questions

Question 1

new central line inserted

Answer 1

nursing intervention - x-ray for placement

Question 2

iv therapy prescribed, picc line immediate attention?

Answer 2

swelling noted

Question 3

nurse delegates care to UAP, which statement about hygiene w/ vascular access?

Answer 3

use plastic bag

Question 4

nurse assesses client enteroperitineal dialysis, client is warm and has abdominal pain, what should nurse expect

Answer 4

infection

Question 5

home care nurse is giving meds, reviews chart before giving meds. Chart says purulent drainage then dressing changed and has sacral wound.. Actions should nurse take?

Answer 5

give antibiotic medication via IV

Question 6

client received tpa after MI. IV heparin now, why does client receive heparin?

Answer 6

heparin keeps artery from getting blocked again.

Question 7

nurse in charge of CVICU, which client should nurse see first?

Answer 7

180/100 BP patient

Question 8

nurse cares for client with r. sided heart failure. why weigh patient daily?

Answer 8

Best indication about retaining fluid

Question 9

digoxin or lenoxin teaching?

Answer 9

do not take 1 hour before antacid.

Question 10

end stage heart failure, client is depressed. i don’t want to become vegetable.

Answer 10

Would you like info about advanced directives?

Question 11

nurses electrocardiograph tracing, not all qrs precedes p wave.

Answer 11

V and A depolarizations are initiating from diff. sites.

Question 12

client with traumatic brain injury fighting ventilator… Nurse intervention?

Answer 12

Give precedex (dexmeth…)

Question 13

client has traumatic brain injury and positive halo sign.

Answer 13

Risk for infection

Question 14

nurses assesses blurred vision, spinal cord injury at t5, bp is elevated.

Answer 14

assess for bladder distention.

Question 15

client tells nurse, 4 months since sisters death… still cries.

Answer 15

feelings are completely normal, and will continue for a while

Question 16

client is receiving o2 at 4l. what task to delegate to UAP?

Answer 16

water soluble ointment to give to client’s lips and nares.

Question 17

teaching diabetes to patient?

Answer 17

abdominal site closest to pancreas.

Question 18

nurses cares for acute rejection patient (kidney transplant). Patient states “hemodialysis treatment is depressing.” What is nurse’s response?

Answer 18

one acute rejection episode doesn’t mean you will lose organ.

Question 19

RN delegates client care to LPN, which standards should guide for IV therapy?

Answer 19

state nurse practice and facilities policy (A&B)

Question 20

blood transfusion, checks blood label with second nurse. Which components must be present on blood label?

Answer 20

abo group and rH, lot # related to donor, unique facility ID (A,B,D), (product code - not sure about this one)

Question 21

teaching a CHF client, nurse assesses client understanding of nutritional intake?

Answer 21

(A,D, E) - read labels, eat oatmeal, substitute fresh vegetables.

Question 22

nurse prepares heart failure discharge for patient

Answer 22

(A, B, D) teach client about dietary restrictions, prescribed ACE inhibitors, echocardiogram has been completed

Question 23

nursing student studies traumatic brain injuries

Answer 23

moderate trauma, glascow of 3 is severe, mild tb and concussion are similar (ABE)

Question 24

Client gets home oxygen therapy, which complications should nurse teach?

Answer 24

Absorptive atelectasis, combustion, dry mucous membranes, toxicity (ABCE)

Question 25

client in ed, has stroke, client gets tpa, client weighs 146lbs. how much medication (0.9mg/kg, not to exceed 90mg)

Answer 25

60mg

Question 26

ph 7.36 (Acidic Side of Normal)
pCO2 (53) (Acid)
hco3 (29) - Basic (22-28 normal)

Answer 26

Fully compensated respiratory acidosis

Question 27

pH= 7.30 (Acid)
PCO2 = 50 (Acid)
HCO3 = 24

Answer 27

Uncompensated Respiratory Acidosis

Question 28

Advanced directive

Answer 28

client’s ad hoc in file.

Question 29

what do hipaa stand for?

Answer 29

health insurance portability, and accountability act

Question 30

dopamine 5mcg/kg/min, patient is 150lbs. 400 mg/250cc, dopamine

Answer 30

12.8