1.
Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?
Correct Answer
B. Sensory deficits
Explanation
Sensory deficits, such as hearing or vision impairment, can cause difficulty for geriatric patients in retaining knowledge about prescribed medications. These deficits can hinder their ability to effectively receive and process information provided by the nurse, making it harder for them to understand and remember the details about the newly prescribed drug.
2.
When examining a patient with abdominal pain the nurse in charge should assess:
Correct Answer
C. The symptomatic quadrant last
Explanation
When examining a patient with abdominal pain, the nurse should assess the symptomatic quadrant last. This is because the nurse needs to gather as much information as possible before focusing on the area of pain. By assessing the other quadrants first, the nurse can establish a baseline and compare the findings to the symptomatic quadrant. This approach helps in identifying any potential patterns or abnormalities that may assist in making an accurate diagnosis.
3.
The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
Correct Answer
C. Patient’s description of pain
Explanation
The nurse should document the patient's description of pain as subjective data because it is based on the patient's personal experience and perception. Vital signs, laboratory test results, and ECG waveforms are all objective data that can be measured and observed by the nurse or healthcare provider. However, the patient's description of pain is subjective and can only be reported by the patient.
4.
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
Correct Answer
C. Cool, pale fingers
Explanation
The nurse should consider cool, pale fingers as an abnormal assessment finding in a male patient with a soft wrist-safety device. Cool and pale fingers may indicate poor circulation or reduced blood flow to the extremities, which could be a sign of compromised vascular function or a potential circulatory issue. This finding should be further evaluated and reported to the healthcare provider for appropriate intervention.
5.
Which of the following planes divides the body longitudinally into anterior and posterior regions?
Correct Answer
A. Frontal plane
Explanation
The frontal plane is the correct answer because it divides the body into anterior (front) and posterior (back) regions. This plane is perpendicular to the sagittal and transverse planes, and it separates the body into two halves - the front and the back. The other planes mentioned in the options do not divide the body in the same way. The sagittal plane divides the body into left and right halves, the midsagittal plane specifically divides it into equal left and right halves, and the transverse plane divides it into superior (upper) and inferior (lower) regions.
6.
A female patient with a terminal illness is in denial. Indicators of denial include:
Correct Answer
A. Shock dismay
Explanation
The correct answer is "Shock dismay" because denial is a common psychological defense mechanism used to cope with the overwhelming reality of a terminal illness. The patient may experience shock and dismay as they struggle to accept their diagnosis and the implications it has on their life. This initial reaction of disbelief and emotional distress is often characterized by a sense of shock and dismay.
7.
The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?
Correct Answer
B. Helps the patient dangle the legs
Explanation
During the transfer of a patient from the bed to a chair, the nurse helps the patient dangle the legs. This action is important as it allows the patient to sit on the edge of the bed and let their legs hang down. Dangling the legs helps the patient adjust to the upright position gradually, preventing orthostatic hypotension (a drop in blood pressure upon standing). It also allows the nurse to assess the patient's balance and stability before fully transferring them to the chair.
8.
A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
Correct Answer
D. Demonstrating the procedure and having the patient return the demonstration
Explanation
Demonstrating the procedure and having the patient return the demonstration would be the best nursing action to help the patient understand wound care instruction. Since the patient speaks little English, verbal communication may not be effective in conveying the instructions. By demonstrating the procedure, the nurse can visually show the patient how to perform wound care. Having the patient return the demonstration ensures that the patient has understood and learned the correct technique. This method eliminates the language barrier and promotes effective understanding and retention of the instructions.
9.
Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
Correct Answer
A. Discard the syringe to avoid a medication error
Explanation
The nurse should discard the syringe to avoid a medication error. Since the syringe is unlabeled, there is no way to verify its contents or ensure that it is the correct medication for the patient. Using the syringe without proper labeling could lead to a medication error and potential harm to the patient. It is important for the nurse to prioritize patient safety and follow proper protocols, which includes discarding any unlabeled medication.
10.
When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects?
Correct Answer
B. Aging-related pHysiological changes
Explanation
As individuals age, their bodies undergo physiological changes that can affect the way drugs are metabolized and eliminated. These changes include a decrease in kidney and liver function, a decrease in the total body water content, and a decrease in the production of certain enzymes. These changes can lead to a slower clearance of drugs from the body, resulting in higher drug levels and an increased risk of adverse effects. Therefore, aging-related physiological changes make geriatric patients more susceptible to adverse drug effects.
11.
A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
Correct Answer
B. Educator
Explanation
The nurse is performing the role of an educator by providing medication teaching to the patient. This role involves teaching and providing information to patients about their health condition, treatment, and medication instructions. By asking the patient to repeat the instructions, the nurse ensures that the patient has understood the information and can effectively manage their medication after discharge.
12.
A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?
