Unit 5

Question 1

The critical care unit environment is very stressful for patients, families, and staff. What
nursing action is directed at reducing environmental stress?
A) Constant evaluation of patient status
B) Limiting visits to immediate family
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C) Bathing all patients during hours of sleep
D) Maintaining quiet during hours of sleep

Answer 1

D

Question 2

A patient is transferred to the ICU from the Birth Center of the hospital in the middle of
the night after experiencing complications during delivery of her baby. The patients
husband is anxious and explains to the ICU nurse that he doesnt understand why his wife
has been moved to the ICU. She is going to die, isnt she? he asks the nurse. What is the
nurses best response?
A) Explain that every measure will be taken to provide his wife with the best care
possible.
B) Explain that the nurse is fully trained and has years of experience.
C) Offer the husband a place to relax.
D) Have appropriate staff discuss his health insurance with him

Answer 2

A

Question 3

A patient is admitted to the ICU with injuries sustained from a fall from a third-story
window. The patient is conscious, his breathing is labored, and he is bleeding heavily
from the abdomen. He groans constantly and complains of severe pain, but his
movements are minimal. His heart rate is elevated. Which of these is a sign that he is in
the second phase of the stress response? Select all that apply.
A) Bleeding heavily from his abdomen
B) Labored, slow breathing
C) Severe pain
D) Elevated heart rate
E) Minimal movement

Answer 3

C E

Question 4

A patient in the ICU is recovering from open-heart surgery. The nurse enters his room
and observes that his daughter is performing effleurage on his arms and talking in a low
voice about an upcoming family vacation that is planned. The room is dimly lit, and she
hears the constant beeping of his heart monitor. From the hall she hears the cries of a
patient in pain. Which of the following are likely stressors for the patient? Select all that
apply.
A) His daughters conversation
B) His daughters effleurage
C) The beeping of the heart monitor
D) The dim lighting of the room
E) The cries of the other patient from the hall

Answer 4

C E

Question 5

A patient in the ICU is complaining that he is not sleeping well at night because of
anxiety. Which of the following would be the most helpful intervention for the nurse to
make?
A) Provide the patient with a bath immediately following his first 90-minute REM
sleep cycle.
B) Increase the patients pain medication.
C) Provide the patient with 5 minutes of effleurage and then minimize disruptions.
D) Monitor the patients brain waves by polysomnography to determine his sleep
pattern.

Answer 5

C

Question 6

A nurse walks into a patients room and begins preparing a syringe to perform a blood
draw on the patient. The nurse observes that the patient is firmly gripping the side of the
bed, averting her eyes, and sweating from her forehead when she sees the needle. What
would be the best intervention for the nurse to make?
A) Proceed with blood draw as quickly as possible, to get it over with.
B) Offer to come back later to perform the blood draw.
C) Encourage the patient to deep breathe.
D) Describe briefly the blood draw procedure and explain why it is necessary

Answer 6

D

Question 7

A 15-year-old boy is in the ICU and preparing for an appendectomy. He is clearly
anxious and fidgets with his IV constantly. He complains that he doesnt want to be there
and he is sick of everyone telling him what to do. What would be the best way for the
nurse to address this patients anxiety?
A) Use physical restraints to keep him from pulling out his IV.
B) Offer him the remote to the television.
C) Lower the head of his bed so that he can rest more easily.
D) Explain to the patient in detail what the appendectomy will consist of

Answer 7

B

Question 8

A nurse in a burn unit observes that a patient is tensed up and frowning but silent. The
nurse asks the patient, Can you tell me what you are thinking now? The patient responds,
I cant take this pain any more! I feel like Im about to die. What would be the best
response for the nurse to give to the patient, considering that the patient is already
receiving the maximum amount pain medication that is safe?
A) Try to get rid of those negative thoughtsthey only make it worse.
B) Try thinking instead, This pain will go away; I can overcome it.
C) Your pain medication is already at the highest possible dose.
D) Would you like me to raise the head of your bed?

Answer 8

B

Question 9

A patient on mechanical ventilation is experiencing severe agitation due to being on the
ventilator. Which nursing intervention would be best?
A) Performing breathing exercises with the patient
B) Offering the patient a patient-controlled analgesic device
C) Asking the physician to prescribe an antianxiety medication
D) Offering the patient the patients own MP3 player to listen to

Answer 9

D

Question 10

A 10-year-old female patient in ICU receiving chemotherapy has requested that her dog
be allowed to visit her. She is currently sharing a room with another patient. The nurse
knows that the hospital does allow for pet visits with owners, but has strict guidelines.
Which of the following scenarios is most likely to be permitted?
A) The girls father may bring the dog in on a leash for a 20-minute visit.
B) The girls sister may bring the dog in with a shirt on (to prevent shedding) for an
overnight stay.
C) The girls mother may bring the dog in on a leash for a visit as long as he has had all
his vaccinations.
D) The dog may be brought in for a brief visit once the girl is moved to a private room.

