NCLEX Exam 75 Questions with Verified Answers,100% CORRECT

NCLEX Exam 75 Questions with Verified Answers The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 yea ...

NCLEX Exam 75 Questions with Verified Answers The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment finding? 1. Increase in Forced Vital Capacity (FVC) 2. A narrowed chest cavity 3. Clubbed fingers 4. An increased risk of cardiac failure - CORRECT ANSWER 1. Increase in Forced Vital Capacity (FVC) Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPD would have a decrease in FVC. Incorrect. 2. A narrowed chest cavity A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest cavity. Incorrect. 3. Clubbed fingers - CORRECT Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels. 4. An increased risk of cardiac failure Although a patient with these conditions would indeed be at an increased risk for cardiac failure, this is a potential complication and not an assessment finding. Incorrect. The nurse is taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer. After being told the patient is complaining of epigastric pain, the nurse expects to note which assessment finding? 1. Melena 2. Nausea 3. Hernia 4. Hyperthermia - CORRECT ANSWER 1. Melena - CORRECT Melena is the finding that there are traces of blood in the stool which presents as black, tarry feces. This is a common manifestation of Duodenal Ulcers, since the Duodenum is further down the gastric anatomy. 2. Nausea Nausea may be present, but is a generalized symptom and by itself doesn't indicate a Duodenal Ulcer. Incorrect. 3. Hernia A Hernia is a protrusion of a segment of the abdomen through another abdominal structure. It is not associated with an Ulcer and is a condition, not an assessment finding. Incorrect. 4. Hyperthermia Hyperthermia, a high temperature, is not an assessment finding of a Duodenal Ulcer. Incorrect A nurse is providing discharge teaching for a patient with severe Gastroesophogeal Reflux Disease. Which of these statements by the patient indicates a need for more teaching? 1. "I'm going to limit my meals to 2-3 per day to reduce acid secretion." 2. "I'm going to make sure to remain upright after meals and elevate my head when I sleep" 3. "I won't be drinking tea or coffee or eating chocolate any more." 4. "I'm going to start trying to lose some weight." - CORRECT ANSWER 1. "I'm going to limit my meals to 2-3 per day to reduce acid secretion." CORRECT - Large meals increase the volume and pressure in the stomach and delay gastric emptying. It's recommended instead to eat 4-6 small meals a day. 2. "I'm going to make sure to remain upright after meals and elevate my head when I sleep" Incorrect - This is a correct verbalization of health promotion for GERD. 3. "I won't be drinking tea or coffee or eating chocolate any more." Incorrect - This is a correct verbalization of health promotion for GERD. 4. "I'm going to start trying to lose some weight." Incorrect - This is a correct verbalization of health promotion for GERD. The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the nurse finds that the patient's blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the PRIORITY intervention? 1. Start a large-bore IV in the patient's arm 2. Ask the patient for a stool sample 3. Prepare to insert an NG Tube 4. Administer intramuscular morphine sulphate as ordered - CORRECT ANSWER 1. Start a large-bore IV in the patient's arm CORRECT - The nurse should suspect that the patient is haemorrhaging and will need need a fluid replacement therapy, which requires a large bore IV. 2. Ask the patient for a stool sample Incorrect - While this is useful in the diagnosis and assessment of Peptic Ulcer Disease, it is not the priority intervention. 3. Prepare to insert an NG Tube Incorrect - While this intervention may be used in the later stages of Peptic Ulcer Disease, it is not the first and priority intervention. 4. Administer intramuscular morphine sulphate as ordered Incorrect - While this is an important intervention to manage pain, it is not the priority intervention. A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately? 1. Hemoglobin 11 g/dl 2. Platelet of 150,000 3. INR of 2.5 4. Potassium of 2.7 mEq/L - CORRECT ANSWER 1. Hemoglobin 11 g/dl This is below normal, but a normal female hemoglobin is 12-14. There is a more critical lab result. 2. Platelet of 150,000 This is also below the normal values, but is not the most critical lab result. 3. INR of 2.5 This is a therapeutic range for a patient who is taking an anticoagulant for atrial fibrillation 4. Potassium of 2.7 mEq/L CORRECT - A potassium imbalance for a patient with a history of dysrhythmia can be life-threatening and can lead to cardiac distress. While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first? 1. Stop the saline infusion immediately 2. Notify Physician 3. Elevate the patient's legs 4. Continue the infusion, since these are normal findings - CORRECT ANSWER 1. Stop the saline infusion immediately CORRECT - the patient has a fluid volume overload as a result of overly rapid fluid replacement. The nurse should stop the infusion and notify the physician. 2. Notify Physician This is not the first action the nurse should take. 3. Elevate the patient's legs This would help with the edema, but is not a priority 4. Continue the infusion, since these are normal findings This is not a normal finding The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress? 1. They must inform household members of their condition 2. They must take their medications exactly as prescribed 3. They must abstain from substance use 4. They must avoid large crowds - CORRECT ANSWER 1. They must inform household members of their condition Incorrect - Each patient has a right to privacy of their medical condition. It is their choice whether they inform household members. 2. They must take their medications exactly as prescribed CORRECT - Antiretrovirals must be taken exactly as prescribed to prevent drug-resistant strains. Even missed doses can reduce the effectiveness of future treatment. 3. They must abstain from substance use Incorrect - While substance use should be discouraged, using safe practices with needles can prevent transmission of HIV. 4. They must avoid large crowds Incorrect - Avoiding large crowds to prevent infection is a priority in the later stages of HIV, when the patient has AIDS. A nurse finds a 30-year-old woman experiencing anaphylaxis from a bee sting. Emergency personnel have been called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should the nurse do first? 1. Initiate cardiopulmonary resuscitation 2. Check for a pulse 3. Ask the woman if she carries an emergency medical kit 4. Stay with the woman until help comes - CORRECT ANSWER 1. Initiate cardiopulmonary resuscitation Incorrect - CPR is premature at this point, and there is another action that can be taken first. 2. Check for a pulse This is the first step when assessing for initiation of CPR, but CPR is not the best and first course of action for this situation. The woman is still breathing, which means CPR is not necessary at this time. 3. Ask the woman if she carries an emergency medical kit CORRECT - Many patients who have a known history of anaphylaxis carry epi-pens in their pockets or belongings. This is the best way to stop a hypersensitivity reaction before it becomes life-threatening. 3. Stay with the woman until help comes Incorrect - While this should be done, it's not the best and first course of action. A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings? 1. The patient states he had a manic episode a week ago 2. The patient states he has been having diarrhea every day 3. The patient has a rashy pruritis on his arms and legs 4. The patient presents as severely depressed 5. The patient's lithium level is 1.3 mcg/L - CORRECT ANSWER 1. The patient states he had a manic episode a week ago Incorrect - Having a manic episode is not an indication of lithium toxicity. This finding indicates that the lithium is not effective or is not at a therapeutic level. 2. The patient states he has been having diarrhea every day Correct - Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity. 3. The patient has a rashy pruritis on his arms and legs Incorrect - This is not a symptom of lithium toxicity 4. The patient presents as severely depressed Incorrect - Having a depressive episode is not an indication of lithium toxicity. This finding indicates that the lithium is not effective or is not at a therapeutic level. 5. The patient's lithium level is 1.3 mcg/L This is within the therapeutic range of lithium A 65 year old man is prescribed Flomax (Tamsulosin) for Benign Prostatic Hyperplasia. The patient lives in an upstairs apartment. The nurse is most concerned about which side effect of Flomax? 1. Hypotension 2. Tachycardia 3. Back Pain 4. Difficulty Urinating - CORRECT ANSWER 1. Hypotension Correct - Hypotension can lead to dizziness and a risk for injury to the patient. 2. Tachycardia Tachycardia can be a side effect of Flomax, but is not an immediate safety risk, nor is it a common side effect. 3. Back Pain Back Pain can be a side effect of Floma, but is not a safety risk 4. Difficulty Urinating Dysuria is a symptom of Benign Prostatic Hyperplasia, not a side effect of Flomax A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin? 1. Back Pain 2. Fever and Chills 3. Risk for Bleeding 4. Dizziness - CORRECT ANSWER 1. Back Pain Incorrect - Back pain, while it can occur, is not an immediate concern 2. Fever and Chills Incorrect - Fever and Chills, while it can occur, is not an immediate concern 3. Risk for Bleeding Correct - A confused patient is at risk for injuring themselves and at risk for hemorrhage should an injury occur 4. Dizziness Incorrect - Dizziness is not a side effect of Heparin A female patient is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test. The nurse is most concerned about which side effect of metformin? 