CSEP-
CEP Profession
vb
EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE
QUESTIONS
Thevbnursevbisvbcaringvbforvbavbclientvbwithvbavbcerebrovascularvbaccidentvb(CVA)vbwhovbisvbreceivingvbenteralvbtubevbfeed
gs.vbWhichvbtaskvbperformedvbbyvbthevbUAPvbrequiresvbimmediatevbinterventionvbbyvbthevbnurse?
A.Suctionsvboralvbsecretionsvbfromvbmouth
B.Positionsvbheadvbofvbbedvbflatvbwhenvbchangingvbsheets
C.Takesvbtemperaturevbusingvbthevbaxillaryvbmethod
D.Keepsvbheadvbofvbbedvbelevatedvbatvb30vbdegreesvb-vbanswer--B
Rationale:
Positioningvbthevbheadvbofvbthevbbedvbflatvbwhenvbenteralvbfeedingsvbarevbinvbprogressvbputsvbthevbclientvbatvbriskvbforvbasp
ationvb(B).vbThevbothersvbarevballvbacceptablevbtasksvbperformedvbbyvbthevbUAPvb(A,vbC,vbandvbD).
Whenvbcaringvbforvbavbpostsurgicalvbclientvbwhovbhasvbundergonevbmultiplevbbloodvbtransfusions,vbwhichvbserumvblabora
ryvbfindingvbisvbofvbmostvbconcernvbtovbthevbnurse?
A.Sodiumvblevel,vb137vbmEq/L
B.Potassiumvblevel,vb5.5vbmEq/L
C.Bloodvbureavbnitrogenvb(BUN)vblevel,vb18vbmg/dL
D.Calciumvblevel,vb10vbmEq/Lvb-vbanswer--B
Rationale:
Multiplevbbloodvbtransfusionsvbarevbavbriskvbfactorvbforvbhyperkalemia.vbAvbserumvbpotassiumvblevelvbhighervbthanvb5.0vbm
q/Lvbindicatesvbhyperkalemiavb(B).vbThevbothersvbarevbnormalvbfindingsvb(A,vbC,vbandvbD).
Whichvbvaccinationvbshouldvbthevbnursevbadministervbtovbavbnewborn?
A.HepatitisvbB
B.Humanvbpapillomavbvirusvb(HPV)
C.Varicella
D.Meningococcalvbvaccinevb-vbanswer--A
Rationale:
ThevbhepatitisvbBvbvaccinationvbshouldvbbevbgivenvbtovballvbnewbornsvbbeforevbhospitalvbdischargevb(A).vbHPVvbisvbnotvbre
ommendedvbuntilvbadolescencevb(B).vbVaricellavbimmunizationvbbeginsvbatvb12vbmonthsvb(C).vbMeningococcalvbvaccine
svbadministeredvbbeginningvbatvb2vbyearsvb(D).
Thevbnursevbisvbcaringvbforvbavbclientvbonvbthevbmedicalvbunit.vbWhichvbtaskvbcanvbbevbdelegatedvbtovbunlicensedvbassistiv
personnelvb(UAP)?
A.Assessvbthevbneedvbtovbchangevbavbcentralvblinevbdressing.
B.Obtainvbavbfingerstickvbbloodvbglucosevblevel.
C.Answervbavbfamilyvbmember'svbquestionsvbaboutvbthevbclient'svbplanvbofvbcare.
D.Teachvbthevbclientvbsidevbeffectsvbtovbreportvbrelatedvbtovbthevbcurrentvbmedicationvbregimen.vb-vbanswer--B
Rationale:
ObtainingvbavbfingerstickvbbloodvbglucosevblevelvbisvbavbsimplevbtreatmentvbandvbisvbanvbappropriatevbskillvbforvbUAPvbtovbp
formvb(B).vb(A,vbC,vbandvbD)vbarevbskillsvbthatvbcannotvbbevbdelegatedvbtovbUAP.
