What is the mneumonic for Anticholinergic toxidromes?

red as a beet, hot as a hare, dry as a bone, mad as a hatter, blind as a bat

RPN directs the student to administer all meds to 22 residents while the RPN does their paperwork. Is this appropriate?

No, this is professional misconduct

pts has pain in RLQ of their abdomen. Which of the following techniques is appropriate for the nurse to take?

Complete an abdominal assessment and examine the tender area last

when assesseing pt nutrional status Optimal nutritional status involves consuming of

sufficient nutrients, to meet physical metabolic needs

What is the best course of action?

Wait to give the medication until it can be checked.

To avoid mistakes, what is the nurse's first step in carrying out the verbal order?

Recognize is not an emergency and request the dr provide a written order

Report immediately to the Charge Nurse

What are classic signs of AAA

unexplained groin back, Sharp back pain, pulsating mass, hypotension(tear or rupture

During convo, the client tells the nurse that they feel they would be better off dead What is the nurse's 1St response?

Ask the client if they have a plan to commit suicide

pt refuses medications. he believed in the power of prayers. refused his medication said he will pray instead.

Explain the need for the medication then document

Pt. refused meds and said he wants to pray what should the nurse do?

Explain the need for the medication then document

Describe Phase 4—Return to Resting State?

its when Heart is polarized during this phaseReady for discharge

I will flush the tube with water before and after giving the medication.

What is the nurse's priority intervention?

Notify the physician of the result

While caring for the client who is experiencing acute alcohol withdrawal. what actions should the nurse take?

Ensure suction equipment is at the bedside, Orient the client to environment and person with each contact, Monitor neurological status on a routine basis

When assessing pupillary light reflex, which of the following techniques should the nurse use

Shine a light across the pupil side, and observe for direct/ consensual

A diabetic patient is suddenly feeling sweaty, anxious and jittery. The most likely explanation is:

low blood sugar, too much food without enough insulin

releasing stored glucose(glycogen)

An elderly pt says to the nurse tells the nurse “I have nothing to live for.” How should the nurse respond?

I see your are having a rough day lets talk about it.

Can the RPN apply transparent dressings to these bruises without a physician's order?

yes, this is within the nurse's scope of practice

just had a baby girl and they were concerned when they saw vaginal discharge on diaper. What should the nurse tell them?

This is normal due to maternal hormones

The nurse caring for an older adult understands which of the following most impacts the client's self-concept?

Adjustment to role change, loss of loved ones, and physical energy

The prescribing provider has written an order which is unclear What should the nurse do!

Call the prescribing provider to check the order

is the SLUDGE mneumonic for Cholinergic Toxidromes this ?

diarrhea, Salivation, emesis, urination, lacrimation, gastrointestinal distress

The nurse applies the following principles of safe medication administration to decrease medication errors

Ask pt their DOB and check wristband before administering medications, Prepare client medication in a quiet, distraction free area.

A nurse shares with you that they are being bullied by the nurse manager How should you respond

Encourage your colleague to talk to the union representative

Which of the following is the priority assessment for the nurse? SEE PICTURE

Check that the oxygen is connected and set at the correct flow rate

The nurse ensures the indwelling catheter drainage bag is lower than the bladder to Prevent

possible infection due to urine flowing back into the bladder

Why is it that elderly patients often do not get the typical warning signs that their blood sugar is getting low?

Autonomic system not as responsive with age

What is the nurse's best course of action?

Write safety report and follow up with the manager at the end of the shift

Which of the following responses from the client would indicate the correct understanding of the teaching?

"I will place a pillow under my knees when I am lying on my back"

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Consoliation Questions practice