Answer 10

D

Question 11

The nurse understands that a patient being cared for in a critical care unit experiences an
acute stress response. What nursing action best demonstrates understanding of the
physiological parts of the initial stress response?
A) Adequate pain control
B) Intravenous sedation
C) Treatment for elevated blood pressure
D) Ignoring an elevated glucose level

Answer 11

A

Question 12

A critically ill patient experiences stress and anxiety from many factors. Treatment of the
patient focuses on reducing stressors and providing supportive care such as nutrition,
oxygenation, pain management, control of anxiety, and specific care of the illness or
injury. What is the best rationale for these interventions?
A) Helps to support the patients immune system
B) Part of good nursing care
C) Mandated by hospital policy
D) Reassures the patient and family

Answer 12

A

Question 13

A patient in a critical care unit has increased stress from the constant noise and light
levels. What nursing intervention best attenuates these sources of stress?
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A) Need for constant observation and evaluation
B) Dimming lights during the night
C) Frequent nursing group rounds for all patients
D) Use of tile floors for ease in cleaning

Answer 13

B

Question 14

The nurse is caring for a patient who is orally intubated and on a mechanical ventilator.
The nurse believes that the patient is experiencing excess anxiety. For this patient, what
behavior best indicates anxiety?
A) Restlessness
B) Verbalization
C) Increased respiratory rate
D) Glasgow Coma Scale score of 3

Answer 14

A

Question 15

The critical care unit environment is very stressful for patients, families, and staff. What
nursing action is directed at reducing environmental stress?
A) Constant expert evaluation of patient status
B) Limiting visits to immediate family
C) Bathing all patients during hours of sleep
D) Maintaining a quiet environment during hours of sleep

Answer 15

D

Question 16

The nurse wishes to enhance sleep cycles in her critically ill patient. Research has shown
that which nursing action improves sleep in critically ill patients?
A) Repositioning every 2 hours
B) Hypnotic medications
C) Five-minute back effleurage
D) Adequate pain control

Answer 16

C

Question 17

The nurse is caring for a critically ill patient with a very concerned family. Given that the
family is under high stress, what nursing intervention will best ameliorate their stress
while preserving independence?
A) Encourage the family to participate in patient care tasks.
B) Teach the family to ask questions of the health care team.
C) Ask the family to select a family representative for communication.
D) Limit visits to immediate family members for limited times

Answer 17

B

Question 18

While caring for a critically ill patient, the nurse knows that fostering patient control over
the environment is a method for stress reduction. What nursing intervention gives the
patient the most environmental control while still adhering to best practice principles?
A) Ask the patient whether he or she wants to get out of bed.
B) Give the patients bath at the same time every day.
C) Explain painful procedures only after giving pain medication.
D) Choose menu items for the patient to ensure a balanced diet.

Answer 18

B

Question 19

The nurse is using presence to reduce the anxiety of a critically ill patient. What nursing
behavior demonstrates an effective use of presence?
A) Staying in the patients room to complete documentation
B) Having a conversation in the patients room that excludes the patient
C) Maintaining eye contact with the patient during explanations
D) Focusing on specific nursing care tasks while in the patients room

Answer 19

C

Question 20

The nurse is caring for a critically ill patient who can speak. The nurse notices that the
patient is demonstrating behaviors indicative of anxiety but is silent. What nursing
strategy would give the nurse the most information about the patients feelings?
A) Explain procedures to the patient and family.
B) Ask the patient to share his or her internal dialogue.
C) Encourage the patient to nap before visiting hours.
D) Ensure that the patient has adequate pain control.

Answer 20

B

Question 21

The patient is undergoing a necessary but painful procedure that is greatly increasing her
anxiety. The nurse decides to use guided imagery to help alleviate the patients anxiety.
What is a key part of this technique?
A) Provide the patient with an external focus point such as a picture.
B) Have the patient take slow, shallow breaths while staring at a focus point.
C) Have the patient remember tactile sensations of a pleasant experience.
D) Encourage the patient to consciously relax all of her muscles.

