* A client with angina complains that the angina pain is prolonged and severe and occurs at the same time each day, most often in the morning, On further assessment a nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as:

a- Stable angina

b- Unstable angina

c- Variant angina

a- Nonanginal pain

* An alert oriented 77 year-old woman lives in a long-term care nursing home although she is usually busy participating in the coordinated activities of the nursing home, the nurse finds her sitting alone in the corridor. Various tests are ordered including a urine analysis  .Blood pressure 128/74 mmHg Heart rate 98/min Respiratory rate 26/min Body temperature 38.3 °C oral Which additional clinical finding would most likely be an indicator of the early onset of her problem? a- Low urea concentration b- Acute confusion c- Increased blood pressure d- Respiratory rate> 22/minute

Which additional clinical finding would most likely be an indicator of the early onset of her problem?

a- Low urea concentration

b- Acute confusion

c- Increased blood pressure

d- Respiratory rate> 22/minute

*. A patient with bowlegs due to abnormal bone formations and deformities has calcium level of 7.5 mg/100ml.

Which of the following foods would the nurse most likely instruct the patient to add to a diet?

a- Organ meats

b- Whole grains

c- Egg yolks

d - Chicken meat

* A patient is one day post-operative repair of a large umbilical hernia. The patient complaints of abdominal pain and describe feeling the sutures give way. Upon assessment of the abdomen the nurse observes an evisceration. The nurse's IMMEDIATE response should be to:

a- Medicate the patient for pain

b- Instruct the patient to cough hard

c- Have the patient perform the Valsalva maneuver

d- Cover the abdomen with a sterile saline spiked dressing

* While reviewing stress management techniques with a patient diagnosed with multiple sclerosis, what would the nurse identify as MOST appropriate?

a- Relaxing in a warm bubble bath

b- Yoga in a cool room

c- Sunbathing

d- Cross-country running

* A four year - old boy presented with a firm and non- tender mass that his mother had discovered in the right upper abdominal quadrant He was admitted to the hospital and underwent complete surgical excision of a renal tumor that had extended beyond the kidney. The child was then scheduled for radiation and chemotherapy treatment.

Which stage was the tumor?

a- I

b- II

c- III

d- IV

* When caring for a patient with an ostomy the nurse knows that extra skin protection for the personal skin is MOST important for those patients with a (an):

a- Ileostomy

b- Ascending colostomy

c- Transverse colostomy

d- Sigmoid colostomy

* The nurse is assessing the growth and development of a healthy three year-old child. The nurse should expect the child to be able to:

a- Ride a bicycle

b- Jump rope

c- Throw a ball overhead

d- Hop on one foot

* The nurse is monitoring a patient recovering parenteral nutrition via a central line catheter for the 24 hours. The patient has polyuria and complaint thirst and headache.

Blood pressure 120/76 mmHg

Heart rate 88/min

Respiratory rate 16/mm

Temperature 37.1°C

Oxygen Saturation 99% an room air

What will the nurse most likely administers?

a- Insulin

b- Dextrose 5% in water

c- Normal saline

d- Calcium gluconate

* A 22 year-old man suffered major injuries to the right leg in a road traffic accident that resulted in an above -the- knee amputation with a rigid dressing. Twelve hours later the patient complains of increasing pressure from the dressing and the feeling that something is crawling around the stump.

a- Notify the physician

b- Remove and reapply the dressing

c- Remind patient phantom limb pain is normal

d- Elevate and apply ice to the residual limb

* A patient with congestive heart failure and severe peripheral edema has a nursing diagnosis of fluid volume excess

What are the two MOST important interventions for the nurse to initiate?

a- Diuretic therapy and intake and output

b- Nutritional education and low-sodium diet

c- Daily weights and intake and output

d- Low-sodium diet and elevate legs when in bed

*. A nurse is providing care to a patient with a new skin graft on the leg. The patient is upset and the nurse notes copious red drainage oozing around the dressing the nurse should immediately:

a- Lift the dressing to assess the area

b- Ask if the patient is having any pain

c- Apply firm pressure for 10 to 15 minutes

d- Assess the apical pulse

* A 25 years-old male patient suffered a spinal cord injury at the T -4 level and is being cared for in hospital. The nurse enters the patient's room and finds the patient sitting upright and looking anxious and restless. He complains of sudden headache and nausea. Sweat forms on his forehead yet his feet are cool to touch

Blood pressure 150/100 mmhg

Heart rate 55/min

Respiratory rate 28/min

Temperature 37.1C

What nursing intervention is initially most appropriate?

a- Assess for a full bladder

b- Lower the head of the bed 30 degrees

c- Loosen clothing and bed sheets

d- Apply heating pad to lower extremities

* To minimize a toddler from scratching and picking at healing skin graft, the nurse should utilize:

a- Mild sedatives

b- Hand mittens

c- Punishment for picking

d- Distractions

* A 30 year-old diabetic woman complains of blood in the urine and dull pain over the left lower abdomen, middle back and above the pubic bone. She feels the urge to urinate frequently and urgently. For the past two days, she has had nausea and vomiting. Abdominal assessment reveals tenderness over the pubic bone; no guarding and bowel sounds are active in all quadrants.

Which home intervention would be most effective?

a- Oral antibiotics

b- Increased fluid intake

c- Increased dietary protein

d- Cold application to left hand

* The nurse calls together an interdisciplinary team with members from medicine, social service, the clergy, and nutritional services to care for a patient with a terminal illness.

Which of the following types of care would the team MOST likely be providing?

a- Palliative

b- Curative

c- Respite

d- Preventive

* Pulse Volume Scale

Absent pulse =0

Weak and Thready pulse=1

Normal=2

Bounding pulse=3

A 26 year- old female patient's radial pulse is assessed for a full minute. The nurse notes the pulse is difficult to palpate and count.

What should the nurse chart?

Blood pressure 82/48mmHg

Respiratory rate 20/min

Temperature 38.8°C

a- 0

b- 1

c- 2

d- 3

* A patient recently underwent coronary artery graft (CABG) surgery.

Which of the following nursing diagnose PRIORITY?

a- Anxiety

b- Impaired gas exchange

c- Acute pain

d- Sleep deprivation

* A child with asthma has an order for albuterol, before administration of the medication the nurse MUST.

a- Pre-oxygenate the patient

b- Assess the patient's heart rate

c- Obtain venous Access

d- Feed the patient a snack

*. A 52 year- old woman is scheduled to undergo an abdomino- perineal resection in three days for removal of a cancer of the rectum. The nurse reviews the care plan with the patient. The patient will receive prophylactic antibiotics and will be given a mechanical bowel preparation the day before.