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Questions 200

Answers

1
What is the mneumonic for Anticholinergic toxidromes?
red as a beet
hot as a hare
dry as a bone
mad as a hatter
Cold as ice
blind as a bat
2
3 months pregnant nurse caring for HIV +ve pt what should she do?
Wear an N95 mask at all times
Work as normal
Request reassignment to avoid exposure
Avoid any patient contact to protect the fetus
3
What is the priority action for the nurse?
Immediately withdraw catheter
slowly count to 10 and remove catheter
the catheter push in further to help pt.
dont do anything until MRP comes to remove catheter
4
RPN directs the student to administer all meds to 22 residents while the RPN does their paperwork. Is this appropriate?
Yes, as long as the student feels comfortable
No, this is professional misconduct
Yes, if the RPN supervises from a distance.
No, only because the student is too slow
5
Which of the following is this an example of?
Proper Delegation
Time Management
Therapeutic Communication
Professional Misconduct
6
Which of the following pts will likely require a smaller than average dose of an oploid analgesic?
A young adult with no history of opioid use
A client recovering from minor dental surgery.
A client who is 86 years old
A middle-aged athlete with chronic back pain
7
Pt. prescribed 2 pain meds, which one should the nurse administer when pt complains of pain?
Ask pt which one works best
Hold both medications and ask the doctor for a different one
Give both medications together for faster relief
Give the stronger medication every time they report pain
8
Which finding is expected in a child with epiglottitis?
Productive cough
Nasal congestion
Drooling
Barking cough
9
What is the best way the nurse can ensure that the pts have a clear understanding of the concept-breast self examination
Return Demo
Have them describe the steps back to you
Give them a brochure to read at home.
Ask if they have any questions
10
pts has pain in RLQ of their abdomen. Which of the following techniques is appropriate for the nurse to take?
Perform deep palpation over the painful area first
Have the patient stand and bend forward to locate the pain
Ignore the painful area and assess only the other quadrants.
Complete an abdominal assessment and examine the tender area last
11
when assesseing pt nutrional status Optimal nutritional status involves consuming of
Only carbohydrates for energy
sufficient nutrients, to meet physical metabolic needs
Minimal food intake to avoid weight gain
Exclusively protein-rich foods.
12
What is the best course of action?
Ask a UCP to double check and proceed
give the medication get it signed afterwards
Wait to give the medication until it can be checked.
wait to give all meds but laxatives are okay to give wihtout double check
13
Which of the following clients is at most risk for elder abuse?
One with dementia
One with estranged kids
one pt who lives independently and drives themselves to appointments.
A client who receives weekly visits from multiple family members.
14
Which of the following foods would be an appropriate option for the client with dysphagia?
cheese and crackers
mashed fruits or veggies
toasted bagel with peanut butter
scrambled eggs
15
To avoid mistakes, what is the nurse's first step in carrying out the verbal order?
Document the order without verifying.
Recognize is not an emergency and request the dr provide a written order
Delay insulin administration for written confirmation only.
Administer insulin without clarification.
16
Which of the following methods is most appropriate to assist an older adult with bladder training
Prompted voiding
Avoid scheduled toileting and wait until the patient asks to go
Encourage the patient to hold urine as long as possible.
Restrict all fluid intake to prevent accidents
17
What are the signs a nurse should look for to detect infiltration?
High fever and chills
Bruising and hard hematoma at the IV site
Swelling/pain/coolness
Warmth and redness at the IV site
18
See photo
Report immediately to the Charge Nurse
Document the incident report directly in the client’s chart.
Blame the previous shift and document that they made the error.
Ignore discrepancy and give the medication because the client is in pain
19
What are classic signs of AAA
unexplained groin back
Sharp back pain
pulsating mass
hypotension(tear or rupture
Sharp chest pain and radiating arm pain
Abdominal cramping and nausea after eating
20
During convo, the client tells the nurse that they feel they would be better off dead What is the nurse's 1St response?
Ask the client if they have a plan to commit suicide
I'm sure things will get better soon. Try to stay positive
Do you want me to call someone to come visit you and cheer you up?
You shouldn't feel that way. Think about all the positive in your life
21
pt refuses medications. he believed in the power of prayers. refused his medication said he will pray instead.
the need for the medication isnt iportant so document
Encourage pt to take medication and explain its a better way.
Explain the need for the medication then document
Explain needs out way the religiosu views for the medication then document
22
Which of the following medications is LEAST likely to cause hypoglycemia:
insulin
metformin
glimepiride
glyburide
23
Pt. refused meds and said he wants to pray what should the nurse do?
Document the refusal and hold the medication for the rest of the day.
Call the physician immediately to report noncompliance
Explain the need for the medication then document
tl pt they must take their medication now or it will be charted as refusal.
24
See photo
If there isnt any proof then leave it until there is proof.
Report to the Authorities
Report to Management
Report to Charge Nurse
25
Describe Phase 4—Return to Resting State?
It’s when the muscle contracts again after a brief pause.
The heart fills with blood and begins depolarizing again
its when Heart is polarized during this phaseReady for discharge
It’s when the neuron releases neurotransmitters to restart the impulse.
26
See Photo
I will flush the tube with water before and after giving the medication.
I will crush all pills mix them together before putting them in the tube
I only need to flush the tube once a day if I’m giving medicine
I don’t need to flush if I’m giving liquid medicine
27
What is considered a good diet for elderly clients?
Proteins
Red Meat
3 Big meals
5 Small Meals
28
What is the nurse's priority intervention?
Notify the physician of the result
Notify the charge nurse of the result
Notify the pt of the result
Notify the family of the result
29
the RPN is caring for a client who has AIDS. What type of precautions would the nurse need?
Gloves N95
Gloves
Glvoes Gown, Mask and Shield
Gloves Mask Gown
30
