Practice Questions + Answers Nursing
Students NZ
A 58-year-old adult client presents to ED with a nosebleed. After applying pressure, what is the
next nursing action?
1.Collect a medical history
2.Check BP
3.Instruct not to pick nose
4.Check HR - ANS-2. Check BP
Nosebleeds can be indicative of high BP in an adult. Of the choices provided, the 1st action of
the nurse should be to check the client's BP. If elevated, the nurse can initiate measures to
decrease the BP. The other options are appropriate but not the highest priority. A medication
history (1) is critical to determine if the client is on any anticoagulation therapy. After assessment
and care, client teaching might include instruction not to pick nose (3). After the bP is measured,
checking the pulse rate (4) would be performed as part of the general vital signs assessment.
\A 62 year old Male client is being discharged home from the hospital. During his stay, he
acquired a nosocomial infection Clostridium difficile. In preparing a teaching plan for the client
and caretaker, which priority point would the nurse include?
1.Report any constipation to your physician immediately.
2. This infection causes diarrhea accompanied by flatus and abdominal discomfort
3.The client should consume a diet high in fiber and low in fat
4. no special cleaning or disinfection will be required in the home. - ANS-2. The infection causes
diarrhea accompanied by flatus and abdominal discomfort
The main clinical manifestation of Clostridium difficile is diarrhea accompanied by excessive
flatus and abdominal discomfort. Constipation (1) is not associated with this infectious disease.
Clients should follow a nutritionally balanced diet high in fiber and low in fats (3) with no specific
restrictions. Cleaning and disinfection of items in the home (4) is key to preventing spread of the
infection because the C. difficile spore is relatively resistant.
\A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which
type of room should this client be assigned by the nurse?
1. Private room
2. Semiprivate room
3. Room with windows that can be opened
4. Negative airflow room - ANS-Tuberculosis is an airborne contagious disease that is best
contained in a negative airflow room. Negative airflow rooms are always private. A private room
(1), Semipriavte room (2), and a room with windows that can be opened (3) are not appropriate
, for the standard of care for a client diagnosed with TB. Additionally, opening windows would
present a possible safety hazard in a client's room.
\A client is determined to be having an impending anaphylactic reaction secondary to a drug
hypersensitivity. What should be the first action for the nurse to perform?
1. Administer Oxygen
2.Insert an IV catheter
3.Take vital signs.
4.Obtain an arterial blood gas analysis - ANS-1. Administer Oxygen
This should be the first action of the nurse for this client. With anaphylaxis there is bronchial
constriction and subsequent vascular collapse, therefore the airway is of primary concern. the
vital signs should be checked (3) after beginning the administration of oxygen. At this point it
would be appropriate to insert an IV catheter (2) to administer emergency medications and
possibly obtain an arterial blood gas analysis (4) to determine oxygenation status.
\A client is ordered to receive morphine via patient-controlled analgesia (PCA). Before beginning
administration of this medication, what should the nurse assess first?
1.Temperature
2.Neurological status
3. Respiration
4.Urinary ouput - ANS-3. Respiration
The nurse must be especially alert to any changed in respirations, because morphine decreases
the respiratory center function in the brain. An order for morphine should be questioned if the
baseline respiration are less than 12 per min. Neurological status (2) along with pulse and BP
would be a priority assessment after respiratory rate. Measurements of temperature (1) and
urinary output (4) are part of the overall client assessment but not a priority with morphine.
\A client is receiving a unit of packed red blood cells (PRBC). The client experiences tingling in
the fingers and headache. What is the nurses's priority action?
1. Call the physician
2.Stop the transfusion
3.Slow the transfusion
4. Assess the IV site for infiltration - ANS-2. Stop the transfusion
Tingling in the fingers and headache may be an indication of an adverse reaction to the
transfusion. The nurse's priority action is to stop the transfusion and begin a normal saline
infusion at KVO (keep vein open). The client should be assessed-including vital signs - then the
physician should be notified. The physician should be called (1) after assessment of the patient
and implementation of immediate action to stop the transfusion. Slowing the infusion rate (3) is
not appropriate if the patient is experiencing a reaction or suspected of having an reaction.