Answer 21

C

Question 22

One of the strategies shown to reduce perception of stress in critically ill patients and
their families is support of spirituality. What nursing action is most clearly supportive of
the patients spirituality?
A) Referring patients to the Catholic chaplain
B) Providing prayer booklets to patients and families
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C) Asking about beliefs about the universe
D) Avoiding discussing religion with those of other faiths

Answer 22

C

Question 23

A critically ill patient tells the nurse that he is not afraid to die because he believes in
reincarnation. What is the most appropriate nursing response?
A) What if reincarnation is not real?
B) This belief gives you strength.
C) I dont believe in reincarnation.
D) You shouldnt base your hopes on such a belief.

Answer 23

B

Question 24

A critically ill patient who is intubated and agitated is restrained with soft wrist restraints.
Based on research findings, what is the best nursing action?
A) Maintain the restraints to protect patient safety.
B) Remove the restraints periodically to check skin integrity.
C) Remove the restraints periodically for range of motion.
D) Assess and intervene for causes of agitation

Answer 24

D

Question 25

A patient has just been admitted to the ICU after being in a severe auto accident and losing one of her legs. Her husband has his hand over his heart and complains of a rapid heart rate. The nurse recognizes his condition as a sign of which stage of the general adaptation syndrome to stress? A) Alarm stage B) Exhaustion stage C) Resistance stage D) Adaptation stage

Answer 25

A

Question 26

The nurse observes that an elderly woman, whose granddaughter has been admitted to the ICU, is struggling to manage her two great-grandsons, who are toddlers, in the waiting room. What is the most likely explanation for the womans inability to manage the children in this situation? A) She is senile. B) She is in the exhaustion stage of the general adaptation syndrome to stress. C) She is assuming the role of caregiver in place of the patient, a role she is not used to. D) She has macular degeneration and cannot see well

Answer 26

C

Question 27

A nurse needs to communicate with a patients family regarding consent to treat an unconscious patient in the ICU. Which member of the group should the nurse approach first? www.nursingpreptips.com A) A man she recognizes as the patients brother B) A teenage boy who approaches the nurse C) A woman who originally escorted the patient in D) A woman in the group whom the others look at and call over when the nurse approaches

Answer 27

D

Question 28

A new nurse has recently joined the ICU from a different hospital, which had a much stricter policy regarding visiting hours. She expresses concern about the impact of open visiting hours on patient well-being. Which of the following would be the best explanation for the purpose of open visiting hours? Select all that apply. A) To better provide rest and quiet B) To strengthen the relationship between the family and health care provider C) To control the number of visitors for a patient D) To provide an undisturbed environment E) To decrease the patients anxiety F) To increase the satisfaction of the family with the experience

Answer 28

B E F

Question 29

A nurse observes that a 38-year-old single father whose 11-year-old daughter is in the ICU is struggling to explain to his 6-year-old son the likelihood that the daughter will die. The young boy asks what will happen to his sister when she dies, but the father breaks down in tears and seems unable to respond. Which of the following would be the most appropriate intervention for the nurse to make? A) Suggest that the father contact his pastor, rabbi, or other spiritual leader for counsel for him and his son B) Sit down with the father and son and share her own religious beliefs C) Ask the patients doctor to explain to the father the odds of the daughter surviving D) Leave the father and son to grieve alone

Answer 29

A

Question 30

A patient is experiencing severe pain, despite receiving pain medication for the past 24 hours. The patients wife expresses concern about this to the nurse. Which response by the nurse would be most empowering to the patients family? A) Explain that the doctor is an expert on pain medication and that the current level of medication is the best. B) Recommend that the family members take turns massaging the patients feet to distract from the pain. C) Encourage the family to request that the physician evaluate the patients pain control. www.nursingpreptips.com D) Ask the family to wait another 24 hours to see whether the patients pain level will go down.

Answer 30

C

Question 31

The sister of a patient in the ICU has been at the patients bedside non-stop for 48 hours. The nurse suggests to her that she return home to rest. Which of the following is the proper rationale for the nurse making such a suggestion? A) The sister is in the way of the health care providers. B) The patient may become annoyed by her continual presence. C) The patient will recover more easily in peace and quiet. D) The sister needs to maintain her own health during this time.

