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1. A client receives an autologous blood transfusion. The nurse should assess the client for which of the following?

1) Low back pain, headache and hematuria.2) Urticaria, pruritus, and bronchospasm.3) Tachycardia, chills, and fever.4) Flushing, palpitations, and nausea.

2. A patient is brought to the emergency room with a compound fracture of the left femur. The patient’s vital signs are BP 80/60, pulse 120, respirations 26, temperature 99.0 degrees Fahrenheit (37.2 Degrees Cel.). Which of the following fluids, if ordered by the physician, should the nurse question? 1) Lactate Ringer’s 2) .45% NaCl. 3) .9% NaCl. 4) Hetastarch

3. The physician orders an IV with 5% dextrose in water (D5W) started for an 86-year-old patient on an acute care medical unit. Which of the following actions by the nurse is BEST?

1) Instruct the patient to breathe slowly and deeply through the mouth during auscultation of the posterior chest.

2) Apply the tourniquet 1 to 2 inches above the IV insertion site.3) Apply a blood pressure cuff above the IV site insertion and inflate the cuff to the same

level as the systolic blood pressure.4) Start the IV using the dorsal veins of the patient’s forearm on the nondominant side.

4. The nurse cares for a patient receiving parenteral nutrition (TPN) through a subclavian triple lumen catheter. It is MOST important for the nurse to take which of the following actions?

1. Remove the old dressing over the insertion site, moving against the direction the catheter is inserted.

2. Clean the insertion site with an alcohol swab, moving from the outside to the inside in a circular pattern.

3. Flush the unused catheter lumens with heparinized saline.4. Use clean gloves to reapply an occlusive dressing to the insertion site.

5. The nurse cares for a client who is receiving hetastarch (Hespan) intravenously. It is MOST important for the nurse to assess which of the following?

1. Pretibial ederma2. Hourly urine output3. Client’s weight.

4. Client’s lung sounds.

6. The nurse teaches a client about lorazepam (Ativan). Which of these statements by the client requires an intervention by the nurse?

1. “If the dose of Ativan is increased, I may feel more sleepy than usual.”2. “I should follow my regular diet when taking this medication.”3. “I may feel dizzy when I take this medication.”4. “It is possible to get addicted to this medication after I take it for one week”

7. The nurse cares for the clients in the family planning clinic. A client using oral contraceptives for birth control is placed on a 7-day course of ampicillin. The nurse determines that teaching is successful if the client makes which of the following statements?

1. “I should take ampicillin with meals”2. “Oral contraceptives will cause fluid retention.”3. “I should use a barrier method of birth control for the rest of my cycle.”4. “I should stop taking the oral contraceptives while taking ampicillin.”

8. A client diagnosed with a bacterial infection has a known allergy to penicillin and sulfa. Which of the following medications, if ordered by the physician, should the nurse question?

1. Tetracycline hydrochloride (Tetracyn)2. Sulfisoxazole (Gantrisin)3. Azithromycin (Zithromax)4. Ciprofloxacin (Cipro)

9. The nurse instructs a client about taking doxycycline calcium (Vibramycin). The nurse should intervene if the client makes which of the following statements?

1. “I should wear a hat and use sunscreen when I am outside”2. “I should take this medication 1 hour before meals.”3. “I should drink more fluids when taking this medication.”4. “I should take this medication at bedtime.”

10. The nurse prepares to administer carbamazepine (Tegretol) 200 mg to a client. The nurse should assess which of the following prior to administration of the medication?

1. Serum platelet levels and hemoglobin.2. Blood urea nitrogen and creatinine.3. Aspartate aminotransferase (AST) and alanine aminotranserase (ALT).4. C-reactive protein and creatinine kinase (CK)

11. The nurse cares for a client receiving propranolol (Inderal). It is MOST important for the nurse to observe for which of the following?

1. Dry cough.2. Pulse rate less than 60 bpm.3. Increased urinary output.4. Difficulty sleeping.

12. The nurse cares for the clients on an acute-care neuroscience unit. Which of the following medications should the nurse administer FIRST?

1. Prednisone (Deltasone) 60 milligrams orally for a client diagnosed with multiple sclerosis reporting increased muscle weakness and fatigue.

2. Pyridostigmine (Mestinon) 75 mg orally for a client diagnosed with myasthenia graves reporting increased difficulty swallowing oral secretions.

3. Benztropine (Cogentin) 1 mg orally for a client diagnosed with Parkinson’s disease who is drooling.

4. Heparin 5,000 units subq for a client diagnosed with a thrombotic stroke 48 hours ago.

13. An elderly client using clonidine hydrochloride (Catapres-TTS) transdermal patches daily comes to be outpatient clinic for monitoring. Which of the following statements, if made by the client to the nurse, indicates further teaching is required?

