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1. The most common nosocomial infection in patients admitted to the hospital?

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Infectious diarrhea (C. difficile)

 

 

Pneumonia (gram negative)

 

 

Urinary tract infection

 

 

Bloodstream infections

 

 

2.  If a nurse accidently sticks herself while giving a patient an IM injection what is the first action?

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems. Elsevier, Inc.

 

Report incident to supervisor/charge nurse.

 

 

Cleanse area with Betadine.

 

 

Irrigate area with sterile water.

 

 

Scrub area vigorously for 5 minutes with soap and water.

 

 

3,  A geriatric patient is unsteady after ambulating from a chair. Which measure should the nurse take all except:  

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Staff must wear a mask, gloves, and gowns.

 

 

Applying restraints

 

 

Give the patient the call light

 

 

Educate the patient on how to use the walker

 

 

4.  Patient presents on your unit with severe dehdration. The doctor orders 1 (L) of normal saline. How many ml should the patient  recieve:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

3.74 mL

 

 

1000mL

 

 

4.75 mL

 

 

2000mL

 

 

5.  A nurse is supervising a nursing student preparing to change a sterile dressing. Which step is most important when donning sterile gloves?

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Access sterile glove inside with ungloved hand.

 

 

Grab cuffs of sterile gloves with ungloved hand.

 

 

Grab sterile glove inside with unsterile gloves.

 

 

None of the above.

 

 

6.  COVID virus is caused by:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

SARS-CoV2

 

 

RHINOVIRUS

 

 

Influzena

 

 

HPV

 

 

7.  A patient with impaired mobility which factor would contribute decreased kidney function:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Hypotension

 

 

Hypertension

 

 

Constipation

 

 

Peristalsis

 

 

8.  A patient on your unit has diabetes. Patient has a regular dose of insulin order daily. The nurse gives an additional dose of NPH insulin and patient suddenly is pale, rapid heart beat, and cold sweats. The patient is suffering from:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Hypoglycemia

 

 

Hyperglycemia

 

 

Is having a epileptic seizure

 

 

Hemolytic anemia

 

 

9.  A 45 yr old male patient is suspected to have  meningitis. The patient is scheduled for a lumbar puncture in the AM. Which action should te nurse take to prevent complications after test:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Applying pressure to puncture site

 

 

Raise head of bed 30-degree angle for comfort

 

 

Encourage fluid intake

 

 

Keep the patient flat for 6 to 8 hours

 

 

 10.  A patient had a stroke 14-days ago. Due to, the stroke patient is now at risk for dysphagia. Patient is at risk for:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Maintaining balance when ambulating

 

 

Choking when eating or drinking

 

 

Holding objects

 

 

Frequent episodes of vertigo

 

 

11.  Patient is prescribed 0.8 micrograms of levothyroxine per kilogram q 12 hours. Patient weight is 92 kilograms. How much medication should the patient be given:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

153.3 mcg

 

 

147,8 mcg

 

 

147.2 mcg

 

 

145.2 mcg

 

 

12.  Mr. Jackson was admitted after suffering a stroke. He has right side hemiparesis and needs help rolling over in bed. He is also incontinent of urine. He is a most risk for developing:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Hypothermia

 

 

Malnutrution

 

 

A skin prerssure injury

 

 

UTI

 

 

13.  A 20 year old male patient is having a grand mal seizure. What is the first action the nurse should take:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Lift the head of bed at a 30 degree angle

 

 

Do not touch patient just monitor

 

 

Lower bed rails in order for patient not to hit his head

 

 

Lower bedrails and roll him onto his side

 

 

14.  Mr. Taylor has been admitted for possible sepsis, dehydration, and mild acidosis. Which nursing action would be most appropriate to take

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Give patient an injection of demerol for pain

 

 

Give patient a 250 mg of Teqin (antibotic) IV every 12 hours

 

 

Hang IV lactated ringers as ordered by doctor

 

