present: being female, and having an estrogen deficiency. While her age issomewhat advanced, 65+ years of age is the cut -off for having a risk factor in women.

A 70-year old caucasian female who takes oral corticosteroids

Correct This patient has by far the most risk factors, 3 of which are primary and one secondary. Age, gender,ethnicity are three primary risk factors, while her corticosteroid treatment is the secondary risk factor, bringingher total up to four.

A 30-year old Caucasian woman who works the night shift has been found to have early bone loss and has a highrisk for osteomalacia and bone degradation. She asks the nurse exactly why she should take Vitamin Dsupplements . What is the nurses best response?

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Its a standard part of the overall nutritional treatment for the prevention of osteomalacia

It helps your intestines absorb calcium, which is important for bone formation.

It stimulates skin cells t o produce calcium, which is then released into the bloodstream to be used for boneformation.

Vitamin D supplements should not be taken by someone of your age.

Submit

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Its a standard part of the overall nutritional treatment for the prevention of osteomalacia

Incorrect While this is true, it doesnt answer the womans question.

It helps your intestines absorb calcium, which is important for bone formation.

Correct This is the correct mechanism of action for Vitamin D

It stimulates s kin cells to produce calcium, which is then released into the bloodstream to be used for boneformation.

Incorrect- This is not the correct mechanism of action for Vitamin D

Vitamin D supplements should not be taken by someone of your age.

Incorrect Vitamin D supplements should be taken for patients who are homebound, institutionalized, or bysome other limitations, unable to meet daily requirements. This soman works the night shift, which may limither ability to absorb Vitamin D naturally.

A nurse is caring for a patient with a cast on the right leg. Which of these assessment findings would mostconcern the nurse?


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32/50

Give the patient a small amount of water to drink.

Incorrect Another important intervention with the administration of bisphosphonates is to give the medicationwith at least 6-8 ounces of plain water.

Feed the patient soon, at most 10 minutes after administration

Incorrect Food and any drink other than plain water should be held 30 minutes after administration so the

medication can be absorbed properly

Assess the patient for back pain or abdominal pain

Incorrect Although these are possible side effects of this medication, they are not the priority nursingconsideration.

A nurse is asked by a patient to describe in laymans terms an overview of the condition ca lled osteomyelitis.What would be the nurses best response?

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Osteomyelitis is a gradual breakdown and weakening of your bones. Its most often age -related.

Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softerand de- mineralized.

Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside orinside your body.

This is a question that should be directed to your Healthcare Provider.

Submit

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Osteomyelitis is a gradual breakdown and weakening of your bones. Its most often age -related.

Incorrect This sentence describes osteoporosis

Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softer and de-mineralized.

Incorrect This sentence describes osteomalacia

Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside orinside your body.

Correct This appropriately explains osteomyelitis

This is a question that should be directed to your Healthcare Provider.

Incorrect A nurse is qualified to educate the patient on this subject matter


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The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cmin diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priorityintervention?

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Place the patient under contact precautions

Use strict aseptic technique when caring for the wound

Place another dressing to reinforce the first one

Elevate the patients leg to prevent more drainage

Submit

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Place the patient under contact precautions

Correct A patient with an infectious wound, especially one not adequately contained by a dressing, should beput under contact precautions.

Use strict aseptic technique when caring for the wound

Incorrect Although this is dependent on each facilitys policy, it is no longer a common practice to use aseptictechnique on a dirty wound. Clean technique is more often used.

Place another dressing to reinforce the first one

Incorrect This is a questionable intervention, and will not promote the safety of this patient and other

patients.

Elevate the patients leg to prevent more drainage

Incorrect Patients with heel ulcers should have their heels elevated to prevent pressure, not the whole legelevated to prevent drainage.

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A nurse in the emergency room receives a patient who had his left elbow fractured in a fight. He had waited 5hours before coming to the emergency room. His left hand has an unequal radial pulse, is swollen, and is numband tingling. What is the nurses priority intervention?

