1. Mrs.

Thomas diagnosed with dementia, is an 85-year-old newly admitted resident of a longterm care facility who has started to wake up in the middle of the night and wander the unit. What is the most appropriate action for the nurse to take? a) ccompany the resident during her walks to ensure safety !)"e#elop a night walking program for the resident c) $scort resident !ack to !ed and raise the side rails to ensure safety d) $nsure resident%s safety and perform an assessment &orrect answer' d) a)(ot an ade)uate inter#ention as assessment is the priority after ensuring the resident is safe. !)This may !e appropriate only after assessing the causes of the resident%s wandering as nurses need to continually assess changes in the resident%s !eha#iour. cThis is not the most appropriate inter#ention as raising the side rails is a form of a physical restraint. *hysical restraints re)uire a doctor%s order and consultation with the resident and with the resident%s family or power of attorney +for incompetent residents) and can !e used only after assessment of the resident%s condition has found that the resident is at risk of falling +,ollins, -../). 0estraints should only !e used when all other inter#entions ha#e !een unsuccessful. d)1nitially, need to ensure resident remains safe and then perform a comprehensi#e assessment as wandering +a symptom of dementia) may !e the resident%s way of communicating 2en#ironmental irritants, physical discomforts or psychological distress3 +(owicki, 4ul!rook, 5 6urns, -.7.8 0eed 5 Tilly, -..8). 2. nna, -- years old, was admitted to the unit with pneumonia. ,he is on -9 of o:ygen #ia nasal prongs. &atherine, nna%s mother, came out and stated' 2 nna is ha#ing difficulty !reathing.3 The nurse notes that patient is diaphoretic, short of !reath, restless, and disorientated. ;er #itals are <=.->&, 7.< !?min, -8 !reaths?min, 7--?88 mm;g, and 8<@ in a semi-4lower%s position. What would !e the nurse%s initial action? a) 0eposition the patient and reassess #ital signs. !) dminister high flow o:ygen #ia nonre!reather mask. c) 1nitiate positi#e pressure #entilation #ia an endotracheal tu!e. d) (otify physician and respiratory therapist immediately.

nswer' 6 a) Aital signs and repositioning the client are important to assess client%s current status and promote ma:imal chest e:pansion. ;owe#er, at this time her o:ygen saturation takes priority. !) 6&%s is a primary initiati#e for patients that !ecome critical. 1n this case, !reathing was affected which results in hypo:ia. &ommon compensation responses to respiratory distress are tachycardia, tachypnea, and a change in !eha#ioral and mental status due to inade)uate o:ygen supply. s o:ygen demands increase, a nonre!reather mask maintains a higher +up to 7.. percent) o:ygen concentration supply in the reser#oir !ag that can !e deli#ered to the patient compared to nasal prongs, which deli#ers --@-BB@ o:ygen. Therefore, one maCor goal for respiratory distress is to maintain ade)uate o:ygenation. c) **A is another inter#ention that is usually initiated in colla!oration with the respiratory therapist when the patient is unresponsi#e to high o:ygen concentrations. d) (otifying the physician and the respiratory therapist is important, yet the nurse must supply 7.. percent o:ygen as an initial response to pre#ent a possi!le respiratory arrest. <. (urse $dith on entering Mr 6%s room noticed that Mr. 6 is feeling congested. Dn e:ploring further, Mr 6 admits that he used to smoke 7. to -. cigarettes per day. ;e stated that any time he coughs there is no secretion. What inter#ention should the nurse implement first in this situation? . 6. &. ". 1nitiate deep-!reathing and coughing e:ercise ,uction the patient gently uscultate the patient%s lungs *erform percussion and postural drainage. 0ationale' The correct answer is & . "eep-!reathing and coughing e:ercise will enhance lung e:pansion !ut is not the first inter#ention for Mr. 6. 6 ssessment of the lungs determines whether suctioning is re)uired &. ssessing the patient first is #ery important to determine the right inter#ention. uscultation of the lungs is appropriate at this time. ".*ercussion and postural drainage is not the right inter#ention at this time 4. ;enry, 7- years old, has arri#ed on the unit following a surgical procedure to correct a left femoral fracture. n hour following the onset of administration of pain medication, the patient indicates increasing le#els of pain that are progressi#ely unrelie#ed and rated 7.?7. on the pain

scale. ;e also indicates loss of sensation to his toes. What should !e the nurse%s primary inter#ention? ) 1n recognition that this le#el of pain is appropriate with a femoral fracture, the nurse should administer additional pain medication according to physician%s orders and continue to monitor and re-assess his pain. 6)&heck #ital signs to o!ser#e for changes in client condition. &) *erform a neuro#ascular assessment of the affected lim! and immediately contact the physician regarding significant findings. ")"ocument findings and enhance client comfort !y repositioning the affected lim!, performing cast care and utiliEing distraction techni)ues. &orrect nswer' & ) This le#el of pain that is progressi#ely unrelie#ed is not normal. 1ncreasing the pain medication does not seek to e:plore the etiology responsi!le for the pain. 6) 0egular #ital assessments will already !e scheduled. This is not a priority o#er performing an initial neuro#ascular assessment. &) The nurse needs to assess the patient%s risk for de#eloping compartment syndrome F a medical emergency. ") This is not a priority o#er performing an initial neuro#ascular assessment 5. Gatie is a / year-old patient who has cere!ral palsy. ,he recently underwent lower-e:tremity orthopedic surgery to lengthen muscles and tendons in order to alle#iate contractures that ha#e caused mo#ement pro!lems. ,he was assigned to your care in the post-surgical unit at 7B<.h. 1t is now 7/..h and she has not yet #oided. ,he has not e:pressed a need to #oid and palpation of her !ladder re#eals no distention. 6ased on her calculated !ladder #olume and estimated time to #oid +B.5 hours), Gatie was ordered to ha#e a !ladder scan. The scan re#ealed that her !ladder was at H5@ of the predicted !ladder capacity. s Gatie%s nurse, you are aware of the postoperati#e risk for urinary retention. Which of the following would not !e the !est nursing inter#ention to encourage spontaneous #oiding and pre#ent complications or inCury?

)&alculating her maintenance intra#enous fluid when she arri#es on the unit. 6)ItiliEe intermittent catheteriEation to pre#ent urinary retention.

&)9et Gatie know it is time for her to #oid, altering her position in !ed to promote use of a !edpan, and running water. ") 0ecogniEe that since Gatie needs large amounts of morphine for pain control, fre)uent nursing assessment of urinary status following the !ladder scan is necessary. &orrect nswer' 6 )&alculating appropriate fluid maintenance will pre#ent dehydration, and su!se)uent decreases in urinary output, and ensure that !ladder #olume is not increased !eyond predicted capacity. This could result in increased incidence of !ladder stretch inCury and urinary retention. 6)&atheteriEation should only !e utiliEed when other less-in#asi#e inter#entions are performed since the procedure has the potential to introduce infection. ,tudies ha#e indicated that if !ladder scan #olumes are less than 7-.@ of the predicted #olume, !ladder scans are to !e repeated e#ery hour until the child #oids or until catheteriEation is re)uired. When the !ladder scan result e)uals the predicted #olume, the nurse initiates non-in#asi#e strategies to encourage spontaneous #oiding. When the !ladder scan indicates approaching or e:ceeding 7-.@ of predicted #olume or the child is uncomforta!le, the child is encouraged to #oid and an order for catheteriEation !ecomes necessary. &)These non-in#asi#e strategies are useful to assist in promote spontaneous #oiding. ");igh doses of pain medication +i.e. morphine) are more likely to cause urinary retention. lso, they are likely to cause increased sedation and decreased awareness of !ladder fullness. ,ince pain control is an essential inter#ention with this surgery, routine assessments of the child%s urinary status are re)uired. 6. Mia%s ne:t client for the day is Mrs. 6rown. ,he is an 8H year-old lady who has !een diagnosed with se#ere dehydration, occurring as a result of decreased fluid intake. Mrs. 6rown recei#es intra#enous +1A) hydration therapy through an 1A site located on her left hand, and re)uires nursing care on a daily !asis. Ipon arri#al, Mia notices that the 1A !ag is full, the 1A fluids are not draining, and Mrs. 6rown%s left hand is swollen, pale and cold. What should the nurse do first? a) pply warm and moist compresses to the left hand !) $le#ate Mrs. 6rown%s hand on a pillow c) 1nspect the 1A site and discontinue the infusion d) 1nsert a new cannula on the other e:tremity and secure it with tape. &orrect answer' c)