1. “When I get out of bed in the morning, I move slowly so I don’t get dizzy.”2. “One time I put adhesive patch on my right arm, and the next time I put it

on my left arm.”3. “I remove the adhesive patch before I take a shower in the morning and

replace it with a new one each evening.”4. “Sometimes the medicine makes me feel sleepy in the middle of the day,

so I take a short nap.”

14. After 2 weeks of receiving lithium therapy, a patient diagnosed with mania becomes depressed. It is MOST important for the nurse to take which of the following actions?”

1. Monitor the patient for suicidal behavior.2. Continue the treatment plan.3. Explore with the patient the reasons the patient appears depressed.4. Contact the physician to discuss the addition of an antidepressant.

15. The nurse assesses a client receiving cyclophosphamide(Cytoxan-anti cancer drug-attack dividing cell in normal and abnormal cell too). It is most important for the nurse to ask which of the following questions?

1. have you noticed any hair loss?2. Have you loss any weight? May vomiting and nausea3. Have you had any nausea and vomiting?4. has consptiation been a problem for you?

Answer: 3

16. The nurse administers packed cells to a client. Rank the following nursing activities in the correct order from first activity to last activity.

1. the nurse starts an IV with a 19-guauge needle-22. The nurse begins the transfusion at 5mil/min-43. The nurse obtains a history of transfusion reactions.-14. The nurse obtains the blood product from the blood bank.3

* must go slowly

17. The nurse cares for a patients several hours after insertion of a central venous line. An IV of .0%NaCl is infusing through the line at 75ml/h. The pt become restless and apprear short of breath. The nurse should take which of the folling actions FIRST?

1. Elevate the head of the bed to 90%2. Check the IV flow rate and insertion site.3. obtain equipment forinsertion of a chest tube4. reassure the patient that everything will be ok.

*pneumothorax..help breath better…but do one thing when I go home..what will be the outcomeAnswer: 1

18. The Dr. orders amoxicillin trihydrate(Amox) 20mg/kg PO q8hrs for a 12 years old pt. The nurse determines that the pt weighs 48kg (106lb). How many milligrams of amoxicillin should the nurse administer for each dose?____mg?

Answer: 20x48=960mg **and if given for each dose (single dose) or in 24 hr: 960mgx3

19. The nurse receives a phone call from a client taking Cipro 250mg po bid for the past 3 days. The client tells the nurse while bathing this morning he noticed a fine macular rash on his body. Which of the following response by the nurse is BEST?

1. Did you use a new bath soap?2. Call me back if the rash gets worse.3. When do you take the medication?4. stop taking the meds.

Answer: 4…pt has a sensitivity of CIPRO

20. The nurse admits a pt with a hx of breast cancer and type 1 diabetes. The RN is aware that careful monitoring of the pt’s blood sugar is necessary if the pt receives which of the following meds?which med increase blood sugar

1. Prednisone (deltasone)-SONE –steroid-increase blood sugar2. captopril (capoten)-PRIL -ACE inhibitor-control blood pressure3. Nifedipine(procardia)-4. Amoxil

21.The nurse instructs a client taking clopidogrel (plavix) 75mg daily. Which of the following statements, if make by the client to the nurse, indicaties understading about the instructions? Plavix-antiplatelet

1. I can continue to take ibuprofen pills for my arthritis pain while taking plavix2. it will be necessary for me to have blood test monitoring done when take plav3. I cannot continue to take ginko for my memory problems while taking plavix4. I will need to take a daily muiltivit pill every day while taking plavix

Answer:3if you deal w/ ginko, garlic and herbal –might be interaction because this is an anti-platelet agentherbal meds interaction w/ meds

22. The nurse cares for a client receiving cisplatin(Platino-AQ)-It is most important for the nurse to follow up on which of the following client statements?

1. I drink 8-10 glasses of water every day2. I now use a soft toothbrush3. I take antiemetics after receiving Platinol-Aq4. My family thinks I ignore them when they are talking to me

Platinol is an anti-cancer drug (can have bone marrow suppression)

Answer: 4

23. The RN receives an order for .5mg bentropine(cogentin) for a client who has a hx of glaucoma and Type 2 diabetes. Which of the following actions whould the nurse take FIRST?

1. withhold the benztropine and contact the doctor2. assess the client’s blood sugar prior to the first dose of the medications3. tell the client that the beneficial effects of the med will decrease over time4. Inform the client that benztropine may cause urinary retention.

Think: interaction w/ other medsBenztrophine did not effect blood sugar but contraindication w/ glaucoma

Answer:1

24. The nruse cares for a client receiving carbidopa/levodopa (sinemet). The nurse is MOST concerned if the client states which of the following? Most concern is mean something goes wrong

1. I take a dialy multivit2. I practivc tai chi dialy3. I take kava for insomnia4. I eat several small meals a day

Carbidopa/levodopa –anti parkingson agent(will decrease to effect If take w/ large amount of perodoxin) normal is okConcern about herbal (kava-decrease anxiety, restlessness and insomnia)

Answer:3

25. The nurse receives a phone call from a mother of an 8 years old taking Ritalin who says that her child has lost 4 lbs in the last two weeks. It is most important for the nurse to make which of the following statements?

