1. A
child who ingested 15 maximum strength acetaminophen tablets 45 minutes
ago is seen in the emergency department. Which of these orders should
the nurse do first?
A) Gastric lavage PRN
B) Acetylcysteine (mucomyst) for age per pharmacy
C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open
D) Activated charcoal per pharmacy
The correct answer is A: Gastric lavage PRN
Removing
as much of the drug as possible is the first step in treatment for this
drug overdose. This is best done by gastric lavage. The next drug to
give would be activated charcoal, then mucomyst and lastly the IV fluids
2. Which of these statements best describes the characteristic of an effective reward-feedback system?
A) Specific feedback is given as close to the event as possible
B) Staff are given feedback in equal amounts over time
C) Positive statements are to precede a negative statement
D) Performance goals should be higher than what is attainable
The correct answer is A: Specific feedback is given as close to the event as possible
Feedback
is most useful when given immediately. Positive behavior is
strengthened through immediate feedback, and it is easier to modify
problem behaviors if the standards are clearly understood.
3. A
triage nurse has these 4 clients arrive in the emergency department
within 15 minutes. Which client should the triage nurse send back to be
seen first?
A) A 2 month old infant with a history of rolling off the bed and has buldging fontanels with crying
B) A teenager who got a singed beard while camping
C) An elderly client with complaints of frequent liquid brown colored stools
D) A middle aged client with intermittent pain behind the right scapula
The correct answer is B: A teenager who got singed a singed beard while camping
This
client is in the greatest danger with a potential of respiratory
distress, Any client with singed facial hair has been exposed to heat or
fire in close range that could have caused damage to the interior of
the lung. Note that the interior lining of the lung has no nerve fibers
so the client will not be aware of swelling.
4. What would the nurse expect to see while assessing the growth of children during their school age years?
A) Decreasing amounts of body fat and muscle mass
B) Little change in body appearance from year to year
C) Progressive height increase of 4 inches each year
D) Yearly weight gain of about 5.5 pounds per year
The correct answer is D: Yearly weight gain of about 5.5 pounds per year
School age children gain about 5.5 pounds each year and increase about 2 inches in height.
5. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?
A) Client must be NPO before the examination
B) Enema to be administered prior to the examination
C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
D) No special orders are necessary for this examination
The correct answer is D: No special orders are necessary for this examination
No special preparation is necessary for this examination
6. A
nurse is to administer meperidine hydrochloride (Demerol) 100 mg,
atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride
(Phenergan) 50 mg IM to a pre-operative client. Which action should the
nurse take first?
A) Raise the side rails on the bed
B) Place the call bell within reach
C) Instruct the client to remain in bed
D) Have the client empty bladder
The correct answer is D: Have the client empty bladder
The
first step in the process is to have the client void prior to
administering the pre-operative medication. The other actions follow
this initial step in this sequence: 4 3 1 2
7. A
client is admitted to the emergency room with renal calculi and is
complaining of moderate to severe flank pain and nausea. The client’s
temperature is 100.8 degrees Fahrenheit. The priority nursing goal for
this client is
A) Maintain fluid and electrolyte balance
B) Control nausea
C) Manage pain
D) Prevent urinary tract infection
The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain
8. A
nurse prepares to care for a 4 year-old newly admitted for
rhabdomyosarcoma. The nurse should alert the staff to pay more attention
to the function of which area of the body?
A) The muscles
B) The cerebellum
C) The kidneys
D) The leg bones
The correct answer is A: All striated muscles
Rhabdomyosarcoma
is the most common children''s soft tissue sarcoma. It originates in
striated (skeletal) muscles and can be found anywhere in the body. The
clue is in the middle of the word and is “myo” which typically means
muscle.
9. A
client who is pregnant comes to the clinic for a first visit. The nurse
gathers data about her obstetric history, which includes 3 year-old
twins at home and a miscarriage 10 years ago at 12 weeks gestation. How
would the nurse accurately document this information?
A) Gravida 4 para 2
B) Gravida 2 para 1
C) Gravida 3 para 1
D) Gravida 3 para 2
The correct answer is C: Gravida 3 para 1
Gravida
is the number of pregnancies and Parity is the number of pregnancies
that reach viability (not the number of fetuses). Thus, for this woman,
she is now pregnant, had 2 prior pregnancies, and 1 viable birth
(twins).
10. A
client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care
provider has written a new order to give metoprolol (Lopressor) 25 mg.
B.I.D. In assessing the client prior to administering the medications,
which of the following should the nurse report immediately to the health
care provider?
A) Blood pressure 94/60
B) Heart rate 76
C) Urine output 50 ml/hour
D) Respiratory rate 16
The correct answer is A: Blood pressure 94/60
Both
medications decrease the heart rate. Metoprolol affects blood pressure.
Therefore, the heart rate and blood pressure must be within normal
range (HR 60-100; systolic B/P over 100) in order to safely administer
both medications.
source: NCSBN
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