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Answer Key
1. Answer: C
The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.
2. Answer: C
It is always critical that patients being discharged from the hospital take prescribed medications as instructed. In the case of antibiotics, a full course must be completed even after symptoms have resolved to prevent incomplete eradication of the organism and recurrence of infection. The patient should resume normal activities as tolerated, as well as a nutritious diet. Continued use of the incentive spirometer after discharge will speed recovery and improve lung function.
3. Answer: C
When a family member is dying, it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. In the Vietnamese culture, it is important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the next life. When possible, allowing the family privacy for this traditional behavior is best for them and the patient. Answers A, B, and D are incorrect because they create unnecessary conflict with the patient and family.
4. Answer: A
The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The labor and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine care. A new patient admitted with suspected MI and scheduled for angiography would require continuous assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient requires staff that can immediately identify symptoms and respond appropriately. A post-operative patient also requires close monitoring and cardiac experience.
5. Answer: B
Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon administration, the patient should respond within 15-20 minutes at which time oral carbohydrates should be given. Glucagon reverses rather than enhances or prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat.
6. Answer: D
One gel pad should be placed to the right of the sternum, just below the clavicle and the other just left of the precordium, as indicated by the anatomic location of the heart. To defibrillate, the paddles are placed over the pads. Options A, B, and C are not consistent with the position of the heart and are therefore incorrect responses.
7. Answer: D
All of the statements are true. The gurgles and clicks described in the question represent normal bowel sounds, which vary with the phase of digestion. Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction. The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurism, for example, and should always be considered abnormal.
8. Answer: A
Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. The irrigation should be continued for at least 10 minutes. Fluorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash, nor is patching the eye. Following irrigation, visual acuity will be assessed.
9. Answer: D
Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. Some pain during repositioning and following physical therapy is to be expected and can be managed with analgesics. A small amount of bloody drainage on the surgical dressing is a result of normal healing.
10. Answer: B
During a witnessed seizure, nursing actions should focus on securing the patient's safely and curtailing the seizure. Restraining the limbs is not indicated because strong muscle contractions could cause injury. A side-lying position with head flexed forward allows for drainage of secretions and prevents the tongue from falling back, blocking the airway. Rectal diazepam may be a treatment ordered by the physician, who should be notified of the seizure.
11. Answer: C
Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention. The patient with fever, headache and muscle aches (classic flu symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. The child's chin laceration may need to be sutured but is also non-urgent.
12. Answer: C
Normal serum calcium is 8.5 - 10 mg/dL. The patient is hypocalcemic. Increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds, abdominal cramping and diarrhea is an indication of hypocalcemia. Numbness in hands and feet and muscle cramps are also signs of hypocalcemia. Positive Chvostek's sign refers to the sustained twitching of facial muscles following tapping in the area of the cheekbone and is a hallmark of hypocalcemia.
13. Answer: A
A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis. Answer B is a normal blood gas. Answer C represents respiratory acidosis. Answer D is borderline normal with slightly low PCO2.
14. Answer: A
The effect of Coumadin is to inhibit clotting. The next step is to check the PT and INR to determine the patient's anticoagulation status and risk of bleeding. Vitamin K is an antidote to Coumadin and may be used in a patient who is at imminent risk of dangerous bleeding. Preparation for transfusion, as described in option C, is only indicated in the case of significant blood loss. If lab results indicate an anticoagulation level that would place the patient at risk of excessive bleeding, the surgeon may choose to delay surgery and discontinue the medication.
15. Answer: A and B
Normal hemoglobin in adults is 12 - 16 g/dL. Total cholesterol levels of 200 mg/dL or below are considered normal. Total serum protein of 7.0-g/dL and glycosylated hemoglobin A1c of 5.4% are both normal levels.
16. Answer: B
An IV site that is red, warm, painful and swollen indicates that phlebitis has developed and the line should be discontinued and restarted at another site. Pain on movement should be managed by maneuvers such as splinting the limb with an IV board or gently shifting the position of the catheter before making a decision to remove the line. An IV line that is running slowly may simply need flushing or repositioning. A hematoma at the site is likely a result of minor bleeding at the time of insertion and does not require discontinuation of the line.
17. Answer: D
Fluid overload occurs when then the fluid volume infused over a short period is too great for the vascular system, causing fluid leak into the lungs. Symptoms include dyspnea, rapid respirations, and discomfort as in the patient described. Febrile non-hemolytic reaction results in fever. Symptoms of allergic transfusion reaction would include flushing, itching, and a generalized rash. Acute hemolytic reaction may occur when a patient receives blood that is incompatible with his blood type. It is the most serious adverse transfusion reaction and can cause shock and death.
18. Answer: B, C, and D
Uterine contractions typically become stronger and occur more closely together following amniotomy. The FHR is assessed immediately after the procedure and followed closely to detect changes that may indicate cord compression. The procedure itself is painless and results in the quick expulsion of amniotic fluid. Following amniotomy, cervical checks are minimized because of the risk of infection
19. Answer: D
An infant discharged home with hyperbilirubinemia (newborn jaundice) should be placed in a sunny rather than dimly lit area with skin exposed to help process the bilirubin. Frequent feedings will help to metabolize the bilirubin. A recheck of the serum bilirubin and a physical exam within 72 hours will confirm that the level is falling and the infant is thriving and is well hydrated. Signs of dehydration, including decreased urine output and skin changes, indicate inadequate fluid intake and will worsen the hyperbilirubinemia.
20. Answer: A
All infants under 1 year of age weighing less than 20 lbs. should be placed in a rear-facing infant car seat secured properly in the back seat. Infant car seats should never be placed in the front passenger seat. Infants should always be placed in an approved car seat during travel, even on that first ride home from the hospital.
source: studyguidezone.con
