Situation 1: A patient has just arrived in the Oncology Unit
from the PACU following a left modifed radical mastectomy ecause of in!ammatory reast cancer "#$C%& She has a pressure dressing over the surgical site and two drains& Assessment shows her vital signs are stale' fully awa(e and claims that pain is under control& )ortune is the nurse assigned to the patient& 1& )rom the following data otained from the chart' which is not a ris( factor which could have predisposed the patient to reast cancer* A& Age + ,, years old $& -eight + ,./0 1eight + 123 ls& C& 4enarche at age 15 6& 4other died of colon cancer /& )ortune read a literature which says that y the time #$C is diagnosed' ,3789,7 have palpale au:iliary lymph nodes' as many as 537 have gross distant metastasis and as few as 537 of patients have an underlying reast mass& 1hich of the following is the appropriate interpretation of the research fndings* A& Au:iliary nodes were palpated on /3 out of 53 women positive for #$C $& Out of the /3 women who were positive for #$C' only , have metastasis C& #f there were 13 women diagnosed with #$C' 5 have positive lymph nodes 6& $reast mass was identifed on ; out of 53 women positive for #$C 5& )ortune recogni<es that adjuvant chemotherapy for reast cancer may include any of the following e:cept A& 4onoclonal antiody $& Proton inhiitors C& Antiiotics 6& Anti8estrogen =& )ortune understands that when the antineoplastic agent lea(s through the peripheral vascular access during chemotherapy' which of the following is e:pected to e done frst* A& >efer to the physician $& Stop the chemotherapy infusion C& Cleanse site with saline solution 6& Call another nurse to chec( the intravenous site& ,& A clinical trial is currently underta(en to test treatments for #$C& ?he research team leader wishes to include the patient as a participant in the study& As a patient advocate' which of the following will )ortune do frst* A& Otain informed consent from the patient $& @:plain to the patient the scope of the clinical trial C& #nAuire from the team leader enefts for the patient 6& >ead more related literature Situation /: 6uring a staB meeting at the #ntensive care unit' the nurse manager reported a list of procedures that need to e reviewed and updated& One of these procedures is the precautionary measure related to ventilator8associated pneumonia& 2& 1hile rainstorming' the group mentioned the use of evidence8ased techniAues& 1hich of the following statements given y the memers of the group re!ect evidence8ased methods* A& CDet us as( the opinion of e:perts&E $& C?he e:periences of the nurses must e otained&E C& C>eview of related literature will e very helpful&E 6& C1e must agree on a common procedure&E 9& ?he nurse manager assigned a group to develop a project intended to improve the e:isting procedure related to the prevention of ventilator8associated pneumonia among #CU patients& A team leader was selected y the group& 1hich of the following will the team leader do frst* A& ?ell the group to state their ojectives $& )ormulate a list of desired outcomes C& Set a target 6& State actions to e done y each memer of the group ;& ?he team leader organi<ed the group& 1hich of the following actions of the team leader re!ect organi<ation* ?he team leader: A& Assigned tas(s to each memer $& @liminated non8performing memers of the group C& Chec(ed the assignments of each memer of the group 6& 6etermined which actions will e done frst F& 1hich of the following data will e most helpful to the group to ensure continuous process improvement* A& Gon8conformances to suctioning procedure $& #ncidences of ventilator8associated pneumonia during the last month C& @:periences of nurses when managing care of intuated patients 6& 6ocumentation of oservation of intuated patients 13& ?he group developed revisions to the e:isting procedure& $efore the procedure could e implemented as a standard procedure' which of the following will e done frst* A& Hather relevant data $& Chec( if procedure is eBective through feedac( C& Plan for the implementation of the procedure 6& 6o the procedure on selected patients Situation 5: Duther' a ,38year8old construction wor(er sustained multiple injuries due to a motorcycle accident& 11& #n the @mergency 6epartment' the physician orderd diagnostic tests' one of which is lood alcohol level& 1hich of the following is the purpose of this test* A& 6etermine level of alcohol dependence $& 6iscover injuries in the rain C& >ule out alcoholism 6& Assessment of client.s level of consciousness 1/& $lood transfusion must e administered immediately ecause of loss of lood volume due to trauma& Duther.s lood type is O' as his nurse' you recogni<e which of the following statements is