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34/50

Place the patient in a supine position

Ask the patient to rate his pain on a scale of 1 to 10.

Wrap the fractured area with a snug dressing

Start an IV in the other arm.

Submit

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Place the patient in a supine position

Incorrect While this may be a beneficial intervention if the arm is also elevated to prevent swelling, this is not apriority intervention.

Ask the patient to rate his pain on a scale of 1 to 10.

Incorrect While assessing pain is a part of the 6 Ps of neurovascular assess ment, the question asks for an

intervention based on already alarming assessment findings.

Wrap the fractured area with a snug dressing

Incorrect The assessment findings indicate the patient may have Acute Compartment Syndrome. Causing moreexternal pressure with a dressing will only exacerbate the condition.

Start an IV in the other arm.

Correct Starting an IV is a nursing priority prior to emergency surgery. The patient may be in the late stages ofAcute Compartment Syndrome and may need a fasciotomy, in which the surgeon relieves pressure by making an

incision into the affected area.

A nurse is caring for a female patient 24 hours after a hip fracture. The patient is on bedrest. The nurse knowsthat which regular assessment or intervention is essential for detecting or preventing the complication of FatEmbolism Syndrome?

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Performing passive, light, range of motion exercises on the hip as tolerated.

Assess the patients mental status for drowsiness or sleepiness.

Assess the pedal pulse and capillary refill in the toes.

Administer a stool softener as ordered

Submit

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Performing passive, light, range of motion exercises on the hip as tolerated.

Incorrect Immobilization and prevention of motion is the best way to reduce risk for fat embolism.


35/50

Assess the patients mental status for drowsiness or sleepiness.

Correct A decreased Level of Consciousness is the earliest sign of FES, caused by decreased oxygen level.

Assess the pedal pulse and capillary refill in the toes.

Incorrect While assessing pedal pulse is important during a neurovascular assessment, it is not relevant to FES.Capillary refill is the least reliable indicator of poor perfusion

Administer a stool softener as ordered

Incorrect While this is an important intervention for patients on bedrest, it is not an intervention relevant toFES

What is the overarching nursing concern when caring for patients being treated with splints, casts, or traction?

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To assess for and prevent neurovascular complications or dysfunction

To ensure adequate nutrition during the healing process

To provide patient education for maintenance of splints, casts, or traction in the community.

To treat acute pain

Submit

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To assess for and prevent neurovascular complications or dysfunction

Correct This is the priority nursing diagnosis for patients with extremity fractures.

To ensure adequate nutrition during the healing process

Incorrect While this is a nursing concern, it is not the first priority

To provide patient education for maintenance of splints, casts, or traction in the community.

Incorrect While this is a nursing concern, it is not the first priority

To treat acute pain

Incorrect While this is a serious nursing concern, it is not the first priority.

What nursing intervention demonstrates the nurse understands the priority nursing diagnosis when caring forpatients being treated with splints, casts, or traction?

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The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.

The nurse orders meals with adequate protein and calcium for the patient.

The nurse teaches the patient never to insert objects under a cast to scratch an itch.


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37/50

Blood pressure of 160/90

Incorrect While this may be a relevant assessment finding, it is not the priority assessment.

The nurse in the day surgery center understands that which nursing consideration is a priority immediately afteran endoscopic procedure?

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Raise the siderails of the patient bed

Do not offer fluids, food or any oral intake

Check the temperature of the patient

Teach the patient to avoid aspirin or NSAIDS

Submit

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Raise the siderails of the patient bed

Incorrect This is a general intervention that applies to all post-procedure care, and not the biggest priority.

Do not offer fluids, food or any oral intake

Correct Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia isgiven to inactivate the gag reflex, making the patient vulnerable to aspiration

Check the temperature of the patient

Incorrect While it is important to monitor the temperature for signs of infection or sepsis, these problems donot occur until hours or days later.