a) $#en though applying warm and moist compresses to the affected hand may !e helpful in decreasing the edema associated with infiltration of the 1A site, this is not the !est answer choice. 1n this situation, instead of focusing her actions on remo#ing the cause that perpetuated the infiltration, such as 1A fluids infusing interstitially, the nurse concentrates on treating the conse)uences of the intra#enous complication. Therefore, although the application of warm and moist compresses may !e incorporated in the treatment plan for Mrs. 6rown%s infiltration, it does not indicate the most appropriate first action of the nurse. !) $le#ating Mrs. 6rown%s hand on a pillow indicates an effecti#e strategy that would promote the a!sorption of fluids, facilitate #enous return, and decrease the edema related to infiltration, !ut is not the most appropriate initial nursing action. 1n addition, !y ele#ating Mrs. 6rown%s hand on a pillow the nurse would not eliminate the root cause of the infiltration, !ut treat the conse)uences of it. c) 1nspecting the 1A site for signs and symptoms of infiltration, including swelling, pallor, coolness and pain, and discontinuing the 1A infusion would !e the most appropriate initial nursing action and the !est answer choice in this case. 1n this instance, the nurse utiliEes her critical thinking a!ilities and understands that the preliminary action should in#ol#e discontinuing the flow of fluids in the interstitial space, and pre#enting any further progress of the infiltration. ;ence, !y inspecting the 1A site and discontinuing the infusion first, the nurse is treating the direct cause of the infiltration and pre#enting any further damage to the client. d) 1nserting a new cannula and securing it with tape is an important aspect of Mrs. 6rown%s hydration treatment plan, primarily !ecause she is suffering from se#ere dehydration. ;owe#er, this is not the !est choice !ecause it does not suita!ly address the )uestion regarding the most appropriate first action of the nurse. 1nitiating a new cannula and securing it properly would !e appropriate only after the infiltrated 1A infusion site is discontinued and further damage is pre#ented. 7. Mrs. *eters has !een admitted to long term care with dia!etes, dementia, and congesti#e heart failure. 1n the morning, the nurse enters the room to check her !lood sugar. Ipon entering the room, the nurse notes Mrs. *eters looks pale, an:ious, sweating and the 6, is <.<. What is nurse%s first priority? a.$ncourage Mrs. *eters to e:ercise !.Ji#e a cookie c.Ji#e 7-5 ml orange Cuice d.0echeck the !lood sugar in 75 minutes &orrect answer' c 0ationale'

a.This is not the first priority for hypoglycemic clients. $:ercising will lower the !lood sugar le#el. !. Ji#ing cookie is not the first priority as comple: car!ohydrates takes too long to a!sor! and is not useful for )uick hypoglycemic treatment. c.(urse%s first priority is to gi#e 75g of simple glucose +7-5 ml orange Cuice) as this will !ring the sugar le#el up. d.(urse%s first priority is to gi#e 75g of simple glucose and then she needs to recheck the !lood sugar to make sure 6, is at optimal le#el. 8. Mr. 0aymond is a =8 year old o!ese client with an history of "AT. ;e had a Jastrectomy due to gastric cancer. 1t has !een -B hours since his surgery. ;e has a *&$ +*atient controlled epidural analgesic), appears to !e a !it drowsy and is on and off in a normal sleep. What important consideration should the nurse add to Mr. 0aymond%s plan of care? a) ssess the client for pain !) $ncourage deep !reathing and coughing e#ery hour c) $ncourage am!ulation?Jet the client up out of !ed d) $nsure the client eats all his !reakfast for ade)uate nutritional intake Correct answer c) a) *ain assessment should !e an important part of assessment8 howe#er, the patient is in a normal sleep and is not showing signs of pain +e.g. guarding, grunting etc) !) *ost operati#e clients are at risk for respiratory complications such as pneumonia, atelectasis etc. This is an important part of patient%s plan of care. ;owe#er, for Mr 0aymond, am!ulation and posture will help decrease respiratory complications. c) m!ulation is encouraged to decrease "AT. 1ncrease stress response after surgery may lead to increase clotting tendencies in the post operati#e client !y increasing platelet production. &lient%s with an history of "AT has a more increased risk for pulmonary em!olism. d) The client had a Jastrectomy8 therefore, will !e (*D. 6owel sounds are fre)uently diminished?decreased. 1A infusion is usually gi#en to maintain fluid and electrolyte !alance. 9. resident has !een gi#en a !ath at the shower room when she started to ha#e a seiEure attack. The resident has a history of seiEure disorder documented on her chart. The personal support worker who was gi#ing the resident a !ath called the nurse on the floor. When the nurse arri#ed, what will she do during the attack?

a.)&all the designated physician immediately. !.)Transport the resident !ack to her !ed. c.)1nsert an oral airway instrument. d.)*ut the resident in a side-lying position and allow the resident to finish her seiEure attack. &orrect answer' d.) a.)This is not a priority at the moment !ecause the physician is aware that the resident has a history of seiEure disorder. 1nform physician after the resident%s seiEure episode. !.)1t is not a good idea to mo#e the resident while she is ha#ing her seiEure !ecause she is unsta!le and transferring her could cause more harm than good. c.)This had !een done in the past to maintain the airway of residents?clients to !e clear !ut was stopped !ecause forcing an airway instrument to the resident who is currently ha#ing the seiEure could cause inCury to the Caw, teeth or to the tongue. lso, if in the process of inserting the oral airway the gag refle: had !een stimulated, it could lead for the resident to #omit which could !e aspirated and can cause greater risk?harm. d.)This is the correct response !ecause putting the resident in a side-lying position would allow any secretions to drain from the mouth and not !e accumulated which could !e aspirated !y the resident. lso, it will allow !etter #entilation for the resident to !e a!le to !reathe while ha#ing the seiEure. The surroundings of the resident who is ha#ing a seiEure should !e clear of any tools or furniture%s that could cause harm throughout the episode. The nurse should o!ser#e the type of the seiEure that the resident is ha#ing for proper documentation and inter#ention afterwards.

