1.
Who is the organ procurement agency for RHJ VAMC?
Correct Answer
B. LifePoint
Explanation
CPM 00-14-16; T drive - All CPMs - type "Organ" in the search box
2.
When would you notify the organ procurement agency?
Correct Answer
A. When death is imminent.
Explanation
CPM 00-14-16; T drive - All CPMs - type "Organ" in the search box
3.
The following are nurses’ actions in the event of a blood transfusion reaction except:
Correct Answer
C. Collect 2 seven ml lavender tubes of blood from distant site from the transfusion.
Explanation
CPM 113-13-01. T drive - All CPMs - type "blood transfusion" in the search box
4.
What values on the glucometer warrant a serum sample to be sent to the lab stat?
Correct Answer
B. 400 in a green cap vial
Explanation
Hypoglycemia-Hyperglycemia Protocol; this policy is located on the T drive--Clinical Guidelines and Protocols. Type in the search box "hypoglycemia" and this will bring up the policy.
CPM 118-12-08
5.
When caring for a SCI patient, what primary care intervention needs to be addressed in the hospital and continued on same home schedule?
Correct Answer
C. Continue bowel and bladder daily routine home care
Explanation
CPG 12-2013 Spinal Cord Injury Treatment Guidelines for Physicians and Nurses. Located on the T drive--Clinical Guidelines and Protocols---Clinical Practice and Guidelines. Type "spinal" in the search box.
6.
A SCI patient is at risk for Autonomic Dysreflexia if he/she has an injury at level ________ or higher?
Correct Answer
C. T6
Explanation
CPG 12-2013 Spinal Cord Injury Treatment Guidelines for Physicians and Nurses. Located on the T drive--Clinical Guidelines and Protocols---Clinical Practice and Guidelines. Type "spinal" in the search box.
7.
What would you do if your SCI patient was showing symptoms of autonomic dysreflexia?
Correct Answer
D. A, B, & C
Explanation
CPG 12-2013 Spinal Cord Injury Treatment Guidelines for Physicians and Nurses. Located on the T drive--Clinical Guidelines and Protocols---Clinical Practice and Guidelines. Type "spinal" in the search box.
8.
Tubes of blood collected for type and cross match are verified and labeled at the nurse's station with two RNs.
Correct Answer
B. False
Explanation
CPM 113-13-01. T drive - All CPMs - type "blood transfusion" in search box
9.
What are the signs and symptoms of blood transfusion reaction? (Select all that apply).
Correct Answer(s)
A. Fever
B. Flushing of skin
C. Chills
D. Dizzness
Explanation
CPM 113-13-01. T drive - All CPMs - type "blood transfusion" in search box
10.
Which of the following are considered to be "High Alert Medications"? (Select all that apply).
Correct Answer(s)
A. TPN
B. Heparin
C. Chemotherapy IV drugs
D. Insulin
Explanation
CPM 110-21 High Alert Medications and Standardized Fusions. Located on the T drive--All CPMs--pharmacy. Type "medications" in the search box.
11.
All of the following are ways in which the nurse can help prevent Autonomic Dysreflexia except:
Correct Answer
C. Use of over the bed trapeze
Explanation
CPG 12-2013 Spinal Cord Injury Treatment Guidelines for Physicians and Nurses. Located on the T drive - Clinical Guidelines and Protocols - Clinical Practice and Guidelines - type "spinal" in the search box.
12.
Which of the following medications are associated with risk for falls (select all that apply):
Correct Answer(s)
A. Diuretics
B. Opioids
C. Antidiabetic
D. Antihistamines
Explanation
CPM 118-13-18 Assessment and Care of Patients-Residents at Risk for Falls. Located on the T drive--All CPMs--type "falls" in the search box.
13.
What blood glucose reading warrants initiating the Hypoglycemia Protocol?
Correct Answer
C. < 70mg/dL
Explanation
Hypoglycemia-Hyperglycemia Protocol; this policy is located on the T drive--Clinical Guidelines and Protocols. Type in the search box "hypoglycemia" and this will bring up the policy.
14.
How often will the LPN document tube feeding management and monitoring in CPRS using the Tube Feed Summary note?
Correct Answer
A. Every shift
Explanation
CPM 12-12-01 Tube-Enteral Nutrition. T drive - All CPMs - type "tube-enteral" in the search box.
15.
Observation of patients receiving PCA pain medication includes:Select all that apply.
Correct Answer(s)
A. Level of sedation
B. Pain intensity score
C. Respiratory rate
D. Number of PCA attempts
E. Number of injections
Explanation
CPM 119-12-11 Use of Patient Controlled Analgesia (PCA) Pumps. T drive - All CPMs - type "PCA" in the search box.
16.
I pledge to demonstrate the core values of the American Nurses Association code of ethics by upholding the standards of honesty and integrity. By answering yes, you certify that you are the person taking this test.
Correct Answer
A. Yes
Explanation
The given answer is "Yes" because by pledging to demonstrate the core values of the American Nurses Association code of ethics and upholding the standards of honesty and integrity, the person taking the test is committing to abide by the ethical principles and professional standards expected of a nurse. This answer indicates their willingness to be accountable for their actions and prioritize the well-being and trust of patients.
17.
Your patient has a blood sugar that warrants you initiating the hypoglycemic protocol; where would you document your interventions for this patient:
Correct Answer
C. CPRS hypoglycemia/hyperglycemia protocol note
Explanation
Hypoglycemia-Hyperglycemia Protocol; this policy is located on the T drive--Clinical Guidelines and Protocols. Type in the search box "hypoglycemia" and this will bring up the policy.
18.
Medications scheduled to be administered every 8 hours will be administered within plus or minus 2 hours of scheduled times unless otherwise noted by the provider.
Correct Answer
B. False
Explanation
CPM 118-14-50 Administration of Medications by Nursing
19.
You enter the your patient’s room to give him his 8am medications, and you notice that the patient is showing signs and symptoms of a stroke, what are the signs and symptoms, select all that apply:
Correct Answer(s)
A. Slurred speech
B. Weakness on one side
C. Facial drooping
E. Sudden confusion
Explanation
Nursing Protocol: Signs and Symptoms of Acute Ischemic Stroke (ASI)
20.
When providing interventions for a patient showing signs and symptoms of a stroke, vital signs will be done every 30 minutes.
Correct Answer
B. False
Explanation
Nursing Protocol: Signs and Symptoms of Acute Ischemic Stroke (ASI)