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75 Practice Questions

Incorrect...
The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After
being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment
finding?
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Increase in Forced Vital Capacity (FVC)
A narrowed chest cavity
Clubbed fingers
An increased risk of cardiac failure
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Increase in Forced Vital Capacity (FVC)
Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPD
would have a decrease in FVC.
A narrowed chest cavity
A patient with COPD often presents with a barrel chest, which is seen as a widened chest cavity.
Clubbed fingers
Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
An increased risk of cardiac failure
Although a patient with these conditions would indeed be at an increased risk for cardiac failure, this is a
potential complication and not an assessment finding.
The nurse is taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer. After being
told the patient is complaining of epigastric pain, the nurse expects to note which assessment finding?
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Melena
Nausea
Hernia
Hyperthermia
Submit

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Melena
Correct Melena is the finding that there are traces of blood in the stool. This is a common manifestation of
Duodenal Ulcers, since the Duodenum is further down the gastric anatomy.
Nausea
Nausea may be present, but is a generalized symptom and by itself doesnt indicate a Duodenal Ulcer
Hernia
A Hernia is a protrusion of a segment of the abdomen through another abdominal structure. It is not associated
with an Ulcer and is a condition, not an assessment finding.
Hyperthermia
Hyperthermia, a high temperature, is not an assessment finding of a Duodenal Ulcer
A nurse is providing discharge teaching for a patient with severe Gastroesophogeal Reflux Disease. Which of
these statements by the patient indicates a need for more teaching?
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Im going to limit my meals to 2-3 per day to reduce acid secretion.
Im going to make sure to remain upright after meals and elevate my head when I sleep
I wont be drinking tea or coffee or eating chocolate any more.
Im going to start trying to lose some weight.
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Im going to limit my meals to 2-3 per day to reduce acid secretion.
Correct Large meals increase the volume and pressure in the stomach and delay gastric emptying. Its
recommended instead to eat 4-6 small meals a day.
Im going to make sure to remain upright after meals and elevate my head when I sleep
Incorrect This is a correct verbalization of health promotion for GERD.
I wont be drinking tea or coffee or eating chocolate any more.
Incorrect This is a correct verbalization of health promotion for GERD.
Im going to start trying to lose some weight.
Incorrect This is a correct verbalization of health promotion for GERD.
The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab
results, the nurse finds that the patients blood pressure is 95/60, pulse is 110 beats per minute, and the patient
reports epigastric pain. What is the priority intervention?
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Start a large-bore IV in the patients arm
Ask the patient for a stool sample
Prepare to insert an NG Tube
Administer intramuscular morphine sulphate as ordered
Submit

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Start a large-bore IV in the patients arm
Correct The nurse should suspect that the patient is haemorrhaging and will need need a fluid replacement
therapy, which requires a large bore IV.
Ask the patient for a stool sample
Incorrect While this is useful in the diagnosis and assessment of Peptic Ulcer Disease, it is not the priority
intervention.
Prepare to insert an NG Tube
Incorrect While this intervention may be used in the later stages of Peptic Ulcer Disease, it is not the first and
priority intervention.
Administer intramuscular morphine sulphate as ordered
Incorrect While this is an important intervention to manage pain, it is not the priority intervention.
A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of
150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the
physician immediately?
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Hemoglobin 11 g/dl
Platelet of 150,000
INR of 2.5
Potassium of 2.7 mEq/L
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Hemoglobin 11 g/dl
This is below normal, but a normal female hemoglobin is 12-14. There is a more critical lab result.
Platelet of 150,000
This is also below the normal values, but is not the most critical lab result.
INR of 2.5
This is a therapeutic range for a patient who is taking an anticoagulant for atrial fibrillation
Potassium of 2.7 mEq/L
Correct A potassium imbalance for a patient with a history of dysrhythmia can be life-threatening and can
lead to cardiac distress.
While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patients lower legs have
become edematous and auscultates crackles in the lungs. What should the nurse do first?
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Stop the saline infusion immediately
Notify Physician
Elevate the patients legs
Continue the infusion, since these are normal findings
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Stop the saline infusion immediately
Correct, the patient has a fluid volume overload as a result of overly rapid fluid replacement. The nurse should
stop the infusion and notify the physician.
Notify Physician
This is not the first action the nurse should take.
Elevate the patients legs
This would help with the edema, but is not a priority
Continue the infusion, since these are normal findings
This is not a normal finding
The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to
stress?
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They must inform household members of their condition
They must take their medications exactly as prescribed
They must abstain from substance use
They must avoid large crowds
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They must inform household members of their condition
Incorrect Each patient has a right to privacy of their medical condition. It is their choice whether they inform
household members.
They must take their medications exactly as prescribed
Correct Antiretrovirals must be taken exactly as prescribed to prevent drug-resistant strains. Even missed
doses can reduce the effectiveness of future treatment.
They must abstain from substance use
Incorrect While substance use should be discouraged, using safe practices with needles can prevent
transmission of HIV.
They must avoid large crowds
Incorrect Avoiding large crowds to prevent infection is a priority in the later stages of HIV, when the patient
has AIDS.
A nurse finds a 30-year-old woman experiencing anaphylaxis from a bee sting. Emergency personnel have been
called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should
the nurse do first?
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Initiate cardiopulmonary resuscitation
Check for a pulse
Ask the woman if she carries an emergency medical kit
Stay with the woman until help comes
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Initiate cardiopulmonary resuscitation
Incorrect CPR is premature at this point, and there is another action that can be taken first.
Check for a pulse
This is the first step when initiating CPR, but not the best and first course of action.
Ask the woman if she carries an emergency medical kit
Correct Many patients who have a known history of anaphylaxis carry epi-pens in their pockets or
belongings. This is the best way to stop a hypersensitivity reaction before it becomes life-threatening.
Stay with the woman until help comes
Incorrect While this should be done, its not the best and first course of action.
A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when
he notices which of these assessment findings?
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The patient states he had a manic episode a week ago
The patient states he has been having diarrhea every day
The patient has a rashy pruritis on his arms and legs
The patient presents as severely depressed
The patients lithium level is 1.3 mcg/L
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The patient states he had a manic episode a week ago
Incorrect Having a manic episode is not an indication of lithium toxicity. This finding indicates that the lithium
is not effective or is not at a therapeutic level.
The patient states he has been having diarrhea every day
Correct Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity.
The patient has a rashy pruritis on his arms and legs
Incorrect This is not a symptom of lithium toxicity
The patient presents as severely depressed
Incorrect Having a depressive episode is not an indication of lithium toxicity. This finding indicates that the
lithium is not effective or is not at a therapeutic level.
The patients lithium level is 1.3 mcg/L
This is within the therapeutic range of lithium
A 65 year old man is prescribed Flomax (Tamsulosin) for Benign Prostatic Hyperplasia. The patient lives in an
upstairs apartment. The nurse is most concerned about which side effect of Flomax?
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Hypotension
Tachycardia
Back Pain
Difficulty Urinating
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Hypotension
Correct Hypotension can lead to dizziness and a risk for injury to the patient.
Tachycardia
Tachycardia can be a side effect of Flomax, but is not an immediate safety risk, nor is it a common side effect.
Back Pain
Back Pain can be a side effect of Floma, but is not a safety risk
Difficulty Urinating
Dysuria is a symptom of Benign Prostatic Hyperplasia, not a side effect of Flomax
A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time
caretaker. The nurse is most concerned about which side effect of heparin?
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Back Pain
Fever and Chills
Risk for Bleeding
Dizziness
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Back Pain
Incorrect Back pain, while it can occur, is not an immediate concern
Fever and Chills
Incorrect Fever and Chills, while it can occur, is not an immediate concern
Risk for Bleeding
Correct A confused patient is at risk for injuring themselves and at risk for hemorrhage should an injury
occur
Dizziness
Incorrect Dizziness is not a side effect of Heparin
An woman is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test.
The nurse is most concerned about which side effect of metformin?
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Diarrhea and Vomiting
Dizziness and Drowsiness
Metallic taste
Hypoglycemia
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Diarrhea and Vomiting
Incorrect While these may occur, the patient is at higher risk for another adverse effect.
Dizziness and Drowsiness
Incorrect While these may occur, the patient is at higher risk for another adverse effect.
Metallic taste
Incorrect While this may occur, the patient is at higher risk for another adverse effect.
Hypoglycemia
Correct The patient is at risk because she is on NPO status and continuing to take an anti-glycemic drug.
The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results
show that the blood lithium value is 1.6 mcg/L. What would the nurse take as the priority action?
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Induce vomiting
Hold the next dose of Lithium
Administer an anti-emetic
Give the next dose of Lithium
Submit

