Solutions
1. A 19-yr-old patient presents to the emergency department
(ED) with multiple lacerations and
tissue avulsion of the left hand. Th epatient denies having any
previous vaccinations. What
would the nurse anticipate administering?
a. Tetanus immunoglobulin (TIG) only
b. TIG and tetanus-diphtheria toxoid (Td)
c. Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only
d. TIG and tetanus-diphtheria toxoid and pertussis vaccine
(Tdap) Correct Answer ANS: D
1. A patient being admitted with a stroke has right-sided facial
drooping and right-sided arm and
leg paralysis. Which other finding would the nurse expect?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions Correct Answer ANS:
D
1. A patient who had a transverse colectomy for diverticulosis
18 hours ago has nasogastric
suction. The patient reports anxiety and incisional pain. The
patient's respiratory rate is 32
breaths/min, and the arterial blood gases (ABGs) indicate
respiratory alkalosis with a normal
arterial oxygen level. Which action would the nurse take first?
a. Check to make sure the nasogastric tube is patent.
,b. Give the patient the PRN IV morphine sulfate 4 mg.
c. Notify the health care provider about the results.
d. Teach the patient to take slow, deep breaths when anxious.
Correct Answer ANS: B
1. A patient who has a small cell cancer of the lung develops
syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse would notify the
health care provider about which
assessment finding?
a. Serum hematocrit of 42%
b. Serum sodium of 120 mg/dL
c. Urinary output of 280 mL in 8 hours
d. Reported weight gain of 2.2 pounds (1 kg) Correct Answer
ANS: B
1. A patient who was admitted to the hospital with
hyperglycemia and newly diagnosed diabetes
is scheduled for discharge the second day after admission.
Which action is the priority for the
nurse?
a. Provide detailed information about dietary control of glucose.
b. Demonstrate blood glucose monitoring and insulin
administration.
c. Give information about the effects of exercise on glucose
control.
d. Instruct about the risk for cardiovascular disease with
hyperglycemia. Correct Answer ANS: B
1. How will the nurse assess for flank tenderness in a patient
with suspected pyelonephritis?
, a. Palpate along both sides of the lumbar vertebral column.
b. Strike a flat hand covering the costovertebral angle (CVA).
c. Push fingers upward into the two lowest intercostal spaces.
d. Percuss between the iliac crest and ribs at the midaxillary line.
Correct Answer ANS: B
1. Which action would the nurse implement when caring for a
patient who has an acute
exacerbation of polycythemia vera?
a. Place the patient on bed rest.
b. Administer iron supplements.
c. Avoid use of aspirin products.
d. Monitor fluid intake and output. Correct Answer ANS: D
1. Which laboratory test result will the nurse monitor to evaluate
the effects of therapy for a
patient who has acute pancreatitis?
a. Lipase
b. Calcium
c. Bilirubin
d. Potassium Correct Answer ANS: A
1. Which laboratory value would the nurse review to determine
whether a patient's
hypothyroidism is caused by a problem with the anterior
pituitary gland?
a. Thyroxine (T4) level
b. Triiodothyronine (T3) level
c. Thyroid-stimulating hormone (TSH) level
d. Thyrotropin-releasing hormone (TRH) level Correct Answer
ANS: C