1. Diarrhea and Vomiting 2. Dizziness and Drowsiness 3. Metallic taste 4. Hypoglycemia - CORRECT ANSWER 1. Diarrhea and Vomiting Incorrect - While these may occur, the patient is at higher risk for another adverse effect. 2. Dizziness and Drowsiness Incorrect - While these may occur, the patient is at higher risk for another adverse effect. 3. Metallic taste Incorrect - While this may occur, the patient is at higher risk for another adverse effect. 4. Hypoglycemia Correct - The patient is at risk because she is on NPO status and continuing to take an anti-glycemic drug. The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action? 1. Induce vomiting 2. Hold the next dose of Lithium 3. Administer an anti-emetic 4. Give the next dose of Lithium - CORRECT ANSWER 1. Induce vomiting Incorrect - This may be warranted for a severe lithium toxicity, but would be premature at this point. Gastric lavage may be attempted if the patient presents within one hour of ingestion, and fluids will be given to restore kidney function and promote the clearance of Lithium from the body.. 2. Hold the next dose of Lithium Correct - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L 3. Administer an anti-emetic Incorrect - While minor toxicity can cause vomiting and nausea, this is not a priority action 4. Give the next dose of Lithium Incorrect - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L A patient asks the nurse why they must have a heparin injection. What is the nurse's best response? 1. "Heparin will dissolve clots that you have." 2. "Heparin will reduce the platelets that make your blood clot" 3. "Heparin will work better than warfarin." 4. "Heparin will prevent new clots from developing." - CORRECT ANSWER 1. "Heparin will dissolve clots that you have." Incorrect - Heparin does not do this. 2. "Heparin will reduce the platelets that make your blood clot" Incorrect - Heparin does not do this 3. "Heparin will work better than warfarin." Incorrect - Heparin has a different mechanism of action than warfarin, and a different route of administration, but achieve similar results. 4. "Heparin will prevent new clots from developing." Correct -This is a correct statement. The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the troponin T value is at 5.3 ng/mL. Which of these interventions, if not completed already, would take priority over the others? 1. Put the patient in a 90 degree position 2. Check whether the patient is taking diuretics 3. Obtain and attach defibrillator leads 4. Check the patient's last ejection fraction - CORRECT ANSWER 1. Put the patient in a 90 degree position Incorrect - This position is optimal for helping a patient breathe, but is not the priority action in an emergency situation. 2. Check whether the patient is taking diuretics Incorrect - Diuretics play a role in CHF by decreasing fluid volume, but this patient is likely having an acute myocardial infarction. 3. Obtain and attach defibrillator leads Correct - This patient is undergoing an emergency cardiac event. Normal Troponin T levels are less than 0.2 ng/mL. Ventricular Fibrillation is the cause of death in most cases of deaths due to sudden cardiac arrest. Defibrillation is the most important action to take to prevent death. 4. Check the patient's last ejection fraction Incorrect - Ejection fraction is a test used to gauge the severity of CHF, not an emergency cardiac arrest. A nurse is caring for a patient undergoing a stress test on a treadmill. The patient turns to talk to the nurse. Which of these statements would require the most immediate intervention? 1. "I'm feeling extremely thirsty. I'm going to get some water after this." 2. "I can feel my heart racing." 3. "My shoulder and arm is hurting." 4. "My blood pressure reading is 158/80" - CORRECT ANSWER 1. "I'm feeling extremely thirsty. I'm going to get some water after this." Incorrect - This does not require immediate intervention. This is a common response to exercise and activity. 2. "I can feel my heart racing." Incorrect - This does not require immediate intervention. This is a common response to exercise and activity. 3. "My shoulder and arm is hurting." Correct - Unilateral arm and shoulder pain is one of the classic symptoms of myocardial ischemia. The stress test should be halted. 4. "My blood pressure reading is 158/80" Incorrect - This does not require immediate intervention. Moderate elevation in blood pressure is a common response to exercise and activity. The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is a 615 pg/ml. What would the nurse take as the priority action? 1. Call a cardiac code and implement emergency measures 2. Check the patient's oxygen saturation 3. Inform the physician that the patient has Congestive Heart Failure Encourage the patient to limit activity - CORRECT ANSWER 1. Call a cardiac code and implement emergency measures Incorrect - There is no evidence that the patient is undergoing a cardiac arrest. 2. Check the patient's oxygen saturation Correct - An elevated BNP indicates that there is decreased cardiac output. A priority intervention would be to ensure proper oxygenation after an assessment. 3. Inform the physician that the patient has Congestive Heart Failure Incorrect - Although BNP suggests Congestive Heart Failure, it is not used in itself to diagnose CHF. An elevated BNP can also be caused by dysrhythmias or renal disease. 4. Encourage the patient to limit activity Incorrect - This is an intervention that can help treat CHF, but not a priority action at this time. A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistant would most require the nurse's immediate intervention? 1. The nursing assistant fills the patient's pitcher with ice cold drinking water 2. The nursing assistant elevates the head of the bed to 60 degrees for a meal 3. The nursing assistant refills the ice pack laying on the insertion site 4. The nursing assistant places an extra pillow under the patient's head on request - CORRECT ANSWER 1. The nursing assistant fills the patient's pitcher with ice cold drinking water Incorrect - It is recommended to generously hydrate after a coronary angiogram to excrete contrast medium, reducing kidney toxicity 2. The nursing assistant elevates the head of the bed to 60 degrees for a meal Correct - For 3-6 hours after a coronary angiogram (depending on the insertion site), the patient should have their bed no higher than 30 degrees and be on bedrest. 3. The nursing assistant refills the ice pack laying on the insertion site Incorrect - An ice pack or dressing is recommended to be placed on the insertion site to minimize risk of bleeding. 4. The nursing assistant places an extra pillow under the patient's head on request Incorrect - An extra pillow will not violate any post-procedural protocols for coronary angiogram. A man is has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea. The nurse is concerned about which side effect of lisinopril? 1. Vertigo 2. Hypotension 3. Palpitations 4. Nagging, dry cough - CORRECT ANSWER 1. Vertigo Incorrect - While this may occur, the patient is at higher risk due to another adverse effect. 2. Hypotension Correct - The patient is particularly at risk for hypotension due to possible dehydration from fluid loss. 3. Palpitations Incorrect - While this may occur, the patient is at higher risk for another adverse effect. 4. Nagging, dry cough Incorrect - While this is a common side effect, the patient is at higher risk for another adverse effect.. The nurse is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the nurse expects to note which assessment finding? 1. Severe and persistent diarrhea 2. Intense pain in the toe 3. Yellow-tinged sclera 4. Headache - CORRECT ANSWER 1. Severe and persistent diarrhea Incorrect - This is not a manifestation of sickle cell disease 2. Intense pain in the toe Incorrect - Gout is a manifestation of Polycythemia Vera, in which the there is an overabundance of red blood cells 3. Yellow-tinged sclera Correct - Jaundice is a common clinical finding of sickle cell disease, caused by bilirubin released from damaged or destroyed RBCs 4. Headache Incorrect - While this may occur, it is not indicative or a classic symptom of sickle cell disease. A client with Multiple Sclerosis reports a constant, burning, tingling pain in the shoulders. The nurse anticipates that the physician will order which medication for this type of pain? 1. alprazolam (Xanax) 2. Corticosteroid injection 3. gabapentin (Neurontin) 4. hydrocodone/acetaminophen (Norco) - CORRECT ANSWER 1. alprazolam (Xanax) Incorrect - alprazolam is used to reduce anxiety 2. Corticosteroid injection Incorrect - Corticosteroid injections are used to reduce inflammation in a localized area, often due to joint breakdown. In MS patients it is used to treat acute exacerbations ("flare-ups"), but the symptoms described do not constitute an acute exacerbation. 3. gabapentin (Neurontin) Correct - Anticonvulsants like gabapentin are often the first line of treatment for nerve pain 4. hydrocodone/acetaminophen (Norco) Incorrect - Opioids would not be the appropriate medication to treat nerve pain. Which of these clients is likely to receive sublingual morphine? 