Which additional preparation should the patient undertake at this time?

a- Wear pressure stockings

b- Perform leg strengthening exercises

c- Maintain high- protein, low- residue diet

d- Take daily ferrous iron tablets

* A 32 year-old female has an adrenocortical hormone disorder. The nurse notes the patient has thin scalp hair, a large trunk and thin extremities.

Blood pressure 152/84 mmHg

Heart rate 64/min

Respiratory rate 16/min

Temperature 37.2°C

Oxygen Saturation 98 % on room air

Which clinical findings are most likely?

a- Decreased bowel sounds and muscle soreness

b- Cardiac arrhythmias and abdominal cramping

c- Headache, confusion and muscle twitching

d- Hunger, trembling and nervousness

* A 62 year-old man is diagnosed with localized non cell tumor of the lung without metastasis and under lobectomy. After the procedure, he is brought to Postoperative Anesthesia Care Unit for recovery with chest tube drainage system in place and administered by nasal cannula.

Which nursing action is initially most important?

a- Assess level of consciousness

b- Attach chest tubes to the bed sheets

c- Perform deep breathing and coughing

d- Apply elastic stockings to the legs

* A 67 year-old man is admitted to the Post-anesthesia Recovery unit following chest surgery. The patient has a right chest tube that is attached to low suction. Three hours after admission to the unit, the nurse observes the drainage output from the chest tube is 300 milliliters.

What is the most appropriate initial intervention?

a- Notify the doctor

b- Reduce IV infusion rate

c- Strip tube with roller device

d- Re-position in left lateral decubitus

* An elderly patient with severe degenerative joint comes to the clinic for routine follow up of management. The patient reports that over the month, the pain has begun to increase in severity patient requests an increase in dosage of the medication. The nurse recognizes that this is most likely due to?

a- Drug addiction

b- Drug tolerance

c- An improvement in condition

d- Lack of efficacy of the current medication

* A community health nurse visits a patient who has suffered a stroke. The patient's spouse explains to the nurse that the patient chokes while eating some times. Which of the following referral orders would the nurse anticipate needing for this patient?

a- Speech therapist

b- Dietician

c- Physical therapist

d- Neurologist

* A patient is transferred to the Intensive Care following a craniotomy. The patient is difficult to arouse and the pupils are pinpoint and non-reactive.

Blood pressure 118/70 mmHg

Heart rate 58/min

Respiratory rate 11/min

Temperature 37.2°C

Which medication should the nurse prepare administer?

a- Adrenaline

b- Thiamine

c- Naloxone

d- Dextrose 50%

* The nurse has been assigned to care for a 60 year old critically ill patient with a

triple-lumen central venous line. The doctor's orders include daily care of the insertion site and catheter device. The nurse creates care plane based on the nursing diagnosis, Risk for infection related to insertion of a venous catheter.

Which intervention is most likely to prevent infection?

a- Re-cap access hub after drawing blood

b- Maintain clean technique

c- Wash hands before performing catheter care

d- Clean catheter tubing with isopropyl alcohol

* A patient who underwent a right knee arthroplasty two days ago has a nursing diagnosis of impaired mobile. The patient refuses to get out of bed and ambulate due chest pain.

Which of the following action would the nurse MOST likely implement?

a- Medicate the patient prior to ambulation

b- Add a nursing diagnosis of non-compliance

c- Let the patient rest now and then try to ambulate later

d- Assess to determine the cause of the chest pain

*. Prior to providing care for a hospitalized infant the nurse who focuses on preventive measures must.

a- Introduce self-parent

b- Perform hand hygiene

c- Have a witness present

d- Assess the child's developmental level

* The nurse is inserting a nasogastric (NG) tube into patient as prescribed. The nurse has advanced the into the patient's posterior pharynx. The nurse show now ask the patient to?

a- Hold the breath

b- Stare upwards with the eyes towards the ceiling

c- Perform the Valsalva maneuver

d- Lower the chin towards the chest

* What would be the long-term management goal for a patient with diabetes

mellitus, type II?

a- Quickly lower blood glucose level by administering insulin

b- Achieve hypoglycemic state

c- Maintain daily exercise

d- Understand how to self-administer msulax

* The nurse administered a dose of morphine sulfate, as prescribed to a patient who is in the post-anesthesia care unit (PACU). The patient appears to be resting comfortably; the respiratory rate is 8 and the O2 saturation on 2L of oxygen via nasal cannula is 86%. The nurse should IMMEDIETLY administer.

a- Flumazenil (Romazicon)

b- Midazolam (Versed)

c- Naloxone (Narcan)

d- Ondansetron (Zofran)

* A patient is 90-minutes post-abdominal hysterectomy and complains of pain in the post anesthesia care unit (PACU). The nurse administers the prescribed dose unit intravenous morphine. Five minutes later, the patient is difficult to arouse, with the following vital signs.

What should the nurse do NEXT?

Respiratory rate 6/min

Saturation 86% on room air

a- Document the efficacy of analgesic therapy

b- Administer naloxone (Narcan)

c- Place in supine position

d- Check the surgical site for bleeding

* The stage of dying as identified by Dr. Elizabeth Kubler-Ross occurs in what order?

a- Anger, depression, bargaining, denial, acceptance

b- Bargaining, denial, Anger, acceptance, depression

c- Denial, Anger, bargaining, depression, acceptance

d- Depression, denial, Anger, bargaining, acceptance

* A 42 year- old patient is in a lower body cast following a motor vehicle accident. In order to minimize muscle strength loss while in the cast, the nurse will instruct the patient in the performance of.

a- Isometric exercises

b- Passive range of motion exercises

c- Active-assistive range of motion exercises

d- Resistive range of motion exercises

* A patient has a history of severe, uncontrolled epistaxis. The patient's blood pressure and platelet count are normal. To minimize the occurrence of bleeding episodes the nurse should teach the patient to.

a- Sleep with the head elevated on at least two to three pillows

b- Apply firm pressure to the nostrils four times a day

c- Apply a water- soluble lubricant to the nasal septum twice daily

d- Minimize the intake of caffeine and increase fluids intake

* A six year-old patient has been diagnosed with acute rheumatic fever. The nurse knows that the antibiotic of choice for this illness is:

a- Benzathine penicillin (Megacillin)

b- Amoxicillin (Amoxil)

c- Erythromycin (Erythrosine)

d- Vancomycin (Vancocin)

* A 20 year- old woman takes cyclosporine 100 mg by mouth twice per day. She had a heart transplant two months ago and complains of dizziness, shortness of breath, light headedness and fatigue. Capillary refill >3.

