Lab Exam

Question 1

NCLEX: A nurse is discussing pain with a newly licensed nurse. What information should the nurse include?

Accepted Answer

pain is whatever the pt says it is

Question 2

A pt tells a nurse in preop that they have a rxn when they wear rubber gloves. Which is the most appropriate action?

Accepted Answer

ask additional questions to assess for a possible latex allergy

Question 3

A patient with a new stoma refuses to view it or participate in care. What should you do?

Accepted Answer

obtain a referral foor WOCN

Question 4

NCLEX: A nurse is planning care for a pt with PICC line. Which interventions should the nurse include

Accepted Answer

use a 10 ml syringe to flush the PICC line, maintain a transparent dressing over the insertion site

Question 5

An older pt is receiving IV NS. The nurse detects new crackles in the lung bases. What is the priority action?

Accepted Answer

decrease the IV flow rate

Question 6

NCLEX: A nurse is caring for a pt who is receiving a blood transfusion. Which actions should she take if there is a rxn?

Accepted Answer

maintain an IV infusion of NS, administer diphenhydramine, stop the transfusion

Question 7

You have an order to insert an NG tube in pt. but find they're confused and unable to follow commands. What do you do?

Accepted Answer

get help from another nurse

Question 8

A newly admitted patient's stoma appears necrotic, what action(s) should you take?

Accepted Answer

notify the HCP, document its appearance

Question 9

NCLEX: Which statement by a pt regarding PCA indicates they understand how to use the device?

Accepted Answer

"I should tell the nurse if the pain doesn't stop after I use this device."

Question 10

A nurse is caring for a client who reports N/V 2 days postop after a hysterectomy. Which action comes first?

Accepted Answer

Assess bowel sounds

Question 11

Which nursing intervention will aid a preop pt in coping with fear of postop pain?

Accepted Answer

explain the pain management plan, including use of a pain scale

Question 12

NCLEX: A nurse is caring for a client who develops MH. Which actions should the nurse take?

Accepted Answer

Infuse iced IV fluids, Provide 100% oxygen, Administer IV dantrolene, Place a cooling blanket on the client

Question 13

NCLEX: A nurse is preparing to administer oxygen continuously to a pt. Which device will deliver a precise amount?

Accepted Answer

venturi mask

Question 14

Which part of the body should be closely examined and assessed BID when a pt has an NG tube?

Accepted Answer

nares

Question 15

NCLEX: What is a nurse's priority action when she notices a pt's chest tube has fallen out?

Accepted Answer

apply sterile gauze to the insertion site

Question 16

Proper attire for the semirestricted area of the surgery dept. is...

Accepted Answer

scrub attire, head cover, shoe covers

Question 17

A cancer pt who reports ongoing, constant moderate pain with short periods of severe pain during dressing changes is...

Accepted Answer

best treated by regularly scheduled short-acting opioids plus acetaminophen

Question 18

NCLEX: A nurse is prepping a client for an exploratory laparotomy. The client's temp was 102. What should the nurse do?

Accepted Answer

Inform the surgeon oof the elevated temperature

Question 19

Which nurse would you expect to administer care for someone with an ostomy?

Accepted Answer

WOCN

Question 20

After admitting a postop pt to the clinical unit, which assessment data require the most immediate attention?

Accepted Answer

O2 sat of 85%

Question 21

Pain is best described as:

Accepted Answer

an unpleasant, subjective experience

Question 22

An example of distraction to provide pain relief is.....

Accepted Answer

music

Question 23

The nurse assesses pain and redness at a CVAD site. Which action is taken first?

Accepted Answer

discontinue the IV infusion

Question 24

The nurse is performing tracheostomy care on a pt. What finding would indicate that the tube has become dislodged?

Accepted Answer

patient speaking to the nurse

Question 25

The nurse's primary responsibility for the care of the patient undergoing surgery is...

Accepted Answer

developing and individualized plan of nursing care for the pt

Question 26

The nurse has a pt with a chest tube for tx of a pneumothorax. Which assessment finding needs the HCP's attention?

Accepted Answer

new, vigorous bubbling in the water seal chamber

Question 27

NCLEX: Which is a correct action made by a new nurse preparing to administer a blood transfusion?

Accepted Answer

obtains VS every 15 minutes throughout procedure

Question 28

Which actions is appropriate to take if a pt c/o nausea or abdomen is distended and painful?

Accepted Answer

notify HCP, verify suction is on as ordered, irrigate the tube

Question 29

What are the priority interventions the nurse performs when admitting a pt to the PACU?

Accepted Answer

assess for airway patency and quality of respirations and obtain VS

Question 30

A preop nurse is prepping a client for a colon resection. Which action should the nurse take?

Accepted Answer

remove nail polish on fingers and toes

Lab Exam

Questions 30

Lab Exam

Questions 30