Teach the patient to avoid aspirin or NSAIDS

Incorrect This is part of the preparation for an endoscopic procedure, not post-procedural care.

A nurse is preparing to palpate and percuss a patients abdomen as part of the assessment process. Which ofthese findings would cause the nurse to immediately discontinue this part of the assessment?

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The patient states That sounds like it might hurt me.

There is a pulsating mass on the upper middle abdomen.

The patient has black, tarry stools and anemia

The patient has had an endoscopic procedure two days prior

Submit

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38/50


39/50

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The nurse uses a pen pad to communicate with the patient

The nurse provides oral care every 2 hours

The nurse listens for bowel sounds every 4 hours.

The nurse suctions as needed and elevates the head of the bedSubmit

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The nurse uses a pen pad to communicate with the patient

Incorrect This intervention is in response to impaired verbal communication, which is not the priority nursingdiagnosis.

The nurse provides oral care every 2 hours

Incorrect This intervention is in response to impaired oral mucous membrane, which is not the priority nursingdiagnosis.

The nurse listens for bowel sounds every 4 hours.

Incorrect This assessment is not relevant to the patients condition

The nurse suctions as needed and elevates the head of the bed

Correct This intervention is in response to Ineffective Airway Clearance, which is the priority nursing diagnosis.

A patient has been taking a mood stabilizing medication, but is afraid of needles. They ask the nurse whatmedication would NOT require regular lab testing. What is the nurses best response?

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Valproic Acid (Depakote)

Clonazapine (Clozaril)

Lithium

Risperidone (Risperdal)

Submit

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Valproic Acid (Depakote)

Incorrect

Clonazapine (Clozaril)

Incorrect


40/50

Lithium

Incorrect

Risperidone (Risperdal)

Correct Risperidone is the only drug that does not require blood draws.

A patient is deciding whether they should take the live influenza vaccine (nasal spray), or the inactivatedinfluenza vaccine (shot). The nurse reviews the clients history. Which condition would NOT contraindicate thenasal (live vaccine) route of administration?

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The patient takes long-term corticosteroids

The patient is not feeling well today

The patient is 55 years old

The patient has young children

Submit

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The patient takes long-term corticosteroids

Incorrect Long-term corticosteroids can weaken the immune system. Live influenza vaccines should only begiven to patients with healthy immune systems.

The patient is not feeling well today

Incorrect This is a contraindication for getting either types of vaccines. While they should get their vaccinelater, now would not be the best time to administer the vaccine.

The patient is 55 years old

Incorrect This is a contraindication for getting the live vaccine, which should be given to patients between theages of 2-49 only.

The patient has young children

Correct This is not a contraindication. It would only be a contraindication for the live vaccine if the youngchildren were immunocompromised, but this is not stated.

A patient asks the nurse whether he is a good candi date to use a CPAP machine. The nurse reviews the clientshistory. Which condition would contraindicate the use of a CPAP machine?

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41/50

The patient is in the late-stage of dementia.

The patient has a history of bronchitis

The patient has had suicidal gestures/attempts in the past

The patient is on beta-blockers

Submit

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The patient is in the late-stage of dementia.

Correct Having an inability to follow commands and understand instructions independently is acontraindication for a CPAP machine, which can only function correctly with proper installation and use.

The patient has a history of bronchitis

Incorrect This is not a contraindication for using a CPAP machine

The patient has had suicidal gestures/attempts in the past


The patient is on beta-blockers


The nurse is caring for a patient who has recently had a successful catheter ablation. Which assessment findingdemonstrates a successful outcome of this procedure?

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The patient is free of electrolyte imbalances

The patients WBC count is within normal limits

The patients EKG reading is regular

The patients urine output is 45mL/hour

Submit

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The patient is free of electrolyte imbalances

Incorrect This does not demonstrate the purpose a catheter ablation

The patients WBC count is within normal limits


The patients EKG reading is regular


42/50

Correct A catheter ablation is a procedure used to treat arrhythmias, especially SVT. A catheter is insertedthrough the femoral vein or artery, and threaded to the conduction fiber in the heart causing the arrhythmia. Aradiofrequency energy uses heat to destroy this fiber, preventing further arrhythmia.