Blood pressure 90/50 mmHg

Heart rate, irregular 100/min

Respiratory rate 28/mm

Temperature 38.0°C

What is the most likely underlying cause of the patient's problem?

a- Cyclosporine toxicity

b- Hyperkalemia

c- Organ rejection

d- Infection

*A patient is transferred to the Intensive Care Unit following a craniotomy. The patient is difficult to arouse and the pupils are pinpoint and non-reactive.

Blood pressure 118/70 mmHg

Heart rate 58/min

Respiratory rate 11/mm

Temperature 37.2°C

Which medication should the nurse prepare to administer?

a- Adrenaline

b- Thiamine

c- Naloxone

d- Dextrose 50%

* A 23 year- old male comes to the Emergency Department in a sickle cell crisis. He reports that his pain level is a 10/10 in all extremities. During the assessment, he cannot lie still because of the pain. There is no cyanosis or clubbing in the extremities and all examination findings are normal. The vital signs recorded were

Blood pressure 132/82 mmHg

Heart rate 110/min

Respiratory rate 18/mm

Temperature 38.4°C

Oxygen Saturation 94 % an room air

Which nursing diagnosis is first priority?

a- Acute pain

b- Fluid volume deficit

c- Ineffective tissue perfusion

d- Ineffective airway clearance

* A patient who underwent a right knee arthroplasty two days ago has a nursing diagnosis of impaired mobility. The patient refuses to get out of bed and ambulate due to chest pain.

Which of the following actions would the nurse MOST likely implement?

a- Medicate the patient prior to ambulation

b- Add a nursing diagnosis of non-compliance

c- Let the patient rest now and then try to ambulate later.

d- Assess to determine the cause of the chest pain

* Upon assessment of an obese patient's back, the nurse observes a forward curvature of the lumbar spine. These findings are indicative of.

a- Kyphosis

b- List

c- Lordosis

d- Scoliosis

* A newborn was delivered pre-term weighing 2700 grams with. Apgar scores of 4 and 6, respectively. When the mother had presented to the Obstetrical Triage Unit, she was already 7 centimeters dilated and fully effaced. Her due date was unknown as she had no parental care. The infant showed signs of fetal distress and was finally delivered by Cesarean section. At birth a large, thin, membranous sac was protruding from the umbilical base.

What is the priority nursing intervention at birth?

a- Maintain cardio respiratory stability

b- Protect the herniated viscera

c- Manage fluid intake and output

d- Establish vascular access

* A surgeon instructs a nurse to serve as a witness to an elderly patient's

informed consent for surgery. During the surgeon's explanation to the patient, it becomes clear that the patient is confused and does not understand the procedure, but reluctantly signs the consent from. The nurse should.

a- Sign the form as a witness, making a notation that the patient did not appear to understand

b- Not sign the form as a witness and notify the nurse supervisor

c- Not sign the form and answer the patient's questions after the surgeon leaves the room

*. A child is treated for superficial (first-degree) thermal burns to the thigh. The child is in great discomfort and does not eat.

Which of the following diagnoses should receive PRIORITY?

a- Altered nutrition

b- Impaired skin integrity

c- Risk for infection

d- Acute pain

* A patient is being prepared for a right breast biopsy under general anesthesia. The patient asks the nurse about the surgical scar and possible postoperative complications.

Which of the following actions would be appropriate for the nurse to take?

a- Review the postoperative risks with the patient

b- Notify the surgeon about the patient's questions

c- Compete the patient's preoperative check list

d- Show the patient photos of breast surgical scar

* A patient who is 4 days postoperative after a total hip replacement surgery, is obese and has not been able to ambulate since the surgery. The patient is now diaphoretic, has chills, and complains of pain in the thigh. There is tenderness over the anteromedial surface of the thigh. The MOST likely cause is.

a- Wound infection

b- Deep vein thrombosis (DVT)

c- Pulmonary edema

d- Dehydration

* A nurse is communicating with a moderately autistic child during a developmental and behavioral assessment. The nurse uses non-verbal techniques to engage the child's cooperation. She uses facial expressions when responding and simple body language to communicate commends.

What is the most likely age of the child?

a- One

b- Three

c- Six

d- Nine

*. A 27 year-old woman presents with stomach cramping with alternating constipation and diarrhea. She had been diagnosed with irritable bowel syndrome two years before and has so far managed the illness with lifestyle changes, including diet and exercise.

What is the most appropriate advice?

a- Increase dairy intake

b- Use antacids to relive pain

c- Increase dietary fiber

d- Avoid emotional stress triggers

* A nine year-old child has been diagnosed with external otitis. In addition to assessing severity of symptoms and need for pain relief, the nurse should assess.

a- The hearing of the child

b- The tympanic temperature

c- Speech and language development

d- Ear hygiene and the need for earplugs

* A 68 year-old man is admitted to the hospital with an exacerbation of chronic obstructive pulmonary disorder. He has breathing difficulties, restlessness and anxiety. He also has a moist and productive cough. The lower extremities are swollen with pitting edema 4+. A blood gas specimen is collected and sent to the laboratory. The patient has not been on supplemental oxygen therapy at home (see lab results)

Blood pressure 180/90 mmHg

Heart rate 90/min

Respiratory rate 28/mm

Body Temperature 37.1°C

Oxygen Saturation 86 % an room air

Test Result Normal Values

ABG PCO2 7.33 4.7-6.0 kPa

PH 7.32 7.36-7.45

ABG PO2 7.73 10.6-14.2 kPa

What is the most likely percentage rate per liter for oxygen administration via nasal cannula for this patient?

a- 0.5-1

b- 1.5-2

c- 2.5-3

d- 5-6

* When performing tracheal suctioning for a client with a tracheotomy the nurse should :

A. Pre-oxygenate the client before suctioning.

B. Apply negative pressure as the catheter is being inserted.

C. Be sure the cuff of the tracheotomy is inflated during suctioning.

D. Instill normal saline into the tracheotomy prior to suctioning.

* A 32 year-old man is brought to the Emergency Department by a friend with whom he had been playing football with earlier that evening. His symptoms came on after twenty minutes of the football match. He appears anxious and restless. Auscultation of the lungs reveals wheezing on exhalation. The patient states that he is unable to get a full breath of air. He had this problem as a child a couple of times after exercising in cold weather.

