Question 1

Julia, a 27-year-old patient, is admitted to the unit following a pneumonectomy. The nurse's primary concern for this patient is to maintain:

Accepted Answer

The nurse's primary concern for this patient is to maintain ventilator exchange. It is the priority because oxygen and carbon dioxide exchange is essential for life. Others are not a priority.

Question 2

A 16-year-old female patient is admitted following a burn injury. She sustained deep-partial thickness burns on her neck, anterior chest, and entire right arm. When assessing for heat inhalation, the nurse should first observe for:

Accepted Answer

When assessing for heat inhalation, the nurse should first observe for nasal discharge containing carbon particles. Singed nasal hair and nasal discharges that contain carbon are warning signs of respiratory inhalation.

Question 3

An adult patient was admitted at the hospital due to a severe respiratory problem. His current respiratory status requires endotracheal intubation and positive pressure ventilation. The best immediate nursing intervention at this point is to:

Accepted Answer

The best immediate nursing intervention at this point is to assess the patient's response to mechanical ventilation. To measure the effectiveness of the therapy, the nurse should assess the patient's response. Option A is indeed important, but it is not a priority.

Question 4

An adult patient who smokes 3 packs of cigarettes a day was admitted to the hospital with a diagnosis of pulmonary emphysema. When the nurse assessed the patient, she noticed shortness of breath and that the patient used his accessory muscles during respirations. The nurse is aware that the patient's dyspnea is due to:

Accepted Answer

The nurse is aware that the patient's dyspnea is due to difficulty in expelling the air trapped in the alveoli. Pulmonary emphysema involves destructive changes in the walls of alveoli that lead to air sac dilation. There is subsequent air trapping and difficulty with expiration.

Question 5

Mariane recently had an abdomino-perineal resection and colostomy. She accuses the nurse of being negligent during the change of dressing because she says the surgical wound looks terrible. The nurse recognizes that Mariane is using which defense mechanism?

Accepted Answer

The nurse recognizes that the patient is using a defense mechanism called projection. Projection is the attribution of unacceptable feelings and emotions towards others.

Question 6

Susan is a 34-year-old female patient who had profuse vaginal bleeding. The physician ordered blood transfusion of 2 "u" PRBC type "AB" with preblood transfusion of acetaminophen. Before administering the blood, the priority nursing intervention would be:

Accepted Answer

Before transfusing the blood, the priority nursing action would be to determine proper typing and cross matching of blood. This is absolutely necessary to prevent an acute immunologic reaction if the blood is not compatible with the recipient's blood.

Question 7

A patient who is admitted with a diagnosis of diabetes type 1 was placed on an insulin pump. When teaching the patient on how to control diabetes, the short-term goal should be: "The patient will ­_____...."

Accepted Answer

The short-term goal should be: "The patient will demonstrate the correct use of the pump." Options A and D are long term goals. Option C is indeed a short-term goal, but is not a priority as compared to option B. The patient needs to master the pump prior to discharge.

Question 8

A 40-year-old patient with chronic atrial fibrillation was placed on an oral anticoagulant therapy. Nurse Victoria is preparing to administer the medication, but she decided to withhold it because she noted that the patient has:

Accepted Answer

Nurse Victoria is preparing to administer the medication, but she decided to withhold it because she noted that the patient has an international normalized ration between 6 and 7. A patient who is receiving an anticoagulant, INR should be maintained between 2 and 3; above this value would predispose a patient to develop hemorrhage.

Question 9

A 28-year-old patient was admitted with a diagnosis of Hepatitis A. The doctor ordered contact precautions. In addition to the standard precautions, what isolation procedures should be strictly implemented?

Accepted Answer

In addition to the standard precautions, the isolation procedures that should be strictly implemented is that a gown and a mask should be worn whenever a person will come in contact with a contaminated body fluids and feces. Hepatitis A is transmitted via oral-fecal route; contact precautions should be followed when there are articles that have a potential urine or fecal contamination.

