AND ANSWERS 2025
Nurse is caring for patient who had total knee replacement
yesterday. Patient up in chair stating he feels good. Pain is 3/10.
Resp. 16, pulse is 75, bp is 110/78. Pulse ox 88 reading is after
incentive spirometer. What actions would you take at this time?
Move pulse ox to another finger on the other hand and recheck.
Nurse admits patient to med surg unit. Resp rate of 38. Patient
using chest muscles to breathe, pulse ox of 87 on room air, pink
frothy sputum. What intervention would you implement first?
O2 at 2 Liters/Min
Caring for pt. who is intubated and receiving mechanical
ventilation. What action by the nurse would decrease the patient's
incidence of developing ventilator associated pneumonia?
Put head of bed at 30-45 degrees.
The nurse is administering acetylcysteine (muca-mist) as nebulizer
treatment to patient. Which should the nurse have available for
adverse effect on the patient?
Suction equipment
, Patient coming in with SOB and resp. rate of 32. ABG results PH 7.3
(acid), Co2-50 Bicarb-28, PO2-70
Resp. Acidosis, what orders do you anticipate carrying out?
Apply O2 and give med-neb treatment.
You have 4 patients in a long term care facility. Which would you
check first?
COPD patient with resp rate of 30, O2 of 87 and on 3 Liters of O2
complaining of dyspnea.
Caring for newly intubated patient getting mechanical ventilation.
Pt.'s wife was not at hosp. when this occurred. Wife appears angry
and states "What have you all done to him?" What would be your
response as a nurse?
Explain to the patient why the patient had to be intubated, continue to
update patient's wife on condition and plan of care, I'm sorry that you
walked in on him like that, I understand this must have been very
frightening.
Patient has SOB, edema in legs and face and has the following labs:
BUN-95 (high), Creatinine of 9.2, Potassium of 6.0 (high). What are
you going to do
Give Kexolate, prepare the patient a central line for dialysis. Cardiac
monitoring.
Working with a UAP, what task can be delegated?