EXAM GRADED A+ 2025
What is required before making a report of elder abuse? - Answer- Suspicion of abuse
You receive your patient with pneumonia from the ED. Antibiotics and steroids have been
initiated by the provider. The patient reports abdominal pain and has a large loose bowel
movement. They inform you this is their third bowel movement in the last two hours. What
would you do FIRST? - Answer- Initiate enteric contact isolation precautions for possible C.
diff
Your patient has developed sepsis from an indwelling urinary catheter. What would be your
PRIORITY intervention? - Answer- Remove catheter.
Your patient is in third degree heart block. What treatment would you MOST likely expect to
be implemented? - Answer- Pacemaker
What are 2 nursing interventions to prevent venous thromboembolism? - Answer- •
Adequate hydration and early mobilization.
• Hemodynamic monitoring and early mobilization. (Wrong)
• Adequate hydration and encouraging a steady amount of green leafy vegetables in diet.
• Hemodynamic monitoring and encouraging a steady amount of green leafy vegetables in
diet.
Your patient is post left pneumonectomy. They have a chest tube in place for drainage. What
would be a PRIORITY in your care? - Answer- Encourage patient to cough and deep breathe
What is the reversal agent for benzodiazepines? - Answer- Flumazenil (Romazicon)
,Your patient is on a patient-controlled analgesia (PCA) pump infusing morphine. They are not
getting relief. What would be your FIRST intervention? - Answer- Obtain order from provider
for an additional dose.
Which finding would assist in the diagnosis of deep vein thrombosis? - Answer- Positive D-
dimer
What is the MOST common symptom of syndrome of inappropriate antidiuretic hormone
secretion (SIADH)? - Answer- Fluid retention
Your patient has nephrotoxicity. At discharge what education would be MOST important for
you to provide? - Answer- • Establish an exercise routine.
• Implement smoking cessation.
• Review your medications with the primary care provider.
• Create a meal plan to maintain kidney health. (Wrong)
Which patient would you ask about the language they would prefer to use for
communication purposes? - Answer- A patient who is newly admitted
Upon arrival to the ED a patient's lab results indicate a BNP of 2000. They are transferred to
the PCU.
What treatment plan would you expect from the attending provider? - Answer- Furosemide
(Lasix®) 40 mg IV BID
Your patient reports chest pain. Which lab orders would you anticipate the provider
ordering? - Answer- Troponin
A patient presents with blood pressure of 90/60, creatinine of 3.0, and decreased urinary
output. What is a possible cause for these findings? - Answer- Acute kidney injury
, You want to help your patient wean from the BiPap. You are collaborating with the
healthcare team.
What is a sign that your patient is fatiguing and you would communicate to the respiratory
therapy team? - Answer- Increased PaCO2
What is an effective nursing intervention for reducing central line-associated bloodstream
infections (CLABSIs)? - Answer- Perform a daily assessment of line necessity.
You are administering 1 unit of packed red blood cells (PRBC) to your patient. They develop
shortness of breath, tachycardia, and distended jugular veins in the first 15 minutes of PRBC
administration. What type of transfusion reaction are they likely experiencing? - Answer- •
Transfusion related hemolytic reaction (Wrong)
• Septic transfusion reaction
• Transfusion related fluid overload
• Anaphylaxis
When should the trough for vancomycin (Firvanq®) be measured? - Answer- Immediately
before the next scheduled dose
What are PRIMARY goals in diabetic ketoacidosis therapy? - Answer- Correct fluid deficit and
replace potassium.
Your patient is receiving an amiodarone (Pacerone®) drip. When would you reduce the dose
from 1 mg/mL to 0.5 mg/mL? - Answer- After 6 hours
You walk into your patient's room. You notice that the chest tube collection chamber has
been knocked over onto its side. There appears to be drainage dispersed throughout the
chambers. What would you do NEXT? - Answer- Replace chamber with a new one.