100% CORRECT WELL DETAILED
A NURSE IS PROVIDING D/C INSTRUCTIONS TO A PT WHO HAS TB AND IS BEGINNING TX W/
MULTIDRUG THERAPY. WHICH OF THE FOLLOWING PT STATEMENTS INDS AN
UNDERSTANDING OF THE TEACHING? - ANSWER -3 consecutive negative sputum tests
will ind that the pt is no longer contagious. BUT Mantoux test will always be +.
-pts who have taken meds to tx TB for 2-3 consecutive weeks are no longer contagious. BUT,
pts will need to continue med therapy for at least 6mos.
-meds for TB can damage liver. avoid consuming alc.
-reg follow-up visits needed w/ TB.
A NURSE IS CARING FOR A PT WHO HAS A CLOSED-HEAD INJ AND IS ON SEIZURE
PRECAUTIONS. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE? -
ANSWER -no padded tongue blade (risk of asp and damage to teeth).
-no side rails raised
-set up suction equipment at bedside.
A NURSE IS DISCUSSING SECURITY MEASURES W/ A PT FOLLOWING DELIV OF AN INFANT.
WHICH OF THE FOLLOWING STATEMENTS SHOULD THE NURSE MAKE? - ANSWER -if pt
or other responsible party must leave the room for any reason, the newborn should be
transported to the newborn nursery.
-security sensor isn't removed until d/c from facility.
-2 plastic ID bracelets needed - one on arm and one on leg. ID #, name, date, time of birth,
and sex are included. replace immediately if off or missing.
-ask for hospital ID prior to allowing anyone to transport their newborn (don't go by colored
scrubs).
1
,A NURSE IS CONDUCTING A PRENATAL CLASS ABT CAR SEAT SAFETY. WHICH OF THE
FOLLOWING STATEMENTS BY A PT INDICATES AN UNDERSTANDING OF TEACHING? -
ANSWER -infants should remain in the rear-facing position until they're at least 2yrs
old to ensure safety.
-secure the retainer clip at lvl of baby's armpits.
-car seat at 45 deg angle.
-extra blankets or padding should not be added to car seat (could create extra air btwn
infant and seat = inj during MVC).
A NURSE IS PERFORMING TRIAGE FOLLOWING A MASS CASUALTY EVENT. WHICH OF THE
FOLLOWING PTS SHOULD THE NURSE REC BE TRANSPORTED FIRST TO A HCF? -
ANSWER -a middle adult pt who has a sucking chest wound
-a child whose thigh is impaled w/ glass and has 2+ pedal pulses has good peripheral circ
and, therefore, can wait.
-ad paralyzed from waist down - low SCI, not an immediate threat and can wait.
-OA w/ agonal breathing - near end of life. not transported first r/t min chance of survival.
A HHN IS PLANNING CARE FOR AN OA PT WHO HAS IMPAIRED VISION. WHICH
INTERVENTIONS SHOULD THE NURSE INCLUDE IN THE PLAN TO PREVENT INJ IN THE HOME?
- ANSWER -secure any area rugs w/ a non-slip pad or adhesive strips to secure to the
floor to prevent sliding.
-extension cords are removed from high-traffic areas in the home and placed along the
edges of walls.
-have adequate lighting - use of light fixtures that use bulbs >40 watts to optimize visibility.
-mark edges of stairs w/ paint or colored tape for contrast.
A NURSE IS DELEGATING MEASUREMENT AND DOC OF A PT'S CAPILLARY BLOOD GLUCOSE
LVL BEFORE LUNCH TO A LPN. WHICH ACTIONS SHOULD THE NURSE TAKE TO EVAL THE
COMPLETION OF THIS TASK? - ANSWER -ensure that the glucose lvl appears in the pt's
med record - task completion!!
2
,A NURSE IS PLANNING CARE FOR A GRP OF PTS. IDENTIFY THAT WHICH OF THE FOLLOWING
TASKS IS OUTSIDE AN RN'S SCOPE OF PRACTICE? - ANSWER -inserting a non tunneled
percutaneous central venous catheter.
A NURSE IS CARING FOR A PT WHO IS HIV+ AND HAS PNEUMONIA. A FAM MEMBER ASKS
THE NURSE, "WHAT IS CAUSING MY SISTER'S PNEUMONIA?" WHICH OF THE FOLLOWING
RESPONSES SHOULD THE NURSE MAKE? - ANSWER -"your sister must give permission
for me to discuss her condition w/ you."