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Induce vomiting
Incorrect This may be warranted for a severe lithium toxicity, but would be premature at this point.
Hold the next dose of Lithium
Correct Lithiums therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L
Administer an anti-emetic
Incorrect While minor toxicity can cause vomiting and nausea, this is not a priority action
Give the next dose of Lithium
Incorrect Lithiums therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L
A patient asks the nurse why they must have a heparin injection. What is the nurses best response?
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Heparin will dissolve clots that you have.
Heparin will reduce the platelets that make your blood clot
Heparin will work better than warfarin.
Heparin will prevent new clots from developing.
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Heparin will dissolve clots that you have.
Incorrect Heparin does not do this.
Heparin will reduce the platelets that make your blood clot
Incorrect Heparin does not do this
Heparin will work better than warfarin.
Incorrect Heparin has a different mechanism of action than warfarin, and a different route of administration,
but achieve similar results.
Heparin will prevent new clots from developing.
Correct -This is a correct statement.
The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results
show that the troponin I value is a 5.3 ng/mL. Which of these intervention, if not completed already, would take
priority over the others?
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Put the patient in a 90 degree position
Check whether the patient is taking diuretics
Obtain and attach defibrillator leads
Check the patients last ejection fraction
Submit

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Put the patient in a 90 degree position
Incorrect This position is optimal for helping a patient breathe, but is not the priority action in an emergency
situation.
Check whether the patient is taking diuretics
Incorrect Diuretics play a role in CHF by decreasing fluid volume, but this patient is likely having an acute
myocardial infarction.
Obtain and attach defibrillator leads
Correct Ventricular Fibrillation is the cause of death in most cases of deaths due to sudden cardiac arrest.
Defibrillation is the most important action to take to prevent death.
Check the patients last ejection fraction
Incorrect Ejection fraction is a test used to gauge the severity of CHF, not an emergency cardiac arrest.
A nurse is caring for a patient undergoing a stress test on a treadmill. The patient turns to talk to the nurse.
Which of these statements would require the most immediate intervention?
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Im feeling extremely thirsty. Im going to get some water after this.
I can feel my heart racing.
My shoulder and arm is hurting.
My blood pressure reading is 158/80
Submit

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Im feeling extremely thirsty. Im going to get some water after this.
Incorrect This does not require immediate intervention. This is a common response to exercise and activity.
I can feel my heart racing.
Incorrect This does not require immediate intervention. This is a common response to exercise and activity.
My shoulder and arm is hurting.
Correct Unilateral arm and shoulder pain is one of the classic symptoms of myocardial ischemia. The stress
test should be halted.
My blood pressure reading is 158/80
Incorrect This does not require immediate intervention. Moderate elevation in blood pressure is a common
response to exercise and activity.
The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results
show that the BNP (B-type Natriuretic Peptide) value is a 615 pg/ml. What would the nurse take as the priority
action?
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Call a cardiac code and implement emergency measures
Check the patients oxygen saturation
Inform the physician that the patient has Congestive Heart Failure
Encourage the patient to limit activity
Submit

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Call a cardiac code and implement emergency measures
Incorrect There is no evidence that the patient is undergoing a cardiac arrest.
Check the patients oxygen saturation
Correct An elevated BNP indicates that there is decreased cardiac output. A priority intervention would be
to ensure proper oxygenation after an assessment.
Inform the physician that the patient has Congestive Heart Failure
Incorrect Although BNP suggests Congestive Heart Failure, it is not used in itself to diagnose CHF. An elevated
BNP can also be caused by dysrhythmias or renal disease.
Encourage the patient to limit activity
Incorrect This is an intervention that can help treat CHF, but not a priority action at this time.
A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistant
would most require the nurses immediate intervention?
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The nursing assistant fills the patients pitcher with ice cold drinking water
The nursing assistant elevates the head of the bed to 60 degrees for a meal
The nursing assistant refills the ice pack laying on the insertion site
The nursing assistant places an extra pillow under the patients head on request
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The nursing assistant fills the patients pitcher with ice cold drinking water
Incorrect It is recommended to generously hydrate after a coronary angiogram to excrete contrast medium,
reducing kidney toxicity
The nursing assistant elevates the head of the bed to 60 degrees for a meal
Correct For 3-6 hours after a coronary angiogram (depending on the insertion site), the patient should have
their bed no higher than 30 degrees and be on bedrest.
The nursing assistant refills the ice pack laying on the insertion site
Incorrect An ice pack or dressing is recommended to be placed on the insertion site to minimize risk of
bleeding.
The nursing assistant places an extra pillow under the patients head on request
Incorrect An extra pillow will not violate any post-procedural protocols for coronary angiogram.
A man is has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea.
The nurse is concerned about which side effect of lisinopril?
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Vertigo
Hypotension
Palpitations
Nagging, dry cough
Submit

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Vertigo
Incorrect While this may occur, the patient is at higher risk due to another adverse effect.
Hypotension
Correct The patient is particularly at risk for hypotension due to possible dehydration from fluid loss.
Palpitations
Incorrect While this may occur, the patient is at higher risk for another adverse effect.
Nagging, dry cough
Incorrect While this is a common side effect, the patient is at higher risk for another adverse effect..
The nurse is taking the health history of a patient being treated for sickle cell disease. After being told the
patient has severe generalized pain, the nurse expects to note which assessment finding?
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Severe and persistent diarrhea
Intense pain in the toe
Yellow-tinged sclera
Headache
Submit

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Severe and persistent diarrhea
Incorrect This is not a manifestation of sickle cell disease
Intense pain in the toe
Incorrect Gout is a manifestation of Polycythemia Vera, in which the there is an overabundance of red blood
cells
Yellow-tinged sclera
Correct Jaundice is a common clinical finding of sickle cell disease, caused by bilirubin released from damaged
or destroyed RBCs
Headache
Incorrect While this may occur, it is not indicative or a classic symptom of sickle cell disease.

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A client with Multiple Sclerosis reports a constant, burning, tingling pain in the shoulders. The nurse anticipates
that the physician will order which medication for this type of pain?
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alprazolam (Xanax)
Corticosteroid injection
gabapentin (Neurontin)
hydrocodone/acetaminophen (Norco)
Submit

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alprazolam (Xanax)
Incorrect alprazolam is used to reduce anxiety
Corticosteroid injection
Incorrect Corticosteroid injections are used to reduce inflammation in a localized area, often due to joint
breakdown. In MS patients it is used to treat acute exacerbations (flare-ups), but the symptoms described do
not constitute an acute exacerbation.
gabapentin (Neurontin)
Correct Anticonvulsants like gabapentin are often the first line of treatment for nerve pain
hydrocodone/acetaminophen (Norco)
Incorrect Opioids would not be the appropriate medication to treat nerve pain.
Which of these clients is likely to receive sublingual morphine?
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A 75-year-old woman in a hospice program
A 40-year-old man who just had throat surgery
A 20-year-old woman with trigeminal neuralgia
A 60-year-old man who has a painful incision
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A 75-year-old woman in a hospice program
Correct Sublingual morphine is often used in hospice because the patients are unable to swallow, and
intravenous access can be painful and not conducive to palliative care.
A 40-year-old man who just had throat surgery
Incorrect Patients who have surgery most likely have an Intravenous line
A 20-year-old woman with trigeminal neuralgia
Incorrect Morphine would not be the first choice for nerve pain
A 60-year-old man who has a painful incision
Incorrect Although Morphine would be an appropriate medications, there is no indication that it should be
administered sublingually
In educating clients on ways to manage pain, which topic can be appropriately delegated to a LPN/LVN who will
continue under supervision?
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Acupuncture
Guided Imagery
Alternating Rest/Activity
Over the counter medications
Submit

