NURS 495: Practice Questions with verified answers
A 19-year-old patient comes to the emergency department with severe
chest pain and agitation. Which action should the nurse take first?
a. Give the PRN naloxone (Narcan) IV.
b. Ask about any use of stimulant drugs.
c. Check blood pressure, pulse, and respirations.
d. Assess orientation to person, place, and time. Ans✓✓✓ c. Check
blood pressure, pulse, and respirations.
The patient has symptoms consistent with the use of cocaine or
amphetamines and is at risk for fatal tachydysrhythmias or
complications of hypertension such as stroke or myocardial infarction.
The nurse also will ask about drug use and assess orientation, but these
are not the priority actions. Naloxone may be given if the patient
develops symptoms of CNS depression, but this patient's current
symptoms indicate stimulant use.
A 20-year-old patient who has inhaled cocaine is admitted to the
emergency department with palpitations and shortness of breath.
Which of these actions ordered by the health care provider will the
nurse implement first?
a. Infuse normal saline at 100 ml/hr.
b. Start O2 at 4 L/minute.
c. Draw blood for drug screening.
d. Obtain a 12-lead ECG Ans✓✓✓ b. Start O2 at 4 L/minute.
,The priority here is to ensure that oxygenation is adequate. The other
orders also should be accomplished as soon as possible but are not the
first priority
A 22-year-old male patient tells the nurse, "I enjoy smoking and have
no plans to quit." Considering the Transtheoretical Model of Health
Behaviour Change, the patient is in the stage of
a. Contemplation
b. Maintenance
c. Preparation
d. Precontemplation Ans✓✓✓ d. Precontemplation
The precontemplation phase indicates that the patient is not
considering a change and is not ready to learn. In the contemplation
phase, a change is being considered. The patient starts gathering
information for the change in the preparation stage. In the
maintenance stage, the change has already occurred.
A 22-year-old patient arrives in the emergency department (ED) with
multiple abrasions after a motor vehicle accident and has an initial
blood pressure (BP) of 180/98. The nurse will plan to
a. start an intravenous (IV) line to administer antihypertensive
medications.
,b. treat the abrasions and discuss the risks associated with
hypertension.
c. discuss the need for hospital admission to control blood pressure.
d. recheck the blood pressure before the patient's discharge from the
ED. Ans✓✓✓ d. recheck the blood pressure before the patient's
discharge from the ED.
Because hypertension is expected when a patient has experienced an
acute stressor, the nurse should plan to check the BP before discharge,
which will provide a more accurate idea of the patient's usual blood
pressure. Hypertension that occurs in response to acute stress does not
increase risk for health problems such as stroke, indicate a need for
hospitalization, or indicate a need for IV antihypertensive medications.
A 43-year-old is diagnosed with type 2 diabetes mellitus after being
admitted to the hospital with an infected foot wound. When applying
principles of adult learning, which teaching strategy by the nurse is
most likely to be effective?
a. Discuss the importance of blood glucose control in maintenance of
long-term health.
b. Wait until after discharge and have a home health nurse teach about
foot care and diabetes management.
c. Demonstrate the correct method for cleaning and redressing the
wound to the patient.
, d. Assure the patient that the nurse is an expert on management of
diabetes complications. Ans✓✓✓ c. Demonstrate the correct method
for cleaning and redressing the wound to the patient.
Principles of adult education indicate that readiness and motivation to
learn are high when facing new tasks (such as wound care) and when
demonstration and practice of skills are available. Although a home
health referral may be needed for this patient, teaching should not be
postponed until discharge. Adult learners are independent; the nurse
should act as a facilitator for learning, rather than as the expert. Adults
learn best when the topic is of immediate usefulness; long-term goals
may not be very motivating.
A 78-year-old patient hospitalized for a fractured hip has recovered
from the surgery but needs to continue to work to improve mobility.
The nurse will anticipate transferring the patient to
a. a transitional care setting.
b. an acute care setting.
c. a residential care facility.
d. their own home with home health nursing. Ans✓✓✓ a. a transitional
care setting.