Blood pressure 126/72 mmHg

Heart rate 90/min

Respiratory rate 28/mm

Temperature 37.0°C

Oxygen Saturation 94 % on room air

Which position is best for this patient?

a- Supine

b- Reverse Trendelenburg's

c- Prone

d- High fowler's

* A 40 year-old woman is undergoing an elective rhinoplasty under general anesthesia. The patient is in the pre-operative room and the nurse is prepared to administer pre-operative intravenous medications. The patient states that she does not have any drug allergies.

Which additional nursing action is most important prior to administering the medicine?

a- Request the patient urinate

b- Perform blood typing and cross matching

c- Ensure the consent form has been signed

d- Clarify contact numbers of her family members

* A 24 year-old man was admitted to the hospital after receiving a closed head injury in a motor vehicle accident. He had a Glasgow Coma Score of 6 on admission and was being mechanically ventilated. The nurse observes the intracranial pressure has slowly and steadily increased over the past hour.

What is the most appropriate initial nursing action?

a- Administer mannitol

b- Administer Phenobarbital

c- Increase respiratory rate

d- Reposition while maintaining neck alignment

* The nurse is caring for a 4 year-old patient with a diagnosis of cystic fibrosis and pneumonia. The child is feeling better on the 3rd day of the hospitalization and "wants to play"

What would be the BEST choice of entertainment?

a- Blowing bubbles

b- Looking at picture books

c- Watching videos

d- Riding in a wagon

* During the immediate postoperative period, a patient reveals an oxygen saturation level of 91 %. The nurse should

a- Position the patient on the left side

b- Administer supplemental oxygen

c- Continue to provide supportive care

d- Lower the temperature of the room

* An 83 year-old woman lives in a long term care facility. During the past two weeks, she has suffered two falls that resulted in minor injuries and now complains of pain in the left shoulder. On auscultation, bowel sounds are diminished in all four quadrants. On palpation, she has tenderness and guarding over the upper left quadrant and complain of a feeling of fullness. What could be the most likely underlying cause of the finding?

a- Constipation

b- Liver distention

c- Splenic rupture

d- Intestinal obstruction

* In evaluating a patient after a cerebrovascular accident (eVA), which of the following is an expected outcome of the nursing diagnosis of impaired physical mobility related to motor deficits?

a- Oriented to person, lace, and time

b- Maintains body alignment, no contractures

c- Communicates appropriately

d- Voids on command at 2-hour intervals

* A patient who has a diagnosis of multiple sclerosis speaks slowly with long pauses between syllables.

The patient is MOST likely in what stage of multiple sclerosis?

a- Prodromal

b- Early

c- Middle

d- Late

* A 70 year-old quadriplegic man has ulceration on the left buttocks with full thickness skin loss. Although several interventions have been used to promote healing, the ulcer does not improve (see image)

Which dietary insufficiency is most likely?

a- Vitamin D

b- Calcium

c- Protein

d- Vitamin C

* In planning a lecture for a community group effect of acquired immunodeficiency syndrome gerontological community, the nurse would be correct in including which of the following stat regarding the incidence of the illness in people be 55 and 64 years of age?

a- The illness is almost unheard of in this age group prior to 2003

b- The illness has more than doubled between 1998 and 2003

c- There are not many people living with the disease as it quickly fatal

d- Treatment is more effective in this age group

*. A home care nurse visits a patient who is wheelchair bound due to a recent motor vehicle accident. The patient has been sitting in the wheelchair for extended periods of time, which has resulted in the development of a stage I pressure sore on the right buttocks.

What is the BEST nursing intervention?

a- Instruct the caretaker to change the patient's position every 2 hours

b- Apply hydrogel to the stage I pressure sore every 8 hours

c- Refer the patient to a wound care specialist for debridement

d- Encourage the patient to consume an increased amount of calcium

* A nurse is caring for an infant with respiratory distress syndrome.

Which of the following nursing intervention is appropriate?

a- Measure oxygen saturation level once a shift

b- Suction frequently for 30-45 seconds each time

c- Monitor for symptoms of hyperglycemia

d- Maintain infant temperature 36.7° and 37.8°C

* A patient who sustained extensive abdominal injuries in a motor vehicle accident has developed a large stage II pressure ulcer on the coccyx. A new diagnosis of alteration in skin integrity is added to the care plan.

What is the BEST short-term goal for the patient?

a- Show evidence of healing within one week

b- Have no discomfort from the pressure ulcer

c- Eat at least 50% of each meal

d- Verbalize strategies to prevent further skin breakdown

* A nursing home resident with chronic osteoarthritis complains of knee pain. A routine order of acetaminophen (Tylenol) 500 mg every 6 hours was administered 2 hours ago with no relief. The patient also has an order for ibuprofen (Motrin) 400 mg every 6 hours as needed. The patient reports some relief, but is still bothered by mild pain. The nurse should

a- Administer ibuprofen (Motrin) 400mg

b- Educate the patient that mild pain is expected with osteoarthritis

c- Call the physician for additional pain medication

d- Administer acetaminophen (Tylenol) 500 mg

* A 55 year-old man has become very anxious about skin lesions he has developed. On the lower right forearm, there is a well demarcated round patch of skin that he feels could be cancerous. It is 2.5 centimeters in diameter and slightly raised. On palpation it is scaly, dry and rough. The affected area appears sun tanned and reddened. The condition has been persistent for the past four years but has only recently become itchy.

What is the most likely underlying problem?

a- Seborrheic keratosis

b- Actinic keratosis

c- Eczematous dermatitis

d- Lupus erythematosus

*. A nurse is assessing several patients who are over the age of 65 years.

Which question would demonstrate the nurse's understanding of changes associated with the normal process of aging?

a- Patient A

b- Patient B

c- Patient C

d- Patient D

* A 65 year-old woman with a history of unstable angina and hypertension presents to the Emergency Department with a dull chest pain that she describes as similar to heartburn. The pain radiates down the left arm. She had taken sublingual nitroglycerin tablets without any relief. An electrocardiograph is performed and shows elevated S- T segments. The nurse is to administer a thrombolytic by intravenous infusion.

Which factor places this candidate at high risk for bleeding?

a- Unstable angina

b- Hypertension

c- Age

d- Elevated S- T segments

Normal

Less than 120

More than 80

Prehypertension

120-139

80-89

Stage 1 hypertension

140-159

90-99

Stage 2 hypertension

More than 160

More than 100

* The following blood pressures have been documented in the patient's chart for the past six months; 124/76 mmHg, 136/83 mmHg and 128/80 mmHg. The Most likely diagnosis is:

a- Normal blood pressure

b- Prehypertension

c- Stage 1 hypertension

d- Stage 2 hypertension

* The nurse is performing a routine examination for a 24 year-old man with diabetes mellitus. He takes insulin injections twice daily and monitors his blood sugar regularly. He is vegetarian with a body mass index of 17. The nurse is concerned about his weight.

