Readiness exam 1

Question 1

TBI after car accident
a) What factor will kill the pt?
b) What do we must monitor?
c) Do they need to require follow up?
GCS 14
T 99.6(37.6)
P 62
BP 132/84

Answer 1

a) Close head injury
major concussion or brain bleed
b) S/S of increased ICP
c) GCS,T,BP

GCS anything below 15 is not normal
Even mild high temp and BP, still need to follow-up

Question 2

Hemorrhagic stroke
a) What to note about vomiting?
b) What it causes?

Increased ICP
c) Worsening what?

Answer 2

a) Vomiting usually without nausea
b) Increased ICP
c) Headache and GCS scale

Question 3

Cushing’s triad
What is it? s/s?

Answer 3

A late sign of increased ICP
s/s -widening BP
-Low HR,RR

Question 4

The nurse collaborates with the health care provider to update the interdisciplinary plan of care with increased ICP. Which order should the nurse anticipate for this client?
Select the 6 orders the nurse anticipates the HCP will order.
a) Fluid restriction
b) Osmotic diuretics
c) Antipyretic therapy
d) Invasive ICP monitoring
e) Arterial blood gas (ABG) analysis
f) Indwelling urinary catheter insertion
g) Comprehensive metabolic panel (CMP)

Answer 4

a,b,c,e,f,g

a-Fluid restriction leads to dehydration and hemoconcentration, which draws fluid across the osmotic gradient and decreases cerebral edema
c-Fever increases ICP
d-invasive ICP monitoring for clients should not be implemented in a client with a GCS greater than 8
e-ensuring optimal systemic oxygenation. Additionally, lower CO2 means lower ICP because carbon dioxide dilates the brain and results in more swelling from blood flow

Question 5

Intervention for increased ICP?

Answer 5

I-immobilize head
log rolling in one unit
C- CO2 Low
P- Position semi-fowler’s
30-45. no coughing/bearing down

Question 6

The nurse is caring for a client following a cystoscopy procedure. One hour after the nurse discontinues the indwelling urinary catheter, the client voids 20 mL of bright red urine and reports a mild burning sensation. Which nursing action is appropriate for the nurse to take next?
a) Call the health care provider and report assessment findings
b) Explain the need for the client to increase the intake of oral fluids

Answer 6

b
A cystoscopy involves inserting a scope through the urethra to diagnose and/or treat problems with the bladder. A small amount of bleeding and burning is common

Question 7

What are interventions to reduce pitting edema?
a) diet?
b) position?
c) other?

Answer 7

a) reduce sodium
b) elevate leg
c) apply compression stockings during the day
bilateral active range of motion to the ankles hourly

Question 8

Epiglottitis
What is the priority and what is the contraindication?

Answer 8

Maintaining airway patency is the first priority
DO NOT stick anything in the mouth, this could further occlude the child’s airway

Question 9

ICU pt reported an inability to sleep at night d/t high level of noise. Which intervention should take?
a) Dimming nursing station lights during the night shift
b) Restricting overhead announcements during the night shift
c) Encouraging the use of pharmacotherapy that promotes sleep
d) Lowering the volume for equipment alarms during the night shift
e) Limiting verbal communication among healthcare professionals during the night shift

Answer 9

b,d
e-Limiting verbal communication among health care professionals in the ICU environment is unrealistic

Question 10

The nurse is preparing to administer an IV chemotherapy drug. Which PPE should the nurse use?

Answer 10

N-95 mask
Goggles
Gloves
Gown
Facial shiels
Chemo is very toxic!!!

Question 11

The pt states I plan to receive weekly acupuncture treatment. The client’s past medical history includes chronic asthma, atrial fibrillation hypertension, and vertigo. Which one is a contraindication?
a) Asthma
b) A fib
c) HTN
d) Vertigo

Answer 11

b
the client take a daily blood thinner to protect against the increased risk for blood clots

acupuncture is contraindicated in individuals with an increased risk for bleeding, active skin infections, or even clients with a permanent pacemaker.