Answer 31

D

Question 32

A young man has just arrived at the ICU from out of town and received news that his girlfriend, who is admitted there, likely only has a few days left to live. Which of the following would be the best approach for the nurse to take in caring for the needs of this young man? A) Recommending that he go home and rest B) Giving him unrestricted visiting hours with the patient C) Suggesting that he meet with the hospital chaplain D) Recommending that he ask the doctor to evaluate the patients pain control measures

Answer 32

B

Question 33

A family of a young girl who has been diagnosed with leukemia has travelled 12 hours by car to admit her to the ICU and be with her during her treatment. Which aspect of the critical care family assistance program would most likely be needed by this family initially? A) Educational materials B) Weekly group family information sessions C) Hospitality programs D) Pet therapy

Answer 33

C

Question 34

A Muslim woman is admitted to the ICU after suffering severe burns over most of her body. Which of the following would be the most appropriate measure for the nurse, a woman, to take in respect for the cultural practices of this patient? A) Insist that only a female doctor be assigned to this patient. B) Ensure that no pork products are included in the patients diet. C) Ensure that direct eye contact is not made with the patients husband. D) Ask the patients husband what religious and cultural preferences should be considered in the patients care.

Answer 34

D

Question 35

A client has been admitted after experiencing multiple trauma and is intubated and sedated. When the five members of the immediate family arrive, they are anxious, angry, and very demanding. They all speak loudly at once and ask for many services and answers. What is the best nursing response? A) Ask the family to leave until visiting hours begin. B) Take them to a private area for initial explanations. C) Page security to have them removed from unit. D) Show them to the clients bedside and leave them alone

Answer 35

B

Question 36

The client has been in the CCU for several weeks and has been very unstable. One family member stays at the bedside constantly and even naps in a bedside chair. The nurse understands that the family member is exhibiting which family member response to critical illness? A) Exhibiting extreme distrust of the health care team B) Seeking evidence for future legal or punitive action C) Trying to maintain a level of control over the situation D) Experiencing extreme fatigue from constant stress

Answer 36

C

Question 37

The nurse is caring for a very seriously ill patient in the CCU. The family visits sporadically, stays for only a short time, and does not ask many questions. How could the nurse best begin to involve the family in the patients care? A) Ask one family member to assist with the patients bath. B) Encourage family members to stay longer at each visit. C) Focus nursing efforts on the patients legal next of kin. D) Ask the family to complete the Critical Care Family Needs Inventory

Answer 37

D

Question 38

As part of the admission process, the nurse asks several questions about family relationships. The nurse bases these actions on which rationale? A) Assessing family relationships is an initial step in including the family in patient care. B) These questions are part of the admission assessment tool required by this CCU. C) The nurse has a natural curiosity and wishes to know how the family members relate for her own knowledge. D) There is an ongoing research study to identify variant family patterns related to disease incidence

Answer 38

A

Question 39

On their first visit to a critically ill patient, family members stand in the doorway of the room, making no effort to approach the patient. What is the most appropriate nursing action? A) Instruct the family where the patient can be touched and what to say. B) Engage the family in social conversation to ease them into the milieu. C) Use visiting hours to explain to the family the general status of the patient. D) Leave the family to adjust to the situation when they are ready

Answer 39

A

Question 40

A critically ill patient is not expected to survive this admission. The family asks the nurse how the patient is doing. When answering this question, what should the nurse include? A) Emphasize that the patient is young and strong and may still survive. B) Refer the family to the physician for all details and answers. C) Give specific information such as descending trends in parameters. D) Ask if the family has determined which funeral home will be called.

Answer 40

C

Question 41

A patients family is exhibiting increasingly impaired coping as the patients condition deteriorates. The nurse asks the family to state the biggest concern from their perspective. What is the most important rationale for this question? A) The question indicates active listening on the part of the nurse. B) The question is used as a way to validate the familys knowledge. C) The question clarifies the nurses understanding of current family needs. D) The question promotes problem definition, which helps define the degree of family understanding

Answer 41

D

Question 42

The nurse recommends that the family of a critically ill patient seek help from the Critical Care Family Assistance Program. What benefit for the family does the nurse anticipate? A) Reduction of health care cost B) More physical comfort C) Multidisciplinary support D) Health promotion information

Answer 42

C

Question 43

While interacting with the family of a critically ill patient, the nurse suggests that the family must be feeling very anxious and perhaps angry. How does this nursing action benefit the family? A) Removes the focus of the conversation from the patient B) Focusing on feelings helps the family avoid delayed grief and unhealthy coping www.nursingpreptips.com C) Gives validation of need for psychological counseling D) Reduces family insistence for patient progress information

Answer 43

B

Question 44

The nurse is caring for a patient from a very different cultural group. In delivering care, how can the nurse best demonstrate cultural sensitivity? A) Ask the family about their cultural beliefs and customs that may apply. B) Assume that the patient and family will adjust to the hospital culture. C) Inform the patient and family that the routines of the hospital take precedence. D) Do a literature search on the patients culture to determine beliefs.