A NURSE MANAGER IS PREPPING A STAFF ED PROGRAM ABT CONFIDENTIALITY. WHICH OF
THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE FIRST? - ANSWER -determine the
staff's current knowledge of confidentiality requirements.
A NURSE IS CARING FOR A NEWBORN WHOSE GUARDIAN HAS REFUSED THE ROUTINE
ADMIN OF ERYTHROMYCIN OINTMENT TO THE NEWBORN'S EYES. WHICH ACTIONS SHOULD
THE NURSE TAKE? - ANSWER -have the guardian sign the facility's refusal form and doc
completion of the form.
-do NOT obtain a culture of the newborn's eye secretions for gonorrhea (as erythromycin is
used as a prophylactic tx for gonorrhea for the prevention of ophthalmia neonatorum. - the
cultures are not part of standard practice for providing care to a newborn).
A NURSE IS DELEGATING CARE FOR A GRP OF PTS. DELEGATE TO THE AP? - ANSWER -
perform postmortem care
(cannot check placement of enteral feeding tube).
A NURSE IS CARING FOR AN ANTEPARTUM PT WHO HAS JUST BEEN INFORMED THAT THEIR
FETUS HAS ANENCEPHALY. THE PT ASKS THE NURSE, "DO YOU THINK I SHOULD TERMINATE
MY PREG?" WHAT SHOULD THE NURSE SAY? - ANSWER "Let's talk abt what YOU think
you should do."
A NURSE IS PREPPING TO ADMIN A MIXTURE OF HALDOL 5mg/ml AND DIPHENHYDRAMINE
50mg/ml IM TO A PT WHO IS AGITATED. NURSING ACTION? - ANSWER -avoid admin
3
, >1ml of med into the deltoid site. both haloperidol and diphenhydramine should be admin
deep into a large muscle mass, such as the VG muscle!!
-use a 2-in needle for an IM injection of this combo of the 2 meds.
-inject air into both vials prior to withdrawing the meds. this action ensures that the nurse
can easily withdraw the med when needed and that the med in the syringe isn't pulled back
into the vials due to negative pressure being formed.
-the nurse should use a filter needle to withdraw med from an ampule; however, the filter
needle is removed and replaced w/ a reg needle prior to admin. these meds for admin are
being withdrawn from vials, not ampules.
A NURSE IS TEACHING A PT WHO HAS A NEW RX FOR HALDOL. INSTRUCTIONS INCLUDED IN
THE TEACHING? - ANSWER -rinse your mouth freq throughout the day - Haldol has
antich s/e like dry mouth.
-taper Haldol slowly to avoid EPS - don't stop abruptly/immediately for sed!!
-reg eye exams (not ear) w/ Haldol.
-use sunscreen products or protective clothing to min unprotected exposure to sunlight b/c
Haldol can cause photosensitivity.
A NURSE IS PROVIDING D/C TEACHING TO A PT WHO HAS A NEW RX FOR CODEINE PRN FOR
PAIN. UNDERSTANDING OF THE TEACHING? - ANSWER "I should take a stool softener
w/ this med" - a/e of opioid analgesics is constip!!!
-may have urinary retention w/ codeine.
A NURSE IS CARING FOR A PT WHO IS TAKING VERAPAMIL AND STATES, "I TAKE MY MED W/
A GLASS OF GFJ EVERY AM." WHICH FINDING INDS A POSS MED-FOOD INTERACTION? -
ANSWER -drowsiness, hypotension (GFJ inhibits metab of this med - higher lvl of
verapamil in the blood --> hypotension). + urinary frequency & wt gain.
A NURSE IS CARING FOR A PT WHO IS RECEIVING 0.9% SODIUM CHLORIDE VIA CONTINUOUS
IV INFUSION THROUGH A PERIPHERAL IV SITE. THE PT HAS A NEW RX FOR CEFAZOLIN 1g VIA
INTERMITTENT IV BOLUS TO INFUSE OVER 30 MINS. WHICH ACTIONS SHOULD THE NURSE
TAKE WHEN INFUSING THE CEFAZOLIN? - ANSWER -infuse the cef thru secondary
tubing CC w/ the 0.9% NaCl infusion (piggyback it AFTER ensuring solutions are compatible).