Question 10

Nurse Dolly was walking in the hallway of the unit when she noticed a patient having a tonic-clonic seizure. Nurse Dolly's priority should be to:

Accepted Answer

Nurse Dolly's priority should be to protect the patient's head from injury. Repeated banging of the head is caused by the rhythmic contraction and relaxation associated with a tonic-clonic seizure.

Question 11

Nurse Jenna is making a short-term goal for an adult male patient who is on his first week of admission following a spinal cord injury at the T3 level. What is an appropriate short-term goal that Jenna should identify?

Accepted Answer

An appropriate short-term goal that Jenna should identify is "The patient will carry out his hygiene activities." The patient has the capability and this also maintains positive identity; moreover, it is necessary for progression of long-term goals.

Question 12

A morbidly obese adult patient who smokes 2 packs of cigarettes daily was admitted for a major abdominal surgery. Postoperatively, the most appropriate laboratory value that a clinical nurse specialist should monitor that would reflect the patient's respiratory status is the:

Accepted Answer

Postoperatively, the most appropriate laboratory value that a clinical nurse specialist should monitor that would reflect the patient's respiratory status is oxygen saturation. Oxygen saturation is a measure of the relationship between hemoglobin and oxygen. It measures the amount of oxygen available to tissues and provides a pulmonary assessment for patients at risk for hypoxia.

Question 13

An adult patient who was diagnosed with chronic obstructive pulmonary disease (COPD) has an acute COPD exacerbation episode. He experiences dyspnea and is anxious. In order to decrease the dyspnea, the nurse's initial action is to:

Accepted Answer

In order to decrease the dyspnea, the nurse's initial action is to teach and encourage the patient to do rhythmic breathing. This method permits more complete exhalation and emptying of carbon dioxide from the lungs, which is the cause for the acute COPD exacerbation episode.

Question 14

Antonio is a patient who is on his first day following a right pneumonectomy. After the morning rounds, he suddenly sits straight up in bed. He has labored breathing; he is making a crowing sound; and his skin is pale, moist, and cool to touch. The nurse should immediately:

Accepted Answer

The nurse should immediately auscultate the left lung. Assessment of the airway would be the priority. A mediastinal shift with airway obstruction may occur because pressure builds up on the operative side, causing the trachea to deviate toward the nonoperative side.

Question 15

After a thoracic surgery, a male adult patient was transported to the unit. He has a chest tube connected to a water-seal drainage attached to suction. The nurse noticed that there is excessive bubbling in the water-seal chamber. The nurse should:

Accepted Answer

The nurse should assess the bottle system for air leaks. Excessive bubbling is an indication of an air leak that must be eliminated to aid in the expansion of the lungs.

Question 16

A male adult patient who has history of chronic renal failure is hospitalized. In order for early detection signs related to renal insufficiency, the nurse should assess the patient for signs that include:

Accepted Answer

In order for early detection signs related to renal insufficiency, the nurse assesses the patient for signs that include edema and pruritus. Pruritus is caused by accumulation of metabolic waste in the blood. Edema is caused by fluid overload due to impairment in renal excretion.

Question 17

An adult female patient with acute renal failure moves into the diuretic phase after 1 week of therapy. During this phase, the patient must be assessed for signs of developing:

Accepted Answer

During this phase, the patient must be assessed for signs of developing hypovolemia. In the diuretic phase, fluid is retained and during the oliguric phase, it is excreted and may reach 3-5 L per day; hypovolemia can occur and fluid should be replaced.

Question 18

In a critical situation, a physician orders the nurse to administer a dose of a drug that the nurse knows would constitute an overdose for the patient. Which statement by the nurse is most appropriate?

Accepted Answer

The statement by the nurse that is most appropriate is "The dose is more than I can give. However, if the dose is medically indicated, please administer it yourself." This informs the physician of your legal position without creating an adversarial professional position.