true* A& ?ype O lood has oth types of antiodies $& Persons with type O lood can also receive ?ype A lood C& ?ype O lood has no antiodies 6& Persons with ?ype O lood are also called universal recipients 15& 1hen assessing Duther for hypovolemic shoc(' which of the following data indicates that he is in the irreversile stage of shoc(* A& >estless' an:ious and confused $& Anuria C& S(in moist' pale and moist 6& Pulse rapid and wea( 1=& ?he physician ordered colloid solution such as 6e:tran =3& 6uring the infusion' Duther complained of dyspnea& Upon auscultation' you noted whee<es& 1hich of the following will you do frst* A& 6iscontinue the infusion $& Place Duther on a )owler.s position C& 6ecrease the infusion rate 6& Call the attending physician 1,& Duther.s central venous pressure is monitored every hour& 1hen you measure the CIP using a water manometer' you are e:pected to oserve which of the following to ensure accuracy of CIP measurement* A& 4aintain the client on a )owler.s position $& Use a one8way stopcoc( to regulate !ow of #I !uids to the water manometer C& #mmoili<e the client.s right arm 6& Jeep the <ero point of the manometer in level with the client.s right atrium Situation =: Kou are caring for 1arren' ,; years old' who is diagnosed with laryngeal cancer& 12& 1arren is scheduled for a total laryngectomy and radical nec( dissection for cancer of the laryn:& -e as(s you' C-ow will # tal( after surgery*E As his nurse' your est response will e A& CKou will reathe through a permanent opening in your nec(' ut you will not e ale to communicate orally&E $& CKou won.t e ale to tal( right after the surgery' ut you will e ale to spea( again once the tracheostomy tue is removed&E C& CKou will have a permanent opening into your nec(' and you will need to have rehailitation for some type of voice restoration&E 6& CKou won.t e ale to spea( as you used to' ut there are artifcial voice devices that will give you the aility to spea( normally&E 19& 1arren returns from surgery with a tracheostomy tue after a total laryngectomy and radical nec( dissection& #n caring for 1arren during the frst /= hours after surgery' your priority nursing action is to A& Avoid changing the tracheostomy ties $& 4onitor for leeding around the stoma C& Assess airway patency and reath sounds 6& Clean the inner cannula every ; hours 1;& After doing assessment' one of the nursing diagnosis you identifed is C$ody image 6isturance related to loss of control of personal care&E ?o evaluate eBectiveness of your interventions' the e:pected outcome for the prolem that 1arren should demonstrate is that he A& Dets his wife provide hygiene and stoma care $& 1ears clothing that minimi<es the disfgurement caused y the surgery C& As(s that only family memers e allowed to visit 6& Dearns to remove and clean the laryngectomy tue independently 1F& 1arren is scheduled to start radiation therapy& Kou have just taught 1arren all aout radiation therapy& 1hich of the following statements y 1arren would indicate that your teaching has een eBective* A& C# can use lotions to moisturi<e the s(in on my throat&E $& C# will need to uy water ottle to carry with me&E C& C# need to use alcohol8ased mouthwashes to help clean oral ulcers&E 6& C# may e:perience diarrhea' # may have diarrhea until the radiation is complete&E /3& After completing the discharge instructions for 1arren' you determine that additional instruction is needed when he says A& C# can participate in most of my prior ftness activities e:cept swimming&E $& C# should wear a 4edic Alert racelet that identifes me as a nec( reather&E C& C# must (eep the stoma covered with a loose sterile dressing at all times&E 6& C# need to eat nutritious meals even though # can.t smell or taste very well&E Situation ,: $oy' 11 years old' was admitted ecause of hematuria& 6iagnosis is 6engue fever& /1& 1hich of the following is the most li(ely description of $oy.s fever prior to the onset of hematuria that supports the physician.s diagnosis of dengue fever* A& #ntermittent fever for = days $& Onset of fever was arupt and remained elevated for = days C& Arupt onset of fever and sudden drop on the = th day 6& Hradual increase of ody temperature and sudden drop on the = th day //& ?he nurse understands that the cycle of transmission of dengue fever virus egins during which of the following* A& #nfected mosAuito ites an uninfected human $& Iirus multiply in the midgut of the mosAuito C& 4osAuito feeds on an infected human 6& 4osAuito.s saliva is invaded y the virus during suseAuent iting of infected human /5& ?he nurse noted that Aspirin and GSA#6 are contraindicated for $oy& 1hich of the following is the rationale ehind this order* A& Patient may e allergic $& 6rug contains