Question: Which nurse action when caring for a patient with shock indicates a need for more education?
Answer Choices:
Administering epinephrine for anaphylaxis
Maintaining cool room temp for neurogenic shock
Placing pulse oximeter on ear for septic shock
Keeping head of bed flat for hypovolemic shock
Answer: Keeping the head of the bed flat for a patient with hypovolemic shock
Question: A nurse cares for a client with burns on front and back of both legs and arms. What is the TBSA?
Answer Choices:
36 percent
54 percent
9 percent
18 percent
Answer: 36 percent
Question: Although a patient in shock may have normal hemodynamic values, which labs should be checked? (Select all that apply.)
Answer Choices:
Base deficit
Potassium
Anion gap
pH
Serum lactate level
Answer: Base deficit, Anion gap, pH, Serum lactate level
Question: A nurse admits a client to PACU who received a neuromuscular blocking agent. What should be at bedside?
Answer Choices:
Chest tube equipment
Defibrillator machine
Central venous catheter tray
Bag valve mask device
Answer: Bag valve mask device
Question: A nurse is caring for a client in the compensatory stage of shock. Which finding should the nurse expect?
Answer Choices:
Heart rate 160/min
Hypokalemia
Blood pressure 115/68 mmHg
Mottled skin
Answer: Heart rate 160/min
Question: A client with bipolar disorder demands the nurse call the provider at 3 AM. What is the appropriate response?
Answer Choices:
“Go back to your room, I’ll try to reach your doctor.”
“I can’t call unless it’s an emergency.”
“You must be very upset about something.”
“You’re being unreasonable.”
Answer: “You must be very upset about something.”
Question: The nurse caring for a patient with Guillain-Barre syndrome notes decreased mobility. What are the best actions? (Select all that apply.)
Answer Choices:
Refer to social worker/chaplain
Work with speech therapy
Provide info on support groups
Ask occupational therapy to help
Consult provider for physical therapy
Answer: Provide the patient with information on support groups, Ask occupational therapy to help, Consult with the provider about a physical therapy consult
Question: A nurse cares for a client with anaphylaxis following a bee sting. What should the nurse do first?
Answer Choices:
Administer epinephrine
Auscultate for wheezing
Monitor for hypotension
Assess LOC
Answer: Administer epinephrine
Question: A nurse is reviewing data for four children. Which child should the nurse assess first?
Answer Choices:
10-year-old with sickle cell anemia and severe chest pain
4-year-old with asthma and a PCO₂ of 37 mmHg
7-year-old with diabetes insipidus and specific gravity 1.016
1-year-old with roseola and temperature 39°C
Answer: 10-year-old with sickle cell anemia and severe chest pain
Question: A nurse obtains a CVP reading of 1 mmHg that doesn’t correlate with assessment. What’s the best first action?
Answer Choices:
Sit the patient up to 90° and recheck CVP
Administer 1L of saline over 2 hours
Call the physician
Level the transducer and zero the system
Answer: Level the transducer and zero the system
Question: When assessing a client with bacterial meningitis, which finding needs immediate intervention?
Answer Choices:
Temperature 101°F
Nuchal rigidity
Positive Kernig’s sign
BP 88/42 mmHg
Answer: The patient’s blood pressure is 88/42 mm Hg
Question: A nurse assesses a client prescribed furosemide for heart failure. Which finding is an adverse effect?
Answer Choices:
Weight gain
Hypoglycemia
Increased blood pressure
Leg cramps
Answer: Leg cramps
Question: A nurse is planning care for a child with suspected epiglottitis. Which action should the nurse take?
Answer Choices:
Place the child in an upright position
Transport the child for a throat x-ray
Visualize the epiglottis with a tongue depressor
Obtain a throat culture
Answer: Place the child in an upright position
Question: A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which finding should the nurse expect?
Answer Choices:
Decreased specific gravity
Increased pulmonary artery wedge pressure (PAWP)
Elevated central venous pressure (CVP)
Decreased brain natriuretic peptide (BNP)
Answer: Elevated central venous pressure (CVP)
Question: A nurse is reviewing PT, aPTT, and INR for a client with acute DIC. What should the nurse expect?
Answer Choices:
The laboratory values are decreased.
The laboratory values are prolonged.
The laboratory values are within the expected range.
The laboratory values are the same as previous test values.
Answer: The laboratory values are prolonged.
Question: A patient is in ICU after spinal cord injury 2 days ago. What nursing care should be included? (Select all that apply.)
Answer Choices:
Monitor and maintain systemic BP
Minimize environmental stimuli
Prepare transfer to long-term care
Administer corticosteroids
Monitor for respiratory complications
Answer: Monitoring and maintaining systemic blood pressure, Administering corticosteroids, Monitoring for respiratory complications
Question: A nurse cares for a client with alcohol use disorder shouting about bugs on him. What is the appropriate response?
Answer Choices:
“I don’t see any bugs, but you seem very frightened.”
“I do not see anything. This is part of withdrawal.”
“I’m sure the bugs will not harm you.”
“Tell me more about the bugs you see.”
Answer: “I don’t see any bugs, but you seem very frightened.”