10. Mr. JonEales, 58 years old, has returned to a surgical unit following transurethral resection of the prostate. ;e has an 1A (, infusing at 7.. mls per hour, a three-way urinary catheter in place and continuous !ladder irrigation with sterile (, solution. fter a short while, Mr. JonEales complains of a!dominal pain and !ladder spasms. s you enter his room, Mr JonEales an:iously says, 21%m in pain, could you do something a!out it?3 Which nursing action is most appropriate in this situation? a.) 1rrigate the !ladder manually with 5. cc irrigating solution !.) ssess the catheter patency for kinks or clots c.) dminister antispasmodics +e.g., o:y!utynin) as ordered d.) ,top the &61 and notify the physician immediately

&orrect nswer' 6 0ationale' a.) 1rrigating the !ladder manually is done when tu!e patency is confirmed +ie, catheter tu!ing is kinked or !locked with clots). 1n this case, 5. cc of irrigating solution should !e instilled and then withdrawn with a syringe to remo#e clots that may !e in the !ladder and catheter. 1n this case, tu!e patency is not confirmed yet and there is no identifia!le cause for Mr. JonEales% a!dominal pain?!ladder spasms yet. !.) &atheter patency must !e checked first in order to identify the cause of Mr. JonEales% pain and !ladder spasms. 1f present, the clots should !e remo#ed !y irrigation so that urine can flow freely. This is the most immediate nursing action: to assess and identify the pro !em first then proceed with your p!an. c.) ntispasmodics +e.g., o:y!utynin or "itropan) along with rela:ation techni)ues +e.g., guided imagery) are used to relie#e the pain and decrease spasm. 1n this case, you know that Mr. JonEales #er!ally e:pressed he%s in pain and asking if you could do something a!out it. &onsidering the phases of the (ursing *rocess +ie, ssessment, "iagnosis, *lanning, 1mplementation and $#aluation), you must collect !oth the su!Cecti#e and o!Cecti#e data in order to analyEe and critically think what is going on first "#$%&# you implement an inter#ention. 1t is totally e:plica!le that Mr. JonEales is in pain and you would like to help alle#iate that pain, !ut you must first identify the pro!lem in order to sol#e it. a.) This may !e a serious situation !ut stopping the &61 and notifying the physician immediately is done only if the outflow is !locked and patency of the tu!ing cannot !e re-esta!lished !y manual irrigation. Therefore, at this time you are not sure yet if this is considered an emergency situation +ie, life threatening) 11. (urse Kane accompanied !y a nursing assistance walked into a patient%s room at a!out 75..hrs and o!ser#ed the patient to !e pale and diaphoretic. The patient complained of headache, and then tells (urse Kane to 2go away3. ;is hands are #ery shaky. s the nurse caring for this patient, the most appropriate initial management of this situation is to' . 1nstruct the nursing assistance to stay with the patient while you o!tain a glass of orange Cuice and call the doctor 6. 1nstruct the nursing assistance to remain with the patient while you o!tain some insulin and report to the team leader &.,tay with the patient and try to o!tain a urine specimen while the nursing assistance reports to the team leader ". 0emain with the patient and ask the nursing assistance to )uickly o!tain the glucometer and a glass of Cuice..

0ationale' The correct answer is " . The patient is confused at this stage, and it is not right to lea#e him at that time. 6.1t is important to check the !lood sugar reading first !efore administering insulin &. Irine specimen is not the right inter#ention at this time ". These are signs of hypoglycaemia, checking the !lood sugar is #ery important and gi#ing *atrick a glass of Cuice is the !est option at this stage. 12. Mr. 0aines is a =- year old gentleman admitted to the med-surg unit from emergency with confusion, chills and intermittent chest pain. Aital signs on admission are temperature </.7 degrees &, 6*- 7=H?/8, ;0- 775, and 0--=. 4ollowing a &T scan and M01 the client has !een diagnosed with septicemia due to an infected artificial mitral #al#e. ;e is started on 7gram &eftria:one L8hrs 1A and (, to run at 7..mls?hour with a heparin drip titrating to **T le#els. &ode status' 4ull &ode The call !ell rings, its Mr. 0aines roommate reporting that Mr. 0aines is coughing and gasping for a !reath. Dn arri#al the client is not !reathing, unconscious, colour appears dusky from the chest up, diaphoretic, pink frothy sputum is coming from the client%s mouth and nose, 6*- H5?<B, ;0- 7B8 and faint, all symptoms indicati#e of a pulmonary em!olism +*$).What is the nurses priority action?

a)*lace client in semi to high fowler%s and administer o:ygen #ia non-re!reather mask !)*erform a thorough chest assessment and call another nurse for assistance. c) dminister analgesic and monitor #ital signs as client is a "(0 d)*lace the client in trendelen!urg, call a code !lue, and !egin cardio pulmonary resuscitation. &orrect 0esponse' ' a)This is an appropriate inter#ention if the client was ha#ing a su!-massi#e or non-massi#e pulmonary em!olus. !)The client is not !reathing therefore immediate life sa#ing inter#entions are re)uired, chest assessment could hinder o:ygenation potentially leading to undesira!le outcomes such as !rain death.

c)$ssential to a clients care plan is ad#anced directi#es including code status, nurses must !e aware of the client%s status in order to pro#ide the appropriate care. s stated in the case study, this client is a full code and would re)uire all life sa#ing inter#entions. d)Trende!en urg position promotes o(ygenated !ood f!ow to the rain preser)ing rain function. *cti)ating a code a!ters the response team to egin in)asi)e medica! inter)entions. 13. Mr. ;all, =- years old, has had a left carotid endarterectomy, and upon assessment of cranial ner#e function the nurse notes that he has difficulty articulating, slurs when saying the phrase, 2Mom and "ad !ought puppies,3 and has an asymmetrical droop on the left side of his mouth. What initial action should the nurse take? a) &all the physician and the critical care outreach team +&&DT) ,T T to inform them in the change of Mr. ;all%s condition. !) "ocument the findings and report to the charge nurse concerning the change in Mr. ;all%s condition. c) &all the patient%s wife and ask her to clarify whether or not Mr. ;all has e:perienced symptoms like this !efore. d) pply o:ygen at B9?minute #ia nasal cannula, start intra#enous therapy of ../@ normal saline, and continue to monitor. Correct *nswer: a) a) This indicates cranial ner#e damage and must !e assessed !y the physician and &&DT. !) The nurse would document findings, !ut must notify the physician. c) This would !e inappropriate at the time, the physician must !e notified. d) The nurse would apply o:ygen only if Mr. ;all%s o:ygen saturation was low, and the nurse would need an order prior to initiating 1A therapy. 14. Mr. *aul is a =. years old client with chronic renal failure who has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to e#aluate the client%s status immediately after dialysis? a) Aital signs and 6I( !) Weight and potassium le#el c) 6I( and creatinine le#els d) Aital signs and weight

&orrect nswer' d) 0ationale for correct answer' d) fter hemodialysis, the client%s #ital signs are assessed to see if the client is sta!le hemodynamically. &lient%s weight is measured and compared with the client%s pre-dialysis weight to check how much !lood filtration has occurred and the effecti#eness of fluid remo#al. 0ationale for incorrect choices' a) 6I( le#el is not an immediate standard inter#ention at the end of e#ery hemodialysis treatment as it is not #ia!le to do la! tests for e#ery client after each dialysis. !) "oing !lood test for potassium is critical to identify acute changes in clients and is done on case !y case !asis. 6ut it is not a standard post dialysis protocol. c) 9a!oratory tests like potassium and 6I( le#el are done as per hospital protocol !ut are not necessarily done after the hemodialysis treatment has ended. 15. Mou ha#e !een working with Mrs. Kones who is a /- year old post operati#e patient who underwent a hip replacement. "uring your initial assessment Mrs. Kones has lower than normal !lood pressure, generaliEed weakness, and pallor. 9ooking at the results from her !lood work you notice that her haemoglo!in is H5g?9. Mou immediately call the doctor to recei#e an order for !lood. Dnce the !lood has arri#ed and consent o!tained the nurse will then? ) 1ndependently #erify the patient identification num!er, !lood unit num!er and then administer the !lood. 6) dminister the !lood after the check has !een performed. &) 6egins the infusion rate at 7..ml?hr. ") "iscuss the signs and symptoms of ad#erse reactions should any occur. &orrect nswer' ") ) The nurse must #erify with another nurse when reading the codes. 6) 6efore administration of !lood a !aseline assessment of #ital signs must !e documented in case of a reaction. &) The infusion rate will !e prescri!ed !y the physician for each person and should !egin slowly for the first fifteen minutes of administering !lood. ") 0ight, after o!taining consent the nurse should further e:plain what the ad#erse reactions would !e like as so the patient can pay attention to any changes as they occur during the infusion. 16. Mr rawinda a 5/yr old male walks into your triage station from the waiting room in an emergency department. Dn assessment you notice your client%s skin is pale and he appears ,D6. Mour D:ygen sat pro!e is malfunctioning, radial pulse is 58, 6* /.?5=, T- <=.7, 0- -B Mour client e:plains he has !een feeling lousy since morning and had pain in his upper !ack and neck and a sore left arm. Mour client continues to say and that he thinks he may ha#e the flu !ut came to the unit today, to ha#e his pain addressed as he felt he may ha#e pulled some muscles lifting !o:es at work.