1. A 75-year-old woman in a hospice program 2. A 40-year-old man who just had throat surgery 3. A 20-year-old woman with trigeminal neuralgia 4. A 60-year-old man who has a painful incision - CORRECT ANSWER 1. A 75-year-old woman in a hospice program Correct - Sublingual morphine is often used in hospice because the patients are unable to swallow, and intravenous access can be painful and not conducive to palliative care. 2. A 40-year-old man who just had throat surgery Incorrect - Patients who have surgery most likely have an Intravenous line 3. A 20-year-old woman with trigeminal neuralgia Incorrect - Morphine would not be the first choice for nerve pain 4. A 60-year-old man who has a painful incision Incorrect - Although Morphine would be an appropriate medications, there is no indication that it should be administered sublingually In educating clients on ways to manage pain, which topic can be appropriately delegated to a LPN/LVN who will continue under supervision? 1. Acupuncture 2. Guided Imagery 3. Alternating Rest/Activity 4. Over the counter medications - CORRECT ANSWER 1. Acupuncture Incorrect - This is outside the nursing scope of practice and requires special training or education 2. Guided Imagery Incorrect - This also requires additional training or education 3. Alternating Rest/Activity Correct - This is within the nursing scope of practice and within the training and education provided to all nurses. It is safe to use and a standard treatment. 4. Over the counter medications Incorrect - This is outside the nursing scope of practice. A healthcare provider (doctor, nurse practitioner, or physician's assistant) should be consulted before taking over the counter medications. The nurse assesses a patient suspected of having an asthma attack. Which of the following is a common clinical manifestation of this condition? 1. Audible crackles and orthopnea 2. An audible wheeze and use of accessory muscles 3. Audible crackles and use of accessory muscles 4. Audible wheeze and orthopnea - CORRECT ANSWER 1. Audible crackles and orthopnea Incorrect - Crackles indicate fluid in the lungs, which is not a cause of asthma. Orthopnea is not associated with asthma. 2. An audible wheeze and use of accessory muscles Correct - Both of these are associated with asthma. 3. Audible crackles and use of accessory muscles Incorrect - Crackles indicate fluid in the lungs, which is not a cause of asthma. 4. Audible wheeze and orthopnea Incorrect - Orthopnea is not associated with asthma. The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition? 1. A high WBC count and decreased level of consciousness 2. A high WBC count and manic activity 3. A low WBC count and manic activity 4. A low WBC count and decreased level of consciousness - CORRECT ANSWER 1. A high WBC count and decreased level of consciousness Correct - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness. 2. A high WBC count and manic activity Incorrect - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness. 3. A low WBC count and manic activity Incorrect - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness. 4. A low WBC count and decreased level of consciousness Incorrect - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness. A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make? 1. Assess the patient for nuchal rigidity 2. Determine the patient's past exposure to infectious organisms 3. Check the patient's WBC lab values 4. Monitor for increased lethargy and drowsiness - CORRECT ANSWER 1. Assess the patient for nuchal rigidity Incorrect - Although neck stiffness can be a symptom of Meningitis, it is not used to define meningitis, neither is it a sign of further neurological deterioration. 2. Determine the patient's past exposure to infectious organisms Incorrect - Although this is an important part of the history gathering process, and meningitis is most often caused by a viral or bacterial infection, it is not the priority assessment. 3. Check the patient's WBC lab values Incorrect - Although WBCs do rise during an infection like Mengingitis, it is not the priority assessment. 4. Monitor for increased lethargy and drowsiness Correct - Lethargy and drowsiness indicate a decreased level of consciousness, which is the cardinal sign of increased ICP (Intracranial Pressure), which can be life-threatening. The nurse is caring for clients in the pediatric unit. A 6-year patient is admitted who has 2nd and 3rd degree burns on his arms. The nurse should assign the new patient to which of the following roommates? 1. A 4-year old with sickle-cell disease 2. A 12-year old with chickenpox 3. A 6-year old undergoing chemotherapy 4. A 7-year old with a high temperature - CORRECT ANSWER 1. A 4-year old with sickle-cell disease Correct - The nurse should be concerned about the burn patient's vulnerability to infection. Sickle cell disease is not a communicable disease. 2. A 12-year old with chickenpox Incorrect - Chickenpox is a communicable disease 3. A 6-year old undergoing chemotherapy Incorrect - This patient is already immunosuppressed and should not have a roommate regardless. 4. A 7-year old with a high temperature Incorrect - An unspecified fever is often indicative of an infection of some type. A patient with Meningitis is being treated with Vancomycin intravenously 3 times per day. The nurse notes that the urine output during the last 8 hours was 200mL. What is the nurse's priority action? 1. Check the patient's last BUN 2. Ask the patient to increase their fluid intake 3. Ask the physician to order a diuretic 4. Notify the physician of this finding - CORRECT ANSWER 1. Check the patient's last BUN Incorrect - This may be relevant to nephrotoxicity and poor urine output, but is not the priority action. An assessment finding has already been done and indicates an immediate intervention. 2. Ask the patient to increase their fluid intake Incorrect - Increasing oral intake without other interventions will increase risk of increased ICP and fluid overload. 3. Ask the physician to order a diuretic Incorrect - This is premature and would not be the correct intervention. 4. Notify the physician of this finding Correct - Vancomycin is a nephrotoxic drug and can cause impaired renal perfusion, which would cause a decreased urine output. This is a serious adverse effect and should be reported to the physician. A patient is being admitted to the ICU with a severe case of encephalitis. Which of these drugs would the nurse not be expect to be prescribed for this condition? 1. Acyclovir (Zovirax) 2. Mannitol (Osmitrol) 3. Lactated Ringer's 4. Phenytoin (Dilantin) - CORRECT ANSWER 1. Acyclovir (Zovirax) Incorrect- Acyclovir is a common antiviral drug for the treatment of viral encephalitis 2. Mannitol (Osmitrol) Incorrect - Mannitol is a hyperosmolar drug that helps reduce Intracranial Pressure by acting as a diuretic and decreasing fluid in the body. 3. Lactated Ringer's Correct - Lactated Ringer's solution is often used in fluid replacement therapy, which is not warranted if a patient is at risk for high ICP. 4. Phenytoin (Dilantin) Incorrect - Phenytoin is an anticonvulsant and is often used to prevent seizures, which can complicate and worsen a patient's neurological state. The nurse is treating a patient who has Parkinson's Disease. Which of these practices would not be included in the care plan? 1. Decrease the calorie content of daily meals to avoid weight gain 2. Allow the patient extra time to respond to questions and do ADLs 3. Use thickened liquids and a soft diet 4. Encourage the patient to hold the spoon when eating - CORRECT ANSWER 1. Decrease the calorie content of daily meals to avoid weight gain Correct - Calorie content should be increased for patients with Parkinson's Disease because of dysphagia (difficulty swallowing), as well as calories burned due to muscle rigidity. 2. Allow the patient extra time to respond to questions and do ADLs Incorrect - This is a best practice when working with PD patients. 3. Use thickened liquids and a soft diet Incorrect - This is often used to reduce the risk of aspiration 4. Encourage the patient to hold the spoon when eating Incorrect - The patient should be encouraged to perform ADLs as independently as possible. A 45-year old woman is prescribed ropinirole (Requip) for Parkinson's Disease. The patient is living at home with her daughter. The nurse is most concerned about which side effect of ropinirole? 1. Slurred speech 2. Sudden dizziness 3. Masklike facial expression 4. Stooped Posture - CORRECT ANSWER 1. Slurred speech Incorrect - Slurred speech is a common symptom of PD, not a side effect of this drug. 2. Sudden dizziness Correct - Dizziness and orthostatic hypotension are serious adverse effects of this drug that can lead to an increased risk of falls. Ropinirole's drug class is a dopamine agonist, which mimic dopamine in the brain (PD is characterized by a lack of dopamine). 3. Masklike facial expression Incorrect - Masklike facial expression is a common symptom of PD, not a side effect of this drug. 4. Stooped Posture Incorrect - Stooped Posture is a common symptom of PD, not a side effect of this drug. The nurse is taking the health history of a patient being treated for Parkinson's Disease. After being told the patient has classic symptoms of Parkinson's, the nurse expects to note which assessment finding? 1. Tremors 2. Low Urine Output 3. Exaggerated arm movements 4. Risk for Falls - CORRECT ANSWER 1. Tremors Correct - Tremors is one of four cardinal signs of PD: the other three are rigidity, bradykinesia (slow movements), and postural instability 2. Low Urine Output Incorrect - This is not a relevant symptom to PD 3. Exaggerated arm movements Incorrect - A symptom of PD would be rigidity and slow arm movements, rather than exaggeration of arm movements 4. Risk for Falls Incorrect - This is not an assessment finding. This is a nursing diagnosis. A nurse enters a patient's room and finds them unconscious with a rhythmic jerking of all four extremities. The patient is foaming heavily at the mouth. The patient was on seizure precautions and the bedrails are up and padded. What is the nurse's priority action? 