NSG 4800 EXAM WUTH ACTUAL QUESTIONS AND CORRECT ANSWERS
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which
sign, if noted, would be an early sign of excessive blood loss?
A .temperature of 100.4°F (38°C)
B. An increase in the pulse rate from 88 to 102 beats/minute
C. A blood pressure change from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22 breaths/minute - CORRECT ANSWER-B, During
the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked
every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss
because the heart pumps faster to compensate for reduced blood volume. A slight increase in
temperature is normal. The blood pressure decreases as the blood volume diminishes, but a
decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is
slightly increased from normal.
The nurse in the ambulatory care unit is providing home care instructions to a client after
cryotherapy for the treatment of malignant skin lesions. Which statement would be most
appropriate for the nurse to include in the home care instructions for this client?
"Apply ice to the site to prevent swelling."
"Clean the site with alcohol 3 times daily."
"Apply a warm, damp washcloth if discomfort occurs."
"Avoid showering or taking baths until seen by the health care provider in 1 week." - CORRECT
ANSWER-3, Cryotherapy involves the local application of liquid nitrogen to the lesion; this causes cell
death and tissue destruction. Tissue freezing is followed in 1 to 2 days by hemorrhagic blister
formation; therefore, ice is not applied to the site. The application of a warm, damp washcloth
intermittently to the site will provide relief of any discomfort. The nurse instructs the client to clean
, the site with the prescribed solution to prevent secondary infection. A topical antibiotic also may be
prescribed. Alcohol would cause irritation to the skin. There is no reason for the client to avoid
showering or bathing.
The registered nurse is caring for the following clients. It would be a priority for the nurse to initiate a
multidisciplinary conference for the client who is
A.12 years old with Autism who is starting a new school and recently had a URI (upper respiratory
tract infection)
B.39 years old, has type 2 Diabetes Mellitus, is homeless and had a recent Hemoglobin A1c of 13%
C.52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and is
employed as a mail carrier
D.79 years old, has bipolar and schizophrenia, lives alone and reports hearing non threatening voices.
- CORRECT ANSWER-B
A client with uncontrolled Diabetes Mellitus would require the greatest number of disciplines
(multidisciplinary) to manage their care i.e. Medicine, Nursing, Social Work, Nutritionist; the other
choices do not require as many providers of care to meet their needs.
A client is scheduled to begin therapy with carbamazepine. The nurse should assess the results of
which test(s) before administering the first dose of this medication to the client?
Liver function tests
Renal function tests
Pancreatic enzyme studies
Complete blood cell count - CORRECT ANSWER-D. Carbamazepine may be used to treat a seizure
disorder. It can cause leukopenia, anemia, thrombocytopenia, and, very rarely, fatal aplastic anemia.
To reduce the risk of serious hematological effects, a complete blood cell count should be done
before treatment and periodically thereafter. This medication should be avoided in clients with
preexisting hematological abnormalities. The client also is told to report the occurrence of fever, sore
throat, pallor, weakness, infection, easy bruising, and petechiae. The results of the remaining tests
listed in the options are not associated with the use of this medication.
A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood
glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting
insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now
decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which
medication?
An ampule of 50% dextrose
NPH insulin subcutaneously
IV fluids containing dextrose
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which
sign, if noted, would be an early sign of excessive blood loss?
A .temperature of 100.4°F (38°C)
B. An increase in the pulse rate from 88 to 102 beats/minute
C. A blood pressure change from 130/88 to 124/80 mm Hg
D. An increase in the respiratory rate from 18 to 22 breaths/minute - CORRECT ANSWER-B, During
the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked
every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss
because the heart pumps faster to compensate for reduced blood volume. A slight increase in
temperature is normal. The blood pressure decreases as the blood volume diminishes, but a
decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is
slightly increased from normal.
The nurse in the ambulatory care unit is providing home care instructions to a client after
cryotherapy for the treatment of malignant skin lesions. Which statement would be most
appropriate for the nurse to include in the home care instructions for this client?
"Apply ice to the site to prevent swelling."
"Clean the site with alcohol 3 times daily."
"Apply a warm, damp washcloth if discomfort occurs."
"Avoid showering or taking baths until seen by the health care provider in 1 week." - CORRECT
ANSWER-3, Cryotherapy involves the local application of liquid nitrogen to the lesion; this causes cell
death and tissue destruction. Tissue freezing is followed in 1 to 2 days by hemorrhagic blister
formation; therefore, ice is not applied to the site. The application of a warm, damp washcloth
intermittently to the site will provide relief of any discomfort. The nurse instructs the client to clean
, the site with the prescribed solution to prevent secondary infection. A topical antibiotic also may be
prescribed. Alcohol would cause irritation to the skin. There is no reason for the client to avoid
showering or bathing.
The registered nurse is caring for the following clients. It would be a priority for the nurse to initiate a
multidisciplinary conference for the client who is
A.12 years old with Autism who is starting a new school and recently had a URI (upper respiratory
tract infection)
B.39 years old, has type 2 Diabetes Mellitus, is homeless and had a recent Hemoglobin A1c of 13%
C.52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and is
employed as a mail carrier
D.79 years old, has bipolar and schizophrenia, lives alone and reports hearing non threatening voices.
- CORRECT ANSWER-B
A client with uncontrolled Diabetes Mellitus would require the greatest number of disciplines
(multidisciplinary) to manage their care i.e. Medicine, Nursing, Social Work, Nutritionist; the other
choices do not require as many providers of care to meet their needs.
A client is scheduled to begin therapy with carbamazepine. The nurse should assess the results of
which test(s) before administering the first dose of this medication to the client?
Liver function tests
Renal function tests
Pancreatic enzyme studies
Complete blood cell count - CORRECT ANSWER-D. Carbamazepine may be used to treat a seizure
disorder. It can cause leukopenia, anemia, thrombocytopenia, and, very rarely, fatal aplastic anemia.
To reduce the risk of serious hematological effects, a complete blood cell count should be done
before treatment and periodically thereafter. This medication should be avoided in clients with
preexisting hematological abnormalities. The client also is told to report the occurrence of fever, sore
throat, pallor, weakness, infection, easy bruising, and petechiae. The results of the remaining tests
listed in the options are not associated with the use of this medication.
A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood
glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting
insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now
decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which
medication?
An ampule of 50% dextrose
NPH insulin subcutaneously
IV fluids containing dextrose