6ased on this initial story, what would !e the nurses ne:t step !e to pro#ide the !est care for this client in a timely fashion. a) ssess the client for pain so they can recei#e prompt analgesia appropriate for the le#el of pain the client descri!es !)Dffer the client D:ygen as they appear ,D6 and you do not ha#e a functioning D- pro!e c)$nsure the client has an $&J and continue the assessment d)Triage the client to the orthopaedic dedicated section of the $0 for prompt N-ray &orrect nswer' & a)While it is important to conduct a proper pain assessment for a client, pain relief is secondary in priority to recogniEing the possi!le symptoms of an acute M1, also pain relief may also mask some of the symptoms prolonging time to proper re-perfusion treatment in an acute M1. !)The client was a!le to walk into the triage station and into the unit itself, D:ygen may !e offered in the course of treatment !ut it is not a priority inter#ention that will route the client to the correct health ser#ices promptly. c) *ro#ision of an $&J early in the treatment cycle for this type of client will ensure that they recei#e appropriate targeted care for the e:act condition they may !e presenting with today. lso their story descri!es many of the symptoms of an acute M1 or cardiac e#ent including ,D6, !radycardia, low 6*, pain profile. 0uling out or confirming a cardiac e#ent will help !est create a plan of care for this client d) While the client may ha#e actually pulled muscles or a fracture !ut an $&J would help rule out a cardiac e#ent and a muscle pull or !roken !one is unlikely to !e as conse)uential as a possi!le M1. The client may !e routed to the wrong health professionals or an inappropriate plan of care may !e created. 17. Mr. *eterson,5., is in the surgical unit since - days after his appendectomy surgery. ;e reported ha#ing passed li)uid stools / times in the past 8 hours. 4rom assessment, nurse finds that he is weak and disoriented. The patient%s skin is cold and clammy. (urse takes Aital ,igns +A,). 6*' 8H?B<, *-77., ,aD-- 8=@ on -9 o:ygen #ia nasal prongs, 0espirations-7-?minute ;is *0( orders are' 1modium +To !e gi#en in the case of diarrhea) (a&l !olus +when fluid loss is greater than =..ml) D:ygen --B 9 Which one of the following inter#entions would !e the most appropriate initial action for the nurse to take? a- &alculate the amount of stool and accordingly plan to administer the (a&l !olus !- 1ncrease o:ygen deli#ery to B9 and ask a secondary nurse to monitor A,. c- &all the physician and inform him a!out Mr. *eterson%s deteriorating A,

d- dminister 1modium to treat diarrhea, and assess amount of fluid loss. &orrect nswer' +!) 0ationale' a- The patient is showing symptoms of hypo#olemic shock' low !lood pressure, rapid pulse, cold and clammy skin. lthough, treating hypotension is important, it should always !egin with o:ygen therapy to promote o:ygenation of hypoperfused organs. ;ence, calculating the amount of stool and planning to administer the (a&l !olus should not !e the nurses% immediate action. !- This is the !est response. Mr. *eterson is showing signs of hypo#olemic shock. Treating this 2should always start with o:ygen therapy to promote o:ygenation of hypoperfused organs3 +,mith, -..=, p.B.B). The patient has low o:ygen saturation and is disoriented. O"isorientation could !e a sign that the !rain is not recei#ing ade)uate o:ygen% +,mith, -..=). Mr. *eterson is currently recei#ing -9 o:ygen #ia nasal prongs. ;is order reads --B 9 o:ygen. Thus, increasing the o:ygen deli#ered to B9 and asking a secondary nurse to monitor A, is the !est first action. c- lthough calling the physician is important, the priority in this situation is to recall Mr. *eterson%s *0( medication orders, apply critical thinking and recogniEe that o:ygen can !e increased and later (a&l !olus could !e gi#en. d- dministering 1modium to treat diarrhea is not a priority while considering immediate action in this situation. 1t is more important to ensure ade)uate o:ygenation and perfusion of #ital organs. 1+. Mrs. 9orenEa, B5, has a diagnosis of dia!etes and is in the surgical unit. ,he has an ulcer on her right foot and one of her toe is necrotic. ,he reported ha#ing pain of =?7. on the right foot and her pain medication F morphine - was administered. lthough, her ne:t dose is due after < hours, she reports ha#ing unrelie#ed pain. ,he has pain of F H?7. F in the same area. The nurse got to know that Mrs. 9orenEa has !een using morphine for B months prior to her hospitaliEation. What is the most appropriate initial response !y the nurse? a- Ise patient preferred non-drug therapy to relie#e pain till ne:t dose is scheduled. !- d#ice patient that applying cold compress o#er her foot is most effecti#e to relie#e pain till ne:t scheduled dose. c- Take #ital signs and perform an assessment of the foot. d- &onsult the pain specialist and inform him a!out ineffecti#eness of the medication &orrect nswer' +c) 0ationale' a- Mrs. 9orenEa is showing signs of tolerance to her pain medication i.e . e:periencing end of dose failure +$rsek 5 *oe, -..=). ;owe#er, it is important to rule out possi!le infection or disease progression as the cause of pain !efore considering the possi!ility of drug tolerance +$rsek 5 *oe, -..=). ;ence this is not the !est response. !- This is not the !est response since the priority nursing action should !e to rule out drug tolerance +$rsek 5 *oe, -..=). lso, cold compress should not !e applied to areas with poor circulation +$rsek 5 *oe, -..=) F which might !e the reason why the patient%s foot is ulcerous and necrotic +Warren, -.7.). c- This is the !est initial response since the nurse first suspects drug tolerance and uses critical thinking to e#aluate if there were other reasons for an increase in pain +$rsek 5 *oe, -..=). This is e#ident as she performs foot assessment and takes #ital signs.

d- lthough it is important to inform the pain specialist a!out unrelie#ed pain +0( D, -..-), the priority in this situation is to get necessary information through assessment. 19. Mrs. "aley, 5B years old, is admitted to the acute respiratory unit with a diagnosis of pneumonia. ,he has tracheostomy tu!e and on <=@ 4iD-. fter three hospitaliEed weeks, now she is ha#ing difficulty e:pectorating sputum and mucus rattling in the tu!e is heard. ;er respiratory rate is <. !reaths? min. what is the most appropriate action? a) 1ncreasing o:ygen le#el. !) Maintaining head of !ed at <. to B. degrees. c) *ro#iding oral care. d) ,uctioning the tracheostomy tu!e. &orrect answer' d) a) ;ypero:ygenation will ensure that the patient%s o:ygen le#el does not drop during suctioning. 1ncreasing o:ygen le#el can not help the patient clear musus from tracheostomy tu!e. ,hould suction initially. !) The head of !ed should !e maintained at <. to B. degrees to the patient for proper !reathing, !ut is not the most appropriate action. c) Dral care needs to !e pro#ided, !ut it is not the most appropriate action to relie#e her pro!lem. d) ,hould clear the patient%s airway make sure the airway is patent. ,uctioning the tracheostomy tu!e is needed to clear secretions in the tu!e. 20. =< year old male, presents with atrial fi!rillation since he was admitted to &&I, two days ago. ;is #itals on the monitor show pulse in 55s, 6* F 75.?H5 and respirations as -<. <P pitting edema present on lower e:tremities and pedal pulses audi!le !y "oppler. Geeping in mind the presenting pro!lem, which medication would you ensure this patient is administered to pre#ent the worsening of this patient%s cardiac status? a) 9asi: +diuretic) !) Metoprolol +anti-hypertensi#e) c) ;eparin +anti-coagulant) d) (itroglycerin 1A +#asodilator) &orrect nswer c)