Question 12

Which population does the nurse identify as at great risk for sexual maltreatment? SATA
a) Children under the age of three years.
b) Older adults who are diagnosed with dementia
c) Disabled persons of any age or care setting
d) School-age children living in a single parent family
e) Any person who uses illicit drugs or alcohol

Answer 12

a,b,c,d,e

Question 13

A staff nurse to formulate a plan aimed at reducing the number of medication errors that occur on the unit.
Put correct order
1)Research the problem on appropriate websites
2)State the specific problem or concern, as assigned;
3)Present proposed plan to appropriate nursing personnel.
4)Gather input from the unit nursing staff
5)Formulate a proposed plan based on findings

Answer 13

2 state the specific problem
4.gather input/info
1.reserach the problem
5.forumlate a proposed plan
3.present proposed plan

Question 14

Aclient with cellulitis at the site utilized to inject illicit drugs. The client states, “Don’t talk to me about getting clean, I tried and it didn’t work.” Further conversation reveals the client is homeless and shares needles with another person, stating, “He’s a good clean guy and I trust him.” Which health promotion instruction is best for the nurse to provide to the client?
a) “It often takes multiple times in treatment to be successful.”
b) “Pathogens injected directly into a vein can cause a deadly infection.”
c) “Here is a list of several needle exchange sites you can use to enhance safety.”

Answer 14

c
This program addresses a high-risk behavior that increases the client’s risk for disease

a,b are true statements but it doesn’t address safety

Question 15

A client who tests positive for the breast cancer gene 1 (BRCA 1) mutation. Which education should the nurse provide to the client regarding prevention strategies? SATA
a) Mammography every six months is an appropriate surveillance strategy
b) Annual magnetic resonance imagery (MRI) is an appropriate surveillance strategy
c) Ultrasonography of the breast will be scheduled with other diagnostic surveillance
d) Studies indicate that daily intake of two glasses of red wine may decrease your risk

Answer 15

b,c
a-implementation annually with MRI and ultrasonography for all
d-Daily intake of two to five glasses of an alcoholic beverage has been shown to increase the risk for breast cancer

Question 16

a) otolaryngologist
b) gastroenterologist

Answer 16

a) ENT for short
an ear, nose, and throat doctor
removal of foreign objects
b) for GI
digestive disease

Question 17

The post-procedure care unit (PACU) nurse monitors the client carefully after the completion of a bronchoscopy with successful retrieval of a foreign body.
Select the 2 findings that would require the nurse to take immediate action.
a) Absence of gag reflex
b) Bright red sputum
c) Stridor
d) Drowsiness
e) Hoarseness

Answer 17

b,c
b-This finding indicates active bleeding
c-An airway sound of stridor is indicative of laryngospasm

a,d-expected finding since the throat is still numb from the topical agent and used sedation
e-expected finding after the procedure due to the irritation of the throat

Question 18

The nurse manager is observing a dressing change by a newly licensed RN. Which action by the RN requires intervention by the nurse manager?
a) The wound is cleansed from the least dirty to the most dirty area.
b) A blood saturated dressing is placed in a clear plastic trash bag
c) A clean dressing is not applied to a dry, well-approximated surgical wound.

Answer 18

b
Any dressing that is saturated in blood should be disposed of in the biohazard container
a- outward and from top to bottom
c- A surgical wound that is closed, dry, and well-approximated may be left open to air

well-approximated
Wounds that fit neatly together, easily close

Question 19

What incident report used for?

