Comp predictor B
Study online at https://quizlet.com/_e3o2u8
1. A nurse is preparing to replace a patient's trans- B) Ask another nurse to wit-
dermal fentanyl patch after 72 hours of use. After ness the disposal of the new
opening the packet with the new pouch, the patient patch.
refuses to accept it. Which action should the nurse
take?
A) Withhold pain medications for 24 hr after the old
patch is removed.
B) Ask another nurse to witness the disposal of the
new patch.
C) Seal the patches in a plastic bag and place in the
client's trash basket.
D) Stick the two patches to each other and place
them in the sharps bin.
2. A nurse is caring for a client with a PE. The client is C) Withhold the heparin in-
receiving heparin IV at 1,200 units/hr and warfarin fusion.
5 mg PO daily. The morning lab values are aPTT 98
seconds and INR 1.8. Which action should the nurse The expected value for aPTT
take? is 40 seconds. A therapeu-
A) Prepare to administer vitamin K1. tic level of heparin increases
B) Prepare to administer alteplase. the aPTT by a factor of 1.5
C) Withhold the heparin infusion. to 2, making the aPTT 60 to
D) Withhold the next dose of warfarin. 80 seconds. An aPTT level of
98 is above the expected ref-
erence range, indicating that
the dosage should be re-
duced or the infusion with-
held until the aPTT returns to
the therapeutic range.
3. A nurse at an urgent care clinic is assessing a patient B) Floating dark spots
with impaired vision in 1 eye. Which report from the
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
patient should indicate to the nurse that the client
has a detached retina?
A) Halos around lights
B) Floating dark spots
C) Pain in the affected eye
D) Cloudy vision
4. A nurse is assessing an infant with hydrocephalus B) Irritability when being
and is 6 hours post-op following placement of a VP held
shunt. Which finding should the nurse report to the
provider?
A) Heart rate 122/min
B) Irritability when being held
C) Hypoactive bowel sounds
D) Urine specific gravity 1.018
5. A nurse is assessing a newborn's HR. Which action D) Auscultate the apical
should the nurse take? pulse and count beats for at
A) Assess the apical pulse while the newborn is cry- least 1 min.
ing to detect cardiac problems.
B) Palpate the radial pulse and determine the rate
based on number of beats per minute.
C) Listen to the apical pulse while palpating the radial
pulse to detect variance.
D) Auscultate the apical pulse and count beats for at
least 1 min.
6. A nurse is caring for a client with a fecal impaction. D) Insert a lubricated gloved
Which action should the nurse take when digitally finger and advance along
evacuating the stool? the rectal wall.
A) Place the client in the lithotomy position.
B) Elicit a vagal response by performing gentle rectal
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
stimulation.
C) Administer oral bisacodyl 30 min prior to the pro-
cedure.
D) Insert a lubricated gloved finger and advance
along the rectal wall.
7. A nurse is providing dietary teaching to a patient A) Broccoli
taking phenelzine. Which food recommendations B) Yogurt
should the nurse make? (Select all) D) Cream cheese
A) Broccoli
B) Yogurt
C) Pepperoni pizza
D) Cream cheese
E) Bologna sandwich
8. A nurse administers an incorrect dose of a med to B) Time the medication was
a client. The nurse recognizes the error immediately given
and completes an incident report. Which fact related
to the incident should the nurse document in the
client's medical record?
A) Completion of the incident report
B) Time the medication was given
C) Reason for the medication error
D) Notification of the pharmacist
9. A nurse on a pediatric unit received report on 4 chil- D) A 10-year-old child who
dren. Which child should the nurse assess first? is awaiting surgery for an
A) A 6-month-old infant who has croup and an O2 appendectomy and experi-
saturation of 92% on room air enced sudden relief from
B) A 15-year-old adolescent who is 2 hr postoperative pain
following an open reduction and internal fixation of
the left ankle and is requesting pain medication Using the urgent vs. non-ur-
gent approach to client care,
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
C) A 3-year-old toddler who has gastroenteritis, mod- the nurse should determine
erate dehydration, and had two loose bowel move- that the client to assess first
ments over the past 24 hr is the child awaiting an ap-
D) A 10-year-old child who is awaiting surgery for an pendectomy who sudden-
appendectomy and experienced sudden relief from ly experiences pain relief as
pain this can be an indication of
peritonitis from a ruptured
appendix.
10. A community health nurse is providing teaching D) "Have grab bars installed
about home safety with a group of elderly clients. around your bathtub and
Which statement should the nurse make? toilet."
A) "Unplug your appliances by grasping the cord and
pulling it straight from the outlet."
B) "Set your water heater temperature at 130 de-
grees Fahrenheit."
C) "Use throw rugs in high-traffic areas to partially
cover wood floors."
D) "Have grab bars installed around your bathtub
and toilet."
11. A nurse in the ED is assessing a school-age child who D) Contact child protective
was brought in by her parents and has scald burns to services.
both hands and wrists. The nurse suspects physical
abuse. Which action should the nurse take?
A) Discuss his suspicion of physical abuse with the
provider.
B) Confront the parents with his suspicion of physical
abuse.
C) Ask the hospital security to detain and question
the parents.
D) Contact child protective services.