While caring for the client who is experiencing acute alcohol withdrawal. what actions should the nurse take?
Ensure suction equipment is at the bedside
Administer antiseizure drugs and sedatives to relieve symptoms withdrawal
Orient the client to environment and person with each contact
Monitor neurological status on a routine basis
31
When assessing pupillary light reflex, which of the following techniques should the nurse use
Shine the light directly into both eyes simultaneously
Ask the patient to close their eyes while shining the light.
Shine a light across the pupil side, and observe for direct/ consensual
Hold the light far away from the eyes and observe general response
32
A diabetic patient is suddenly feeling sweaty, anxious and jittery. The most likely explanation is:
high blood sugar
too much insulin with not enough food
low blood sugar
too much food without enough insulin
33
Glucagon works by:
releasing stored glucose(glycogen)
releasing stored glucose (glycogen)
enhancing cell permeability to glucose
enhancing glucose absorption through the GI tract
34
What is the nurse's priority action?
Check tubing for placement.
Crush a potassium tablet and mix it with water instead.
Administer the liquid potassium undiluted
Administer the potassium first and flush the tube afterward.
35
An elderly pt says to the nurse tells the nurse “I have nothing to live for.” How should the nurse respond?
Let’s get your mind off things and focus on something positive.
You shouldn’t feel that way — you have a lot going for you.
I see your are having a rough day lets talk about it.
Don’t say that, things will get better.
36
Can the RPN apply transparent dressings to these bruises without a physician's order?
yes, this is within the nurse's scope of practice
Only if the patient requests it.
Yes, for all injuries
no, this is within the nurse's scope of practice
37
metformin Reduces glucose formation in liver and increases glucose uptake in cells
False
True
38
just had a baby girl and they were concerned when they saw vaginal discharge on diaper. What should the nurse tell them?
You’ll need to bring her in for testing right away
This means your baby has a vaginal infection
You should avoid wiping the area to prevent irritation
This is normal due to maternal hormones
39
Which dietary instruction is appropriate for a patient taking warfarin?
Avoid foods high in vitamin K
Increase intake of green leafy vegetables
Limit fluid intake
Consume high-protein foods
40
The nurse caring for an older adult understands which of the following most impacts the client's self-concept?
Color preference in clothing
Choice of favorite hobby
Amount of television watched daily.
Adjustment to role change, loss of loved ones, and physical energy
41
A non-breastfeeding mother tells the nurse that her breasts are sore. How should the nurse respond?
Pump Breasts
Massage Breasts
Apply ice to brests
Keep feeding baby as it needs the nutrients.
42
The prescribing provider has written an order which is unclear What should the nurse do!
Call the prescribing provider to check the order
Ask another nurse to interpret the order and proceed.
Ignore the order and continue with other tasks
Guess the meaning and administer the medication.
43
is the SLUDGE mneumonic for Cholinergic Toxidromes this ?
diarrhea
Salivation
emesis
urination
lacrimation
gastrointestinal distress
44
The nurse applies the following principles of safe medication administration to decrease medication errors
Rely on the electronic health record alone to verify medication accuracy
Ask pt their DOB and check wristband before administering medications
Ignore unclear orders and proceed with administration
Administer medications without verifying the patient's identity
Skip double-checking high-alert medications if busy.
Prepare client medication in a quiet, distraction free area.
45
A nurse shares with you that they are being bullied by the nurse manager How should you respond
You should quit if it’s that bad.
It’s probably your fault for misunderstanding.
Just ignore it and move on
Encourage your colleague to talk to the union representative
46
Which of the following is the priority assessment for the nurse? SEE PICTURE
Monitor urinary catheter output only.
Check the client’s pain level first.
Check that the oxygen is connected and set at the correct flow rate
Assess the nasogastric tube placement last.
47
The nurse ensures the indwelling catheter drainage bag is lower than the bladder to Prevent
to avoid having to change it daily
possible infection due to urine flowing back into the bladder
so its not showing off infront of pts family visits.
to allow flowing back into the bladder so urine gets cleaned twice.
48
Why is it that elderly patients often do not get the typical warning signs that their blood sugar is getting low?
Autonomic system not as responsive with age
Because they usually have higher blood sugar levels
Because their appetite is reduced due to age
Because their insulin dose is too high
49
What is the nurse's best course of action?
Leave the unit early
Refuse to help with tasks
Write safety report and follow up with the manager at the end of the shift
Ignore patient care delays
50
Which of the following responses from the client would indicate the correct understanding of the teaching?
"No deep breaths."
"I'll stay in bed."
"I will place a pillow under my knees when I am lying on my back"
"I will avoid walking."
51
pt has a fracture with an open reduction internal fixature (ORIF). pt is at risk for a Fat embolism
False
True
52
Which of the following symptoms would require priority monitoring?
Occasional headache
Hypotension angina, dizziness, confusion
Slightly cool extremities
Mild fatigue after activity
53
Nurse is preparing to auscultate a client's enlarged thyroid for the presence of a bruit.nurse is listening for:
Bowel sounds
Heart murmurs
Lung crackles
Soft, whooshing, blowing sound best heard with the bell of the stethoscope
54
What needle gauge is required for a subcut injection?
27-gauge needle
20-gauge needle
23-gauge needle
18-gauge needle
55
What should the nurse do to maintain trust with their clients
Share personal details about other patients
Call the pt's they have not visited yet to let them know they will be late
Withhold information about treatment options
Ignore patient concerns and questions
56
The nurse understands this to indicate:
Blood vessel dilation in response to an injured area.
Blood vessel dilation causing decreased blood flow to the injured area.
A permanent narrowing of blood vessels after injury.
Constriction of blood vessels in response to injury.
57
Tolerance to nitroglycerine-induced vasodilation can be prevented by teaching the client which of the following?
Schedule an 12 hour nitrate-free period every night
Schedule an 6 hour nitrate-free period every night
Schedule an 10 hour nitrate-free period every night
