A patient with a 3-day history of a stroke that left her confused and unable to communicate
returns from interventional radiology following placement of a gastronomy tube. The patient
has been taking Hydrocodone/ APAP 5/325 up to four tablets/day before her stroke for arthritic
pain. The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1 tab, per
gastronomy tube, q4h, prn." Which action by the nurse is most appropriate? Request to
have the order changed to around the clock (ATC) for the first 48 hours.
A patient who has been hospitalized after experiencing a heart attack will most likely receive a
diet consisting of:
A. Low fat, low sodium, and low carbohydrates
B. Low fat, low sodium, and high carbohydrates
C. Low fat, high protein, and high carbohydrates
D. Liquids for several days, progressing to a soft and then a regular diet A
Because an older adult is at increased risk for respiratory complications after surgery, the nurse
needs to:
A. Withhold pain medications and ambulate the patient every 2 hours
B. Monitor fluid and electrolyte status every shift and vital signs with temperature every 4
hours
C. Orient the patient to the surrounding environment frequently and ambulate him or her every
2 hours
D. Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate
pain control D
Obesity places patients at an increased surgical risk because of which of the following factors?
(Select all that apply)
A. Risk for bleeding is increased
B. Ventilatory capacity is reduced.
C. fatty tissue has a poor blood supply.
D. metabolic demands are increased. B,C
,When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and
mild confusion, one of the first assessments includes which of the following?
The amount of family support
A 3-day diet recall
A thorough physical assessment
Threats to safety in her home C
The nurse is gathering a sexual health history on a patient being admitted to the hospital for
surgery. Which question asked by the nurse demonstrates a nonjudgmental attitude?
A. Can you tell me your sexual orientation?
B. How do you and your wife feel about intimacy?
C. Do you have sex with men, women, or both?
D. Do you have sexual intercourse at your age? A
Which represents the correct order of the stages from Kübler-Ross' Stages of Dying Theory ?
19. A) Anger B) Acceptance C) Denial D) Bargaining E) Depression
A. C, D, E, A, B
B. C, B, E, A, D
C. A, B, E, C, D
D. C, A, D, E, B D
The nurse is caring for a patient with glaucoma. When developing a discharge plan, which
priority intervention enables the patient to function safely with existing deficits and continue a
normal lifestyle?
A. Encourage the patient to rearrange her home furnishings regularly to keep active.
B. Suggest to the patient that he or she consider either moving to a smaller home or long-term
facility.
,C. Say nothing because it is most appropriate that the patient identify personal interventions to
compensate for a sensory alteration.
D. Work closely with the patient and family to identify in-home modifications to create a
comfortable and accessible environment. D
In the post-anesthesia care unit (PACU) a nurse notes that a patient is having difficulty
breathing and suspects an upper-airway obstruction. The nurse's priority intervention at this
time is:
A. Suction the pharynx and bronchial tree.
B. Give oxygen through a mask at 4 L/min.
C. Ask the patient to use an incentive spirometer.
D. Position the patient one on one side with the face down and the neck slightly extended so
that the tongue falls forward. D
A patient was admitted following a motor vehicle accident with multiple fractured ribs.
Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the
most common assessment findings associated with a pneumothorax? Select all that apply.
A. Sharp pleuritic pain that worsens on inspiration
B. Crackles over lung bases of affected lung
C. Tracheal deviation toward the affected lung
D. Worsening dyspnea
E. Absent lung sounds to auscultation on affected side A,D,E
A nurse understands that during her shifts at the hospital she will have patients who are from
different cultures that hold different cultural beliefs than her. She decides that before she
begins her rotations, she will need to examine her own cultural background and recognize any
biases she may have towards other people from different cultures. What is the nurse
specifically doing in this situation?
A. Giving culturally congruent care
B. Being culturally aware of her situation
C. Providing the patient with culturally competent care
, D. Encountering a patient with a different cultural background B
What is the best method of communicating with a patient who is experiencing expressive
aphasia?
A. asking open-ended questions
B. speaking to the patient as in easy-to-understand language
C. using written communication using a pen and paper or a dry erase board.
D. avoiding the use of non-verbal communication including gestures. C
What organization was developed in 2000 by the Office of Minority Health? These standards
are intended to advance health equity, improve quality, and help eliminate health care
disparities by establishing a blueprint to help individuals and health care organizations
implement culturally and linguistically appropriate services.
A. Alliance of Young Nurse Leaders and Advocates
B. Culturally and Linguistically Appropriate Services (CLAS)
C. Centers for Medicare and Medicaid Services
D. The National Commission on Quality Assurance B
Nursing Standards of care are set out in every state by...
A. HITEC
B. HIPPA
C. Nurse Practice Acts
D. Good Samaritan Laws C
A nurse understands that during her shifts at the hospital she will have patients who are from
different cultural backgrounds who also hold different cultural beliefs than her. She decides
that before she begins her rotations, she will need to examine her own cultural background and
recognize any biases she may have towards other people from different cultures. What is the
nurse specifically doing in this situation?
A. Giving culturally congruent care