My Final Practice quiz

RN evaluat'n neurological signs of pt in spinal shock following SCI. Which observations indicate spinal shock persists?

Which stage of frostbite has small blisters filled with a dark fluid?

Guillain-Barre pt w ascendn paralysis, intubated, receivn mech vent. What strategies would RN incorporate in POC

Which of the following is not a intervention for a halo device?

RN is working on med surg unit a fire breaks out in stairwell near RN’s station. What describes RN first action?

RN is working in the triage area of ED & 4 pts approach desk @ same times. What order should RN assesses these pts?

a Nurse is preparing to administer heparin 3500 units subcutaneously every 12 hours. The amount avail is 5000units/ML

Myasthenia gravis. The use of intravenous immune globulin is for which response?

Sudden chest pain combined w dyspnea, cyanosis, & tachycardia, are symptoms associated w which complications of sx?

when preparing 2 teach pt about phenytoin sodium therapy, RN should urge pt not 2 stop drug suddenly due 2 what concerns

CVA result difficulty discern'n position of body w/o looking at it RN’s doc describes pt’s nability see spatial position

Shivering while cooling a client with heat stroke is an expected finding

Reminds group of CNA’s that for pt w an elevated temp, quickest & simplest technique to reduce temp is what?

RN is assessing a pt for decorticate posturing. What should RN assess pt for?

Alzheimer’s pt is admitted to hosp. Which psychosocial assessment is most important for the nurse to complete?

Before undergoing a CT scan w contrast medium, RN assesses the pt for which of the following potential complications?

Developing POC for pt w bacterial meningitis. Which interventions will reduce risk of increased intracranial pressure?

RN eval'n pre adm labs: CBC, Coagulation, & electrolytes & creatinine What levels will cause sx 2 b postponed

RN caring for several pts at risk for shock. Which lab value requires RN to call HP?

Pt w spinal cord injury is prone to experiencing AD RN would include which of measures to minimize recurrence risk

Receive pre-op dose of lorazepam 20 mins ago Which is the priority intervention the nurse should take to promote safety?

RN assessing motor function of unconscious pt RN would use which test to C pt’s peripheral response to pain

develops care plan, pt recovering from sx. What nsg interventions will RN include minimizing effects of venous stasis?

Conducting pre-screening assessment for Parkinson’s disease. RN knows which clinical finding may indicate this disease?

Obtaining pts signature on a surgical consent form. Pt states “I didn’t really understand what my surgeon……”

RN wants 2 b involved comm disaster preparedness & interest n helpin set up & staff 1st-aid stations/comm ACC n disaster

order for 0.45% sodium chloride 1 L to infuse over 15 hours. What rate in ml/hr?

Pt w new-onset status epilepticus on phenytoin. After teaching pt tx. RN knows pt’s knows.

Which of the following is not post CVA medication regimen?

What is the priority nursing intervention in the postictal phase of a seizure?

Pt will have an electroencephalogram in the morning. RN instructs pt to have which foods/fluids for breakfast?

RN caring for pt who has experience seizure while in bed. Which of actions by RN would be contraindicated?

Which of the following is not an intervention for heat stroke?

Progressive proximal 2 distal muscle weakness & mild diplopia. RN realizes these findings indicate pt suffers from what

RN prepares to give IV Cimetidine to pt w new burn injury. Pt askes, “Why am I taking this med?” How would RN respond?

RN cautions when cooling down heat stroke pt, 1 must b careful preventing shivering because shivering causes?

Preparing educ for pt w migraine prescribed beta-blocker qd to manage. What instruction is appropriate

RN is triaging pts in the ER. Which pt would RN classify as non-urgent?

RN assesses pt w drainage from nose after basilar skull fx. Which eval by RN helps positively identify drainage as CSF?

RN caring for pt after sx RR increased 12 - 18/min, & the HR increased 86 - 98/min pt last assess 4 hrs ago priority is

RN gives instructions to pt w Parkinson’s about maintaining mobility. RN determines that pt understands directions when?

Pt w basilar skull fracture. Clear nose drainage w halo sign & concerned about potential CSF Leak. What should the RN do

RN is assessing a pt w multiple traumas who at risk for developing ARDS. RN assesses for earliest sign of ARDS?

RN caring for several pts on burn unit w extensive tissue damage. what electrolyte imbalance is typical?

RN assesses frost bite on pt’s hands & feet to be 2nd-degree because the skin has which of following assessment findings

RN is teaching pt w myasthenia gravis prevention of myasthenic & cholinergic crises RN tells pt most effectively done by

assessing LOC w head injury pt, opens eyes only n response 2 pain responds w mumbled sounds, GCS is 6, What should RN do

When @ public park encounters person immediately after bee sting lips swollen & audible wheezing What action to take 1st

assessin child @ school bus crash, L arm several bruises & superficial 5 cm laceration that not bleedin What triage cat

orienting new RN to PICU & discussing care of drowning recovery pt. What statement accurately demonstrates understand

During 1st 24 hrs after thromabolytic tx for ischemic stroke, RNs’ primary goal is to control what VS?

post-op pt asks Y it’s important 2 DB&C after sx. response incorporates understandin that retained pulm secretions in pt

Enters room witnesses a client experiencing a seizure. What is the nurses priority intervention?

experienced RN is teachn new RN hosp emerg plans & personal emerg preparedness, which statement need more teaching.