anticoagulant properties C& 6ue to stomach upset eBects of the drug 6& 6rugs enhance production of maculopapular rashes /=& ?he condition of $oy is closely watched for signs of hypovolemic shoc(& 1hich of the following should the nurse report as early signs of hypovolemic shoc(* 1& Dethargy /& >apid pulse 5& Clammy s(in =& Cyanosis ,& >estlessness 2& -ematemesis A& /' 5' = and , $& 1' /' 5 and , C& 1' /' , and 2 6& 1' 5' = and 2 /,& ?o prevent transmission of the virus to others' which of the following is the most appropriate isolation measure the nurse should implement in the care of $oy* A& Screen the environment $& $lood and ody secretion isolation C& Use gown' gloves and mas( 6& Use strict universal isolation techniAue Situation 2: Agua $endita' 5, years old' was admitted to the hospital ecause of near drowning& #n the #CU where she was admitted for oservation' her o:ygen saturation dropped to ;=7 and suseAuent lood gases showed PaO/ of ,,mm-g& 6iagnosis is proaly Acute >espiratory 6istress Syndrome "A>6S%& @ndotracheal intuation and mechanical ventilation were ordered& /2& ?he nurse is aware that in A>6S' the asic changes in the lungs result from the injury to the alveolar wall and capillary memrane leading to the following pathological changes' e:cept A& )luid and protein lea(s into alveoli and interstitial tissue $& 6amaged surfactant producing cells C& #ncreased surfactant production 6& #ncreased alveolar capillary permeaility /9& 1hich of the following ventilator settings re!ect the amount of air delivered within each ventilator reath* A& #nspiration to e:piration ratio $& Pressure limit C& ?idal volume D. O:ygen concentration ")iO/% /;& 1hich of the following will the nurse closely monitor to ensure that the percentage of o:ygen delivered with ventilator reaths is adeAuate* A& >espiratory rate $& Central venous pressure C& Pulse o:imeter.s reading 6& Cardiac monitor /F& ?he nurse is e:pected to closely watch the client for complications related to mechanical ventilation& 1hich of the following will the nurse do to assess sucutaneous emphysema* A& Oserve for signs of uneAual chest e:pansion $& Auscultate the lungs and oserve for crac(les C& Palpate nec( for air ule8popping sensation 6& Percuss for hyperresonant percussion tone 53& ?he nurse oserved air lea(s from the endotracheal tue and decreased reath sounds& 1hich of the following will the nurse do frst* A& >eport to the physician $& Call the respiratory therapist C& Place patient on semi8fowlers position 6& >eposition the endotracheal tue Situation 9: Kou admitted @ngleert' 93 years old' ecause of pulmonary edema& -e has a history of congestive heart failure' type / diaetes mellitus and hypertension& 51& $ased on the history' you specifcally noted that @ngleert regularly too( Dano:in "6igo:in%& 1hich of the following is the specifc action of this drug on the patient* A& #mproves myocardial contractility' decreases the heart rate' and reduces o:ygen consumption $& Causes vasoconstriction' increased resistance preload and dilation of the ventricles C& >educes peripheral vascular resistance and afterload' reducing myocardial wor(load 6& #nterfered with the production of angiotensin ## resulting in improved cardiac output and reducing pulmonary congestion 5/& 1hich of the following specifc positions would e most helpful for @ngleert to facilitate and trap e:cess !uids in the lower e:tremities* A& -ead ent forward on an overed tale supported with pillows $& Upright sitting position with the legs dangling C& Dateral position with the upper leg !e:ed and lower leg e:tended 6& )owler.s position with the patient lying on the left side 55& )urosemide "Dasi:% /3 mg was administered y #I push at 13 am with urinary output from indwelling catheter at the level of 1/3 cc& At 13:1, A4' the nurse oserved that the urinary output did not change& 1hich of the following will you chec( frst* A& )oley cathter connecting tue for (in(s $& Patient.s hypogastrium for urinary retention C& #ntravenous site for swelling 6& )oley catheter for lea(age 5=& 1hile preparing the medication' you chec(ed the medication which was dispensed y the pharmacist with the written order of the physician& 1hich of the following actions will you do frst if you found out that instead of >egular insulin' the pharmacist dispensed GP- insulin* A& Ialidate the order with the physician $& 6ocument the error C& As( the pharmacist to change the drug 6& >eport the error to the unit manager 5,& Kou administered morphine Sulfate 1 mg intravenously as ordered& ?he following are the intended actions of this drug e:cept A& #mproved eLcacy of reathing $& >educe preload C& 6ecrease an:iety 6& >elieve pain Situation ;: -elen' a Pediatric #ntensive Care Unit