Anda di halaman 1dari 12

1. Which activities are the circulating nurse's responsibilities in the operating room?

a. Monitor the position of the patient, prepare the surgical site, monitor patient safety.

b. Give preoperative medication in the holding area and monitor patient's reaction to anesthesia.

c. Prepare sutures, set up surgical field, maintain count of all sponges, needles and instruments.

d. Prepare medications to be given by the anesthesiologist and change the tubing in the anesthesia
machine.
2. The circulating nurse observes the surgical scrub technician remove a sponge from the edge of
the sterile field with a clamp and place the sponge and clamp in a designated area. Which action
should the nurse implement?
a. Place the sponge back where it was. c. Tell the technician not to waste supplies.
b. Do nothing because this is the correct procedure. D. Take the sponge out of the room immediately.

3. The circulating nurse and the scrub technician find a discrepancy in the sponge count. What
action should the circulating nurse take first?
a. Notify the patient's surgeon. C. Complete an occurrence report.
b. Contact the surgical manager. d. Re-count all the sponges.

4. Which violation of surgical asepsis would require immediate intervention by the circulating
nurse?
a. Surgical supplies were cleaned and sterilized prior to the case.
b. The circulating nurse is wearing a long sleeved sterile gown.
c. Masks covering the mouth and nose are being worn by the surgical team.
d. The scrub nurse setting up the sterile field is wearing artificial nails.

5. The nurse identifies the nursing diagnosis "risk for injury related to positioning" for the patient
in the operating room. Which intervention should the nurse implement?
a. Avoid using the cautery unit which does not have a biomedical tag on it.
b. Carefully pad the patient's elbows before covering the patient with a blanket.
c. Apply a warming pad on the OR table before placing the client on the table.
d. Check the chart for any prescription or over the counter medication use.

6. The circulating nurse is positioning clients for surgery. Which client has the greatest potential
for nerve damage?
a. The 16 year old in the dorsal recumbent position having an appendectomy.

b. The 68 year old in the trendelenburg position having a cholecystectomy.


c. The 45 year old in the reverse trendelenburg position having a biopsy.

d. The 22 year old in the lateral position having a nephrectomy.

7. Which situation demonstrates the circulating nurse acting as the patient's advocate?
a. Plays the patient's favorite audio book during surgery.
b. Keeps the family informed of the findings of the surgery.
c. Keeps the operating room door closed at all times.
d. Calls the patient by the first name when the patient is recovering.

8. The circulating nurse is planning the care for an intraoperative client. Which statement is the
expected outcome?
a. The client has no injuries from the OR equipment.
b. The client has no postoperative infection.
c. The client has stable vital signs during anesthesia.
d. The client recovers from anesthesia.

9. Which surgical nursing intervention has the highest priority when preparing the client for a
surgical procedure?
a. Pad the client's elbows and knees.
b. Apply soft restraint straps to the extremities.
c. Prepare the client's incision site.
d. Document the temperature of the room.

10. The nurse manager is making assignments for the OR. Which case should the manager assign for
the inexperienced nurse?
a. The patient with open heart procedure.
b. The patient with biopsy of the breast.
c. The patient with laser eye surgery.
d. The patient with laproscopic knee repair.

11. The nurse assesses tachycardia and hypotension in the patient. Which of these interventions
should the nurse implement?
a. Prepare icepacks and mix dantrolene sodium.
b. Request that a defibrillator be brought into the OR.
c. Draw a PTT and prepare a heparin drip.
d. Obtain a blood glucose finger stick immediately.

10. The nurse is planning care for a patient undergoing conscious sedation. Which of these interventions
is the highest priority?
a. Monitor the patient's respiratory status.
b. Take a 12 lead ECG prior to injection.
c. Keep the patient focused.
d. Monitor the patient's urinary output.