GN is doing d/c teaching for pt new dx migraine ha’s. Which statement made by GN indicates understanding

RN works @ comm center for older adults What self-management measure can RN teach pts prevent shock?

. ER RN is educating a new RN on the traditional triage system. The new RN shows correct understating

nurse is assisting w sponge & instrument count in OR. Which operative phase does this occur in?

Pt w Parkinson’s disease. Which intervention does RN implement to prevent respiratory complications in pt?

RN field-triaging pts after an industrial accident. What pt condition would RN triage w a red tag?

Which of the following is not characteristic of pneumothorax?

client w Parkinson’s. Display bradykinesia. Which of following statements from pt indicates an understanding of disease?

RN caring for an elderly pt who suffers from MI. RN identifies need for vigilant monitoring against which form of shock

Pt’s neuro status declines over hrs, & craniotomy is done to remove hematoma. nsg interv. indicates decrease ICP issue

During a rapid assessment in ED, the triage nurse does not take which of the following into consideration:

RN assessing pt n postictal phase of generalized tonic-clonic seizures RN determines pt assessment findings

Pt is immobile form recent sx. Which intervention does RN implement to prevent complications in this client?

Assessing a client in post-op. What is a sign that something is wrong

ER, w pt who has cervical spinal cord injury. Which priority assessment does the emergency dept nurse perform first?

RN is eval s/o pt who had craniotomy 3 days ago. RN should suspect pt developing meningitis as compl if exhibits what

When preparing for a surgical prod, which of the following factors will influence how RN will position pt? SATA

RN has instructed family of CVA pt w homonymous hemianopsia about helping overcome deficit. Correct statement?

Pt w Parkinson’s disease is prescribed levodopa therapy. Improvement in which area indicates the therapy is effective?

Which role is responsible for verifying that consent form is signed & that surgical site is marked?

RN is assessing resp s/o pt who has suffered a fxd rib. RN would expect to note which of following?

Glasgow coma scale screening tool to assess LOC in 3 major areas. When analyzing a pt’s score, RN identifies 3 areas

Pt recover'n from head injury, arousable & participat'n n care RN determines pt knows steps 2 prevent elevated ICP if

RN compl d/c instruction 4 pt w application of halo & determines pt needs more clarification of instructions if says

Pt presents to the ER w c/f BLE loss of sensation started in feet but now progressed to knees & hips. Which disease

Pt scheduled for sx is confused & shows signs of dementia. RN should ask which person to sign the consent for pt?

to receive general anesthesia has serum potassium level of 5.8 what should be the nurse’s first response?

pt’s BP 104/50. After determining MAP, RN understands this patient is at risk for which of the following complications?

RN is helping to prepare a pt for non-emergency sx. RN should perform which of the following

Pt is admitted 2 hosp w dx Guillain-Barre syndrome RN inquires during nsg adm interview if pt has hx which of following?

Which of the following aPTT results does not require adjustment to the heparin dose?

RN is monitoring s/o post-op pt. RN would most concerned w following signs that could indicate an evolving complication?

low-pressure alarm vent sounds RN assesses pt attempts 2 find cause unsuccessful & takes what initial action

To prevent a pt w/ Parkinson's from getting too tired, a nurse should cluster activities

RN is assessing a pt w multiple traumas who @ risk for developing ARDS. Does RN assess for earliest sign of ARDS?

RN is developing POC for pt who had thrombotic stroke. What priority nsg assessment in 1st 24 hr after pt adm

Pt w MS receiving baclofen. RN determines that drug is effective when it causes which action?

Teaching class about transient ischemic attacks. Which information should the nurse include in the teaching?

Which of the following is not a sign of heat stroke

Ergotamine tartrate medications are beneficial in migraine headaches due to which action?

male, 69 yo, eval’d by neurologist w signs of muscle rigidity, masklike face & propulsive gait RN interprets findings as

RN wants t bcome part of Disaster med assistance team DMAT but concerned about maintainin lic n several states.

Which stage of Parkinson's is characterized by shuffling gait and mask-like face?

injured MVA, ER w head injury. Which test should not be done if there is indication of increased intracranial pressure?

RN developing POC for pt in acute phase of burn injury. Which of following would be priority nsg dx for pt?

during sx, pt exhibits tachycardia, diaphoresis, & rising body temp. Which is priority intervention circulating RN