Thevbnursevbisvbcaringvbforvbavbclientvbwithvbanvbischemicvbstrokevbwhovbhasvbavbprescriptionvbforvbtissuevbplasminogenvba
vatorvb(t-PA)vbIV.vbWhichvbaction(s)vbshouldvbthevbnursevbexpectvbtovbimplement?vb(Selectvballvbthatvbapply.)
1vb/
vb25
, CSEP-
CEP Profession
vb
A.Administervbaspirinvbwithvbtissuevbplasminogenvbactivatorvb(t-PA).
B.CompletevbthevbNationalvbInstitutevbofvbHealthvbStrokevbScalevb(NIHSS).
C.Assessvbthevbclientvbforvbsignsvbofvbbleedingvbduringvbandvbaftervbthevbinfusion.
D.Startvbt-PAvbwithinvb6vbhoursvbaftervbthevbonsetvbofvbstrokevbsymptoms.
E.Initiatevbmultidisciplinaryvbconsultvbforvbpotentialvbrehabilitation.vb-vbanswer--B,C,E
Rationale:
Neurologicvbassessment,vbincludingvbthevbNIHSS,vbisvbindicatedvbforvbthevbclientvbreceivingvbt-
PA.vbThisvbincludesvbclosevbmonitoringvbforvbbleedingvbduringvbandvbaftervbthevbinfusion;vbifvbbleedingvborvbothervbsignsvbo
neurologicvbimpairmentvboccur,vbthevbinfusionvbshouldvbbevbstoppedvb(B,vbC,vbandvbE).vbAspirinvbisvbcontraindicatedvbwit
t-PAvbbecausevbitvbincreasesvbthevbriskvbforvbbleedingvb(A).vbThevbadministrationvbofvbt-
PAvbwithinvb6vbhoursvbofvbsymptomsvbisvbconcurrentvbwithvbavbdiagnosisvbofvbavbmyocardialvbinfarctionvbandvbwithinvb4.5vb
ursvbofvbsymptomsvbisvbconcurrentvbforvbavbstrokevb(D).
Whenvbcaringvbforvbavbclientvbinvblabor,vbwhichvbfindingvbisvbmostvbimportantvbtovbreportvbtovbthevbprimaryvbhealthvbcarevbpr
ider?
A.Maternalvbheartvbrate,vb90vbbeats/min.
B.Fetalvbheartvbrate,vb100vbbeats/min
C.Maternalvbbloodvbpressure,vb140/86vbmmvbHg
D.Maternalvbtemperature,vb100.0°vbFvb-vbanswer--B
Rationale:
Avbfetalvbheartvbratevb(FHR)vbofvb100vbbeats/
minvbmayvbindicatevbfetalvbdistressvb(B)vbbecausevbthevbaveragevbFHRvbatvbtermvbisvb140vbbeats/
minvbandvbthevbnormalvbrangevbisvb110vbtovbbeats/
minvb160.vbThevbothersvb(A,vbC,vbandvbD)vbarevbnormalvbfindingsvbforvbavbwomanvbinvblabor.
Thevbnursevbisvbcaringvbforvbavbclientvbwithvbheartvbfailurevbwhovbdevelopsvbrespiratoryvbdistressvbandvbcoughsvbupvbpinkv
othyvbsputum.vbWhichvbactionvbshouldvbthevbnursevbtakevbfirst?
A.Drawvbarterialvbbloodvbgases.
B.Notifyvbthevbprimaryvbhealthvbcarevbprovider.
C.PositionvbinvbavbhighvbFowler'svbpositionvbwithvbthevblegsvbdown.
D.ObtainvbavbchestvbX-ray.vb-vbanswer--C
Rationale:
PositioningvbthevbpatientvbinvbavbhighvbFowler'svbpositionvbwithvbdanglingvbfeetvbwillvbdecreasevbfurthervbvenousvbreturnvbt
thevbleftvbventriclevb(C).vbThevbothervbactionsvbshouldvbbevbperformedvbaftervbthevbchangevbinvbpositionvb(A,vbB,vbandvbD).
