Critical Care, Pediatrics & Shock Management
Question: A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for?
Answer Options:
Fever, Malaise, Dyspnea, Anorexia
Answer: Dyspnea
Question: The nurse is caring for a patient 2 days after a CABG. What should the nurse perform in order to best prevent common complications? (Select all that apply.)
Answer Options:
Give instructions about sternal precautions, Instruct and assist with incentive spirometry usage every hour while awake, Monitor a strict intake and output on the patient, Encourage patient to cough and deep breathe, Draw liver enzymes daily as ordered by the physician
Answer: Give instructions about sternal precautions, Instruct and assist with incentive spirometry usage every hour while awake, Encourage patient to cough and deep breathe
Question: A nurse is providing care for an older adult client who has diabetes insipidus (DI). The nurse should monitor the client for which of the following neurologic effects?
Answer Options:
Ataxia, Hypotension, Poor skin turgor, Dilute urine
Answer: Ataxia
Question: A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply.)
Answer Options:
Substance use disorder, Female gender, Currently married, Age greater than 45 years old, Schizophrenia
Answer: Substance use disorder, Schizophrenia
Question: A nurse is caring for a client who is receiving magnesium sulfate to treat severe preeclampsia and asks the nurse “Is the medication working?” Which of the following responses should the nurse make?
Answer Options:
“The medication is working, because your blood pressure is normal.”, “The medication is working because there are no contractions.”, “The medication is working, because there is no seizure activity.”, “The medication is working, because all your lung fields are clear.”
Answer: “The medication is working, because there is no seizure activity.”
Question: A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?
Answer Options:
Preparation for cesarean birth, A magnesium sulfate infusion, Examination to determine cervical status, Initiation of pushing
Answer: Preparation for cesarean birth
Question: The ICU nurse is caring for a patient requiring mechanical ventilation. Which of the following interventions are the best that the nurse should include to assist in preventing ventilator-associated pneumonia? (Select all that apply.)
Answer Options:
Provide meticulous mouth care Q2H and as needed, Implement intermittent suctioning of oral and pharynx secretions prn, Reposition the patient at least every 2 hours and prn, Begin weaning from mechanical ventilation after patient is alert, Complete hand hygiene before and after care of the patient
Answer: Provide meticulous mouth care Q2H and as needed, Implement intermittent suctioning of oral and pharynx secretions prn, Reposition the patient at least every 2 hours and prn, Complete hand hygiene before and after care of the patient
Question: The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms?
Answer Options:
Respiratory acidosis associated with hyperventilation, Decreasing PaO2 levels despite increased FiO2 administration, Elevated alveolar surfactant levels, Increased lung compliance with increased FiO2 administration
Answer: Decreasing PaO2 levels despite increased FiO2 administration
Question: A nurse is caring for a pre-school age child who has epiglottitis with a barking cough. Which of the following actions should the nurse take?
Answer Options:
Initiate airborne precautions, Obtain a throat culture, Monitor oxygen saturation, Use a tongue depressor to observe the epiglottis
Answer: Monitor oxygen saturation
Question: A patient with symptomatic mitral valve prolapse has atrial and ventricular dysrhythmias. In addition to monitoring for decreased cardiac output, what is an important nursing intervention related to the dysrhythmias?
Answer Options:
Give sleeping pills to decrease paroxysmal nocturnal dyspnea, Teach the patient exercises to prevent recurrence of dysrhythmias, Monitor breathing pattern related to hypervolemia, Encourage calling for assistance when getting out of bed
Answer: Encourage calling for assistance when getting out of bed
Question: A nurse is caring for a client who is 8 hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?
Answer Options:
High Fowler’s with neck extended, High Fowler’s with neck in a neutral position, Semi-Fowler’s with neck extended, Semi-Fowler’s with neck in a neutral position
Answer: Semi-Fowler’s with neck in a neutral position
Question: You are providing discharge teaching to parents of an infant with a myelomeningocele. Which of the following would you include as the most common problem associated with myelomeningocele?
Answer Options:
Bladder incontinence, Hip dysplasia, Respiratory compromise, Intellectual impairment
Answer: Bladder incontinence
Question: A charge nurse has access to the facility’s electronic client records. Is it appropriate for the charge nurse to share her personal password with whom?