Question 19

A female adult patient was admitted with a chief complaint of body weakness and was formerly diagnosed with diabetes mellitus. The physician orders 30 units of insulin to be incorporated in an IV of glucose and water. The nurse understands that the only insulin compatible to use is:

Accepted Answer

The nurse understands that the only insulin compatible to use is humulin R. This type of insulin acts rapidly and is compatible with intravenous solutions. Others are all not compatible with intravenous solutions.

Question 20

Digoxin (lanoxin) is ordered for a patient with a diagnosis of heart failure. The nurse is doing a care plan including observation of digoxin toxicity; therefore, the nurse should monitor the patient for:

Accepted Answer

The nurse should monitor the patient for blurring of vision. Blurring of vision and yellow or green vision are signs of toxicity.

Quiz 1: Adult

Julia, a 27-year-old patient, is admitted to the unit following a pneumonectomy. The nurse's primary concern for this patient is to maintain:

A 16-year-old female patient is admitted following a burn injury. She sustained deep-partial thickness burns on her neck, anterior chest, and entire right arm. When assessing for heat inhalation, the nurse should first observe for:

An adult patient was admitted at the hospital due to a severe respiratory problem. His current respiratory status requires endotracheal intubation and positive pressure ventilation. The best immediate nursing intervention at this point is to:

Mariane recently had an abdomino-perineal resection and colostomy. She accuses the nurse of being negligent during the change of dressing because she says the surgical wound looks terrible. The nurse recognizes that Mariane is using which defense mechanism?

Susan is a 34-year-old female patient who had profuse vaginal bleeding. The physician ordered blood transfusion of 2 "u" PRBC type "AB" with preblood transfusion of acetaminophen. Before administering the blood, the priority nursing intervention would be:

A patient who is admitted with a diagnosis of diabetes type 1 was placed on an insulin pump. When teaching the patient on how to control diabetes, the short-term goal should be: "The patient will _____...."

A 40-year-old patient with chronic atrial fibrillation was placed on an oral anticoagulant therapy. Nurse Victoria is preparing to administer the medication, but she decided to withhold it because she noted that the patient has:

A 28-year-old patient was admitted with a diagnosis of Hepatitis A. The doctor ordered contact precautions. In addition to the standard precautions, what isolation procedures should be strictly implemented?

Nurse Dolly was walking in the hallway of the unit when she noticed a patient having a tonic-clonic seizure. Nurse Dolly's priority should be to:

Nurse Jenna is making a short-term goal for an adult male patient who is on his first week of admission following a spinal cord injury at the T3 level. What is an appropriate short-term goal that Jenna should identify?

A morbidly obese adult patient who smokes 2 packs of cigarettes daily was admitted for a major abdominal surgery. Postoperatively, the most appropriate laboratory value that a clinical nurse specialist should monitor that would reflect the patient's respiratory status is the:

An adult patient who was diagnosed with chronic obstructive pulmonary disease (COPD) has an acute COPD exacerbation episode. He experiences dyspnea and is anxious. In order to decrease the dyspnea, the nurse's initial action is to:

Antonio is a patient who is on his first day following a right pneumonectomy. After the morning rounds, he suddenly sits straight up in bed. He has labored breathing; he is making a crowing sound; and his skin is pale, moist, and cool to touch. The nurse should immediately:

After a thoracic surgery, a male adult patient was transported to the unit. He has a chest tube connected to a water-seal drainage attached to suction. The nurse noticed that there is excessive bubbling in the water-seal chamber. The nurse should:

A male adult patient who has history of chronic renal failure is hospitalized. In order for early detection signs related to renal insufficiency, the nurse should assess the patient for signs that include:

An adult female patient with acute renal failure moves into the diuretic phase after 1 week of therapy. During this phase, the patient must be assessed for signs of developing:

In a critical situation, a physician orders the nurse to administer a dose of a drug that the nurse knows would constitute an overdose for the patient. Which statement by the nurse is most appropriate?