staB nurse' is assigned to a =8year8old female unconscious patient due to an acute head injury sustained from a vehicular accident& 52& -elen identifes which of the following nursing diagnosis to e of highest priority* A& >is( for injury related to increased intracranial pressure $& 6istured sensory perception relation to central nervous system impairment C& >is( for aspiration related to impaired motor functions 6& #neBective airway clearance related to depressed sensorium 59& 1hen interpreting the patient.s degree of depressed coma' the pediatric Hlasgow Coma Scale is used& 1hich of the following is not included in the three8 part assessment of the scale* A& 4otor responses $& >esponse to auditory and veral stimuli C& Pupil si<e and reaction 6& @ye opening 5;& 1hen assessing the level of consciousness of the patient' which of the following should the nurse consider most appropriate in eliciting a desired response* A& @nvironment should e Auiet' well8lighted and ventilated $& Jeep eAuipment at the edside C& Parent should e present 6& -ave record readily availale for accurate documentation& 5F& 6uring assessment' the nurse oserves asence of doll.s eye movement& 1hich of the following is the correct interpretation of this oservation* A& >uptures aneurysm $& 4eningeal in!ammation C& $rainstem injury 6& Sudural hematoma =3& 6ue to hypothalamic dysfunction' a syndrome of inappropriate antidiuretic hormone develops& 1hich of the following manifestations should the nurse watch closely* A& #ncreased urine output' decreased specifc gravity' decreased serum sodium $& #ncreased urine output' increased urine specifc gravity' increased serum sodium C& 6ecreased urine output' decreased urine specifc gravity' decreased serum sodium 6& 6ecreased urine output' increased urine specifc gravity' increased serum sodium Situation F: ?eddy' ; years old' was playing in the garden when all of a sudden he stopped playing and started scratching his legs& ?eddy.s mother washed his legs ut ?eddy complained of diLculty of reathing0 was nauseated and had cold moist s(in& #n the emergency department' anaphyla:is was suspected& #nsect ites were noted on ?eddy.s legs& =1& ?he health team suspects that ?eddy e:perienced a sting at some previous time& 1hich of the following could e the rationale for the itchy s(in* A& #rritation caused y digestive sustance released y the insect $& #nfltration of in!ammatory cells into the epidermis C& Sensory nerve endings irritated y histamine 6& Accumulation of histamine at the insect ite =/& 1hich of the following drugs will the nurse e:pect the physician to prescrie initially* A& Corticosteroids $& Aminophylline C& @pinephrine 6& 6ipenhydramine =5& ?he mother as(ed the nurse what could have caused her son to e:perience diLculty of reathing& 1hich of the following is the most appropriate response of the nurse* A& C#t was an early sympatetic response to the insect ite&E $& CChemical mediators due to hypersensitivity reactions caused y edema in the ronchioles&E C& C-istamine released due to allergic reaction caused narrowing of the airway&E 6& C#t was due to threatening laryngeal edema&E ==& ?he mother claimed that this is the frst time it happened& 1hich of the following should e given priority y the nurse* A& #nstruct the mother on emergency measures in care recurrence $& >ecommend desensiti<ation C& #dentifcation of allergens 6& #dentifcation of environmental ha<ards =,& Since ?eddy is allergic to insect venom' which of the following is the most appropriate measure to ensure that ?eddy gets immediate treatment during recurrence* A& -ave ?eddy carry an emergency (it all the time $& ?each ?eddy how to use an emergency (it C& Use of a medical information such as racelet or nec(lace 6& ?each ?eddy to get help when symptoms develop Situation 13: >adiation therapy is another modality of cancer management& 1ith the emphasis on multi8disciplinary management' you have important responsiilities when caring for patients receiving radiation therapy& =2& ?hromocytopenia often results from one marrow depression& As a nurse' you should oserve for the following symptoms that include A& -eadache' di<<iness' lurred vision $& Severe sore throat' acteremia' hepatomegaly C& Petechiae' ecchymosis' epista:is 6& 1ea(ness' easy fatigaility' pallor =9& 1hen caring for a client who has thromocytopenia' which of the following intervention should you include in the care plan* A& Provide rest etween activities $& Place the patient on strict isolation precaution C& #nspect the patient.s s(in for petechiae' ruising' H# leeding regularly 6& Administer antipyretics if the patient.s temperature 5;MC =;& A patient is receiving e:ternal radiation therapy and he complains of fatigue and malaise& 