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Acupuncture
Incorrect This is outside the nursing scope of practice and requires special training or education
Guided Imagery
Incorrect This also requires additional training or education
Alternating Rest/Activity
Correct This is within the nursing scope of practice and within the training and education provided to all
nurses. It is safe to use and a standard treatment.
Over the counter medications
Incorrect This is outside the nursing scope of practice. A healthcare provider (doctor, nurse practitioner, or
physicians assistant) should be consulted before taking over the counter medications.
The nurse assesses a patient suspected of having an asthma attack. Which of the following is a common clinical
manifestation of this condition?
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Audible crackles and orthopnea
An audible wheeze and use of accessory muscles
Audible crackles and use of accessory muscles
Audible wheeze and orthopnea
Submit

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Audible crackles and orthopnea
Incorrect Crackles indicate fluid in the lungs, which is not a cause of asthma. Orthopnea is not associated with
asthma.
An audible wheeze and use of accessory muscles
Correct Both of these are associated with asthma.
Audible crackles and use of accessory muscles
Incorrect Crackles indicate fluid in the lungs, which is not a cause of asthma.
Audible wheeze and orthopnea
Incorrect Orthopnea is not associated with asthma.
The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical
manifestation of this condition?
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A high WBC count and decreased level of consciousness
A high WBC count and manic activity
A low WBC count and manic activity
A low WBC count and decreased level of consciousness
Submit

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A high WBC count and decreased level of consciousness
Correct Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining
feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.
A high WBC count and manic activity
Incorrect Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining
feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.
A low WBC count and manic activity
Incorrect Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining
feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.
A low WBC count and decreased level of consciousness
Incorrect Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining
feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.
A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the
nurse to make?
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Assess the patient for nuchal rigidity
Determine the patients past exposure to infectious organisms
Check the patients WBC lab values
Monitor for increased lethargy and drowsiness
Submit

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Assess the patient for nuchal rigidity
Incorrect Although neck stiffness can be a symptom of Meningitis, it is not used to define meningitis, neither is
it a sign of further neurological deterioration.
Determine the patients past exposure to infectious organisms
Incorrect Although this is an important part of the history gathering process, and meningitis is most often
caused by a viral or bacterial infection, it is not the priority assessment.
Check the patients WBC lab values
Incorrect Although WBCs do rise during an infection like Mengingitis, it is not the priority assessment.
Monitor for increased lethargy and drowsiness
Correct Lethargy and drowsiness indicate a decreased level of consciousness, which is the cardinal sign of
increased ICP (Intracranial Pressure), which can be life-threatening.
The nurse is caring for clients in the pediatric unit. A 6-year patient is admitted who has 2nd and 3rd degree
burns on his arms. The nurse should assign the new patient to which of the following roommates?
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A 4-year old with sickle-cell disease
A 12-year old with chickenpox
A 6-year old undergoing chemotherapy
A 7-year old with a high temperature
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A 4-year old with sickle-cell disease
Correct The nurse should be concerned about the burn patients vulnerability to infection. Sickle cell disease is
not a communicable disease.
A 12-year old with chickenpox
Incorrect Chickenpox is a communicable disease
A 6-year old undergoing chemotherapy
Incorrect This patient is already immunosuppressed and should not have a roommate regardless.
A 7-year old with a high temperature
Incorrect An unspecified fever is often indicative of an infection of some type.
A patient with Meningitis is being treated with Vancomycin intravenously 3 times per day. The nurse notes that
the urine output during the last 8 hours was 200mL. What is the nurses priority action?
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Check the patients last BUN
Ask the patient to increase their fluid intake
Ask the physician to order a diuretic
Notify the physician of this finding
Submit

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Check the patients last BUN
Incorrect This may be relevant to nephrotoxicity and poor urine output, but is not the priority action. An
assessment finding has already been done and indicates an immediate intervention.
Ask the patient to increase their fluid intake
Incorrect Increasing oral intake without other interventions will increase risk of increased ICP and fluid
overload.
Ask the physician to order a diuretic
Incorrect This is premature and would not be the correct intervention.
Notify the physician of this finding
Correct Vancomycin is a nephrotoxic drug and can cause impaired renal perfusion, which would cause a
decreased urine output. This is a serious adverse effect and should be reported to the physician.
A patient is being admitted to the ICU with a severe case of encephalitis. Which of these drugs would the nurse
not be expect to be prescribed for this condition?
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Acyclovir (Zovirax)
Mannitol (Osmitrol)
Lactated Ringers
Phenytoin (Dilantin)
Submit

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Acyclovir (Zovirax)
Incorrect- Acyclovir is a common antiviral drug for the treatment of viral encephalitis
Mannitol (Osmitrol)
Incorrect Mannitol is a hyperosmolar drug that helps reduce Intracranial Pressure by acting as a diuretic and
decreasing fluid in the body.
Lactated Ringers
Correct Lactated Ringers solution is often used in fluid replacement therapy, which is not warranted if a
patient is at risk for high ICP.
Phenytoin (Dilantin)
Incorrect Phenytoin is an anticonvulsant and is often used to prevent seizures, which can complicate and
worsen a patients neurological state.
The nurse is treating a patient who has Parkinsons Disease. Which of these practices would not be included in
the care plan?
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Decrease the calorie content of daily meals to avoid weight gain
Allow the patient extra time to respond to questions and do ADLs
Use thickened liquids and a soft diet
Encourage the patient to hold the spoon when eating
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Decrease the calorie content of daily meals to avoid weight gain
Correct Calorie content should be increased for patients with Parkinsons Disease because of dysphagia
(difficulty swallowing), as well as calories burned due to muscle rigidity.
Allow the patient extra time to respond to questions and do ADLs
Incorrect This is a best practice when working with PD patients.
Use thickened liquids and a soft diet
Incorrect This is often used to reduce the risk of aspiration
Encourage the patient to hold the spoon when eating
Incorrect The patient should be encouraged to perform ADLs as independently as possible.

A 45-year old woman is prescribed ropinirole (Requip) for Parkinsons Disease. The patient is living at home with
her daughter. The nurse is most concerned about which side effect of ropinirole?
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Slurred speech
Sudden dizziness
Masklike facial expression
Stooped Posture
Submit

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Slurred speech
Incorrect Slurred speech is a common symptom of PD, not a side effect of this drug.
Sudden dizziness
Correct Dizziness and orthostatic hypotension are serious adverse effects of this drug that can lead to an
increased risk of falls. Ropiniroles drug class is a dopamine agonist, which mimic dopamine in the brain (PD is
characterized by a lack of dopamine).
Masklike facial expression
Incorrect Masklike facial expression is a common symptom of PD, not a side effect of this drug.
Stooped Posture
Incorrect Stooped Posture is a common symptom of PD, not a side effect of this drug.
The nurse is taking the health history of a patient being treated for Parkinsons Disease. After being told the
patient has classic symptoms of Parkinsons, the nurse expects to note which assessment finding?
Top of Form
Tremors
Low Urine Output
Exaggerated arm movements
Risk for Falls
Submit

