NS520 Exam 1 Material
UPDATED ACTUAL Questions and CORRECT Answers
Question: The nurse is administering a medica- tion to a client with myeloid leukemia and does not
know the use, dose, or side effects. To obtain the most up-to-date information about this
drug, what should the nurse do? A: Check a commercially published drug guide. B: Read a
pharmacology textbook. C: Consult the drug guide provided by the clinical agency. D:
Review information at the drug manufacturer's website.
Correct Answer: C. The most current pharmacology information is found in the clinical agency's drug
guide. A com- mercially published drug guide and pharmacology textbooks are
outdated once published, therefore may not have current information. The
manufactur- er's website has the potential for bias.
Question: The patient with right upper quad- rant abdominal pain has an abdomi- nal ultrasound that
reveals cholelithi- asis. What is the nurse's priority? A: Prevent all oral intake. B: Control
abdominal pain. C: Provide enteral feedings. D: Avoid dietary cholesterol.
Correct Answer: B. Patients with cholelithiasis can have se- vere pain, so controlling pain is important
until the problem can be treated. NPO status may be needed if the patient will have
surgery but will not be used for all patients with cholelithiasis. Patients with pan-
creatitis may be NPO. Enteral feedings should not be needed, and avoiding dietary
cholesterol is not used to treat cholelithiasis.
Question: A patient with a gunshot wound to the right side of the chest arrives in the emergency
department with severe shortness of breath and decreased breath sounds on the right side of
the chest. Which action should the nurse take immediately? A. Cover the chest wound with a
non- porous dressing taped on three sides. B. Pack the chest wound with sterile saline soaked
gauze and tape secure- ly. C. Stabilize the chest wall with tape and initiate positive pressure
ventila- tion. D. Apply a pressure dressing over the wound to prevent excessive loss of
blood.
, Correct Answer: A. The patient has a sucking chest wound (open pneumothorax). Air enters the
pleural space through the chest wall during inspiration. Emer- gency treatment
consists of covering the wound with an occlusive dressing that is secured on three
sides. During inspiration, the dressing pulls against the wound, preventing air from
entering the pleural space. During expiration, the dressing is pushed out and air
escapes through the wound and from under the dressing.
Question: The nurse is performing a respirato- ry assessment for a patient admitted with pneumonia.
Which clinical man- ifestation would the nurse expect to find? A. Hyperresonance on
percussion B. Vesicular breath sounds in all lobes C. Increased vocal fremitus on palpa- tion
D. Fine crackles in all lobes on auscul- tation
Correct Answer: C. A typical physical examination finding for a patient with pneumonia is increased
vocal fremi- tus on palpation. Other signs of pulmonary consol- idation include
bronchial breath sounds, egopho- ny, and crackles in the affected area. With pleural
effusion, there may be dullness to percussion over the affected area.
Question: The nurse is performing a respiratory assessment. Which finding best sup- ports the presence
of impaired airway clearance? A: Basilar crackles B: Oxygen saturation of 85% C: Presence
of greenish sputum D: Respiratory rate of 28 breaths/min
Correct Answer: A. The presence of adventitious breath sounds indicates that there is accumulation of
se- cretions in the lower airways. This would be con- sistent with impaired airway
clearance because the patient is retaining secretions. The rapid respiratory rate, low
oxygen saturation, and presence of green- ish sputum may occur with other lower
respiratory problems.
Question: An order is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that
treat- ment of pain is not a standard thera- peutic indication or dose for this drug. The nurse
believes that the health care provider meant to write hydromor- phone. What should the
nurse do? A: Call the health care provider to clar- ify the order. B. Give the patient
hydromorphone, as it was meant to be written. C. Administer the medication and monitor the
UPDATED ACTUAL Questions and CORRECT Answers
Question: The nurse is administering a medica- tion to a client with myeloid leukemia and does not
know the use, dose, or side effects. To obtain the most up-to-date information about this
drug, what should the nurse do? A: Check a commercially published drug guide. B: Read a
pharmacology textbook. C: Consult the drug guide provided by the clinical agency. D:
Review information at the drug manufacturer's website.
Correct Answer: C. The most current pharmacology information is found in the clinical agency's drug
guide. A com- mercially published drug guide and pharmacology textbooks are
outdated once published, therefore may not have current information. The
manufactur- er's website has the potential for bias.
Question: The patient with right upper quad- rant abdominal pain has an abdomi- nal ultrasound that
reveals cholelithi- asis. What is the nurse's priority? A: Prevent all oral intake. B: Control
abdominal pain. C: Provide enteral feedings. D: Avoid dietary cholesterol.
Correct Answer: B. Patients with cholelithiasis can have se- vere pain, so controlling pain is important
until the problem can be treated. NPO status may be needed if the patient will have
surgery but will not be used for all patients with cholelithiasis. Patients with pan-
creatitis may be NPO. Enteral feedings should not be needed, and avoiding dietary
cholesterol is not used to treat cholelithiasis.
Question: A patient with a gunshot wound to the right side of the chest arrives in the emergency
department with severe shortness of breath and decreased breath sounds on the right side of
the chest. Which action should the nurse take immediately? A. Cover the chest wound with a
non- porous dressing taped on three sides. B. Pack the chest wound with sterile saline soaked
gauze and tape secure- ly. C. Stabilize the chest wall with tape and initiate positive pressure
ventila- tion. D. Apply a pressure dressing over the wound to prevent excessive loss of
blood.
, Correct Answer: A. The patient has a sucking chest wound (open pneumothorax). Air enters the
pleural space through the chest wall during inspiration. Emer- gency treatment
consists of covering the wound with an occlusive dressing that is secured on three
sides. During inspiration, the dressing pulls against the wound, preventing air from
entering the pleural space. During expiration, the dressing is pushed out and air
escapes through the wound and from under the dressing.
Question: The nurse is performing a respirato- ry assessment for a patient admitted with pneumonia.
Which clinical man- ifestation would the nurse expect to find? A. Hyperresonance on
percussion B. Vesicular breath sounds in all lobes C. Increased vocal fremitus on palpa- tion
D. Fine crackles in all lobes on auscul- tation
Correct Answer: C. A typical physical examination finding for a patient with pneumonia is increased
vocal fremi- tus on palpation. Other signs of pulmonary consol- idation include
bronchial breath sounds, egopho- ny, and crackles in the affected area. With pleural
effusion, there may be dullness to percussion over the affected area.
Question: The nurse is performing a respiratory assessment. Which finding best sup- ports the presence
of impaired airway clearance? A: Basilar crackles B: Oxygen saturation of 85% C: Presence
of greenish sputum D: Respiratory rate of 28 breaths/min
Correct Answer: A. The presence of adventitious breath sounds indicates that there is accumulation of
se- cretions in the lower airways. This would be con- sistent with impaired airway
clearance because the patient is retaining secretions. The rapid respiratory rate, low
oxygen saturation, and presence of green- ish sputum may occur with other lower
respiratory problems.
Question: An order is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that
treat- ment of pain is not a standard thera- peutic indication or dose for this drug. The nurse
believes that the health care provider meant to write hydromor- phone. What should the
nurse do? A: Call the health care provider to clar- ify the order. B. Give the patient
hydromorphone, as it was meant to be written. C. Administer the medication and monitor the