AvbclientvbwhovbisvbprescribedvbchlorpromazinevbHClvb(Thorazine)vbforvbschizophreniavbdevelopsvbrigidity,vbavbshufflingv
ait,vbandvbtremors.vbWhichvbactionvbbyvbthevbnursevbisvbmostvbimportant?
A.Administervbavbdosevbofvbbenztropinevbmesylatevb(Cogentin)vbPRN.
B.Determinevbifvbthevbclientvbhasvbincreasedvbphotosensitivity.
C.Providevbcomfortvbmeasuresvbforvbsorevbmuscles.
D.Assessvbthevbclientvbforvbvisualvbandvbauditoryvbhallucinations.vb-vbanswer--A
Rationale:
Rigidity,vbshufflingvbgait,vbpill-
rollingvbhandvbmovements,vbtremors,vbdyskinesia,vbandvbmasklikevbfacevbarevbextrapyramidalvbsidevbeffectsvbassociate
withvbThorazine.vbItvbisvbmostvbimportantvbforvbthevbnursevbtovbadministervbanvbanticholinergicvbsuchvbasvbCogentinvbtovbre
ersevbthesevbeffectsvb(A).vbThevbothersvb(B,vbC,vbD)vbmayvbbevbappropriatevbinterventionsvbbutvbarevbnotvbasvburgentvbasvb
).
Avbnursevbisvbinterviewingvbavbmothervbduringvbavbwell-
childvbvisit.vbWhichvbfindingvbwouldvbalertvbthevbnursevbtovbcontinuevbfurthervbassessmentvbofvbthevbinfant?
A.Two-month-oldvbwhovbisvbunablevbtovbrollvbfromvbbackvbtovbabdomen
2vb/
vb25
, CSEP-
CEP Profession
vb
B.Ten-month-oldvbwhovbcannotvbsitvbwithoutvbsupport
C.Nine-month-oldvbwhovbcriesvbwhenvbhisvbmothervbleavesvbthevbroom
D.Eight-month-oldvbwhovbhasvbnotvbyetvbbegunvbtovbspeakvbwordsvb-vbanswer--B
Rationale:
Asvbavbdevelopmentalvbmilestone,vbinfantsvbshouldvbsitvbunsupportedvbbyvb8vbmonthsvb(B).vbThevbmilestonevbofvbrollingvb
ervbisvbachievedvbatvb5vbtovb6vbmonthsvbforvbmostvbinfantsvb(A).vbStrangervbanxietyvbisvbcommonvbfromvb7vbtovb9vbmonthsvb(
.vbSpeakingvbavbfewvbwordsvbisvbexpectedvbatvbaboutvb12vbmonthsvb(D).
Whichvbinterventionvbshouldvbbevbincludedvbinvbthevbplanvbofvbcarevbforvbavbclientvbadmittedvbtovbthevbhospitalvbwithvbulcer
vevbcolitis?
A.Administervbstoolvbsofteners.
B.Placevbthevbclientvbonvbfluidvbrestriction.
C.Providevbavblow-residuevbdiet.
D.Addvbavbmilkvbproductvbtovbeachvbmeal.vb-vbanswer--C
Rationale:
Avblow-
residuevbdietvb(C)vbwillvbhelpvbdecreasevbsymptomsvbofvbdiarrhea,vbwhichvbarevbclinicalvbmanifestationsvbofvbulcerativevbc
itis.vb(A,vbB,vbandvbD)vbarevbcontraindicatedvbandvbcouldvbworsenvbthevbcondition.
ThevbnursevbisvbcaringvbforvbavbclientvbwithvbdeepvbveinvbthrombosisvbwhovbisvbonvbavbcontinuousvbIVvbheparinvbinfusion.vbT
evbactivatedvbpartialvbprothrombinvbtimevb(aPTT)vbisvb120vbseconds.vbWhichvbactionvbshouldvbthevbnursevbtake?
