PRACTICE QUESTIONS WITH [A
GRADED] ANSWERS
The mnurse mis mcaring mfor ma mclient mwith ma mcerebrovascular maccident m(CVA) mwho
mis mreceiving menteral mtube mfeedings. mWhich mtask mperformed mby mthe mUAP
mrequires mimmediate mintervention mby mthe mnurse?
A.Suctions moral msecretions mfrom mmouth
B.Positions mhead mof mbed mflat mwhen mchanging msheets
C.Takes mtemperature musing mthe maxillary mmethod
D.Keeps mhead mof mbed melevated mat m30 mdegrees m- mANS--B
Rationale:
Positioning mthe mhead mof mthe mbed mflat mwhen menteral mfeedings mare min mprogress
mputs mthe mclient mat mrisk mfor maspiration m(B). mThe mothers mare mall macceptable
mtasks mperformed mby mthe mUAP m(A, mC, mand mD).
When mcaring mfor ma mpostsurgical mclient mwho mhas mundergone mmultiple mblood
mtransfusions, mwhich mserum mlaboratory mfinding mis mof mmost mconcern mto mthe
mnurse?
A.Sodium mlevel, m137 mmEq/L
B.Potassium mlevel, m5.5 mmEq/L
C.Blood murea mnitrogen m(BUN) mlevel, m18 mmg/dL
D.Calcium mlevel, m10 mmEq/L m- mANS--B
Rationale:
Multiple mblood mtransfusions mare ma mrisk mfactor mfor mhyperkalemia. mA mserum
mpotassium mlevel mhigher mthan m5.0 mmEq/L mindicates mhyperkalemia m(B). mThe
mothers mare mnormal mfindings m(A, mC, mand mD).
Which mvaccination mshould mthe mnurse madminister mto ma mnewborn?
A.Hepatitis mB
B.Human mpapilloma mvirus m(HPV)
C.Varicella
D.Meningococcal mvaccine m- mANS--A
Rationale:
The mhepatitis mB mvaccination mshould mbe mgiven mto mall mnewborns mbefore mhospital
mdischarge m(A). mHPV mis mnot mrecommended muntil madolescence m(B). mVaricella
mimmunization mbegins mat m12 mmonths m(C). mMeningococcal mvaccine mis
madministered mbeginning mat m2 myears m(D).
,The mnurse mis mcaring mfor ma mclient mon mthe mmedical munit. mWhich mtask mcan mbe
mdelegated mto munlicensed massistive mpersonnel m(UAP)?
A.Assess mthe mneed mto mchange ma mcentral mline mdressing.
B.Obtain ma mfingerstick mblood mglucose mlevel.
C.Answer ma mfamily mmember's mquestions mabout mthe mclient's mplan mof mcare.
D.Teach mthe mclient mside meffects mto mreport mrelated mto mthe mcurrent mmedication
mregimen. m- mANS--B
Rationale:
Obtaining ma mfingerstick mblood mglucose mlevel mis ma msimple mtreatment mand mis man
mappropriate mskill mfor mUAP mto mperform m(B). m(A, mC, mand mD) mare mskills mthat
mcannot mbe mdelegated mto mUAP.
The mnurse mis mcaring mfor ma mclient mwith man mischemic mstroke mwho mhas ma
mprescription mfor mtissue mplasminogen mactivator m(t-PA) mIV. mWhich maction(s)
mshould mthe mnurse mexpect mto mimplement? m(Select mall mthat mapply.)
A.Administer maspirin mwith mtissue mplasminogen mactivator m(t-PA).
B.Complete mthe mNational mInstitute mof mHealth mStroke mScale m(NIHSS).
C.Assess mthe mclient mfor msigns mof mbleeding mduring mand mafter mthe minfusion.
D.Start mt-PA mwithin m6 mhours mafter mthe monset mof mstroke msymptoms.
E.Initiate mmultidisciplinary mconsult mfor mpotential mrehabilitation. m- mANS--B,C,E
Rationale:
Neurologic massessment, mincluding mthe mNIHSS, mis mindicated mfor mthe mclient
mreceiving mt-PA. mThis mincludes mclose mmonitoring mfor mbleeding mduring mand mafter
mthe minfusion; mif mbleeding mor mother msigns mof mneurologic mimpairment moccur, mthe
minfusion mshould mbe mstopped m(B, mC, mand mE). mAspirin mis mcontraindicated mwith mt-
PA mbecause mit mincreases mthe mrisk mfor mbleeding m(A). mThe madministration mof mt-
PA mwithin m6 mhours mof msymptoms mis mconcurrent mwith ma mdiagnosis mof ma
mmyocardial minfarction mand mwithin m4.5 mhours mof msymptoms mis mconcurrent mfor ma
mstroke m(D).