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Tremors
Correct Tremors is one of four cardinal signs of PD: the other three are rigidity, bradykinesia (slow
movements), and postural instability
Low Urine Output
Incorrect This is not a relevant symptom to PD
Exaggerated arm movements
Incorrect A symptom of PD would be rigidity and slow arm movements, rather than exaggeration of arm
movements
Risk for Falls
Incorrect This is not an assessment finding. This is a nursing diagnosis.
A nurse enters a patients room and finds them unconscious with a rhythmic jerking of all four extremities. The
patient is foaming heavily at the mouth. The patient was on seizure precautions and the bedrails are up and
padded. What is the nurses priority action?
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Administer Lorazepam (Ativan)
Turn the patient to his/her side
Call the physician
Suction the patient
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Administer Lorazepam (Ativan)
Incorrect If a seizure lasts more than 5 minutes, it is called Status epilepticus and can be life-threatening.
Physicians will often order anxiolytics or sedatives to treat this condition. However, at this point it would not be
appropriate for the nurse to administer this drug.
Turn the patient to his/her side
Correct Turning the patient to the side will keep the airway open, which is the first priority
Call the physician
Incorrect This would be a priority action after ensuring the patients safety, or in the case of Status epilepticus
Suction the patient
Incorrect This intervention is warranted, but after an assessment of the patients airway, since forcing a
suction catheter into a patients mouth is a last resort.
A nurse is giving a discharge education to a patient who has been diagnosed with epilepsy. Which of these
teachings would she stress the most?
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Avoid doing alcohol and drugs
Follow up with the neurologist, physician, or other health care provider as prescribed
Do not stop taking anticonvulsants, even if seizures have stopped
Wear a medical alert bracelet or carry an ID card indicating epilepsy
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Avoid doing alcohol and drugs
Incorrect Although this is a general teaching that would be applied to any hospital discharge situation, it is not
the priority to be stressed.
Follow up with the neurologist, physician, or other health care provider as prescribed
Incorrect Although this is correct to include in discharge education, following this instruction is not directly
contributing to their safety, so is not the priority.
Do not stop taking anticonvulsants, even if seizures have stopped
Correct Following this instruction is essential for their safety, since stopping anti-epileptic drugs suddenly can
cause seizures and an increased chance of status epilecticus
Wear a medical alert bracelet or carry an ID card indicating epilepsy
Incorrect Although this is correct to include in discharge education, following this instruction is not directly
contributing to their safety, so is not the priority.
The nurse is caring for a patient in the ICU who has had a spinal cord injury. She observes that his last blood
pressure was 100/55, and his pulse is 48. These have both trended downwards from the baseline. What should
the nurse expect to be the next course of action ordered by the physician?
Top of Form
Assess the patient for decreased level of consciousness
Administer Normal Saline
Insert an NG Tube
Connect and read an EKG
Submit

Bottom of Form
Assess the patient for decreased level of consciousness
Incorrect An assessment has already been made, and an intervention is warranted.
Administer Normal Saline
Correct The patient is entering neurogenic shock. Normal saline will replace fluid volume, treating the
hypotension and bradycardia symptomatically. Atropine sulfate is also commonly used to increase the heart
rate.
Insert an NG Tube
Incorrect An NG tube would not be relevant in this situation.
Connect and read an EKG
Incorrect An EKG would not be needed in this situation.
A nurse is caring for a patient who is suspected to have sustained a spinal cord injury. What best describes the
overarching principles used to guide the care for this type of condition?
Top of Form
Immobilize the cervical area to prevent further injury
Monitor the patients level of consciousness to prevent neurologic deterioration
Help the patient with activities of daily living and provide emotional and physical support to help them
adjust to their injury
Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing
Submit

Bottom of Form
Immobilize the cervical area to prevent further injury
Incorrect While this is an essential part of caring for a spinal cord injury, it does not adequately describe
guiding principles for a complete plan of care
Monitor the patients level of consciousness to prevent neurologic deterioration
Incorrect While this is an essential part of caring for a spinal cord injury, it does not adequately describe
guiding principles for a complete plan of care
Help the patient with activities of daily living and provide emotional and physical support to help them adjust to
their injury
Incorrect These are important in the later stages of a spinal cord injury after the patient has been stabilized,
but at this point would be premature.
Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing
Correct Maintaining airway, breathing, and circulation is both essential and guides the overall plan of care for a
patient with a spinal cord injury.
A 23-year-old woman is admitted to the infusion clinic after a Multiple Sclerosis Exacerbation. The physician
orders methylprednisolone infusions (Solu-Medrol). The nurse would expect which of the following outcomes
after administration of this medication?
Top of Form
A decrease in muscle spasticity and involuntary movements
A slowed progression of Multiple Sclerosis related plaques
A decrease in the length of the exacerbation
A stabilization of mood and sleep
Submit

Bottom of Form
A decrease in muscle spasticity and involuntary movements
Incorrect While muscle spasticity and involuntary movements can be symptoms of MS, a corticosteroid
infusion is not meant to directly treat these symptoms.
A slowed progression of Multiple Sclerosis related plaques
Incorrect Special drugs like Interferon Beta, Natalizumab, or Glatiramir acetate are used as first-line
treatments to slow the progression of MS. While corticosteroids can be used in conjunction with these drugs on
a long-term basis, they would not be infused. They would be taken orally.
A decrease in the length of the exacerbation
Correct A methylprednisolone infusion is the first line of treatment during an acute exacerbation and is used to
decrease the length and severity of a relapse.
A stabilization of mood and sleep
Incorrect Some of the frequent side effects of a Methylprednisolone infusion are anxiety, insomnia, and mood
swings.
A nurse knows that which of these patients are at greatest risk for a stroke?
Top of Form
A 60-year old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past.
a 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic.
A 40-year old female who has high cholesterol and uses oral contraceptives
A 65-year old female who is African American, has sickle cell disease and smokes cigarettes.
Submit

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A 60-year old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past.
Correct Common risk factors for developing stroke include: Atrial fibrillation, arteriosclerosis, previous stroke
or ischemic attack, heart surgery, valvular heart disease, diabetes, smoking, substance abuse,obesity, sedentary
lifestyle, oral contraceptive use, genetic tendency, migraines, older age, male, African
American/Hispanic/American Indian, Sickle Cell Anemia, and brain trauma. This man has the greatest risk based
on these risk factors.
a 75-year old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic.
Incorrect See Common Risk Factors for Developing a Stroke.
A 40-year old female who has high cholesterol and uses oral contraceptives
Incorrect See Common Risk Factors for Developing a Stroke.
A 65-year old female who is African American, has sickle cell disease and smokes cigarettes.
Incorrect See Common Risk Factors for Developing a Stroke.
A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most
concerned about which of these assessment findings?
Top of Form
INR is 3 seconds long
Heart rate is 110 beats per minute
Intracranial Pressure is 22 mm/Hg
Blood pressure is 140/80
Submit

Bottom of Form
INR is 3 seconds long
Incorrect This is actually within a therapeutic range for clotting times for patients with coagulation risks. A
normal INR is .9-1.2 seconds, while a therapeutic INR can be as high as 3.5 seconds.
Heart rate is 110 beats per minute
Incorrect While tachycardia is a concern, general tachycardia without other associated symptoms would not
pose an immediate danger, and is not of greater priority than the next answer.
Intracranial Pressure is 22 mm/Hg
Correct The patient is at greatest risk for an increased ICP resulting from edema 72 hours after a stroke. A
target ICP should be less than or equal to 15-20 mm/Hg
Blood pressure is 140/80
Incorrect Blood pressure is often kept higher than usual following a stroke to maintain perfusion. Systolic BP
higher than 180, or diastolic BP higher than 105, would be the upper limit and required intervention. 140/80
would not pose an immediate danger to the patients health.
A nurse is caring for a patient scheduled to have cataract surgery. The patient asks why they developed cataracts
and how they can prevent it from happening again. What is the nurses best response?
Top of Form
Age is the biggest factor contributing to cataracts.
Unprotected exposure to UV lights can cause cataracts
Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.
Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most
easily treated eye conditions.
Submit

Bottom of Form
Age is the biggest factor contributing to cataracts.
Incorrect While true, this answer leaves out many other contributing factors to cataracts and does not address
prevention.
Unprotected exposure to UV lights can cause cataracts
Incorrect While true, this answer is not complete
Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.
Correct This answer covers the most common contributing factors for cataracts and includes preventable risk
factors.
Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily
treated eye conditions.
Incorrect While most cataracts are age-related cataracts, there are still ways to prevent eye damage and
cataract development.
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A nurse is educating a patient about bimatoprost (Lumigan) eyedrops for the treatment of Glaucoma. Which of
the following indicates that the patient has a correct understanding of the expected outcomes following
treatment?
Top of Form
I should be experiencing less blurriness in my central field of vision
This medication wont help my vision at all, but will keep it from getting worse.
My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so.
This medication will help my eye restore intraocular fluid and increase intraocular pressure
Submit