A.Increasevbthevbratevbofvbthevbheparinvbinfusionvbusingvbavbnomogram.
B.DecreasevbthevbheparinvbinfusionvbratevbandvbgivevbvitaminvbKvbIM.
C.Continuevbthevbheparinvbinfusionvbatvbthevbcurrentvbprescribedvbrate.
D.Stopvbthevbheparinvbdripvbandvbpreparevbtovbadministervbprotaminevbsulfate.vb-vbanswer--D
Rationale:
AnvbaPTTvbmorevbthanvb100vbsecondsvbisvbavbcriticallyvbhighvbvalue;vbtherefore,vbthevbheparinvbshouldvbbevbstopped.vbTh
antidotevbforvbheparinvbisvbprotaminevbsulfatevb(D).vbIncreasingvbthevbratevbwouldvbincreasevbthevbriskvbforvbhemorrhagev
).vbThevbinfusionvbshouldvbbevbstopped,vbandvbvitaminvbKvbisvbthevbantidotevbforvbwarfarinvb(Coumadin)vb(B).vbKeepingvbth
binfusionvbatvbthevbcurrentvbratevbwouldvbincreasevbthevbriskvbforvbhemorrhagevb(C).
Whilevbassessingvbavbclientvbwithvbrecurringvbchestvbpain,vbthevbunitvbsecretaryvbnotifiesvbthevbnursevbthatvbthevbclient'svbh
althvbcarevbprovidervbisvbonvbthevbtelephone.vbWhatvbactionvbshouldvbthevbnursevbinstructvbthevbunitvbsecretaryvbtovbimplem
nt?
A.Transfervbthevbcallvbintovbthevbroomvbofvbthevbclient.
B.Instructvbthevbsecretaryvbtovbexplainvbreasonvbforvbthevbcall.
C.Askvbanothervbnursevbtovbtakevbthevbphonevbcall.
D.Askvbthevbhealthvbcarevbprovidervbtovbseevbthevbclientvbonvbthevbunit.vb-vbanswer--C
Rationale:
Anothervbnursevbshouldvbbevbaskedvbtovbtakevbthevbphonevbcallvb(C),vbwhichvballowsvbthevbnursevbtovbstayvbatvbthevbbedsid
btovbcompletevbthevbassessmentvbofvbthevbclient'svbchestvbpain.vb(AvbandvbB)vbshouldvbnotvbbevbdonevbduringvbanvbacutevbc
angevbinvbthevbclient'svbcondition.vbRequestingvbthevbhealthvbcarevbprovidervb(D)vbtovbcomevbtovbthevbunitvbisvbprematurevb
tilvbthevbnursevbcompletesvbassessmentvbofvbthevbclient'svbstatus.
Whichvbinstruction(s)vbshouldvbthevbnursevbincludevbinvbthevbdischargevbteachingvbplanvbofvbavbmalevbclientvbwhovbhasvbha
bavbmyocardialvbinfarctionvbandvbwhovbhasvbavbnewvbprescriptionvbforvbnitroglycerinvb(NTG)?vb(Selectvballvbthatvbapply.)
A.Keepvbthevbmedicationvbinvbyourvbpocketvbsovbthatvbitvbcanvbbevbaccessedvbquickly.
B.Callvb911vbifvbchestvbpainvbisvbnotvbrelievedvbaftervbonevbnitroglycerin.
C.Storevbthevbmedicationvbinvbitsvboriginalvbcontainervbandvbprotectvbitvbfromvblight.
D.Activatevbthevbemergencyvbmedicalvbsystemvbaftervbthreevbdosesvbofvbmedication.