1. What has the child been eating during the last two week?2. Give your childr one-half the prescribed dose every other day during the next week.3. You need to contact your health care provider today?4. It will be necessary to give your child high-calorie nutritious foods while take Ritalin

Think: appetite and Med?Answer: 3

1. A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patient's medication does not cause urine discoloration?

A. Sulfasalazine B. Levodopa C. Phenolphthalein D. Aspirin

2. You are responsible for reviewing the nursing unit's refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerator's contents?

A. Corgard B. Humulin (injection) C. Urokinase D. Epogen (injection)

3. A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?

A. IgA B. IgD C. IgE D. IgG

4. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take?

A. Immediately see a social worker B. Start prophylactic AZT treatment C. Start prophylactic Pentamide treatment D. Seek counseling

5. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?

A. Atherosclerosis B. Diabetic nephropathy C. Autonomic neuropathy D. Somatic neuropathy

6. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?

A. Multiple sclerosis B. Anorexia nervosa C. Bulimia D. Systemic sclerosis

7. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect?

A. Diverticulosis B. Hypercalcaemia C. Hypocalcaemia D. Irritable bowel syndrome

8. Rho gam is most often used to treat____ mothers that have a ____ infant.

A. RH positive, RH positive B. RH positive, RH negative C. RH negative, RH positive D. RH negative, RH negative

9. A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU?

A. A Guthrie test can check the necessary lab values. B. The urine has a high concentration of phenylpyruvic acid C. Mental deficits are often present with PKU. D. The effects of PKU are reversible.

10. A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient?

A. Onset of pulmonary edema B. Metabolic alkalosis C. Respiratory alkalosis D. Parkinson's disease type symptoms

11. A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is?

A. Let others know about the patient's deficits B. Communicate with your supervisor your concerns about the patient's deficits. C. Continuously update the patient on the social environment. D. Provide a secure environment for the patient.

12. A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient?

A. Deep breathing techniques to increase O2 levels. B. Cough regularly and deeply to clear airway passages. C. Cough following bronchodilator utilization D. Decrease CO2 levels by increase oxygen take output during meals.

13. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?

A. Slow pulse rate B. Weight gain C. Decreased systolic pressure D. Irregular WBC lab values

14. A mother has recently been informed that her child has Down's syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down's syndrome?

A. Simian crease B. Brachycephaly C. Oily skin D. Hypotonicity

15. A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered?

A. Streptokinase B. Atropine C. Acetaminophen D. Coumadin

16. A patient asks a nurse, “My doctor recommended I increase my intake of folic acid. What type of foods contain folic acids?”

A. Green vegetables and liver B. Yellow vegetables and red meat C. Carrots D. Milk

17. A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans?

A. S. pneumonia B. H. influenza C. N. meningitis D. Cl. difficile

18. A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC's last in my body? The correct response is.

A. The life span of RBC is 45 days. B. The life span of RBC is 60 days. C. The life span of RBC is 90 days. D. The life span of RBC is 120 days.

19. A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient?

A. Following surgery B. Upon admit C. Within 48 hours of discharge D. Preoperative discussion

20. A child is 5 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the child in?

A. Trust vs. mistrust B. Initiative vs. guilt C. Autonomy vs. shame D. Intimacy vs. isolation

21. A toddler is 16 months old and has been recently admitted into the hospital. According to Erickson which of the following stages is the toddler in?

A. Trust vs. mistrust B. Initiative vs. guilt C. Autonomy vs. shame D. Intimacy vs. isolation

22. A young adult is 20 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the adult in?

A. Trust vs. mistrust B. Initiative vs. guilt C. Autonomy vs. shame D. Intimacy vs. isolation

23. A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?

A. 11 year old male – 90 b.p.m, 22 resp/min., 100/70 mm Hg B. 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg C. 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg D. 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg

24. When you are taking a patient's history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking?

A. Elavil B. Calcitonin C. Pergolide D. Verapamil

25. Which of the following conditions would a nurse not administer erythromycin?

A. Campylobacterial infection B. Legionnaire's disease C. Pneumonia D. Multiple Sclerosis

Answer Key 1. D 2. A 3. D 4. B 5. C 6. B 7. B 8. C 9. D 10. D 11. D 12. C 13. B 14. C 15. A 16. A 17. D 18. D 19. B 20. B 21. A 22. D 23. B 24. A 25. D

The proper sequence of precautions for taking care of a pt on Infection Control Precautions are as follows :

1) Wash hands upon completion2). Care for pt3). Don mask/gown/gloves 4). Enter Room5). Remove mask/gown/gloves

7. What type of precaution is used with persons that have Cytomegalovirus

infection?