Which additional information is most likely required to calculate his ideal daily caloric intake?

a- Daily elimination pattern

b- Protein and carbohydrate intake

c- Activity and exercise level

d- HDL and LDL cholesterol levels

* A nurse is assessing a child with suspected lead poisoning.

For which of the following should the nurse assess?

a- Developmental delay, constipation, anorexia, clumsiness, and pallor

b- Confusion, delirium, seizures, lethargy, stupor, and coma

c- Respiratory depression, obstruction, pulmonary edema, and tachypnea

d- Peripheral circulatory collapse and heart failure

*. The following pain medications are ordered for a patient who had a right leg amputation. Oxycodone 5 mg every 4 hours as needed and morphine 5 mg every 4 hours as needed. The nurse administered oxycodone 2 hours ago, but the patient reports pain rated 8 on a scale of 0 (no pain) to 10 (severe pain) as the dressing change beings.

After evaluating the effectiveness of the pain medication, what action should the nurse take?

Blood pressure 169/98 mmHg

Heart rate 112/min

Respiratory rate 22/mm

Temperature 36.7°C

a- Administer additional oxycodone 5 mg

b- Administer morphine 5 mg

c- Change the dressing quickly

d- Encourage deep breathing

* A 72 year-old woman who is alert and oriented has been hospitalized with atrial fibrillation. Since admission four days ago, she has been receiving digoxin intravenous injection. Today is the first day the digoxin injection will be discontinued and she will change to oral tablets. Although she acknowledges the medication benefits, she refuses to take it as it makes her feel nauseous.

What is the most appropriate nursing action?

a- Continue administering by intravenous push

b- Withhold medication and notify the physician

c- Withhold medication and file an incident report

d- Provide it in liquid from mixed into a drink

* The district nurse visits a 30 year-old woman at home following the delivery of her second child, a full term girl. Following the delivery of her first child, she had developed a breast infection and stopped breastfeeding because of the pain. She asks the nurse how she can best prevent it with this infant.

What is the most appropriate response?

a- Provide feedings on demand

b- Apply vitamin E cream to the nipples

c- Request a prophylactic antibiotic

d- Apply heat to the breasts after feedings

* A patient has returned to the medical-surgical unit after surgery for a benign ovarian tumor. The nurse observes that in the first 30 minutes after admission to the unit, the patient's abdomen is rapidly distending and the patient complains of increasing pain. The nurse would anticipate.

a- Aspiration pneumonia

b- Surgical site infection

c- Retention of surgical supplies

d- Intra-abdominal hemorrhage

* A nurse is caring for a postoperative patient who is on subcutaneous, low-dose heparin. When administering an injection on the abdomen, the nurse avoids the umbilicus area because of the possibility of.

a- Entering a larger blood vessel

b- Causing increased pain

c- Precipitating hyperventilation

d- Umbilical infection

* The nurse caring for a mobile patient with a destroyed tympanic membrane and an intact stapes.

What type of repair process should the nurse anticipate?

a- Myringoplasty

b- Tymoanostapedopexy

c- Cavum minor

d- Tympanoplasty and fenestration of lateral semicircular canal

* An 82 year-old woman with Alzheimer's disease had moved into a long-term care facility two weeks previously. Since then, the staff has found her wondering in the hallways in middle of the night. When approached, she is confused and frustrated, often forgetting where she is.

Which intervention would most likely decrease the patient's confusion?

a- Administer a sleeping sedative

b- Provide full-time nursing care

c- Place a nightlight in the room

d- Provide a large meal before bed

* A 25 year-old woman resents to the clinic with abdominal pain. She reports the last bowel movement was two days previously. There is no vomiting or diarrhea and her body temperature is normal. During percussion of the lower left quadrant the nurse hears tympanic sounds.

What is the most likely underlying cause for the finding?

a- Gas

b- Tumor

c- Liquid

d- Feces

* A 40 year-old woman present with painful leg cramps and muscle twitching, which wakens her at night. Her menstrual cycles are irregular and cause painful abdominal cramping. The hair, skin and nails appear dry and brittle (see lab results)

Test Result Normal Values

Calcium 2.09 2. 15-2.62mmollL

Phosphate, inorganic 1.69 0.82-1.51mmollL

Magnesium 0.55 0.7-1.0mmollL

What type of lifelong diet would be most beneficial for this patient?

a- Increased magnesium and vitamin C

b- Increased calcium and vitamin D

c- Increased dairy and iron

d- High protein and high calorie

* A community is experiencing an outbreak of staphylococcal infections. The nurse instructs residents that the MOST common mode of transmission is by

a- Respiratory droplets

b- Contaminated foods

c- Hands

d- Soil

* A home care nurse changes the dressing of a patient who has a chronic lower leg ulcer and a history of leg swelling. The wound bed is 3 cm diameter, red in color and is covered with fibrous yellow tissue (see image)

What type of ulcer is most likely?

a- Arterial

b- Venous

c- Decubitus

d- Neuropathic

Blood glucose level

Medication

<80mg/dl

Glucagon 1 mg

150-200mg/dl

0 units of regular insulin

201-250mg/dl

2 units of regular insulin

251-300mg/dl

4 units of regular insulin

301-350mg/dl

6 units of regular insulin

351-400mg/ dl

8 units of regular insulin

>401mg/dl

Call the physician

86. The home care nurse visits a diabetic patient, recently started on sliding scale insulin injection. The patient is confused about how many units of regular insulin to inject. During the home visit the patient's glucose level before their meal is 301 mg/dL

How many units of regular insulin should the nurse instruct the patient to administer?

a- 2 units

b- 4 units

c- 6 units

d- 8 units

* A 30 year-old woman has been prescribed albuterol PNR1 and prophylactic inhaled corticosteroids to be taken once per day. She has been taking the prophylactic as prescribed but has needed to use the albuterol more often than usual. She has a chronic cough and often has air hunger.

Which intervention is initially most appropriate?

a- Refer for a chest X-ray

b- Administer magnesium sulfate

c- Assess peak flow measurement

d- Perform arterial blood gas analysis

* A first time mother of a three week-old breastfed baby brings the infant to the clinic and complains that her child has been forcefully vomiting after feeding. He was born at 40 weeks gestation, weighing 3.6 kilograms. He is constantly hungry and irritable. Examination reveals a swollen abdomen and a palpable mass in the middle upper right quadrant.

