1.
While receiving a blood transfusion, Mr. Costas develops chills and headache. What would be the nurse's initial action?
Correct Answer
B. Stop the transfusion immediately
Explanation
The correct answer is to stop the transfusion immediately. Mr. Costas developing chills and headache during a blood transfusion could indicate a transfusion reaction. It is important to stop the transfusion to prevent further complications and assess the patient's condition. The nurse should then notify the physician and follow their instructions for further management.
2.
Mrs. Lam has fallen out of bed. What should the nurse document in the health record?
Correct Answer
B. An assessment of Mrs. Lam's condition after the fall
Explanation
The nurse should document an assessment of Mrs. Lam's condition after the fall in the health record. This is important to ensure that her immediate medical needs are addressed and appropriate care is provided. The assessment will include information such as any injuries sustained, vital signs, level of consciousness, and any other relevant observations. This documentation will serve as a record of Mrs. Lam's condition and can be used for future reference or to communicate with other healthcare providers involved in her care.
3.
Choose the most therapeutic response to Mr. Santos's question: "Am I going to die?"
Correct Answer
D. "Would you like to talk about your condition and prognosis?"
Explanation
This response is the most therapeutic because it acknowledges Mr. Santos's fear and concern about his condition and allows him the opportunity to discuss his feelings and concerns. It shows empathy and provides an open and supportive space for him to express his thoughts and emotions.
4.
Select the most appropriate lunch for a healthy three year old child.
Correct Answer
B. Cheese sandwich and carrot sticks
Explanation
The most appropriate lunch for a healthy three-year-old child would be a cheese sandwich and carrot sticks. This option provides a balanced meal with protein from the cheese, carbohydrates from the bread, and vitamins and fiber from the carrots. It is important to offer a variety of food groups to ensure the child receives all the necessary nutrients for their growth and development.
5.
Which of the following would be a common indication of infiltration of a peripheral intravenous infusion?
Correct Answer
A. Redness and swelling around the insertion site
Explanation
Redness and swelling around the insertion site would be a common indication of infiltration of a peripheral intravenous infusion. Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of entering the vein. This can cause local inflammation, leading to redness and swelling around the insertion site. Other signs of infiltration may include pain, coolness or hardness at the site, and slowed or stopped flow of the IV fluid. Monitoring for these signs is important to detect infiltration early and prevent complications.
6.
Which of the following is a side effect of digoxin?
Correct Answer
B. Bradychardia
Explanation
Digoxin is a medication commonly used to treat heart conditions. One of the side effects of digoxin is bradychardia, which refers to a slower than normal heart rate. This can occur because digoxin increases the strength of the heart's contractions, leading to a slower heart rate. Bradychardia can cause symptoms such as dizziness, fatigue, and shortness of breath. It is important for patients taking digoxin to be monitored for any changes in heart rate and to report any symptoms to their healthcare provider.
7.
Before taking Mr. Sanderson's vital signs, the nurse ask him if he is taking any medications. He answers: "Digoxin every morning, and Tylenol in the evening." Which of the following vital signs changes might the nurse anticipate?
Correct Answer
B. Decreases pulse to 53 bpm
Explanation
Taking Digoxin can cause a decrease in heart rate, known as bradycardia. Digoxin is a medication that is commonly used to treat heart conditions, but it can also have side effects on the heart rate. Therefore, it is expected that Mr. Sanderson's pulse would decrease to 53 bpm as a result of taking Digoxin every morning.
8.
The nurse is about to give Mr. Sanderson hismorning digoxin. His radial pulse is 45 bpm. What is the nurse's first action?
Correct Answer
A. Check his apicalpulse
Explanation
The nurse's first action should be to check Mr. Sanderson's apical pulse. This is because digoxin is a medication that affects the heart rate and rhythm. The radial pulse may not accurately reflect the heart rate, especially in cases of irregular rhythms. The apical pulse, which is taken by listening to the heart sounds with a stethoscope, provides a more accurate assessment of the heart rate. If the apical pulse is also below 60 bpm, the nurse should withhold the digoxin and notify the physician.
9.
Camilla, an RN, has been a smoker for 30 years. Michael, her co-worker, is very "antismoking." What interpersonal approach should Michaeltake with Camilla?
Correct Answer
B. Work with her without prejudice
Explanation
Michael should work with Camilla without prejudice. This means that he should not let his personal beliefs or opinions about smoking affect the way he interacts with her. Instead, he should approach their working relationship with an open mind and treat her with fairness and respect, regardless of her smoking habit. This approach will help maintain a professional and positive working environment between the two coworkers.
