AH2 EXAM 1 LATEST ACTUAL EXAM
2024-2025 QUESTIONS AND DETAILED
CORRECT ANSWERS | ALREADY
GRADED A+
A patient has been admitted to the medical unit from the
emergency department with a peripheral IV in situ and
normal saline infusing by gravity. How should the nurse
best ensure that the patient's ordered solution infuses at
the correct rate?
Selected Answer:
A. Assess the patient often for signs and symptoms of fluid
overload.
B. Change from gravity infusion to an electronic IV pump.
C. Monitor the patient's IV infusion hourly.
D. Label the patient's bag of IV solution with a time-
calibrated strip of tape. Correct Answer B. Change from
gravity infusion to an electronic IV pump.
A practitioner orders IV fluids and ciprofloxacin (Cipro)
IVPB for a client. The nurse, using gravity to instill the IV,
hangs the piggyback ciprofloxacin higher than the primary
IV bag. When the piggyback bag isempty, the client
observes air in the tubing of the IVPB and becomes
frightened. The nurse should explain that:
1. Air in the tubing, even if it got into the vein, will not be
fatal unless it is a large amount
,2. The antibiotic and now the air are flowing into the large
IV bag, not into the venous system directly
3. The solution from the large IV bag begins to flow when
the solution from the smaller bag ceases to flow
4. The clamps on the tubing leading from both bags can
be closed for a few minutes to prevent air from entering
the vein Correct Answer 3. The solution from the large IV
bag begins to flow when the solution from the smaller bag
ceases to flow
A nurse is on his way to work when he witnesses an
automobile accident. As he assesses the scene, it
appears one individual has a possible head and neck
trauma. The most important intervention to implement first
is:
A. Assist the patient to a lying position
B. Start C-spine precautions, immobilizing the patient's
neck
C. Perform active range of motion exercises to assess for
nerve damage
D. Call 911 and wait for medical assistance to arrive
Correct Answer Answer: B. Start C-spine precautions
A patient who suffered a spinal cord injury experiences a
sudden depression of motor, sensory, reflex, and
autonomic function. However, these symptoms cease and
he recovers in a few hours. This patient likely experienced:
A. Spinal shock
B. Neurogenic Shock
C. Spinal relapse
,D. Autonomic dysreflexia Correct Answer Answer: A.
Spinal shock
When is a patient who suffered a spinal cord injury likely to
experience orthostatic hypotension? Correct Answer
Answer: When the patient first attempts to get out of bed,
often around 2 weeks after initial injury
A patient with a spinal cord injury experiences loss of
function of the autonomic nervous system below his spinal
lesion. The nurse notes bradycardia and hypotension due
to vasodilation upon assessment, and the patient reports
he is unable to perspire. These symptoms persist for an
extended period of time. This patient is experiencing:
A. Spinal Shock
B. Neurogenic shock
C. Autonomic dysreflexia Correct Answer Answer: B
Neurogenic shock
A patient with spinal cord injury reports a severe headache
to his nurse. He complains of nausea and nasal
congestion as well. Upon assessment, the nurse notes
bradycardia, hypertension, and that the patient is sweating
profusely. What is this patient likely experiencing? Correct
Answer Answer: Autonomic Dysreflexia
The nurse is caring for four clients receiving intravenous
therapy. Which client should the nurse assess first?
Correct Answer Older adult client with normal saline
infusing
, -Older adults are more prone to fluid overload and
resulting congestive heart failure. Becausethis client
is receiving continuous IV fluid, he or she is at risk for
fluid overload and needs to beassessed. All the other
clients would need to be assessed for complications
of IV catheters.However, they do not need immediate
assessment.
The nurse has just performed an IV start on a client. After
the catheter has been threaded its full length in the client's
vein, which action does the nurse perform next?
a. Secure the IV with a securement device or tape.
b. Dispose of the IV needle in the sharps container.
c. Engage the safety mechanism of the IV catheter
d. Note the date and time of the dressing application over
the insertion site. Correct Answer c. Engage the safety
mechanism of the IV catheter
To determine the status of a client's carotid pulse, the
nurse should palpate: Correct Answer At the anterior neck,
lateral to the trachea
A client's serum potassium level has increased to 5.8
mEq/L. What action should the nurse implement first?
1. Call the laboratory to repeat the test.
2. Take vital signs and notify the charge nurse or health
care provider.