Bottom of Form
I should be experiencing less blurriness in my central field of vision
Incorrect Cataracts cause blurriness in the central field of vision, while Glaucoma presents as loss of the field of
vision peripherally.
This medication wont help my vision at all, but will keep it from getting worse.
Correct Glaucoma cannot be cured, just treated. Treatment revolves around preventing further deterioration.
My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so.
Incorrect Glaucoma treatment does not result in restoration of vision already lost.
This medication will help my eye restore intraocular fluid and increase intraocular pressure
Glaucoma is caused by an increase in intraocular fluid. Eyedrops work in various ways to decrease Intraocular
Pressure, not increase it.
A patient with Glaucoma is verbalizing his daily medication routine to the nurse. He states he has two different
eyedrop medications, both every twelve hours. He washes his hands, instills the drops, closes his eyes gently,
and presses his finger to the corner of his eye nearest his nose. After waiting 1 minute with his eyes closed, he
instills the other medication in the same way. What is the nurses best response?
Top of Form
You should wait more than 1 minute between different medications.
Your routine is very good! Can you demonstrate it for me?
It is actually not the best practice to close your eyes after instilling eyedrops.
You should actually be pressing your finger in the other corner of the eye.
Submit

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You should wait more than 1 minute between different medications.
Correct It is recommended to wait 10-15 minutes between different eyedrop medications to give them time to
absorb an avoid one medication washing another one out.
Your routine is very good! Can you demonstrate it for me?
Incorrect There is something wrong with what the patient described as his routine. After the nurse corrects
this, a return demonstration would be appropriate.
It is actually not the best practice to close your eyes after instilling eyedrops.
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You should actually be pressing your finger in the other corner of the eye.
Incorrect THis is not true.
A nurse would evaluate which of these patients as appropriate candidates for a closed MRI without contrast,
based on the information given?
Top of Form
A 20-year old woman who has unexplained joint pain and a low BMI.
A 35-year old woman with Multiple Sclerosis and has been trying to conceive.
A 67-year old man who has had an open-heart surgery 4 years ago.
A 40-year old woman who has been in a hypomanic state for the last 2 days.
Submit

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A 20-year old woman who has unexplained joint pain and a low BMI.
Correct MRI can be used to diagnose musculoskeletal disorders, and this patient has no contraindications to an
MRI.
A 35-year old woman with Multiple Sclerosis and has been trying to conceive.
Incorrect Pregnant women, or women who have a possibility of being pregnant, are not recommended to
receive MRIs.
A 67-year old man who has had an open-heart surgery 4 years ago.
Incorrect Patients with pacemakers, stents, or implants should not have MRIs. More information would have
to be gathered about this patient before an MRI can be done.
A 40-year old woman who has been in a hypomanic state for the last 2 days.
Incorrect Hypomania is a mild form of mania, and a patient with hypomania would have a very difficult time
laying still in a supine position for up to an hour. Sedation may be required, which requires more information
and assessment of this patient.
A nurse is caring for a patient in the cardiac care unit who is taking bumetanide (Bumex) and is diagnosed with
Parkinsons Disease. An unlicensed assistive personnel is assisting with feeding the patient. Which of these foods
would the nurse stress for the patient to eat most?
Top of Form
Foods containing the least amount of salt
Foods containing the most amount of potassium
Foods containing the most amount of calories
Foods containing the most amount of fiber
Submit

Bottom of Form
Foods containing the least amount of salt
Incorrect While this is a good practice, in light of the information given, this is not the greatest priority.
Foods containing the most amount of potassium
Correct Bumex is a loop diuretic and can cause hypokalemia. Ensuring potassium is included in the diet is a
priority and can directly avoid a hypokalemic crisis.
Foods containing the most amount of calories
Incorrect While this is a good practice, in light of the information given, this is not the greatest priority.
Foods containing the most amount of fiber
Incorrect While this is a good practice, in light of the information given, this is not the greatest priority.
A nurse knows that which of these patients are at greatest risk for a developing osteoporosis?
Top of Form
An 80-year old man who has a thin build
A 48-year old african american female who smokes cigarettes and drinks alcohol
A 55-year old female with an estrogen deficiency
A 70-year old caucasian female who takes oral corticosteroids
Submit

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An 80-year old man who has a thin build
Incorrect Age and thin build are two primary risk factors, but another patient has more.
A 48-year old african american female who smokes cigarettes and drinks alcohol
Smoking cigarettes and drinking alcohol are both primary risk factors, but being African American actually
decreases the risk for osteoporosis
A 55-year old female with an estrogen deficiency
Incorrect Only two risk factors are present: being female, and having an estrogen deficiency. While her age is
somewhat advanced, 65+ years of age is the cut-off for having a risk factor in women.
A 70-year old caucasian female who takes oral corticosteroids
Correct This patient has by far the most risk factors, 3 of which are primary and one secondary. Age, gender,
ethnicity are three primary risk factors, while her corticosteroid treatment is the secondary risk factor, bringing
her total up to four.
A 30-year old Caucasian woman who works the night shift has been found to have early bone loss and has a high
risk for osteomalacia and bone degradation. She asks the nurse exactly why she should take Vitamin D
supplements. What is the nurses best response?
Top of Form
Its a standard part of the overall nutritional treatment for the prevention of osteomalacia
It helps your intestines absorb calcium, which is important for bone formation.
It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone
formation.
Vitamin D supplements should not be taken by someone of your age.
Submit

Bottom of Form
Its a standard part of the overall nutritional treatment for the prevention of osteomalacia
Incorrect While this is true, it doesnt answer the womans question.
It helps your intestines absorb calcium, which is important for bone formation.
Correct This is the correct mechanism of action for Vitamin D
It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone
formation.
Incorrect- This is not the correct mechanism of action for Vitamin D
Vitamin D supplements should not be taken by someone of your age.
Incorrect Vitamin D supplements should be taken for patients who are homebound, institutionalized, or by
some other limitations, unable to meet daily requirements. This soman works the night shift, which may limit
her ability to absorb Vitamin D naturally.
A nurse is caring for a patient with a cast on the right leg. Which of these assessment findings would most
concern the nurse?
Top of Form
The capillary refill time is 2 seconds
The patient complains of itching and discomfort
The cast has a foul-smelling odor
The patient is on antibiotics
Submit

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The capillary refill time is 2 seconds
Incorrect A capillary refill time of 2 seconds is within normal limits. Capillary refill is the least reliable method
of assessing neurovascular integrity.
The patient complains of itching and discomfort
Incorrect This is a common effect of a cast
The cast has a foul-smelling odor
Correct A foul-smelling odor is a sign of infection or a pressure ulcer within the cast. Other symptoms include a
feeling of warmth, tightness and pain.
The patient is on antibiotics
Incorrect This is not an assessment finding and is not relevant to this situation.
A nurse is orally administering alendronate (Fosamax), a bisphosphonate drug. The patient is largely bed-bound
and being treated for osteoporosis. What nursing consideration is most important with administration of this
drug?
Top of Form
Sit the head of the bed up for 30 minutes after administration
Give the patient a small amount of water to drink.
Feed the patient soon, at most 10 minutes after administration
Assess the patient for back pain or abdominal pain
Submit

Bottom of Form
Sit the head of the bed up for 30 minutes after administration
Correct Bisphosphonates are associated with esophageal irritation that can lead to esophagitis. Sitting upright
decreases the time the medication spends in the esophagus.
Give the patient a small amount of water to drink.
Incorrect Another important intervention with the administration of bisphosphonates is to give the medication
with at least 6-8 ounces of plain water.
Feed the patient soon, at most 10 minutes after administration
Incorrect Food and any drink other than plain water should be held 30 minutes after administration so the
medication can be absorbed properly
Assess the patient for back pain or abdominal pain
Incorrect Although these are possible side effects of this medication, they are not the priority nursing
consideration.
A nurse is asked by a patient to describe in laymans terms an overview of the condition called osteomyelitis.
What would be the nurses best response?
Top of Form
Osteomyelitis is a gradual breakdown and weakening of your bones. Its most often age-related.
Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softer
and de-mineralized.
Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or
inside your body.
This is a question that should be directed to your Healthcare Provider.
Submit