When mcaring mfor ma mclient min mlabor, mwhich mfinding mis mmost mimportant mto mreport
mto mthe mprimary mhealth mcare mprovider?
A.Maternal mheart mrate, m90 mbeats/min.
B.Fetal mheart mrate, m100 mbeats/min
C.Maternal mblood mpressure, m140/86 mmm mHg
D.Maternal mtemperature, m100.0° mF m- mANS--B
Rationale:
A mfetal mheart mrate m(FHR) mof m100 mbeats/min mmay mindicate mfetal mdistress m(B)
mbecause mthe maverage mFHR mat mterm mis m140 mbeats/min mand mthe mnormal mrange
mis m110 mto mbeats/min m160. mThe mothers m(A, mC, mand mD) mare mnormal mfindings
mfor ma mwoman min mlabor.
The mnurse mis mcaring mfor ma mclient mwith mheart mfailure mwho mdevelops mrespiratory
mdistress mand mcoughs mup mpink mfrothy msputum. mWhich maction mshould mthe mnurse
mtake mfirst?
A.Draw marterial mblood mgases.
,B.Notify mthe mprimary mhealth mcare mprovider.
C.Position min ma mhigh mFowler's mposition mwith mthe mlegs mdown.
D.Obtain ma mchest mX-ray. m- mANS--C
Rationale:
Positioning mthe mpatient min ma mhigh mFowler's mposition mwith mdangling mfeet mwill
mdecrease mfurther mvenous mreturn mto mthe mleft mventricle m(C). mThe mother mactions
mshould mbe mperformed mafter mthe mchange min mposition m(A, mB, mand mD).
A mclient mwho mis mprescribed mchlorpromazine mHCl m(Thorazine) mfor mschizophrenia
mdevelops mrigidity, ma mshuffling mgait, mand mtremors. mWhich maction mby mthe mnurse
mis mmost mimportant?A.Administer ma mdose mof mbenztropine mmesylate m(Cogentin)
mPRN.
B.Determine mif mthe mclient mhas mincreased mphotosensitivity.
C.Provide mcomfort mmeasures mfor msore mmuscles.
D.Assess mthe mclient mfor mvisual mand mauditory mhallucinations. m- mANS--A
Rationale:
Rigidity, mshuffling mgait, mpill-rolling mhand mmovements, mtremors, mdyskinesia, mand
mmasklike mface mare mextrapyramidal mside meffects massociated mwith mThorazine. mIt
mis mmost mimportant mfor mthe mnurse mto madminister man manticholinergic msuch mas
mCogentin mto mreverse mthese meffects m(A). mThe mothers m(B, mC, mD) mmay mbe
mappropriate minterventions mbut mare mnot mas murgent mas m(A).
A mnurse mis minterviewing ma mmother mduring ma mwell-child mvisit. mWhich mfinding
mwould malert mthe mnurse mto mcontinue mfurther massessment mof mthe minfant?
A.Two-month-old mwho mis munable mto mroll mfrom mback mto mabdomen
B.Ten-month-old mwho mcannot msit mwithout msupport
C.Nine-month-old mwho mcries mwhen mhis mmother mleaves mthe mroom
D.Eight-month-old mwho mhas mnot myet mbegun mto mspeak mwords m- mANS--B
Rationale:
As ma mdevelopmental mmilestone, minfants mshould msit munsupported mby m8 mmonths
m(B). mThe mmilestone mof mrolling mover mis machieved mat m5 mto m6 mmonths mfor mmost
minfants m(A). mStranger manxiety mis mcommon mfrom m7 mto m9 mmonths m(C). mSpeaking
ma mfew mwords mis mexpected mat mabout m12 mmonths m(D).
Which mintervention mshould mbe mincluded min mthe mplan mof mcare mfor ma mclient
madmitted mto mthe mhospital mwith mulcerative mcolitis?
A.Administer mstool msofteners.