1. Administer Lorazepam (Ativan) 2. Turn the patient to his/her side 3. Call the physician 4. Suction the patient - CORRECT ANSWER 1. Administer Lorazepam (Ativan) Incorrect - If a seizure lasts more than 5 minutes, it is called Status epilepticus and can be life-threatening. Physicians will often order anxiolytics or sedatives to treat this condition. However, at this point it would not be appropriate for the nurse to administer this drug. 2. Turn the patient to his/her side Correct - Turning the patient to the side will keep the airway open, which is the first priority 3. Call the physician Incorrect - This would be a priority action after ensuring the patient's safety, or in the case of Status epilepticus 4. Suction the patient Incorrect - This intervention is warranted, but after an assessment of the patient's airway, since forcing a suction catheter into a patient's mouth is a last resort. A nurse is giving a discharge education to a patient who has been diagnosed with epilepsy. Which of these teachings would she stress the most? 1. Avoid doing alcohol and drugs 2. Follow up with the neurologist, physician, or other health care provider as prescribed 3. Do not stop taking anticonvulsants, even if seizures have stopped 4. Wear a medical alert bracelet or carry an ID card indicating epilepsy - CORRECT ANSWER 1. Avoid doing alcohol and drugs Incorrect - Although this is a general teaching that would be applied to any hospital discharge situation, it is not the priority to be stressed. 2. Follow up with the neurologist, physician, or other health care provider as prescribed Incorrect - Although this is correct to include in discharge education, following this instruction is not directly contributing to their safety, so is not the priority. 3. Do not stop taking anticonvulsants, even if seizures have stopped Correct - Following this instruction is essential for their safety, since stopping anti-epileptic drugs suddenly can cause seizures and an increased chance of status epilecticus 4. Wear a medical alert bracelet or carry an ID card indicating epilepsy Incorrect - Although this is correct to include in discharge education, following this instruction is not directly contributing to their safety, so is not the priority. The nurse is caring for a patient in the ICU who has had a spinal cord injury. She observes that his last blood pressure was 100/55, and his pulse is 48. These have both trended downwards from the baseline. What should the nurse expect to be the next course of action ordered by the physician? 1. Assess the patient for decreased level of consciousness 2. Administer Normal Saline 3. Insert an NG Tube 4. Connect and read an EKG - CORRECT ANSWER 1. Assess the patient for decreased level of consciousness Incorrect - An assessment has already been made, and an intervention is warranted. 2. Administer Normal Saline Correct - The patient is entering neurogenic shock. Normal saline will replace fluid volume, treating the hypotension and bradycardia symptomatically. Atropine sulfate is also commonly used to increase the heart rate. 3. Insert an NG Tube Incorrect - An NG tube would not be relevant in this situation. 4. Connect and read an EKG Incorrect - An EKG would not be needed in this situation. A nurse is caring for a patient who is suspected to have sustained a spinal cord injury. What best describes the overarching principles used to guide the care for this type of condition? 1. Immobilize the cervical area to prevent further injury 2. Monitor the patient's level of consciousness to prevent neurologic deterioration 3. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury 4. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing - CORRECT ANSWER 1. Immobilize the cervical area to prevent further injury Incorrect - While this is an essential part of caring for a spinal cord injury, it does not adequately describe guiding principles for a complete plan of care 2. Monitor the patient's level of consciousness to prevent neurologic deterioration Incorrect - While this is an essential part of caring for a spinal cord injury, it does not adequately describe guiding principles for a complete plan of care 3. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury Incorrect - These are important in the later stages of a spinal cord injury after the patient has been stabilized, but at this point would be premature. 4. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing Correct - Maintaining airway, breathing, and circulation is both essential and guides the overall plan of care for a patient with a spinal cord injury. A 23-year-old woman is admitted to the infusion clinic after a Multiple Sclerosis Exacerbation. The physician orders methylprednisolone infusions (Solu-Medrol). The nurse would expect which of the following outcomes after administration of this medication? 1. A decrease in muscle spasticity and involuntary movements 2. A slowed progression of Multiple Sclerosis related plaques 3. A decrease in the length of the exacerbation 4. A stabilization of mood and sleep - CORRECT ANSWER 1. A decrease in muscle spasticity and involuntary movements Incorrect - While muscle spasticity and involuntary movements can be symptoms of MS, a corticosteroid infusion is not meant to directly treat these symptoms. 2. A slowed progression of Multiple Sclerosis related plaques Incorrect - Special drugs like Interferon Beta, Natalizumab, or Glatiramir acetate are used as first-line treatments to slow the progression of MS. While corticosteroids can be used in conjunction with these drugs on a long-term basis, they would not be infused. They would be taken orally. 3. A decrease in the length of the exacerbation Correct - A methylprednisolone infusion is the first line of treatment during an acute exacerbation and is used to decrease the length and severity of a relapse. 4. A stabilization of mood and sleep Incorrect - Some of the frequent side effects of a Methylprednisolone infusion are anxiety, insomnia, and mood swings. A nurse knows that which of these patients are at greatest risk for a stroke? 1. A 60-year old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past. 2. A 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic. 3. A 40-year old female who has high cholesterol and uses oral contraceptives 4. A 65-year old female who is African American, has sickle cell disease and smokes cigarettes. - CORRECT ANSWER 1. A 60-year old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past. Correct - Common risk factors for developing stroke include: Atrial fibrillation, arteriosclerosis, previous stroke or ischemic attack, heart surgery, valvular heart disease, diabetes, smoking, substance abuse,obesity, sedentary lifestyle, oral contraceptive use, genetic tendency, migraines, older age, male, African American/Hispanic/American Indian, Sickle Cell Anemia, and brain trauma. This man has the greatest risk based on these risk factors. 2. A 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic. Incorrect - See Common Risk Factors for Developing a Stroke. 3. A 40-year old female who has high cholesterol and uses oral contraceptives Incorrect - See Common Risk Factors for Developing a Stroke. 4. A 65-year old female who is African American, has sickle cell disease and smokes cigarettes. Incorrect - See Common Risk Factors for Developing a Stroke. A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings? 1. INR is 3 seconds long 2. Heart rate is 110 beats per minute 3. Intracranial Pressure is 22 mm/Hg 4. Blood pressure is 140/80 - CORRECT ANSWER 1. INR is 3 seconds long Incorrect - This is actually within a therapeutic range for clotting times for patients with coagulation risks. A normal INR is .9-1.2 seconds, while a therapeutic INR can be as high as 3.5 seconds. 2. Heart rate is 110 beats per minute Incorrect - While tachycardia is a concern, general tachycardia without other associated symptoms would not pose an immediate danger, and is not of greater priority than the next answer. 3. Intracranial Pressure is 22 mm/Hg Correct - The patient is at greatest risk for an increased ICP resulting from edema 72 hours after a stroke. A target ICP should be less than or equal to 15-20 mm/Hg 4. Blood pressure is 140/80 Incorrect - Blood pressure is often kept higher than usual following a stroke to maintain perfusion. Systolic BP higher than 180, or diastolic BP higher than 105, would be the upper limit and required intervention. 140/80 would not pose an immediate danger to the patient's health. A nurse is caring for a patient scheduled to have cataract surgery. The patient asks why they developed cataracts and how they can prevent it from happening again. What is the nurse's best response? 1. "Age is the biggest factor contributing to cataracts." 2. "Unprotected exposure to UV lights can cause cataracts" 3. "Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts." 4. "Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily treated eye conditions." - CORRECT ANSWER 1. "Age is the biggest factor contributing to cataracts." Incorrect - While true, this answer leaves out many other contributing factors to cataracts and does not address prevention. 