11.The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse
determines that further teaching is necessary related to colorectal cancer if the client identifies
which item as an associated risk factor?
a. Age younger than 50 years c. History of colorectal polyps
b. Family history of colorectal cancer d. Chronic inflammatory bowel disease

12. A nurse is providing teaching to a client who has an allergy to peanuts. Which instruction will be
priority for the nurse to include in the teaching?
a. Inform other health care professionals of the allergy.
b. Wear a medical identification tag.
c. Carry an emergency anaphylaxis kit.
d. Keep a food diary.

13.A nurse is reviewing the daily laboratory results for a female client who has acute leukemia. Which
value is an expected finding?
a. WBC count 21,000
b. HgB 14
c. Hct 40%
d. Platelets 170,000
14. A nurse is caring for a client who reports a skin change. Which finding will the nurse report to the
provider?
a. An asymmetrical papule that is pigmented.
b. A patch of silvery-white scales with a red epidermal base.
c. A collection of irregular dry papules that are black.
d. An elevated red lesion that arises from a scar.

15. A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for
methotrexate. Which will the nurse include in the teaching?
a. Avoid crowds. c. Expect symptoms to subside in 1-2 weeks.
b. Increase intake of Vitamin D. d. Anticipate constipation.

16. A nurse is providing teaching for a client who is HIV-positive. Which instruction will the nurse
include in the teaching?
a. Clean bathroom surfaces with full-strength bleach.
b. Discard beverages that have been unrefrigerated for 1 hour.
c. Wash laundry soiled with a body fluid in warm water.
d. Work in the garden for exercise.

17. A nurse is caring for a client who has a new prescription for clindamycin to treat acute pelvic
inflammatory disease. The nurse will monitor for and report which finding to the provider immediately?
a. Watery diarrhea b. Vaginitis c. Furry tongue d. Nausea and vomiting

18. A nurse is planning an education program about testicular cancer for a group of male adolescents.
Which information will the nurse include?
a. Testicular cancer is more common in men older than 65.
b. With early treatment, the survival rate is 50%.
c. Examine the testicles immediately after showering.
d. Schedule an annual ultrasound to screen for testicular cancer.

19. A nurse in the ER is assessing a newly admitted client. Which finding places the client at increased
risk for contracting Hepatitis B?
a. Residing in an institutional setting. c. Engaging in unprotected sexual intercourse.
b. Working with hazardous chemical waste materials. d. Traveling to a foreign country.

20. A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat
asthma. Which information will the nurse include in the teaching?
a. "The spacer increases the amount of medication delivered to the oropharynx."
b. "The spacer increases the amount of medication delivered to the lungs."
c. "Inhale rapidly using the spacer with the MDI."
d. "Cover exhalation slots of the spacer with lips when inhaling."

21. A nurse is assessing a client who has type 1 DM and finds the client lying in bed, sweating, and
reporting feeling anxious. Which complication will the nurse suspect?
a. Hypoglycemia b. Nephropathy c. Hyperglycemia d. Ketoacidosis

22. A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers
a loop of bowel through an opening in the surgical incision. Which action will the nurse take?
a. Place the head of the client's bed in the flat position.
b. Gently reinsert the bowel back into the client's wound.
c. Apply moistened sterile gauze to the site.
d. Position the client on the left side.