4
A NURSE IS PROVIDING D/C INSTRUCTIONS TO A PT WHO HAS TB AND IS BEGINNING TX W/
MULTIDRUG THERAPY. WHICH OF THE FOLLOWING PT STATEMENTS INDS AN
UNDERSTANDING OF THE TEACHING? - ANSWER -3 consecutive negative sputum tests
will ind that the pt is no longer contagious. BUT Mantoux test will always be +.
-pts who have taken meds to tx TB for 2-3 consecutive weeks are no longer contagious. BUT,
pts will need to continue med therapy for at least 6mos.
-meds for TB can damage liver. avoid consuming alc.
-reg follow-up visits needed w/ TB.
A NURSE IS CARING FOR A PT WHO HAS A CLOSED-HEAD INJ AND IS ON SEIZURE
PRECAUTIONS. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE? -
ANSWER -no padded tongue blade (risk of asp and damage to teeth).
-no side rails raised
-set up suction equipment at bedside.
A NURSE IS DISCUSSING SECURITY MEASURES W/ A PT FOLLOWING DELIV OF AN INFANT.
WHICH OF THE FOLLOWING STATEMENTS SHOULD THE NURSE MAKE? - ANSWER -if pt
or other responsible party must leave the room for any reason, the newborn should be
transported to the newborn nursery.
-security sensor isn't removed until d/c from facility.
-2 plastic ID bracelets needed - one on arm and one on leg. ID #, name, date, time of birth,
and sex are included. replace immediately if off or missing.
-ask for hospital ID prior to allowing anyone to transport their newborn (don't go by colored
scrubs).
1
,A NURSE IS CONDUCTING A PRENATAL CLASS ABT CAR SEAT SAFETY. WHICH OF THE
FOLLOWING STATEMENTS BY A PT INDICATES AN UNDERSTANDING OF TEACHING? -
ANSWER -infants should remain in the rear-facing position until they're at least 2yrs
old to ensure safety.
-secure the retainer clip at lvl of baby's armpits.
-car seat at 45 deg angle.
-extra blankets or padding should not be added to car seat (could create extra air btwn
infant and seat = inj during MVC).
A NURSE IS PERFORMING TRIAGE FOLLOWING A MASS CASUALTY EVENT. WHICH OF THE
FOLLOWING PTS SHOULD THE NURSE REC BE TRANSPORTED FIRST TO A HCF? -
ANSWER -a middle adult pt who has a sucking chest wound
-a child whose thigh is impaled w/ glass and has 2+ pedal pulses has good peripheral circ
and, therefore, can wait.
-ad paralyzed from waist down - low SCI, not an immediate threat and can wait.
-OA w/ agonal breathing - near end of life. not transported first r/t min chance of survival.
A HHN IS PLANNING CARE FOR AN OA PT WHO HAS IMPAIRED VISION. WHICH
INTERVENTIONS SHOULD THE NURSE INCLUDE IN THE PLAN TO PREVENT INJ IN THE HOME?
- ANSWER -secure any area rugs w/ a non-slip pad or adhesive strips to secure to the
floor to prevent sliding.
-extension cords are removed from high-traffic areas in the home and placed along the
edges of walls.
-have adequate lighting - use of light fixtures that use bulbs >40 watts to optimize visibility.
-mark edges of stairs w/ paint or colored tape for contrast.
A NURSE IS DELEGATING MEASUREMENT AND DOC OF A PT'S CAPILLARY BLOOD GLUCOSE
LVL BEFORE LUNCH TO A LPN. WHICH ACTIONS SHOULD THE NURSE TAKE TO EVAL THE
COMPLETION OF THIS TASK? - ANSWER -ensure that the glucose lvl appears in the pt's
med record - task completion!!
2
,A NURSE IS PLANNING CARE FOR A GRP OF PTS. IDENTIFY THAT WHICH OF THE FOLLOWING
TASKS IS OUTSIDE AN RN'S SCOPE OF PRACTICE? - ANSWER -inserting a non tunneled
percutaneous central venous catheter.
A NURSE IS CARING FOR A PT WHO IS HIV+ AND HAS PNEUMONIA. A FAM MEMBER ASKS
THE NURSE, "WHAT IS CAUSING MY SISTER'S PNEUMONIA?" WHICH OF THE FOLLOWING
RESPONSES SHOULD THE NURSE MAKE? - ANSWER -"your sister must give permission
for me to discuss her condition w/ you."