a) "iuretics will !e needed, since this patient has <P pitting edema. ;owe#er, the arrhythmia this male patient is present since - days, is a higher risk factor for the worsening of his cardiac functioning. !) anti-hypertensi#e will also !e prescri!ed to the patient, most pro!a!ly from the time he was at home !ecause high !lood-pressure is one of the causes that increase the chances of one getting a heart disease. 1f he was not on anti-hypertensi#e earlier, then it can !e the !ody%s way of compensating for low cardiac output which is caused !y the arrhythmia. c) ,ince this patient is presenting atrial fi!rillation continuously for the last B8 hours, the maCor manifestation of it is the formation of throm!us in the atrium. This is due to the incomplete contraction of the atrium which causes the !lood to accumulate and clot +Watson, ,hantsila, 5 9ip, -../). ;ence, it should always !e ensured that the patient is on an anti-coagulant to pre#ent the formation of a throm!us. Throm!us can lead to further complications !y dislodging into a peripheral #ein or coronary artery. d) cardiac patient will ha#e a Oprn% order for nitro spray for chest pain. (itro 1A can !e used for some patients to dilate coronary !lood #essels for proper o:ygenation of the heart. Met again, this is not the priority right now, since there is no pain, !ut could !e used to lower the 6* and helping to reduce the workload on the heart. 21. Mr. Kohnson has !een on dialysis for the past fi#e years. ;e Cust had a kidney transplant two days ago with *& pump. ;is medical history includes hypertension, dia!etes +(1"M), and $,04 +end stage renal failure). The doctor has ordered mpicillin 7 g po D", Metformin 5..mg po 61", "imenhydrinate 5. mg 1A T1" *0( and packed 06& to !e infused o#er - hours. Two hours after lea#ing Mr. Kohnson%s room he calls and starts complaining of se#ere pain at the incision site, he is diaphoretic and restless. What se)uence of actions should the nurse take under this circumstance? ). &all the doctor-e:plain what Cust happened, gi#e mpicillin and document. 6). &heck #ital signs, gi#e mpicillin and document. &). &heck #ital signs, gi#e "imenhydrinate and document. "). &heck #ital signs, check operati#e site, call doctor and document. a). &alling the doctor without a complete assess of the patient will not ena!le the doctor to order the right medical inter#entions for the patient. !). &heck #ital signs, gi#e mpicillin and document-the results of #ital signs has to !e reported to the doctor in order for the doctor to order the right medical inter#entions. c). &heck #ital signs, gi#e "imenhydrinate and document the results of #ital signs has to !e reported to the doctor in order for the doctor to order the right medical inter#entions. d). &heck #ital signs, check operati#e site, call doctor and document

the correct answer is '- a complete assessment !y the nurse will ena!le the doctor to prescri!e the right inter#ention for the patient. lso patients with kidney transplant are put on antireCection medications which increase their chances of ac)uiring infection +9ewis, -..=, p.B7B). 22. Mrs. M a B5 year old woman was admitted to the neurology reha! unit following a !rain tumour. ,he was recently diagnosed with a urinary tract infection. "uring a #isit her physician had ad#ised her to drink more fluids on a regular !asis. Mrs. M discusses her physician%s ad#ice with the nurse and states that she is worried that an increase in fluids will increase urinary fre)uency and cause discomfort as a result of the urinary tract infection. 1n this case what should !e the nurse%s !est response? a) 2There%s nothing to worry a!out.3 !)2 lthough fluids will increase fre)uency, it will also dilute the urine and help flush out !acteria.3 c)2 lthough drinking fluids is important, alcohol, chocolate, and spicy food should !e a#oided in order to manage the urinary tract infection3. d)2Mou should drink fluids e#ery B hours3. &orrect answer' !) 0ationale' a)This response fails to address the patient%s concerns. !)The nurse is #alidating the patient%s concerns of increase fre)uency while pro#iding health teaching regarding the importance of drinking fluids. c) This nurse pro#ides information that is rele#ant, although the patient%s concerns were different from what the nurse wanted her to know. d)"rinking fluids e#ery B hours is insufficient and also disregards the patient%s concerns. 2,. Mr. 6ones, H- years old, had undergone hip surgery after he fell at his home. ;e is recei#ing a postoperati#e pain medication which is morphine 1.A. through *atient &ontrolled nalgesia +*& ) infusion pump as physician ordered. Which of the following nursing inter#ention is appropriate in managing his pain? a. Tell him to wait until he is feeling uncomforta!le !efore pressing the !utton. !. Teach his wife how to assist him in operating the *& de#ice. c. dminister another oral analgesic as needed !reakthrough pain and assess )7h. d. Monitor and record the client%s sedation le#el as per hospital policy. &orrect nswer' c 0ationale'

a. *atient should !e encouraged to administer the analgesic !efore pain intensity is greater than the patient%s desired pain intensity goal !. (o one else administers the *& for the patient, only the patient !y himself. c.*& can not !e enough to decrease pain and discomfort le#el since pt is in post-op pain. dditionally, *0( analgesics will !e controlled the se#erity of the pain effecti#ely. d. lthough to monitor and record the client%s sedation le#el is necessary, !ut it is not the appropriate nursing inter#ention to manage the patient%s pain. 24. Mrs. Kones, <. years old was !rought into the emergency department !y am!ulance with -nd degree !urns to the right side of her face and neck. The client%s #oice is #ery shallow and she tells you that she was trying to light a cigarette when her hair caught on fire. s her nurse what is your first priority? . $sta!lish 1A access to increase fluid #olume 6. 0emo#e clothing to assess !urns elsewhere on the !ody &. sses airway patency " *ro#ide pain relief &orrect answer' & $sta!lishing 1A access is important for fluid replacement howe#er it is not as important as maintaining the airway. 6.0emo#al of the clothing can !e done after the 6&%s are completed. & ssessing airway patency is essential !ecause the client may ha#e inhaled flames. This would make the airway !ecome edematous and the client can go into respiratory arrest. s the nurse it is our responsi!ility to assess the airway and determine if the client will need intu!ation !efore the airway is too swollen. Ising our assessment skills and anticipatory planning the nurse can pre#ent the client from needing a tracheotomy. ". *ro#iding pain relief is important !ut not the main priority !ecause the client may not !e feeling that much pain depending on the e:tent of ner#e damage. 25. fter her patient recei#ed an epidural, the nurse noticed a rapid dip in the fetal heart rate +4;0) down to =. !eats per minute for a length of - minutes. What would the nurse%s priority of care !e? a) 0eassure the mother that this is a normal reaction to the epidural and the 4;0 will return to a normal range within a few minutes. !) *age the D!stetrician on call and prepare the patient for a cesarean section. c) 0eposition the patient, apply o:ygen #ia face mask and perform fetal scalp stimulation. d) "iscontinue the epidural infusion and remo#e the epidural catheter. &orrect nswer' & &ationa!e

