1. The nurse is caring for a patient who is to have a MRI scan performed.
w e we we w e w e w e w e w e we we we w e we we
Which
assessmentfindingleadsthenursetoreportthatthepatientmaynotbe able t w
e w
e w
e w
e w
e w
e w
e w
e w
e w
e w
e w
e we we
o have
we
the test? we
A. The patient has an implanted insulin pump
we we we we we we
B. The patient is breastfeeding her newborn infant
we we we we we w e
C. The patient is severely allergic to iodine and latex
we we we we we we we we
D. The patient has profound hearing loss we w e w e w e w e
2. The nurse is caring for a patient who is to collect a 24-hour urine specimen.
we we we we we we we we we we we we we we
Which
statement by the patient indicates that additional teaching is required?
we we we we we we we we we
A. “I will keep the urine container on ice to keep it chilled until I bring it to the lab”
we we we we we we we we we we we we we we we we we we
B. “I will start the test over if I forget and urinate into the toilet during the testing
we we we we we we we we we we we we we we we we
time”
C. “Iwillstartthetesttomorrow afterIurinatefirstthing inthemorning”
w
e we w
e w
e w
e we w
e w
e w
e w
e we we w
e
D. “I will drink extra fluids so that the lab will have a large specimen to test.”
we we we we we we we we we we we we we we we
3. The nurse is caring for a patient with a urinary tract infection. Which test wi
w e w e w e w e w e w e w e w e w e w e w e w e w e we
ll indicate
we
whichantibioticswillbeeffectivetotreattheinfection?
w
e w
e w
e w
e w
e w
e w
e w
e
A. Complete blood count (CBC) we we we
B. Culture and sensitivity (C&S) we we we
C. Renal scan and angiography we we we
D. Radioreceptor assay for HCG w e w e w e
4. The nurse is caring for a patient who has just undergone paracentesis. For which
we we we we we we we we we we we we we
complication willthe nurse carefully monitor? we we we we we
A. Collapse of the lung with shortness of breath we we we we we we we
B. Fecal impaction from retained barium in the colon
we we we we we we we
C. Cerebrospinal fluid leak resulting in severe headache we we we we we we
D. Perforation of the bowel resulting in abdominal infection we we we we we we we
5. The nurse is caring for a patient who reports an urgent need to urinate but is unab
we we we we we we we we we we we we we we we we
le to we
pass more than a few drops of urine in the toilet. Which is the priority assessment to
we we we we we we we we we we we we we we we we we
be
performed by the nurse? we we we
A. Bladder scan to determine the amount of urine in the bladder we we we we we we we we we we
B. Auscultation to assess circulation through the right and left renal arteries we we we w e we we we we we we
, C. Bimanual palpation to assess for possible enlargement of the kidneys w e w e w e w e w e w e w e w e w e
D. Calculate the patient’s intake and output to check for fluid volume deficit we we we we we we we we we we we
6. The nurse is caring for a patient who has urinary retention resulting from benig
we we we we we we we we we we we we we
n
prostatic hyperplasia (BPH). The patient requires catheterization in order to drain t
we we we we we we we we we we we
he
urine from his bladder. Which action will the nurse take to facilitate this procedure?
we we we we we we we we we we we we we
A. Obtain a Coudé catheter for insertion we we we we we
B. Attach a leg bag to the catheter prior to insertion we we we we we we we we we
C. Trim the pubic hair before cleaning the perineal area
we we we we we we we we
D. Wait until the bladder is full to perform catheterization
we we we w
e we we we we
7. The nurse is placing an indwelling catheter in a female patient. The nurse acciden
we we we we we we we we we we we we we
tally inserts it into the vagina. What is the next action for the nurse to implement?
we we we we we we we we we we we we we we we
1. Collect a urine specimen and notify the PCP we we we we we we we
2. Leave the catheter in place and insert a new catheter into the urethra
we we we we we we we we we we we we
3. Remove the catheter from the vagina and place it into the urethrawe we we we we we we we we we we
4. Ask another nurse to attempt the catheterization of the patient
we we we we we we we we we
8. In your assessment of a normal adult, where would you expect to palpate the
we we we we we we we we we we we we we
apical impulse? we
A. Third left intercostal space at the midclavicular line we we we we we we we
B. Fourth left intercostal space at the sternal border we we we we we we we
C. Fifthleftintercostal space atthe midclavicular line we we w
e w
e w
e we w
e
D. Fourth left intercostal space at the anterior axillary line we we we we we we we we
9. You are performing a peripheral vascular assessment on a bedridden patient.
we we we we we we we we we we we
You note the following findings in the right leg: increased warmth, swelling, red
we we we we we we we we we we we we
ness, and tenderness to palpation. You would:
we we we we we we
A. reevaluate the patient in a few hours we we we we we we
B. consider this a normal finding for a bedridden patient we we we we we we we we
C. seek an immediate referral due to the risk of pulmonary embolism we we we we we we we we we we
D. ask the patient to raise his leg off of the bed and check for pain on elevati
we we we we we we we we we we we we we we we we
on
10. On inspection if the apical impulse is more vigorous than expected to the chest
we we we we we we we we we we we we we we
wall, it is called a:
we we we we
A. lift.
B. thrill
C. bruit