A. Standard precautionsB. Contact precautionsC. Droplet precautionsD. Airborne precautions

8. What illness/disease process requires the use of disposable dishware according to the center for disease control guidelines? Choose all that apply:

A. TuberculosisB. MRSA (methicillin-resistant Staphylococcus aureus).C. MeningitisD. Chicken pox

9. What are the symptoms of Acinetobacter infection caused by pneumonia? Check all that apply:

A. Fever B. ChillsC. SneezingD. CongestionE. CoughF. Runny Nose

10. When caring for someone on “Contact Isolation”. The following is true. 2 part answers must be entirely correct. Check all that apply:

1. Wear gloves for all contact with the patient, the patient's bedside equipment, and the patient's environment.a. Change gloves between distinctive tasks (e.g. wound care, perinealcare, suctioning). b. Gloves must always be removed before leaving the room.

2. Wear a disposable gown for direct contact with the patient or the environment if the patient is incontinent, or has diarrhea or a draining wound.a. Gowns are removed and placed in a special container for next use.b. Cloth gowns may be substituted if there is no risk of splash

3. As per Standard Precautions, wear a mask and protective eyewearwhen performing procedures that generate aerosols (StandardPrecautions)

1. A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing action should take priority?

A. A complete history with emphasis on preceding events. B. An electrocardiogram. C. Careful assessment of vital signs. D. Chest exam with auscultation.

2. A patient has been hospitalized with pneumonia and is about to be discharged. A nurse provides discharge instructions to a patient and his family. Which misunderstanding by the family indicates the need for more detailed information?

A. The patient may resume normal home activities as tolerated but should avoid physical exertion and get adequate rest. B. The patient should resume a normal diet with emphasis on nutritious, healthy foods. C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved. D. The patient should continue use of the incentive spirometer to keep airways open and free of secretions.

3. A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take?

A. Restrict visiting hours and ask the family to limit visitors to two at a time. B. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed. C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family. D. Contact the physician to report the unusual rituals and activities.

4. The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery?

A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and scheduled for an angiogram. C. A patient with unstable angina being closely monitored for pain and medication titration. D. A post-operative valve replacement patient who was recently admitted to the unit because all surgical beds were filled.

5. A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct?

A. Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after injection. B. Glucagon treats hypoglycemia resulting from insulin overdose. C. Glucagon treats lipoatrophy from insulin injections. D. Glucagon prolongs the effect of insulin, allowing fewer injections.

6. A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation. The advanced cardiac life support team prepares to defibrillate. Which of the following choices indicates the correct placement of the conductive gel pads?

A. The left clavicle and right lower sternum. B. Right of midline below the bottom rib and the left shoulder. C. The upper and lower halves of the sternum. D. The right side of the sternum just below the clavicle and left of the precordium.

7. The nurse performs an initial abdominal assessment on a patient newly admitted for abdominal pain. The nurse hears what she describes as "clicks and gurgles in all four quadrants" as well as "swishing or buzzing sound heard in one or two quadrants." Which of the following statements is correct?

A. The frequency and intensity of bowel sounds varies depending on the phase of digestion. B. In the presence of intestinal obstruction, bowel sounds will be louder and higher pitched. C. A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal. D. All of the above.

8. A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. Which of the following nursing actions is a priority?

A. Irrigate the eye repeatedly with normal saline solution. B. Place fluorescein drops in the eye. C. Patch the eye. D. Test visual acuity.

9. A nurse is caring for a patient who has had hip replacement. The nurse should be most concerned about which of the following findings?

A. Complaints of pain during repositioning. B. Scant bloody discharge on the surgical dressing. C. Complaints of pain following physical therapy. D. Temperature of 101.8 F (38.7 C).

10. A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writes orders for actions to be taken in the event of a seizure. Which of the following actions would NOT be included?

A. Notify the physician. B. Restrain the patient's limbs. C. Position the patient on his/her side with the head flexed forward. D. Administer rectal diazepam.

11. Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority?

A. A patient with low-grade fever, headache, and myalgias for the past 72 hours. B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident. C. A patient with abdominal and chest pain following a large, spicy meal. D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed.

12. A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the following symptoms would you NOT expect to see in this patient?

A. Numbness in hands and feet. B. Muscle cramping. C. Hypoactive bowel sounds. D. Positive Chvostek's sign.

13. A nurse cares for a patient who has a nasogastric tube attached to low suction because of a suspected bowel obstruction. Which of the following arterial blood gas results might be expected in this patient?