A NURSE MANAGER IS PREPPING A STAFF ED PROGRAM ABT CONFIDENTIALITY. WHICH OF
THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE FIRST? - ANSWER -determine the
staff's current knowledge of confidentiality requirements.
A NURSE IS CARING FOR A NEWBORN WHOSE GUARDIAN HAS REFUSED THE ROUTINE
ADMIN OF ERYTHROMYCIN OINTMENT TO THE NEWBORN'S EYES. WHICH ACTIONS SHOULD
THE NURSE TAKE? - ANSWER -have the guardian sign the facility's refusal form and doc
completion of the form.
-do NOT obtain a culture of the newborn's eye secretions for gonorrhea (as erythromycin is
used as a prophylactic tx for gonorrhea for the prevention of ophthalmia neonatorum. - the
cultures are not part of standard practice for providing care to a newborn).
A NURSE IS DELEGATING CARE FOR A GRP OF PTS. DELEGATE TO THE AP? - ANSWER -
perform postmortem care
(cannot check placement of enteral feeding tube).
A NURSE IS CARING FOR AN ANTEPARTUM PT WHO HAS JUST BEEN INFORMED THAT THEIR
FETUS HAS ANENCEPHALY. THE PT ASKS THE NURSE, "DO YOU THINK I SHOULD TERMINATE
MY PREG?" WHAT SHOULD THE NURSE SAY? - ANSWER "Let's talk abt what YOU think
you should do."
A NURSE IS PREPPING TO ADMIN A MIXTURE OF HALDOL 5mg/ml AND DIPHENHYDRAMINE
50mg/ml IM TO A PT WHO IS AGITATED. NURSING ACTION? - ANSWER -avoid admin
3
, >1ml of med into the deltoid site. both haloperidol and diphenhydramine should be admin
deep into a large muscle mass, such as the VG muscle!!
-use a 2-in needle for an IM injection of this combo of the 2 meds.
-inject air into both vials prior to withdrawing the meds. this action ensures that the nurse
can easily withdraw the med when needed and that the med in the syringe isn't pulled back
into the vials due to negative pressure being formed.
-the nurse should use a filter needle to withdraw med from an ampule; however, the filter
needle is removed and replaced w/ a reg needle prior to admin. these meds for admin are
being withdrawn from vials, not ampules.
A NURSE IS TEACHING A PT WHO HAS A NEW RX FOR HALDOL. INSTRUCTIONS INCLUDED IN
THE TEACHING? - ANSWER -rinse your mouth freq throughout the day - Haldol has
antich s/e like dry mouth.
-taper Haldol slowly to avoid EPS - don't stop abruptly/immediately for sed!!
-reg eye exams (not ear) w/ Haldol.
-use sunscreen products or protective clothing to min unprotected exposure to sunlight b/c
Haldol can cause photosensitivity.
A NURSE IS PROVIDING D/C TEACHING TO A PT WHO HAS A NEW RX FOR CODEINE PRN FOR
PAIN. UNDERSTANDING OF THE TEACHING? - ANSWER "I should take a stool softener
w/ this med" - a/e of opioid analgesics is constip!!!
-may have urinary retention w/ codeine.
A NURSE IS CARING FOR A PT WHO IS TAKING VERAPAMIL AND STATES, "I TAKE MY MED W/
A GLASS OF GFJ EVERY AM." WHICH FINDING INDS A POSS MED-FOOD INTERACTION? -
ANSWER -drowsiness, hypotension (GFJ inhibits metab of this med - higher lvl of
verapamil in the blood --> hypotension). + urinary frequency & wt gain.
A NURSE IS CARING FOR A PT WHO IS RECEIVING 0.9% SODIUM CHLORIDE VIA CONTINUOUS
IV INFUSION THROUGH A PERIPHERAL IV SITE. THE PT HAS A NEW RX FOR CEFAZOLIN 1g VIA
INTERMITTENT IV BOLUS TO INFUSE OVER 30 MINS. WHICH ACTIONS SHOULD THE NURSE
TAKE WHEN INFUSING THE CEFAZOLIN? - ANSWER -infuse the cef thru secondary
tubing CC w/ the 0.9% NaCl infusion (piggyback it AFTER ensuring solutions are compatible).
4