 

Hang Normal saline every 4 hours

 

 

15.  The doctor prescribes Procrit 5000 units SQ. Where should injection be given:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Ventrogluteal muscle

 

 

Vastus lateralis muscle

 

 

Upper quadrant of the buttocks

 

 

Back of patient arm

 

 

16.  A nurse taking care of a 2-year old patient with a temperature of 104.1 (rectal). The patient is at risk for what issue if fever is not addressed:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Hypotension

 

 

Headache

 

 

Dehydration

 

 

Febrile seizure

 

 

17.  Which of the following is NOT a physical sign/symptom of a behavioral crisis:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Sleeping disorders

 

 

Immunocomprised and increased risk of infecions

 

 

Gastrointestinal disturbances

 

 

Reduced fertility

 

 

18.  The nurse is completeing the inital assessment on a newly admitted patient. Which lifeastyle choice discussed can cause severe damaged to the liver:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

Chewing tobacco

 

 

Use of ilicit drugs

 

 

Excessive alcohol consumption

 

 

Taking steriods

 

 

19.  How many liters of oxygen can a patient be placed on without a doctors order:

Rationale:  Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing : Assessment and management of clinical problems (11th ed.,). Elsevier, Inc.

 

4 liters

 

 

3 liters

 

 

5 liters

 

 

2 liters

 

 

20.  What factor is often associated with obesity:

Rationale:  Papa, K. (2021). Essential In-services for Long-term Care (2021st ed.). HCPro, a divison of Simplify Compliance LLC. (Original work published 2021).

 

Vegetarian diet

 

 

Drinking excessive amounts of alcohol

 

 

Smoking

 

 

Type 2 diabetes

 

 

21.  Skin care for obese patients can be challenging due to:

Papa, K. (2021). Essential In-services for Long-term Care (2021st ed.). HCPro, a divison of Simplify Compliance LLC. (Original work published 2021)

 

Moisture trapping in skin folds

 

 

Immobility

 

 

Incontinence (urine and fecal)

 

 

Poor diet

 

 

All of the above

 

 

22.  When assisting a patient with selecting an appropriate food choice for lunch/dinner should include all except. Select all that apply:

Papa, K. (2021). Essential In-services for Long-term Care (2021st ed.). HCPro, a divison of Simplify Compliance LLC. (Original work published 2021)

 

Lean meat

 

 

Fruit

 

 

Foods high in sugar

 

 

Processed foods

 

 

Vegetables

 

 

23.  Which of the following conditions should be reported to the charge nurse immediately:

Papa, K. (2021). Essential In-services for Long-term Care (2021st ed.). HCPro, a divison of Simplify Compliance LLC. (Original work published 2021)

 

The patient with a cough. runny nose, and sneezing x 4 days

 

 

The family brings a diabetic patient cookies and candy whn they visit

 

 

The patient requessting to stay in bed all day and watch TV.

 

 

The patient appears short of breath, swelling in lower extremities with pain.

 

 

24.  A patient with emphysema is admitted to your unit. The patient is short of breath and purse lip breathing. The nurse identifies the cause as:

Papa, K. (2021). Essential In-services for Long-term Care (2021st ed.). HCPro, a divison of Simplify Compliance LLC. (Original work published 2021)

 

Bronchi spasms

 

 

An increase in lung vital capacity

 

 

Rapid expulsion of air

 

 

Air trapping and difficulty expelling air

 

 

All of the above

 

 

25.  A patient is admitted to your unit with a 15-year history of COPD. The nurses assessment should include monitoring for:

Papa, K. (2021). Essential In-services for Long-term Care (2021st ed.). HCPro, a divison of Simplify Compliance LLC. (Original work published 2021)

 

Accessory muscle use with breathing

 

 

Chest pain

 

 

Respiratory alkalosis

 

 

Prolonged inspiration with ambulation

 

 

 

 

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