A. pH 7.52, PCO2 54 mm Hg. B. pH 7.42, PCO2 40 mm Hg. C. pH 7.25, PCO2 25 mm Hg. D. pH 7.38, PCO2 36 mm Hg.

14. A patient is admitted to the hospital for routine elective surgery. Included in the list of current medications is Coumadin (warfarin) at a high dose. Concerned about the possible effects of the drug, particularly in a patient scheduled for surgery, the nurse anticipates which of the following actions?

A. Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) level. B. Administer vitamin K. C. Draw a blood sample for type and crossmatch and request blood from the blood bank. D. Cancel the surgery after the patient reports stopping the Coumadin one week previously.

15. The follow lab results are received for a patient. Which of the following results are abnormal? Note: More than one answer may be correct.

A. Hemoglobin 10.4 g/dL. B. Total cholesterol 340 mg/dL. C. Total serum protein 7.0 g/dL. D. Glycosylated hemoglobin A1C 5.4%.

16. A nurse is performing routine assessment of an IV site in a patient receiving both IV fluids and medications through the line. Which of the following would indicate the need for discontinuation of the IV line as the next nursing action?

A. The patient complains of pain on movement. B. The area proximal to the insertion site is reddened, warm, and painful. C. The IV solution is infusing too slowly, particularly when the limb is elevated. D. A hematoma is visible in the area of the IV insertion site.

17. A hospitalized patient has received transfusions of 2 units of blood over the past few hours. A nurse enters the room to find the patient sitting up in bed, dyspneic and uncomfortable. On assessment, crackles are heard in the bases of both lungs, probably indicating that the patient is experiencing a complication of transfusion. Which of the following complications is most likely the cause of the patient's symptoms?

A. Febrile non-hemolytic reaction. B. Allergic transfusion reaction. C. Acute hemolytic reaction. D. Fluid overload.

18. A patient in labor and delivery has just received an amniotomy. Which of the following is correct? Note: More than one answer may be correct.

A. Frequent checks for cervical dilation will be needed after the procedure. B. Contractions may rapidly become stronger and closer together after the procedure. C. The FHR (fetal heart rate) will be followed closely after the procedure due to the possibility of cord compression. D. The procedure is usually painless and is followed by a gush of amniotic fluid.

19. A nurse is counseling the mother of a newborn infant with hyperbilirubinemia. Which of the following instructions by the nurse is NOT correct?

A. Continue to breastfeed frequently, at least every 2-4 hours. B. Follow up with the infant's physician within 72 hours of discharge for a recheck of the serum bilirubin and exam. C. Watch for signs of dehydration, including decreased urinary output and changes in skin turgor. D. Keep the baby quiet and swaddled, and place the bassinet in a dimly lit area.

20. A nurse is giving discharge instructions to the parents of a healthy newborn. Which of the following instructions should the nurse provide regarding car safety and the trip home from the hospital?

A. The infant should be restrained in an infant car seat, properly secured in the back seat in a rear-facing position. B. The infant should be restrained in an infant car seat, properly secured in the front passenger seat. C. The infant should be restrained in an infant car seat facing forward or rearward in the back seat. D. For the trip home from the hospital, the parent may sit in the back seat and hold the newborn.

Answer Key

1. Answer: C

The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.

2. Answer: C

It is always critical that patients being discharged from the hospital take prescribed medications as instructed. In the case of antibiotics, a full course must be completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection. The patient should resume normal activities as tolerated, as well as a nutritious diet. Continued use of the incentive spirometer after discharge will speed recovery and improve lung function.

3. Answer: C

When a family member is dying, it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. In the Vietnamese culture, it is important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the next life. When possible, allowing the family privacy for this traditional behavior is best for them and the patient. Answers A, B, and D are incorrect because they create unnecessary conflict with the patient and family.

4. Answer: A

The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. A post-operative patient also requires close monitoring and cardiac experience.

5. Answer: B

Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon administration, the patient should respond within 15-20

minutes at which time oral carbohydrates should be given. Glucagon reverses rather than enhances or prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat.

6. Answer: D

One gel pad should be placed to the right of the sternum, just below the clavicle and the other just left of the precordium, as indicated by the anatomic location of the heart. To defibrillate, the paddles are placed over the pads. Options A, B, and C are not consistent with the position of the heart and are therefore incorrect responses.

7. Answer: D

All of the statements are true. The gurgles and clicks described in the question represent normal bowel sounds, which vary with the phase of digestion. Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction. The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurism, for example, and should always be considered abnormal.

8. Answer: A

Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. The irrigation should be continued for at least 10 minutes. Fluorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash, nor is patching the eye. Following irrigation, visual acuity will be assessed.

9. Answer: D

Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. Some pain during repositioning and following physical therapy is to be expected and can be managed with analgesics. A small amount of bloody drainage on the surgical dressing is a result of normal healing.

10. Answer: B

During a witnessed seizure, nursing actions should focus on securing the patient's safely and curtailing the seizure. Restraining the limbs is not indicated because strong muscle contractions could cause injury. A side-lying

position with head flexed forward allows for drainage of secretions and prevents the tongue from falling back, blocking the airway. Rectal diazepam may be a treatment ordered by the physician, who should be notified of the seizure.

