R.L.

E 70 (MTW) Group 1 PRE-TEST Name: _____________________________ Score: _________ Date: Direction: Encircle the letter of the correct answer. A. Multiple Choice. 1.) The nurse obtaining a nursing history can enhance data collection by utilizing the communication technique contained in which of the following questions? A. "Did your pain begin recently?" B. "You said the pain started yesterday?" C. "Can you tell me more about how the pain began?" D. "The pain isn't bad right now, is it?" 2.) A nurse who is revising the nursing plan's goals and interventions would require which of the following? A. Knowledge of the hospital's standards of care B. Medical assessment and written orders C. Healthcare team conferences D. Validation of the effectiveness of the interventions 3.) The nurse assesses for hyperkalemia in a client with which of the following problems? A. Renal failure B. Nausea and vomiting C. Excessive laxative use D. Loop diuretic use _________

4.) Baseline arterial blood gases are drawn on a healthy adult scheduled for surgery. The nurse expects the findings to be which of the following? A. PO2 30 mmHg and PCO2 15 mmHg B. pH 7.32 and HCO3 21 mEq/L C. PO2 90 mmHg and pH 7.40 D. PCO2 49 mmHg and HCO3 21 mEq/L

5.) In assessing the laboratory findings for a client the nurse should be aware that a decrease in the serum level of which laboratory value might cause digitalis toxicity? A. Sodium B. Potassium C. Chloride D. Calcium

6.) The nurse is preparing the client for an ultrasound of the gallbladder. Which of the following statements would be the most important to prepare the client for the test? A. "You will have food and fluids restricted for 4 to 8 hours prior to the test."

B. "Stool in the bowel may cause a reporting of inaccurate findings." C. "There is no special preparation for this procedure. You may eat and drink as usual." D. "You will be asked to drink a solution of radionuclide 2 hours prior to the procedure." 7.) Your client has recently returned to the unit following a bronchoscopy and is requesting a glass of water. Your first consideration in fulfilling the request would be which of the following? A. Is the client able to ambulate without assistance? B. Are the side rails up on the client's bed? C. Did the client receive a local anesthetic during the procedure? D. Is the call light within reach? 8.) Your client is experiencing shortness of breath after oxygen that was being delivered by nasal cannula was decreased to 2 L/min. Pulse oximetry reveals an oxygen saturation reading of 71 percent. Which of the following would be the most appropriate immediate nursing action? A. Closely monitor the client's condition and increase the oxygen concentration to 15 L/min. B. Place the client in a semi-Fowler's position and continue to monitor. C. Do nothing; the drop in oxygen concentration is expected with the change in oxygen being delivered. D. Sit the client up, assess the client's status, and notify the physician immediately. 9.) Which of the following steps of the nursing process would the nurse use when determining specific client needs based on the admission history database? A. Client teaching B. Team collaboration C. Diagnosing D. Developing a clinical pathway

10.) The nurse is implementing a plan of care. Which of the following actions would the nurse take in this phase of the nursing process? A. Listen for carotid bruits B. Assist the client to use the incentive spirometer every 2 hours C. Prioritize care issues D. Consult the physical therapist about the client's progress

B. Give the meaning of the following medical abbreviations: 1. ANST 2. FBS 3. BVM 4. IVPB 5. HAMA C. IV and Drug Computation. Please show your solutions. (2pts. each) Problem 1. A 1500 ml IV Saline is ordered over 12 hours. Using a drop factor of 15 drops / ml, how many drops per minute need to be delivered?

Problem 2. A patient, admitted with a head injury, has an order for D5NS at 25 ml/hour. The IV tubing has a calibration of 10gtt/ml. What is the correct rate of flow for this patient?

Problem 3. You have on hand diazepam (Valium) 5 mg/mL. You need to administer 8 mg IV push stat. to a patienthaving a seizure. How much should you draw into the syringe?

Problem 4.

Problem 5. A Potassium penicillin 1,200,000 u has been ordered for your patient. The available tablets are 400,000 u each. What amount will you give?

Good Luck!

