NURSING MISC EXAM WITH VERIFIED QUESTIONS AND
ELABORATE SOLUTIONS. 2022/2023-Highly recommended
A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use. After
opening the packet with the new pouch, the patient refuses to accept it. Which action should the
nurse take?
A) Withhold pain medications for 24 hr after the old patch is removed.
B) Ask another nurse to witness the disposal of the new patch.
C) Seal the patches in a plastic bag and place in the client's trash basket.
D) Stick the two patches to each other and place them in the sharps bin.
B) Ask another nurse to witness the disposal of the new patch.
A nurse is caring for a client with a PE. The client is receiving heparin IV at 1,200 units/hr and
warfarin 5 mg PO daily. The morning lab values are aPTT 98 seconds and INR 1.8. Which action
should the nurse take?
A) Prepare to administer vitamin K1.
B) Prepare to administer alteplase.
C) Withhold the heparin infusion.
D) Withhold the next dose of warfarin.
C) Withhold the heparin infusion.
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by
a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the
expected reference range, indicating that the dosage should be reduced or the infusion withheld
until the aPTT returns to the therapeutic range.
A nurse at an urgent care clinic is assessing a patient with impaired vision in 1 eye. Which report
from the patient should indicate to the nurse that the client has a detached retina?
A) Halos around lights
B) Floating dark spots
C) Pain in the affected eye
,D) Cloudy vision
,B) Floating dark spots
A nurse is assessing an infant with hydrocephalus and is 6 hours post-op following placement of
a VP shunt. Which finding should the nurse report to the provider?
A) Heart rate 122/min
B) Irritability when being held
C) Hypoactive bowel sounds
D) Urine specific gravity 1.018
B) Irritability when being held
A nurse is assessing a newborn's HR. Which action should the nurse take?
A) Assess the apical pulse while the newborn is crying to detect cardiac problems.
B) Palpate the radial pulse and determine the rate based on number of beats per minute.
C) Listen to the apical pulse while palpating the radial pulse to detect variance.
D) Auscultate the apical pulse and count beats for at least 1 min.
D) Auscultate the apical pulse and count beats for at least 1 min.
A nurse is caring for a client with a fecal impaction. Which action should the nurse take when
digitally evacuating the stool?
A) Place the client in the lithotomy position.
B) Elicit a vagal response by performing gentle rectal stimulation.
C) Administer oral bisacodyl 30 min prior to the procedure.
D) Insert a lubricated gloved finger and advance along the rectal wall.
D) Insert a lubricated gloved finger and advance along the rectal wall.
, A nurse is providing dietary teaching to a patient taking phenelzine. Which food
recommendations should the nurse make? (Select all)
A) Broccoli
B) Yogurt
C) Pepperoni pizza
D) Cream cheese
E) Bologna sandwich
A) Broccoli
B) Yogurt
D) Cream cheese
A nurse administers an incorrect dose of a med to a client. The nurse recognizes the error
immediately and completes an incident report. Which fact related to the incident should the nurse
document in the client's medical record?
A) Completion of the incident report
B) Time the medication was given
C) Reason for the medication error
D) Notification of the pharmacist
B) Time the medication was given
A nurse on a pediatric unit received report on 4 children. Which child should the nurse assess
first?
A) A 6-month-old infant who has croup and an O2 saturation of 92% on room air
B) A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal
fixation of the left ankle and is requesting pain medication
C) A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel
movements over the past 24 hr
D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden
relief from pain
ELABORATE SOLUTIONS. 2022/2023-Highly recommended
A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use. After
opening the packet with the new pouch, the patient refuses to accept it. Which action should the
nurse take?
A) Withhold pain medications for 24 hr after the old patch is removed.
B) Ask another nurse to witness the disposal of the new patch.
C) Seal the patches in a plastic bag and place in the client's trash basket.
D) Stick the two patches to each other and place them in the sharps bin.
B) Ask another nurse to witness the disposal of the new patch.
A nurse is caring for a client with a PE. The client is receiving heparin IV at 1,200 units/hr and
warfarin 5 mg PO daily. The morning lab values are aPTT 98 seconds and INR 1.8. Which action
should the nurse take?
A) Prepare to administer vitamin K1.
B) Prepare to administer alteplase.
C) Withhold the heparin infusion.
D) Withhold the next dose of warfarin.
C) Withhold the heparin infusion.
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by
a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the
expected reference range, indicating that the dosage should be reduced or the infusion withheld
until the aPTT returns to the therapeutic range.
A nurse at an urgent care clinic is assessing a patient with impaired vision in 1 eye. Which report
from the patient should indicate to the nurse that the client has a detached retina?
A) Halos around lights
B) Floating dark spots
C) Pain in the affected eye
,D) Cloudy vision
,B) Floating dark spots
A nurse is assessing an infant with hydrocephalus and is 6 hours post-op following placement of
a VP shunt. Which finding should the nurse report to the provider?
A) Heart rate 122/min
B) Irritability when being held
C) Hypoactive bowel sounds
D) Urine specific gravity 1.018
B) Irritability when being held
A nurse is assessing a newborn's HR. Which action should the nurse take?
A) Assess the apical pulse while the newborn is crying to detect cardiac problems.
B) Palpate the radial pulse and determine the rate based on number of beats per minute.
C) Listen to the apical pulse while palpating the radial pulse to detect variance.
D) Auscultate the apical pulse and count beats for at least 1 min.
D) Auscultate the apical pulse and count beats for at least 1 min.
A nurse is caring for a client with a fecal impaction. Which action should the nurse take when
digitally evacuating the stool?
A) Place the client in the lithotomy position.
B) Elicit a vagal response by performing gentle rectal stimulation.
C) Administer oral bisacodyl 30 min prior to the procedure.
D) Insert a lubricated gloved finger and advance along the rectal wall.
D) Insert a lubricated gloved finger and advance along the rectal wall.
, A nurse is providing dietary teaching to a patient taking phenelzine. Which food
recommendations should the nurse make? (Select all)
A) Broccoli
B) Yogurt
C) Pepperoni pizza
D) Cream cheese
E) Bologna sandwich
A) Broccoli
B) Yogurt
D) Cream cheese
A nurse administers an incorrect dose of a med to a client. The nurse recognizes the error
immediately and completes an incident report. Which fact related to the incident should the nurse
document in the client's medical record?
A) Completion of the incident report
B) Time the medication was given
C) Reason for the medication error
D) Notification of the pharmacist
B) Time the medication was given
A nurse on a pediatric unit received report on 4 children. Which child should the nurse assess
first?
A) A 6-month-old infant who has croup and an O2 saturation of 92% on room air
B) A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal
fixation of the left ankle and is requesting pain medication
C) A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel
movements over the past 24 hr
D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden
relief from pain