Study online at https://quizlet.com/_e3o2u8
1. A nurse is preparing to replace a patient's trans- B) Ask another nurse to wit-
dermal fentanyl patch after 72 hours of use. After ness the disposal of the new
opening the packet with the new pouch, the patient patch.
refuses to accept it. Which action should the nurse
take?
A) Withhold pain medications for 24 hr after the old
patch is removed.
B) Ask another nurse to witness the disposal of the
new patch.
C) Seal the patches in a plastic bag and place in the
client's trash basket.
D) Stick the two patches to each other and place
them in the sharps bin.
2. A nurse is caring for a client with a PE. The client is C) Withhold the heparin in-
receiving heparin IV at 1,200 units/hr and warfarin fusion.
5 mg PO daily. The morning lab values are aPTT 98
seconds and INR 1.8. Which action should the nurse The expected value for aPTT
take? is 40 seconds. A therapeu-
A) Prepare to administer vitamin K1. tic level of heparin increases
B) Prepare to administer alteplase. the aPTT by a factor of 1.5
C) Withhold the heparin infusion. to 2, making the aPTT 60 to
D) Withhold the next dose of warfarin. 80 seconds. An aPTT level of
98 is above the expected ref-
erence range, indicating that
the dosage should be re-
duced or the infusion with-
held until the aPTT returns to
the therapeutic range.
3. A nurse at an urgent care clinic is assessing a patient B) Floating dark spots
with impaired vision in 1 eye. Which report from the
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
patient should indicate to the nurse that the client
has a detached retina?
A) Halos around lights
B) Floating dark spots
C) Pain in the affected eye
D) Cloudy vision
4. A nurse is assessing an infant with hydrocephalus B) Irritability when being
and is 6 hours post-op following placement of a VP held
shunt. Which finding should the nurse report to the
provider?
A) Heart rate 122/min
B) Irritability when being held
C) Hypoactive bowel sounds
D) Urine specific gravity 1.018
5. A nurse is assessing a newborn's HR. Which action D) Auscultate the apical
should the nurse take? pulse and count beats for at
A) Assess the apical pulse while the newborn is cry- least 1 min.
ing to detect cardiac problems.
B) Palpate the radial pulse and determine the rate
based on number of beats per minute.
C) Listen to the apical pulse while palpating the radial
pulse to detect variance.
D) Auscultate the apical pulse and count beats for at
least 1 min.
6. A nurse is caring for a client with a fecal impaction. D) Insert a lubricated gloved
Which action should the nurse take when digitally finger and advance along
evacuating the stool? the rectal wall.
A) Place the client in the lithotomy position.
B) Elicit a vagal response by performing gentle rectal
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
stimulation.
C) Administer oral bisacodyl 30 min prior to the pro-
cedure.
D) Insert a lubricated gloved finger and advance
along the rectal wall.
7. A nurse is providing dietary teaching to a patient A) Broccoli
taking phenelzine. Which food recommendations B) Yogurt
should the nurse make? (Select all) D) Cream cheese
A) Broccoli
B) Yogurt
C) Pepperoni pizza
D) Cream cheese
E) Bologna sandwich
8. A nurse administers an incorrect dose of a med to B) Time the medication was
a client. The nurse recognizes the error immediately given
and completes an incident report. Which fact related
to the incident should the nurse document in the
client's medical record?
A) Completion of the incident report
B) Time the medication was given
C) Reason for the medication error
D) Notification of the pharmacist
9. A nurse on a pediatric unit received report on 4 chil- D) A 10-year-old child who
dren. Which child should the nurse assess first? is awaiting surgery for an
A) A 6-month-old infant who has croup and an O2 appendectomy and experi-
saturation of 92% on room air enced sudden relief from
B) A 15-year-old adolescent who is 2 hr postoperative pain
following an open reduction and internal fixation of
the left ankle and is requesting pain medication Using the urgent vs. non-ur-
gent approach to client care,
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
C) A 3-year-old toddler who has gastroenteritis, mod- the nurse should determine
erate dehydration, and had two loose bowel move- that the client to assess first
ments over the past 24 hr is the child awaiting an ap-
D) A 10-year-old child who is awaiting surgery for an pendectomy who sudden-
appendectomy and experienced sudden relief from ly experiences pain relief as
pain this can be an indication of
peritonitis from a ruptured
appendix.
10. A community health nurse is providing teaching D) "Have grab bars installed
about home safety with a group of elderly clients. around your bathtub and
Which statement should the nurse make? toilet."
A) "Unplug your appliances by grasping the cord and
pulling it straight from the outlet."
B) "Set your water heater temperature at 130 de-
grees Fahrenheit."
C) "Use throw rugs in high-traffic areas to partially
cover wood floors."
D) "Have grab bars installed around your bathtub
and toilet."
11. A nurse in the ED is assessing a school-age child who D) Contact child protective
was brought in by her parents and has scald burns to services.
both hands and wrists. The nurse suspects physical
abuse. Which action should the nurse take?
A) Discuss his suspicion of physical abuse with the
provider.
B) Confront the parents with his suspicion of physical
abuse.
C) Ask the hospital security to detain and question
the parents.
D) Contact child protective services.