Answer 44

A

Question 45

A nurse from the ICU is participating in the hospitals disaster response preparedness team. One issue that proves difficult for the team to agree on is a statement regarding the standard of medical care observed during a disaster. Which of the following do you think the nurse should recommend to the team? A) The goal should be to provide the highest care possible, with limited resources and equipment. B) The lack of resources should not diminish the standard of care that the hospital provides. C) The medical staff should tend to the needs of the most critically ill first. www.nursingpreptips.com D) If electrical power should be lost to the facility, patients on life support should be given lowest priority.

Answer 45

A

Question 46

A nurse learns that local law enforcement officials have informed the hospital that an imminent terrorist attack has been threatened in a building just down the street from the hospital. Which of the following are appropriate responses? Select all that apply. A) Explain to the patients in the ICU that a terrorist attack is expected and that their care may be interrupted. B) Begin making preparations to move all ICU patients to other hospital facilities in the area in the event of an attack. C) Review the hospitals disaster plan and make sure that it is distributed to the rest of the medical staff. D) Determine what her specific role in the disaster plan is. E) Not be concerned because federal deployable medical teams will likely be sent to the hospital in the event of an attack. F) Check the number of ventilators available in the ICU to determine whether more would be needed in the event of an attack.

Answer 46

C D F

Question 47

The nurse is at the bedside of her 90-year-old patient, Ruth, who is comatose and on life support in the ICU, when she begins to feel the room shaking violently. The power suddenly fails and emergency generators have not started yet. The nurse provides bag￾mask resuscitation for Ruth while she waits for the power to be restored. Moments later, the ICU is inundated with patients injured by the collapse of a nearby apartment building as a result of the earthquake. The nurse is called to help. Kevin has been impaled by a metal rod through the chest, is in a state of shock, and will die without immediate intervention. Gwyneth has compound fractures of the femur and a dislocated shoulder, is in pain, but is responsive. Mason is unconscious and unresponsive. Based on the START triage categories, whom should the nurse assist first in this situation? A) Ruth B) Kevin C) Gwyneth D) Mason

Answer 47

B

Question 48

A patient arrives at the ICU after being injured by car bomb that exploded 20 feet away. The patient sustained only primary blast injuries. Which of the following are injuries he might have sustained? Select all that apply. A) Perforated eardrum caused by a sudden change in atmospheric pressure B) Laceration from a shard of glass that struck the patient C) Concussion as a result of his body being thrown against a brick wall www.nursingpreptips.com D) Hemorrhagic contusion of the lungs E) Gastrointestinal hemorrhage F) Blunt force trauma from a piece of metal shrapnel that struck the patients head

Answer 48

A D E

Question 49

A group of patients, colleagues from the same office, arrive at the ICU with symptoms of nausea, vomiting, and diarrhea. It is determined that they are suffering from radiation exposure as a result of an inconspicuous device placed in the office that leaked radiation over a period of days. The nurse suspects that which of the following was used in this terrorist attack? A) Radiological dispersal device B) Improvised nuclear device C) Nuclear weapon D) Simple radiological device

Answer 49

D

Question 50

A patient arrives at the ICU with symptoms of radiation exposure. While in the ICU, he begins gasping for air and clutching his throat with his hand. What intervention should take priority at this point? A) Perform CPR on the patient to restore normal respiratory function. B) Evaluate the degree of radiation exposure in the patient using a Geiger counter. C) Undress the patient and have him shower and wash with soap to decontaminate himself. D) Administer potassium iodide

Answer 50

A

Question 51

A woman arrives at the ICU after being the victim of a terrorist attack in a nearby shopping center involving a gas that spewed from a metal canister. The woman complains of a burning sensation in her eyes, mouth, and throat, and the nurse observes blistering on her face and arms. What chemical agent should the nurse suspect, and what intervention should she implement? A) Vesicant agent; apply lotion B) Nerve agent; administer benzodiazepine C) Vesicant agent; soap and water blot D) Nerve agent; provide ventilatory support

Answer 51

C

Question 52

A worker at a local chemical plant arrives at the ICU following an industrial accident involving a gas leak. The patient shows signs of pulmonary edema and bronchospasm. What chemical should the nurse suspect is involved, and what intervention would be most appropriate? A) Nitrogen mustard; soap and water blot www.nursingpreptips.com B) Chlorine; airway management and ventilatory support C) Tear gas; irrigation of eyes with water D) Cyanide; sodium nitrate

Answer 52

B

Question 53

A man presents to the ICU with a severe case of H1N1 viral infection. What would be the most appropriate intervention for this patient? A) Administer an H1N1 vaccine. B) Administer an antibiotic. C) Administer an antiviral agent. D) Administer potassium iodide.

