ANSWERS
Patient is administered penicillin, and experiencing anaphylaxis. Which of the following
manifestations should the nurse expect?
- Pruritus
(Difficulty breathing, including wheezing or shortness of breath
Swelling of the face, lips, tongue, or throat
Hives or rash
Rapid or weak pulse
Low blood pressure
Nausea, vomiting, or diarrhea
Anxiety, confusion, or a sense of impending doom)
Patient has a new placement of colostomy, which of the following indicate that the colostomy is
functioning properly?
Red beefy after surgery, moist,shiny
The nurse sees that patient urine is red-orange color. Which of the following medications can
cause this issue
Rifampin
Patient is post-op and has DVT, nurse should?
Maintain pt on bed rest
The nurse noted a foul-smelling infectious wound. What would be an appropriate action?
Put patient in a private room with a private bathroom (contact precaution)
Patient has terminal cancer, what would be an appropriate action by the nurse on pain control?
nurse should administer analgesia around the clock for pain control
, Manifestation of opioid toxicity?
Hypotension
Patient is having dumping syndrome, what should the nurse include in teaching?
Eliminate simple sugar
Identify risk factors for osteoporosis?
Smoking cigarette
The nurse is attending a meeting for health promotion, which of the following
recommendations should be included?
Women patient should perform breast self examination (BSE) a week AFTER period
Pt is 24 hr post-op following a total hip arthroplasty, which of the following actions the
nurse should include in the care plan?
"Performing range of motion by adducting"
Pt has pulmonary embolism (PE) and is experiencing dspnea. Which of the following actions
would be the highest priority the nurse should perform first?
Put pt in high Fowler position
Pt is experiencing aspirate pneumonia and active hypoxia. Which of the following actions should
the nurse include in the pt care plan?
Initiate fall precaution
Pt received penicillin 30 mins ago, and began to develop hives and itching. Which of the
following is the nurse's highest priority question?
"Are you having any difficulty breathing?"
Pt has osteoarthritis, and states having knee stiffness upon ambulation, what should the nurse
include in the care plan?
Apply moist heat prior to ambulation
Reinforcing teaching for pt has just returned home following a total hip arthroplasty, what
should the nurse include in teaching?
electrical cords against the wall