Exam 1 Practice Question

Question 1

While the nurse is washing the face of a patient in renal failure, the patient demonstrates a spasm of the lips and face. The nurse examines the recent electrolyte levels to assess the level of:
a. potassium.
b. calcium.
c. sodium.
d. magnesium.

Answer 1

ANS: B. Calcium

Question 2

Prior to hanging an IV containing potassium, the nurse will confirm that there is a:
a. blood pressure of at least 60 mm Hg diastolic.
b. urine output of at least 30 mL/hr.
c. filter on the IV line.
d. pulse of at least 50 beats/min.

Answer 2

ANS: B. urine output of at least 30 mL/hr.

Question 3

The patient with long-term obstructive pulmonary disease has a pH of 7, HCO3 of 18 mEq/L, and a PaCO2 of 40 mm Hg. From this laboratory information, the nurse assesses the patient is in:
a. respiratory alkalosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. metabolic acidosis.

Answer 3

d. metabolic acidosis.

Question 4

To help prevent respiratory acidosis in a young person with asthma, the nurse would encourage:
a. deep-breathing exercises every 2 hours.
b. drinking 8 ounces of fluid every 4 hours.
c. ambulating for 15 minutes twice a day.
d. sleeping with the head of the bed elevated 45 degrees.

Answer 4

a. deep-breathing exercises every 2 hours.

Question 5

The patient who has had diarrhea for the last 3 days has blood gases of pH of 7.1, HCO3 of 20 mEq/L, and PCO2 of 36 mm Hg. The nurse recognizes these values indicate:
a. respiratory alkalosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. metabolic acidosis.

Answer 5

d. metabolic acidosis.

Question 6

The nurse is assessing a patient with renal failure and notes fatigue, muscle cramps, confusion, and headache. The nurse will monitor the patient’s _____ level.
a. potassium
b. sodium
c. calcium
d. chloride

Answer 6

b. sodium

Question 7

The patient has a potassium level of 5.0. The nurse closely monitors the patient for: (Select all that apply.)
a. muscle weakness.
b. cardiac dysrhythmias.
c. decreased reflexes.
d. urinary retention.
e. hypotension.

Answer 7

ANS:
A. muscle weakness.
B. cardiac dysrhythmias.
E. hypotension.

Question 8

The patient received a preoperative dose of lorazepam (Ativan) 20 minutes ago. The safety precaution the nurse should take in regard to this drug is to:
a. monitor respiratory status.
b. raise bed rails.
c. elevate the head of the bed 30 degrees.
d. take seizure precautions.

Answer 8

b. raise bed rails.

Question 9

The nurse explains that the National Patient Safety Goals protocol requires that:
a. a licensed caregiver accompany the patient to the operating room.
b. side rails should be raised and head of bed elevated 30 degrees.
c. surgical site be verified and marked.
d. all prosthetic devices be identified.

Answer 9

the surgical site be verified and marked.

Question 10

10. During the course of surgery, a patient exhibits tachycardia, diaphoresis, and rising body temperature. The priority intervention by the circulating nurse is to:
    a. continue to monitor the patient for any further changes in condition.
    b. note the patient’s oxygen saturation and blood pressure.
    c. ask the scrub nurse to verify the assessment findings.
    d. alert the anesthesiologist and surgeon immediately.

Answer 10

d. alert the anesthesiologist and surgeon immediately.

Question 11

The nurse is planning care for four postoperative patients. The nurse determines that the patient who is most likely to develop postoperative complications is the patient who is:
a. 36 years old with a history of controlled diabetes.
b. 52 years old with a history of hypothyroidism.
c. 45 years old with a history of a myocardial infarction (MI).
d. 79 years old with mild osteoarthritis.

Answer 11

d. 79 years old with mild osteoarthritis.

Question 12

The patient recovering in the PACU awakes confused and disoriented. The nurses most appropriate intervention is to:
a. take vital signs.
b. encourage the patient to return to sleep.
c. say, Your surgery is over. You are in the recovery area.
d. chart, Patient awake and disoriented.