Answer 53

C

Question 54

A young man arrives at the ICU after being held hostage while a passenger on a commercial airplane. He sustained a bullet wound in his chest and has undergone surgery to repair his lung. He is now receiving an analgesic for his pain. The nurse observes that the patient frequently complains that he is sick to his stomach and has no appetite. His sleep is regularly interrupted by nightmares, and he is prone to outbursts of anger and grief. What is the most likely cause of these symptoms? A) Adverse reaction to pain medication B) Reaction to severe pain C) Post-traumatic stress disorder D) Delirium resulting from an infection

Answer 54

C

Question 55

The nurse is caring for a group of patients from the same workplace who have similar symptoms of cough, respiratory distress, and nausea and vomiting. What should the nurse suspect? A) Food poisoning at local restaurant B) Mass exposure to an inhaled agent C) Allergic response to a new cleaning agent D) Acute asthma exacerbation syndrome

Answer 55

B

Question 56

The nurse is part of a planning committee developing a disaster response plan for a hospital that serves as the major trauma center for the local area. The committee has identified that the most likely cause of a disaster in the community is a devastating tornado that significantly damages most major structures, including hospitals of all sizes, in the community. What component of the plan is least likely to be realistic? A) Transfer all noncritical patients to smaller hospitals in the community. B) Provide for secure storage of emergency supplies and equipment. www.nursingpreptips.com C) Agree with other hospitals in town to share supplies and equipment. D) Interface with the city disaster management plan and command center

Answer 56

A

Question 57

The nurse is preparing to assist with triage of victims from a large mass casualty incident. The patients are sorted into categories at the door of the facility. What category will receive care last? A) Minimal B) Delayed C) Immediate D) Expectant

Answer 57

D

Question 58

The nurse is assisting with triage in the emergency department. A large group of patients from a mass casualty incident arrive. These patients have been classified at the scene as minimal, delayed, immediate, and expectant. What is the best nursing approach? A) Use the classifications from the scene to determine the order of treatment. B) Reassess and reclassify patients quickly to determine the order of treatment. C) Treat the patients in the order they arrive at the emergency department. D) After the first 20 patients, refer all others to another emergency care facility.

Answer 58

B

Question 59

The nurse is caring for a patient who was exposed to a high dose of external radiation. What is the least likely nursing action? A) Assess for and facilitate treatment of life-threatening injuries. B) Assess radiological measurements with a Geiger counter. C) Remove clothing and shower patient as soon as possible. D) Assist in removing penetrating radioactive materials

Answer 59

D

Question 60

The nurse is caring for a patient who has been exposed to radiation. The patient has been increasingly unstable, with decreasing lymphocytes, leukocytes, thrombocytes, and erythrocytes, along with shock, diarrhea, and altered level of consciousness for some weeks. Today, there is clear evidence of worsening shock, subnormal body temperature, and increased intracranial pressure. The family asks what the patients prognosis is. The best nursing response is based on what rationale? A) Increased intracranial pressure following other symptoms is a sign of impending death. B) The symptoms listed are typical of the latent phase of recovery, which lasts several weeks. C) Full recovery from radiation exposure can take many weeks to months. www.nursingpreptips.com D) The absence of fever indicates the patient has entered the latent phase of recovery

Answer 60

A

Question 61

The nurse is caring for a patient with a suspected cyanide exposure. The patient is anxious and hyperventilating. What is the nursing priority of care? A) Give antiseizure medications. B) Send toxicology screen. C) Give cyanide antidote. D) Obtain history of exposure

Answer 61

C

Question 62

The nurse is assisting with the initial care and assessment of a group of patients with a massive topical toxic chemical exposure. What is the best way to decontaminate these patients? A) Use an antidote to the chemical of exposure. B) Use an alkaline substance for an acid contaminant. C) Soap-and-water shower first for most chemicals D) Administer 100% oxygen under positive pressure

Answer 62

C

Question 63

A worker in a tanning factory comes to the emergency department with itchy, papular lesions on his hands and arms. Some of the lesions have black eschar in the center and some are vesicular. What biological exposure is most likely? A) Cutaneous anthrax B) Pulmonary anthrax C) Cutaneous smallpox D) Pneumonic plague

Answer 63

A

Question 64

A patient and his family have been exposed to probable anthrax spores through contaminated postal contents within the past 8 hours. Upon arrival at the emergency department, all members of the family are anxious and say they are afraid of dying. The best nursing response is based on what rationale? A) There is no treatment for anthrax exposure and their fears are realistic. B) A vaccine given in the first 3 days after exposure will stop the disease. C) Antibiotic therapy is very effective for cutaneous anthrax. D) A toxicology screen is necessary to determine whether there really was an exposure

Answer 64

C

Question 65

An elderly patient is being treated after taking too much cardiac medication. The patient states, I didnt mean to do it. I cant see as well as I used to and cant see the writing on the medication labels. What intervention by the discharge planning nurse would help prevent this from occurring again? A) Transfer the patient to the nursing home where she will have her medications administered to her. B) Call the patients family and tell them they must administer the medications to the patient when they are scheduled. C) Make a home health referral for evaluation of resources and medication dispensing. D) Encourage the health care provider to prescribe less toxic medication for this patient.

