VERIFIED ANSWERS (UPDATED TO PASS)
PCA pump Correct answer-what order to have and monitor on pt = continuous pulse ox.
Which assessment is highest priority before administering PCA pump Correct answer-rate and
depth of respiration, reassess pain q 4hrs, at least 16-18rpm
Compartment syndrome s/s of impending organ failure Correct answer-dark, scanty urine
Who can push the PCA button? Correct answer-Only the patient
Multiple Sclerosis (MS) Correct answer-weak, fatigue, incontinence, swallowing difficulties = always
make sure to have suction at bedside with yonker.
Spastic cerebral palsy - will child be able to walk normally? Correct answer-difficult to predict, if
he's able to bear weight, it's a positive sign.
Male client in terminal stage of ca, cared at home with family, takes morphine, pt wakes and asks
nurse for increased in morphine. RR is 10/min, what is nurses best action? Correct answer-increase
morphine - titrate it up. Must provide comfort.
ADHD - what to expect to find with child with this Correct answer-fidgeting, inable to concentrate,
up and around, can't sit still.
EOL - pt in hospice and gurgling on inspiration, what is nursing action with highest priority? Correct
answer-inform family death is imminent.
S/s of ICP with baby? Correct answer-bulging fontanelle, sunset eyes, bradycardia, irritabile, high
pitched cry.
Client with major depression and thinking suicide, what highest NI in plan of care? Correct answer-
check bags to make sure nothing is in them.
nurse to teach pt with ED to alter lifestyle to avoid what? Correct answer-Alcohol
Compartment syndrome - what to see where the cast is? Correct answer-can't perform active
movements, intense throbbing pain, pulses absent distal to fx site.
Amputation pt - stump in first 24hrs Correct answer-we elevate it. Supine, pain meds, take away
elevation. Give meds for phantom pain.
Bacterial meningitis, what as the nurse to do Correct answer-neuro checks every 2-4 hours