Answer 12

C. say, your surgery is over. You are in the recovery area.

Question 13

The nurse is caring for a 90-year-old postoperative patient. The nurse notes that the oxygen saturation is frequently dropping below 90%. This is most likely related to:
a. prolonged use of a walker.
b. poor fluid intake.
c. weakened respiratory muscles.
d. increased elasticity of costal cartilages.

Answer 13

c. weakened respiratory muscles.

Question 14

Which assessment finding on a patient who had a right total knee replacement this morning should be reported to the charge nurse immediately?
a. Pain at level of 8 at operative site
b. Capillary refill of right toe of 7 seconds
c. Right foot warm to touch
d. Swelling of right knee

Answer 14

b. Capillary refill of right toe of 7 seconds

Question 15

For the surgical patient who complains of excessive gas, the nurse will:
a. offer iced fluids.
b. arrange for large meal servings.
c. provide a straw for drinking fluids.
d. ambulate the patient in the hall.

Answer 15

d. ambulate the patient in the hall.

Question 16

The nurse reminds the postsurgical patient that smoking will complicate postsurgical recovery by:
a. increasing probability of hemorrhage.
b. increasing blood pressure.
c. delaying healing.
d. increasing the need for pain medication.

Answer 16

c. delaying healing.

Question 17

The student nurse understands proper documentation of a pain assessment as evidenced by which note in the patients record?
a. Pt. complains of local sharp pain (4/5) in lower abdomen upon standing.
b. Pt. complains of stomach pain after eating (3/5).
c. Pt. reports standing makes his stomach hurt.
d. Pt. reports sharp pain in stomach.

Answer 17

a. Pt. complains of local sharp pain (4/5) in lower abdomen upon standing.

Question 18

The patient on frequent doses of meperidine (Demerol) complains of constipation. The initial intervention the nurse should make is:
a. offer fruit such as prunes or apricots.
b. request an order for an enema.
c. report the condition to the charge nurse.
d. increase oral fluid intake.

Answer 18

d. increase oral fluid intake.

Question 19

When the patient receiving morphine sulfate intravenously breaks out in hives and begins to itch, the nurse should initially:
a. slow the flow rate of the morphine.
b. stop the IV drip.
c. report the condition to the charge nurse.
d. give prescribed antihistamine.

Answer 19

b. stop the IV drip.

Question 20

The nurse explains to the patient with neuropathic pain that the most effective pain control will be achieved through the use of: (Select all that apply.)
a. analgesics.
b. opioids.
c. antidepressants.
d. anti-inflammatory agents.
e. anticonvulsants.

Answer 20

c. antidepressants.
d. anti-inflammatory agents.
e. anticonvulsants.

Question 21

The nurse stresses to the patient with sickle cell anemia that one of the most elementary home interventions to help prevent sickle cell crisis is to:
a. take iron supplements daily.
b. maintain adequate fluid intake.
c. engage in daily exercise.
d. eat leafy green vegetables.

Answer 21

b. maintain adequate fluid intake.

Question 22

Blood must be started within _____ minutes of its arrival on the unit.
a. 10
b. 15
c. 30
d. 60

Answer 22

c. 30

Question 23

The nurse recommends to a patient with iron deficiency anemia to include foods high in iron, such as: (Select all that apply.)
a. liver.
b. lima beans.
c. prune juice.
d. cabbage.
e. dried apricots.

Answer 23

a. liver.
b. lima beans.
c. prune juice.
e. dried apricots.

Question 24

The nurse monitoring a patient who is receiving a transfusion will stop the transfusion in the event of the patient complaining of: (Select all that apply.)
a. feeling cold.
b. a headache.
c. back pain.
d. a rash.
e. urticaria.

Answer 24

b. a headache.
c. back pain.
d. a rash.
e. urticaria.