Home health nursing is appropriate for patients who need continued
rehabilitation and can implement this in their own home. The patient is
no longer in need of the more continuous assessment and care given in
acute care settings. There is no indication that the patient will need the
A 19-year-old patient comes to the emergency department with severe
chest pain and agitation. Which action should the nurse take first?
a. Give the PRN naloxone (Narcan) IV.
b. Ask about any use of stimulant drugs.
c. Check blood pressure, pulse, and respirations.
d. Assess orientation to person, place, and time. Ans✓✓✓ c. Check
blood pressure, pulse, and respirations.
The patient has symptoms consistent with the use of cocaine or
amphetamines and is at risk for fatal tachydysrhythmias or
complications of hypertension such as stroke or myocardial infarction.
The nurse also will ask about drug use and assess orientation, but these
are not the priority actions. Naloxone may be given if the patient
develops symptoms of CNS depression, but this patient's current
symptoms indicate stimulant use.
A 20-year-old patient who has inhaled cocaine is admitted to the
emergency department with palpitations and shortness of breath.
Which of these actions ordered by the health care provider will the
nurse implement first?
a. Infuse normal saline at 100 ml/hr.
b. Start O2 at 4 L/minute.
c. Draw blood for drug screening.
d. Obtain a 12-lead ECG Ans✓✓✓ b. Start O2 at 4 L/minute.
,The priority here is to ensure that oxygenation is adequate. The other
orders also should be accomplished as soon as possible but are not the
first priority
A 22-year-old male patient tells the nurse, "I enjoy smoking and have
no plans to quit." Considering the Transtheoretical Model of Health
Behaviour Change, the patient is in the stage of
a. Contemplation
b. Maintenance
c. Preparation
d. Precontemplation Ans✓✓✓ d. Precontemplation
The precontemplation phase indicates that the patient is not
considering a change and is not ready to learn. In the contemplation
phase, a change is being considered. The patient starts gathering
information for the change in the preparation stage. In the
maintenance stage, the change has already occurred.
A 22-year-old patient arrives in the emergency department (ED) with
multiple abrasions after a motor vehicle accident and has an initial
blood pressure (BP) of 180/98. The nurse will plan to
a. start an intravenous (IV) line to administer antihypertensive
medications.
,b. treat the abrasions and discuss the risks associated with
hypertension.
c. discuss the need for hospital admission to control blood pressure.
d. recheck the blood pressure before the patient's discharge from the
ED. Ans✓✓✓ d. recheck the blood pressure before the patient's
discharge from the ED.
Because hypertension is expected when a patient has experienced an
acute stressor, the nurse should plan to check the BP before discharge,
which will provide a more accurate idea of the patient's usual blood
pressure. Hypertension that occurs in response to acute stress does not
increase risk for health problems such as stroke, indicate a need for
hospitalization, or indicate a need for IV antihypertensive medications.
A 43-year-old is diagnosed with type 2 diabetes mellitus after being
admitted to the hospital with an infected foot wound. When applying
principles of adult learning, which teaching strategy by the nurse is
most likely to be effective?
a. Discuss the importance of blood glucose control in maintenance of
long-term health.
b. Wait until after discharge and have a home health nurse teach about
foot care and diabetes management.
c. Demonstrate the correct method for cleaning and redressing the
wound to the patient.
, d. Assure the patient that the nurse is an expert on management of
diabetes complications. Ans✓✓✓ c. Demonstrate the correct method
for cleaning and redressing the wound to the patient.
Principles of adult education indicate that readiness and motivation to
learn are high when facing new tasks (such as wound care) and when
demonstration and practice of skills are available. Although a home
health referral may be needed for this patient, teaching should not be
postponed until discharge. Adult learners are independent; the nurse
should act as a facilitator for learning, rather than as the expert. Adults
learn best when the topic is of immediate usefulness; long-term goals
may not be very motivating.
A 78-year-old patient hospitalized for a fractured hip has recovered
from the surgery but needs to continue to work to improve mobility.
The nurse will anticipate transferring the patient to
a. a transitional care setting.
b. an acute care setting.
c. a residential care facility.
d. their own home with home health nursing. Ans✓✓✓ a. a transitional
care setting.
Home health nursing is appropriate for patients who need continued
rehabilitation and can implement this in their own home. The patient is
no longer in need of the more continuous assessment and care given in
acute care settings. There is no indication that the patient will need the
