1. A clinic patient reports experiencing an allergic reaction to an unknown allergen
several weeks ago. Which action is appropriate for the registered nurse to delegate
to a licensed practical vocational nurse?
2.
3. A) review diagnostic study results with the patient
4. B) obtain the health history from the patient
5. C) perform a focused physical assessment
6. D) administer cutaneous scratch skin test - ANS-D
7. A couple who recently had a son with hemophilia Ais consulting with the nurse. They
want to know if their next child will have hemophilia A. The nurse can tell the patient
that if their child is a
8.
9. A) girl she will be a carrier of hemophilia a
10. B) boy he will be a carrier of hemophilia a
11. C) girl there's a 50% chance she will be a carrier of hemophilia a
12. D) boy he will have hemophilia a - ANS-C
13. A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which
action by the new nurse indicates a need for further teaching about pressure ulcer
care?
14.
15. a. The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer.
16. b. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer.
17. c. The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL
syringe.
18. d. The new nurse cleans the ulcer with a sterile dressing soaked in half-strength
peroxide. - ANS-d
19. a nurse has obtained donor tissue typing information about a patient who is waiting
for a kidney transplant. Which results should be reported to the transplant surgeon?
20.
21. a) panel of reactive antibodies (PRA) percentage is low
22. b) six antigen matches are present in HLA typing
23. c) patient is Rh positive and donor is Rh negative
24. d) results of patient-donor crossmatching are positive - ANS-d
25. a patient 1 day postoperative after abdominal surgery has incisional pain, 99.5 temp,
slight erythema at the incision margins, and 30 mL serosanguinous drainage in the
Jackson-Pratt drain. Based on the assessment, what conclusion would the nurse
make?
26.
27. a) the patient is having a normal inflammatory response
28. b) the abdominal incision shows signs of infection
29. c) the patients HCP must be notified of her condition
30. d) the abdominal incision shows signs of impending dehiscence - ANS-a
, 31. a patient from a long term care facility is admitted to the hospital with a sacral
pressure injury. The base of the wound includes subq tissue. How would the nurse
classify this pressure injury?
32.
33. a) stage 3
34. b) stage 2
35. c) stage 4
36. d) tage 1 - ANS-a
37. a patient in the health care providers office for allergen testing using the cutaneous
scratch method develops itching and walking at the skin site. Which action should the
nurse plan to take first?
38.
39. a) monitor the patients edema
40. b) administer dose of epinephrine
41. c) assess the patients use of new skin products
42. d) obtain a prescription for oral antihistamine - ANS-b
43. a patient is admitted to the hospital with acute rejection of a kidney transplant. Which
intervention will the nurse expect for this patient?
44.
45. a) testing for HLA match
46. b) insertion of an arteriovenous graft for hemodialysis
47. c) placement of the patient on a transplant waiting list
48. d) administration of immunosuppressant medications - ANS-d
49. A patient is anxious and reports difficulty breathing after being stung by a wasp.
50. What is the nurse's priority action?
51.
52. a. Provide high-flow oxygen.
53. b. Assess the patient's airway.
54. c. Administer antihistamines.
55. d. Remove the stinger from the
56. site. - ANS-b
57. a patient is being evaluated for possible atopic dermatitis. The nurse should expect
elevation of which laboratory value?
58.
59. a) neutrophils
60. b) IgE
61. c) basophils
62. d) IgA - ANS-b
63. a patient seeks care in the ED after sharing needles for heroin injection with a friend
who has hepatitis B. To provide immediate protection from infection, what medication
will the nurse expect to administer?
64.
65. a) corticosteroids
66. b) Gamma globulin
67. c) Hepatitis B vaccine
68. d) Fresh frozen plasma - ANS-b
69. a patient tells the nurse, "I would like to use a home genetic test to see if I will
develop breast cancer". Which is the nurse's best initial response?
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