E.Dovbnotvbusevbwithinvb1vbhourvbofvbtakingvbsildenafilvbcitratevb(Viagra).vb-vbanswer--B,C
3vb/
vb25
CEP Profession
vb
EXIT HESI COMPREHENSIVE B EVOLVE PRACTICE
QUESTIONS
Thevbnursevbisvbcaringvbforvbavbclientvbwithvbavbcerebrovascularvbaccidentvb(CVA)vbwhovbisvbreceivingvbenteralvbtubevbfeed
gs.vbWhichvbtaskvbperformedvbbyvbthevbUAPvbrequiresvbimmediatevbinterventionvbbyvbthevbnurse?
A.Suctionsvboralvbsecretionsvbfromvbmouth
B.Positionsvbheadvbofvbbedvbflatvbwhenvbchangingvbsheets
C.Takesvbtemperaturevbusingvbthevbaxillaryvbmethod
D.Keepsvbheadvbofvbbedvbelevatedvbatvb30vbdegreesvb-vbanswer--B
Rationale:
Positioningvbthevbheadvbofvbthevbbedvbflatvbwhenvbenteralvbfeedingsvbarevbinvbprogressvbputsvbthevbclientvbatvbriskvbforvbasp
ationvb(B).vbThevbothersvbarevballvbacceptablevbtasksvbperformedvbbyvbthevbUAPvb(A,vbC,vbandvbD).
Whenvbcaringvbforvbavbpostsurgicalvbclientvbwhovbhasvbundergonevbmultiplevbbloodvbtransfusions,vbwhichvbserumvblabora
ryvbfindingvbisvbofvbmostvbconcernvbtovbthevbnurse?
A.Sodiumvblevel,vb137vbmEq/L
B.Potassiumvblevel,vb5.5vbmEq/L
C.Bloodvbureavbnitrogenvb(BUN)vblevel,vb18vbmg/dL
D.Calciumvblevel,vb10vbmEq/Lvb-vbanswer--B
Rationale:
Multiplevbbloodvbtransfusionsvbarevbavbriskvbfactorvbforvbhyperkalemia.vbAvbserumvbpotassiumvblevelvbhighervbthanvb5.0vbm
q/Lvbindicatesvbhyperkalemiavb(B).vbThevbothersvbarevbnormalvbfindingsvb(A,vbC,vbandvbD).
Whichvbvaccinationvbshouldvbthevbnursevbadministervbtovbavbnewborn?
A.HepatitisvbB
B.Humanvbpapillomavbvirusvb(HPV)
C.Varicella
D.Meningococcalvbvaccinevb-vbanswer--A
Rationale:
ThevbhepatitisvbBvbvaccinationvbshouldvbbevbgivenvbtovballvbnewbornsvbbeforevbhospitalvbdischargevb(A).vbHPVvbisvbnotvbre
ommendedvbuntilvbadolescencevb(B).vbVaricellavbimmunizationvbbeginsvbatvb12vbmonthsvb(C).vbMeningococcalvbvaccine
svbadministeredvbbeginningvbatvb2vbyearsvb(D).
Thevbnursevbisvbcaringvbforvbavbclientvbonvbthevbmedicalvbunit.vbWhichvbtaskvbcanvbbevbdelegatedvbtovbunlicensedvbassistiv
personnelvb(UAP)?
A.Assessvbthevbneedvbtovbchangevbavbcentralvblinevbdressing.
B.Obtainvbavbfingerstickvbbloodvbglucosevblevel.
C.Answervbavbfamilyvbmember'svbquestionsvbaboutvbthevbclient'svbplanvbofvbcare.
D.Teachvbthevbclientvbsidevbeffectsvbtovbreportvbrelatedvbtovbthevbcurrentvbmedicationvbregimen.vb-vbanswer--B
Rationale:
ObtainingvbavbfingerstickvbbloodvbglucosevblevelvbisvbavbsimplevbtreatmentvbandvbisvbanvbappropriatevbskillvbforvbUAPvbtovbp
formvb(B).vb(A,vbC,vbandvbD)vbarevbskillsvbthatvbcannotvbbevbdelegatedvbtovbUAP.