The patients urine output is 45mL/hour


Application The nurse is caring for a patient who has the following labs: Creatinine 2.5mg/dL, WBC 11,000cells/mL, and Hemoglobin of 12 g/dL. Based on this information, which of these orders would the nursequestion?

Top of Form

Administer 30 Units of Lantus Daily

CT of the spine with contrast

X-ray of the abdomen and chest

Administer heparin subcutaneous 5,000 Units every 12 hours

Submit

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Administer 30 Units of Lantus Daily

Incorrect None of the above labs contraindicate this order

CT of the spine with contrast

Correct The creatinine level of this patient indicates impaired kidney function. Contrast is nephrotoxic and iscontraindicated for patients with nephropathy.

X-ray of the abdomen and chest


Administer heparin subcutaneous 5,000 Units every 12 hours


Application A nurse is caring for a patient admitted in the emergency room for an ischemic stroke with markedfunctional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogenactivator). Which history-gathering question would not be important for the nurse to ask?

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What time was the first time you noticed symptoms appearing consistently?

Have you been taking any blood thinners like heparin, lovenox, or warfarin?

Have you had another stroke or head trauma in the previous 3 months?


43/50

Have you had any blood transfusions within the previous year?

Submit

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What time was the first time you noticed symptoms appearing consistently?

Incorrect This is a relevant question because TPA is usually used no more than 5-6 hours after onset. This is thetimeframe that damage to tissue is still reversible.

Have you been taking any blood thinners like heparin, lovenox, or warfarin?

Incorrect This is a relevant question because current anticoagulant use, or an INR of greater than 1.7, is acontraindication to TPA use.

Have you had another stroke or head trauma in the previous 3 months?

Incorrect This is a relevant question because having a stroke or head trauma in the last 3 months

contraindicates TPA use

Have you had any blood transfusions within the previous year?

Correct This is not a relevant question and would not affect the decision to use TPA

A patient is being discharged from the med-surgical unit. The patient has a history of gastritis. The nursequestions the patient on his usual routine at home. Which of these statements would alert the nurse thatadditional teaching is required?

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I avoid NSAIDS. I only take a daily aspirin for my heart health.

I always avoid eating hot and spicy foods

I will continue taking my antacids with or immediately after meals

I will only drink coffee once a week, if even that often.

Submit

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I avoid NSAIDS. I only take a daily aspirin for my heart health.

Correct Aspirin is classified as an NSAID and can exacerbate already existing stomach problems. Aspirin shouldbe avoided just like any NSAID for patients with gastritis.

I always avoid eating hot and spicy foods

Incorrect This is a good practice for patients with gastritis

I will continue taking my antacids with or immediately after meals

Incorrect This is a good practice for patients with gastritis


44/50

I will only drink coffee once a week, if even that often.

Incorrect This is a good practice for patients with gastritis. Coffee is not recommended for patients withgastritis.

A nurse is meeting a patient in their home. The patient has been taking Naproxen for back pain. Whichstatement made by the patient most indicates that the nurse needs to contact the physician?

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I get an upset stomach if I dont take Naproxen with my meals.

My back pain right now is about a 3/10.

I get occasional headaches since taking Naproxen

I have ringing in my ears.

Submit

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I get an upset stomach if I dont take Naproxen with my meals.

Incorrect This is a common and less severe side effect of Naproxen

My back pain right now is about a 3/10.

Incorrect Although a 3/10 is bordering on the acceptable amount of pain, this would not be the most pressingissue at hand.

I get occasional headaches since taking Naproxen

Incorrect This is a common and less severe side effect of Naproxen

I have ringing in my ears.