11. Answer: C

Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention. The patient with fever, headache and muscle aches (classic flu symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. The child's chin laceration may need to be sutured but is also non-urgent.

12. Answer: C

Normal serum calcium is 8.5 - 10 mg/dL. The patient is hypocalcemic. Increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds, abdominal cramping and diarrhea is an indication of hypocalcemia. Numbness in hands and feet and muscle cramps are also signs of hypocalcemia. Positive Chvostek's sign refers to the sustained twitching of facial muscles following tapping in the area of the cheekbone and is a hallmark of hypocalcemia.

13. Answer: A

A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis. Answer B is a normal blood gas. Answer C represents respiratory acidosis. Answer D is borderline normal with slightly low PCO2.

14. Answer: A

The effect of Coumadin is to inhibit clotting. The next step is to check the PT and INR to determine the patient's anticoagulation status and risk of bleeding. Vitamin K is an antidote to Coumadin and may be used in a patient who is at imminent risk of dangerous bleeding. Preparation for transfusion, as described in option C, is only indicated in the case of significant blood loss. If lab results indicate an anticoagulation level that would place the

patient at risk of excessive bleeding, the surgeon may choose to delay surgery and discontinue the medication.

15. Answer: A and B

Normal hemoglobin in adults is 12 - 16 g/dL. Total cholesterol levels of 200 mg/dL or below are considered normal. Total serum protein of 7.0-g/dL and glycosylated hemoglobin A1c of 5.4% are both normal levels.

16. Answer: B

An IV site that is red, warm, painful and swollen indicates that phlebitis has developed and the line should be discontinued and restarted at another site. Pain on movement should be managed by maneuvers such as splinting the limb with an IV board or gently shifting the position of the catheter before making a decision to remove the line. An IV line that is running slowly may simply need flushing or repositioning. A hematoma at the site is likely a result of minor bleeding at the time of insertion and does not require discontinuation of the line.

17. Answer: D

Fluid overload occurs when then the fluid volume infused over a short period is too great for the vascular system, causing fluid leak into the lungs. Symptoms include dyspnea, rapid respirations, and discomfort as in the patient described. Febrile non-hemolytic reaction results in fever. Symptoms of allergic transfusion reaction would include flushing, itching, and a generalized rash. Acute hemolytic reaction may occur when a patient receives blood that is incompatible with his blood type. It is the most serious adverse transfusion reaction and can cause shock and death.

18. Answer: B, C, and D

Uterine contractions typically become stronger and occur more closely together following amniotomy. The FHR is assessed immediately after the procedure and followed closely to detect changes that may indicate cord compression. The procedure itself is painless and results in the quick expulsion of amniotic fluid. Following amniotomy, cervical checks are minimized because of the risk of infection

19. Answer: D

An infant discharged home with hyperbilirubinemia (newborn jaundice) should be placed in a sunny rather than dimly lit area with skin exposed to help process the bilirubin. Frequent feedings will help to metabolize the bilirubin. A recheck of the serum bilirubin and a physical exam within 72

hours will confirm that the level is falling and the infant is thriving and is well hydrated. Signs of dehydration, including decreased urine output and skin changes, indicate inadequate fluid intake and will worsen the hyperbilirubinemia.

20. Answer: A

All infants under 1 year of age weighing less than 20 lbs. should be placed in a rear-facing infant car seat secured properly in the back seat. Infant car seats should never be placed in the front passenger seat. Infants should always be placed in an approved car seat during travel, even on that first ride home from the hospital.

2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min.

You should immediately determine whether the patient has:

A. stridor.

B. delayed capillary refill time.

C. weak pulses.

D. the ability to tolerate oral feedings.

2. A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min.

Abdominal breathing in this patient should be viewed as a:

A. normal finding for a toddler.

B. sign of impending respiratory failure.

C. sign of decreased perfusion to the respiratory center.

D. compensatory mechanism to increase the volume of air inhaled and respiratory rate.

3. A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min.

The first step in treatment is to:

A. administer a nebulizer treatment with a beta-agonist medication.

B. administer humidified oxygen via blow-by method.

C. suction the oropharynx for secretion.

D. deliver bag-valve-mask ventilations.

4. A 6-year-old boy who was struck by a car while he was riding his bicycle is unresponsive and has pale, cool skin. Assessment reveals abrasions to his left shoulder and back and a swollen, deformed left thigh. He has a blood pressure of 74/62 mm Hg, a pulse of 152 beats/min, and respirations of 44 breaths/min. without increased work of breathing. What do these findings tell you about the patient s condition?

