(1) A 40 years old man is admitted to the hospital. Admission orders include heparin 2000unit/hr in 5% Dextrose water.
Since patient is on heparin therapy.Which of the medications listed below did the Nurse need to have available?
(2)66 years old woman is brought into the Emergency room complaining of pressure in her chest.Her BP 150/96,pulse 89,Respiration 20.The admitting nurse gave nitroglycerin 0.4 mg sublingual as ordered by the doctor.For the nurse to evaluate the effect of this medication, the nurse should expect which of the following changes in patient vital sign.
(a)The heart rate will definitely change with respiration.
(b)BP and heart rate will decrease.
(c )BP 102/60,pulse 94,Respiration 20.That is reduced peripheral resistance,
will lead to decrease BP and pulse will increase while respiration will not change .
(d) Only blood pressure will decrease after getting nitroglycerin three times.
(3)The early signs of left CHF could be.
(a)Dyspnea, crackles and orthopnea.
(c)Pitting edema, weight gain,and distended neck vein.
(d)Confusion and increased CVP line.
(4) Who do you call when there is a problem with your patient(s)?
(a) You should call the supervisor.
(b) Call the primary or the doctor that is on call.
(c) Call the case manager and social worker ,because they are managers of cases.
(d) Tell charge nurse to call the doctor.
(5)Functions of chest tube drainage include.
(a)Prevention of escape of air from pleural space.
(b)Removal of air from pleural space.
(c) Encourage negative alveolar pressure.
( d) Equalization of air cavity pressure.
(6)Patient was admitted under the trauma team after a motorcycle accident, and he develop small pneumothorax to the right chest.He was placed on three-Chamber water seal drainage system at 20cm suction.
The nurse observed that there is a continuous bubbling in the water seal chamber during inspiration and expiration.
(a) The nurse suspected that there is a leak and notify MD.
(b)Nothing, after all the vital signs are stable.
(c)It was like that in the previous shift and they did nothing.
(d)Patient is in stable condition.
(7)A 73 years old female sustains a fracture of her left femur in a car accident.
To treat the fracture ,the orthopedic doctor performs an open reduction internal fixation.Which of these statement if made by the nurse shows a clear understanding of
the advantages of performing of ORIF.
(a) The nurse educate the patient and family on early mobilization with this procedure.
Your doctor ordered physical Therapist to help you regain strength and motion on the affected leg.Exercise is important for you to be able to use your leg again.I will medicate you for pain before PT and as needed.
(b) With this kind of surgery you just need to rest.
(c) Your doctor do not want you to move but just take your pain medications.
(d) None of the above.
(8) A sixty years old male”s family pushed the call light ,and the nurse went in to respond
to the call light,and the patient complained of shortness of breath and crushing chest pain.
The doctor notified and ABG was ordered.What result will indicate respiratory acidosis?
(a) PH 7.5,Pao2 90,paco2 60
(b) PH 7.29,Pao2 75,paco2 46.
(c) PH 7.45,Pao2 80,paco245.
(d)PH 7.35,Pao2 76,paco2 56.
(9) Partial Thickness wound can be classified as
(a) Stage IV.
(b) Stage 111.
(c) Stage 11 loss of dermis,shallow open ulcer without slough.
(d) Wound covered with eschar and some slough.
(10) The nurse received an eighty three years old female from emergency
room with the diagnosis of dizziness.She is very skinny,appeared malnourished,and weight lost of 5lbs in the last three months.02 @ 3L NC,with a saturation of 93%,alert and oriented x3,stable,breath sound clear ,bowel sound normal.
But there is no doctor orders.The nurse will:
(a) Call the doctor and obtain admitting orders and make the patient comfortable.
(b) Be patient the doctor will eventually put in the orders.
(c) Notify the doctor,charge nurse ,supervisor and patient family.
(d) A and C.
ANSWERS 1. A Protamine sulfate is an antidote for heparin.It helps to reverse the effect of heparin.
8 B. Respiratory acidosis Because the lung is compromised and is not getting rid of carbon dioxide so it stays in the blood and the lung.