SE T A

SITUATIONAL
Situation: 1. A client with invasive cervical carcinoma is receiving internal radiation therapy. c. d. An RN who has allergy to seafood An RN who has a 3 year old child at home

Which RN should not be assigned to care for her? a. An RN who is 6 months postpartum b. An RN who is currently pregnant

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"ou are aware that the most appropriate acti#ity order for her is $$$$$ a. %omplete bed rest c. &ut of bed to a nearby chair only b. &ut of bed ad lib d. 'ed rest with bathroom pri#ileges When caring for her( you should obser#e which principle? a. )imit contact time with her to 1 hour total per * hour shift b. +ont e#er allow any pregnant women to come into any contact with her c. Remo#e the dosimeter badge when entering the room d. ,ndi#iduals younger than 16 years of age may be allowed to go inside the room as long as they are 6 feet away from her .er husband as/s you if he can spend the night with his wife. "ou should e0plain that $$$$$ a. &#ernight stays by family members is against the hospital policy b. 1here is no need for him to stay because staffing is ade2uate c. .is wife will rest much better /nowing that he is at home with their children d. 3isitation is limited to 34 minutes ma0imum as long as the radioacti#e implant is in place While gi#ing care( you find the radioacti#e implant on the bed. Which is your initial action? a. %all the physician b. Reinsert the radioacti#e implant into the #agina immediately c. 6ic/ up the radioacti#e implant with glo#ed hands and flush it down the toilet d. 6ic/ up the radioacti#e implant with long handled forceps and place it into a lead Nursing Management of Clients with Cardiac Disorders d.

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Situation: 6.

7le#ated 81 segments during the early phase of an acute myocardial infarction are indicati#e of $$$$$ a. ,n9ury b. ,schemia c. Necrosis Reperfusion When a client recei#es a drug with negati#e chronotropic effects( you e0pect which outcome? a. )oss of sympathetic tone c. +ecreased contractility b. +ecreased #ascular tone d. +ecreased heart rate

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"ou should be most concerned about which finding associated with chest pain? a. 6ain increases with inspiration c. 6ain is relie#ed with 1 nitroglycerin b. 6ain lasts longer than !4 minutes d. 6ain is relie#ed with rest

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"ou who are preparing to administer digo0in <)ano0in= disco#er that a client( who pre#iously had a regular heart rate( now has an irregular heart rate of -*. Which action by you represents best practice? a. "ou reassess the apical heart rate for a full minute c. "ou administer the dose to regulate the heart rate b. "ou withhold the ordered dose of medication d. "ou assess for signs of hypo#olemia 14. "ou /now that an ,3 dose of heparin will begin to e0ert anticoagulant effects within which time frame? a. Almost immediately c. After ! hours b. ,n 34 minutes d. Within ! to 3 days You are assigned to care for a client with a chest tube attached to closed chest drainage system. c. ?onitor for fluctuations in the water seal chamber d. ?onitor the drainage from the chest tube

Situation: 11.

"ou a#oid which action as part of routine chest tube care? a. >eep the collection chamber below his chest b. %lamp the chest tube when he gets out of bed

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"ou note continuous bubbling in the water seal chamber. "ou interpret that $$$$$ a. 1here is an air lea/ somewhere in the system c. 1he system is intact b. A pneumothora0 is resol#ing d. 1he suction to the system is shut off "ou are assisting him to get out of bed. 1he tubing accidentally gets caught in the bed rail and disconnects. +uring the attempt to reestablish the connection( the closed chest drainage system falls o#er and crac/s. "ou should first $$$$$ a. %all the physician c. Apply a petrolatum gau@e o#er the end of the chest b. ,mmerse the chest tube in a bottle of sterile normal saline d. %lamp the chest tube

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"ou determine that his lung has completely e0panded if $$$$ a. 1he o0ygen saturation is greater than ;!A c. b. Bluctuations in the water seal chamber ceased longer needed 15.

6leuritic chest pain has resol#ed d. 8uction in the chest drainage system is no

"ou assist the physician with the remo#al of a chest tube. +uring remo#al of the chest tube( you instruct him to $$$$$ a. 1a/e a deep breath( e0hale( and bear down c. 70hale upon actual remo#al of the tube

b. .old the breath for ! minutes and e0hale slowly remo#al Situation: 16. Nursing Management of Clients with ascular Disorders

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%ontinually breathe deeply in and out during