Thevbnursevbisvbcaringvbforvbavbclientvbwithvbanvbischemicvbstrokevbwhovbhasvbavbprescriptionvbforvbtissuevbplasminogenvba
vatorvb(t-PA)vbIV.vbWhichvbaction(s)vbshouldvbthevbnursevbexpectvbtovbimplement?vb(Selectvballvbthatvbapply.)
1vb/
vb25
, CSEP-
CEP Profession
vb
A.Administervbaspirinvbwithvbtissuevbplasminogenvbactivatorvb(t-PA).
B.CompletevbthevbNationalvbInstitutevbofvbHealthvbStrokevbScalevb(NIHSS).
C.Assessvbthevbclientvbforvbsignsvbofvbbleedingvbduringvbandvbaftervbthevbinfusion.
D.Startvbt-PAvbwithinvb6vbhoursvbaftervbthevbonsetvbofvbstrokevbsymptoms.
E.Initiatevbmultidisciplinaryvbconsultvbforvbpotentialvbrehabilitation.vb-vbanswer--B,C,E
Rationale:
Neurologicvbassessment,vbincludingvbthevbNIHSS,vbisvbindicatedvbforvbthevbclientvbreceivingvbt-
PA.vbThisvbincludesvbclosevbmonitoringvbforvbbleedingvbduringvbandvbaftervbthevbinfusion;vbifvbbleedingvborvbothervbsignsvbo
neurologicvbimpairmentvboccur,vbthevbinfusionvbshouldvbbevbstoppedvb(B,vbC,vbandvbE).vbAspirinvbisvbcontraindicatedvbwit
t-PAvbbecausevbitvbincreasesvbthevbriskvbforvbbleedingvb(A).vbThevbadministrationvbofvbt-
PAvbwithinvb6vbhoursvbofvbsymptomsvbisvbconcurrentvbwithvbavbdiagnosisvbofvbavbmyocardialvbinfarctionvbandvbwithinvb4.5vb
ursvbofvbsymptomsvbisvbconcurrentvbforvbavbstrokevb(D).
Whenvbcaringvbforvbavbclientvbinvblabor,vbwhichvbfindingvbisvbmostvbimportantvbtovbreportvbtovbthevbprimaryvbhealthvbcarevbpr
ider?
A.Maternalvbheartvbrate,vb90vbbeats/min.
B.Fetalvbheartvbrate,vb100vbbeats/min
C.Maternalvbbloodvbpressure,vb140/86vbmmvbHg
D.Maternalvbtemperature,vb100.0°vbFvb-vbanswer--B
Rationale:
Avbfetalvbheartvbratevb(FHR)vbofvb100vbbeats/
minvbmayvbindicatevbfetalvbdistressvb(B)vbbecausevbthevbaveragevbFHRvbatvbtermvbisvb140vbbeats/
minvbandvbthevbnormalvbrangevbisvb110vbtovbbeats/
minvb160.vbThevbothersvb(A,vbC,vbandvbD)vbarevbnormalvbfindingsvbforvbavbwomanvbinvblabor.
Thevbnursevbisvbcaringvbforvbavbclientvbwithvbheartvbfailurevbwhovbdevelopsvbrespiratoryvbdistressvbandvbcoughsvbupvbpinkv
othyvbsputum.vbWhichvbactionvbshouldvbthevbnursevbtakevbfirst?
A.Drawvbarterialvbbloodvbgases.
B.Notifyvbthevbprimaryvbhealthvbcarevbprovider.
C.PositionvbinvbavbhighvbFowler'svbpositionvbwithvbthevblegsvbdown.
D.ObtainvbavbchestvbX-ray.vb-vbanswer--C
Rationale:
PositioningvbthevbpatientvbinvbavbhighvbFowler'svbpositionvbwithvbdanglingvbfeetvbwillvbdecreasevbfurthervbvenousvbreturnvbt
thevbleftvbventriclevb(C).vbThevbothervbactionsvbshouldvbbevbperformedvbaftervbthevbchangevbinvbpositionvb(A,vbB,vbandvbD).