Correct Answer
D. “Let’s talk about what’s bothering you.”
Explanation
The response "Let's talk about what's bothering you" is most likely to reduce the patient's anxiety because it shows that the nurse is willing to listen and provide support. By encouraging the patient to express their concerns and fears, the nurse can help the patient to process their emotions and potentially find solutions or coping strategies. This response acknowledges the patient's feelings and offers a safe space for them to discuss their anxieties, which can help to alleviate their distress.
13.
A scrub nurse in the operating room has which responsibility?
Correct Answer
C. Handling surgical instruments to the surgeon
Explanation
The scrub nurse in the operating room is responsible for handling surgical instruments to the surgeon. This involves ensuring that the surgeon has the necessary instruments during the procedure, passing instruments to the surgeon in a sterile manner, and maintaining the instrument count throughout the surgery. The scrub nurse plays a crucial role in assisting the surgeon and maintaining a sterile environment in the operating room.
14.
A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?
Correct Answer
C. Return shortly to the patient’s room and remain there until the patient takes the medication
Explanation
The nurse should return shortly to the patient's room and remain there until the patient takes the medication to ensure that the medication is taken as prescribed and to monitor the patient for any adverse reactions or difficulties in taking the medication. Leaving the medication at the bedside without supervision may result in the patient forgetting to take it or taking it incorrectly. Telling the patient to be sure to take the medication and leaving it at the bedside does not provide direct supervision. Waiting for the patient to return to bed and leaving the medication at the bedside also does not ensure that the medication is taken correctly.
15.
The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?
Correct Answer
C. 3/4 ml
Explanation
The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. To determine the amount of heparin for each dose, we can set up a proportion. Since there are 10,000 units in 1 ml, we can write the proportion as 10,000 units/1 ml = 7,500 units/x ml. Cross-multiplying gives us 10,000x = 7,500, and solving for x gives us x = 7,500/10,000 = 0.75 ml. Therefore, the nurse should anticipate giving 3/4 ml of heparin for each dose.
16.
The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
Correct Answer
C. 38.9 degrees C
Explanation
The correct answer is 38.9 degrees C. To convert Fahrenheit to Celsius, you can use the formula: C = (F - 32) * 5/9. Plugging in the given temperature of 102 degrees F into the formula, we get: C = (102 - 32) * 5/9 = 70 * 5/9 = 350/9 = 38.9 degrees C.
17.
To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
Correct Answer
D. Arterial blood gas (ABG) analysis
Explanation
To evaluate a patient for hypoxia, the physician is most likely to order an arterial blood gas (ABG) analysis. This test measures the levels of oxygen and carbon dioxide in the blood, as well as other parameters such as pH and bicarbonate. ABG analysis provides a direct assessment of the patient's respiratory function and can help determine if there is a deficiency of oxygen in the blood. Red blood cell count, sputum culture, and total hemoglobin tests do not specifically assess oxygen levels in the blood and are therefore less likely to be ordered for evaluating hypoxia.
18.
The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
Correct Answer
B. The diapHragm detects high-pitched sounds best
Explanation
The diaphragm of a stethoscope is designed to detect high-pitched sounds best. This is because the diaphragm is a flat, circular disc that vibrates when it comes into contact with sound waves. These vibrations are then transmitted to the nurse's ears, allowing them to hear the sounds. High-pitched sounds, such as lung sounds and normal heart sounds, are best heard through the diaphragm because they produce higher frequency vibrations. The bell of a stethoscope, on the other hand, is better suited for detecting low-pitched sounds, such as certain abnormal heart sounds or bruits.
19.
A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?
Correct Answer
C. Within 6 months
Explanation
The nurse should explain to the patient that they must fill the prescription for the controlled substance within 6 months after the date it was written. This is because controlled substances have a limited shelf life and may lose their potency or effectiveness over time. Additionally, there may be legal restrictions on the validity of prescriptions for controlled substances, and filling the prescription within 6 months ensures that the patient is within the legal timeframe to obtain the medication.
20.
Which human element considered by the nurse in charge during assessment can affect drug administration?
Correct Answer
D. The patient’s cognitive abilities
Explanation
The nurse in charge considers the patient's cognitive abilities during drug administration because it can affect their understanding and compliance with medication instructions. If a patient has impaired cognitive abilities, they may have difficulty comprehending the purpose of the medication, the dosage instructions, or any potential side effects. This could lead to medication errors or non-adherence, which can negatively impact the patient's health outcomes. Therefore, the nurse needs to assess the patient's cognitive abilities to ensure safe and effective drug administration.
21.
An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
Correct Answer
A. Primary prevention
Explanation
The establishment of a physical exercise area in the workplace and encouraging employees to use it falls under the category of primary prevention. Primary prevention aims to prevent the development of diseases or injuries before they occur. In this case, the employer is taking proactive measures to promote physical activity and prevent the onset of health issues among employees. By providing a space for exercise and encouraging its use, the employer is promoting overall health and well-being, reducing the risk of chronic diseases, and creating a healthier work environment.