Schedule an 8 hour nitrate-free period every night
58
see photo
Yes, parents gave consent
no, parents gave consent
wait and confirm
Yes, POA gave consent
59
What is the nurse's priority action?
Assess the client's pain
Assess the client's wound area
Assess the client's level of consciousness.
Assess the client's level of breathing
60
What defines a good community?
Ability to come together to solve problem
A community where everyone earns the same income
A community that only focuses on emergency healthcare services
A community with no rules so people can do whatever they want.
61
Which of the following is a priority nursing intervention caring an infant with an upper respiratory tract infection?
Give small amounts of fluids frequently to prevent dehydration
Give fluids infrequently to prevent dehydration
Give abundance of fluids frequently to prevent dehydration
Give alot of fluids frequently to prevent dehydration
62
See photo
Adminsiter Antabuse immediately
Let him lie on his left side
Establish patient airway
Start IV
63
nurse receives care of a pt recovering from fractures of left tibia and fibula. What is the priority nursing assessment?
Check neurovascular status distal to the injuries
Check respiratory status distal to the injuries
Check cardiovascular status distal to the injuries
Check muskeletal status distal to the injuries
64
The nurse understands that which of the following may place a client at an increased risk for falls?
Normal vision and hearing
young age with no health conditions
Regular physical activity
History falls Administration of Clonazepam Bond Confusion or disorientation
65
What is the common triad that is found in trauma patients relating to shock
Hypertension, tachypnea, infection
Hypoglycemia, anemia, dehydration
Bradycardia, hypoxia, hypokalemia
Acidosis , coagulapathy , hypothermia
66
A COPD client went to the ER. What would the nurse do first?
Vitals
Administer O2
Do Arterial Blood Gases
Check Respiratory
67
Which vaccine can be given to a pregnant woman?
Meningococcal
Polio
Hep A
Hep B
68
Which sign is indicative of digoxin toxicity?
Dry Cough
Blurred Vision
Hypertension
Tachycardia
69
What is the most appropriate response from the nurse!
"I'll have to report this to your healthcare provider as non-compliance."
Traditional practices are not allowed during your treatment."
"You need to throw that away immediately."
Can you tell me more about meds? im concerned w interactions with our meds
70
pt had a long-bone fracture nurse is concerned about a fat embolism. What should the nurse look for when assessing pt
Hypertension and bradycardia
Hematoma formation at the fracture site
Petechiae
A localized rash at the surgical incision
71
Which following nursing diagnoses regarding alterations in urinary function is the nurse's priority for intervention?
Impaired Social Interaction related to embarrassment about urinary issues
Readiness for Enhanced Self-Care related to urinary habits
Risk for Deficient Knowledge related to urinary health education
Risk of infection
72
The nurse has given docusate sodium 100 mg PO to the wrong client. What is the appropriate action for the nurse to take?
Document the medication as given correctly without reporting the error
Call the physician and request an assessment
Do not inform the client or the healthcare provider.
Ignore the error since docusate is a mild medication
73
infection makes the blood vessels dilate, which drops blood pressure is septic shock ?
False
True
74
A mother of a 7 moths old baby demonstrates good learning about feeding her baby when she says which of the following?
"I’ll give my baby honey if they have a cough."
"I’ll introduce several new foods at once to save time."
I will introduce any new food slowly to my baby before giving the bottle
"I will offer cow’s milk instead of breastmilk or formula now."
75
After abdominal surgery, the client is complaining of pain. What should the nurse do?
Immediately give the prescribed PRN pain medication
Administer Pain Meds
Reassure the client that pain is normal and leave the room
Call the physician right away.
76
What is the nurse's priority assessment?
Pt History
Vitals
Acute Lung Sounds
Blood Cultures
77
see photo
Capril
Valium
Lasix
Viagra
78
Pt experiencing a lack of appetite due to sore mouth. Which instructions from the nurse would encourage adequate nutrit.
Eat spicy and acidic foods to stimulate appetite
Avoid eating until the soreness completely resolves
Try shakes made liquid supplements or smoothies with protein powders
Stick to dry, rough foods for better chewing practice.
79
Which of the following should the nurse include in their teaching?
Palliative care is only for cancer patients
Palliative care only begins in the final days of life
Palliative care focuses on comfort rather than cure
Curative treatments are never part of palliative care
80
A client has fluid volume excess and a low haemoglobin count. What would the nurse expect that the doctor to order?
Increase fluid intake to raise blood volume
Start a high-protein diet to fix hemoglobin
Monitor only and repeat labs in a few days
Packed red blood cells
81
What is a sign that a client with asthma is getting worse?
Decreased Wheezing
Increased coughing
Use of accessory muscles when breathing
Elevated respiratory rate (tachypnea)
82
A client gave birth five days ago. What kind of lochia is the nurse expecting to see with this woman?
Lochia Serosa
No Lochia willbe present.
Lochia Alba
Lochia Rubra
83
A nurse walks in pt’s room and finds him on the floor unharmed. The bed rails are up. How should the nurse document?
Incident report filed about fall.
Only document facts client on floor. No harm. Side rails up.
Client not injured and didn’t complain, so no action needed
Client fell because they tried to climb over the rails
84
Which statement by the new colleague would indicate the teaching was effect?
The UCP can assess and evaluate the patient’s condition
I don’t need to follow up once I delegate a task
I can delegate any task, even if the UCP hasn’t been trained.
UCP's insist with routine activities of care within the agreed upon plan o
85
Which of the following characteristics should the nurse include in their teaching regarding acute grief?
Occurs in waves lasting for varying periods of time.
Avoid expressing feelings to cope faster
There is no emotional distress
Grief resolves within hours
86
Which of the following side effects would the nurse monitor for administration?
Drowsiness, Dizziness, Confusion
A policy change implemented in one hosp.without supporting research studies
policy change implemented in one hospital with supporting research studies
Anecdotal reports nurses stating fewer catheter insertions on their shifts
87
Which of the following actions would help this client reduce engorgement?
