Answers
Case:Mrs. Smith, 64 years old, has been on a medical unit recovering from a myocardial
infarction. Upon arriving in Mrs. Smith's room to provide morning care, the practical nurse
discovers her condition has changed.
Which data would best indicate to the practical nurse that Mrs. Smith's health status has
deteriorated and that her condition should be reported immediately?
A)Cold, clammy skin
B)Bounding pulse
C)Elevated blood pressure
D)Increased muscular activity - ✔✔A)Cold, clammy skin
Mrs. Smith, 64 years old, has been on a medical unit recovering from a myocardial infarction.
Upon arriving in Mrs. Smith's room to provide morning care, the practical nurse discovers her
condition has changed.
Mrs. Smith becomes confused and responds inappropriately. Which question by the practical
nurse would best help in the assessment of Mrs. Smith's level of orientation?
A)What is your name?
B)What does two plus two equal?
C)When did your bowels last move?
D)What did you think about that television program? - ✔✔A)What is your name?
Mrs. Smith, 64 years old, has been on a medical unit recovering from a myocardial infarction.
Upon arriving in Mrs. Smith's room to provide morning care, the practical nurse discovers her
condition has changed.
,The physician has ordered an IV of normal saline to run at 100mls/hr what does the practical
nurse do when first initiating the IV?
A)Shave any hair from the selected site
B)Briskly tap and massage the selected vein
C)Select a proximal site in the non-dominant extremity
D)Apply a tourniquet 4 to 6 inches above the selected site - ✔✔D)Apply a tourniquet 4 to 6
inches above the selected site
Mrs. Smith, 64 years old, has been on a medical unit recovering from a myocardial infarction.
Upon arriving in Mrs. Smith's room to provide morning care, the practical nurse discovers her
condition has changed.
While assessing Mrs. Smith, the practical nurse would become concerned with which of the
following symptoms related to the IV infusion?"
A)Polyuria
B)Crackles in the lungs
C)Dry mucous membranes
D)Decreased blood pressure - ✔✔B)Crackles in the lungs
Mrs. Smith, 64 years old, has been on a medical unit recovering from a myocardial infarction.
Upon arriving in Mrs. Smith's room to provide morning care, the practical nurse discovers her
condition has changed.
Mrs. Smith is ordered Heparin subcutaneously every 12 hours. The practical nurse expects the
physician will decrease the dose when blood work indicates which of the following?
A)INR below therapeutic range
B)INR above therapeutic range
C)Potassium below therapeutic range
D)Potassium above therapeutic range - ✔✔B)INR above therapeutic range
,Justin, 16 years old, has been admitted to hospital for gastroenteritis. He is very upset and
angry about not being able to participate in a baseball tournament with his friends.
Which action by the practical nurse is most appropriate for encouraging Justin to participate in
his care?
A)Encourage Justin to help develop a plan of care
B)Tell Justin what he needs to do to help with his care
C)Ask Justin's parents to help draw up the plan of care
D)Request that the physician tell Justin how to care for himself - ✔✔A)Encourage Justin to help
develop a plan of care
Justin, 16 years old, has been admitted to hospital for gastroenteritis. He is very upset and
angry about not being able to participate in a baseball tournament with his friends.
Which procedure, related to Justin's care after he has had a bowel movement, is most
important for the practical nurse to teach him to prevent the spread of bacteria?
A)Wash his hands with soap and water
B)Wear latex gloves when cleaning himself
C)Use a disinfectant to clean the toilet seat
D)Notify the practical nurse after each bowel movement - ✔✔A)Wash his hands with soap and
water
Justin, 16 years old, has been admitted to hospital for gastroenteritis. He is very upset and
angry about not being able to participate in a baseball tournament with his friends.
Justin is on enteric precautions. Which suggestion by the practical nurse would provide an
appropriate diversion for Justin?
A)Encourage him to play video games
B)Encourage him to make a cake for his family
C)Encourage him to play cards with another patient on the unit
, D)Encourage him to invite some of the players from his baseball team for a visit -
✔✔A)Encourage him to play video games
Justin, 16 years old, has been admitted to hospital for gastroenteritis. He is very upset and
angry about not being able to participate in a baseball tournament with his friends.
When providing the client with instructions on how to collect a stool specimen for Clostridium
difficile (C. difficile) which of the following is important information to teach?
A)Use a clean container to collect stool
B)Use stick provided to smear stool on card
C)Ensure rectal swab comes in contact with stool
D)Ensure stool collection container remains sterile - ✔✔A)Use a clean container to collect stool
Justin, 16 years old, has been admitted to hospital for gastroenteritis. He is very upset and
angry about not being able to participate in a baseball tournament with his friends.
Concerned about further dehydration after discharge, which of the symptoms should Justin or
his family seek further medical attention for?
A)Anuria
B)Pyrexia
C)Polyphagia
D)Diaphoresis - ✔✔A)Anuria
Mrs. Mitchell, 76 years old, has been recovering from a cerebrovascular accident (CVA), that
resulted in right-sided weakness, expressive aphasia and occasional bladder incontinence. She
wishes to maintain some independence and would like to continue to live alone once she is
discharged.
Which action by the practical nurse would be most helpful in establishing bladder and bowel
retraining for Mrs. Mitchell?