Q. A nurse is caring for a client who has acute osteomyelitis. Which intervention is the nurse's priority?
answer choices
Provide the client with antipyretic therapy.Administer antibiotics to the client.Increase the client's
protein intake.Teach relaxation breathing to reduce the client's pain.
Question 14 30 seconds
Q. A nurse is assessing an older adult client for manifestations of dehydration. Which finding will the
nurse expect?
answer choices
HypothermiaProtruding eyeballsElevated blood pressureFurrows in the tongue
Question 15 30 seconds
Q. A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin to
treat angina pectoris. Which instruction will the nurse include?
answer choices
"Place the tablet under your tongue, and then take a small sip of water.""The medication can take up to
15 minutes to take effect.""Avoid taking the medication prior to exercising.""Stop taking the medication
and notify your provider if you develop a headache."
Question 16 30 seconds
Q. A nurse is observing a newly licensed nurse prepare a sterile field. For which action will the nurse
intervene?
answer choices
Positions the wrapped package on the bedside table so the outer flap is away from her.Holds a bottle of
solution with the label away from the palm of the hand.Holds gauze packages 15 cm ( 6 in) above the
sterile field.Wears sterile gloves when moving sterile items on the sterile field.
Question 17 30 seconds
Q. A nurse is teaching a client who is scheduled for a dual-energy x-ray absorptiometry (DXA) to screen
for osteoporosis. Which instruction will the nurse include in the teaching?
answer choices
"You will need to remove all jewelry before the test.""You will need to lie flat for 4 hours following the
test.""You will need to empty your bladder before the test.""You will need to fast for 12 hours before
the test."
Question 18 30 seconds
Q. A nurse is instructing a client who has GERD about positions that can help minimize the effects of
reflux during sleep. Which statement indicates to the nurse that the client understands the instructions?
answer choices
"I will lie on my left side to sleep at night.""I will lie on my right side to sleep at night.""I will sleep on my
back with my head flat.""I will sleep on my stomach with my head flat."
Question 19 30 seconds
Q. A nurse is teaching a middle-age client about hypertension. Which information will the nurse include
in the teaching?
answer choices
"Reaching your goal blood pressure will occur within 2 months.""Diuretics are the first type of
medication to control hypertension.""Limit your alcohol consumption to three drinks a day.""Plan to
lower saturated fats to 10 percent of your daily calorie intake."
Question 20 30 seconds
Q. A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery
and notes the presence of serosanguineous drainage. The nurse will recognize that this is an indication
of which cirumstance?
answer choices
Serosanguineous drainage at this time is expected after abdominal surgery.Serosanguineous drainage at
this time is a manifestation of possible dehiscence.Serosanguineous drainage at this time is a
manifestation of hemorrhage.Serosanguineous drainage at this time is a manifestation of infection.
Question 21 30 seconds
Q. A nurse is administering sucralfate to a client who has a gastric ulcer. Which action will the nurse
take?
answer choices
Instruct the client to chew the sucralfate for fasting absorption.Administer the medication without food
or fluids.Limit the client's fluids while on sucralfate therapy.Administer sucralfate with an antacid.
Question 22 30 seconds
Q. A nurse is assessing a client who has heart failure and is prescribed furosemide. Which finding is an
adverse effect of this medication?
answer choices
Weight gainIncreased blood pressureHypoglycemiaLeg cramps
Question 23 30 seconds
Q. A client is planning to perform nasotracheal suction for a client who has COPD and an artifical airway.
answer choices
Perform suction up to 4 passes.Apply suction to the catheter when advancing it into the
tracheaPreoxygenate the client with 100% oxygen for up to 3 minutesLimit each suction pass to 25
seconds
1. A nurse is preparing to administer a 300 ml bolus tube feeding to a client. The nurse assesses that
there is a 200 ml gastric residual and the patient is vomiting. What should the nurse do next?
Hold the feeding and reassess the residual in 1 hour.Administer an antiemetic as prescribed.Give the
feeding as prescribed.Notify nutritional services.
Q2. A nurse is assessing a client with a duodenal ulcer. What does the nurse expect the client to state?
"I usually vomit right after I eat.""I have lost over 10 pounds.""I typically have pain 2 to 3 hours after I
eat.""I have noticed that I am often constipated.
Q3. A nurse has just initiated TPN for a client. Which assessment is the priority?
Auscultate bowel sounds every shift.Measure abdominal girth every shift.Assess blood glucose levels
every 4 hours.Ask the client about nausea or vomiting every 2 hours.
Q4. A nurse is caring for a client following open cholecystectomy. Which nursing action is the priority?
Assisting the client to cough and deep breath every 2 hours.Ask the nursing assistant to ambulate the
client every 4 hours.Teach the client about low fat food selections.Monitor weight and urinary output.
Q5. A client is recovering from an abdominal perineal resection. Which intervention will promote
healing of the perineal wound?
Packing the wound with betadine. dressings to prevent infection.Applying a heating pad to the area to
promote increased blood flow.Sitting on a doughnut cushion for pain relief.Taking a Sitz bath 4 times a
day to keep the area clean.
Q6. A nurse is caring for a client scheduled for an upper GI series. What teaching should the nurse
provide?
You will need a nasogastric tube inserted for this procedure.Don't eat anything after midnight before
the exam.Patient's often require antiemetics after this procedure.Eat a low fat diet following this
procedure.
Q7. A nurse is teaching a class about hepatitis. What does the nurse tell clients is the best way to
prevent Hepatitis B?
Avoiding all persons with hepatitis B.Barrier protection during sexual activity.Vaccine
administrationAvoid sharing toothbrushes and other items.
Q8. Lactulose is administered to reduce which of the following?
PotassiumAmmoniaAlcoholCalcium
Q9. A nurse is caring for a client who has a nasogastric tube attached to low intermittent suction and
observes that there is a decrease of drainage. What should the nurse do next?
Remove the tube and reinsert.Verify placement of the tube.Reposition the tube,Clamp the tube.
Q10. All patient with gastrostomy tubes (PEGs) are kept NPO.
TrueFalse
Q11. A T-Tube is used following some gall bladder surgeries to remove bile and promote healing.
TrueFalse
Q12. A client presents with complaints of blood in her stools. Upon inspection, the nurse notes streaks
of bright red blood visible on the outer surface of formed stool. Which of the following will the nurse
further investigate with this client?
Ingestion of cherry sodaRecent barium studiesIngestion of cocoaPresence or history of hemorrhoids
Q13. Which of the following actions is most appropriate for a client after removal of a nasogastric tube?