B.Place mthe mclient mon mfluid mrestriction.
C.Provide ma mlow-residue mdiet.
D.Add ma mmilk mproduct mto meach mmeal. m- mANS--C
Rationale:
A mlow-residue mdiet m(C) mwill mhelp mdecrease msymptoms mof mdiarrhea, mwhich mare
mclinical mmanifestations mof mulcerative mcolitis. m(A, mB, mand mD) mare mcontraindicated
mand mcould mworsen mthe mcondition.
, The mnurse mis mcaring mfor ma mclient mwith mdeep mvein mthrombosis mwho mis mon ma
mcontinuous mIV mheparin minfusion. mThe mactivated mpartial mprothrombin mtime m(aPTT)
mis m120 mseconds. mWhich maction mshould mthe mnurse mtake?
A.Increase mthe mrate mof mthe mheparin minfusion musing ma mnomogram.
B.Decrease mthe mheparin minfusion mrate mand mgive mvitamin mK mIM.
C.Continue mthe mheparin minfusion mat mthe mcurrent mprescribed mrate.
D.Stop mthe mheparin mdrip mand mprepare mto madminister mprotamine msulfate. m- mANS--
D
Rationale:
An maPTT mmore mthan m100 mseconds mis ma mcritically mhigh mvalue; mtherefore, mthe
mheparin mshould mbe mstopped. mThe mantidote mfor mheparin mis mprotamine msulfate
m(D). mIncreasing mthe mrate mwould mincrease mthe mrisk mfor mhemorrhage m(A). mThe
minfusion mshould mbe mstopped, mand mvitamin mK mis mthe mantidote mfor mwarfarin
m(Coumadin) m(B). mKeeping mthe minfusion mat mthe mcurrent mrate mwould mincrease mthe
mrisk mfor mhemorrhage m(C).
While massessing ma mclient mwith mrecurring mchest mpain, mthe munit msecretary mnotifies
mthe mnurse mthat mthe mclient's mhealth mcare mprovider mis mon mthe mtelephone. mWhat
maction mshould mthe mnurse minstruct mthe munit msecretary mto mimplement?
A.Transfer mthe mcall minto mthe mroom mof mthe mclient.
B.Instruct mthe msecretary mto mexplain mreason mfor mthe mcall.
C.Ask manother mnurse mto mtake mthe mphone mcall.
D.Ask mthe mhealth mcare mprovider mto msee mthe mclient mon mthe munit. m- mANS--C
Rationale:
Another mnurse mshould mbe masked mto mtake mthe mphone mcall m(C), mwhich mallows
mthe mnurse mto mstay mat mthe mbedside mto mcomplete mthe massessment mof mthe
mclient's mchest mpain. m(A mand mB) mshould mnot mbe mdone mduring man macute mchange
min mthe mclient's mcondition. mRequesting mthe mhealth mcare mprovider m(D) mto mcome
mto mthe munit mis mpremature muntil mthe mnurse mcompletes massessment mof mthe
mclient's mstatus.
Which minstruction(s) mshould mthe mnurse minclude min mthe mdischarge mteaching mplan
mof ma mmale mclient mwho mhas mhad ma mmyocardial minfarction mand mwho mhas ma mnew
mprescription mfor mnitroglycerin m(NTG)? m(Select mall mthat mapply.)
A.Keep mthe mmedication min myour mpocket mso mthat mit mcan mbe maccessed mquickly.
B.Call m911 mif mchest mpain mis mnot mrelieved mafter mone mnitroglycerin.
C.Store mthe mmedication min mits moriginal mcontainer mand mprotect mit mfrom mlight.
D.Activate mthe memergency mmedical msystem mafter mthree mdoses mof mmedication.
E.Do mnot muse mwithin m1 mhour mof mtaking msildenafil mcitrate m(Viagra). m- mANS--B,C
Rationale:
Emergency maction mshould mbe mtaken mif mchest mpain mis mnot mrelieved mafter mone
mnitroglycerin mtablet m(B). mThe mmedication mshould mbe mkept min mthe moriginal
mcontainer mto mprotect mfrom mlight m(C). mKeeping mthe mmedication min mthe mshirt
mpocket mprovides man menvironment mthat mis mtoo mwarm m(A). mThe mnewest
mguidelines mrecommend mcalling m911 mafter mone mnitroglycerin mtablet mif mchest mpain