What is the most likely health problem?

a- Intussusception

b- Pyloric stenosis

c- Gastroeosophageal reflux

d- Diaphragmatic hernia

* A 40 year-old man present to the clinic with a weight loss of three kilograms over the past month. His health problem produces moderate spastic body movements, hyper-reflexia, muscular contractions followed by relaxation, and a positive Babinski reflex. He has difficulty speaking due to poor muscle tone and has recently developed swallowing difficulties. The nurse creates a care plan to address his developing problem.

Which is the priority nursing intervention?

a- Increase caloric intake

b- Aspiration prevention

c- Infection control

d- Improved muscle control

* A 62 year-old diabetes type II patient is admitted to hospital for ampulation of the right foot due to gangrene and ischemia, Pre-operatively, the patient rates the pain as 9 (using the 1-10 pain scale). How can this patient's phantom (sprit) pain best be controlled?

a- Post-operative elevation of limp

b- Apply pressure bandage to stump

c- Control pain pre-operatively

d- Apply ice to the site for twenty minutes

* The nurse cares for a 60 year-old woman has a history of hypertension, hypothyroidism and elevated cholesterol levels. She takes tablets daily for each of the health problems. The doctor orders a routine dual-energy X-ray absorptimetry test shows decreased bone density.

Which medication most likely contributed to the test results?

a- Statins

b- Anti-hypertensive

c- Synthetic thyroid hormones

d- Cholesterol absorption inhibitors

* A 32 year-old woman with diabetes mellitus type 1 underwent a cholecystectomy and is now on day two of recovery. The patient's bowel sounds have returned and she has resumed a normal diet but has been finishing less than half of each meal on the tray. The nurse enters the room to perform a routine assessment and finds the patient confused and shaky

Blood pressure 110/60 mmHg

Heart rate 96/min

Respiratory rate 22/mm

Temperature 37.0°C

What is the most appropriate initial intervention?

a- Administer glucagon

b- Notify the physician

c- Given an insulin injection

d- Offer a glass of juice

* Prior to providing care for a hospitalized infant, the nurse who focuses on preventive measures must.

a- Introduce self to parent

b- Perform hand hygiene

c- Have a witness present

d- Assess the child's developmental level

* A nurse is admitting a two year-old child with an umbilical hernia.

Which of the following interventions does NOT meet the child's developmental needs?

a- Allowing the child to make choices when possible

b- Providing rooming in and unlimited visitation

c- Attempting to continue rituals used house

d- Maintaining strict bed rest

* A woman who has been discharged from hospital with a permanent colostomy in lace is performing irrigation at home for the first time. After five minutes from the start of the procedure, she begins to have stomach cramps.

Which intervention would most likely decrease the symptoms?

a- Increase the flow of irrigation solution

b- Decrease the temperature of the water

c- Clamp the catheter for 1-2 minutes

d- Elevate the bag of irrigation solution

* A 17 year-old is brought to the clinic by her mother. She complains of episodes during which her fingers become cold, numb and white. After this subsides, the fingers turn red, swell and cause severe and throbbing pain. On examination, the fingers all appear normal and the patient has no pain. The nurse performs a history assessment to identify potential causes.

Which trigger is most likely?

a- Excessive exercise

b- Ingestion of tea

c- Exposure to cold

d- Washing up

* A patient on a medical floor is diagnosed with pneumonia.

Which of the following interventions is appropriate for a nursing diagnosis of ineffective airway clearance related to tracheobronchial secretions secondary to infection?

a- Explain diagnostic procedures and address any of patient's concerns

b- Assess patient for signs of discomfort and pain

c- Monitor oxygen therapy and encourage to cough and deep breathe

d- Monitor patient for shock

*. The nurse is inserting a nasogastric (NG) tube into a patient as prescribed. The nurse has advanced the tube into the patient's posterior pharynx. The nurse should now ask the patient to.

a- Hold the breath

b- Stare upwards with the eyes towards the ceiling

c- Perform the Valsalva maneuver

d- Lower the chin towards the chest

*. A community is experiencing an outbreak of staphylococcal infections. The nurse instructs residents that the MOST common mode of transmission is by:

a- Respiratory droplets

b- Contaminated foods

c- Hands

d- Soil

* A patient with bacterial pneumonia reports increased pain during deep

breathing and coughing exercises. To minimize the patient's pain, the nurse should teach the patient to.

a- Take a cough suppressant prescribed P.R.N at regular time intervals

b- Turn onto the side before doing the respiratory exercises

c- Hold a pillow tightly against the chest while coughing

d- Drink warm liquids right before taking deep breaths

* A patient has an acute inflammation of the gallbladder. The physician orders the nurse to schedule the patient for surgery

Which of the following surgical procedures will the physician MOST likely perform?

a- Pancreatectomy

b- Cholecystectomy

c- Hepatectomy

d- Cricothoracotom

* A patient with a history of chronic obstructive pulmonary disease prepares for a colonoscopy with conserve sedation. Due to the patient's history the nurse should very cautious about administering.

a- Antibiotics

b- Sedation

c- Oxygen

d- Intravenous fluid

* A 45 year-old woman is receiving chemotherapy for breast cancer. Two weeks after the initial treatment she telephoned the nurse at the cancer center and reports she has hair loss, nausea, tiredness, a body temperature is 38.1 C, and air hunger Which finding most likely indicates she needs to report the clinic?

a- Pyrexia

b- Nausea

c- Hair loss

d- Air hunger

* A patient present to the clinic voicing a concern above being exposed to hepatitis A (HA V) one week ago. Upon questioning, the nurse finds the patient

purchased for from a person recently diagnosed with HAV. The number would be MOST correct when instructing the patient

a- The incubation period is 3 to 5 weeks

b- HA V is spread by sexual transmission

c- HA V is spread by blood contact

d- The incubation period is 2 to 5 months

* A gravid 3, para 2 presents to the Labor and Delivery Unit with contractions occurring every 3-5 minutes and lasting for 60-90 seconds. During contractions, she closed her eyes and is focused on breathing to cope with the pain. At the end of each contraction she opens her eyes and resumes talking with the nurse and her husband. What is the expected cervical dilatation in centimeters?

a- 1-3

b- 4-7

c- 8-10

d- 11-13

* The nurse is preparing a discharge plane for a 65 year-old man with a new diagnosis of congestive heart failure. The discharge orders include furosemide 40 milligrams by mouth twice per day. The nurse recommends foods to reduce unwanted medication side effects.