Breastfeed the infant every 3-6 hours
Breastfeed the infant every 1-2 hours
Breastfeed the infant every 2-3 hours
Breastfeed the infant every 2-4 hours
88
Which of the following is the most concerning lab value?
A potassium level of 3.0
A potassium level of 4.0
A calcium level of 9.5
A sodium level of 140
89
See photo
Call the doctor for new orders on how to proceed
Restart the IV herself since she knows how
Tell the client they’ll have to wait until the next visit
Contact agency /RN to report the situation request appropriate staff
90
What does the lymphatic system do?
It pumps lymph through the body using the heart
fluid regulation
It produces red blood cells and controls oxygen levels in the blood
filters bacteria and toxins
91
pt had IV penicillin transfusion. pt tells the nurse he feels itchy. The RPN finds hives how should the nurse proceed?
Apply a cool compress and reassess in 30 minutes
Discontinue IV and continue normal saline then report to dr
Document the hives and continue the medication.
Slow the infusion rate and continue monitoring
92
see photo
Refuse to proceed unless both partners consent.
Encourage the client to wait until she and her husband agree
Proceed as pt wants and document
Tell the husband privately so he’s aware of her decision
93
What is the nurse's best course of action?
Call the prescriber to clarify the medication order.
Research the drug
Administer med as per pt history
Hold meds
94
The following are side-effects to treatment of DKA with fluid:
adult respiratory distress syndrome
cerebro vascular accident
cerebral edema
myocardial infarction
95
Polyphagia is defined as:
excessive urine output
excessive thirst
sleep deprivation
excessive hunger
96
pt blood work reveals low GFR and that he is in kidney failure. What is the most concerning lab value for the nurse?
Electrolytes
BUN
Potassium
Creatinine
97
The most common cause of Hypoglycemia is what:
not eating enough
injecting to much insulin
unusual amounts of exercise
taking glyburide
98
Which of the following would be strong evidence for this initiative?
Anecdotal reports from nurses stating fewer catheter insertions on shifts
Long term catheter use increases the risk of urinary tract infections.
A single case study showing one pt had a + outcome after catheter removal.
A policy change implemented in one hospital without supporting research.
99
A pt has a fever and chills. Blood and urine cultures plus IV antibiotics are ordered. What should the nurse do first?
Obtain the urine and blood specimens before beginning antibiotic therapy
Administer the antibiotic before collecting the specimens.
Ignore specimen collection and give the prescribed antibiotic immediately.
Delay both specimen collection antibiotic admin until the fever resolves.
100
See Photo
Firmly tell the patient to calm down and get dressed immediately.
Quickly leave the room to get more staff before doing anything.
Client Dignity is first priority
Physically restrain the patient without attempting verbal de-escalation.
101
What are low white blood cells count called?
Leukocells
Leukopenia
Leukocyte
Leukocytosis
102
A child with leukemia is receiving chemotherapy. Which lab value requires immediate attention?
Hemoglobin of 12 g/dL
WBC count of 5,000/mmÑ
Platelet count of 20,000/mmÑ
Hematocrit of 36%
103
which the following assessments necessary to prevent or control the most common complications of a myocardial infarction
Monitoring urine output as the sole assessment.
Checking for dehydration symptoms such as dry mouth and sunken eyes
Cardiac monitoring
Assessing for skin rashes and itching as a primary focus.
104
Pt. in LTC and the family loves the nurse caring for him and they invite her to a dinner how should she respond?
Ask management if she can go since the family invited her
Go to the dinner but avoid talking about work
go it is an invitation
No, it is inappropriate
105
following signs and symptoms are common both HHS (hyperglycemic hyperosmolaric state) and DKA (diabetic ketoacidosis):
acetone breath
abdominal pain
nausea/vomiting
kussmauls breathing
106
What is the appropriate action for the nurse to take?
Encourage rest and continue routine medications as prescribed
Administer another dose of haloperidol for symptom management
Hold antipsychotic med, report to dr request order for a complete blood#
Apply a cold compress and reassess in an hour.
107
What are the stages of labour?
Flexion descent, extension, internal rotation, expulsion, external rotation
Descent, engagement, external rotation, flexion, expulsion, extension
engagmnt descent flexion internal rotation ext external rotation expulsion
Engagmnt, internal rotation descent extension, external rotation expulsion
108
A patient with COPD is receiving oxygen therapy. Which finding indicates the need to adjust oxygen delivery?
Clear lung sounds
Respiratory rate of 20 breaths per minute
Drowsiness and decreased responsiveness
Oxygen saturation of 95%
109
What are 3 common causes of syncope
Iron overload, urinary retention, and bruising
Ear infection, migraine, and indigestion
vasovagal, postural, cardiac Hx
Asthma attack, pneumonia, and hyperglycemia
110
What social determinants of health contribute higher COPD/asthma rates among Indigenous people compared other Canadians
Frequent exercise and physical activity.
High access to specialized healthcare services.
Increased income and wealth.
Family health practices, work environment, and colonialism
111
What hlth teaching should nurse provide help prevent cardiovascular complications in a pt with chronic kidney disease?
no restrictions in place.
flush system with bolus of fluids
Restrict sodium and fluid intake.
influx of sodium and fluid intake.
112
What should a nurse educate a client, who is in forth stage renal failure, about?
Focus only on adjusting his diet to manage symptoms
Tell the client that medications will stop the disease from getting worse.
Medication to manage his current condition
Dialysis
113
A client is vomiting profusely and had diarrhea. What is the nurse most concernedabout?
The client is at risk for respiratory acidosis
The client may develop low calcium
The client might be constipated
Fluid and Electrolyte imbalance.
114
You are caring for a pt is quadriplegic and hospitalized for uti Which approach will best facilitate the pts access?
Provide care without explaining procedures since they can't move
Keep the call bell out of reach to avoid frequent calls.
Limit communication since the patient is already stable
Provide client with an appropriate call system
115
A client is taking Novolin and did not eat breakfast, what time should the nurse suspect the client to be hypoglycemic?
Peak is 3-6hrs
Peak is 2-4 hrs
Peak is 6-8hrs
Peak is 4-6hrs
116
Which of the following is the best interpretation of this situation? SEE PICTURE