Bottom of Form
Osteomyelitis is a gradual breakdown and weakening of your bones. Its most often age-related.
Incorrect This sentence describes osteoporosis
Osteomyelitis is caused by not having enough Vitamin D, which in turn causes a your bones to be softer and de-
mineralized.
Incorrect This sentence describes osteomalacia
Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or
inside your body.
Correct This appropriately explains osteomyelitis
This is a question that should be directed to your Healthcare Provider.
Incorrect A nurse is qualified to educate the patient on this subject matter
The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm
in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority
intervention?
Top of Form
Place the patient under contact precautions
Use strict aseptic technique when caring for the wound
Place another dressing to reinforce the first one
Elevate the patients leg to prevent more drainage
Submit

Bottom of Form
Place the patient under contact precautions
Correct A patient with an infectious wound, especially one not adequately contained by a dressing, should be
put under contact precautions.
Use strict aseptic technique when caring for the wound
Incorrect Although this is dependent on each facilitys policy, it is no longer a common practice to use aseptic
technique on a dirty wound. Clean technique is more often used.
Place another dressing to reinforce the first one
Incorrect This is a questionable intervention, and will not promote the safety of this patient and other
patients.
Elevate the patients leg to prevent more drainage
Incorrect Patients with heel ulcers should have their heels elevated to prevent pressure, not the whole leg
elevated to prevent drainage.

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A nurse in the emergency room receives a patient who had his left elbow fractured in a fight. He had waited 5
hours before coming to the emergency room. His left hand has an unequal radial pulse, is swollen, and is numb
and tingling. What is the nurses priority intervention?
Top of Form
Place the patient in a supine position
Ask the patient to rate his pain on a scale of 1 to 10.
Wrap the fractured area with a snug dressing
Start an IV in the other arm.
Submit

Bottom of Form
Place the patient in a supine position
Incorrect While this may be a beneficial intervention if the arm is also elevated to prevent swelling, this is not a
priority intervention.
Ask the patient to rate his pain on a scale of 1 to 10.
Incorrect While assessing pain is a part of the 6 Ps of neurovascular assessment, the question asks for an
intervention based on already alarming assessment findings.
Wrap the fractured area with a snug dressing
Incorrect The assessment findings indicate the patient may have Acute Compartment Syndrome. Causing more
external pressure with a dressing will only exacerbate the condition.
Start an IV in the other arm.
Correct Starting an IV is a nursing priority prior to emergency surgery. The patient may be in the late stages of
Acute Compartment Syndrome and may need a fasciotomy, in which the surgeon relieves pressure by making an
incision into the affected area.
A nurse is caring for a female patient 24 hours after a hip fracture. The patient is on bedrest. The nurse knows
that which regular assessment or intervention is essential for detecting or preventing the complication of Fat
Embolism Syndrome?
Top of Form
Performing passive, light, range of motion exercises on the hip as tolerated.
Assess the patients mental status for drowsiness or sleepiness.
Assess the pedal pulse and capillary refill in the toes.
Administer a stool softener as ordered
Submit

Bottom of Form
Performing passive, light, range of motion exercises on the hip as tolerated.
Incorrect Immobilization and prevention of motion is the best way to reduce risk for fat embolism.
Assess the patients mental status for drowsiness or sleepiness.
Correct A decreased Level of Consciousness is the earliest sign of FES, caused by decreased oxygen level.
Assess the pedal pulse and capillary refill in the toes.
Incorrect While assessing pedal pulse is important during a neurovascular assessment, it is not relevant to FES.
Capillary refill is the least reliable indicator of poor perfusion
Administer a stool softener as ordered
Incorrect While this is an important intervention for patients on bedrest, it is not an intervention relevant to
FES
What is the overarching nursing concern when caring for patients being treated with splints, casts, or traction?
Top of Form
To assess for and prevent neurovascular complications or dysfunction
To ensure adequate nutrition during the healing process
To provide patient education for maintenance of splints, casts, or traction in the community.
To treat acute pain
Submit

Bottom of Form
To assess for and prevent neurovascular complications or dysfunction
Correct This is the priority nursing diagnosis for patients with extremity fractures.
To ensure adequate nutrition during the healing process
Incorrect While this is a nursing concern, it is not the first priority
To provide patient education for maintenance of splints, casts, or traction in the community.
Incorrect While this is a nursing concern, it is not the first priority
To treat acute pain
Incorrect While this is a serious nursing concern, it is not the first priority.
What nursing intervention demonstrates the nurse understands the priority nursing diagnosis when caring for
patients being treated with splints, casts, or traction?
Top of Form
The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.
The nurse orders meals with adequate protein and calcium for the patient.
The nurse teaches the patient never to insert objects under a cast to scratch an itch.
The nurse administers oral painkillers as ordered
Submit

Bottom of Form
The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.
Correct The priority nursing diagnosis would be Risk for Peripheral Neurovascular Dysfunction related to
fractures, which is demonstrated by this intervention.
The nurse orders meals with adequate protein and calcium for the patient.
Incorrect This intervention relates to the diagnosis Imbalanced Nutrition: Less than Body Requirements. It is
not the priority diagnosis.
The nurse teaches the patient never to insert objects under a cast to scratch an itch.
Incorrect This intervention relates to the diagnosis Insufficient Knowledge related to Traumatic Injury. It is not
the priority diagnosis
The nurse administers oral painkillers as ordered
Incorrect This intervention relates to the diagnosis Acute Pain related to Traumatic Injury. It is not the priority
diagnosis.
A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be
reported to the healthcare provider immediately?
Top of Form
Abdominal distention
A bruit near the epigastric area
3 episodes of vomiting in the last hour
Blood pressure of 160/90
Submit

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Abdominal distention
Incorrect While this is a relevant assessment finding, it is not the priority assessment.
A bruit near the epigastric area
Correct A bruit in the aortic area signals the presence of an aneurysm. This is life-threatening and must be
reported immediately.
3 episodes of vomiting in the last hour
Incorrect While this is a relevant assessment finding, it is not the priority assessment.
Blood pressure of 160/90
Incorrect While this may be a relevant assessment finding, it is not the priority assessment.
The nurse in the day surgery center understands that which nursing consideration is a priority immediately after
an endoscopic procedure?
Top of Form
Raise the siderails of the patient bed
Do not offer fluids, food or any oral intake
Check the temperature of the patient
Teach the patient to avoid aspirin or NSAIDS
Submit

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Raise the siderails of the patient bed
Incorrect This is a general intervention that applies to all post-procedure care, and not the biggest priority.
Do not offer fluids, food or any oral intake
Correct Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia is
given to inactivate the gag reflex, making the patient vulnerable to aspiration
Check the temperature of the patient
Incorrect While it is important to monitor the temperature for signs of infection or sepsis, these problems do
not occur until hours or days later.
Teach the patient to avoid aspirin or NSAIDS
Incorrect This is part of the preparation for an endoscopic procedure, not post-procedural care.
A nurse is preparing to palpate and percuss a patients abdomen as part of the assessment process. Which of
these findings would cause the nurse to immediately discontinue this part of the assessment?
Top of Form
The patient states That sounds like it might hurt me.
There is a pulsating mass on the upper middle abdomen.
The patient has black, tarry stools and anemia
The patient has had an endoscopic procedure two days prior
Submit

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The patient states That sounds like it might hurt me.
Incorrect While the nurse should address this concern with the patient, this does not necessarily mean the
assessment should be stopped.
There is a pulsating mass on the upper middle abdomen.
Correct This is an indication of a life-threatening aortic aneurysm. Palpating or percussing is dangerous to the
patients life.
The patient has black, tarry stools and anemia
Incorrect These are common symptoms of GI bleed, and dont contraindicate percussion and palpation.
The patient has had an endoscopic procedure two days prior
Incorrect An endoscopic procedure two days prior does not contraindicate percussion and palpation.
A nurse understands that which of these patients are at risk for developing Oral Candidiasis, a type of
stomatitis?
Top of Form
A 77-year old woman in a long-term care facility taking an antibiotic
A 35-year old man who has had HIV for 6 years
A 40-year old man who is undergoing chemotherapy
An 80-year old woman with dentures
Submit