Which of the following foods would be most appropriate to include in the teaching plan?

a- Green and leafy vegetables

b- Bananas and oranges

c- Chicken and Fish

* A patient who is scheduled for a tonsillectomy is in the preoperative unit. The nurse notes an order for preanesthetic medication to be given "on call to operating room." The nurse should give this medication.

a- Immediately upon being notified to prepare the patient for transport

b- When the operating room staff arrives to transport the patient

c- Only if clearly needed after

Admission

Report at 22.45(10.45 P.M)

Diagnosis

14 years old admitted 18 hours ago

Remain fibrils, maximum

Temperature that shift 39.3°C(102.8°P)

Respiration rate 12-11 per min

Blood pressure level within base line normal range

Next dose of intravenous active infective is done at 08.00(8.00a.m)

Bacterial

* Refer to the accompanying figure.

Which of the following goals should receive PRIORITY during the shift?

a- The patient will rest for 6 hours without interruption

b- The patient will consume 90% of each meal

c- The patient will perform deep breathing and coughing exercises

d- The patient will drink 1920 ml (64 ounces of fluid)

* A 45 year-old man has a family history of heart disease. His father died for heart disease at the age of 61 and he is concerned that he is at high risk. He reports that he walks for twenty minutes three times per week. He drinks three to five cup of coffee daily and does not smoke cigarettes. His medical history includes diabetes, which is well controlled with to sit for long periods of time (see lab result).

Blood pressure 138/88 mmHg

Heart rate 70/min

Respiratory rate 18/min

Temperature 37°C

Test Result Normal Values

Cholesterol (HDL) 1.0 > 1.03mmolIL

Cholesterol (LDL) 4.0 <3.36mmollL

Total Cholesterol 5.2 <5.1mmollL

Triglycerides 2.2 <2. 16mmolIL

Which lifestyle modification would most likely decrease this patient risk factor?

a- Decrease stress

b- Increase exercise

* A 66 year-old woman is admitted to the hospital with a history hypertension. She present with breathing difficulties that worsen with activity and while sleeping, she is generally weak and feels that her heart misses beats and that it

sometimes beats loudly. An electrocardiogram shows atrial fibrillation, right ventricular hypertrophy and deviation towards the right.

Which nursing intervention is most appropriate for this patient?

a- Provide a bedside commode (portable toilet)

b- Place in right side lying position

c- Encourage family and friends to visit

d- Encourage independent hygienic activities

* A 66 year-old woman is admitted to the hospital with a history hypertension. She present with breathing difficulties that worsen with activity and while sleeping, she is generally weak and feels that her heart misses beats An electrocardiogram Conform atrial fibrillation, right ventricular hypertrophy and deviation towards the right

What was the most likely origin of the disorder?

a- Hypertension

b- Rheumatic fever

c- Atherosclerosis

d- Genetic predisposition

* A 76 year-old woman present with facial drooping on the left side and muscle weakness of the left arm and leg after suffering a fall at home.

Which type of paresis is most likely?

a- Monoparesis

b- Paraparesis

c- Hemiparesis

d- Quadriparesis

* The nurse has administered an intravenous infusion of Cyclophosphamide to a 43 year-old patient with breast cancer. The nurse formulates a care plan with the nursing problem of risk for infection related to leucopenia secondary to chemotherapy. The patient is discharged home following treatment.

Which findings should the patient report immediately?

a- Dyspnea

b- Tachycardia

c- Sore throat

d- Discoloration of urine

* When given postoperative discharge instruction to a patient who had abdominal surgery, all of the following regarding wound healing is true EXPECT

a- Bathing to soak abdomen is preferred over showering

b- A void tight belts and clothes with seams that may rub the wound

c- Pain medication may affect ability to drive

d- Irregular bowel habits can be expected

* An eight year-old boy has a new diagnosis of Attention Deficit Hyperactive Disorder (ADHD) and begins pharmacological and psychological therapies. His medication regimen includes short-acting methylphenidate 5 mg orally every 12 hours.

Which side effect is most likely?

a- Insomnia

b- Initial increased hyperactivity

c- Lethargy

d- Hypertension

* The nurse is caring for a full-term new born who was delivered vaginally 5 minutes ago. The infant's APGAR score was 8 at one minute and 10 at 5 minutes. Which of the following has the highest PRIORITY?

a- Maintaining the infant in the supine position

b- Assessing the infant's red reflex

c- Preventing heat loss from the infant

d- Administering humidified oxygen to the infant

* The district nurse attends a 73 year-old woman on a daily basis. The woman's husband had passed away three years previously and she now lives alone. Besides assisting in activities of daily living the nurse encourages the patient to talk about her past experiences and events.

Which theoretical frame work is most likely guiding the nurse's care plan?

a- Erickson's model of psychosocial development

b- Piaget's theory of cognitive development

c- Watson's theory of human caring

d- Roy's adaptation model

* A home care patient with chronic obstructive pulmonary disease (COPD) reports an upset stomach. The patient is taking theophylline (Theo-Dur) and triamcinolone acetonide (Azmacort), the nurse should instruct the patient to take

a- Theo-Dur on an empty stomach

b- Theo- Dur and Azmacort at the same time

c- Theo- Dur and Azmacort 12 hours apart

d- Theo-Dur with milk or crackers

* A 64 year-old woman with hepatitis B has significant scarring on the liver and present to the clinic with swelling around the eyes. She is disoriented to time and place and seems confused. Her responses are slow and she has difficulty staying awake. A neurological assessment reveals hypoactive reflexes.

Blood pressure 164/96 mmHg

Heart rate 58/min

Respiratory rate 22/min shallow

Temperature 37.0°C tympanic

Which of the following nursing interventions is most appropriate?

a- Prevent aspiration

b- Encourage small meals

c- Administer fluid bolus d- Inject

* A patient is being followed in the clinic for hypertension, adult onset diabetes, and obesity. The patient is apathetic about learning about nutritional guidelines to reach the goals of weight loss and consumption of a healthy diet. The patient admitted to eating "whatever is put in front of me"

Which of the following actions would the nurse take?

a- Collaborate with the patient to set goals

b- Add a nursing diagnosis of non-compliance

c- Refer for psychiatric screening for depression

d- Discuss nutritional interventions with the spouse

* A 16 year-old boy is in the Post-Operative Care Unit two hours after a tonsillectomy. He is alert and oriented but complains of severe throat pain and difficulty swallowing. He rates the pain at a level 7, on a scale of 1-10. The urine output from the folly catheter is 45 ml over the past two hours.