Assessment of the IV site (4) is part of the general patient assessment and is not related to a
blood transfusion reaction
Students NZ
A 58-year-old adult client presents to ED with a nosebleed. After applying pressure, what is the
next nursing action?
1.Collect a medical history
2.Check BP
3.Instruct not to pick nose
4.Check HR - ANS-2. Check BP
Nosebleeds can be indicative of high BP in an adult. Of the choices provided, the 1st action of
the nurse should be to check the client's BP. If elevated, the nurse can initiate measures to
decrease the BP. The other options are appropriate but not the highest priority. A medication
history (1) is critical to determine if the client is on any anticoagulation therapy. After assessment
and care, client teaching might include instruction not to pick nose (3). After the bP is measured,
checking the pulse rate (4) would be performed as part of the general vital signs assessment.
\A 62 year old Male client is being discharged home from the hospital. During his stay, he
acquired a nosocomial infection Clostridium difficile. In preparing a teaching plan for the client
and caretaker, which priority point would the nurse include?
1.Report any constipation to your physician immediately.
2. This infection causes diarrhea accompanied by flatus and abdominal discomfort
3.The client should consume a diet high in fiber and low in fat
4. no special cleaning or disinfection will be required in the home. - ANS-2. The infection causes
diarrhea accompanied by flatus and abdominal discomfort
The main clinical manifestation of Clostridium difficile is diarrhea accompanied by excessive
flatus and abdominal discomfort. Constipation (1) is not associated with this infectious disease.
Clients should follow a nutritionally balanced diet high in fiber and low in fats (3) with no specific
restrictions. Cleaning and disinfection of items in the home (4) is key to preventing spread of the
infection because the C. difficile spore is relatively resistant.
\A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which
type of room should this client be assigned by the nurse?
1. Private room
2. Semiprivate room
3. Room with windows that can be opened
4. Negative airflow room - ANS-Tuberculosis is an airborne contagious disease that is best
contained in a negative airflow room. Negative airflow rooms are always private. A private room
(1), Semipriavte room (2), and a room with windows that can be opened (3) are not appropriate
, for the standard of care for a client diagnosed with TB. Additionally, opening windows would
present a possible safety hazard in a client's room.
\A client is determined to be having an impending anaphylactic reaction secondary to a drug
hypersensitivity. What should be the first action for the nurse to perform?
1. Administer Oxygen
2.Insert an IV catheter
3.Take vital signs.
4.Obtain an arterial blood gas analysis - ANS-1. Administer Oxygen
This should be the first action of the nurse for this client. With anaphylaxis there is bronchial
constriction and subsequent vascular collapse, therefore the airway is of primary concern. the
vital signs should be checked (3) after beginning the administration of oxygen. At this point it
would be appropriate to insert an IV catheter (2) to administer emergency medications and
possibly obtain an arterial blood gas analysis (4) to determine oxygenation status.
\A client is ordered to receive morphine via patient-controlled analgesia (PCA). Before beginning
administration of this medication, what should the nurse assess first?
1.Temperature
2.Neurological status
3. Respiration
4.Urinary ouput - ANS-3. Respiration
The nurse must be especially alert to any changed in respirations, because morphine decreases
the respiratory center function in the brain. An order for morphine should be questioned if the
baseline respiration are less than 12 per min. Neurological status (2) along with pulse and BP
would be a priority assessment after respiratory rate. Measurements of temperature (1) and
urinary output (4) are part of the overall client assessment but not a priority with morphine.
\A client is receiving a unit of packed red blood cells (PRBC). The client experiences tingling in
the fingers and headache. What is the nurses's priority action?
1. Call the physician
2.Stop the transfusion
3.Slow the transfusion
4. Assess the IV site for infiltration - ANS-2. Stop the transfusion
Tingling in the fingers and headache may be an indication of an adverse reaction to the
transfusion. The nurse's priority action is to stop the transfusion and begin a normal saline
infusion at KVO (keep vein open). The client should be assessed-including vital signs - then the
physician should be notified. The physician should be called (1) after assessment of the patient
and implementation of immediate action to stop the transfusion. Slowing the infusion rate (3) is
not appropriate if the patient is experiencing a reaction or suspected of having an reaction.
Assessment of the IV site (4) is part of the general patient assessment and is not related to a
blood transfusion reaction