a) 1s incorrect !ecause any prolonged fetal heart deceleration is considered a!normal and concerning. While you do not want to alarm the patient, it is unethical to reassure her that e#erything is fine, when actions need to !e taken +&anadian (urses ssociation, -..8). !) 1s incorrect !ecause it is not the role of the 0( to determine the need for surgery. lthough, he?she would page the o!stetrician and update them on the condition of the patient +$#ans, $#ans, 6rown, 5 Drshan, -../). c) 1s correct !ecause all of these inter#entions are the standard protocol for reesta!lishing the fetal heart. 0epositioning the mother might help if the !a!y is pinching the um!ilical cord and that is the reason for the deceleration. Ji#ing the mother o:ygen ensure increased o:ygen to the !a!y, who may !e ha#ing difficult reco#ering from contractions. With fetal scalp stimulation, the hope is that the we will see accelerations of the fetal heart rate +9ee, ,prague, Mee 5 $hman, -../) d) 1s incorrect !ecause although the fetal heart deceleration did occur after the epidural was initiated +commonly referred to as a post-epi dip), remo#ing the epidural will not resol#e the issue and would only mean that the patient would need to go through the whole procedure again +9ee, ,prague, Mee 5 $hman, -../). 26. When coming onto your shift you do your initial assessments of your patients. fter first rounds you see that one of your patients is agitated and calling out. 4rom the report that the night staff ga#e is that this particular patient is 2Cust old and a nuisance3. Ipon your initial assessment you find out that the patient is gasping for air and is wheeEing. ;e has only !een a!le to settle when he is in an upright sitting position. Ipon re#iew of the karde: again you see that there has !een #ery little output into the catheter !ag that this patient has. There are no *0( medications ordered. Mour ne:t course of action is to' a) Mou listen to what nights ha#e said to you and ignore what your assessments ha#e told you. 9et this patient struggle for air in the Jeri-chair. !) Jet an order from the physician for a #entolin treatment to deal with the shortness of !reath and the wheeEing. c) &ontact the sending facility to see a!out a proper history on the patient. ,ee if this calling out is common or if it is a new thing. d)&ontact physician to get an order for lasi: to help reduce the fluid in the lungs and eliminate the wheeEing. nswer' a)1s wrong !ecause you are o!ligated to treat any patient regardless of how they are or what another nurse has told you. !)1s wrong e#en though Aentolin is a good option !ut due to the fact that this patient has little to no input is a good indicator that this is not a pro!lem that #entolin treatment cannot treat.

c) 1s wrong !ecause Cust seeing if this calling out and erratic !eha#iour is new or not is a good option it will not help in treating congesti#e heart failure. d) 1s correct !ecause the patient is ha#ing no output and is only a!le to !reathe in an upright position. The patient is e:periencing fluid accumulation in his lungs and needs to reduce the fluid as soon as possi!le. 27.Mr. ,mith is admitted to the hospital for congesti#e heart failure. ;is condition has !een sta!le for the past two days, howe#er, today he !egan to complain of shortness of !reath, fatigue, and there is a greater presence of pitting edema in his e:tremities. What is the most important inter#ention that the nurse needs to perform? a) Weigh Mr. ,mith !) dminister lasi: c) Maintain o:ygen therapy and o!tain o:ygen saturation le#el d) "ecrease and manage patients acti#ity le#el &orrect nswer' & a) lthough this is #ery important to monitor how much fluid Mr. ,mith is retaining, or dieresis and or weight reduction, howe#er it is not a priority at this moment. !) dministering lasi: will help Mr. ,mith decrease the amount of fluid in his !ody, !ut this is also not the first priority in the situation. c) This is the correct answer. dministering o:ygen therapy will decrease the risk of hypo:emia, and it will esta!lish the range of the D- ,aturation. d) This will help with the fatigue and allow Mr. ,mith to retain energy, and once the client feels fatigued he will automatically stop or decrease his acti#ity le#el. 2+. Mrs. ,cott is a <5 year old woman who is <8 weeks pregnant. This is her fourth pregnancy and she has two children at home. Mrs. ,cott was admitted to la!our and deli#ery at -<.. hours. Ipon her admission, the nurse does routine #itals and attaches the fetal monitor to Mrs. ,cott. Mrs. ,cott%s la!our progresses !ut the nurse notices decelerations in the !a!y%s heart rate on the monitor. What should the nurse do to correct the pro!lem? a)Geep the patient in the same position that she is in !ecause the nurse does not want to make the decelerations worse !) Jet the patient up to walk in the hall !ecause this will increase the intensity and strength of the contractions c)0eposition the patient on the left side !y placing a pillow or !lanket under her right side. d) dminister D:ytocin in order to increase the intensity and fre)uency of the contractions so the !a!y can !e deli#ered )uickly.

&orrect answer' c a)Geeping the patient in the same position is not correct !ecause the !lood flow to the #ena ca#e could !e compromised due to positioning. 1n order to correct the decelerations and increase !lood flow, repositioning the patient is re)uired. !) Jetting the patient to walk in the hall helps to get the !a!y%s head in the !irth canal !ut that is not this patients concern. 1n order to increase the intensity and strength of the contractions, the o!stetrician may order a medication called D:ytocin. This medication helps to increase the intensity and fre)uency of contractions in order to speed up the la!our process. D:ytocin is not administered if there are deceleration. c) 0epositioning Mrs. ,cott on her left side helps to increase !lood flow to the #ena ca#a. The #ena ca#a is responsi!le for carrying !lood to the right atrium of the mother%s heart. 1t is important to make sure the mother is getting ade)uate amounts of !lood !ecause in doing so the !a!y is also getting sufficient amounts of !lood. 0epositioning the patient on her left side is one of the many ways to help rectify the decelerations that the nurse sees in the !a!y%s heart rate. d) dministering D:ytocin to the patient is not an appropriate action !ecause this can cause the deceleration to get worse. 4or e:ample if the decelerations are caused !y the !a!y%s head !eing compressed with each contraction, the !a!y%s head will continue to get compressed !ut at a higher rate. This would cause the !a!y%s heart rate to drop more drastically. 1f the patient was on D:ytocin to help with the progression of la!our and the nurse notices decelerations, the priority of the nurse would !e to stop D:ytocin. This is one of the many actions of uterine resuscitation. 29. Mrs. Gikelomo, << years old, J7*7. ,he is hepatitis 6 negati#e, ru!ella immune, group 6 streptococcus +J6,) positi#e and treated twice. ,he has a history of asthma and smoked until -. weeks of pregnancy. ,he is gestational dia!etes mellitus +J"M) on insulin. ,he has undergone spontaneous #aginal deli#ery with - degree episiotomy. 6a!y is 8 hours old, weighs B.5., pgar score H, /, at 7 and 5 minutes respecti#ely and has shoulder dystocia. Dn entering the room, you found !a!y Cittery. Mou should first' a. $ncourage the mother to feed !a!y !. 4acilitate skin to skin contact c.&heck !a!y%s !lood glucose le#el d Transfer !a!y to the neonatal intensi#e care unit+(1&I) &orrect answer' & 0ationales a.4eeding the !a!y is rele#ant !ut not a priority at this time !.4acilitating skin to skin contact is important !ut not a priority for this !a!y. c.Kittery is a sign and symptom of hypoglycemia in infants, since the mother is J"M on insulin, it makes sense that the !a!y is e:periencing low !lood glucose. 1n order to effecti#ely treat hypoglycemia, careful !lood glucose monitoring is critical. d.There is no need to transfer !a!y to (1&I. ,0. Mou are a nurse on a ,chiEophrenia Init in a Mental ;ealth ;ospital. 1t is your weekend to work. Kohn is one of your primary clients and presents at the nursing station complaining of a stiff and sore neck. Mou !egin to in)uire as to the source of the discomfort, the client re)uests the