1hich of the following nursing interventions would e most appropriate* A& >efer the patient to the physician $& -elp the patient plan activities and rest periods C& >eassure the patient that these feelings are normal 6& ?ell the patient that sometimes these feelings can e psychogenic =F& @:ternal eam radiation is planned for a patient with endometrial cancer& Kou teach her that the important measure to prevent complications from the eBects of radiation is to A& 4aintain a high8residue and high8fat diet $& Perform perineal care with sit< ath and meticulous cleaning C& ?est all stools for the presence of lood 6& #nspect the mouth and throat daily for the appearance of thrush ,3& A post total hysterectomy ilateral salphyngo8 oophorectomy patient had chemotherapy and radiation therapy& ?he nurse oriented her on the rationale and the measures to e done to prevent movement of the radioactive source which include the following' e:cept: A& Complete ed rest while source is implanted $& Spinal anesthesia while source is implanted C& $owel cleansing prior to insertion of source 6& Placement of urinary )oley catheter while source is implanted Situation 11: #t is important and necessary that the nurse is well8educated aout Severe Acute >espiratory Syndrome "SA>S%' an emerging gloal threat& ,1& #f you were a nurse who wor(s in a health clinic' and you suspect that a patient has SA>S' which of the following will you do frst* A& Contact the hospital $& Protect self y putting on an GF, disposale mas( C& >efer the patient to the physician for medical diagnosis 6& -ave your patient put on surgical face mas( ,/& 1hich of the following confrms the diagnosis of SA>S* A& ?ravel to an area with (nown SA>S outrea( $& Signs and symptoms C& -istory of contact with someone suspected of SA>S 6& Presence of antiody to SA>S ,5& ?he SA>S virus is transmitted through A& Airorne droplets $& Contact with urine C& 4osAuito ites 6& Contaminated needle ,=& #f the nurse has an unprotected e:posure to SA>S during incuation' which of the following will e done* A& Ioluntary Auarantine of 13 days $& Gurse is placed on vacation from wor( C& Gurse will e given a high dose of gamma gloulin 6& Administer vaccine to the nurse ,,& After e:posure to a patient with SA>S' it is e:pected that SA>S can develop in A& /813 days $& 2 wee(s + 2 months C& 53 days 6& 1/81= days Situation 1/: Kou are assigned at the medical ward caring for clients with !uid and electrolyte imalances& Kou (now that you have very important collaoration responsiilities when you give your patients their medications to correct their illness& ,2& Samson is ta(ing -ydrochlorothia<ide' a potassium8 wasting diuretic' for treatment of hypertension& As a nurse' you will teach him to report symptoms of adverse eBects such as A& )acial muscle spasms $& )reAuent loose stools C& 4ood changes 6& Henerali<ed wea(ness ,9& Spironolactone "Aldactone%' an aldosterone antagonist' is prescried for -ermin as a diuretic& 1hich statement made y -ermin indicated that the teaching aout his medication has een eBective* A& C# can use a salt8sustituteE $& C# can have apple juice instead of orange juice&E C& C# can have low8fat cheeseE 6& C# will drin( at least 2 glasses of water every day&E ,;& Noseph has een receiving diuretic therapy and is admitted to the hospital with a serum potassium level of 5&1 m@AOD& Of the following medications that he has een ta(ing at home' which you e most concerned aout* A& Oral digo:in "Dano:in% 3&/, mg daily $& Dantus insulin /5 U sucutaneously every evening C& #uprofen "4otrrin% =33 mg every 2 hours 6& 4etoprolol "Dopressor% 1/&, mg orally daily ,F& Kou administered 57 Saline to 1anda who has hyponatremia& As her nurse' which one of your assessment fndings will reAuire your most rapid response* A& -er lood pressure increased from 1/3O;3 to 1=/OF= mm-g $& ?here is sediment and lood in 1anda.s urine C& 1anda.s radial pulse is 13, eats per minute 6& ?here are crac(les audile throughout her oth lung felds 23& 1hen caring for @dna who has just een admitted with septic choc(' which of these assessment data will e your greatest concern* A& Arterial o:ygen saturation of F37 $& $P of ;;O,2 C& Apical pulse of 113 eats per minute 6& Urine output of 1, mD for / hours Situation 15: ?imothy' ,2 years old' was admitted ecause of aortic dissection type $& 21& ?he nurse recogni<es which of the following as the correct description of the patient.s diagnosis* A& ?ear in the intima of the aorta with hemorrhage into the tunica media $& Stretching of the walls of the aorta involving one layer of the aorta C& One8sided protrusions of one distinct area of the aorta 6& Pulsating hematoma on three layers of the aorta 2/& Of the following diagnostic tests