liquid intake the nurse will document? Breakfast: 180 ml coffee, 6 oz. water, half pint of milk into 3 oz. cheerios, two scrambled eggs and toast with jam. Morning medication: 2 tablespoons of Robitussin, 2 ibuprofen capsules and 30ml of milk of magnesia. For lunch: One cup of cream of tomato soup, a roll, 6 oz. of coffee, 4 oz. liquid jello, and a 3 oz. Chocolate cookie
a-1,517ml b- 1,010ml c- 1,200ml d-1,4667
2. A nurse is showing a patient how to use crutches at home and instructing his mother about how to change his bandages. At this time, the nurse is primarily acting as:
a- Patient advocate
b- Decision Maker
d- Manager of care
3. Common nursing interventions that are carried out during the implementing phase are:
a- Pain management
b- Teaching and educating patients
c- Nursing procedures
d- Preventing complications
e- All answers are correct
4. Goal setting occurs during which phase of the nursing process?
5- The nursing process includes all of the following except:
a- A flexible process that can be modified
b- A rigid set of steps for nurses to follow
c- A framework for thinking through problems
d- A way to organize critical thinking skills
e- A tool that allows for creativity
6-A nursing diagnosis is best described as:
A. a determination of the etiology of disease.
B. a pattern of coping.
C. an individual’s perception of health.
D. a concise statement of actual or potential health concerns or level of wellness.
7-Which of the following attribute to falls:
a- Older age
b- Sexual orientation
c- Impaired mobility
d- Cultural behavior
e- Cognitive and/or sensory impairment
f- Bowel and bladder dysfunction
g- Adverse effects of medication
h- History of falls
8-Reasons to place a patient in semi-fowlers include:
a- gastric feeding
b- need to keep patient’s head low
c- increased ICP
d- respiratory illness complications
e- postoperative cataract removal
f- need to keep pt at 90 degrees
9- The nurse is documenting information reported from a patient that is being admitted for back pain. All of the following are appropriate actions except for the ISBAR:
a- Recording patient had a car accident in 1999 into patient history.
b- Identifying that the daughter is reporting sections of the patient history.
c- Recording necessary interventions in the Request/Recommendation section.
d- Recording patient history of tonsillectomy in the chief complaint section.
10- The CNA is preparing to place a dinner order for a patient that has difficulty sleeping. The RN intervenes when she hears the Assistant order which of the following for dessert:
a- Vanilla ice cream
b- Chocolate cake
c- Cherry pie
d- Rice pudding
11- The nurse is giving an objective data report to the Charge nurse at the end of her 7am-3pm Shift. The Charge nurse will advise the nurse to return to the patient when she states which of the following:
a- Mr. Jones voided 160ml of urine via self-catheterization at noon today.
b- Mr. Jones’ blood pressure is controlled with medication. His BP was 132/72 this afternoon.
c- Mr. Jones reported increased back pain at 2:30pm today. He just received 400mg of Ibuprofen.
d- Mr. Jones looked flush and was sweating after recreation. His temp was 37.3 Celsius.
12- A patient with a recent history of edema seems to have a reduction of swelling. He has multiple seeping wounds and has been sweating throughout the day today. The patient does not have a fever. He does not have an order for Intake and Output. The best action by the nurse to account for insensible loss would be to:
a- Recommend the patient be placed on I&O the rest of the day.
b- Ask the patient if he’d like more iced tea.
c- Weigh the patient.
d- Order the patient an increase sodium meal for dinner.
13- A patient has refused to take her tablets of antibiotic stating they are too large to swallow. Which would be the best intervention by the nurse?
a- Call the doctor and ask that the order be changed.
b- Tell the patient she needs to complete all the antibiotic to ensure the infection clears up completely.
c- Break the scored tablet in half and ask the patient to try to take them again.
d- Tell the patient she can try again later when she feels less anxious.
14- A patient is in the ICU after a motor vehicle accident left him with multiple broken bones including several ribs and broken jaw. The nurse anticipates that the patient will need to be monitored for:
a- Respiratory Acidosis
b- Respiratory Alkalosis
c- Metabolic Acidosis
d- Metabolic Alkalosis
15- Interventions implemented by the nurse for this patient would be (select all that apply)
a- explaining importance of incentive spirometer
b- administering oxygen per order
c- telling the CNA to ensure pt remains in semi or high fowlers
d- administering pain medication
e- ensure pulse ox remains on patient’s finger
f- ask patient about his pain level
16- The patient above has utilized his PCA narcotic pump and is having break through pain of 5/10. He has an order of 1000mg acetaminophen every six hours by mouth as needed for pain, not to exceed 3000mg per day. The pharmacy sent acetaminophen 500mg tablets. What will the nurse do first?
a- call the pharmacy
b- call the doctor
c- give the medication
d- explain to the patient that he needs to wait
17- The RN has asked the nursing assistant to spend time with each of the following patients who is depressed due to a perceived loss. The assistant will go to
a- Mr. Jones whose wife just died
b- Mrs. Smith whose dog just died
c- Mrs. Peters whose company just through her a retirement party
d- Mr. Frank whose house burned down
18- The charge nurse knows the education provided to the new nurse was effective when he states:
a- All my patients with Alzheimer’s need help due to loss of vision.
b- Some of my Alzheimer’s patients are forgetful.
c- My Alzheimer’s patients will need me to be patient.
d- Alzheimer’s and Dementia are the same thing.
19- A patient has just learned that her husband has died suddenly. The nurse explains to the PCT that (select all that apply)
a- How her husband died will affect her grieving.
b- How she was raised will affect her grieving
c- She will go through all the stages of grief in order.
d- The good thing is everyone grieves the same
e- How close she and her husband were will affect her grieving.
20- Understanding the nursing process is imperative because (choose the best answer)
a- The professors at Chamberlain
b- All of nursing is based on this process.
c- Test questions are based on this.
d- I’m still not sure
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