2. "Unprotected exposure to UV lights can cause cataracts" Incorrect - While true, this answer is not complete 3. "Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts." Correct - This answer covers the most common contributing factors for cataracts and includes preventable risk factors. 4. "Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily treated eye conditions." Incorrect - While most cataracts are age-related cataracts, there are still ways to prevent eye damage and cataract development. A nurse is educating a patient about bimatoprost (Lumigan) eyedrops for the treatment of Glaucoma. Which of the following indicates that the patient has a correct understanding of the expected outcomes following treatment? 1. "I should be experiencing less blurriness in my central field of vision" 2. "This medication won't help my vision at all, but will keep it from getting worse." 3. "My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so." 4. "This medication will help my eye restore intraocular fluid and increase intraocular pressure" - CORRECT ANSWER 1. "I should be experiencing less blurriness in my central field of vision" Incorrect - Cataracts cause blurriness in the central field of vision, while Glaucoma presents as loss of the field of vision peripherally. 2. "This medication won't help my vision at all, but will keep it from getting worse." Correct - Glaucoma cannot be cured, just treated. Treatment revolves around preventing further deterioration. 3. "My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so." Incorrect - Glaucoma treatment does not result in restoration of vision already lost. 4. "This medication will help my eye restore intraocular fluid and increase intraocular pressure" Glaucoma is caused by an increase in intraocular fluid. Eyedrops work in various ways to decrease Intraocular Pressure, not increase it. A patient with Glaucoma is verbalizing his daily medication routine to the nurse. He states he has two different eyedrop medications, both every twelve hours. He washes his hands, instills the drops, closes his eyes gently, and presses his finger to the corner of his eye nearest his nose. After waiting 1 minute with his eyes closed, he instills the other medication in the same way. What is the nurse's best response? 1. "You should wait more than 1 minute between different medications." 2. "Your routine is very good! Can you demonstrate it for me?" 3. "It is actually not the best practice to close your eyes after instilling eyedrops." 4. "You should actually be pressing your finger in the other corner of the eye." - CORRECT ANSWER 1. "You should wait more than 1 minute between different medications." Correct - It is recommended to wait 10-15 minutes between different eyedrop medications to give them time to absorb an avoid one medication washing another one out. 2. "Your routine is very good! Can you demonstrate it for me?" Incorrect - There is something wrong with what the patient described as his routine. After the nurse corrects this, a return demonstration would be appropriate. 3. "It is actually not the best practice to close your eyes after instilling eyedrops." 4. "You should actually be pressing your finger in the other corner of the eye." Incorrect - THis is not true. A nurse would evaluate which of these patients as appropriate candidates for a closed MRI without contrast, based on the information given? 1. A 20-year old woman who has unexplained joint pain and a low BMI. 2. A 35-year old woman with Multiple Sclerosis and has been trying to conceive. 3. A 67-year old man who has had an open-heart surgery 4 years ago. 4. A 40-year old woman who has been in a hypomanic state for the last 2 days. - CORRECT ANSWER 1. A 20-year old woman who has unexplained joint pain and a low BMI. Correct - MRI can be used to diagnose musculoskeletal disorders, and this patient has no contraindications to an MRI. 2. A 35-year old woman with Multiple Sclerosis and has been trying to conceive. Incorrect - Pregnant women, or women who have a possibility of being pregnant, are not recommended to receive MRIs. 3. A 67-year old man who has had an open-heart surgery 4 years ago. Incorrect - Patients with pacemakers, stents, or implants should not have MRIs. More information would have to be gathered about this patient before an MRI can be done. 4. A 40-year old woman who has been in a hypomanic state for the last 2 days. Incorrect - Hypomania is a mild form of mania, and a patient with hypomania would have a very difficult time laying still in a supine position for up to an hour. Sedation may be required, which requires more information and assessment of this patient. A nurse is caring for a patient in the cardiac care unit who is taking bumetanide (Bumex) and is diagnosed with Parkinson's Disease. An unlicensed assistive personnel is assisting with feeding the patient. Which of these foods would the nurse stress for the patient to eat most? 1. Foods containing the least amount of salt 2. Foods containing the most amount of potassium 3. Foods containing the most amount of calories 4. Foods containing the most amount of fiber - CORRECT ANSWER 1. Foods containing the least amount of salt Incorrect - While this is a good practice, in light of the information given, this is not the greatest priority. 2. Foods containing the most amount of potassium Correct - Bumex is a loop diuretic and can cause hypokalemia. Ensuring potassium is included in the diet is a priority and can directly avoid a hypokalemic crisis. 3. Foods containing the most amount of calories Incorrect - While this is a good practice, in light of the information given, this is not the greatest priority. 4. Foods containing the most amount of fiber Incorrect - While this is a good practice, in light of the information given, this is not the greatest priority. A nurse knows that which of these patients are at greatest risk for a developing osteoporosis? 1. An 80-year old man who has a thin build 2. A 48-year old african american female who smokes cigarettes and drinks alcohol 3. A 55-year old female with an estrogen deficiency 4. A 70-year old caucasian female who takes oral corticosteroids - CORRECT ANSWER 1. An 80-year old man who has a thin build Incorrect - Age and thin build are two primary risk factors, but another patient has more. 2. A 48-year old african american female who smokes cigarettes and drinks alcohol Smoking cigarettes and drinking alcohol are both primary risk factors, but being African American actually decreases the risk for osteoporosis 3. A 55-year old female with an estrogen deficiency Incorrect - Only two risk factors are present: being female, and having an estrogen deficiency. While her age is somewhat advanced, 65+ years of age is the 'cut-off' for having a risk factor in women. 4. A 70-year old caucasian female who takes oral corticosteroids Correct - This patient has by far the most risk factors, 3 of which are primary and one secondary. Age, gender, ethnicity are three primary risk factors, while her corticosteroid treatment is the secondary risk factor, bringing her total up to four. A 30-year old Caucasian woman who works the night shift has been found to have early bone loss and has a high risk for osteomalacia and bone degradation. She asks the nurse exactly why she should take Vitamin D supplements. What is the nurse's best response? 1. "It's a standard part of the overall nutritional treatment for the prevention of osteomalacia" 2. "It helps your intestines absorb calcium, which is important for bone formation." 3. "It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone formation." 4. "Vitamin D supplements should not be taken by someone of your age." - CORRECT ANSWER 1. "It's a standard part of the overall nutritional treatment for the prevention of osteomalacia" Incorrect - While this is true, it doesn't answer the woman's question. 2. "It helps your intestines absorb calcium, which is important for bone formation." Correct - This is the correct mechanism of action for Vitamin D 3. "It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone formation." Incorrect- This is not the correct mechanism of action for Vitamin D 4. "Vitamin D supplements should not be taken by someone of your age." Incorrect - Vitamin D supplements should be taken for patients who are homebound, institutionalized, or by some other limitations, unable to meet daily requirements. This woman works the night shift, which may limit her ability to absorb Vitamin D naturally. A nurse is caring for a patient with a cast on the right leg. Which of these assessment findings would most concern the nurse? 1. The capillary refill time is 2 seconds 2. The patient complains of itching and discomfort 3. The cast has a foul-smelling odor 4. The patient is on antibiotics - CORRECT ANSWER 1. The capillary refill time is 2 seconds Incorrect - A capillary refill time of 2 seconds is within normal limits. Capillary refill is the least reliable method of assessing neurovascular integrity. 2. The patient complains of itching and discomfort Incorrect - This is a common effect of a cast 3. The cast has a foul-smelling odor Correct - A foul-smelling odor is a sign of infection or a pressure ulcer within the cast. Other symptoms include a feeling of warmth, tightness and pain. 4. The patient is on antibiotics Incorrect - This is not an assessment finding and is not relevant to this situation. A nurse is orally administering alendronate (Fosamax), a bisphosphonate drug. The patient is largely bed-bound and being treated for osteoporosis. What nursing consideration is most important with administration of this drug? 1. Sit the head of the bed up for 30 minutes after administration 2. Give the patient a small amount of water to drink. 