AvbclientvbwhovbisvbprescribedvbchlorpromazinevbHClvb(Thorazine)vbforvbschizophreniavbdevelopsvbrigidity,vbavbshufflingv
ait,vbandvbtremors.vbWhichvbactionvbbyvbthevbnursevbisvbmostvbimportant?
A.Administervbavbdosevbofvbbenztropinevbmesylatevb(Cogentin)vbPRN.
B.Determinevbifvbthevbclientvbhasvbincreasedvbphotosensitivity.
C.Providevbcomfortvbmeasuresvbforvbsorevbmuscles.
D.Assessvbthevbclientvbforvbvisualvbandvbauditoryvbhallucinations.vb-vbanswer--A
Rationale:
Rigidity,vbshufflingvbgait,vbpill-
rollingvbhandvbmovements,vbtremors,vbdyskinesia,vbandvbmasklikevbfacevbarevbextrapyramidalvbsidevbeffectsvbassociate
withvbThorazine.vbItvbisvbmostvbimportantvbforvbthevbnursevbtovbadministervbanvbanticholinergicvbsuchvbasvbCogentinvbtovbre
ersevbthesevbeffectsvb(A).vbThevbothersvb(B,vbC,vbD)vbmayvbbevbappropriatevbinterventionsvbbutvbarevbnotvbasvburgentvbasvb
).
Avbnursevbisvbinterviewingvbavbmothervbduringvbavbwell-
childvbvisit.vbWhichvbfindingvbwouldvbalertvbthevbnursevbtovbcontinuevbfurthervbassessmentvbofvbthevbinfant?
A.Two-month-oldvbwhovbisvbunablevbtovbrollvbfromvbbackvbtovbabdomen
2vb/
vb25
, CSEP-
CEP Profession
vb
B.Ten-month-oldvbwhovbcannotvbsitvbwithoutvbsupport
C.Nine-month-oldvbwhovbcriesvbwhenvbhisvbmothervbleavesvbthevbroom
D.Eight-month-oldvbwhovbhasvbnotvbyetvbbegunvbtovbspeakvbwordsvb-vbanswer--B
Rationale:
Asvbavbdevelopmentalvbmilestone,vbinfantsvbshouldvbsitvbunsupportedvbbyvb8vbmonthsvb(B).vbThevbmilestonevbofvbrollingvb
ervbisvbachievedvbatvb5vbtovb6vbmonthsvbforvbmostvbinfantsvb(A).vbStrangervbanxietyvbisvbcommonvbfromvb7vbtovb9vbmonthsvb(
.vbSpeakingvbavbfewvbwordsvbisvbexpectedvbatvbaboutvb12vbmonthsvb(D).
Whichvbinterventionvbshouldvbbevbincludedvbinvbthevbplanvbofvbcarevbforvbavbclientvbadmittedvbtovbthevbhospitalvbwithvbulcer
vevbcolitis?
A.Administervbstoolvbsofteners.
B.Placevbthevbclientvbonvbfluidvbrestriction.
C.Providevbavblow-residuevbdiet.
D.Addvbavbmilkvbproductvbtovbeachvbmeal.vb-vbanswer--C
Rationale:
Avblow-
residuevbdietvb(C)vbwillvbhelpvbdecreasevbsymptomsvbofvbdiarrhea,vbwhichvbarevbclinicalvbmanifestationsvbofvbulcerativevbc
itis.vb(A,vbB,vbandvbD)vbarevbcontraindicatedvbandvbcouldvbworsenvbthevbcondition.
ThevbnursevbisvbcaringvbforvbavbclientvbwithvbdeepvbveinvbthrombosisvbwhovbisvbonvbavbcontinuousvbIVvbheparinvbinfusion.vbT
evbactivatedvbpartialvbprothrombinvbtimevb(aPTT)vbisvb120vbseconds.vbWhichvbactionvbshouldvbthevbnursevbtake?
