Physiological Integrity
Question: A 62-year-old patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital. What is the priority action for the nurse?
Answer Choices: Administering a bronchodilator
Initiating oxygen therapy
Assessing respiratory rate and effort
Encouraging fluid intake
Correct Answer: Assessing
respiratory rate and effort
Rationale: The priority action is to assess the respiratory status to determine the severity of the condition and the effectiveness of current treatments.
Health Promotion and Maintenance
Question: A nurse is teaching a group of adolescents about the prevention of sexually transmitted infections (STIs). Which statement by one of the adolescents indicates a need for further teaching?
Answer Choices: "I should always use a condom during sexual intercourse."
"Getting vaccinated for HPV can help prevent some STIs."
"I can still get an STI even if I use a condom."
"Douching after intercourse will prevent STIs."
Correct Answer: "Douching after intercourse will prevent STIs."
Rationale: Douching does not prevent STIs and may actually increase the risk by disrupting the natural flora of the vagina.
Psychosocial Integrity
Question: A patient with depression is prescribed an antidepressant and expresses concern about the time it will take to feel better. What is the best response by the nurse?
Answer Choices: "You should start feeling better within a few days."
"It may take 2 to 4 weeks before you notice an improvement."
"You'll feel an improvement as soon as you start taking the medication."
"It varies; you might feel better after a couple of months."
Correct Answer: "It may take 2 to 4 weeks before you notice an improvement."
Rationale: Antidepressants typically take several weeks to start showing
therapeutic effects.
Safe and Effective Care Environment
Question: A nurse is reviewing the plan of care for a patient with a central venous catheter (CVC). Which of the following interventions should be included in the care plan?
Answer Choices: Change the dressing using sterile technique.
Avoid flushing the catheter to prevent dislodging.
Administer all medications via the CVC without checking compatibility.
Change the catheter site every 72 hours.
Correct Answer: Change the dressing using sterile technique.
Rationale: To prevent
infection, it is crucial to maintain sterile technique when changing the dressing of a CVC.
Pharmacological and Parenteral Therapies
Question: A patient is prescribed warfarin (Coumadin). Which laboratory test will the nurse monitor to determine the effectiveness of the medication?
Answer Choices: Complete blood count (CBC)
International normalized ratio (INR)
Serum potassium
Blood urea nitrogen (BUN)
Correct Answer: International normalized ratio (INR)
Rationale: The INR is used to monitor the effectiveness of
warfarin therapy and ensure the patient is within the therapeutic range.
Reduction of Risk Potential
Question: A nurse is caring for a patient who just had a seizure. What is the priority nursing action?
Answer Choices: Administering anti-seizure medication
Reorienting the patient to their surroundings
Assessing the patient’s vital signs and respiratory status
Documenting the seizure activity in the medical record
Correct Answer: Assessing the patient’s vital signs and respiratory status
Rationale: It is important to first assess the patient’s
vital signs and respiratory status to ensure they are stable post-seizure.