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A 77-year old woman in a long-term care facility taking an antibiotic
Correct This patient has the most risk factors for developing Candidiasis. Candidiasis is caused most commonly
by long-term antibiotic therapy, immunosupressive therapy (chemotherapy, radiation, or corticosteroids), older
age, living in a long-term care facility, diabetes, having dentures, and poor oral hygiene.
A 35-year old man who has had HIV for 6 years
Incorrect Another patient has the most/more relevant risk factors for developing Candidiasis.
A 40-year old man who is undergoing chemotherapy
Incorrect Another patient has the most/more relevant risk factors for developing Candidiasis.
An 80-year old woman with dentures
Incorrect Another patient has the most/more relevant risk factors for developing Candidiasis.
What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring
for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?
Top of Form
The nurse uses a pen pad to communicate with the patient
The nurse provides oral care every 2 hours
The nurse listens for bowel sounds every 4 hours.
The nurse suctions as needed and elevates the head of the bed
Submit

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The nurse uses a pen pad to communicate with the patient
Incorrect This intervention is in response to impaired verbal communication, which is not the priority nursing
diagnosis.
The nurse provides oral care every 2 hours
Incorrect This intervention is in response to impaired oral mucous membrane, which is not the priority nursing
diagnosis.
The nurse listens for bowel sounds every 4 hours.
Incorrect This assessment is not relevant to the patients condition
The nurse suctions as needed and elevates the head of the bed
Correct This intervention is in response to Ineffective Airway Clearance, which is the priority nursing diagnosis.
A patient has been taking a mood stabilizing medication, but is afraid of needles. They ask the nurse what
medication would NOT require regular lab testing. What is the nurses best response?
Top of Form
Valproic Acid (Depakote)
Clonazapine (Clozaril)
Lithium
Risperidone (Risperdal)
Submit

Bottom of Form
Valproic Acid (Depakote)
Incorrect
Clonazapine (Clozaril)
Incorrect
Lithium
Incorrect
Risperidone (Risperdal)
Correct Risperidone is the only drug that does not require blood draws.

A patient is deciding whether they should take the live influenza vaccine (nasal spray), or the inactivated
influenza vaccine (shot). The nurse reviews the clients history. Which condition would NOT contraindicate the
nasal (live vaccine) route of administration?
Top of Form
The patient takes long-term corticosteroids
The patient is not feeling well today
The patient is 55 years old
The patient has young children
Submit

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The patient takes long-term corticosteroids
Incorrect Long-term corticosteroids can weaken the immune system. Live influenza vaccines should only be
given to patients with healthy immune systems.
The patient is not feeling well today
Incorrect This is a contraindication for getting either types of vaccines. While they should get their vaccine
later, now would not be the best time to administer the vaccine.
The patient is 55 years old
Incorrect This is a contraindication for getting the live vaccine, which should be given to patients between the
ages of 2-49 only.
The patient has young children
Correct This is not a contraindication. It would only be a contraindication for the live vaccine if the young
children were immunocompromised, but this is not stated.
A patient asks the nurse whether he is a good candidate to use a CPAP machine. The nurse reviews the clients
history. Which condition would contraindicate the use of a CPAP machine?
Top of Form
The patient is in the late-stage of dementia.
The patient has a history of bronchitis
The patient has had suicidal gestures/attempts in the past
The patient is on beta-blockers
Submit

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The patient is in the late-stage of dementia.
Correct Having an inability to follow commands and understand instructions independently is a
contraindication for a CPAP machine, which can only function correctly with proper installation and use.
The patient has a history of bronchitis
Incorrect This is not a contraindication for using a CPAP machine
The patient has had suicidal gestures/attempts in the past
Incorrect This is not a contraindication for using a CPAP machine
The patient is on beta-blockers
Incorrect This is not a contraindication for using a CPAP machine
The nurse is caring for a patient who has recently had a successful catheter ablation. Which assessment finding
demonstrates a successful outcome of this procedure?
Top of Form
The patient is free of electrolyte imbalances
The patients WBC count is within normal limits
The patients EKG reading is regular
The patients urine output is 45mL/hour
Submit

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The patient is free of electrolyte imbalances
Incorrect This does not demonstrate the purpose a catheter ablation
The patients WBC count is within normal limits
Incorrect This does not demonstrate the purpose a catheter ablation
The patients EKG reading is regular
Correct A catheter ablation is a procedure used to treat arrhythmias, especially SVT. A catheter is inserted
through the femoral vein or artery, and threaded to the conduction fiber in the heart causing the arrhythmia. A
radiofrequency energy uses heat to destroy this fiber, preventing further arrhythmia.
The patients urine output is 45mL/hour
Incorrect This does not demonstrate the purpose a catheter ablation
Application The nurse is caring for a patient who has the following labs: Creatinine 2.5mg/dL, WBC 11,000
cells/mL, and Hemoglobin of 12 g/dL. Based on this information, which of these orders would the nurse
question?
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Administer 30 Units of Lantus Daily
CT of the spine with contrast
X-ray of the abdomen and chest
Administer heparin subcutaneous 5,000 Units every 12 hours
Submit