A. He is unresponsive and his skin is cool because of a low body temperature from being outside

B. His heart rate is fast because of pain in his shoulder and leg

C. His respirations are fast because the impact affected the respiratory center in his brain

D. His blood pressure is low because compensatory mechanisms for blood loss are failing

5. A 3-month-old infant who is extremely lethargic has had a cough, vomiting, and diarrhea for the past 3 days. Assessment reveals that he responds to pain, has mottled skin color, and a capillary refill time of 4 seconds. He has a blood pressure of 74/60 mm Hg, a pulse of 190 beats/min, and rapid, respirations without increased work of breathing at 60 breaths/min.

The tachycardia in this infant is most likely due to:

A. anxiety.

B. hypovolemia.

C. pneumothorax.

D. swelling of the brain.

6. A 3-month-old infant who is extremely lethargic has had a cough, vomiting, and diarrhea for the past 3 days. Assessment reveals that he responds to pain, has mottled skin color, and a capillary refill time of 4 seconds. He has a blood pressure of 74/60 mm Hg, a pulse of 190 beats/min, and rapid, respirations without increased work of breathing at 60 breaths/min.

The appropriate initial treatment is to:

A. administer 100% oxygen by mask.

B. administer dopamine intravenously.

C. administer epinephrine via an intraosseous needle.

D. perform endotracheal intubation.

7. Which of the following findings in a 2-year-old child assists in identifying the cause of a grand mal seizure?

A. Fever

B. Crackles in the lungs

C. Abdominal tenderness

D. Cardiac dysrhythmia

8. Activated charcoal is contraindicated in a patient who has ingested a toxic substance if:

A. there is a history of abdominal surgery.

B. there is a history of diarrhea or vomiting.

C. the substance was corrosive.

D. the substance was ingested approximately one hour ago.

9. A 10-year-old girl is unresponsive when she surfaces after diving into a quarry. Bystanders report

that she was shaking all over as they pulled her out of the water. The first step in caring for this patient is to:

A. stabilize her cervical spine to reduce the risk of further spinal injury.

B. elevate her head to reduce the risk of aspiration.

C. turn her on her side to allow any water to drain from her mouth.

D. open her mouth and insert an oropharyngeal airway to maintain a patent airway.

10. An 8-year-old boy fell 7 feet out of a tree, landing on his right arm and falling to his right side. He is crying and appears agitated. Assessment reveals that he has pale, warm skin, multiple abrasions on his right shoulder and hip, and a deformed right forearm. He has a blood pressure of 92/74 mm Hg, a pulse of 128 beats/min, and respirations of 32 breaths/min.

What is the best approach to conducting the assessment of this patient?

A. Telling him he must lie still or he may become paralyzed

B. Exposing only those areas currently being assessed and then covering them

C. Asking him if it is okay to listen to his lungs and touch his chest and stomach

D. Asking him what hurts the most and begin by assessing that area of the body

11. An 8-year-old boy fell 7 feet out of a tree, landing on his right arm and falling to his right side. He is crying and appears agitated. Assessment reveals that he has pale, warm skin, multiple abrasions on his right shoulder and hip, and a deformed right forearm. He has a blood pressure of 92/74 mm Hg, a pulse of 128 beats/min, and respirations of 32 breaths/min.

After completing your initial assessment, the first step in caring for this patient is to:

A. manually stabilize the cervical spine to reduce the risk of spinal injury.

B. initiate hyperventilation to reduce the accumulation of acids in the body.

C. cover him with blankets to prevent heat loss.

D. place him in a position of comfort to decrease anxiety.

12. An 8-year-old boy fell 7 feet out of a tree, landing on his right arm and falling to his right side. He is crying and appears agitated. Assessment reveals that he has pale, warm skin, multiple abrasions on his right shoulder and hip, and a deformed right forearm. He has a blood pressure of 92/74 mm Hg, a pulse of 128 beats/min, and respirations of 32 breaths/min.

What is the most likely cause for the abnormal appearance of this patient?

A. Secondary brain injury

B. Hypoxia

C. Pain

D. Hypothermia

13. What information is important to obtain about a child with smoke inhalation?

A. Presence of windows or ventilation in the room

B. Position of the patient when found

C. History of recent cold symptoms

D. Location in the room where the patient was found

14. A 6-month-old infant who is being cared for by a babysitter is unresponsive and has warm, pink skin and respirations without increased work of breathing.. The babysitter appears anxious and frustrated and explains that the infant had been crying for hours and would not stop. The babysitter states, "I couldn t get her to stop crying. I tried everything. All of a sudden she got really quiet, and I couldn't wake her up. Please help her. I can't take her crying any more." The babysitter states that she does not think that the infant has been sick recently. The infant s altered level of consciousness is most likely due to:

A. toxic exposure.

B. shaken baby syndrome.

C. seizures.

D. respiratory failure.

15. An 18-month-old boy who reportedly fell down the stairs earlier in the day just isn t acting right, according to his caregivers. Assessment reveals multiple bruises on his thighs and back and a deformity of his right thigh. He is alert and crying. What is the best way to interact with the

caregivers?

