Practice Questions Week 3-Return to instructor for feedback. Questions will not be reviewed
in a CAStutoring session.
Identify the choice that best completes the statement or answers the question.
____ 1. Which of these orders will the nurse act on first for a patient who has just been admitted with
probable bacterial pneumonia and sepsis?
a. Administer aspirin suppository.
b. Send to radiology for chest x-ray.
c. Give ciprofloxacin (Cipro) 400 mg IV.
d. Obtain blood cultures from two sites.
____ 2. Which assessment information obtained by the nurse when caring for a patient who has just had
a thoracentesis is most important to communicate to the health care provider?
a. BP is 150/90 mm Hg.
b. Oxygen saturation is 89%.
c. Pain level is 5/10 with a deep breath.
d. Respiratory rate is 24 when lying flat.
____ 3. The nurse observes nursing assistive personnel (NAP) doing all the following activities when
caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when
a. lower the head of the patient’s bed to 10 degrees.
b. splint the patient’s chest during coughing.
c. help the patient to ambulate to the bathroom.
d. assist the patient to a bedside chair for meals.
____ 4. After the nurse has received change-of-shift report about the following four patients, which
patient should be assessed first?
a. A 77-year-old patient with tuberculosis (TB) who has four antitubercular
medications due in 15 minutes
b. A 23-year-old patient with cystic fibrosis who has pulmonary function testing
c. A 46-year-old patient who has a deep vein thrombosis and is complaining of
sudden onset shortness of breath.
d. A 35-year-old patient who was admitted the previous day with pneumonia and has
a temperature of 100.2° F (37.8° C)
____ 5. The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have
immigrated to the United States. Before doing a TB skin test on a patient, which question is most
important for the nurse to ask?
a. “Is there any family history of TB?”
b. “Have you received the bacilleCalmette-Guérin (BCG) vaccine for TB?”
c. “How long have you lived in the United States?”
d. “Do you take any over-the-counter (OTC) medications?”
____ 6. A patient is admitted to the emergency department with an open stab wound to the right chest.
What is the first action that the nurse should take?
a. Position the patient so that the right chest is dependent.
b. Keep the head of the patient’s bed at no more than 30 degrees elevation.
c. Tape a nonporous dressing on three sides over the chest wound.
d. Cover the sucking chest wound firmly with an occlusive dressing.
____ 7. A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis.
Which of these actions included in the standard TEE orders will the nurse need to accomplish
a. Administer O2 per mask.
b. Start a large-gauge IV line.
c. Place the patient on NPO status.
d. Give lorazepam (Ativan) 1 mg IV.
____ 8. A patient with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and a
low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The
nurse’s first action will be to
a. ask the patient to recall the dietary intake for the last 3 days.
b. question the patient about the use of the prescribed medications.
c. assess the patient for clinical manifestations of acute heart failure.
d. teach the patient about the importance of dietary sodium restrictions.
____ 9. When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking,
it will be most important for the nurse to include information about
a. computed tomography (CT) screening for lung cancer.
b. options for smoking cessation.
c. reasons for annual sputum cytology testing.
d. erlotinib (Tarceva) therapy to prevent tumor risk.
____ 10. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
a. exercise more than usual while the monitor is in place.
b. remove the electrodes when taking a shower or tub bath.
c. keep a diary of daily activities while the monitor is worn.
d. connect the recorder to a telephone transmitter once daily.
____ 11. During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous
distention (JVD) with the head of the patient’s bed elevated 45 degrees. The nurse knows this
a. decreased fluid volume.
b. jugular vein atherosclerosis.
c. elevated right atrial pressure.
d. incompetent jugular vein valves.
____ 12. Which action will the nurse include in the plan of care when caring for a patient admitted with
acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)?
a. Monitor blood pressure frequently.
b. Encourage patient to ambulate in room.
c. Titratenesiritide rate slowly before discontinuing.
d. Teach patient about safe home use of the medication.
____ 13. A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse
use to promote airway clearance?
a. Assist the patient to splint the chest when coughing.
b. Educate the patient about the need for fluid restrictions.
c. Encourage the patient to wear the nasal oxygen cannula.
d. Instruct the patient on the pursed lip breathing technique.
____ 14. The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left 5th intercostal
space and midclavicular line. How will the nurse record this information?
a. “Systolic murmur heard at mitral area.”
b. “Diastolic murmur heard at aortic area.”
c. “Systolic murmur heard at Erb’s point.”
d. “Diastolic murmur heard at tricuspid area.”
____ 15. The RN is observing a student nurse who is doing a physical assessment on a patient. The RN
will need to intervene immediately if the student nurse
a. places the patient in the left lateral position to check for the point of maximal
b. presses on the skin over the tibia for 10 seconds to check for edema.
c. palpates both carotid arteries simultaneously to compare pulse quality.
d. documents a murmur heard along the left sternal border as an aortic murmur.
____ 16. Which information obtained by the nurse who is admitting the patient for magnetic resonance
imaging (MRI) will be most important to report to the health care provider before the MRI?
a. The patient has an allergy to shellfish and iodine.
b. The patient has a history of coronary artery disease.
c. The patient has a permanent ventricular pacemaker in place.
d. The patient took all the prescribed cardiac medications today.
____ 17. A patient who has chronic heart failure tells the nurse, “I felt fine when I went to bed, but I woke
up in the middle of the night feeling like I was suffocating!” The nurse will document this
assessment information as
b. two-pillow orthopnea.
c. acute bilateral pleural effusion.
d. paroxysmal nocturnal dyspnea.
____ 18. During a visit to a 72-year-old with chronic heart failure, the home care nurse finds that the
patient has ankle edema, a 2-kg weight gain, and complains of “feeling too tired to do anything.”
Based on these data, the best nursing diagnosis for the patient is
a. activity intolerance related to fatigue.
b. disturbed body image related to leg swelling.
c. impaired skin integrity related to peripheral edema.
d. impaired gas exchange related to chronic heart failure.
Complete each statement.
1. The nurse notes new onset confusion in an 89-year-old patient in a long-term care facility. The
patient is normally alert and oriented. In which order should the nurse take the following actions?
Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________
a. Obtain the oxygen saturation.
b. Check the patient’s pulse rate.
c. Document the change in status.
d. Notify the health care pr