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Describe Pertussis - ANSWER -Initially mimics common cold. Second stage of
pertussis, pt experiences fever and unremitting paroxysmal bursts of coughing
ending with.a high-pitched "Whoop" (pertussis = whooping cough).
A patient has just been prescribed the "morning after" pill, and the nurse has
administered the first dose. Which of the following statements indicates the patient
understands discharge teaching? - ANSWER -The medication may cause N/V. The
usual course of dosing is 2 pills now and 2 more in 12 hours. This tx does not
stimulate a menstrual cycle.
The nurse is caring for a patient who is 2 days postpartum, is hypertensive and
complaining of a severe headache. The nurse should prepare to administer -
ANSWER -Mag sulfate. The patient is experiencing symptoms of preeclampsia,
the primary treatment for which is magnesium sulfate, along with blood pressure
management
During quality review, the Quality Improvement Committee identifies a variance
from the standard of nursing care of two patients with chest pain. Which of the
following is the MOST appropriate recommendation by the Committee? -
ANSWER -Conducting a random audit is most appropriate in this scenario. -- The
Quality Improvement Committee needs to determine whether these two cases are
isolated incidents or if there is an ongoing deficiency in the standard of care
delivered. Discipline, inservices, or new flow sheets are not considered until the
scope of the problem is defined.
A patient has an open pneumothorax secondary to a gunshot injury. What is the
proper sequence of steps in management?
A. Initiate an IV of lactated Ringer's solution, check for a pulse, and place the
patient on the affected side.
B. Initiate an IV of normal saline solution, apply an occlusive dressing to the
wound, and prepare for intubation.
C. Apply an occlusive dressing to the wound, check for a pulse, and initiate an IV
of normal saline solution.
,D. Obtain baseline vital signs, initiate an IV of lactated Ringer's solution and place
the patient on the unaffected side. - ANSWER -C. Apply an occlusive dressing to
the wound, check for a pulse, and initiate an IV of normal saline solution.
This ANSWER addresses the "C" or "circulation" of the primary survey. A life-
threatening wound has been identified. Upon identification, the nurse must apply
an occlusive dressing, check for a pulse, and initiate an IV of normal saline. These
are all interventions under circulation and follows the Primary assessment and
Intervention rules for trauma.
Which of the following medications should a nurse anticipate administering
initially to an adult patient in status epilepticus?
diazepam (Valium), fosphenytoin (Cerebyx), flumazenil (Romazicon), or
phenobarbital - ANSWER -Diazepam (Valium) is a benzodiazepine used as a first-
line drug in the treatment of status epilepticus. Fosphenytoin (Cerebyx) is the
second-line drug for seizure treatment after a benzodiazepine. Flumazenil
(Romazicon) is a reversal agent for benzodiazepine overdose and can precipitate
seizures. Phenobarbital is a long-term treatment to prevent seizure recurrence and
is not a first-line medication for status epilepticus.
What clotting disorder is caused by the absence or deficiency of factor IX? -
ANSWER -Hemophilia B is caused by the absence or functional deficiency of
factor IX.
The skin of a patient in early septic shock is most likely to be:
cool and pale.; cool and cyanotic.; warm and flushed.; warm and pale. - ANSWER
-Warm and flushed -- Signs and symptoms of early septic shock include increased
heart rate, increased respiratory rate, and warm, flushed skin, hence the term,
"warm shock."
A patient with tuberculosis is considered infectious as long as - ANSWER -viable
tubercle bacilli are discharged in the sputum. -- A patient is considered infectious
until 14 days of directly observed therapy, 3 negative AFB smears, decrease in
cough, and afebrile.
The nurse is caring for a patient who has an ectopic pregnancy. The patient has
stable vital signs and states that she has an appointment with her obstetrical
physician tomorrow. The nurse should prepare the patient for - ANSWER -
administration of methotrexate (Folex) -- Methrotrexate (Folex) administration is
optimal in a hemodynamically stable patient who can follow up with their
,physician. Admission to the operating room is not indicated since the patient is
hemodynamically stable.