Blood pressure 130/74 mmHg

Heart rate 64/min

Respiratory rate 18/min

Oxygen saturation 98 % on room air

Which clinical finding is most important to report to the doctor?

a- Oxygen saturation

b- Difficulty swallowing

c- Urinary output

d- Pain level

* A patient is being treated for pneumonia. Considering Maslow's hierarchy of needs, which of the following nursing diagnoses would have HIGHEST priority?

a- Risk for impaired skin integrity

b- Ineffective coughing.

c- Disturbed sleep pattern

d- Ineffective breathing pattern

A

Knowledge deficit related to diabetes Mellitus

B

Anxiety related to new diagnosis of diabetes Mellitus

C

Altered nutrition more than body requirement

D

Altered health maintenance related to elevated blood glucose

E

Altered in fluid and electrolyte balance related to ketoacidosis

F

Risk for infection related to chronic disease

* An insulin dependent diabetic patient is admitted to the hospital in ketoacidosis. Of the nursing diagnoses shown in the table which is the two with the HIGHEST priority?

a- A, C

b- E, F

c- D, E

d- B, E

* A patient who is receiving chemotherapy has a platelet count of 49,000/mm3 (normal value 150,000 to 400,000/mm3)

Which of the following nursing action is necessary?

a- Minimize invasive procedures

b- Crush oral medications

c- Limit intake of vitamin k rich foods

d- Monitor the temperature every 4 hours

* A child present to the emergency department with complaint of chest pain on exertion, shortness of breath, and dizziness. Upon examination the nurse notes palpitation and a systolic ejection murmur at the right upper sterna border. Skin color is normal. The nurse suspect.

a- Aortic stenosis

b- Aortic regurgitation

c- Mitral stenosis

d- Mitral valve prolapse

* A four year-old girl was playing outside in a park when she came running to her mother crying and holding her right, upper arm, with pain and itching at the site as well as swelling of the oral mucosa. The child seems anxious

What is the next most appropriate step in management?

a- Administer subcutaneous epinephrine

b- Maintain a patent airway

c- Administer oral diphenhydramine

d- Prepare intubation equipment

* A patient is on oxygen using a nasal cannula at home. The doctor has ordered this patient to receive oxygen delivered at a concentration of 35 %. The nurse would set the oxygen at:

a- 2L

b- 3L

c- 4L

d- 5L

* A nurse who is assigned to care for a client with dementia and agitated behaviors knows that the client worked as a housekeeper prior to becoming ill,

Which of the following activities is MOST likely to help the client if agitation develops?

a- Watching a movie about a house keeper

b- Reading a sheet of paper that contains stains removing tips

c- Dusting furniture in the assigned room with a cloth

d- Singing songs about cleaning

* A diabetic patient with an infected right second toe is treated with a 14-day course of antibiotics. The patient returns for a follow- up visit after finishing the prescribed course of antibiotics.

What can be inferred from the accompanying blood laboratory result drawn at the follow-up visit?

Test Result Normal Value

WBC 12.0 4-10.5x109/L

HCT 0.41 0.41-0.50

Hemoglobin 153 135-171g/d1

Blood urea nitrogen 6.4 2.8-8.9nuno1/L

Creatinine clearance 106. 70-103nuno1/L

Glucose, fasting 16.6 3.5-6.5nuno1/L

a- Diabetes is effectively managed but toe infection is not managed well

b- Diabetes and toe infection are effectively managed

c- Diabetes and toe infection are effectively managed but toe infection is effectively managed

d- Diabetes and toe infection are not effectively managed

* A 60 year-old woman, with no previous medical history is diagnosed with an adenocarcinoma of the duodenum head of the pancreas and the distal end of the bile duct. Staging shows it has not grown into the large blood vessels and has not metastasized to any lymph node or distant site. The patient undergoes surgery. Which post-operative clinical finding is most likely?

a- Increased serum glucose

b- Constipation

c- Weight loss >15%

d- Paralytic ileus

*. A 62 year-old patient has been treated for congestive heart failure and a nursing diagnosis of fluid volume excess. After diuretic therapy and dietary interventions, the patient has met all short-term goals. The nurse should.

a- Revise the care plan with a diagnosis of risk for alteration in fluid balance

b- Add a new diagnosis of risk of fluid volume deficit

c- Discontinue the care plane as the diagnosis is resolved

d- Continue the care plan as written

* The nurse assists with a lumbar puncture on a child with suspected bacterial meningitis. If the diagnosis is correct the cerebrospinal fluid should have which of the following qualities?

a- Pink viscous appearance

b- Clear fluid appearance

c- Turbid appearance

d- Blood-tinged appearance

* A patient presents with pneumonia. Which of the following intervention would the nurse implement to improve the patient's gas exchange?

Heart rate 80/min

Respiratory rate 32/min

Temperature 40°C

a- Encourage the patient to increase fluid intake

b- Position the patient in an upright position

c- Instruct the patient the patient to splint when coughing

d- Apply heat and or cold to the chest as ordered

* While providing care to a hospitalized child with third-degree burns over 20% of the body, the child rapidly becomes disoriented. The nurse knows this is an indicator of:

a- Septic shock

b- Separation anxiety

c- Dehydration

d- Depression

* A brick-layer has been diagnosed with multiple sclera. The nurse knows that construction work places has increased risk of aggravated symptoms because exposure to.

a- Dust

b- Sunlight

c- Heat

d- Heights

* A 68 year-old male patient has a chest tube and properly fixed following cardiac surgery. The chest tube is patent and functioning. When the nurse removes the dressing the tube falls out of the chest.

Which is the most appropriate initial intervention the nurse should take?

a- Reinsert the chest tube and notify the surgeon

b- Apply an occlusive dressing to the insertion site

c- Place the open end of the tube in 20 cm of water

d- Administer O2 at 10L/min via non-rebreather mask

* During surgery requiring general anesthesia, the patient's heart stops and a carotid pulse is not palpated.

How many compressions per minute should be administered?

a- 50

b- 60

c- 80

d- 100

* A 64 year-old man present with a weight gain of four kilograms in the past week. A physical examination shows an enlarged liver, an enlarged abdomen with a fluid wave, and jugular venous distension. The nurse creates a care plan based on the following nursing diagnosis. Decreased cardiac output related to ventricular damage, ischemia and restriction secondary to fluid overload.

Which would be an appropriate defining characteristic?

a- Altered preload

b- Altered afterload

c- Poor ventricular contractility

d- Increased pulmonary congestion