Answer Options:
The nurse manager, No one, A nursing student who is completing a preceptorship on the unit, The unit clerk
Answer: No one
Question: The nurse is caring for a set of hospitalized clients. Which of the following actions would be best for the nurse to include in the plan of care to reduce the possibility of these clients developing shock? (Select all that apply.)
Answer Options:
Assessing and identifying clients at risk, Monitoring the daily white blood cell count, Limiting the client’s visitors until more stable, Performing proper hand hygiene, Removing invasive lines as soon as possible, Using aseptic technique during procedures
Answer: Assessing and identifying clients at risk, Performing proper hand hygiene, Removing invasive lines as soon as possible, Using aseptic technique during procedures
Question: The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
Answer Options:
Assess the capillary refill, Evaluate chest expansion, Check pupillary response to light, Check client’s response to questions about place and time
Answer: Evaluate chest expansion
Question: A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?
Answer Options:
Increased heart rate from 68 to 72/min, Increased respiratory rate from 18 to 44/min, Increased blood pressure from 112/68 to 120/72 mm Hg, Increased oral temperature from 36.6°C (97.8°F) to 37°C (98.6°F)
Answer: Increased respiratory rate from 18 to 44/min
Question: You are caring for a patient with thermal burns with an inhalation injury. Which of the following would you include in the plan of care for this patient? (Select all that apply.)
Answer Options:
Keep room temperature cooled, Continued airway assessment, Initiate fluid resuscitation, Provide pain management through IM route, Monitor strict I&O
Answer: Continued airway assessment, Initiate fluid resuscitation, Monitor strict I&O
Question: A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? (Select all that apply.)
Answer Options:
Apply elastic compression stockings, Perform passive range of motion exercises, Assess legs for redness, Massage the calves every shift, Place pillows under the client’s knees when in bed
Answer: Apply elastic compression stockings, Perform passive range of motion exercises
Question: A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which the following laboratory findings indicate a therapeutic effect of the medication?
Answer Options:
Serum sodium 146 mEq/L, Blood glucose 80 mg/dL, Urine specific gravity 1.015, Blood urea nitrogen (BUN) 15 mg/dL
Answer: Urine specific gravity 1.015
Question: The nurse is admitting a patient with a head injury who has ecchymoses around both eyes and clear drainage from the patient’s nose. Which of the following admission orders should the nurse question first?
Answer Options:
Turn patient side to side every 2 hours, Insert nasogastric tube to low suction, Keep the head of bed elevated, Apply cold packs intermittently to face
Answer: Insert nasogastric tube to low suction
Question: A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client’s restored rhythm is symptomatic bradycardia?
Answer Options:
Epinephrine, Atropine, Sodium bicarbonate, Magnesium
Answer: Atropine
Question: A nurse is caring for a client who is 8 hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?
Answer Options:
High Fowler’s with neck extended, High Fowler’s with neck in a neutral position, Semi-Fowler’s with neck extended, Semi-Fowler’s with neck in a neutral position
Answer: Semi-Fowler’s with neck in a neutral position
Question: People worldwide link old age with _____.
Answer Options:
a) mental decline, b) anger, c) kindness, d) caring
Answer: a) mental decline
Question: Which memory suggestion is LEAST helpful for older people?
Answer Options:
a) Avoid situations where you have to multitask, b) Don’t tax your brain by trying to memorize material, c) Use mnemonic techniques, d) Avoid situations where you have to learn and remember material very quickly
Answer: b) Don’t tax your brain by trying to memorize material
Question: Who is MOST likely to be depressed?
Answer Options:
a) a 70-year-old who has never married, b) a 100-year-old who is married, with close friends, c) a 65-year-old who has just retired, d) a 90-year-old who is socially isolated and physically frail
Answer: d) a 90-year-old who is socially isolated and physically frail
Question: Compared to a 20-year-old, socioemotional selectivity implies an 80-year-old would:
Answer Options:
a) prefer social media to talking one to one, b) dislike social media, c) use social media far less frequently, d) use social media only to keep in touch with family
Answer: d) use social media only to keep in touch with family