Answer 19

Communicate important safety information to hospital administrators
To identify and eliminate potential risks necessary to prevent future mistakes

Report about the impact of poor staffing practices on patient care.
This is the purpose of filing an incident report in this instance. The report should address how inadequate staffing negatively affected client care during that shift

Question 20

A pt with new hearing aids increase in background noise is intolerable. Which instruction from the nurse is appropriate?
SATA
a) Suggest that the client initially use the hearing aids for short intervals
b) Recommend wearing the hearing aids in quiet areas first until adjusted to the noise level.
c) Ask people to ensure that the television and other devices are adjusted to a normal level.
d) Adjust the hearing aid volume as needed in noisy environments

Answer 20

a,b,c
a-starting with short intervals of wear helps the client to adjust to the new volume of noise
c-the client may have had the volume on devices turned up for so long that they now have a hard time recognizing a “normal” level

d-newer hearing aids have the technology to automatically adjust to different noise leve

Question 21

Atorvastatin
a) contraindication
b) ADR
c) what is toxic? what needs to be monitored?

Answer 21

a) pregnancy
grapefruit
b) rhabdomyolysis
-muscle cramps or aches and pain
should report HCP
c) liver
liver function labs were drawn regularly

Question 22

Preparing to perform a sterile procedure, place correct orders
1)Clean the work surface thoroughly with alcohol
2) Remove existing dressing with clean gloves
3) Perform hand hygiene and don sterile gloves
4) Check expiration date on needed items
5) Open sterile package away from the RN

Answer 22

4
1
5
2
3

Question 23

Preschool aged client having IM shots. Which approach by the nurse is appropriate? STAT
a) State to the child, “You will feel a quick little pinch.”
b) Allow the child to look at and examine required equipment.
c) Ask the caregiver to hold the child down during the procedure
d) State to the child, “If you don’t cry you will get a prize after your shot.

Answer 23

a,b
a-It is important to inform a child about sensations that may be experienced during procedures. BUT just right before IM shot
c-Restraining a child can be more traumatic than the actual procedure
d-Children should be encouraged to cry and express feelings associated with IM

Question 24

The nurse inserted an indwelling urinary catheter, the pt had an allergic reaction. Place the correct order
1) Report the incident to the HCP
2) Confirm access to O2
3) Monitor for systemic allergic reactions
4.) Gently clean the urinary meatus
5) Remove the urinary cathter

Answer 24

5- must always take is to remove the allergen
3- If the reaction is localized, the nurse should then perform a quick, focused assessment for systemic manifestations
2
4
1

Question 25

Discontinue a peripheral IV on a client. Place the correct orders

1) Clamp IV catheter tubing, turn off infusion, and d/c tubing
2) Explain the procedure to the pt
3) Withdraw the IV catheter and apply pressure to the site with sterile gauze
4) Inspect the tip of the catheter
5) Holding the skin taut, remove the dressing over the IV site
6) Don clean gloves

Answer 25

2
1
6
5
3
4

Question 26

What should the case manager assess?

Answer 26

The client’s need for equipment and materials to achieve or maintain independence in the home environment after hospital discharge

Question 27

The nurse case manager is assigned to assist with the discharge needs for a client who is recovering from Covid-19. Which question should the nurse include when assessing the client’s needs in the home environment? SATA
a) Who is your primary care practitioner
b) Do you require oxygen with ambulation?
c) Does anyone in your home currently smoke
d) What is the name of your insurance provider
e) Is your albuterol administered with a inhaler or a nebulizer

Answer 27

b,e

Question 28

Which QI initiative is most likely to decrease the need for acute care management for clients diagnosed with CHF?
a) Present dietary teaching to the client prior to discharge
b) Review symptoms indicative for exacerbation with the client
c) Provide each client with a scale to monitor daily weights
d) Arrange for a home care nurse to assess the client monthly

Answer 28

c
While clients are taught to monitor daily weights as an important aspect of CHF management, many may not have access to a scale and, if they do it may not be reliable; therefore, providing each client with a scale for daily weight monitoring is an appropriate QI initiative that can be implemented to reduce the need for readmission to the hospital.

a,b,d
this is an existing intervention recommended by evidence-based practice (EBP) guidelines for the management of this condition

Question 29

newly placed colostomy,place the correct orders
1) Clean the skin and stoma with unscented soap
2) Empty the ostomy bag as usual
3) Remove the current bag and wafer and dispose in a sealed bag
4) Apply the new wafer and press firmly in place
5. Cut the correct size opening in the new wafer

Answer 29

2
3
1
5
4

Question 30

The nurse is planning a presentation to parents of toddlers about safety and development. Which information should the nurse include in the presentation? SATA
a) Toddlers have a strong sense of curiosity.
b) This age group is prone to falls from heights.
c) The toddler has no understanding of “no.”
d) Toddlers do not play well with other children.
e) This age group may not be able to express exactly how they’re feeling.

