A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and
swollen. Which of the following interventions would the nurse perform first?
A. Stop the infusion
B. Call the attending physician
C. Slow that infusion to 20 ml/hr
D. Place a cold towel on the site - ansA. Stop the infusion
The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm
not cold towel on the affected site.
A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following
would be an appropriate nursing action?
A. Administer a sedative at bedtime, as ordered by the physician
B. Ambulate the patient for 5 minutes before he retires
C. Give the patient a glass of warm milk before bedtime
D. Close the patient's door from 9pm to 7am - ansC. Give the patient a glass of warm milk before bedtime
Warm milk will relax the patient because it contains tryptophan, a natural sedative.
A skin lesion which is fluid-filled, less than 1 cm in size is called:
A. Papule
B. Vesicle
C. Bulla
D. Macule - ansB. Vesicle
Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister,
chicken pox).
A sudden redness of the skin is known as:
A. Flush
B. Cyanosis
C. Jaundice
D. Pallor - ansA. Flush
Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin discoloration caused by
abnormal amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration of the skin,
mucous membranes and sclera caused by excessive amounts of bilirubin in the blood. Pallor is an
unnatural paleness or absence of color in the skin indicating insufficient oxygen and excessive carbon
dioxide in the blood.
According to Maslow's hierarchy of needs, which of the following is a basic physiologic need after
oxygen?
A. Safety
B. Activity
C. Love
D. Self esteem - ansB. Activity
According to Maslow, activity is one of the man's most basic physiologic needs, along with oxygen,
shelter, food, water, thirst, sleep and temperature maintenance.
Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated.
Which of the following is an expected response?
A. Low blood pressure
B. Warm, dry skin
C. Decreased serum sodium levels
D. Decreased urine output - ansD. Decreased urine output
, Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This
results to decreased urine output.
Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the
patient has had pain for more than:
A. 3 months
B. 6 months
C. 9 months
D. 1 year - ansB. 6 months
Chronic pain is usually defined as pain lasting longer than 6 months.
Constipation is a common problem for immobilized patients because of:
A. Decreased tightening of the anal sphincter
B. An increased defecation reflex
C. Decreased peristalsis and positional discomfort
D. Increased colon motility - ansC. Decreased peristalsis and positional discomfort
Increased adrenalin production in the immobile patient results in decrease peristalsis and colon motility
and more tightly constricted sphincters.
During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of
the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of
the patient?
A. That the patient verbalized, "My headache is gone."
B. That the patient's barium enema performed 3 days ago was negative
C. Patient's NGT was removed 2 hours ago
D. Patient's family came for a visit this morning. - ansC. Patient's NGT was removed 2 hours ago
The change-of-shift report should indicate significant recent changes in the patient's condition that the
nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical
enough to include in the report
During a physical assessment, the nurse closes and door and provides drape to promote privacy. The
nurse is performing her role as a/an:
A. Advocate
B. Communicator
C. Change agent
D. Caregiver - ansD. Caregiver
The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness
by viewing a person holistically. As an advocate the nurse intercedes or works on behalf of the client.
Identifying the need and problems of the client and communicating it to other members of the health team
is doing the role of a communicator. As a change agent, the nurse assists the client to MODIFY their
BEHAVIOR.
During application of medication into the ear, which of the following is inappropriate nursing action?
A. In an adult, pull the pinna upward
B. Instill the medication directly into the tympanic membrane
C. Warm the medication at room or body temperature
D. Press the tragus of the ear a few times to assist flow of medication into the ear canal - ansB. Instill the
medication directly into the tympanic membrane
During the application of medication it is inappropriate to instill the medication directly into the tympanic
membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal.
swollen. Which of the following interventions would the nurse perform first?
A. Stop the infusion
B. Call the attending physician
C. Slow that infusion to 20 ml/hr
D. Place a cold towel on the site - ansA. Stop the infusion
The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm
not cold towel on the affected site.
A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following
would be an appropriate nursing action?
A. Administer a sedative at bedtime, as ordered by the physician
B. Ambulate the patient for 5 minutes before he retires
C. Give the patient a glass of warm milk before bedtime
D. Close the patient's door from 9pm to 7am - ansC. Give the patient a glass of warm milk before bedtime
Warm milk will relax the patient because it contains tryptophan, a natural sedative.
A skin lesion which is fluid-filled, less than 1 cm in size is called:
A. Papule
B. Vesicle
C. Bulla
D. Macule - ansB. Vesicle
Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex. Blister,
chicken pox).
A sudden redness of the skin is known as:
A. Flush
B. Cyanosis
C. Jaundice
D. Pallor - ansA. Flush
Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin discoloration caused by
abnormal amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration of the skin,
mucous membranes and sclera caused by excessive amounts of bilirubin in the blood. Pallor is an
unnatural paleness or absence of color in the skin indicating insufficient oxygen and excessive carbon
dioxide in the blood.
According to Maslow's hierarchy of needs, which of the following is a basic physiologic need after
oxygen?
A. Safety
B. Activity
C. Love
D. Self esteem - ansB. Activity
According to Maslow, activity is one of the man's most basic physiologic needs, along with oxygen,
shelter, food, water, thirst, sleep and temperature maintenance.
Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated.
Which of the following is an expected response?
A. Low blood pressure
B. Warm, dry skin
C. Decreased serum sodium levels
D. Decreased urine output - ansD. Decreased urine output
, Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This
results to decreased urine output.
Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the nurse understands that the
patient has had pain for more than:
A. 3 months
B. 6 months
C. 9 months
D. 1 year - ansB. 6 months
Chronic pain is usually defined as pain lasting longer than 6 months.
Constipation is a common problem for immobilized patients because of:
A. Decreased tightening of the anal sphincter
B. An increased defecation reflex
C. Decreased peristalsis and positional discomfort
D. Increased colon motility - ansC. Decreased peristalsis and positional discomfort
Increased adrenalin production in the immobile patient results in decrease peristalsis and colon motility
and more tightly constricted sphincters.
During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of
the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of
the patient?
A. That the patient verbalized, "My headache is gone."
B. That the patient's barium enema performed 3 days ago was negative
C. Patient's NGT was removed 2 hours ago
D. Patient's family came for a visit this morning. - ansC. Patient's NGT was removed 2 hours ago
The change-of-shift report should indicate significant recent changes in the patient's condition that the
nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical
enough to include in the report
During a physical assessment, the nurse closes and door and provides drape to promote privacy. The
nurse is performing her role as a/an:
A. Advocate
B. Communicator
C. Change agent
D. Caregiver - ansD. Caregiver
The role of a nurse as caregiver helps client promote, restore and maintain dignity, health and wellness
by viewing a person holistically. As an advocate the nurse intercedes or works on behalf of the client.
Identifying the need and problems of the client and communicating it to other members of the health team
is doing the role of a communicator. As a change agent, the nurse assists the client to MODIFY their
BEHAVIOR.
During application of medication into the ear, which of the following is inappropriate nursing action?
A. In an adult, pull the pinna upward
B. Instill the medication directly into the tympanic membrane
C. Warm the medication at room or body temperature
D. Press the tragus of the ear a few times to assist flow of medication into the ear canal - ansB. Instill the
medication directly into the tympanic membrane
During the application of medication it is inappropriate to instill the medication directly into the tympanic
membrane. The right thing to do is instill the medication along the lateral wall of the auditory canal.
