Patient Admission

PostTest

1. A patient arrives at the emergency

department complaining of mid-sternal chest
pain. Which of the following nursing action
should take priority?

A. A complete history with emphasis on

preceding events.
B. An electrocardiogram.
C. Careful assessment of vital signs.
D. Chest exam with auscultation.

2. A patient has been hospitalized with pneumonia and

is about to be discharged. A nurse provides discharge
instructions to a patient and his family. Which
misunderstanding by the family indicates the need for
more detailed information?

A.Thepatientmayresumenormalhomeactivitiesastoleratedbutshouldavoidphysicalexertionandgetadequaterest.
B.Thepatientshouldresumeanormaldietwithemphasisonnutritious,healthyfoods.
C.Thepatientmaydiscontinuetheprescribedcourseoforalantibioticsoncethesymptomshavecompletelyresolved.
D.Thepatientshouldcontinueuseoftheincentivespirometertokeepairwaysopenandfreeofsecretions.

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A.Restrictvisitinghoursandaskthefamilytolimitvisitorstotwoatatime.
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C.Ifpossible,keeptheotherbedintheroomunassignedtoprovideprivacyandcomforttothefamily.
D.Contactthephysiciantoreporttheunusualritualsandactivities.

4. The charge nurse on the cardiac unit is

planning assignments for the day. Which of the
following is the most appropriate assignment
for the float nurse that has been reassigned
from labor and delivery?

A.Aone-weekpostoperativecoronarybypasspatient,whoisbeingevaluatedfor
placementofapacemakerpriortodischarge.
B.Asuspectedmyocardialinfarctionpatientontelemetry,justadmittedfromthe
EmergencyDepartmentandscheduledforanangiogram.
C.Apatientwithunstableanginabeingcloselymonitoredforpainandmedicationtitration.
D.Apost-operativevalvereplacementpatientwhowasrecentlyadmittedtotheunit
becauseallsurgicalbedswerefilled.

5. A newly diagnosed 8-year-old child with type I

diabetes mellitus and his mother are receiving diabetes
education prior to discharge. The physician has
prescribed Glucagon for emergency use. The mother
asks the purpose of this medication. Which of the
following statements by the nurse is correct?

A. Glucagon enhances the effect of insulin in case the

blood sugar remains high one hour after injection.
B. Glucagon treats hypoglycemia resulting from insulin
overdose.
C. Glucagon treats lipoatrophy from insulin injections.
D. Glucagon prolongs the effect of insulin, allowing
fewer injections.

6. A patient on the cardiac telemetry unit unexpectedly

goes into ventricular fibrillation. The advanced cardiac
life support team prepares to defibrillate. Which of the
following choices indicates the correct placement of the
conductive gel pads?

A. The left clavicle and right lower sternum.

B. Right of midline below the bottom rib and the left
shoulder.
C. The upper and lower halves of the sternum.
D. The right side of the sternum just below the clavicle
and left of the precordium.

7. The nurse performs an initial abdominal assessment

on a patient newly admitted for abdominal pain. The
nurse hears what she describes as "clicks and gurgles in
all four quadrants" as well as "swishing or buzzing sound
heard in one or two quadrants." Which of the following
statements is correct?

A. The frequency and intensity of bowel sounds varies

depending on the phase of digestion.
B. In the presence of intestinal obstruction, bowel
sounds will be louder and higher pitched.
C. A swishing or buzzing sound may represent the
turbulent blood flow of a bruit and is not normal.
D. All of the above.

8. A patient arrives in the emergency department and

reports splashing concentrated household cleaner in his
eye. Which of the following nursing actions is a priority?

A. Irrigate the eye repeatedly with normal saline solution.

B. Place fluorescein drops in the eye.
C. Patch the eye.
D. Test visual acuity.

9. A nurse is caring for a patient who

has had hip replacement. The nurse
should be most concerned about which
of the following findings?
A. Complaints of pain during repositioning.
B. Scant bloody discharge on the surgical
dressing.
C. Complaints of pain following physical therapy.
D. Temperature of 101.8 F (38.7 C).

10. A child is admitted to the hospital with an

uncontrolled seizure disorder. The admitting
physician writes orders for actions to be taken
in the event of a seizure. Which of the following
actions would NOT be included?