Answer 30

a,b,e
prone to falls 転倒しやすい

Question 31

acute respiratory distress syndrome (SARS). Which type of precaution will the nurse expect to implement?
What’s else other disease will be the same precaution?

Answer 31

Droplet
Pertussis
Influenza
Meningitis
Pneumonia

Surgical Mask & Goggles

Question 32

A client with a compound fracture of the leg and multiple head and face lacerations

What is laceration means?

Answer 32

a deep cut or tear in skin or flesh

Question 33

A client was recently diagnosed with myasthenia gravis. Which information is priority for the nurse to provide to the client?
a) The objective for frequent periods of rest
b) he importance of a strict medication schedule
c) The reasons for a diet high in protein and fiber
d) The benefits related to muscle strengthening exercises

Answer 33

b
For all new diagnoses, pt should be on a strict medication schedule

MG=The first sign is eyebrow droop.
weakness in the arm and leg muscles, double vision, and difficulties with speech and chewing

Question 34

Meniere’s disease

Answer 34

A chronic inner ear disorder that can cause severe episodes of vertigo
Vertigo is a symptom that causes a person to feel like they or the world around them is spinning or moving,

Question 35

As renal insufficiency increase, what impairment will increase?

Answer 35

Memory impairment
Cognitive impairment

Question 36

New diagnosis of moderate Alzheimer’s dementia and being started on donepezil.
2 interventions that should be included

Answer 36

Place client on telemetry monitor
Monitor for signs and symptoms of bleeding

Question 37

The practitioner prescribes gastric lavage in order to remove the medication.
Place correct order
1) Confirm the placement of the orogastric tube
2) Repeatedly introduce 200 to 300 mL of lavage fluid
3) Aspirate and remove gastric contents
4) Administer activated charcoal via the orogastric tube.
5) Place the client on a cardiac monitor and pulse oximeter

Answer 37

5
1
3 吸引する
2
4 if prescribed

Question 38

What are Poison ivy and poison sumac?
What is the first action?

Answer 38

Poisonous plants cause an itchy rash in people who are sensitive to the plants
Take a warm shower and wash and rinse several times.

Question 39

An adolescent client who receives aggressive chemotherapy for a relapse of leukemia. The client tells the nurse, “This my second relapse and I am done with chemo. I just want to enjoy whatever time I have left.” Which action by the nurse indicates an act of advocacy?

a) The nurse discusses the reasons to continue chemotherapy with the adolescent client.
b) The nurse schedules a meeting to inform the client’s parents about the adolescent’s feelings
c) The nurse notifies the client’s health care provider to discontinue treatment based on the adolescent’s wishes
d) The nurse discusses the decision with the adolescent to determine how to best assist the client in the provision of care

Answer 39

d
Typically, health care decisions for pediatric clients are made by their parents or legal guardians. As children grow and mature, however, they should also be included in the decision-making process.

b,c-adolescent cannot independently making their decision

Question 40

The client is turned and repositioned every two hours. Which areas does the nurse assess for skin breakdown after moving the client from the left to the right side-lying position? SATA
a) The occipital area of the head
b) The distal areas of the left pinna
c) The inferior horizontal gluteal crease
d) The lateral area of the left ankle
e) The lateral aspect of the left trochanter

Answer 40

b,d,e
a-back of the head
c-butt
d-outer
e-trochanter 腰の骨

Question 41

What factors are contraindications of oral contraceptives?

Answer 41

Antibiotic therapy
Active migraine in women over 35
CAD
hypertension
Smoking in women over 35
History of breast cancer
Stroke

Question 42

a) Vasospastic angina?
b) Microvascular angina?