A. Confront them by telling them you know that this injury could not have occurred from a fall; therefore, you are obligated to take him to the hospital.

B. Ask them why they waited so long to call for help; the delay has made the child very sick; therefore, you will need to administer oxygen and establish an IV.

C. Contact the local law enforcement agency to request that the caregiver be arrested while you transport the child.

D. Explain that you are very concerned about the child s condition and that he needs to be examined at the hospital for a possible a broken leg.

16. A woman who is about to deliver a baby at home reports that the fluid was thick green when her bag of waters broke. The most important treatment of the newborn is to:

A. vigorously dry and warm the baby.

B. copiously suction the mouth and nose.

C. administer oxygen by nasal cannula at 4 L/min.

D. calculate the APGAR score.

17. Ascertaining the due date of a newborn during an impending delivery helps you to:

A. assemble the correct size of equipment to care for the baby.

B. decide whether the baby will be delivered at the scene or if there is time to transport the mother to the hospital.

C. decide if an on-scene delivery is needed, particularly if the infant is premature, as the labor is often shorter for these infants.

D. determine if meconium aspiration may have occurred.

18. Assessment of a newborn five minutes after delivery reveals cyanosis of the hands, feet, trunk, and face. Vital signs are pulse 160 beats/min and respirations 44 breaths/min. Treatment of this newborn includes:

A. initiating bag-valve-mask ventilations.

B. performing intubation and positive pressure ventilation.

C. applying free flow oxygen by mask at 5 L/min.

D. reassessing the skin color in five minutes and then initiating oxygen therapy if needed.

19. An infant should be immediately evaluated by a physician if which of the following signs or symptoms are present?

A. Use of abdominal muscles to breathe

B. Temperature of 37 degrees (98.6 F)

C. Acting fussier than normal

D. Refuses a pacifier

20. A 3-year-old boy who has a tracheostomy has had difficulty breathing and coughing for 2 days because of increased secretions. He is on continuous oxygen. His mother states that his breathing is getting much worse. Assessment reveals that he is lethargic, has cool, mottled skin, and has copious secretions in the tracheostomy tube. Which of the following signs suggests significant obstruction of the tracheostomy tube?

A. A slow heart rate and poor air exchange

B. Irregular respirations and wheezing

C. Crackles and decreased breath sounds

D. Unequal chest rise and wheezing

21. During transport, what is the correct way to manage the respiratory status of a boy who is on a ventilator but also breathes on his own?

A. Allow the patient to remain on the ventilator if he is not in respiratory distress

B. Immediately deliver bag-valve-mask ventilations because you may not be familiar with the ventilator

C. Switch the patient to oxygen by blow-by method because the ventilator will not work in the ambulance

D. Decrease the flow rate as the oxygen in the ambulance is more potent and requires a lower flow rate

22. What is the danger of using a mask that is too large on a child who requires ventilatory assistance?

A. Eye injuries may occur from the mask touching the globe

B. It will be more difficult to obtain a seal for ventilation

C. More pressure will need to be applied to obtain a mask seal, which may cause dislocation of the mandible

D. If the mask extends across the eyes, it may exert pressure and stimulate the vagus nerve

23. What is the correct method to confirm proper placement of an endotracheal tube?

A. Palpate for chest rise and fall over the anterior chest and abdomen

B. Observe for gastric distention which indicates leakage of air around the tube in the trachea

C. Auscultate the anterior chest and mid-abdominal area for the presence of bubbling or gurgling sounds

D. Auscultate for bubbling or gurgling sounds over the epigastrium and breath sounds at the midaxillary regions

24. When should the child s head be secured to the spine board during the immobilization procedure?

A. After the body straps and lateral stabilization devices have been applied

B. After the body straps have been applied, but before the lateral stabilization devices to ensure that the tape is applied tightly

C. Before any straps or lateral stabilization devices have been applied

D. If the child is quiet the head does not need to be secured once lateral stabilization devices are applied

25. Which of the following substances can be infused via an intraosseous needle?

A. All medications and intravenous fluids

B. All medications except sodium bicarbonate and dextrose

C. Fluids or medications that are not acidic

D. Only medications and fluids that have a neutral pH

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Informed consent is intended to facilitate appropriate, knowledgeable decision making among clients who are hospitalized, receiving specialty services and/or making any type of decision regarding health care. Informed consent should be directed toward the educational and cognitive level of the client. All possible outcomes and consequences of the procedure or treatment should be explained in as much detail as needed to ensure the client fully understands what is to be done and the potential outcomes. Informed consent must be signed and acknowledged by both the physician and the patient; nurses are no longer responsible for the information on and for obtaining informed consent, but do function as the witness to informed consent.