prescried y the physician' which of the following will the nurse e:pect to show precise measurement of the aneurysm* A& Angiography $& Chest P8ray C& ?ransesophageal echocardiography 6& Adominal ultrasonography 25& ?he physician initially treated ?imothy with Propanolol "#nderal%& ?he nurse noted in her nursing care plan that this drug will A& #ncrease contractility of the heart $& @nhance electrical conduction of the heart C& 6ecrease release of epinephrine 6& >educe heart rate 2=& $ased on an understanding of -eparin therapy' the nurse administers it to ?imothy who has undergone repair of aneurysm fro which of the following reasons* A& ?o prevent recurrence of aneurysm $& ?o control hemorrhage C& ?o maintain arterial pressure 6& ?o prevent clot formation 2,& ?o counteract reactions to overdosage of intravenous infusion of -eparin' which of the following drugs will the nurse e:pect the physician to prescrie* A& Protamine sulfate $& @pinephrine C& Iitamin J 6& Atropine Sulfate Situation 1=: Kou are caring for >olando' ,; years old' who was admitted ecause of diLculty of swallowing and stiBening of the nec(& -e has a history of a wound laceration on his right hand sustained while gardening& ?he physician suspects tetanus infection& 22& 1hile you were preparing to administer o:ygen inhalation' >olando had sei<ures assumed an opisthotonic position& 1hich of the following correctly descries this position* A& -ead retracted' ac( arched' and feet e:tended $& Gec(' hip' (nee and feet plantar !e:ed C& -ead !e:ed forward' jaw clenched' arms pronated and feet plantar !e:ed& 6& -ead hypere:tended hip !e:ed' and feet e:tended 29& ?a(ing into consideration the incuation period' which of the following data in >olando.s health history will you consider relevant* A& Positive for type / diaetes mellitus $& #mmuni<ation status unceratain0 no ooster dose administered C& 1ound laceration sustained a wee( ago was treated at home 6& 1ound pain' unearale and unrelieved y analgesic 2;& ?o decrease stimuli that cause spasms and sei<ures' which of the following nursing interventions is least relevant for you to do* A& 4aintain a Auiet' well8ventilated and dar(ened room $& Administer sedatives as prescried C& 4onitor for ha<ards of immoility 6& Perform physical care during time of ma:imal sedation 2F& ?he priority nursing diagnosis for >olando is C>is( for ineBective airway clearance related to which of the following* A& StiBness of the jaw $& $ac( muscle spasms C& Sei<ures 6& #nfection 93& 6uring a sei<ure' which of the following are you e:pected to do frst* A& 4onitor vital signs especially the respiratory rate $& Provide a padded tongue lade in the patient.s mouth C& Provide mechanical ventilation 6& ?urn patient to his side Situation 1,: #n the medical unit' Connie was assigned to wor( with Sandy' a staB nurse with / years e:perience 91& 1hich of the following reports of Connie will Sandy attend to immediately* A& A 2,8year8old unconscious due to e turned to prevent ed sores $& A ,,8year8old diaetic' frst day post8operative for elow8the8(nee amputation' complains of severe pain C& A 9,8year8old with hepatic encephalopathy' intravenous infusion due in = hours consumed 6& A =,8year8old scheduled for partial thyroidectomy wishes to go home 9/& Connie oserves Sandy perform peripheral catheter insertion for intravenous infusion& ?he patient insisted to sit on the edge of the ed& After a second unsuccessful attempt on cannulation' the patient suddenly ecame an:ious' diaphoretic' nauseated and di<<y& 1hich of the following will Sandy do frst* A& Place the patient on a supine position $& #nstruct Connie to call the physician C& Chec( vital signs 6& 6iscontinue the #I !uids 95& Sandy e:plained to Connie that the patient e:periences a vasovagal reaction& 1hich of the following vital signs will the nurse e:pect* A& Gormal lood pressure and increased pulse $& 6ecreased lood pressure and decreased cardiac rate C& #ncreased lood pressure and tachycardia 6& Gormal pulse and increased lood pressure 9=& One of Connie.s patients is Hreg who just had ronchoscopy& Sandy as(ed Connie what she should e alert for in oserving Hreg* A& Sore throat and hoarseness $& $lood tinged sputum and coughing C& Gausea and vomiting 6& Shortness of reath and laryngeal stridor 9,& At the end of the shift' Sandy told Connie to do self8 evaluation of competencies developed during the wee(& 1hich of the following indicators will Connie consider as an improvement of her aility to respond to the urgency of her patient.s conditions* A& Ale to identify adverse reactions of drugs $& >esponds to inAuiries promptly C& >ecogni<e anormal laoratory results 6& Administer medications on time Situation 12: Gurse have crucial legal