Palpate the abdomen. Provide mouth care

Check bowel soundsOrder a clear liquid diet.

Q1. An appropriate nursing intervention for a hospitalized patient who states she cannot cope with her
illness is
controlling the environment to prevent sensory overload and promote sleep.encouraging the patient's
family to offer emotional support by frequent visiting.arranging for the patient to phone family and
friends to maintain emotional bonds.asking the patient to describe previous stressful situations and how
she manage to resolve them.
Q2. Which are not considered adventitious breath sounds
Clear bilaterally

rhonchi

wheezing

crackles
Q3. The schol nurse is presenting to a class of students on how to prevent the transmission of the
common cold . Which information should the nurse include
Instruct the children to always keep a tissue with them

Explain to the children the importance of getting immunized against virus that causes the cold

Tell the students that they should go to the doctor immediaely

Instruct the student on proper hand washing hygine

Q4. What information is PRIORITY when teaching a client about acute sinusitis
Teach how to irrigate nasal passages

Teach the importance of completion of antibiotics

Teach proper blowing ing nasal passages techniques

Teach patient on the importance of narcotics for headaches

Q5. The influenza vaccine is in shopt supply. Which group of clients would the nurse consider PRIORITY
when administering the vaccine?
Elderly and Chronic ill patients

Child care providers and children < age of 4 years of age

Hospital chaplains

students living in a dormitory

Q6. A patient with Influenza A is being discharged from the emergency department with prescription
antibiotics . Which statement by the client indicates and understanding for this prescription
The pills will make you feel better fast and I can return to work

The antibiotics will help prevent me from developing bacterial pneumonia

If I had gotten this prescription sooner, I could have been prevented

I need to take these pills until I feel better

Q7. A newly admitted patient with a productive cough has the following v/s 148/89, 108, 32,102, PsO2
of 95%, Which order would be implemented first
Place on contact precautions
Adminiser ibuprofen

Hang Ancef IVPB

Call lab to get a stat blood culture

Q8. The nurse is reviewing the charts for these patients who are scheduled in October for yearly physical
examinations. Which patients will the nurse plan to administer the influenza vaccine? Choose all that
apply
50 year old female with asthma