Answer 65

C

Question 66

The nurse is assigned to a patient who has been in the hospital for 24 hours with a diagnosis of acute alcohol intoxication. The patient states, I am so stressed out in my www.nursingpreptips.com marriage and with my job. Drinking is the only way that I can relieve that stress. What priority intervention would be beneficial for this patient? A) Commit the patient to a state mental health facility. B) Refer the patient to a comprehensive treatment program. C) Make an appointment for the patient to see a psychiatrist. D) Inform that there are other methods to relieve stress other than drinking alcohol.

Answer 66

B

Question 67

An adolescent patient has arrived at the emergency department via ambulance after friends reported that she ingested a large quantity of unknown pills after having an argument with her boyfriend. The patient is combative and refuses to divulge the type of pills that she ingested. What lab studies should be performed at this time? Select all that apply. A) Electrolyte studies B) T3 and T4 C) Serum osmolality test D) Liver panel E) Lipid panel F) Acetaminophen level

Answer 67

A C D F

Question 68

The nurse administers morphine sulfate IV to a patient for complaints of abdominal pain. The order was for 2 mg and the nurse realized that she gave the patient 10 mg. The patients respiratory rate is 10 and she is unresponsive. What is the nurses priority intervention at this time? A) Call the charge nurse. B) Administer a stat dose of 50% dextrose. C) Administer naloxone (Narcan). D) Fill out a risk management incident report

Answer 68

C

Question 69

A patient is receiving chelation therapy. What would the nurse explain to the patient is the purpose of chelation therapy? A) Chelation therapy will remove carbon monoxide from the blood. B) Chelation therapy will help to reverse the effects of narcotics. C) Chelation therapy will help promote bowel movements so that the medication will pass through the large intestine. D) Chelation therapy will remove toxic levels of metals from the body.

Answer 69

D

Question 70

A patient in the intensive care unit is in acute renal failure secondary to acute tubular necrosis from a nephrotoxic medication and has an anion gap of 20 mEq/L. What does this laboratory value indicate? A) The patient has metabolic acidosis. B) The patient has metabolic alkalosis. C) The lab value is within normal range for this patient. D) The patient is in end-stage renal failure.

Answer 70

A

Question 71

A toddler is being discharged from the hospital after being monitored for 24 hours due to a possible ingestion of household cleaner. What priority instruction should be provided to the parents before discharge? A) The parents should be informed that if the toddler is brought to the hospital again, child protective services will be called. B) Inform the parents that they were negligent in the care of their child and need to lock up the household cleaners. C) Educate the parents on methods to child-proof the home so that the child will not have access to various harmful materials. D) Tell the parents not to worry; many parents bring their children in for similar problems.

Answer 71

C

Question 72

A patient has arrived at the emergency department via ambulance. The EMT states, She is barely responsive. She took all of the Ativan in this bottle. What medication should the nurse prepare to administer to the patient? A) Naloxone (Narcan) B) Physostigmine (Antilirium) C) Methylene blue D) Flumazenil (Romazicon)

Answer 72

D

Question 73

The patient has been taking amitriptyline (Elavil) for neuropathic pain in the lower extremities. He comes into the emergency room stating, I took 15 of them right before I got here. I was tired of it all but should never have done this. Someone help me! What intervention can help prevent absorption of the medication? A) Syrup of ipecac B) Benzodiazepines C) Gastric lavage D) Hyperbaric oxygen therapy

Answer 73

C

Question 74

The patient has been found to have a defective and leaking fentanyl (Sublimaze) patch used for severe pain from recurring migraine headaches. What observations by the nurse indicate complications from this defect? A) Respirations 10 breaths per/minute B) Blood pressure 96/68 C) Heart rate 106 beats/minute D) Blood pressure 160/86

Answer 74

A

Question 75

A patient is admitted to the emergency department after ingesting an unknown amount of a mixed substance containing cocaine and an opioid. What nursing assessment finding would indicate that the patients life is in immediate danger? A) Agitation and combativeness B) Tachycardia and elevated blood pressure C) Depressed respiratory rate and volume D) Hypoxemia and metabolic acidosis