Prepared by: P.C.Is : Jean Daisy R. Ranario Maitta Joy G. Saligumba

Answer Key:
1. C. "Can you tell me more about how the pain began?" Rationale: Open-ended questions encourage the client to speak freely and to elaborate and clarify answers as needed. Restrictive questions that only require a "yes" or "no" answer (option 1) do not encourage free exchange of information nor does frequent rephrasing of the client's answer (as in option 2). Leading questions (option 4) tend to elicit the answer that the nurse anticipated. 2. D. Validation of the effectiveness of the interventions Rationale: Validation of the effectiveness of the interventions to achieve the client-specific goals encompasses input from the healthcare team members and knowledge of hospital standards of care. Medical assessment and written orders are components of the client care but not the focus of the nursing plan of care. 3. A. Renal failure Rationale: Renal failure results in the inability of the kidneys to excrete potassium and that leads to hyperkalemia. Nausea, vomiting, excessive laxative use, and loop diuretic use will cause hypokalemia. 4. C. PO2 90 mmHg and pH 7.40 Rationale: Arterial blood gas findings of PO2 90 mmHg (80 to 100 mmHg normal) and pH 7.40 (7.35 to 7.45 normal) would be within the normal range for an adult. All the other options list abnormal findings. 5. B. Potassium Rationale: A low-serum potassium level enhances the action of digitalis and predisposes the client receiving digitalis to develop toxicity. The other lab values do not contribute to digitalis toxicity. 6. A. "You will have food and fluids restricted for 4 to 8 hours prior to the test." Rationale: The client will be required to have an empty stomach for the procedure to allow visualization of the gallbladder and adjacent structures to accurately rule out tumors, structural abnormalities, or the presence of stones. Since the lower GI tract is not visualized during this procedure, there is no need for the bowel to be empty. Also, ultrasound does not require the use of radioactive isotopes.

7. C. Did the client receive a local anesthetic during the procedure? Rationale: The administration of a local anesthetic is possible during the procedure to decrease the gag reflex and increase comfort. The nurse should check for the return of the gag reflex to prevent the potential for aspiration. The position of the side rails, availability of the call light, and the ability to ambulate without assistance are safety concerns but are not related to the specific client request.

8. D. Sit the client up, assess the client"s status, and notify the physician immediately.

Rationale: An oxygen saturation of less than 80 percent with observable signs of shortness of breath indicates respiratory distress, which requires immediate intervention. A full respiratory assessment should be performed and the physician advised of the findings immediately. Symptomatic respiratory distress should not be ignored. The repositioning of the client and the receiving of a physician's order to increase the oxygen being delivered would be helpful. The client should be continually monitored but 15 L/min flow rate of oxygen may be excessive. 9. C. Diagnosing Rationale: Diagnosing is a specific step of the nursing process that utilizes the information collected during the client-specific database collection. Client teaching is a nursing intervention. Team collaboration is important in the intervention and evaluation phases of the nursing process. The utilization of a previously developed clinical pathway includes components of all steps of the nursing process. 10. B. Assist the client to use the incentive spirometer every 2 hours Rationale: Assisting the client to use the incentive spirometer actively operationalizes the client's plan of care to maintain optimal oxygenation status. Auscultation of carotid bruits would be a part of the assessment process from which a care need may be identified. Prioritization of care issues is part of the planning stage of the nursing process from which nursing interventions are determined. Consultation with other care providers is used in evaluating the effectiveness of the planning of care and gathering information for possible revision.

http://web.squ.edu.om/medLib/MED_CD/E_CDs/Medical%20Surgical%20Nursing%20Reviews%20&%20Rationales/ch et_hogan_medsurg_1/chapter1/deluxe.html Computation: 1. 2. 3. 4. 31.25gtts/min or 31gtts/min 4gtts/min 1.6mL 52.5 ml/hr 5. 3tabFormula to Problem # 4.
(mcg x kg) X 60 1000 First, convert mcg/kg/min into mg/hr. In the example above, the dose would be 84 mg/hr. (20mcg x 70kg) X 60 = 84 1000 Next, use the IV dosage formula to solve the rest of the problem. dose ordered X volume available dose available In the example, 84 mg is the dose ordered, 800 mg is the dose available, 500 mL is the volume. 84mg X 500ml = 52.5 ml/hr 800mg