An 82-year-old patient sustained a fractured hip in a recent fall. In evaluating the
patient's condition, the nurse should be especially concerned about the
cause of the fall
time the fall occurred
Degree that the affected leg is rotated outward
Pt's hx of drug allergies - ANSWER -Cause of the fall -- Elderly patients are at risk
for falls. The etiology of the fall is investigated to rule out a cardiac, vascular, or
neurologic origin.
A nurse is splashed in the eye with the blood from a trauma patient who is HIV
seropositive. The nurse should
Irrigate the eye wit zidovudine (AXT)
irrigate the eye with diluted hypochlorite solution
Begin a regimen of interferon
Undergo serum testing for HIV - ANSWER -Undergo serum testing for HIV --
Following direct exposure of healthcare workers to HIV infected blood, a baseline
HIV test is indicated. Healthcare workers who have had significant exposure to
known HIV should undergo baseline blood testing. Medications such as mono-
antiretroviral or combination antiretroviral therapy may also be started, but not
Interferon. The eye should be flushed with normal saline or lactated Ringers, but
not with AZT or hypochlorite solution.
A 30-year-old patient who has had a cold for approximately 10 to 14 days now has
a paroxysmal cough with loud end-cough whooping noises, a low-grade fever, and
anorexia. The nurse should prepare to - ANSWER -admin IV fluids and abx -- For
a patient with pertussis and decreased oral intake, the nurse should establish IV
access for administration of crystalloid solution and administer antibiotics because
it is a bacterial infection.
A patient presents with purulent nasal discharge and a frontal area headache that
worsens when bending over. Which of the following nursing interventions is
MOST effective? - ANSWER -Apply heat to the face (sinusitis) -- Frontal pain
exacerbated when bending over, headache and purulent nasal discharge indicate
sinusitis. Treatment includes nasal/systemic decongestants, nasal steroids, keeping
the head of the bed elevated to promote sinus drainage and applying heat to the
face to relieve pressure.
, An essential requirement that needs to be proved in a medical negligence case is
the presence of
a. incorrect action
b. failure to act
c. damages
d. intent to damage - ANSWER -c. damages -- Four elements of negligence that
must be proven include duty, breach of duty, proximate cause, and damages.
Incorrect actions or failure to act alone are not essential elements of negligence.
Every negligence case must prove damages.
The nurse is caring for a patient with complaints of progressive, ascending
paralysis starting from the feet and progressing over the last week. It would be a
PRIORITY for the nurse to monitor the patient's - ANSWER -Respiratory status --
The patient is exhibiting signs of Guillain-Barré Syndrome, of which the most
severe complication is respiratory arrest. Pupillary response, peripheral pulses and
blood glucose are part of the secondary assessment, but airway is the chief priority.
A 10-month-old infant who has a sudden onset of wheezing, cough, and stridor
should immediately be assessed for
a. presence of abdominal breathing
b. unequal breath sounds
c. axillary subcutaneous emphysema
d. hx of bhronodilator use - ANSWER -b. unequal breath sounds -- Sudden onset
of respiratory distress frequently indicates aspiration of a foreign body, so
assessment should include bilateral breath sounds to determine if there is
obstruction.
The nurse is caring for a patient who has a serum potassium level of 2.2 mEq/L.
The nurse would question orders for
aldactone (Spironolactone)
magnesium sulfate
potassium
furosemide (Lasix) - ANSWER -Lasix -- Lasix should be given cautiously in
hypokalemic patients as Lasix is not potassium-sparing and can cause increased
hypokalemia. Aldactone (Spironolactone) is a potassium sparing diuretic.
Hypokalemia is associated with hypomagnesemia, and the severity of the
hypokalemia correlates with a similar degree of hypomagnesemia. Magnesium
replacement should usually accompany potassium repletion