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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 eep airways open and free of secretions.

. A nurse is caring for an elderly !ietnamese patient in the terminal stages of lung cancer. "any 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. !estrict visiting hours and as the family to limit visitors to two at a time.

B. "otify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food

allowed.

C. #f possible, eep 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.

#. $he 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$wee postoperative coronary bypass patient, who is being evaluated for placement of a pacemaer

prior to discharge.

B. A suspected myocardial infarction patient on telemetry, %ust admitted from the &mergency Department andscheduled 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.

%. A newly diagnosed &-year-old child with type ' diabetes mellitus and his mother are receiving diabetes

education prior to discharge. $he physician has prescribed (lucagon for emergency use. $he mother asks

the purpose of this medication. Which of the following statements by the nurse is correct?

A. 'lucagon enhances the effect of insulin in case the blood sugar remains high one hour after in%ection.B. 'lucagon treats hypoglycemia resulting from insulin overdose.

C. 'lucagon treats lipoatrophy from insulin in%ections.

D. 'lucagon prolongs the effect of insulin, allowing fewer in%ections.

). A patient on the cardiac telemetry unit une*pectedly goes into ventricular fibrillation. $he 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. !ight 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 %ust below the clavicle and left of the precordium.

+. $he nurse performs an initial abdominal assessment on a patient newly admitted for abdominal pain.

$he nurse hears what she describes as ,clicks and gurgles in all four uadrants, as well as ,swishing or

buzzing sound heard in one or two uadrants., Which of the following statements is correct?

A. The frequency and intensity of bowel sounds varies depending on the phase of digestion.

B. #n the presence of intestinal obstruction, bowel sounds will be louder and higher pitched.

C. A swishing or bu((ing sound may represent the turbulent blood flow of a bruit and is not normal.

D. All of the above.

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&. 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. #rrigate the eye repeatedly with normal saline solution.

B. )lace fluorescein drops in the eye.

C. )atch the eye.D. Test visual acuity.

. A nurse is caring for a patient who has had hip replacement. $he nurse should be most concerned

about which of the following findings?

A. Complaints of pain during repositioning.

B. *cant bloody discharge on the surgical dressing.

C. Complaints of pain following physical therapy.

D. Temperature of ++.- /0-.1 C2.

1/. A child is admitted to the hospital with an uncontrolled seizure disorder. $he admitting physician

writes orders for actions to be taken in the event of a seizure. Which of the following actions would 0$

be included?A. "otify the physician.

B. !estrain the patient3s limbs.

C. )osition the patient on his4her side with the head flexed forward.

D. Administer rectal dia(epam.

11. mergency 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 15 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 %umping on hisbed.

12. A patient is admitted to the hospital with a calcium level of )./ mg3d4. Which of the following

symptoms would you 0$ e*pect to see in this patient?

A. "umbness in hands and feet.

B. 6uscle cramping.

C. 7ypoactive bowel sounds.

D. )ositive Chvoste3s sign.

1. 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 e*pected in this patient?A. p7 1.85, )C95 8: mm 7g.

B. p7 1.:5, )C95 : mm 7g.

C. p7 1.58, )C95 58 mm 7g.

D. p7 1.0-, )C95 0; mm 7g.

1#. A patient is admitted to the hospital for routine elective surgery. 'ncluded in the list of current

medications is 5oumadin 6warfarin7 at a high dose. 5oncerned about the possible effects of the drug8

particularly in a patient scheduled for surgery8 the nurse anticipates which of the following actions?

A. Draw a blood sample for prothrombin /)T2 and international normali(ed ratio /#"!2 level.

B. Administer vitamin

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1). A nurse is performing routine assessment of an '! site in a patient receiving both '! fluids and

medications through the line. Which of the following would indicate the need for discontinuation of the '!

line as the ne*t 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 #? solution is infusing too slowly, particularly when the limb is elevated.D. A hematoma is visible in the area of the #? insertion site.

1+. 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 bed8 dyspneic and uncomfortable. n assessment8 crackles

are heard in the bases of both lungs8 probably indicating that the patient is e*periencing a complication of

transfusion. Which of the following complications is most likely the cause of the patient:s symptoms?

A. ebrile non$hemolytic reaction.

B. Allergic transfusion reaction.

C. Acute hemolytic reaction.

D. luid overload.

1&. A patient in labor and delivery has ;ust received an amniotomy. Which of the following is correct?0ote9 "ore than one answer may be correct.

A. requent checs for cervical dilation will be needed after the procedure.

B. Contractions may rapidly become stronger and closer together after the procedure.

C. The 7! /fetal heart rate2 will be followed closely after the procedure due to the possibility of cordcompression.

D. The procedure is usually painless and is followed by a gush of amniotic fluid.

1. A nurse is counseling the mother of a newborn infant with hyperbilirubinemia. Which of the following

instructions by the nurse is 0$ correct?

A. Continue to breastfeed frequently, at least every 5$: hours.

B. ollow up with the infant3s physician within 15 hours of discharge for a rechec of the serum bilirubin and

exam.C. @atch for signs of dehydration, including decreased urinary output and changes in sin turgor.

D.

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Answers and rationale

1. Answer9 5

The priority nursing action for a patient arriving at the &D in distress is always assessment of vital signs. Thisindicates 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 liely that anelectrocardiogram will be performed as well, but these are not the first priority. *imilarly, chest exam with

auscultation may offer useful information after vital signs are assessed.

2. Answer9 5

#t is always critical that patients being discharged from the hospital tae prescribed medications as instructed. #n

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.

. Answer9 5

@hen 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. #n the ?ietnamese 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 thenext life. @hen 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.

#. Answer9 A

The charge nurse planning assignments must consider the sills of the staff and the needs of the patients. Thelabor 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$wee post$operative and nearing discharge is liely to require

routine care. A new patient admitted with suspected 6# 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.

%. Answer9