3. Feed the patient soon, at most 10 minutes after administration 4. Assess the patient for back pain or abdominal pain - CORRECT ANSWER 1. Sit the head of the bed up for 30 minutes after administration Correct - Bisphosphonates are associated with esophageal irritation that can lead to esophagitis. Sitting upright decreases the time the medication spends in the esophagus. 2. Give the patient a small amount of water to drink. Incorrect - Another important intervention with the administration of bisphosphonates is to give the medication with at least 6-8 ounces of plain water. 3. Feed the patient soon, at most 10 minutes after administration Incorrect - Food and any drink other than plain water should be held 30 minutes after administration so the medication can be absorbed properly 4. Assess the patient for back pain or abdominal pain Incorrect - Although these are possible side effects of this medication, they are not the priority nursing consideration. A nurse is asked by a patient to describe in layman's terms an overview of the condition called osteomyelitis. What would be the nurse's best response? 1. "Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age-related." 2. "Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softer and de-mineralized." 3. "Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body." 4. "This is a question that should be directed to your Healthcare Provider." - CORRECT ANSWER 1. "Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age-related." Incorrect - This sentence describes osteoporosis 2. "Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softer and de-mineralized." Incorrect - This sentence describes osteomalacia 3. "Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body." Correct - This appropriately explains osteomyelitis 4. "This is a question that should be directed to your Healthcare Provider." Incorrect - A nurse is qualified to educate the patient on this subject matter The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention? 1. Place the patient under contact precautions 2. Use strict aseptic technique when caring for the wound 3. Place another dressing to reinforce the first one 4. Elevate the patient's leg to prevent more drainage - CORRECT ANSWER 1. Place the patient under contact precautions Correct - A patient with an infectious wound, especially one not adequately contained by a dressing, should be put under contact precautions. 2. Use strict aseptic technique when caring for the wound Incorrect - Although this is dependent on each facility's policy, it is no longer a common practice to use aseptic technique on a "dirty" wound. Clean technique is more often used. 3. Place another dressing to reinforce the first one Incorrect - This is a questionable intervention, and will not promote the safety of this patient and other patients. 4. Elevate the patient's leg to prevent more drainage Incorrect - Patients with heel ulcers should have their heels elevated to prevent pressure, not the whole leg elevated to prevent drainage. A nurse in the emergency room receives a patient who had his left elbow fractured in a fight. He had waited 5 hours before coming to the emergency room. His left hand has an unequal radial pulse, is swollen, and is numb and tingling. What is the nurse's priority intervention? 1. Place the patient in a supine position 2. Ask the patient to rate his pain on a scale of 1 to 10. 3. Wrap the fractured area with a snug dressing 4. Start an IV in the other arm. - CORRECT ANSWER 1. Place the patient in a supine position Incorrect - While this may be a beneficial intervention if the arm is also elevated to prevent swelling, this is not a priority intervention. 2. Ask the patient to rate his pain on a scale of 1 to 10. Incorrect - While assessing pain is a part of the 6 P's of neurovascular assessment, the question asks for an intervention based on already alarming assessment findings. 3. Wrap the fractured area with a snug dressing Incorrect - The assessment findings indicate the patient may have Acute Compartment Syndrome. Causing more external pressure with a dressing will only exacerbate the condition. 4. Start an IV in the other arm. Correct - Starting an IV is a nursing priority prior to emergency surgery. The patient may be in the late stages of Acute Compartment Syndrome and may need a fasciotomy, in which the surgeon relieves pressure by making an incision into the affected area. A nurse is caring for a female patient 24 hours after a hip fracture. The patient is on bedrest. The nurse knows that which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome? 1. Performing passive, light, range of motion exercises on the hip as tolerated. 2. Assess the patient's mental status for drowsiness or sleepiness. 3. Assess the pedal pulse and capillary refill in the toes. 4. Administer a stool softener as ordered - CORRECT ANSWER 1. Performing passive, light, range of motion exercises on the hip as tolerated. Incorrect - Immobilization and prevention of motion is the best way to reduce risk for fat embolism. 2. Assess the patient's mental status for drowsiness or sleepiness. Correct - A decreased Level of Consciousness is the earliest sign of FES, caused by decreased oxygen level. 3. Assess the pedal pulse and capillary refill in the toes. Incorrect - While assessing pedal pulse is important during a neurovascular assessment, it is not relevant to FES. Capillary refill is the least reliable indicator of poor perfusion 4. Administer a stool softener as ordered Incorrect - While this is an important intervention for patients on bedrest, it is not an intervention relevant to FES What is the overarching nursing concern when caring for patients being treated with splints, casts, or traction? 1. To assess for and prevent neurovascular complications or dysfunction 2. To ensure adequate nutrition during the healing process 3. To provide patient education for maintenance of splints, casts, or traction in the community. 4. To treat acute pain - CORRECT ANSWER 1. To assess for and prevent neurovascular complications or dysfunction Correct - This is the priority nursing diagnosis for patients with extremity fractures. 2. To ensure adequate nutrition during the healing process Incorrect - While this is a nursing concern, it is not the first priority 3. To provide patient education for maintenance of splints, casts, or traction in the community. Incorrect - While this is a nursing concern, it is not the first priority 4. To treat acute pain Incorrect - While this is a serious nursing concern, it is not the first priority. What nursing action demonstrates the nurse understands the priority nursing diagnosis when caring for patients being treated with splints, casts, or traction? 1. The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour. 2. The nurse orders meals with adequate protein and calcium for the patient. 3. The nurse teaches the patient never to insert objects under a cast to scratch an itch. 4. The nurse administers oral painkillers as ordered - CORRECT ANSWER 1. The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour. Correct - The priority nursing diagnosis would be Risk for Peripheral Neurovascular Dysfunction related to fractures, which is demonstrated by this action. 2. The nurse orders meals with adequate protein and calcium for the patient. Incorrect - This intervention relates to the diagnosis Imbalanced Nutrition: Less than Body Requirements. It is not the priority diagnosis. 3. The nurse teaches the patient never to insert objects under a cast to scratch an itch. Incorrect - This intervention relates to the diagnosis Insufficient Knowledge related to Traumatic Injury. It is not the priority diagnosis 4. The nurse administers oral painkillers as ordered Incorrect - This intervention relates to the diagnosis Acute Pain related to Traumatic Injury. It is not the priority diagnosis. A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be reported to the healthcare provider immediately? 1. Abdominal distention 2. A bruit near the epigastric area 3. 3 episodes of vomiting in the last hour 4. Blood pressure of 160/90 - CORRECT ANSWER 1. Abdominal distention Incorrect - While this is a relevant assessment finding, it is not the priority assessment. 2. A bruit near the epigastric area Correct - A bruit in the aortic area signals the presence of an aneurysm. This is life-threatening and must be reported immediately. 3. 3 episodes of vomiting in the last hour Incorrect - While this is a relevant assessment finding, it is not the priority assessment. 4. Blood pressure of 160/90 Incorrect - While this may be a relevant assessment finding, it is not the priority assessment. The nurse in the day surgery centre cares for a patient who has undergone an endoscopic procedure with general anesthesia. The nurse understands that which nursing consideration is a priority immediately after an endoscopic procedure? 1. Raise the siderails of the patient's bed 2. Do not offer fluids, food or any oral intake 3. Check the temperature of the patient 4. Teach the patient to avoid aspirin or NSAIDS - CORRECT ANSWER 1. Raise the siderails of the patient bed Incorrect - This is a general intervention that applies to all post-procedure care, and not the biggest priority. 2. Do not offer fluids, food or any oral intake Correct - Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia is often given to inactivate the gag reflex, making the patient vulnerable to aspiration. 3.Check the temperature of the patient Incorrect - While it is important to monitor the temperature for signs of infection or sepsis, these problems do not occur until hours or days later. 