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Administer 30 Units of Lantus Daily
Incorrect None of the above labs contraindicate this order
CT of the spine with contrast
Correct The creatinine level of this patient indicates impaired kidney function. Contrast is nephrotoxic and is
contraindicated for patients with nephropathy.
X-ray of the abdomen and chest
Incorrect None of the above labs contraindicate this order
Administer heparin subcutaneous 5,000 Units every 12 hours
Incorrect None of the above labs contraindicate this order
Application A nurse is caring for a patient admitted in the emergency room for an ischemic stroke with marked
functional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogen
activator). Which history-gathering question would not be important for the nurse to ask?
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What time was the first time you noticed symptoms appearing consistently?
Have you been taking any blood thinners like heparin, lovenox, or warfarin?
Have you had another stroke or head trauma in the previous 3 months?
Have you had any blood transfusions within the previous year?
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What time was the first time you noticed symptoms appearing consistently?
Incorrect This is a relevant question because TPA is usually used no more than 5-6 hours after onset. This is the
timeframe that damage to tissue is still reversible.
Have you been taking any blood thinners like heparin, lovenox, or warfarin?
Incorrect This is a relevant question because current anticoagulant use, or an INR of greater than 1.7, is a
contraindication to TPA use.
Have you had another stroke or head trauma in the previous 3 months?
Incorrect This is a relevant question because having a stroke or head trauma in the last 3 months
contraindicates TPA use
Have you had any blood transfusions within the previous year?
Correct This is not a relevant question and would not affect the decision to use TPA
A patient is being discharged from the med-surgical unit. The patient has a history of gastritis. The nurse
questions the patient on his usual routine at home. Which of these statements would alert the nurse that
additional teaching is required?
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I avoid NSAIDS. I only take a daily aspirin for my heart health.
I always avoid eating hot and spicy foods
I will continue taking my antacids with or immediately after meals
I will only drink coffee once a week, if even that often.
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I avoid NSAIDS. I only take a daily aspirin for my heart health.
Correct Aspirin is classified as an NSAID and can exacerbate already existing stomach problems. Aspirin should
be avoided just like any NSAID for patients with gastritis.
I always avoid eating hot and spicy foods
Incorrect This is a good practice for patients with gastritis
I will continue taking my antacids with or immediately after meals
Incorrect This is a good practice for patients with gastritis
I will only drink coffee once a week, if even that often.
Incorrect This is a good practice for patients with gastritis. Coffee is not recommended for patients with
gastritis.
A nurse is meeting a patient in their home. The patient has been taking Naproxen for back pain. Which
statement made by the patient most indicates that the nurse needs to contact the physician?
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I get an upset stomach if I dont take Naproxen with my meals.
My back pain right now is about a 3/10.
I get occasional headaches since taking Naproxen
I have ringing in my ears.
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I get an upset stomach if I dont take Naproxen with my meals.
Incorrect This is a common and less severe side effect of Naproxen
My back pain right now is about a 3/10.
Incorrect Although a 3/10 is bordering on the acceptable amount of pain, this would not be the most pressing
issue at hand.
I get occasional headaches since taking Naproxen
Incorrect This is a common and less severe side effect of Naproxen
I have ringing in my ears.
Correct This is a severe adverse effect of Naproxen and should be reported immediately since it may indicate
toxicity.
The nurse is doing an intake screening for a patient with hypertension. They have been taking ramapril for 4
weeks. Which statement made by the patient would be most important for the nurse to pass on to the
physician?
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I get dizzy when I get out of bed.
Im urinating much more than I used to.
Ive been running on the treadmill 10 minutes each day.
I cant get rid of this cough.
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I get dizzy when I get out of bed.
Incorrect This may require some medication teaching but is not the priority assessment finding.
Im urinating much more than I used to.
Incorrect ACE Inhibitors like ramapril work, in part, by increasing urine flow. This is a necessary side effect of
the medication and is not a priority.
Ive been running on the treadmill 10 minutes each day.
Incorrect ACE Inhibitors like ramapril work, in part, by increasing urine flow. This is a necessary side effect of
the medication and is not a priority.
I cant get rid of this cough.
Correct A common adverse effect of ACE inhibitors is a persistent, dry cough. A medication change to another
class of antihypertensives, like an ARB, may be needed
The nurse in the emergency room sees a patient who has been abusing alprazolam (Xanax). The patient reports
that he suddenly stopped taking Xanax about 24 hours ago. He presents with a visible tremor, is pacing,
expresses fear, and has impaired concentration and memory. Which of these intervention takes priority?
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Have the patient lie down on a stretcher with bedrails up
Give the patient a cup of water to drink and a small amount of food
Assure the patient that he will be okay
Alert the physician that the patient needs Xanax
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Have the patient lie down on a stretcher with bedrails up
Correct The 1-4 day period after Xanax withdrawal is the most dangerous. Xanax is a benzodiazepine and
withdrawal symptoms include life-threatening seizures. Having the patient lie down with bedrails up is part of
seizure precautions and is the first priority
Give the patient a cup of water to drink and a small amount of food
Incorrect This is not a priority intervention
Assure the patient that he will be okay
Incorrect This is not a priority intervention
Alert the physician that the patient needs Xanax
Incorrect This is not a priority intervention
A nurse cares for a child that is diagnosed with Hepatitis A. Which of these following precautions would be most
important to take to prevent transmission of this infectious disease?
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Encourage the Hepatitis A vaccine for family members and siblings
Use needleless systems if possible, otherwise use careful needle precautionary measures
Teach the child and enforce strict and frequent hand washing
Teach the child and family the dangers of contaminated food and water
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Encourage the Hepatitis A vaccine for family members and siblings
Incorrect Although this is a valuable point for patient education, this does not take the priority, since the
patient is still at risk of transmitting Hepatitis A to others right now.
Use needleless systems if possible, otherwise use careful needle precautionary measures
Incorrect Hepatitis A is transmitted through the fecal-oral route.
Teach the child and enforce strict and frequent hand washing
Correct Hand washing is the single most effective way to prevent transmission of Hepatitis A. Hepatitis A is a
virus transmitted via the oral-fecal route and lives on human hands.
Teach the child and family the dangers of contaminated food and water
Incorrect Although this is a valuable teaching point, it is not the priority intervention.

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A nurse is treating a patient suspected to have Hepatitis. The nurse notes on assessment that the patients eyes
are yellow-tinged. Which of these diagnostic results would further assist in confirming this diagnosis?
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Decreased serum Bilirubin
Elevated serum ALT levels
Low RBC and Hemoglobin with increased WBCs
Increased Blood Urea Nitrogen level
Submit

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Decreased serum Bilirubin
Incorrect Bilirubin levels correlate with the appearance of Jaundice. An increased serum bilirubin would be the
expected finding for this patient.
Elevated serum ALT levels
Correct ALT is a liver enzyme, and hepatitis is a liver disease. Elevated liver enzymes will often signal liver
damage.
Low RBC and Hemoglobin with increased WBCs
Incorrect This is not a common finding for Hepatitis patients
Increased Blood Urea Nitrogen level
Incorrect BUN is an indicator of renal (kidney) health, not hepatic (liver) function.
Which of these patients would the nurse suspect as having the greatest risk of contracting Hepatitis B?
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A sexually active 45-year old man who has Type 1 Diabetes
A 75-year old woman who lives in a crowded nursing home
A child who lives in a country with poor sanitation and hygiene standards
A sexually active 23-year old man who works in a hospital
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A sexually active 45-year old man who has Type 1 Diabetes
Incorrect This person is sexually active, but it is not specified with how many partners. Having Type 1 Diabetes
is not a risk factor for Hepatitis.
A 75-year old woman who lives in a crowded nursing home
Incorrect Age is not a risk factor for Hepatitis B, and close living accommodations is a stronger risk factor for
Hepatitis A and E, which are oral-fecal transmissions.
A child who lives in a country with poor sanitation and hygiene standards
Incorrect This is a relevant risk factor for Hepatitis A and E
A sexually active 23-year old man who works in a hospital
Correct This person is both sexually active and works in a healthcare environment.
The nurse calculates the IV flow rate of a patient receiving lactated ringers solution. The patient is to receive
2000mL of Lactated Ringers over 36 hours. The IV infusion set has a drop factor of 15 drops per milliliter. The
nurse should set the IV to deliver how many drops per minute?
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8
10
14
18
Submit

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8
Incorrect
10
Incorrect
14
Correct Drops Per Minute = Milliliters x Drop Factor / Time in Minutes
18
Incorrect
The nurse calculates the IV flow rate of a patient receiving an antibiotic. The patient is to receive 100mL of the
antibiotic over 30 minutes. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should set
the IV to deliver how many drops per minute?
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11
19
26
33
Submit

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11
Incorrect
19
Incorrect
26
Incorrect
33
Correct Drops Per Minute = Milliliters x Drop Factor / Time in Minutes
Which of the following statements made by a client during an individual therapy session would the nurse most
identify as reflecting schizoaffective disorder?
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I just want to stab myself with this pen.
Whats the point in life anyways?
My thoughts are racing because of the conspiracies against me.
I hear voices every day and sometimes see old friends that dont exist.
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I just want to stab myself with this pen.
Incorrect This is a suicidal ideation, but not a classic symptom of schizoaffective disorder
Whats the point in life anyways?
Incorrect This is a verbalization of hopelessness, which can manifest in depression, bipolar disorder, or
schizoaffective disorder.
My thoughts are racing because of the conspiracies against me.
Correct Schizoaffective disorder is characterized by the mania and depression of bipolar disorder with the
delusions/disturbed thought process of schizophrenia. Racing thought are a classic symptom of a manic episode,
while conspiracies indicate paranoia.
I hear voices every day and sometimes see old friends that dont exist.
Incorrect While visual and auditory hallucinations can manifest in schizoaffective disorder, there is no
indication of bipolar symptoms (mania or depression)
How Ready Are You To Take Your NCLEX?
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I think Im ready right now. Thank you and goodbye!
Im feeling pretty good. Ill do some more practice NCLEX questions, but dont want to kill myself
studying.
I want to study more. I need to learn more content, get really good with NCLEX Strategies, and boost my
confidence.
I give up. I think Ill just dress as a nurse on Halloween once in a while and leave it at that.
Submit

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I think Im ready right now. Thank you and goodbye!
Good on you! Good Luck!
Im feeling pretty good. Ill do some more practice NCLEX questions, but dont want to kill myself studying.
NCLEX Practice questionswait, we have those!
I want to study more. I need to learn more content, get really good with NCLEX Strategies, and boost my
confidence.
Youve come to the right place. Click the button NOW!
I give up. I think Ill just dress as a nurse on Halloween once in a while and leave it at that!
Incorrect This is not an appropriate intervention. Let us help you!