A patient informs the nurse that they are taking an OTC garlic supplement. What possible effect does garlic have
on the body?
Answer: Effects blood clotting increases risk of bleeding
2. A patient has a complete spinal cord injury at the third cervical vertebra. At what level would you expect th...
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1. A patient informs the nurse that they are taking an OTC garlic supplement. What possible effect does garlic have
on the body?
Answer: Effects blood clotting increases risk of bleeding
2. A patient has a complete spinal cord injury at the third cervical vertebra. At what level would you expect the
patient to respond to light sensation?
Answer: DIAGRAM OF BODY with boxes that you must select to indicate the level. Top box only. FACE
3. After placement of a permanent pacemaker what which would you report as a complication of placement?
Answer: Hiccups (Pg. 325)
4. How to take off a condom
Answer: Take of off while penis is still erect
5. Ph of 7.30 paCO2 49 others WNL– what are they in?
Answer: Respiratory acidosis
6. Left sided weakness while using a cane – what is indicative of needing further teaching?
Answer: Puts cane on weak side (cane should be on stronger side)
9. A patient returns to the clinic 72 hours after receiving a subcutaneous dose of purified protein derivative (PPD)
to test for tuberculosis exposure. The nurse inspects the injection site on the patient’s forearm and finds an
induration measuring 12 mm. The nurse informs the client that
Answer: “Your skin test was positive for TB exposure, we need to perform an acid-fast bacillus test and a chest X-
ray Pg. 250
10. What to do after a hemolytic reaction to a blood transfusion?
Answer: Stop the infusion, change the tubing and give NS
11. How do you insert a PICC?
PICC- Flat on back (Review Pg. 303)
Subclavian IV catheter- Trendelenburg position (head below feet)
12. You are removing a peripheral inserted central catheter, which of the following would you do following removal?
Answer: Measure the length of the external portion of the catheter
, 13. Removing a peripheral IV catheter- Answer: make sure the tip is intact
14. Patient has INR of 1.5 prior to surgery. What are you going to do?
Answer: Prep the patient for surgery
15. Following the surgical placement of a new ileostomy, which of the following would you teach them?
Answer: chew food well
Rationale: Patients with a new ostomy involving the small intestine (i.e. an ileostomy) are told post-op to avoid
foods that increase flatus (green leafy vegetables, beer, carbonated beverages, dairy, and corn); avoid high-fiber
foods for first 2 months; CHEW FOOD WELL; increase fluid intake; and evaluate evidence of blockage.
16. A patient is on isolation due to C difficile infection; which of the following represents correct infection protection
protocol?
Answer: Collect fecal sample with gloves
17. A patient (has either a list of symptoms or a new prescription for anti-coagulant) during medical
history they report they have been TAKING IBUPROFEN FOR 3 YEARS. What lab would you expect to be drawn?
Answer: Fecal Testing/Stool Guaiac/ Fecal Occult Blood Test (FOBT)
18. A patient has been on total parenteral nutrition for 10 full days, which of the following would be an indication
that the nutrition therapy is effective?
Answer: Potassium 4.0 (Pg.524)
19. Which of the following clients is MOST at risk for developing atelectasis?
Answer: Post anesthesia for bowel resection
o Rationale: This patient was the only patient who had abdominal surgery; patients with abdominal
surgery are at the HIGHEST risk for atelectasis because the pain from incision/surgical procedure causes
them to reflexively breathe in a shallow, cautious way. Positioning (guarding) also causes decreased in
lung expansion.
20. The nurse is preparing a patient for paracentesis procedure, which of the following instructions would be given
to the patient to decrease the risk of perforation?
Answer: Instruct patient to empty their bladder prior to the procedure, this is done in order to decrease the size of a
bladder and it reduces the chance of accidental bladder perforation.Pg 527
21. The nurse is providing home care for a patient receiving peritoneal dialysis, the patient has a fever of 102, and
the catheter has decreased dialysate outflow. Which of the following should the nurse perform first?
Answer: Reposition the patient
o Rationale: Nursing Actions regarding reduced or inadequate outflow include: repositioning the
client (b/c this moves the distal lumen of the catheter which may become pressed up against the
abdominal wall = obstruction); milk the tubing if a visible clot is present in the catheter; check
the tubing for kinks or closed clamps, determine when the patient’s last bowel movement was
(constipation can also cause low outflow, pts on peritoneal dialysis are instructed to use a stool
softener daily and consume a high-fiber diet).
22. The nurse is caring for a patient with Crohn’s Disease. Which of the following would be an expected lab value for
this patient? Pg 582
• HCT and HGB – LOW in crohn’s due to anemia
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