school children often do request support even though they want it
school children often do request support even though they dont want it
school children often dont request support even though they need/want it
school children often do require support even though they need/want it
117
If a client needs a blood transfusion, which of the following acts is the responsibility of the nurse?
nurse can administer blood without consent if the client is unconscious.
nurse personally explains all the risks and benefits of transfusion to pt
Make sure consent is on file
nurse can write a verbal consent in the chart if the client says it's okay.
118
The parents of a 7-year-old child with asthma. Which statement by the parents indicates further teaching is needed?
"Our child should avoid exercise completely to prevent asthma attacks."
“I will never let my child do any exercise”
"We will stop giving the controller medication once our child feels better"
"We only need to use the inhaler if our child is coughing at night."
119
Which of the following are appropriate health teaching measures to include?
apropriate sleep schedule
maintain a healthy balanced diet
interaction with socail supports
Avoid all stressful situations completely
120
A patient with a nasogastric tube connected to suction is at risk for which electrolyte imbalance?
Hypokalemia
Hypophosphatemia
Hypernatremia
Hypercalcemia
121
Which of the following results would require further investigation
FHR slightly increasing during uterine contractions.
180 beats/min.
FHR with moderate variability and occasional accelerations
30-140 bpm
122
What does Kussmauls Respirations mean?
True
False
123
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Call for assistance
Administer pain medication to the post-op patient.
Assist the dementia patient back to bed immediately
Call for help before checking on any patient
124
The following drug is classified as a sulphonylurea:
metformin
none of the above
glyburide
insulin
125
A nurse should report it as a cause for concern if an 18-month-old toddler walks by holding onto furniture.
False
True
126
The nurse educating healthy adults on immunizations fulfills which purpose of patient education?
Discouraging preventive care
Promoting illness.
promotion health
Reducing health awareness.
127
At which age will a community nurse introduce puberty education to a girl?
12
10
7
15
128
see photo
Onset level
Trough level
Peak level
random level
129
What is the most likely reason the client has become uncomfortable?
hes uncomfrotable with nurses
hes a germaphobe
he thnks its times for meds
violation of personal space
130
what is important for the nurse to consider?
Use the half the amount of oxygen necessary to achieve maximum oxygenation
Use room air for necessary to achieve maximum oxygenation
Use the least amount of oxygen necessary to achieve maximum oxygenation
Use the most amount of oxygen necessary to achieve maximum oxygenation
131
What is the most concerning adverse effect for a client on morphine?
Itching
Nausea and vomiting
Respiratory depression
Constipation
132
The nurse understands that the frequency of contractions during labor are determined by
The time from the end of one contraction to the beginning of the next.
The time from the beginning of one contraction to its peak.
The time from the peak of one contraction to the peak of the next.
the time between the beginning of one contraction and the beginning of next
133
Mode of transmission of hepatitis B.
Airborne droplets from coughing or sneezing
Bloodily/ body fluids
Contaminated food and water
Touching contaminated skin without a break
134
When assisting with feeding, the nurse notices pt coughing after every swallow of food. What is the nurse's next action?
Request a swallowing assessment from a certified health care professional.
Encourage the client to drink more water to clear the throat
Position the client flat in bed for comfort while feeding
Continue feeding and monitor closely for further coughing
135
nurse is opening a sterile pack to complete a dressing change for their client. Which would compromise the sterility?
Holding or moving an object below the waist
Positioning the contents of the pack at the very edge of the drape
Allow for minimal movement around the sterile field
Opening the pack right before the procedure
Obtaining non latex gloves for the procedure
Obtaining non sterile gloves for the procedure
136
A manic client in a psychiatric facility and requires constant attention. What should the nurse do?
Let the client roam freely between staff to burn off energy
Restrictions amount of attention she gets,all staff must adhere to the plan
Assign a new nurse every shift to give the client variety.
Provide constant praise and reassurance to meet emotional needs
137
The nurse recognizes that this measure is important to identify which of the following complications?
Pulmonary embolism
liver failure
Electrocardiogram (ECG) changes and dysrhythmias related to hypokalemia
respiratory alkalosis
138
Which medication is the nurse most concerned about for a client with asthma?
Oral contraceptives
Antibiotics like amoxicillin
Acetaminophen
Beta-blockers(LOL's)
139
What is the nurse's interpretation of this assessment? SEE PICTURE
Cervix dilated 7 cm, 70% effaced, presenting part 2 cm above ischial spines
Cervix dilated 5 cm, 50% effaced, presenting part 1 cm below ischial spines
Cervix fully dilated, 100% effaced, presenting part at station 0.
Cervix dilated 3 cm, 25% effaced, presenting part above ischial spines.
140
A visitor walks out of a patient room and asks the nurse how his friend is doing. How should the nurse respond?
You can ask him yourself, but he’s been resting all day
Let me check his chart and get back to you
What is your relationship with the patient
He’s doing much better now, thanks for asking
141
Why should diabetic patients that take long-acting sulphonylureas should never be "signed off"?
Hypoglycemia from skipping meals
Postprandial hypoglycemia after a large meal
Insulin shock caused by overdose
Rebound hypoglycemia
142
Before administering digoxin, which vital sign is important to check?
Apical heart rate (hold medication is less than 100 beats/min)
Apical heart rate (hold medication is less than 60 beats/min)
Apical heart rate (hold medication is less than 40 beats/min)
Apical heart rate (hold medication is less than 80 beats/min)
143
Which of the following should the nurse include?
The importance of skipping helmets during sports.
How to perform CPR independently.
Handling sharp tools without supervision
Instruct in basic rules of water safety
144
nurse understands which of the following has been shown to be an effective deterrent suicide in Indigenous communities?
Reducing access to mental health services
Limiting community gatherings.