A. Notify the physician.

B. Restrain the patient's limbs.
C. Position the patient on his/her side with the head
flexed forward.
D. Administer rectal diazepam.

POST TEST

Answer Key

1.
1. Answer: C
The priority nursing action for a patient arriving at
the ED in distress is always assessment of vital
signs. This indicates the extent of physical
compromise and provides a baseline by which to
plan further assessment and treatment. A
thorough medical history, including onset of
symptoms, will be necessary and it is likely that an
electrocardiogram will be performed as well, but
these are not the first priority. Similarly, chest
exam with auscultation may offer useful
information after vital signs are assessed.

2.
2. Answer: C
It is always critical that patients being discharged
from the hospital take prescribed medications as
instructed. In the case of antibiotics, a full course
must be completed even after symptoms have
resolved to prevent incomplete eradication of the
organism and recurrence of infection. The patient
should resume normal activities as tolerated, as
well as a nutritious diet. Continued use of the
incentive spirometer after discharge will speed
recovery and improve lung function.

3.
3. Answer: C
When a family member is dying, it is most helpful for
nursing staff to provide a culturally sensitive
environment to the degree possible within the hospital
routine. In the Vietnamese culture, it is important that
the dying be surrounded by loved ones and not left
alone. Traditional rituals and foods are thought to ease
the transition to the next life. When possible, allowing
the family privacy for this traditional behavior is best
for them and the patient. Answers A, B, and D are
incorrect because they create unnecessary conflict
with the patient and family.

4.
Answer: A
The charge nurse planning assignments must consider the
skills of the staff and the needs of the patients. The labor
and delivery nurse who is not experienced with the needs of
cardiac patients should be assigned to those with the least
acute needs. The patient who is one-week post-operative
and nearing discharge is likely to require routine care. A
new patient admitted with suspected MI and scheduled for
angiography would require continuous assessment as well
as coordination of care that is best carried out by
experienced staff. The unstable patient requires staff that
can immediately identify symptoms and respond
appropriately. A post-operative patient also requires close
monitoring and cardiac experience.

5.
Answer: B
Glucagon is given to treat insulin overdose
in an unresponsive patient. Following
Glucagon administration, the patient
should respond within 15-20 minutes at
which time oral carbohydrates should be
given. Glucagon reverses rather than
enhances or prolongs the effects of insulin.
Lipoatrophy refers to the effect of repeated
insulin injections on subcutaneous fat.

6.
Answer: D
One gel pad should be placed to the right
of the sternum, just below the clavicle and
the other just left of the precordium, as
indicated by the anatomic location of the
heart. To defibrillate, the paddles are
placed over the pads. Options A, B, and C
are not consistent with the position of the
heart and are therefore incorrect
responses.

7.
Answer: D
All of the statements are true. The gurgles and
clicks described in the question represent
normal bowel sounds, which vary with the
phase of digestion. Intestinal obstruction
causes the sounds to intensify as the normal
flow is blocked by the obstruction. The swishing
and buzzing sound of turbulent blood flow may
be heard in the abdomen in the presence of
abdominal aortic aneurism, for example, and
should always be considered abnormal.

8.
Answer: A
Emergency treatment following a chemical
splash to the eye includes immediate
irrigation with normal saline. The irrigation
should be continued for at least 10 minutes.
Fluorescein drops are used to check for
scratches on the cornea due to their
fluorescent properties and are not part of the
initial care of a chemical splash, nor is
patching the eye. Following irrigation, visual
acuity will be assessed.

9.
Answer: D
Post-surgical nursing assessment after hip
replacement should be principally concerned with
the risk of neurovascular complications and the
development of infection. A temperature of 101.8 F
(38.7 C) postoperatively is higher than the low
grade that is to be expected and should raise
concern. Some pain during repositioning and
following physical therapy is to be expected and
can be managed with analgesics. A small amount
of bloody drainage on the surgical dressing is a
result of normal healing.

10.
Answer: B
During a witnessed seizure, nursing actions
should focus on securing the patient's safely
and curtailing the seizure. Restraining the limbs
is not indicated because strong muscle
contractions could cause injury. A side-lying
position with head flexed forward allows for
drainage of secretions and prevents the tongue
from falling back, blocking the airway. Rectal
diazepam may be a treatment ordered by the
physician, who should be notified of the seizure.