responsiilities in the e:ercise of her profession 92& 4ary Nane' a 5 rd year nursing student assigned to the surgical unit as(s your permission to photocopy the surgical record from a patient.s chart for an assignment that she must write& 1hich of the following is your appropriate nursing action* A& Allow 4ary Nane to photocopy the pages without the client.s name $& Photocopy the pages for 4ary Nane C& As( the physician for permission to photocopy the pages 6& Allow 4ary Nane to write down pertinent information ut not identifying 99& Kou are caring for )elisa who has dementia and is soiled with feces ut you failed to clean and athe her ecause it is endorsement time already& Kou endorse her to the ne:t shift nurse& ?he nurse reports that you are guilty of A& 4alpractice $& Gonmalefcence C& Assault 6& Gegligence 9;& Kou are invited to tal( to new graduate nurses aout negligence& 1hich of the following situations is a priority for you to include as an e:ample of negligence* A& ?al(ing aout client outside of the health care facility $& Got allowing a family memer to awa(en an adult client who is sleeping C& Got giving a prescried medication to an older patient 6& Got turning oB the o:ygen at the edside when a client wants to smo(e in ed 9F& Kou call the physician of your patient @rlinda' 92 years old' to report a change in her condition and to reAuest orders for a pain medication& ?he physician is unale to ta(e the call and the message is left with the oLce secretary who repeats a veral order from the physician& 1hich of the following is your most appropriate nursing action* A& >efuse to accept the order from the oLce secretary and call ac( later $& Accept the order form the oLce secretary and document it appropriately C& Accept the order as it comes from the physician as interpreted y the oLce secretary 6& #nsist on spea(ing to the physician personally ;3& Kou oserve ruises and s(in tears on Agatha' an ;38 year8old client& She does not ma(e eye contact and appears fearful& 1hich of the following is your priority nursing action* A& As( the client aout the ruises and s(in tears $& As( the family memers what has happened C& 6ocument your fndings 6& Call the physician Situation 19: Kou are assigned in the Pediatric #CU and your critical decisions and proper documentation are important& Kou are caring for Charlie' , years old' who was admitted following a vehicular accident& Clinical data otained were0 $P ;3O,; mm-g' heart rate 1/3' respirations 5/' peripheral pulse slightly diminished' hematocrit 537' pulse o:imeter F=7' serum electrolytes normal& C? scan is positive for anormal leeding& 1eight /3 (g& ;1& $ased on the aove data' which of the following nursing diagnosis would you select as eing appropriate in Charlie.s care* A& )luid volume defcit $& #neBective airway clearance C& #mpaired gas e:change 6& Altered cardiac output: decreased Answer: A ;/& Charlie is placed on a cardiac monitor and a urinary catheter is inserted& One peripheral #I line in the left arm is infltrated and discontinued& An indirect $P reading is 93O=3 mm-g and a heart rate of 1=3 is noted& 1hich of the following orders should e initiated frst* A& #I access $& Serum hematocrit and hemogloin C& Arterial line set8up 6& 6opamine continuous infusion ;5& 1hat parenteral solution would you anticipate to prepare for Charlie.s volume replacement* A& ,7 6e:trose in 3&/,7 normal saline $& /,7 alumin C& 3&F7 Gormal Saline 6& ,7 6e:trose in water ;=& Charlie.s mother verali<es her concerns regarding Charlie.s condition& She informs you that Charlie is their only child and that her husand is wor(ing overseas& 1hat would e your est response* A& -old her hand' and have an eye contact with her and reassure her that you are doing your est& $& As( one of your con8staB to assist Charlie.s mother C& ?ell her you understand how she feels ut your priority is to ta(e care of Charlie 6& ?ell her to pray and leave everything to Hod ;,& Charlie.s condition worsens& -e develops respiratory arrest& 1hat nursing intervention should you perform frst* A& Assemle intuation (it $& Administer o:ygen C& 6o chest compression 6& Ientilate with a ag8valve mas( device Situation 1;: Jevin' // years old' swerved his car and hit a tree head8on when he avoided a dog crossing the street& Jevil loss consciousness' sustained several cuts on his forehead and was leeding from his nose and mouth& -e was diagnosed in the @mergency 6epartment with ?raumatic $rain #njury "?