Correct This is a severe adverse effect of Naproxen and should be reported immediately since it may indicatetoxicity.

The nurse is doing an intake screening for a patient with hypertension. They have been taking ramapril for 4weeks. Which statement made by the patient would be most important for the nurse to pass on to thephysician?

Top of Form

I get dizzy when I get out of bed.

Im urinating much more than I used to.

Ive been running on the treadmill 10 minutes each day.

I cant get rid of this cough.

Submit


45/50

Bottom of Form

I get dizzy when I get out of bed.

Incorrect This may require some medication teaching but is not the priority assessment finding.

Im urinating much more than I used to.

Incorrect ACE Inhibitors like ramapril work, in part, by increasing urine flow. This is a necessary side effect ofthe medication and is not a priority.

Ive been running on the treadmill 10 minutes each day.

Incorrect ACE Inhibitors like ramapril work, in part, by increasing urine flow. This is a necessary side effect ofthe medication and is not a priority.

I cant get rid of this cough.

Correct A common adverse effect of ACE inhibitors is a persistent, dry cough. A medication change to anotherclass of antihypertensives, like an ARB, may be needed

The nurse in the emergency room sees a patient who has been abusing alprazolam (Xanax). The patient reportsthat he suddenly stopped taking Xanax about 24 hours ago. He presents with a visible tremor, is pacing,expresses fear, and has impaired concentration and memory. Which of these intervention takes priority?

Top of Form

Have the patient lie down on a stretcher with bedrails up

Give the patient a cup of water to drink and a small amount of food

Assure the patient that he will be okay

Alert the physician that the patient needs Xanax

Submit

Bottom of Form

Have the patient lie down on a stretcher with bedrails up

Correct The 1-4 day period after Xanax withdrawal is the most dangerous. Xanax is a benzodiazepine andwithdrawal symptoms include life-threatening seizures. Having the patient lie down with bedrails up is part of

seizure precautions and is the first priority

Give the patient a cup of water to drink and a small amount of food

Incorrect This is not a priority intervention

Assure the patient that he will be okay


Alert the physician that the patient needs Xanax


46/50


A nurse cares for a child that is diagnosed with Hepatitis A. Which of these following precautions would be mostimportant to take to prevent transmission of this infectious disease?

Top of Form

Encourage the Hepatitis A vaccine for family members and siblings

Use needleless systems if possible, otherwise use careful needle precautionary measures

Teach the child and enforce strict and frequent hand washing

Teach the child and family the dangers of contaminated food and water

Submit

Bottom of Form

Encourage the Hepatitis A vaccine for family members and siblings

Incorrect Although this is a valuable point for patient education, this does not take the priority, since thepatient is still at risk of transmitting Hepatitis A to others right now.

Use needleless systems if possible, otherwise use careful needle precautionary measures

Incorrect Hepatitis A is transmitted through the fecal-oral route.

Teach the child and enforce strict and frequent hand washing

Correct Hand washing is the single most effective way to prevent transmission of Hepatitis A. Hepatitis A is avirus transmitted via the oral-fecal route and lives on human hands.

Teach the child and family the dangers of contaminated food and water

Incorrect Although this is a valuable teaching point, it is not the priority intervention.

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A nurse is treating a patient suspected to have Hepatitis. The nurse notes on assessment that the patients eyesare yellow-tinged. Which of these diagnostic results would further assist in confirming this diagnosis?

Top of Form

Decreased serum Bilirubin

Elevated serum ALT levels

Low RBC and Hemoglobin with increased WBCs


47/50

Increased Blood Urea Nitrogen level

Submit

Bottom of Form

Decreased serum Bilirubin

Incorrect Bilirubin levels correlate with the appearance of Jaundice. An increased serum bilirubin would be theexpected finding for this patient.

Elevated serum ALT levels

Correct ALT is a liver enzyme, and hepatitis is a liver disease. Elevated liver enzymes will often signal liverdamage.