4. Teach the patient to avoid aspirin or NSAIDS Incorrect - This is part of the preparation for an endoscopic procedure, not post-procedural care A nurse is preparing to palpate and percuss a patient's abdomen as part of the assessment process. Which of these findings would cause the nurse to immediately discontinue this part of the assessment? 1. The patient states "That sounds like it might hurt me." 2. There is a pulsating mass on the upper middle abdomen. 3. The patient has black, tarry stools and anemia 4. The patient has had an endoscopic procedure two days prior - CORRECT ANSWER 1. The patient states "That sounds like it might hurt me." Incorrect - While the nurse should address this concern with the patient, this does not necessarily mean the assessment should be stopped. 2. There is a pulsating mass on the upper middle abdomen. Correct - This is an indication of a life-threatening aortic aneurysm. Palpating or percussing is dangerous to the patient's life. 3. The patient has black, tarry stools and anemia Incorrect - These are common symptoms of GI bleed, and don't contraindicate percussion and palpation. 4. The patient has had an endoscopic procedure two days prior Incorrect - An endoscopic procedure two days prior does not contraindicate percussion and palpation. A nurse understands that which of these patients are at risk for developing Oral Candidiasis, a type of stomatitis? 1. A 77-year old woman in a long-term care facility taking an antibiotic 2. A 35-year old man who has had HIV for 6 years 3. A 40-year old man who is undergoing chemotherapy 4. An 80-year old woman with dentures - CORRECT ANSWER 1. A 77-year old woman in a long-term care facility taking an antibiotic Correct - This patient has the most risk factors for developing Candidiasis. Candidiasis is caused most commonly by long-term antibiotic therapy, immunosupressive therapy (chemotherapy, radiation, or corticosteroids), older age, living in a long-term care facility, diabetes, having dentures, and poor oral hygiene. 2. A 35-year old man who has had HIV for 6 years Incorrect - Another patient has the most/more relevant risk factors for developing Candidiasis. 3. A 40-year old man who is undergoing chemotherapy Incorrect - Another patient has the most/more relevant risk factors for developing Candidiasis. 4. An 80-year old woman with dentures Incorrect - Another patient has the most/more relevant risk factors for developing Candidiasis. What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions? 1. The nurse uses a pen pad to communicate with the patient 2. The nurse provides oral care every 2 hours 3. The nurse listens for bowel sounds every 4 hours. 4. The nurse suctions as needed and elevates the head of the bed - CORRECT ANSWER 1. The nurse uses a pen pad to communicate with the patient Incorrect - This intervention is in response to impaired verbal communication, which is not the priority nursing diagnosis. 2. The nurse provides oral care every 2 hours Incorrect - This intervention is in response to impaired oral mucous membrane, which is not the priority nursing diagnosis. 3. The nurse listens for bowel sounds every 4 hours. Incorrect - This assessment is not relevant to the patient's condition 4. The nurse suctions as needed and elevates the head of the bed Correct - This intervention is in response to Ineffective Airway Clearance, which is the priority nursing diagnosis. A patient has been taking a mood stabilizing medication, but is afraid of needles. They ask the nurse what medication would NOT require regular lab testing. What is the nurse's best response? 1. Valproic Acid (Depakote) 2. Clozapine (Clozaril) 3. Lithium 4. Risperidone (Risperdal) - CORRECT ANSWER 1. Valproic Acid (Depakote) Incorrect 2. Clozapine (Clozaril) Incorrect 3. Lithium Incorrect 4. Risperidone (Risperdal) Correct - Risperidone is the only drug that does not require blood draws. A patient is deciding whether they should take the live influenza vaccine (nasal spray), or the inactivated influenza vaccine (shot). The nurse reviews the client's history. Which condition would NOT contraindicate the nasal (live vaccine) route of administration? 1. The patient takes long-term corticosteroids 2. The patient is not feeling well today 3. The patient is 55 years old 4. The patient has young children - CORRECT ANSWER 1. The patient takes long-term corticosteroids Incorrect - Long-term corticosteroids can weaken the immune system. Live influenza vaccines should only be given to patients with healthy immune systems. 2. The patient is not feeling well today Incorrect - This is a contraindication for getting either types of vaccines. While they should get their vaccine later, now would not be the best time to administer the vaccine. 3. The patient is 55 years old Incorrect - This is a contraindication for getting the live vaccine, which should be given to patients between the ages of 2-49 only. 4. The patient has young children Correct - This is not a contraindication. It would only be a contraindication for the live vaccine if the young children were immunocompromised, but this is not stated. A patient asks the nurse whether he is a good candidate to use a CPAP machine. The nurse reviews the client's history. Which condition would contraindicate the use of a CPAP machine? 1. The patient is in the late-stage of dementia. 2. The patient has a history of bronchitis 3. The patient has had suicidal gestures/attempts in the past 4. The patient is on beta-blockers - CORRECT ANSWER 1. The patient is in the late-stage of dementia. Correct - Having an inability to follow commands and understand instructions independently is a contraindication for a CPAP machine, which can only function correctly with proper installation and use. 2. The patient has a history of bronchitis Incorrect - This is not a contraindication for using a CPAP machine 3. The patient has had suicidal gestures/attempts in the past Incorrect - This is not a contraindication for using a CPAP machine 4. The patient is on beta-blockers Incorrect - This is not a contraindication for using a CPAP machine The nurse is caring for a patient who has recently had a successful catheter ablation. Which assessment finding demonstrates a successful outcome of this procedure? 1. The patient is free of electrolyte imbalances 2. The patient's WBC count is within normal limits 3. The patient's EKG reading is regular 4. The patient's urine output is 45mL/hour - CORRECT ANSWER 1. The patient is free of electrolyte imbalances Incorrect - This does not demonstrate the purpose a catheter ablation 2. The patient's WBC count is within normal limits Incorrect - This does not demonstrate the purpose a catheter ablation 3. The patient's EKG reading is regular Correct - A catheter ablation is a procedure used to treat arrhythmias, especially SVT. A catheter is inserted through the femoral vein or artery, and threaded to the conduction fiber in the heart causing the arrhythmia. A radiofrequency energy uses heat to destroy this fiber, preventing further arrhythmia. 4. The patient's urine output is 45mL/hour Incorrect - This does not demonstrate the purpose a catheter ablation Application - The nurse is caring for a patient who has the following labs: Creatinine 2.5mg/dL, WBC 11,000 cells/mL, and Hemoglobin of 12 g/dL. Based on this information, which of these orders would the nurse question? 1. Administer 30 Units of Lantus Daily 2. CT of the spine with contrast 3. X-ray of the abdomen and chest 4. Administer heparin subcutaneous 5,000 Units every 12 hours - CORRECT ANSWER 1. Administer 30 Units of Lantus Daily Incorrect - None of the above labs contraindicate this order 2. CT of the spine with contrast Correct - The creatinine level of this patient indicates impaired kidney function. Contrast is nephrotoxic and is contraindicated for patients with nephropathy. 3. X-ray of the abdomen and chest Incorrect - None of the above labs contraindicate this order 4. Administer heparin subcutaneous 5,000 Units every 12 hours Incorrect - None of the above labs contraindicate this order Application - A nurse is caring for a patient admitted in the emergency room for an ischemic stroke with marked functional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogen activator). Which history-gathering question would not be important for the nurse to ask? 1. "What time was the first time you noticed symptoms appearing consistently?" 2. "Have you been taking any blood thinners like heparin, lovenox, or warfarin?" 3. "Have you had another stroke or head trauma in the previous 3 months?" 4. "Have you had any blood transfusions within the previous year?" - CORRECT ANSWER 1. "What time was the first time you noticed symptoms appearing consistently?" Incorrect - This is a relevant question because TPA is usually used no more than 5-6 hours after onset. This is the timeframe that damage to tissue is still reversible. 2. "Have you been taking any blood thinners like heparin, lovenox, or warfarin?" Incorrect - This is a relevant question because current anticoagulant use, or an INR of greater than 1.7, is a contraindication to TPA use. 3. "Have you had another stroke or head trauma in the previous 3 months?" Incorrect - This is a relevant question because having a stroke or head trauma in the last 3 months contraindicates TPA use 4. "Have you had any blood transfusions within the previous year?" Correct - This is not a relevant question and would not affect the decision to use TPA A patient is being discharged from the med-surgical unit. The patient has a history of gastritis. The nurse questions the patient on his usual routine at home. Which of these statements would alert the nurse that additional teaching is required? 