1. A patient informs the nurse that they are taking an OTC garlic supplement. What possible effect does garlic have
on the body?
Effects blood clotting increases risk of bleeding
2. A patient has a complete spinal cord injury at the third cervical vertebra. At what level would you expect the
patient to respond to light sensation?
DIAGRAM OF BODY with boxes that you must select to indicate the level. Top box only.
3. After placement of a permanent pacemaker what which would you report as a complication of placement?
Hiccups (Pg. 325
4.
5. Ph of 7.30 paCO2 49 others WNL– what are they in?
Respiratory acidosis
6. Left sided weakness while using a cane – what is indicative of needing further teaching?
Puts cane on weak side (cane should be on stronger side)
7. What causes intrarenal failure?
, acute glomerulonephritis, NSAIDS, blood transfusion
reaction Pg 675
8. Signs of Peripheral vascular complication?
Ulcer formations, Pulmonary embolism Pg. 404
9. A patient returns to the clinic 72 hours after receiving a subcutaneous dose of purified protein derivative (PPD)
to test for tuberculosis exposure. The nurse inspects the injection site on the patient’s forearm and finds an
induration measuring 12 mm. The nurse informs the client that
“Your skin test was positive for TB exposure, we need to perform an acid-fast bacillus test and a chest X-
10. What to do after a hemolytic reaction to a blood transfusion?
Stop the infusion, change the tubing and give NS
11. How do you insert a PICC?
Flat on back (Review Pg. 303)
Trendelenburg position (head below feet
12. , which of the following would you do following removal?
Measure the length of the external portion of the catheter
13. Removing a peripheral IV catheter- make sure the tip is intact
1|Page
, 14. Patient has INR of 1.5 prior to surgery. What are you going to
do? Answer: Prep the patient for surgery
15. Following the surgical placement of a new ileostomy, which of the following would you teach
them?
Answer: chew food well
Rationale: Patients with a new ostomy involving the small intestine (i.e. an ileostomy) are told
post-op to avoid foods that increase flatus (green leafy vegetables, beer, carbonated
beverages, dairy, and corn); avoid high-fiber foods for first 2 months; CHEW FOOD WELL;
increase fluid intake; and evaluate evidence of blockage.
16. A patient is on isolation due to C difficile infection; which of the following represents correct
infection protection protocol?
Answer: Collect fecal sample with gloves
17. A patient ____(has either a list of symptoms or a new prescription for anti-coagulant)________
during medical history they report they have been TAKING IBUPROFEN FOR 3 YEARS . What
lab would you expect to be drawn?
Answer: Fecal Testing/Stool Guaiac/ Fecal Occult Blood Test (FOBT)
18. A patient has been on total parenteral nutrition for 10 full days, which of the following would
be an indication that the nutrition therapy is effective?
Answer: Potassium 4.0 (Pg.524)
19. Which of the following clients is MOST at risk for developing atelectasis?
Answer: Post anesthesia for bowel resection
o Rationale: This patient was the only patient who had abdominal surgery; patients with
abdominal surgery are at the HIGHEST risk for atelectasis because the pain from
incision/surgical procedure causes them to reflexively breathe in a shallow, cautious
way. Positioning (guarding) also causes decreased in lung expansion.
20. The nurse is preparing a patient for paracentesis procedure, which of the following
instructions would be given to the patient to decrease the risk of perforation?
Answer: Instruct patient to empty their bladder prior to the procedure, this is done in order to
decrease the size of a
bladder and it reduces the chance of accidental bladder
perforation.Pg 527
21. The nurse is providing home care for a patient receiving peritoneal dialysis, the patient has a
fever of 102, and the catheter has decreased dialysate outflow. Which of the following should
the nurse perform first?
Answer: Reposition the patient
o Rationale: Nursing Actions regarding reduced or inadequate outflow include:
repositioning the client (b/c this moves the distal lumen of the catheter which
may become pressed up against the abdominal wall = obstruction); milk the
tubing if a visible clot is present in the catheter; check the tubing for kinks or
closed clamps, determine when the patient’s last bowel movement was
(constipation can also cause low outflow, pts on peritoneal dialysis are
instructed to use a stool softener daily and consume a high-fiber diet).