Low RBC and Hemoglobin with increased WBCs

Incorrect This is not a common finding for Hepatitis patients

Increased Blood Urea Nitrogen level

Incorrect BUN is an indicator of renal (kidney) health, not hepatic (liver) function.

Which of these patients would the nurse suspect as having the greatest risk of contracting Hepatitis B?

Top of Form

A sexually active 45-year old man who has Type 1 Diabetes

A 75-year old woman who lives in a crowded nursing home

A child who lives in a country with poor sanitation and hygiene standards

A sexually active 23-year old man who works in a hospital

Submit

Bottom of Form

A sexually active 45-year old man who has Type 1 Diabetes

Incorrect This person is sexually active, but it is not specified with how many partners. Having Type 1 Diabetes

is not a risk factor for Hepatitis.

A 75-year old woman who lives in a crowded nursing home

Incorrect Age is not a risk factor for Hepatitis B, and close living accommodations is a stronger risk factor forHepatitis A and E, which are oral-fecal transmissions.

A child who lives in a country with poor sanitation and hygiene standards

Incorrect This is a relevant risk factor for Hepatitis A and E

A sexually active 23-year old man who works in a hospital


48/50

Correct This person is both sexually active and works in a healthcare environment.

The nurse calculates the IV flow rate of a patient receiving lactated ringers solution. The patient is to receive2000mL of Lactated Ringers over 36 hours. The IV infusion set has a drop factor of 15 drops per milliliter. Thenurse should set the IV to deliver how many drops per minute?

Top of Form

8

10

14

18

Submit

Bottom of Form

8

Incorrect

10

Incorrect

14

Correct Drops Per Minute = Milliliters x Drop Factor / Time in Minutes

18

Incorrect

The nurse calculates the IV flow rate of a patient receiving an antibiotic. The patient is to receive 100mL of theantibiotic over 30 minutes. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should setthe IV to deliver how many drops per minute?

Top of Form

11

19

26

33

Submit

Bottom of Form

11


49/50

Incorrect

19

Incorrect

26

Incorrect

33

Correct Drops Per Minute = Milliliters x Drop Factor / Time in Minutes

Which of the following statements made by a client during an individual therapy session would the nurse mostidentify as reflecting schizoaffective disorder?

Top of Form

I just want to stab myself with this pen.

Whats the point in life anyways?

My thoughts are racing because of the conspiracies against me.

I hear voices every day and sometimes see old friends that dont exist.

Submit

Bottom of Form

I just want to stab myself with this pen.

Incorrect This is a suicidal ideation, but not a classic symptom of schizoaffective disorder

Whats the point in life anyways?

Incorrect This is a verbalization of hopelessness, which can manifest in depression, bipolar disorder, orschizoaffective disorder.

My thoughts are racing because of the conspiracies against me.

Correct Schizoaffective disorder is characterized by the mania and depression of bipolar disorder with thedelusions/disturbed thought process of schizophrenia. Racing thought are a classic symptom of a manic episode,while conspiracies indicate paranoia.

I hear voices every day and sometimes see old friends that dont exist.

Incorrect While visual and auditory hallucinations can manifest in schizoaffective disorder, there is noindication of bipolar symptoms (mania or depression)

How Ready Are You To Take Your NCLEX?

Top of Form


50/50

I think Im ready right now. Thank you and goodbye!

Im feeling pretty good. Ill do some more practice NCLEX questions, but dont want to kill myselfstudying.

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I think Im ready right now. Thank you and goodbye!

Good on you! Good Luck!

Im feeling pretty good. Ill do some more practice NCLEX questions, but dont want to kill myself studying.

NCLEX Practice questionswait, we have those!

I want to study more. I need to learn more content, get really good with NCLEX Strategies, and bo ost myconfidence.

Youve come to the right place. Click the button NOW!

I give up. I think Ill just dress as a nurse on Halloween once in a while and leave it at that!

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75 RN Practice Questions

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