Teaching youth to make traditional indigenous art
Discouraging cultural practices.
145
See Photo
Respect clients wishes
Delay documenting the refusal until the situation is reassessed later.
Proceed administering blood products if the situation becomes critical.
Tell pt they must reconsider because the transfusion could save their life.
146
Signs of compromised IV bag select all apply
Clear fluid with no particles.
Expiration date has not passed
Clear, colorless solution
Discoloration of the solution
Leaking of the packaging or bag
Precipitate is visible
147
Nurse realized she didn't advocate well enough for her pt in family conference what should she do?
Document her mistakes in the patient’s chart
Blame the healthcare team for silencing her input
Ask the patient to complain to management on her behalf.
Reflect
148
How would a nurse determine the patency of a fistula?
Listen for bruit
Take a blood pressure on the arm with the fistula
Check the pulse distal to the fistula to ensure circulation
Insert an IV line above the fistula to check for blood flow
149
performing a sterile procedure at the bedside, the UCP can assist by helping the nurse by positioning the client
True
False
150
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Tell Candy her relationship with the client is is wonderful
Talk 2 nurse and tell her that her behavior may perceived as inappropriate
Immediately report Candy to management.
Ignore the client’s request and continue providing care.
151
A school nurse is education the children about hand hygiene. What prevention level is this?
Tertiary prevention
Primary prevention
Secondary prevention
Disease prevention after an outbreak
152
The nurse understandings that during an abdominal assessment, deep palpation is used to determine
Presence of bowel sounds
Surface-level tenderness only
Skin texture and temperature
Enlarged organs
153
Type 1 diabetes is characterized by which of the following:
Peripheral insulin resistance
Juvenile Onset, Lean Build
Autoimmune beta cell destruction
Adult Onset, Obesity
154
During periods of high blood sugar, the cells are:
hypoxic
fluid overloaded
overworked, trying to deal with all the sugar
starved
155
Deep rapid respirations are seen in which diabetic complication:
retinopathy
hyperglycemic hyperosmolar state
diabetic ketoacidosis
hypoglycemia
156
A pt with congestive heart failure is prescribed furosemide. Which electrolyte imbalance should the nurse monitor for?
Hypernatremia
Hyperkalemia
Hypokalemia
Hypocalcemia
157
What is the most important measure for the nurse to take to prevent the spread to other clients on the unit?
void wearing gloves when providing care
Change the dressing only when visibly soiled
Allow the client to use shared equipment without cleaning it between uses
Wear gloves during client care and ensure proper hand hygiene
158
A client with osteoporosis says his knees hurt when he exercises. What should the nurse suggest to him?
You should stop exercising completely to avoid more joint pain
Do aqua exercises
Try jogging or using the stair climber to strengthen your legs
Increase the intensity of your workout to build bone strength faster
159
A 15-year- girl call the clinic to ask about the abortion clinic. She says she had unprotected sex what nurse shud do?
Tell her to wait a few weeks and then take a pregnancy test.
Advise her to start taking daily oral contraceptives immediately.
Tell her about oral contraceptives that prevent implantation
Refer her to an abortion clinic without discussing emergency contraception
160
A client is taking digoxin, what lab value is most important to check regularly?
Sugars
Digoxin levels
Potassium
Electrolytes
161
See Photo
Do her way as it smore effiecient
Ignore it and do it her way
Follow agency policy
Follow policies of the ay she was trained at her old job
162
The nurse is concerned because they have not cared for surgical clients since graduation. What should the nurse do?
Review the unit's surgical procedures, policies and skilled
Not provide direct client care until they feel competent
Talk to an RPN on the surgical unit about their nursing requirements
Review the standards of the College of Nurses of Ontario
163
pt who is on multiple medications tell the nurse he is experiencing many side effects. What would the nurse ask the pt?
t’s normal to have side effects from so many meds.
If meds are taken correctly
Just take them at different times to avoid side effects
You should stop taking any meds that cause side effects
164
What assessment findings would indicate portal hypertension?
yperactive Bowel Sounds
Bradycardia
Decreased Urine Output
Ascites and hematemesis
165
What is the nurse's next step?
Allow the UCP to perform the suctioning independently without supervision.
Assign the task permanently to the UCP without further evaluation
Assess the unregulated health provider's ability to learn this procedure
Skip verifying the UCP's competency since the client is stable
166
A client had an MI 2 weeks ago. Which blood work value shows muscle damage?
BUN
Potassium
Calcium
CK (creatinine kinase)
167
The client has a DNR do not resuscitate status. What should the nurse do?
Wait until the next scheduled assessment to evaluate the client
instruct UCP to make the patient comfortable as outlined in plan of care
Ignore the symptoms since the client has a DNR
Tell the UCP to monitor the client closely and report back later.
168
The nurse understands which of the following behaviors may cross the boundaries of the nurse-client relationship?
Keeping secrets with a client from the health care team
Providing emotional support during a difficult time
Maintaining professional empathy and active listening
Explaining a care plan clearly to the client and family.
169
A client with COPD is receiving oxygen via nasal cannula. Which sign indicates oxygen-induced hypoventilation?
Increased respiratory effort
Oxygen saturation of 94%
Decreased respiratory rate
Use of accessory muscles
170
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Wait until tomorrow to start ambulating so the pain lessens
You shouldn't be in pain if the surgery went well
Just push through the pain; it will get better after a few walks
Take pain meds to have more energy to do his exercises
171
You are caring for pt when their partner requests access to chart in pt chart. What is the nurse's best response?
Sure, I'll show you the chart since you're the partner.
I'll get the info for you since you're probably involved in their care
I can't show you the chart, but I can tell you everything in it.
You will need your partner's permission
172
A patient reports suicidal thoughts. What is the nurse's priority action?
Notiofy physcian
stay with patient
provide pt with safe environment
document findings
173
See Photo
Reflect