2|Page
on the body?
Effects blood clotting increases risk of bleeding
2. A patient has a complete spinal cord injury at the third cervical vertebra. At what level would you expect the
patient to respond to light sensation?
DIAGRAM OF BODY with boxes that you must select to indicate the level. Top box only.
3. After placement of a permanent pacemaker what which would you report as a complication of placement?
Hiccups (Pg. 325
4.
5. Ph of 7.30 paCO2 49 others WNL– what are they in?
Respiratory acidosis
6. Left sided weakness while using a cane – what is indicative of needing further teaching?
Puts cane on weak side (cane should be on stronger side)
7. What causes intrarenal failure?
, acute glomerulonephritis, NSAIDS, blood transfusion
reaction Pg 675
8. Signs of Peripheral vascular complication?
Ulcer formations, Pulmonary embolism Pg. 404
9. A patient returns to the clinic 72 hours after receiving a subcutaneous dose of purified protein derivative (PPD)
to test for tuberculosis exposure. The nurse inspects the injection site on the patient’s forearm and finds an
induration measuring 12 mm. The nurse informs the client that
“Your skin test was positive for TB exposure, we need to perform an acid-fast bacillus test and a chest X-
10. What to do after a hemolytic reaction to a blood transfusion?
Stop the infusion, change the tubing and give NS
11. How do you insert a PICC?
Flat on back (Review Pg. 303)
Trendelenburg position (head below feet
12. , which of the following would you do following removal?
Measure the length of the external portion of the catheter
13. Removing a peripheral IV catheter- make sure the tip is intact
1|Page
, 14. Patient has INR of 1.5 prior to surgery. What are you going to
do? Answer: Prep the patient for surgery
15. Following the surgical placement of a new ileostomy, which of the following would you teach
them?
Answer: chew food well
Rationale: Patients with a new ostomy involving the small intestine (i.e. an ileostomy) are told
post-op to avoid foods that increase flatus (green leafy vegetables, beer, carbonated
beverages, dairy, and corn); avoid high-fiber foods for first 2 months; CHEW FOOD WELL;
increase fluid intake; and evaluate evidence of blockage.
16. A patient is on isolation due to C difficile infection; which of the following represents correct
infection protection protocol?
Answer: Collect fecal sample with gloves
17. A patient ____(has either a list of symptoms or a new prescription for anti-coagulant)________
during medical history they report they have been TAKING IBUPROFEN FOR 3 YEARS . What
lab would you expect to be drawn?
Answer: Fecal Testing/Stool Guaiac/ Fecal Occult Blood Test (FOBT)
18. A patient has been on total parenteral nutrition for 10 full days, which of the following would
be an indication that the nutrition therapy is effective?
Answer: Potassium 4.0 (Pg.524)
19. Which of the following clients is MOST at risk for developing atelectasis?
Answer: Post anesthesia for bowel resection
o Rationale: This patient was the only patient who had abdominal surgery; patients with
abdominal surgery are at the HIGHEST risk for atelectasis because the pain from
incision/surgical procedure causes them to reflexively breathe in a shallow, cautious
way. Positioning (guarding) also causes decreased in lung expansion.
20. The nurse is preparing a patient for paracentesis procedure, which of the following
instructions would be given to the patient to decrease the risk of perforation?
Answer: Instruct patient to empty their bladder prior to the procedure, this is done in order to
decrease the size of a
bladder and it reduces the chance of accidental bladder
perforation.Pg 527
21. The nurse is providing home care for a patient receiving peritoneal dialysis, the patient has a
fever of 102, and the catheter has decreased dialysate outflow. Which of the following should
the nurse perform first?
Answer: Reposition the patient
o Rationale: Nursing Actions regarding reduced or inadequate outflow include:
repositioning the client (b/c this moves the distal lumen of the catheter which
may become pressed up against the abdominal wall = obstruction); milk the
tubing if a visible clot is present in the catheter; check the tubing for kinks or
closed clamps, determine when the patient’s last bowel movement was
(constipation can also cause low outflow, pts on peritoneal dialysis are
instructed to use a stool softener daily and consume a high-fiber diet).
2|Page