A.Increasevbthevbratevbofvbthevbheparinvbinfusionvbusingvbavbnomogram.
B.DecreasevbthevbheparinvbinfusionvbratevbandvbgivevbvitaminvbKvbIM.
C.Continuevbthevbheparinvbinfusionvbatvbthevbcurrentvbprescribedvbrate.
D.Stopvbthevbheparinvbdripvbandvbpreparevbtovbadministervbprotaminevbsulfate.vb-vbanswer--D
Rationale:
AnvbaPTTvbmorevbthanvb100vbsecondsvbisvbavbcriticallyvbhighvbvalue;vbtherefore,vbthevbheparinvbshouldvbbevbstopped.vbTh
antidotevbforvbheparinvbisvbprotaminevbsulfatevb(D).vbIncreasingvbthevbratevbwouldvbincreasevbthevbriskvbforvbhemorrhagev
).vbThevbinfusionvbshouldvbbevbstopped,vbandvbvitaminvbKvbisvbthevbantidotevbforvbwarfarinvb(Coumadin)vb(B).vbKeepingvbth
binfusionvbatvbthevbcurrentvbratevbwouldvbincreasevbthevbriskvbforvbhemorrhagevb(C).
Whilevbassessingvbavbclientvbwithvbrecurringvbchestvbpain,vbthevbunitvbsecretaryvbnotifiesvbthevbnursevbthatvbthevbclient'svbh
althvbcarevbprovidervbisvbonvbthevbtelephone.vbWhatvbactionvbshouldvbthevbnursevbinstructvbthevbunitvbsecretaryvbtovbimplem
nt?
A.Transfervbthevbcallvbintovbthevbroomvbofvbthevbclient.
B.Instructvbthevbsecretaryvbtovbexplainvbreasonvbforvbthevbcall.
C.Askvbanothervbnursevbtovbtakevbthevbphonevbcall.
D.Askvbthevbhealthvbcarevbprovidervbtovbseevbthevbclientvbonvbthevbunit.vb-vbanswer--C
Rationale:
Anothervbnursevbshouldvbbevbaskedvbtovbtakevbthevbphonevbcallvb(C),vbwhichvballowsvbthevbnursevbtovbstayvbatvbthevbbedsid
btovbcompletevbthevbassessmentvbofvbthevbclient'svbchestvbpain.vb(AvbandvbB)vbshouldvbnotvbbevbdonevbduringvbanvbacutevbc
angevbinvbthevbclient'svbcondition.vbRequestingvbthevbhealthvbcarevbprovidervb(D)vbtovbcomevbtovbthevbunitvbisvbprematurevb
tilvbthevbnursevbcompletesvbassessmentvbofvbthevbclient'svbstatus.
Whichvbinstruction(s)vbshouldvbthevbnursevbincludevbinvbthevbdischargevbteachingvbplanvbofvbavbmalevbclientvbwhovbhasvbha
bavbmyocardialvbinfarctionvbandvbwhovbhasvbavbnewvbprescriptionvbforvbnitroglycerinvb(NTG)?vb(Selectvballvbthatvbapply.)
A.Keepvbthevbmedicationvbinvbyourvbpocketvbsovbthatvbitvbcanvbbevbaccessedvbquickly.
B.Callvb911vbifvbchestvbpainvbisvbnotvbrelievedvbaftervbonevbnitroglycerin.
C.Storevbthevbmedicationvbinvbitsvboriginalvbcontainervbandvbprotectvbitvbfromvblight.
D.Activatevbthevbemergencyvbmedicalvbsystemvbaftervbthreevbdosesvbofvbmedication.
E.Dovbnotvbusevbwithinvb1vbhourvbofvbtakingvbsildenafilvbcitratevb(Viagra).vb-vbanswer--B,C
3vb/
vb25