A female adult patient was admitted with a chief complaint of body weakness and was formerly diagnosed with diabetes mellitus. The physician orders 30 units of insulin to be incorporated in an IV of glucose and water. The nurse understands that the only insulin compatible to use is:

Digoxin (lanoxin) is ordered for a patient with a diagnosis of heart failure. The nurse is doing a care plan including observation of digoxin toxicity; therefore, the nurse should monitor the patient for:

Quiz 1: Adult

Julia, a 27-year-old patient, is admitted to the unit following a pneumonectomy. The nurse's primary concern for this patient is to maintain:

A 16-year-old female patient is admitted following a burn injury. She sustained deep-partial thickness burns on her neck, anterior chest, and entire right arm. When assessing for heat inhalation, the nurse should first observe for:

An adult patient was admitted at the hospital due to a severe respiratory problem. His current respiratory status requires endotracheal intubation and positive pressure ventilation. The best immediate nursing intervention at this point is to:

Mariane recently had an abdomino-perineal resection and colostomy. She accuses the nurse of being negligent during the change of dressing because she says the surgical wound looks terrible. The nurse recognizes that Mariane is using which defense mechanism?

Susan is a 34-year-old female patient who had profuse vaginal bleeding. The physician ordered blood transfusion of 2 "u" PRBC type "AB" with preblood transfusion of acetaminophen. Before administering the blood, the priority nursing intervention would be:

A patient who is admitted with a diagnosis of diabetes type 1 was placed on an insulin pump. When teaching the patient on how to control diabetes, the short-term goal should be: "The patient will ­_____...."

A 40-year-old patient with chronic atrial fibrillation was placed on an oral anticoagulant therapy. Nurse Victoria is preparing to administer the medication, but she decided to withhold it because she noted that the patient has:

A 28-year-old patient was admitted with a diagnosis of Hepatitis A. The doctor ordered contact precautions. In addition to the standard precautions, what isolation procedures should be strictly implemented?

Nurse Dolly was walking in the hallway of the unit when she noticed a patient having a tonic-clonic seizure. Nurse Dolly's priority should be to:

Nurse Jenna is making a short-term goal for an adult male patient who is on his first week of admission following a spinal cord injury at the T3 level. What is an appropriate short-term goal that Jenna should identify?

A morbidly obese adult patient who smokes 2 packs of cigarettes daily was admitted for a major abdominal surgery. Postoperatively, the most appropriate laboratory value that a clinical nurse specialist should monitor that would reflect the patient's respiratory status is the:

An adult patient who was diagnosed with chronic obstructive pulmonary disease (COPD) has an acute COPD exacerbation episode. He experiences dyspnea and is anxious. In order to decrease the dyspnea, the nurse's initial action is to:

Antonio is a patient who is on his first day following a right pneumonectomy. After the morning rounds, he suddenly sits straight up in bed. He has labored breathing; he is making a crowing sound; and his skin is pale, moist, and cool to touch. The nurse should immediately:

After a thoracic surgery, a male adult patient was transported to the unit. He has a chest tube connected to a water-seal drainage attached to suction. The nurse noticed that there is excessive bubbling in the water-seal chamber. The nurse should:

A male adult patient who has history of chronic renal failure is hospitalized. In order for early detection signs related to renal insufficiency, the nurse should assess the patient for signs that include:

An adult female patient with acute renal failure moves into the diuretic phase after 1 week of therapy. During this phase, the patient must be assessed for signs of developing:

In a critical situation, a physician orders the nurse to administer a dose of a drug that the nurse knows would constitute an overdose for the patient. Which statement by the nurse is most appropriate?

A female adult patient was admitted with a chief complaint of body weakness and was formerly diagnosed with diabetes mellitus. The physician orders 30 units of insulin to be incorporated in an IV of glucose and water. The nurse understands that the only insulin compatible to use is:

Digoxin (lanoxin) is ordered for a patient with a diagnosis of heart failure. The nurse is doing a care plan including observation of digoxin toxicity; therefore, the nurse should monitor the patient for:

A patient who is admitted with a diagnosis of diabetes type 1 was placed on an insulin pump. When teaching the patient on how to control diabetes, the short-term goal should be: "The patient will _____...."