3. Inform the cardiac arrest team to place them on alert.
2024-2025 QUESTIONS AND DETAILED
CORRECT ANSWERS | ALREADY
GRADED A+
A patient has been admitted to the medical unit from the
emergency department with a peripheral IV in situ and
normal saline infusing by gravity. How should the nurse
best ensure that the patient's ordered solution infuses at
the correct rate?
Selected Answer:
A. Assess the patient often for signs and symptoms of fluid
overload.
B. Change from gravity infusion to an electronic IV pump.
C. Monitor the patient's IV infusion hourly.
D. Label the patient's bag of IV solution with a time-
calibrated strip of tape. Correct Answer B. Change from
gravity infusion to an electronic IV pump.
A practitioner orders IV fluids and ciprofloxacin (Cipro)
IVPB for a client. The nurse, using gravity to instill the IV,
hangs the piggyback ciprofloxacin higher than the primary
IV bag. When the piggyback bag isempty, the client
observes air in the tubing of the IVPB and becomes
frightened. The nurse should explain that:
1. Air in the tubing, even if it got into the vein, will not be
fatal unless it is a large amount
,2. The antibiotic and now the air are flowing into the large
IV bag, not into the venous system directly
3. The solution from the large IV bag begins to flow when
the solution from the smaller bag ceases to flow
4. The clamps on the tubing leading from both bags can
be closed for a few minutes to prevent air from entering
the vein Correct Answer 3. The solution from the large IV
bag begins to flow when the solution from the smaller bag
ceases to flow
A nurse is on his way to work when he witnesses an
automobile accident. As he assesses the scene, it
appears one individual has a possible head and neck
trauma. The most important intervention to implement first
is:
A. Assist the patient to a lying position
B. Start C-spine precautions, immobilizing the patient's
neck
C. Perform active range of motion exercises to assess for
nerve damage
D. Call 911 and wait for medical assistance to arrive
Correct Answer Answer: B. Start C-spine precautions
A patient who suffered a spinal cord injury experiences a
sudden depression of motor, sensory, reflex, and
autonomic function. However, these symptoms cease and
he recovers in a few hours. This patient likely experienced:
A. Spinal shock
B. Neurogenic Shock
C. Spinal relapse
,D. Autonomic dysreflexia Correct Answer Answer: A.
Spinal shock
When is a patient who suffered a spinal cord injury likely to
experience orthostatic hypotension? Correct Answer
Answer: When the patient first attempts to get out of bed,
often around 2 weeks after initial injury
A patient with a spinal cord injury experiences loss of
function of the autonomic nervous system below his spinal
lesion. The nurse notes bradycardia and hypotension due
to vasodilation upon assessment, and the patient reports
he is unable to perspire. These symptoms persist for an
extended period of time. This patient is experiencing:
A. Spinal Shock
B. Neurogenic shock
C. Autonomic dysreflexia Correct Answer Answer: B
Neurogenic shock
A patient with spinal cord injury reports a severe headache
to his nurse. He complains of nausea and nasal
congestion as well. Upon assessment, the nurse notes
bradycardia, hypertension, and that the patient is sweating
profusely. What is this patient likely experiencing? Correct
Answer Answer: Autonomic Dysreflexia
The nurse is caring for four clients receiving intravenous
therapy. Which client should the nurse assess first?
Correct Answer Older adult client with normal saline
infusing
, -Older adults are more prone to fluid overload and
resulting congestive heart failure. Becausethis client
is receiving continuous IV fluid, he or she is at risk for
fluid overload and needs to beassessed. All the other
clients would need to be assessed for complications
of IV catheters.However, they do not need immediate
assessment.
The nurse has just performed an IV start on a client. After
the catheter has been threaded its full length in the client's
vein, which action does the nurse perform next?
a. Secure the IV with a securement device or tape.
b. Dispose of the IV needle in the sharps container.
c. Engage the safety mechanism of the IV catheter
d. Note the date and time of the dressing application over
the insertion site. Correct Answer c. Engage the safety
mechanism of the IV catheter
To determine the status of a client's carotid pulse, the
nurse should palpate: Correct Answer At the anterior neck,
lateral to the trachea
A client's serum potassium level has increased to 5.8
mEq/L. What action should the nurse implement first?
1. Call the laboratory to repeat the test.
2. Take vital signs and notify the charge nurse or health
care provider.
3. Inform the cardiac arrest team to place them on alert.