1he nursing assistant reports a blood pressure reading to you( who note that the cuff used was too large for a client. Which effect would the si@e of the blood pressure cuff ha#e on the blood pressure? a. 1he blood pressure measurement would be unaffected c. 1he blood pressure measurement would be falsely low b. 1he blood pressure measurement would be falsely high d. 1he blood pressure measurement would be !4A higher 1:. Which 9ob would potentially be the best CfitD for a person with Raynauds disease? a. 6ostal carrier on a wal/ing route c. 6ersonal fitness trainer b. +ownhill s/i instructor d. 8chool bus dri#er "ou are assigned to care for a client who was admitted with 'uergers disease. 'ased on /nowledge about this disease( you anticipate which information? a. .e is li/ely to be a young male c. .e is li/ely to be an elderly male b. 8he is li/ely to be a young female d. 8he is li/ely to be an elderly female "ou will be recei#ing a client admitted with a diagnosis of Cstro/e.D "ou are aware that which are considered to be ris/ factors for stro/e? Select all that apply. $$$$$ a. +iabetes $$$$$ b. &besity $$$$$ c. %ocaine use $$$$$ d. Bemale $$$$$ e. .ypertension !4. "ou are pro#iding education to a client about clinical manifestations of a transient ischemic attac/ <1,A=. Which statement by him indicates a need for further education? a. TIA is like a warning when blood supply to part of the brain is interrupted. b. TIA is nothing to worry about because the effects are only temporary. c. Symptoms might include numbness or weakness on one side of my body. d. If I have a TIA, I might lose my vision and have difficulty talking. After undergoing a transurethral resection of the prostate !"#$%& to treat benign prostatic hyperplasia !'%(&) a client is returned to the medical unit with continuous bladder irrigation !C'*&. Bacilitate the measurement of urinary output 6ro#ide continuous pressure on the prostatic

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Situation: !1.

"ou reali@e that the purpose of continuous bladder irrigation <%',= is $$$$$ a. 8timulate continuous formation of urine c. b. 6re#ent the formation of blood clots in the bladder d. fossa A triple

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lumen <3 way= Boley catheter is inserted for continuous bladder irrigation <%',=. ,n addition to balloon inflation( the functions of the three lumens include $$$$$ a. %ontinuous inflow and intermittent outflow of irrigation solution b. %ontinuous inflow and outflow of irrigation solution c. ,ntermittent inflow and continuous outflow of irrigation solution d. ,ntermittent inflow and outflow of irrigation solution Which finding suggests that the Boley catheter is occluded? a. 1he urine in the drainage bag appears red to pin/ b. .e reports bladder spasms and the urge to #oid c. 1he normal saline irrigation solution is infusing at a rate of 54 drops d. About 1(444 ml of irrigation solution ha#e been instilledE 1(!44 ml of drainage ha#e been returned ,n which circumstance would you increase the irrigation flow rate? a. When the drainage is continuous but slow c. b. When the drainage appears cloudy and yellow irrigation solution When the drainage becomes bright red d. When there is no drainage of urine and

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+uring your shift( 644 m) of one bag of irrigation solution has infused and 1(544 m) of the ne0t has also infused. Fpon draining the urine bag three times during your shift( you measure the #olumes to be *44 m)( 1(454 m)( and ;54 m). What is his true urine output? a. !44 m) b. 354 m) c. :44 m) d. *54 m)

INDIVIDUAL QUESTIONS !6. "ou teaching a mothers class tell them that the best way to position their infants during the first couple of wee/s of life is to lay them on their $$$$$ a. 8tomachs with their heads flat c. Right side with their heads slightly ele#ated b. 'ac/s or sides with their heads flat d. 8tomachs with their heads slightly ele#ated ,nduction of #omiting is indicated for accidental poisoning of a child who has ingested $$$$$

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Aspirin Rust remo#er

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"ou inad#ertently gi#e a client a double dose of a prescribed medication. After disco#ering the error( whom should you notify? a. .im b. .is spouse c. 1he prescriber d. "our lawyer .ow often should you release the restraints? a. &nce per hour b. &nce per shift c. 7#ery ! hours d. 7#ery 3 hours

"ou are called to a clients room by another nurse. When you arri#e at the room( you disco#er that a fire has occurred in his closet. "ou ha#e remo#ed him from the room. Which is your ne t action? a. 7#acuate the unit c. %onfine the fire b. 70tinguish the fire d. Acti#ate the fire alarm "ou hear a client calling out for help. "ou hurry down the hallway to his room and find him lying on the floor. "ou perform a thorough assessment and assist him bac/ to bed. 1he physician is notified of the incident( and you complete an incident report. "ou document which on the incident report? a. 1he client was found lying on the floor b. 1he client climbed o#er the side rails c. 1he client fell out of bed d. 1he client became restless and tried to get out of bed Bour clients in9ured in an automobile accident enter the emergency department <7+= at the same time and are immediately seen by you( as a triage nurse. "ou would assign the highest priority to the client with the $$$$$ a. )umbar spinal cord in9ury and lower e0tremity paralysis b. ?a0illofacial in9ury and gurgling respirations c. 8e#ere head in9ury and no blood pressure d. 8econd trimester pregnancy in premature labor +uring a mass disaster drill simulating a terrorist attac/( you must triage numerous se#erely ill persons. 1he client who should recei#e care first is $$$$$ a. %yanotic and not breathing c. Apneic and has an apical rate of 54 b. Gasping for breath and conscious d. .a#ing a sei@ure and is incontinent of urine When a #ictim has been field triaged and categori@ed as emergent( you recogni@e that $$$$$ a. .is condition is life threatening( and he must be seen immediately b. .e has serious health problem( but not immediately life threatening one( and he must be seen within 1 hour c. .e has episodic illness that can be addressed within !- hours without increased morbidity d. .e re2uires simple first aid or basic primary care 6lace the following 667 in order of remo#al $$$$$ a. Gown( eye protection( glo#es( and mas/ b. ?as/( gown( eye protection( and glo#es Which procedure or practice re2uires surgical asepsis? a. .and washing b. Nasogastric tube <NG1= insertion c. Glo#es( mas/( gown( and eye protection d. 7ye protection( glo#es( mas/( and gown ,ntra#enous <,3= catheter insertion %olostomy irrigation d. 6assi#e artificial

