RHYTHM STRIP FOR INTERPRETATION
ACTUAL EXAM 100 QUESTIONS AND
CORRECT DETAILED
ANSWERS|AGRADE
Your trauma patient, who is 4 days post fracture of the right femur, suddenly develops shortness of
breath. The most likely cause is:
1. Fat embolus
2. Pneumonia
3. Pleural effusion
4. Pulmonary edema - answer-Fat embolism
To help prevent ventilator acquired pneumonia (VAP), the most important nursing action would be to:
1. keeping FIO2 at 60%
2. changing the ventilator tubing qshift
3. careful hand-washing and use of gloves when suctioning
4. treat low peak-inspiratory pressures - answer-Careful hand-washing and use of gloves when
suctioning
The most important nursing activity for a patient admitted with the diagnosis of cervical spinal cord
injury is:
1. keeping the patient flat
2. immobilizing the head
3. noting change in feeling extremities
4. doing hourly neuro checks - answer-Immobilizing the head
In a patient with cervical spine injury, the most important observations the nurse makes concerns which
of the following physiological parameters?
,1. heart rate
2. respirations
3. urinary output
4. pupillary response to light - answer-respirations
The earliest sign of increased intracranial pressure generally involves changes in:
1. response to pain
2. level of consciousness
3. equality of pupillary reactions
4. respiratory rate - answer-level of consciousness
53. Deepening intracranial pressure is characterized by:
1. tachycardia
2. pinpoint pupils
3. widened pulse pressure
4. increasing respirations - answer-Widened pulse pressure
The drug of choice used to reduce increased intracranial pressure is:
1. the calcium channel blocker
2. phenobarbital
3. Mannitol
4. Furosemide (Lasix) - answer-Mannitol
A positive Babinski response in an adult:
1. Indicates depressed reflexes
2. Is an expected finding
3. Is plantar flexion (curling under) of the toes
4. Indicates an abnormal finding - answer-Indicates an abnormal finding
, The nursing care of patient during the acute phase of a stroke does not include which response below?
1. Providing a quiet environment for the patient and family
2. Control of airway breathing and secretions
3. Initiating t-PA, if within first 8 hours post stroke
4. Alertness to any bleeding that might occur - answer-Initiating t-PA, if within first 8 hours post stroke
The most important part of a neuro check is:
1. Testing strength of grip
2. Assessing pupillary response to light
3. Evaluating the level of consciousness
4. Comparing any change in speech patterns - answer-Evaluating the level of consciousness
Signs and symptoms of diabetic ketoacidosis include:
1. Increasingly severe headache, and slow and shallow breathing
2. Hyperactivity, and diaphoresis and absence of urine ketones
3. Dilated pupils, and flushed and warm skin
4. Fruity breath, and deep and rapid breathing - answer-Fruity breath, and deep and rapid breathing
Impending insulin shock (hypoglycemia) should be suspected when the diabetic patient complains of or
manifests:
1. Decreased skin turgor, abdominal pain, restlessness
2. Flushed skin, tachycardia, Kussmal breathing
3. Thirst, hypotension, fruity odor to the breath
4. Weakness, headache, diaphoresis - answer-Weakness, headache, diaphoresis
Measures that would be taken to treat a patient in diabetic ketoacidosis coma would not include which
response below?
1. Dextrose 50% IV infusion
2. Insulin IV drip