Which of the following nursing interventions would be the most appropriate?
1. The patient was discharged from the hospital and the urinary catheter was removed this morning. The nurse arrives for the shift later in the afternoon. Four hours post-catheter removal the patient states the need to void, but is unable to. Which of the following nursing interventions would be the most appropriate?
a. Prepare the patient for medical transport back to the discharging hospital
b. Employ techniques to encourage the initiation of a stream, such as running warm water c. Encourage the patient to drink fluids every 15 minutes until able to void
d. Place an indwelling catheter until the patient can void independently
2. How often does an immobile patient need to be repositioned to avoid skin breakdown?
a. Every thirty minutes b. Every 1-2 hours
c. Every shift
d. Every four hours
3. When preparing to administer an enteral bolus feeding via a gastrostomy tube, which of the following would be considered a normal assessment finding?
a. Hyperactive bowel sounds
b. Coffee-ground aspirate in gastrostomy tubing
c. Soft and flat abdomen with active bowel sounds
d. Firm and distended abdomen with hypoactive bowel sounds
4. The most important instruction the nurse should provide to a patient and families to prevent the development of antibiotic-resistant bacterial infection is to:
a. Ensure adequate hand washing after toileting and before eating b. Avoid crowds and contact with other individuals with infections
c. Request antibiotic therapy when a cold or the flu does not resolve in 2-3 days
d. Take prescribed antibiotics exactly as ordered, being sure to finish all of the medication
5. The nurse’s notes from the previous shifts indicate that the patient was tachypnic. What would the nurse expect to see documented?
a. Respiratory rate 64 b. Respiratory rate 6
c. Heart rate 112 d. Heart rate 42
6. Which is the main concern for a patient with an acute asthma exacerbation?
a. Risk of infection
b. Imbalanced nutrition
c. Ineffective pattern of breathing d. Body image disturbance
7. The patient’s apnea monitor begins to alarm. The nurses first action should be to:
a. Assess the patient b. Silence the alarm
c. Troubleshoot the equipment d. Call 911 and start CPR
8. The nurse arrives for an 8am shift. The family member gives report and states that the 9am medications have already been drawn up and are ready to administer. The nurse should:
a. Inform the family member it is a nursing standard not to administer medications unless drawn up by the nurse who is preparing to administer.
b. Give the medications to avoid conflict
c. Don’t say anything to the caregiver and waste the meds she drew up. Draw up new doses and administer.
d. Hold the 9 am medications until the family member returns at noon and let her administer the doses she drew up.
9. The primary purpose of chest physiotherapy (CPT) is to?
a. Provide humidification b. Prevent barrel chest
c. Dilate the bronchioles d. Mobilize secretions
10. The single most effective way to prevent infection is:
a. Prophylactic antibiotic therapy
b. Frequent, thorough hand washing c. Correct aseptic technique
d. Wearing gloves
11. When attempting to provide rescue breaths but there is no obvious chest rise and fall, what is the next appropriate step?
a. Reposition the chin lift – jaw thrust and reattempt rescue breath b. Attempt to blow harder to try and force the airway open
c. Call EMS immediately
d. Begin performing chest compressions
12. During high quality CPR, the rate of compressions for adult CPR should be at least:
a. 60 compressions per minute b. 80 compressions per minute c. 100 compressions per minute d. 120 compressions per minute
13. Which of the following symptoms of VP shunt malfunction require physician notification?
a. Headaches and vomiting b. Lethargy
d. All of the above
14. When caring for a patient who is actively seizing, the most important intervention is:
a. Insert a mouth guard to prevent the patient from swallowing their tongue b. Use your finger to hold the tongue down
c. Hold them down to prevent injury
d. Clear the surrounding area to prevent injury
15. When caring for a patient with Type I Diabetes, which of the following symptoms would be a sign of hyperglycemia?
a. Dizziness and shakiness
b. Increased thirst and urination c. Increased heart rate
16. The nurse is alone with a patient and witnesses a sudden collapse. The patient is unresponsive and not breathing. There are no signs of respiratory distress. When should EMS be activated?
b. After 5 cycles of CPR or two minutes c. After 1 cycle of CPR
d. Before you initiate chest compressions
17. Which of the following should be assessed with any dressing change?
a. Appearance of wound bed b. Presence of drainage
c. Measurement of wound d. All of the above
18. Which of the following signs indicates an anaphylactic reaction that requires immediate medical attention?
a. Swollen tongue and lips b. Itchy, raised rash
c. Diaphoresis d. Lethargy
19. What is the most common cause of cardiac arrest in children?
a. Blunt head trauma b. Head injuries
c. Respiratory arrest
d. Accidental ingestion
20. When caring for a patient who has been prescribed an anticonvulsant. Which of the following medications would the nurse expect to see on their medication list?
a. Hydrocodone b. Phenobarbital c. Furosemide
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