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,mmunity by antibody formation during the course of a disease is $$$$$ a. Acti#e natural b. 6assi#e natural c. Acti#e artificial Who is most susceptible to infection? a. A 6 year old girl with a fractured femur b. A -! year old man with a recent( uncomplicated appendectomy c. An *6 year old man with burns from using a heating pad d. An 1* year old man with diabetes mellitus

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Into which color coded waste bin should you instruct him to dispose of used tissues? a. Green b. Black c. Yellow d. When palpating a clientHs body to detect warmth( you should use which part of the hand? a. Binger tips b. Binger pads c. 6almar aspect d.

Clear +orsal aspect

When auscultating a clients heart( you understand that the first heart sound <81= is produced by the closure of the $$$$$ a. ?itral and tricuspid #al#es c. ?itral and pulmonic #al#es b. Aortic and tricuspid #al#es d. Aortic and pulmonic #al#es "ou /now that the e0pected closure time for the anterior fontanel is between the ages of $$$$$ a. 6 and * months c. 13 and 1* months b. ; and 1! months d. 1; and !- months "ou teach a premenopausal woman that the best time in the menstrual cycle to e0amine her breasts is during $$$$$ a. 1he wee/ that o#ulation occurs c. 1he wee/ that menstruation occurs b. 1he first wee/ after menstruation d. 1he wee/ before menstruation occurs Which color band indicates mil/? a. Green b. Red c. 'lue d. 6urple

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'y how much should a breastfeeding client increase her caloric inta/e? a. !44 calories per day c. -44 calories per day b. 344 calories per day d. 544 calories per day

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A mother of a toddler is concerned because her child is still insisting on a bottle at naptime and at bedtime. Which is an appropriate suggestion to her? a. Allow the bottle if it contains 9uice c. +o not allow her child to ha#e the bottle b. Allow the bottle if it contains water d. Allow the bottle during naps but not at bedtime A post a. b. %3A client has dysphagia. Which action might ma/e swallowing most difficult for him? Beeding him clear li2uids c. 6ro#iding a diet of semisolid foods 6ositioning him upright d. Adding a thic/ening agent to drin/s

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%oncerning fluid inta/e to manage dumping syndrome( you should ad#ise a client to $$$$$ a. Restrict fluid inta/e to 1 )Iday c. +onHt drin/ li2uids ! hours before meals b. +rin/ li2uids only with meals d. +rin/ li2uids only between meals Which food group is lowest in sodium? a. ?eats b. +airy products A #egan is at ris/ for which nutritional deficiency? a. 3itamin '3 b. 3itamin '6 c. c. Bresh fruits 3itamin '; d. d. Bresh #egetables 3itamin '1!

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ALTERNATE FORMAT QUESTIONS 51. A client with profuse bleeding as a result of ?3A is admitted to the emergency department. Which assessment indicates to you the de#elopment of hypo#olemic shoc/? Select all that apply. $$$$$ a. Restlessness $$$$$ b.,ncreased systolic blood pressure $$$$$ c. %ool( clammy s/in $$$$$ d.%apillary refill lasting 1 ! seconds

$$$$$ e. +ecreased urinary output 5!. A client suddenly begins to ha#e a sei@ure while he is lying on the bed. Which nursing action is contraindicated? Select all that apply. $$$$$ a.1urn him to the side $$$$$ b. 1ry to force a bite stic/ into his mouth $$$$$ c. Restrain him $$$$$ d.)oosen restricti#e clothing $$$$$ e. )et the pillow remain under his head 53. ,soen@yme laboratory studies are ordered for a client who is suspected of ha#ing a myocardial infarction. What are they? Select all that apply. $$$$$ a. 1roponin , or 1 $$$$$ b.Alanine aminotransferase $$$$$ c. %> ?' 1 !

$$$$$ d. )actate dehydrogenase $$$$$ e.)actate dehydrogenase