acetaminophen again, !ut with more urgency. Mou approach the client and notice the clients% right hand has tremors. Kohn also appears to !e thrusting his tongue and speaking as if his tongue is swollen. The client has come to the nursing station re)uesting a prn cetaminophen to help with the neck stiffness. Mour initial response would !e? a) a) dminister 5..-7...mg of prn cetaminophen for pain as re)uested !y client and document as necessary. !) !) sk your client if they ha#e taken any non-prescription medication or any street drugs and order a Irine "rug ,creen to test for illegal drug use as these symptoms could !e that of withdrawal. c) c) &all the duty doctor and re)uest that they come to assess the client. d) d) &heck prn medication sheet and administer 6enEtropine po prn for e:trapyramidal symptoms. 1f not ordered, call the psychiatrist and get a stat order for 6enEtropine. &orrect answer' d) a) a) *ain management is important, !ut not a priority due to the other noticea!le symptoms. !) !) Irine "rug ,creens are only ordered for the clients who ha#e a history of addiction. history of addiction was not indicated for Kohn. c) c) The duty doctor will not consider this to !e of an urgent nature and the client is re)uesting immediate attention. d) d) (eck stiffness, tongue thrusting, tremors are all identifia!le symptoms of !enEodiaEepines use, called $:trapyramidal symptoms and are treated with 6enEtropine. ,1. T. * is a -B year old patient with the history of chronic ulcerati#e colitis. *atient%s ulcerati#e colitis !ecame #ery se#ere and physician decided that surgical inter#ention with possi!le permanent colostomy will !e necessary in this case. *atient is #ery an:ious and upset. Which of the following nursing inter#entions would pro#ide the !est support for T. *? A)*reoperati#e health teaching on colostomy care B)*ro#ide patient with the assurance that whate#er happens, you will !e at her side C) dminister Aalium as ordered preoperati#e D) llow patient to e:press her feelings Correct answer is '.

) *atient education on self care of ostomy is #ery important since it increases patient%s independence and enhances self-esteem when the patient demonstrated the correct skill !efore the discharge. ;owe#er, in this case it is not considered to !e as a !est support for T. * since she is an:ious and upset. Thus, nurse should 7st attend to her psychological well-!eing. 6) *ro#iding assurance to the patient- will create a communication !lock and will not allow nurse to further e:plore patients% feelings and concerns. &) Mes, the patient is an:ious and upset and !y gi#ing her Aalium will not sol#e her root causes for concerns. s a competent nurse, he?she should e:plore patient%s feelings !ecause permanent stoma at her young age could lead to distorted !ody image, isolation, depression and change in lifestyle. ") This is the correct answer. *sychological health is #ery important to this young patient. 1n this case, the nurse allows patient to e:press her immediate feelings, concerns and an:ieties related to permanent stoma. ,2. Mr. 6rady, 5H years old is a patient in the &ardio#ascular ,urgery Init who was admitted with &;4. Dn entering the room, it is o!ser#ed that the patient is in !ed and is sleepy. nurse enters the room to administer digitalis !ut !efore she does it she takes the #ital signs. The patient%s A, read as' 6* 755?/-, 00-78, D--/5, ;0-5/. Which of the following is the most appropriate action to !e taken !y the nurse? a) administer medication as per M" order !) withhold the medication c) report to the physician immediately d) retake #ital signs &orrect answer' !) a) the patient%s heart ate is lower than =. !eats per minute. This could !e a sign of drug to:icity, therefore this is the wrong answer. !) this is the most appropriate action to !e taken so as to pre#ent digo:in to:icity c) this is also the right answer, !ut this is not the priority d) #ital signs can !e taken later !ut the priority is to withhold medication ,,. Mrs. 6uttercup is B7 years old recently had thyroidectomy. What sign should a nurse check for to identify symptoms of hypocalcaemia? a) Joodell%s sign

!) ;omansQ sign c) TinelQs sign d) &h#ostekQs and TrousseauQs signs &orrect answer' d) a) Softening of the cervix; a sign of pregnancy. b) Discomfort behind the knee on forced dorsiflexion of the foot, a sign of thrombosis c) A tingling sensation in the distal end of a limb when percussion is made over the site of a divided nerve. ndicates a partial lesion not calcium deficiency. d) !witching of all facial muscles when tapped and carpal spasm with use of "#$ cuff indicates hypocalcaemia. ,4. -anie is p!anning discharge for her patient. /eorge. who has een diagnosed with *cute &ena! $ai!ure. 0hich comment from /eorge wou!d indicate to -anie that he wou!d re1uire additional hea!th teaching2

a. infection. !. c. d.

1 should monitor my temperature !ecause this is my !est indicator for a possi!le Mouth care is important due to my increased ammonia le#els. My diet should !e high in calories. 1 should use humidified o:ygen and deep !reathing to pre#ent pneumonitis. %orrect answer is &a'. a F This response would tell Kanie that Jeorge re)uires additional health teaching !ecause often patients with renal failure ha#e a !lunted fe!rile response to infection and therefore an ele#ated temperature may not !e present +;olechek, -..B). F This is true8 mouth care is important !ecause it pre#ents stomatitis, which de#elops when ammonia +produced !y !acterial !reakdown of urea) in sali#a irritates the mucous mem!ranes +;olechek, -..B). c F This is true8 good nutrition is necessary in reco#ery from cute 0enal 4ailure +;olechek, -..B). d F This is true8 ;umidified o:ygen and deep !reathing are two techni)ues which help maintain ade)uate respiratory #entilation +Drmandy, -..8). ,5. client with end-stage renal disease arri#es at the hospital with a !lood pressure of -..?7.. mm ;g, heart rate of 77. !eats? minute, and a respiratory rate of <= !reaths? minute. D:ygen saturation on room air is 8/@. ;e complains of shortness of !reath, and you note P- pedal edema.

;is last hemodialysis treatment was yesterday. Which of the following inter#entions should you do first? a) dminister o:ygen. !) $le#ate the foot of the !ed. c) 0estrict the clientQs fluids. d) *repare the client for hemodialysis &orrect answer' a a) irway and o:ygenation always are the first priority. 6ecause the client is complaining of shortness of !reath and his o:ygen saturation is only 8/@, you need to administer o:ygen to increase the *aD-. !) fter taking care of airway and o:ygenation, you also need to ensure that the client is dialyEed to remo#e the e:cessi#e fluid. c) Thirdly, his fluids must !e restricted in order to pre#ent further o#erload of fluid. d) The foot of the !ed may !e ele#ated to reduce edema, !ut this is not a priority. <5. Mrs. ,. is HH years old, diagnosed with T-&ell 9ymphoma. ,he got a chemotherapy treatment two days ago. &urrently complaining of constipation and stomach cramps, her recent unsta!le la! results are platelet 5= +normal' 7B.-B.. $/?9), and W6& count- .B5 +normal' B...-77... $/?9). 6ased on her constipation complain, and !eing in lots of discomfort, crying and trying to push out the feces, what is the !est inter#ention the nurse should do? a) Ji#e her a fleet enema *0( to ease the stool. !)$ncourage Mrs. , to push out the feces slowly c)&all the "octor to get an order for suppository stool softener. d) Ji#e her all her oral *0( la:ati#e medications, and place a warm towel on her lower a!domen &orrect answer' d a) s a nurse, you need to first gi#e her all the oral medication then wait to see if it will !e effecti#e, and since it%s Cust her first complaint of constipation. lso, !ased on her unsta!le la! result you should not insert any o!Cect into her anus !ecause of the low W6& and platelet count she has. ny inCury she sustains will lead to an infection. The reason for her low W6& count and platelet is a side effect of chemotherapy. s a nurse, a preadministration assessment +e.g. la!oratory results) needs to !e done, in order to gi#e medication appropriately. !) "o not encourage her to push when you ha#e not gi#en her any medication to soften the stool8 also pushing might rupture her anus, and that will lead to infection c)Mou do not ha#e to call the doctor for a new order of la:ati#e +suppository), as you ha#e not gi#en her any of the ordered *0( medication the doctor ordered, also you cannot insert anything into her anus !ecause it might rupture her anus d)Ji#ing her all her oral prescri!ed la:ati#e including the syrups and the ta!lets is the most effecti#e way to help her at that moment. ccording to &(D +-..8), nurses ha#e to !e a!le to competently assess clients for the appropriate *0( medication to administer. lso placing a warm towel on her lower a!domen will relie#e the cramps. Then whate#er result you get after doing all this, if it

