Nursing Practice Exam Review

Jun 25, 2024

Nursing Practice Exam Review

Question 1

Scenario: 55-year-old male with type 2 diabetes, blurred vision, and dizziness.

Actions:

  • A: Check blood glucose level.

Rationale: Assessing for hypo/hyperglycemia is priority due to potential life-threatening conditions.

Question 2

Scenario: Postoperative patient on morphine with respiratory rate of 8 breaths/min.

Actions:

  • D: Hold morphine and notify physician.

Rationale: Respiratory depression contraindicates morphine; prioritize patient’s respiratory status.

Question 3

Scenario: Congestive heart failure patient with fluid overload.

Actions:

  • C: Administer prescribed diuretics.

Rationale: Diuretics remove excess fluid, relieve symptoms, and prevent complications.

Question 4

Scenario: Preparing for blood transfusion.

Actions:

  • A: Verify patient’s identity with two identifiers.

Rationale: Verifying identity prevents transfusion errors and ensures safety.

Question 5

Scenario: Patient with severe abdominal pain and suspected appendicitis.

Actions:

  • D: Ask about location and onset of pain.

Rationale: Initial assessment helps in diagnosing appendicitis and guiding further tests.

Question 6

Scenario: COPD patient experiencing shortness of breath.

Actions:

  • C: Assess oxygen saturation.

Rationale: Oxygen saturation guides appropriate interventions (oxygen, nebulizer, breathing techniques).

Question 7

Scenario: Hypertension patient education.

Needs More Education:

  • B: “I can add salt to my meals as long as I drink enough water.”

Rationale: Misunderstanding about salt intake; excessive salt increases blood pressure.

Question 8

Scenario: Agitated and confused patient, elevated heart rate, and sweating.

Actions:

  • B: Perform a thorough physical assessment.

Rationale: Identify underlying cause of symptoms for appropriate intervention.

Question 9

Scenario: Pediatric patient with anaphylaxis after peanut ingestion.

Actions:

  • D: Monitor vital signs and oxygen saturation continuously.

Rationale: Continuous monitoring assesses response to epinephrine and further needs.

Question 10

Scenario: Atrial fibrillation patient on warfarin with high INR.

Actions:

  • B: Prepare to administer vitamin K.

Rationale: Vitamin K reverses over-anticoagulation and reduces bleeding risk.

Question 11

Scenario: Chemotherapy patient with nausea.

Actions:

  • B: Administer prescribed antiemetic.

Rationale: Immediate relief of nausea and prevention of complications.

Question 12

Scenario: Acute asthma exacerbation.

Actions:

  • A: Administer short-acting beta agonist by nebulizer.

Rationale: Immediate relief of airway constriction.

Question 13

Scenario: Suspected DVT in lower leg.

Findings Indicative of DVT:

  • A: Warmth and redness over the affected area.

Rationale: Classic signs of DVT due to inflammation and clot formation.

Question 14

Scenario: Patient with dehydration.

Priority Outcome:

  • D: Urinary output of at least 30 mL/hour.

Rationale: Indicates adequate hydration and kidney function.

Question 15

Scenario: Post-op patient refuses incentive spirometer due to pain.

Response:

  • B: Explain importance to prevent complications like pneumonia.

Rationale: Education motivates use despite pain, emphasizing prevention of pulmonary complications.

Question 16

Scenario: New diabetes patient education.

Effective Method:

  • C: Demonstrate blood glucose check and allow practice.

Rationale: Hands-on experience enhances learning and retention of diabetic self-care skills.

Question 17

Scenario: Patient with bipolar disorder in a manic episode.

Intervention:

  • B: Provide a quiet environment and limit stimulation.

Rationale: Reduce agitation and prevent symptom escalation.

Question 18

Scenario: Patient reports feeling anxious.

Physiological Manifestation:

  • C: Diaphoresis.

Rationale: Common response to anxiety due to sympathetic nervous system activation.

Question 19

Scenario: Pain, redness, and swelling at IV site.

First Action:

  • B: Discontinue IV infusion immediately.

Rationale: Prevent further tissue damage, assess site, and possibly start a new IV line.

Question 20

Scenario: Patient at risk for falls.

Effective Intervention:

  • C: Ensure patient’s footwear has non-slip soles.

Rationale: Non-slip footwear enhances stability and prevents slips and falls.

Question 21

Scenario: Patient fasting for 12 hours pre-surgery, feeling light-headed and dizzy.

First Action:

  • D: Help patient lie down and elevate legs.

Rationale: Prevent falls and improve cerebral perfusion by promoting venous return.

Question 22

Scenario: Patient with severe anxiety about upcoming surgery.

Intervention:

  • C: Teach relaxation techniques and deep breathing exercises.

Rationale: Helps manage anxiety and provides a sense of control, especially preoperatively.

Question 23

Scenario: Chronic kidney disease patient on hemodialysis, weight gain of 2 kg since last session.

Action:

  • B: Assess for signs of fluid overload and edema.

Rationale: Weight gain likely indicates fluid retention; assess for and manage fluid overload.

Question 24

Scenario: Discharge instructions for patient on warfarin.

Dietary Advice:

  • C: Maintain consistent intake of vitamin K-rich foods.

Rationale: Consistency in vitamin K intake avoids fluctuations in INR levels and manages therapeutic effects.

Question 25

Scenario: Preparing subcutaneous injection for thin elderly patient.

Site and Technique:

  • C: Abdominal site using a 45° angle.

Rationale: Abdominal site and angle ensure medication delivery to subcutaneous tissue, minimizing risk of injury.