Document the family’s decisions without mentioning the client’s concerns.
Ignore it and assume the team made the right decisions
Immediately confront the healthcare team in front of the client and family.
174
What is an appropriate action for the nurse to take?
Reapply the same appliance without cleaning the skin
Ignore the skin irritation and continue with routine care
Tape around the leaking appliance instead of replacing it
Request a referral for an Enterostomy nurse to visit the client.
175
The nurse notices a client slap her child in the waiting room. What should the nurse do?
Go over and speak with the client and tell them it isnt right to hit child
Ignore it as its just a parent scolding their child
It is none of our business
Call Child Protective Services (CAS)
176
A 2-year-old is scheduled for surgery. Which is the most appropriate preoperative teaching method?
Showing videos of the surgery
Detailed explanation using medical terms
Providing written materials
Using dolls to demonstrate procedures
177
What must the nurse ensure to do while providing client care?
gnore the IV site assessment unless the patient complains of pain
Administer the antibiotics whenever convenient during the shift
Wash hands before and after handling the intravenous equipment.
Discontinue the antibiotics early if the patient feels better
178
The nurse would recognize which of these as the five rights of medication administration?
right documentation, right dose , right drug preparation, right phar
Right pt, right teaching, right drug, right transcription, right response
right drug, right time, right patient, right dose, right route
Right room, right time, right storage, right chart, right signatur
179
nurse is caring for a client that has returned from a thyroidectomy. What is an appropriate short-term goal for this pt.
"The pt will run a marathon within 24 hours after surgery."
"The pt will be completely free of pain within 6 hours post-surgery."
The pt will maintain, clear open airway as evidenced normal breath sounds
the pt will be discharged home independently within 12 hours of surgery."
180
A chronic disease of the arterial system characterized abnormal thickening hardening of vessel walls is arteriosclerosis
False
True
181
A new mother is concerned when her menstrual cycle will return after childbirth. How should the nurse respond?
"It usually returns within 2 to 3 weeks after birth."
Menstruation doesn't return until the baby is weaned,non-breastfeeding moms
"It usually takes about a year for all women, no matter what."
In non-breastfeeding moms, it takes 6-8 weeks
182
The characteristics of unstable anginais that It is unpredictable
False
True
183
What is the most common precipitating factor to DKA (diabetic ketoacidosis) or HHS (hyperglycemic hyperosmolaric state):
pancreatitis
myocardial infarction
infection
cerebral vascular accident
184
The family tells you they would like the team to consider an experimental medication. How should you respond?
That's not my responsibility, ask someone else.
Experimental treatments are allowed
Organize a team meeting with the family to discuss this request
Experimental treatments are never allowed here
185
Which statement, made by the care provider, would indicate a correct understanding of the teaching?
"I may cut a gauze pad to fit around the tracheal tube"
We should suction the tracheostomy tube every 4 hours when awake"
Ensure the tracheostomy holder is tight against the skin
"Skipping medications occasionally won't affect treatment outcomes."
186
How should the nurse respond?
" would like to hear more about what you are feeling
Fine, I'll leave you alone until you're ready to talk
You need to stop being so dramatic
If you don't talk, I can't help you
187
Which of the following is the priority action for the nurse when a client is experiencing a panic attack?
Encourage the client to discuss their feelings immediately.
Administer anti-anxiety medication as the first intervention
Leave the client alone to calm down
Stay with the client.
188
A pt had attempted multiple suicide attempts and was just admitted to a psychiatric facility. What should the nurse do?
Call the family to reassure them she’s safe now
Let her rest first before asking any questions
keep her on a 24hr hold
Place her in a regular room and check on her every hour
189
Which of the following would require priority intervention for a client taking furosemide?
potassium level of 4.0 mmol / L
Blood potassium level of 3.5 mmol / L
Blood potassium level of 3.0 mmol / L
Blood potassium level of 3.5 mmol / L
190
nurse is providing d/c instructions to their client with heart failure What should nurse include in the discharge info
Weigh yourself at every mealtime everyday
Weigh yourself at the same time every day
Weigh yourself at different times every day
Weigh yourself once a week
191
see photo
"A"
"X"
"D"
"B"
192
Hyperglycemic hyperosmolar states usually develop over which period of time:
days to weeks
a day
6-8 hrs
4-5hrs
193
A client is bedridden. What should the nurse do to protect his skin integrity?
Apply lotion heavily over bony areas and leave the client in bed.
Encourage pt to stay in one comfortable position to avoid disturbing him
Reposition pt frequently
Massage any reddened areas of skin to restore blood flow.
194
The longterm effects of diabetes are most often caused by:
skin damage from repeated insulin injections
vessel damage from sugar molecules
vessel damage from beta cell fragments
brain damage from repeated seizures
195
Which of the following is the most appropriate nursing intervention for a client with a potassium level of 2.6 mmol/L?
Monitor for bradycardia
Encourage fluid intake
Administer oral potassium supplements
Discontinue potassium-rich foods
196
A nurse can initiate a Urinary Catheter?
False
True
197
Which lab value should be monitored for a patient on heparin therapy?
INR
Platelet count
PT
aPTT
198
What is an appropriate nursing action?
Ignore the client's complaint since vital signs are stable.
Cover the client with a warm blanket
Increase the transfusion rate to finish faster
Stop the transfusion immediately and discard the remaining blood
199
Which of the following is an appropriate communication strategy for a client with a cognitive deficit)
Explain instructions step by step
Avoid eye contact and speak from a distance
Speak quickly to cover more information at once
Use medical jargon to explain the care plan.
200
pt with dementia agitated refuses have a glucometer reading completed. Which of the following is an appropriate action?
Provide distraction to the client and try again in a ten minutes
Administer insulin without checking blood glucose levels
Forcefully restrain the patient to complete the test.
Document the refusal and skip the blood sugar check entirely

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