COMPLETE QUESTIONS AND SOLUTIONS
◉ Your post-op patient has a Jackson-Pratt (JP) drain in place. How
do you ensure effective drain function? Answer: Compress the drain,
then plug the bulb to establish suction
◉ Your male patient complains of discomfort while inflating the
balloon during insertion of an indwelling urinary catheter. What
would be the MOST appropriate action? Answer: Deflate the balloon,
advance the catheter further, then reinflate the balloon
◉ Your patient has symptomatic anemia but is refusing a blood
transfusion for religious reason. What is an appropriate response?
Answer: Respect his wishes and notify the provider
◉ Your patient is admitted with diverticulitis. What type of diet do
you expect to be ordered for the patient? Answer: broth, jello, soft
fruit no skin,
◉ You were hired to work the medical unit and when you arrive at
work the charge nurse has assigned you to the post-surgical unit
since they are understaffed. Which is the MOST appropriate action?
Answer: Report to the post-surgical unit.
,◉ What is a proton pump inhibitor, such as pantoprazole (Protonix)
used for? Answer: Acid Reduction
◉ Which adaptive equipment would be MOST appropriate to use for
a severely contracted patient who is unable to bear weight when
transferring from the bed to the chair? Answer: Patient lift (e.g.,
Hoyer)
◉ Which tool should you use to assess pain in you 80-year-old
patient with severe dementia? Answer: PAINAD scale
◉ Your patient is admitted from the ED with failure to thrive and
advanced dementia. You note he is extremely underweight, appears
unbathed for some time, and has a stage 4 pressure injury to his
coccyx. You were told in report that he lives at home with family
members. What should you do? Answer: Notify the charge nurse and
social worker of your concerns.
◉ Your 85-year-old patient with atrial fibrillation fell at home 3 days
ago. You notice she has been having several episodes of acute
confusion since being admitted to your unit. What is the MOST
important order you should anticipate from the provider? Answer:
Stat CT of head
, ◉ Your patient has a temp of 102.3 F, HR 122, and has had 15 mL of
urine from the indwelling urinary catheter in the last 2 hours. What
is your patient MOST likely experiencing. Answer: Sepsis
◉ What type of personal protective equipment (PPE) is applied
prior to entering a room for a patient with C. diff? Answer: Gown
and gloves
◉ Your patient continues to pull at their IV site located in their left
forearm despite verbal reminders and increased observation. The
nursing assistant recommends using soft mitt restraints on the
patient. What is your recommendation? Answer: Request an order
for soft mitts as they are the least restrictive
◉ Your patient was admitted for a hypertensive crisis and has a
history of HTN, Parkinson's disease, depression, and alcohol use. On
his second hospitalized day, you notice he is more anxious and
restless than his baseline. What would be your FIRST nursing
intervention? Answer: Ask the patient when his last drink of alcohol
was.
◉ What is the BEST indication of an acute neurological problem?
Answer: Change in level of consciousness
◉ While in a supine position your patient states, "I'm tired and
cannot catch my breath." Physical assessment reveals jugular vein