22.
What does the nurse in charge do when making a surgical bed?
Correct Answer
A. Leaves the bed in the high position when finished
Explanation
The nurse in charge leaves the bed in the high position when finished making a surgical bed because it allows for easy access to the patient during the surgical procedure. This position also ensures that the bed is at a comfortable height for the surgical team to work efficiently. Additionally, leaving the bed in the high position allows for easier transfer of the patient onto the bed after the surgery is completed.
23.
The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug should the nurse give?
Correct Answer
C. 1/2 ml
Explanation
The drug vial contains 500 mg of the drug in 1 ml. The physician has prescribed 250 mg of the drug. To determine how much of the drug the nurse should give, we need to find the volume of the drug that contains 250 mg. Since 500 mg is contained in 1 ml, we can set up a proportion: 500 mg/1 ml = 250 mg/x ml. Solving for x, we find that x = 1/2 ml. Therefore, the nurse should give 1/2 ml of the drug.
24.
Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
Correct Answer
C. Potential for drug dependence
Explanation
Barbiturate use is associated with the potential for drug dependence. This means that patients who take barbiturates may develop a psychological and physical reliance on the medication, leading to addiction. This can be a major disadvantage as it can result in withdrawal symptoms and difficulty discontinuing the medication. It is important for healthcare providers to closely monitor patients on barbiturate therapy to minimize the risk of drug dependence and provide appropriate support if needed.
25.
Which nursing action is essential when providing continuous enteral feeding?
Correct Answer
A. Elevating the head of the bed
Explanation
Elevating the head of the bed is essential when providing continuous enteral feeding because it helps prevent aspiration and reflux. By elevating the head of the bed, the patient's head and upper body are in an upright position, which helps to promote the flow of the formula and prevent it from flowing back into the esophagus and causing complications. This position also helps to reduce the risk of aspiration, where the formula enters the airway instead of the stomach, which can lead to pneumonia and other respiratory issues.
26.
When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the:
Correct Answer
C. Floor of the mouth
Explanation
The nurse should instruct the patient to place the sublingual tablet on the floor of the mouth. This is because sublingual medications are designed to be absorbed through the mucous membranes under the tongue. Placing the tablet on the floor of the mouth allows it to dissolve and be absorbed directly into the bloodstream, bypassing the digestive system. Placing the tablet on the top of the tongue, roof of the mouth, or inside of the cheek would not facilitate proper absorption and may result in the medication being swallowed and metabolized differently.
27.
Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?
Correct Answer
C. Cleaning briskly around the site with alcohol
Explanation
Cleaning briskly around the site with alcohol is the essential action when cleaning the area around a Jackson-Pratt wound drain. Alcohol is commonly used as an antiseptic to clean the skin and prevent infection. Cleaning briskly helps to remove any dirt or bacteria from the area. This action helps to maintain the cleanliness and integrity of the wound site, reducing the risk of complications such as infection. Wearing sterile gloves and a mask is important for maintaining a sterile environment, but it is not specifically essential for cleaning the area around the drain. Removing the drain before cleaning the skin is not necessary and may cause unnecessary discomfort or trauma to the patient. Cleaning from the center outward in a circular motion is not the recommended technique for cleaning a wound drain.
28.
The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
Correct Answer
C. 32 drop per minute
Explanation
The nurse should run the I.V. infusion at a rate of 32 drops per minute because there are 15 drops per milliliter and the total volume to be infused is 1,000 ml over 8 hours. To calculate the rate, we need to convert the total volume and time into minutes. 8 hours is equal to 480 minutes. Therefore, the rate would be 1,000 ml / 480 minutes = 2.08 ml per minute. Since there are 15 drops per ml, the rate in drops per minute would be 2.08 ml per minute * 15 drops per ml = 31.2 drops per minute. Rounding up, the nurse should run the infusion at a rate of 32 drops per minute.
29.
A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock?
Correct Answer
A. Restlessness
Explanation
Restlessness can be an early sign of shock in a patient who has undergone a total abdominal hysterectomy. Shock is a life-threatening condition that occurs when there is inadequate blood flow to the body's organs and tissues. Restlessness can indicate that the patient is experiencing decreased oxygenation and perfusion, causing them to become agitated and anxious. It is important for the nurse to recognize this early sign of shock and intervene promptly to prevent further deterioration of the patient's condition.
30.
Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
Correct Answer
D. Carotid
Explanation
During a rapid assessment of an unconscious male adult, the nurse should palpate the carotid pulse. The carotid pulse is located in the neck, specifically in the carotid artery. This pulse is easily accessible and provides a reliable indication of the patient's circulation and perfusion. Palpating the carotid pulse allows the nurse to quickly assess the patient's heart rate and rhythm, which are essential in determining the patient's overall condition and the need for immediate intervention.