20 year old male on prednison

90 year old male in a assisted living facility

70 year old with a egg allergy

45 year old with a pacemaker

Q9. The nurse is assessing the client diagnosed with COPD which data is required for immediate
intervention
Large amounts of thick white sputum

Oxygen flowmeter is set up on 8L

Usse the acessory muscles during inspiration

Presence of a barrel chest and dyspnea

Q10. A patient who has sleep apnea and has used a CPAP for 2 weeks, and has return to the sleep clinic
the patient tells the nurse "My sleep has not improved at all" Which response by the nurses is most
appropriate
CPAP results takes more than a few weeks to achieve the maxium effect

Have you been using the CPAP every night?

Do you want to talk to the doctor about surgery

Have you tried to increase the CPAP pressure higher?

Q11. Nursing care of a patient who has had a broncoscopy,. What is the PRIORITY nursing intervention.
NPO until gag reflexes have returned.

Administering the need of IV pain medication

Raising HOB up at 90% until patient is fully recovered from sedation

Keep patient in a lateral position to keep dressing dry and intact

Q12. A patinet diagnosed with lung cancer is being discharged . Which statement made by the client
indicates more learning is needed.
It doesnt matter if I smoke now. I already have cancer

I should see an ocologist at my schedule appointment

If I begim to run fever, I should notify the HCP

I should plan for periods of rest through out the day

Q13. The client diagnosed with restrictive airway (asthma) has been prescribed a glucocorticoid inhailed
medication. What information should the nurse teach regarding this medication
Do not abruptley stop taking the medication , it must be tapered off.

Immediately rinse the mouth following administration of the drug.

Hold the medication in the mouth for 15 seconds before swallowing.

Take the medication immediately when an attack starts.

Q14. The charge nurse is making rounds. Which client should the nurse assess first?
The 29 year old client diagnosed with reactive airway disease who is complaining the nurse caring for
him was rude.

The 76 year old client diagnised with heart failure who has 2+ edema of the lower extremeties.

The 15-year old client diagnosed with diabetic ketoaidosis after a bout witht the flu who has a blood
glucose reading of 189mg/dl.

The 62 year old client diagnosed with COPD and pneumonia who is receiving O2 by nasal cannula at
2L/pm.

Q15. A 56 year old client is admitted with a diagnosis of rule out TB. Which type of precautions will the
nurse implement
Standard Precautions

Contact Precautions

Droplet Precautions

Airborn Precautions

Q16. What instruction does the nurse provide while teaching a patient with asthma the appropriate use
of a peak meter flow?
Take and record peak flow readings when having asthma symptoms or an attack

Increase the doses of long term control medications for the peak in the red zone

Use of the flow meter each morning after taking asthma medications

Empty the lungs and then inhale rapidly through the mouthpiece

Q17. A patient has been diagnosed with chroni sinusitis Which sign and symptom alerts the nurse as
priority
Muscle weakness

Prulent sputum

Nuchal rigidity

Intermittent loss of muscle control

Q18. When teaching a client with asthma about the use of the peak flowmeter, the nurse instructs the
patient
Increase the use of quick relief medications if the meter indates the yellow zone

Carry the flow meter at all times

Close the mouth around the mouth piece and inhale quickly when using the flow meter

Go to the emergency room if the meter indicates the yellow zone

Q19. When a pulse oximetry monitor indicates a patient has a drop in Spo2 from 96% to 85% over 4
hours . What is the nurses PRIORITY
Request an order for stat arterial blood gases
Start the parient on oxygen by nasal canula at 2L/min

Notify thephyscian of the change

Check the position of the probe on the patients finger or earlobe

Q20. A patient is scheduled to undergo bronchoscopy. the nurse will anticipate an order to hold which
of the following medications on the morning of the procedure
Ibuprofen

Atenolol

Omeprazole

Digoxin