Answer 75

C

Question 76

A patient is admitted to the emergency department after ingesting a large amount of an unknown substance while at a beach party. The nurse finds delirium, dry and flushed skin, dilated pupils, fever, decreased bowel sounds, and tachycardia. Urinary catheter insertion shows urinary retention. What ingested substance does the nurse most suspect? A) Malathion B) Jimson weed C) Opiates D) Cocaine

Answer 76

B

Question 77

During the initial treatment of a patient with a poisoning or overdose, treatments to prevent absorption and to enhance elimination of the agent are of primary importance. What substance does the nurse administer to enhance elimination of an orally ingested alkaline caustic substance? A) Mild acid B) Antivenin C) Emetic D) Activated charcoal

Answer 77

D

Question 78

A 2-year-old has been resuscitated after ingestion of a cleaning solution. As part of discharge teaching, what is the most important information for the nurse to include? A) Developmental characteristics of toddlers www.nursingpreptips.com B) Proper storage and labeling of poisons C) Use of the poison control phone number D) A list of most common household poisons

Answer 78

B

Question 79

A patient has been admitted to the emergency department after ingesting an unknown substance. The nurse finds agitation, tachycardia, hypertension, and episodes of tonic￾clonic muscle movements. Arterial blood gases reveal normal oxygenation and metabolic acidosis. What ingested substance does the nurse most suspect? A) Antihistamine cold medication B) Carbamate insecticide C) Lomotil D) Cocaine

Answer 79

D

Question 80

The patient has been admitted to the CCU after taking a large amount of cocaine accompanied by large amounts of opioid. Initial detoxification was started in the emergency department. The patient is currently intubated and on mechanical ventilation. To identify life-threatening complications from these substances, what is the nursing priority? A) Continuous cardiac monitoring B) Assisting respirations with bag-mask device C) Use of jaw thrust maneuver to protect airway D) Monitor serum drug levels of opioids

Answer 80

A

Question 81

The nurse is providing initial care for a patient who has experienced an ocular splash injury of a toxic liquid. What is the priority of care? A) Irrigate eyes for 15 to 30 minutes with tap water. B) Flush eyes with antidote to the substance. C) Telephone the poison control center for instructions. D) Obtain ophthalmology consult at bedside.

Answer 81

A

Question 82

The patient has extensive dermal exposure to a dermal toxin. What is the nursing priority of care? A) Remove clothing and shower for 15 to 30 minutes. B) Irrigate affected area with an alkaline solution. C) Include use of soap in initial shower. D) Apply a topical soothing and moisturizing agent.

Answer 82

A

Question 83

The nurse is caring for a patient who has inhaled an airborne toxin. What is the priority of care? A) Protect the patients airway. B) Administer supplemental oxygen. C) Protect the airways of rescuers. D) Administer antidote to toxin.

Answer 83

C

Question 84

A child has ingested an unknown amount of household bleach, an alkaline substance. The child is currently tachypneic and lethargic. What is the nursing priority treatment? A) Have the child drink 8 ounces of water. B) Insert a nasogastric tube for lavage. C) Administer a mild acid such as vinegar. D) Administer supplemental oxygen

Answer 84

B

Question 85

A patient is admitted to the emergency department after ingesting a large number of tablets. Gastric lavage is ordered. What is the best nursing action during this procedure? A) Insert a small-bore nasogastric tube to minimize aspiration risks. B) Position the patient in the left lateral decubitus position with his head down. C) Lavage the stomach with 200 mL of fluid until pill fragments are seen. D) Initiate the lavage procedure no sooner than 2 hours after ingestion.

Answer 85

B

Question 86

A patient has swallowed a large amount of pills. Activated charcoal, an adsorbent, is ordered to reduce toxic absorption. For best use of this substance, what action does the nurse initiate? A) Administer via nasogastric tube to increase the speed of administration. B) Verify that the ingested pills will be adsorbed by activated charcoal. C) Administer the charcoal 4 hours after the pills were ingested. D) Combine the charcoal with an emetic to increase elimination of toxins.

Answer 86

B

Question 87

The patient has experienced an accidental salicylate overdose. Urine alkalinization with intravenous sodium bicarbonate solution is ordered. What symptom, if found by the nurse, most indicates a complication of this therapy? A) Increased urine pH B) Increased urine salicylate levels C) Compensated metabolic alkalosis www.nursingpreptips.com D) Altered level of consciousness

Answer 87

D