1. "I avoid NSAIDS. I only take a daily aspirin for my heart health." 2. "I always avoid eating hot and spicy foods" 3. "I will continue taking my antacids with or immediately after meals" 4. "I will only drink coffee once a week, if even that often." - CORRECT ANSWER 1. "I avoid NSAIDS. I only take a daily aspirin for my heart health." Correct - Aspirin is classified as an NSAID and can exacerbate already existing stomach problems. Aspirin should be avoided just like any NSAID for patients with gastritis. 2. "I always avoid eating hot and spicy foods" Incorrect - This is a good practice for patients with gastritis 3. "I will continue taking my antacids with or immediately after meals" Incorrect - This is a good practice for patients with gastritis 4. "I will only drink coffee once a week, if even that often." Incorrect - This is a good practice for patients with gastritis. Coffee is not recommended for patients with gastritis. A nurse is meeting a patient in their home. The patient has been taking Naproxen for back pain. Which statement made by the patient most indicates that the nurse needs to contact the physician? 1. "I get an upset stomach if I don't take Naproxen with my meals." 2. "My back pain right now is about a 3/10." 3. "I get occasional headaches since taking Naproxen" 4. "I have ringing in my ears." - CORRECT ANSWER 1. "I get an upset stomach if I don't take Naproxen with my meals." Incorrect - This is a common and less severe side effect of Naproxen 2. "My back pain right now is about a 3/10." Incorrect - Although a 3/10 is bordering on the acceptable amount of pain, this would not be the most pressing issue at hand. 3. "I get occasional headaches since taking Naproxen" Incorrect - This is a common and less severe side effect of Naproxen 4. "I have ringing in my ears." Correct - This is a severe adverse effect of Naproxen and should be reported immediately since it may indicate toxicity. The nurse is doing an intake screening for a patient with hypertension. They have been taking ramapril for 4 weeks. Which statement made by the patient would be most important for the nurse to pass on to the physician? 1. "I get dizzy when I get out of bed." 2. "I'm urinating much more than I used to." 3. "I've been running on the treadmill 10 minutes each day." 4. "I can't get rid of this cough." - CORRECT ANSWER 1. "I get dizzy when I get out of bed." Incorrect - This may require some medication teaching but is not the priority assessment finding. 2. "I'm urinating much more than I used to." Incorrect - ACE Inhibitors like ramapril work, in part, by increasing urine flow. This is a necessary side effect of the medication and is not a priority. 3. "I've been running on the treadmill 10 minutes each day." Incorrect - ACE Inhibitors like ramapril work, in part, by increasing urine flow. This is a necessary side effect of the medication and is not a priority. 4. "I can't get rid of this cough." Correct - A common adverse effect of ACE inhibitors is a persistent, dry cough. A medication change to another class of antihypertensives, like an ARB, may be needed The nurse in the emergency room sees a patient who has been abusing alprazolam (Xanax). The patient reports that he suddenly stopped taking Xanax about 24 hours ago. He presents with a visible tremor, is pacing, expresses fear, and has impaired concentration and memory. Which of these intervention takes priority? 1. Have the patient lie down on a stretcher with bedrails up 2. Give the patient a cup of water to drink and a small amount of food 3. Assure the patient that he will be okay 4. Alert the physician that the patient needs Xanax - CORRECT ANSWER 1. Have the patient lie down on a stretcher with bedrails up Correct - The 1-4 day period after Xanax withdrawal is the most dangerous. Xanax is a benzodiazepine and withdrawal symptoms include life-threatening seizures. Having the patient lie down with bedrails up is part of seizure precautions and is the first priority 2. Give the patient a cup of water to drink and a small amount of food Incorrect - This is not a priority intervention 3. Assure the patient that he will be okay Incorrect - This is not a priority intervention 4. Alert the physician that the patient needs Xanax Incorrect - This is not a priority intervention A nurse cares for a child that is diagnosed with Hepatitis A. Which of these following precautions would be most important to take to prevent transmission of this infectious disease? 1. Encourage the Hepatitis A vaccine for family members and siblings 2. Use needleless systems if possible, otherwise use careful needle precautionary measures 3. Teach the child and enforce strict and frequent hand washing 4. Teach the child and family the dangers of contaminated food and water - CORRECT ANSWER 1. Encourage the Hepatitis A vaccine for family members and siblings Incorrect - Although this is a valuable point for patient education, this does not take the priority, since the patient is still at risk of transmitting Hepatitis A to others right now. 2. Use needleless systems if possible, otherwise use careful needle precautionary measures Incorrect - Hepatitis A is transmitted through the fecal-oral route. 3. Teach the child and enforce strict and frequent hand washing Correct - Hand washing is the single most effective way to prevent transmission of Hepatitis A. Hepatitis A is a virus transmitted via the oral-fecal route and lives on human hands. 4. Teach the child and family the dangers of contaminated food and water Incorrect - Although this is a valuable teaching point, it is not the priority intervention. A nurse is treating a patient suspected to have Hepatitis. The nurse notes on assessment that the patient's eyes are yellow-tinged. Which of these diagnostic results would further assist in confirming this diagnosis? 1. Decreased serum Bilirubin 2. Elevated serum ALT levels 3. Low RBC and Hemoglobin with increased WBCs 4. Increased Blood Urea Nitrogen level - CORRECT ANSWER 1. Decreased serum Bilirubin Incorrect - Bilirubin levels correlate with the appearance of Jaundice. An increased serum bilirubin would be the expected finding for this patient. 2. Elevated serum ALT levels Correct - ALT is a liver enzyme, and hepatitis is a liver disease. Elevated liver enzymes will often signal liver damage. 3. Low RBC and Hemoglobin with increased WBCs Incorrect - This is not a common finding for Hepatitis patients 4. Increased Blood Urea Nitrogen level Incorrect - BUN is an indicator of renal (kidney) health, not hepatic (liver) function. Which of these patients would the nurse suspect as having the greatest risk of contracting Hepatitis B? 1. A sexually active 45-year old man who has Type 1 Diabetes 2. A 75-year old woman who lives in a crowded nursing home 3. A child who lives in a country with poor sanitation and hygiene standards 4. A sexually active 23-year old man who works in a hospital - CORRECT ANSWER 1. A sexually active 45-year old man who has Type 1 Diabetes Incorrect - This person is sexually active, but it is not specified with how many partners. Having Type 1 Diabetes is not a risk factor for Hepatitis. 2. A 75-year old woman who lives in a crowded nursing home Incorrect - Age is not a risk factor for Hepatitis B, and close living accommodations is a stronger risk factor for Hepatitis A and E, which are oral-fecal transmissions. 3. A child who lives in a country with poor sanitation and hygiene standards Incorrect - This is a relevant risk factor for Hepatitis A and E 4. A sexually active 23-year old man who works in a hospital Correct - This person is both sexually active and works in a healthcare environment. The nurse calculates the IV flow rate of a patient receiving lactated ringer's solution. The patient is to receive 2000mL of Lactated Ringer's over 36 hours. The IV infusion set has a drop factor of 15 drops per milliliter. The nurse should set the IV to deliver how many drops per minute? 1. 8 2. 10 3. 14 4. 18 - CORRECT ANSWER 1. 8 Incorrect 2. 10 Incorrect 3. 14 Correct - Drops Per Minute = Milliliters x Drop Factor / Time in Minutes 4. 18 Incorrect The nurse calculates the IV flow rate of a patient receiving an antibiotic. The patient is to receive 100mL of the antibiotic over 30 minutes. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should set the IV to deliver how many drops per minute? 11 19 26 33 - CORRECT ANSWER 11 Incorrect 19 Incorrect 26 Incorrect 33 Correct - Drops Per Minute = Milliliters x Drop Factor / Time in Minutes Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder? 1. "I just want to stab myself with this pen." 2. "What's the point in life anyways?" 3. "My thoughts are racing because of the conspiracies against me." 4. "I hear voices every day and sometimes see old friends that don't exist." - CORRECT ANSWER 1. "I just want to stab myself with this pen." Incorrect - This is a suicidal ideation, but not a classic symptom of schizoaffective disorder 2. "What's the point in life anyways?" Incorrect - This is a verbalization of hopelessness, which can manifest in depression, bipolar disorder, or schizoaffective disorder. 3. "My thoughts are racing because of the conspiracies against me." Correct - Schizoaffective disorder is characterized by the mania and depression of bipolar disorder with the delusions/disturbed thought process of schizophrenia. Racing thought are a classic symptom of a manic episode, while conspiracies indicate paranoia. 4. "I hear voices every day and sometimes see old friends that don't exist." Incorrect - While visual and auditory hallucinations can manifest in schizoaffective disorder, there is no indication of bipolar symptoms (mania or depression)