10.
Ms. Brankston is in the emergency room after being involved in a traffic accident. What would be an early sign of hemorrhagic shock?
Correct Answer
C. Increased pulse
Explanation
An increased pulse would be an early sign of hemorrhagic shock. Hemorrhagic shock occurs when there is severe blood loss, causing a decrease in blood volume. To compensate for this loss, the body increases the heart rate in an attempt to maintain blood flow to vital organs. Therefore, an increased pulse is an indication that the body is trying to compensate for the reduced blood volume and is a potential early sign of hemorrhagic shock.
11.
Ms. Brankston is in the emergency room after being involved in a traffic accident. What would be an early sign of hemorrhagic shock?
Correct Answer
C. Increased pulse
Explanation
An increased pulse would be an early sign of hemorrhagic shock. Hemorrhagic shock occurs when there is significant blood loss, leading to inadequate blood flow to the body's organs and tissues. In response to the decreased blood volume, the body tries to compensate by increasing the heart rate to maintain blood pressure. Therefore, an increased pulse is a physiological response to hemorrhagic shock and can be an early indicator of this condition.
12.
Which of the following is most important when performing a preoperative assessment?
Correct Answer
A. pHysical assessment
Explanation
A preoperative assessment is an important step before surgery to gather information about the patient's overall health and identify any potential risks or complications. Physical assessment involves a comprehensive evaluation of the patient's body systems, including the cardiovascular, respiratory, gastrointestinal, and musculoskeletal systems. This assessment helps the healthcare team understand the patient's baseline health status, identify any abnormalities or potential problems that may affect the surgical outcome, and plan appropriate interventions or modifications to the surgical plan. Therefore, physical assessment is crucial in ensuring the patient's safety and optimal surgical outcome.
13.
Ms. Forbes is suffering from Gary's asymmetrical dystrophy. Which of the following therapeutic activities would be appropriate for her?
Correct Answer
C. Social interactions with other clients in the unit
Explanation
Social interactions with other clients in the unit would be appropriate for Ms. Forbes because it would provide her with social support and a sense of belonging. It can also help her to feel connected and engaged with others, which can have a positive impact on her overall well-being. Additionally, social interactions can provide opportunities for emotional expression, empathy, and understanding, which can be beneficial for individuals with dystrophy.
14.
Aubrey tells the nurse, "I am tired of waiting for you to brush my hair. You're never here when I want you." WHich of the following responses by the nurse is the most appropriate?
Correct Answer
A. "I'm sorry you have to wait. I'll get your hairbrush out for you and be back in 15 minutes to do your hair."
Explanation
The most appropriate response by the nurse is to acknowledge Aubrey's feelings and apologize for the wait. The nurse shows empathy by offering a solution and a specific time frame for when she will return to brush Aubrey's hair. This response validates Aubrey's concerns and demonstrates the nurse's commitment to meeting her needs.
15.
Ms. Macleod asks the nurse when she can start eating after surgery. What is the most appropriate response by the nurse?
Correct Answer
C. "You'll likely start on clear fluids once bowel sounds can be heard."
Explanation
The nurse's response of "You'll likely start on clear fluids once bowel sounds can be heard" is the most appropriate because it addresses the patient's question about when she can start eating after surgery. It indicates that the patient will begin with clear fluids, which is a common post-surgery dietary progression. The mention of bowel sounds suggests that the nurse is considering the patient's gastrointestinal function, which is important in determining when the patient can tolerate oral intake.
16.
Mrs. Sams tells the nurse she and her husband would like to speak with the physician concerning his test results and proposed treatment options. How should the nurse respond to Mrs. Sams?
Correct Answer
C. "I will page the doctor to come to see you."
Explanation
The nurse should respond by saying "I will page the doctor to come to see you." This is the most appropriate response because Mrs. Sams expressed her desire to speak with the physician directly about the test results and treatment options. The nurse acknowledges her request and takes the necessary action to contact the doctor. It shows that the nurse respects Mrs. Sams' wishes and understands the importance of involving the physician in the discussion.
17.
Choose the phrase that would elicit the best information from Mr. Harding about his pain.
Correct Answer
D. "Describe your pain to me."
Explanation
The phrase "Describe your pain to me" would elicit the best information from Mr. Harding about his pain because it allows him to provide a detailed account of his pain, including its location, intensity, and any accompanying symptoms. This open-ended question encourages Mr. Harding to provide a comprehensive description, enabling the healthcare provider to gather more specific and relevant information for diagnosis and treatment.