Answer 42

a)Chest pain at rest or waking from sleep with this pain
b) activity or emotional stress and is most common in individuals assigned female at birth

Question 43

1) Copies a circle with a pencils or crayon
2) Would rather play with others than alone
3) Copies the actions of adults and other children
4) Pulls up to stand and cruises around furniture
5) Can hold a toy and shake it or swing at dangling toys

Answer 43

1
2
4
3
5

Question 44

The nurse is caring for a client who just returned from a femoral artery cardiac catheterization.
➤Which assessment finding requires immediate follow-up?
a) The client rates pain as a level 7 on a 0 to 10 scale
b) A small amount of blood is noted under the client.
c) The pressure dressing exhibits a 2.0 cm spot of blood
d) Peripheral pulses must be confirmed by ultrasound

Answer 44

a
Mild pain is expected following cardiac catheterization. However, severe pain is an unexpected. This could indicate the development of a clot and must be addressed.
b,c-A small amount of blood is not concerning. The nurse should assess for any additional signs of bleeding

Question 45

A follow-up visit for a client who has recently been prescribed levodopa for Parkinson’s.The client reports severe headaches, a blood pressure of 188/102 mmHg, and a temperature of 101°F.
➤Which additional information should the nurse report immediately to the health care provider?
a) The client states a loss of appetite and occasional nausea
b) The client reports frequent periods of eyelid twitching
c) The client feels dizzy when rising from a sitting position
d) The client is treated for persistent, prolonged depression.

Answer 45

d
While levodopa and certain antidepressants (MAOIs) may be used in combination, both increase the amount of norepinephrine in the body. A hypertensive crisis is a potential complication

Question 46

The nurses are at high risk for probable medication errors and improper careThe team of 3 nurses is responsible for 12 clients in total. An hour after the shift began, 2 nurses were moved from the unit and reassigned to another unit to care for 12 additional clients.

➤Which of the following information is important for the nurse to document on the incident/variance report?
a) The nurse is solely responsible for twelve clients
b) Short-staffed units failed to cover their personnel shortages
c) The supervisor did not clear the staff adjustment with the nurse
d) The nurses are at high risk for probable medication errors and improper care

Answer 46

a
b,c,d
Incident reports should contain only exact, factual events. Opinions should never be included in an incident report.

Question 47

The nurse is caring for a neonate born at 32 weeks’ gestation. The primary healthcare provider (PHCP) orders surfactant therapy.

➤Which route should the nurse expect the surfactant to be administered?
a) Intravenous
b) Subcutaneous
c) Intramuscular
d) Endotracheal

Answer 47

d

Question 48

A client who has been prescribed celecoxib and states that they have to take Motrin and aspirin every day when the pain gets really bad.

➤The nurse informs the primary healthcare provider (PHCP) that the client is

a) self-prescribing treatment for pain
b) taking additional anti-inflammatories
c) at risk for adverse side effects

Answer 48

c
These two over-the-counter medications are also NSAIDs, which increase the client’s risk for bleeding and other adverse effects

Question 49

A client who is confused and combative following a surgical procedure.
1) Call the HCP to obtain an order or restrain
2)Check on the pt every 15 mons
3) Apply restraints according to directions and policy
4) Explain the use of restraints to the pt
5) Attempt multiple safety interventions

Answer 49

5
re-orienting the client to their surroundings, providing the client with a book to read, or having a staff member sit at the client’s bedside
1
if not successful then order
4
3
2

Question 50

An infant who has developed oral thrush and is now prescribed nystatin.
➤Which information is most important for the nurse to provide the parents of the infant?
a)Administer the medication after meals and at bedtime
b) Store the reconstituted powder oral suspension in the refrigerator
c) Apply the medication to the affected areas with a calibrated dropper
d) Gently clean infected areas with tepid water after each administration

Answer 50

a
Administering the medication after meals and at bedtime allows the medication to be the most effective against thrush.