$#% ;2& Since volume resuscitation was necessary for Jevin' intravenous 3&F7 normal saline solution was started& ?he nurse who admitted the patient understands that the intravenous solution was considered y the physician ecause it A& 1ill reduce intracranial pressure $& 1ill easily maintain hydration C& 1ill promote !uid shift into the vascular space 6& 1on.t aggravate cereral edema ;9& ?o determine level of consciousness' the Hlasgow Coma Scale "HCS% is used& 1hich of the following is a correct interpretation of the nurse of the HCS score of Jevin* A& ?he higher the score' the higher is the proaility of permanent damage $& ?he lower the score is' the lower is the proaility of delayed recovery C& ?he higher the score' the greater is the impairment in the rain 6& ?he lower the score' the more serious is the rain injury ;;& ?he nurse maintains the ody temperature of Jevin within normal limits& ?his intervention is signifcant in preventing which of the following* A& Cereral ischemia $& #nfection C& Sei<ures 6& 6ehydration ;F& 1hen intracranial pressure increases' which of the following nursing diagnosis is appropriate* A& >is( for ineBective reathing pattern $& 6istured sensory perception C& >is( for cardiac dysfunction 6& #neBective airway clearance F3& 1hich of the following interventions can the nurse include in the plan of care for Jevin to control intracranial pressure* 1& 4aintain his head and nec( in neutral alignment /& #nitiate measures to enhance valsalva maneuver 5& Administer O:ygen to maintain PaO/ QF3 mm-g =& @levate head of the ed as prescried A& 1 and/ $& All e:cept / C& 5 and = 6& All of the aove Situation 1F: Kou are caring for Angelo' 2; years old' who was diagnosed with acute heart failure& Angelo has a history of acute myocardial infarction and underwent coronary artery ypass surgery& -e is complaining of severe shortness of reath and hemoptysis& F1& Kou recogni<e that pulmonary edema may develop ecause of which of the following* A& Dow plasma protein levels decreasing plasma oncotic pressure $& #ncrease capillary permeaility due to lung in!ammation C& #ncreased hydrostatic pressure in the pulmonary capillaries 6& #ncreased surface tension in the alveoli F/& 1hich of the following assessment fndings would you consider as priority for immediate nursing intervention* A& -emoptysis $& $P F,O9/' s(in cool' and diaphoretic C& Signifcant jugular vein distention 6& Severe orthopnea F5& Cardiac assessment reveals apical pulse is lateral to midclavicular line& Kou understand that this fnding means A& 4itral valve regurgitation $& ?he heart is enlarged C& ?hat cardiac output is adeAuateR 6& 6ilated heart F=& Kou oserved for frillation on the cardiac monitor& 1hich of the following @CH characteristics did you oserve on the cardiac monitor* A& CsawtoothE appearance of P waves $& P waves oserved efore' during' and after S>S comple: C& P wave hidden in the S>S comple: 6& P waves unidentifale F,& ?he physician prescried )urosemide to e administered intravenously& 1hich of the following nursing orders is least appropriate to ensure that adverse eBects of the drug are closely monitored on Angelo* A& >eport signifcant weight changes $& 4onitor laoratory results on electrolytes C& 4easure hourly urine output 6& #ntegrate foods rich in potassium in the diet Situation /3: Dilette' =8year8old girl with a recent history of nausea' vomiting and diarrhea is admitted to the Pediatric Unit with a diagnosis of acute gastroenteritis& Kour signifcant physical e:amination includes dry s(in with turgor' sun(en soft eyealls' parched lips' adominal distention& She has tachycardia and fever "5;C% F2& $ased on your assessment fndings' which of the following is your nursing diagnosis* A& #neBective peripheral tissue perfusion related to !uid volume defcit $& )luid volume defcit related to anormal loss and decrease inta(e C& Activity intolerance related to malaise 6& #mpaired s(in integrity related to freAuent diarrhea F9& ?he following management goals for Dilette are most important for you to include in your plan e:cept A& AdeAuate rehydration and !uid maintenance $& Gothing per orem at all times C& Continue assessment of !uid and electrolyte imalance 6& >eintroduction of adeAuate diet F;& ?o ensure adeAuate !uid and electrolyte pelacement' the doctor ordered ,33 ml of alanced electrolyte solution for 13 hours& ?he #I set delivers 23 gttOmin to administer the ,33 ml #I solution' you should set the #I drip rate at A& 5, gttOmin $& 2/ gttOmin C& ,3 gttOmin 6& =1 gttOmin FF& 1hich of the following fndings would est indicate that Dilette.s hydration level has improved* A& Go further weight loss $& Dower hematocrit C& Dower creatinine 6& Dower 1$C 133&Dilette cries whenever her 4ommy and Hrandma leave her& 1hich of the following interventions can reduce her an:iety* A& -ave the same nurse care for her $& Provide her with some new toys and ring her favorite toys C& >estrict visiting hours to decrease her crying 6& @ncourage her playmates to visit her