is not effecti#e, then call the doctor and document appropriately. 1f it is effecti#e, you should document appropriately as well. ,3. Mr. &. is H8 years old. "iagnosed with !ilateral hip pain, has a history of prostate cancer. t 7-am he complained of nausea, and he was gagging as well. Driginally he has a 7-am *D +!y mouth) medication. What should the nurse do? a) Ji#e Jra#ol *0( +*D), and wait <.min-7hour !efore gi#ing him the 7-am *D medication !) Ji#e Rofran? Dndansteron *0( +1A), and his 7-am *D medication c) Ji#e Jra#ol *0( +*D), and his 7-am *D medication d) Ji#e Rofran *0( +1A), and wait <.min-7hour !efore gi#ing him the 7- am *D medication. &orrect answer' d a) ,ince, he feels nauseated and he is gagging, gi#ing him any *D med. 1s not a good idea !ecause he might #omit all the medication !ack, and that will make the matter worst, and he might not e#en !e a!le to take is scheduled 7-am med. an hour or half an hour later. !) Ji#ing him the antiemetic +Rofran) #ia 1A is a good idea, !ut gi#ing him his 7-am *D medication is not a good !ecause he might #omit the medication. c) Ji#ing him any *D medication at the time that he is nauseated is not a good idea !ecause he might #omit all the medication. d) The !est option for him is to take the antiemetic +Rofran) #ia 1A, and then wait for the medication to get to its peak !efore you gi#e him the *D medication. The client can also !e asked if he is still nauseated or not. ,ince medication can !e administer an hour early, and an hour after, it is Dk to gi#e him his scheduled *D med late, that is, he can take the *D med. at 7am. <H. 9ucy, two and half years old, is #ery lethargic, con#ulsing, and has a temperature of </.5 degree centigrade. The physician ordered "iaEepam +Aalium) to !e administered to her rectal. The parents are #ery worry and ask why their daughter is recei#ing this medication. What should the nurse do? a. !. c. d. 1nform them that she is recei#ing a medication rectally to lower her temperature. 0eassure the parents that e#erything possi!le is !eing done for their daughter. $:plain to them that she is recei#ing a medication for her con#ulsion. Wait for her condition to sta!iliEe and ask the physician to talk to the parents. &orrect nswer' 4c) &ationa!es "iaEepam does not lower temperature. This does not answer the parents% )uestions.

5arents need and ha)e a right to recei)e the information. This does not address the parents% immediate concern and it is a nurse%s responsi!ility to teach a!out medication administration. ,+. nita is a nurse in an acute care psychiatric unit caring for Mr. 9in a patient diagnosed with !ipolar mania. nita recogniEes that Mr. 9in has gotten into an altercation with another patient and is putting the patient down stating 2 1 am !etter than you !ecause you are worthless.3 What is the nurses% initial response to dissol#ing the issue? a. *ro#ide the patient with a )uiet room to decrease stimuli !. &arefully indicate that aggressi#e !eha#iour is unaccepta!le c. 0espond to Mr 9in%s remarks stating that he is worthless instead d. 0einforce the !enefits of good !eha#iour &orrect answer' ! a. *ro#iding the patient with a )uiet room to decrease stimuli is likely to help the situation with continuing de-escalation howe#er it is !etter to first let the patient know in a calm matter of fact tone that his actions are unaccepta!le on the unit. !. &arefully confronting unaccepta!le !eha#iour is !eneficial for patients with !ipolar mania !ecause it helps redirect them to engage in healthier interpersonal interactions while pro#iding noticea!le cogniti#e !eha#iour therapy c. 0esponding to Mr. 9ins% remark in anger would further e:acer!ate and prolong the altercation. d. *atients with !ipolar mania need to !e reminded of good !eha#iour howe#er8 unaccepta!le !eha#iour should not !e o#erlooked or ignored. ,9. ,ally is a newly graduated 0( working in la!our and deli#ery. Today she is caring for Kennifer, a multiparous woman who ga#e !irth #aginally to a B-.. gram !a!y !oy <5 minutes ago following a #ery rapid la!our. ,ally is alone with Kennifer in the room completing her new!orn assessments when Kennifer states 21 keep feeling gushes of !lood coming out of me3. ,ally puts the sides up on the !a!y cot and pulls !ack the sheets to see what is on the pads !elow Kennifer. The pads are completely saturated as are the sheets around the pad, in !right ru!ra discharge. What should !e ,ally%s ne:t action? ) *ress the call !ell for assistance and massage the fundus. 6) *ress the call !ell for assistance and take #ital signs. &) 1nitiate a large !ore catheter into her #ein for !lood administration and take #ital signs.

") Massage the fundus and empty the !ladder. This )uestion relates to a maternal?infant area of focus. 1t is testing the nursing inter#ention related to a postpartum hemorrhage. 1t is connected to competency S< of recogniEing limitations of practice and seeking necessary assistance +&ollege of (urses of Dntario, -..8). The correct answer is . 1n the first - hours after !irth, the discharge should not e:ceed that of a hea#y menstrual cycle +Wong, *erry 5 ;ocken!erry, -..=). ,ally would recogniEe the situation as a postpartum hemorrhage which can occur when the uterus is not firm and contracting +Wong et al., -..=). is correct !ecause massaging the fundus is the !est way to get the uterus contracting and firm +Wong et al., -..=). When it is contracting, it stops the !leeding from the #essels within the uterus +Wong et al., -..=). ccording to the ,alus Jlo!al &orporation in their MD0$D6 *ostpartum ;emorrhage document +-.77), the mortality rate associated with a postpartum hemorrhage is greatly decreased when a team approach is taken. 6y calling for assistance, ,ally will ha#e e:tra help to contact the D6 and initiate whate#er step is needed depending on the effect the massage has on the amount of !leeding. ,ally would also recogniEe that Kennifer has some risk factors for a postpartum hemorrhage in that she had a macrosomic !a!y, had a rapid la!our and has a high parity +,alus Jlo!al &orporation, -.77). &hoice 6 is not the most correct although it would !e in other areas of practice if a hemorrhage was suspected. Aital signs are not the !est indicator of going into shock as the postpartum woman has many physiologic adaptations +Wong et al., -..=). lso, the !lood pressure and pulse would !e getting measured e#ery 75 minutes as is standard protocol after a normal #aginal !irth +Wong et al., -..=). &hoice & is not the ne:t logical step. lthough a large !ore catheter may !e re)uired if !lood is needed, it is not as important as stopping the !leeding and getting the uterus to contract. &hoice " is not as correct as in that it does not get the assistance for help. full !ladder may pre#ent a uterus from contracting efficiently and may need to !e emptied !ut when the !leeding is greater than normal, getting assistance is the priority +Wong et al., -..=). 40. Mrs. ,mith, H8 year old client was admitted for shortness of !reath. Mou the nurse enter her room to pro#ide M care and you noticed she is e:periencing respiratory distress. What is the 410,T nursing inter#ention you would perform? a) Ji#e her B9 of o:ygen !) Take a set of #ital signs c) &all the doctor d) 0aise the head of the !ed &orrect nswer' a) *ro#iding o:ygen right away helps correct the situation and pro#ide relief to the client. !) Taking a set of #ital signs take time to do and during that time, the client%s health status could decrease e#en more !ecause no treatment or relief is !eing offered. lso the nurse has a general idea what the #itals would !e due to the signs and symptoms the client is displaying. c) &alling the doctor and waiting for orders takes se#eral minutes which in the end could affect the client%s o#erall health status d) 0aising the head of the !ed is the second inter#ention that would !e performed to help the client%s health status.