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Q1 Score: 1

Question the order.

Administer the medications.

Administer them separately.

Contact the pharmacy.

Q2 Score: 1

Localized heat and redness

Serosanguinous exudates and skin blanching

Separation of the incision

Blood clots and scar tissue are visible

Q3 Score: 1

Replenish her supply every 3 months.

Take one every 15 minutes if pain occurs.

Leave the medication in the brown bottle.

Crush the medication and take it with water.

Q4 Score: 1

Reassess the client’s blood pressure and heart rate

Review the client’s morning calcium level

Request a neurologic consult today

Check the client’s papillary reaction to light

Q5 Score: 1

Provide oral care every 3-4 hours

Monitor for indications of dehydration

Administer 0.45% saline by IV line

Assess daily weights for trends

Q6 Score: 1

Dressing is intact but partially soiled

Left foot is cold to touch and pedal pulse is absent

Left leg in limited functional anatomic position

BP 114/78, pulse of 82 beats/minute

Q7 Score: 1

Instruct client to observe strict bed rest

Check for epidural catheter drainage

Administer analgesia through epidural catheter as prescribed

Assess respiratory rate carefully

Q8 Score: 1

Leg movement

Finger movement

Lip movement

Fighting the ventilator

Q9 Score: 1

I will call my doctor if I experience muscle twitching or seizures.

I will make sure to take my vitamin D with my calcium each day.

I will take my calcium pill every morning before breakfast.

I will avoid dairy products, broccoli, and spinach when I eat.

Q10 Score: 1

Utilize an infusion pump.

Check the blood glucose level.

Place the client in Trendelenburg position.

Cover the solution with foil.

Q11 Score: 1

Serum potassium 5.2 mEq/L

Serum sodium 134 mEq/L

Serum calcium 10.6 mg/dL

Serum magnesium 0.8 mEq/L

Q12 Score: 1

Weighing the client daily

Measuring the extremity

Measuring the intake and output

Checking for pitting

Q13 Score: 1

Acid-base balance

Arterial Blood

Arterial oxygen saturation

Alveoli

Q14 Score: 1

Activity intolerance related to fatigue

Anxiety related to actual threat to health status

Risk for infection related to retained secretions

Impaired gas exchange related to airflow obstruction

Q15 Score: 1

The client’s low phosphorus is probably due to malnutrition.

The client is just worn out form not getting enough rest.

The client’s skeletal muscles are weak because of the low phosphorus.

The client will do more for herself when her phosphorus is normal.

Q16 Score: 1

Administer smallest dose that provides relief with the fewest side effects.

Titrate upward until the client is pain free.

Titrate downwards to prevent toxicity.

Ensure that the drug is adequate to meet the client’s subjective needs.

Q17 Score: 1

Intraspinal

Patient-controlled analgesia (PCA)

Intravenous (IV)

Sublingual

Q18 Score: 1

Report muscle weakness to the physician.

Allow 6 months for the drug to take effect.

Take the medication with fruit juice.

Ask the doctor to perform a complete blood count prior to starting the medication.

Q19 Score: 1

the surgeon greets his client before induction of anesthesia

the surgeon and anesthesiologist are in tandem

strap made of strong non-abrasive material are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board

client is monitored throughout the surgery by the assistant anesthesiologist

Q20 Score: 1

Weight client every morning.

Maintain accurate intake and output.

Restrict fluid to 1500 mL per day.

Administer furosemide (Lasix) 40 mg IV push.

Q21 Score: 1

Encourage oral feeding as soon as possible

Develop an alternative communication method

Keep the tracheostomy cuff fully inflated

Keep the patient flat in bed

Q24 Score: 1

Patients with an acute asthma attack

Patients with narcolepsy

Patients under age 6

Elderly patients

Q25 Score: 1

Macaroni and cheese

Shrimp with rice

Turkey breast

Spaghetti and meatballs

Q26 Score: 1

Administer IV fluids as prescribed by the physician.

Provide straws and offer fluids between meals.

Develop plan for added fluid intake over 24 hours.

Teach family members to assist client with fluid intake.

Q27 Score: 1

Monitor fluctuations in the water-seal chamber

Clamp the chest tube once every shift

Encourage coughing and deep breathing

Milk the chest tube every 2 hours

Q28 Score: 1

Assess the readiness of the client prior to surgery

Ensure that the airway is adequate

Account for the number of sponges, needles, supplies, Used during the surgical procedure

Evaluate the type of anesthesia appropriate for the surgical client

Q29 Score: 1

The client reports pain reduction and decreased activity

The client denies existence of pain

The client can distract himself during pain episodes

The client reports independence from watchers

Q30 Score: 1

Administer Kayexalate 15 g orally.

Administer spironolactone 25 mg orally.

Assess WCG strip for tall T waves.

Administer potassium 10 mEq orally.

Q31 Score: 1

Assess level of consciousness

Verify patient identification and informed consent

Assess vital signs

Check for jewelry, gown, manicure and dentures

Q32 Score: 1

Kinking of the ventilator tubing

A disconnected ventilator tube

An endotracheal cuff leak

A change in the oxygen concentration without resetting the oxygen level alarm

Q33 Score: 1

Contralateral side in a simple pneumothorax

Affected side in a hemothorax

Affected side in a tension pneumothorax

Contralateral side in hemothorax

Q34 Score: 1

Check the MARs and nurses’ notes for the past several days.

Ask the nurse educator to give an in-service about pain management.

Perform a complete pain assessment and history on the client.

Have a conference with the nurses responsible for the care of this client.

Q35 Score: 1

Put side rails up and ask client not to get out of bed

Send the client to ORD with the family

Allow client to get up to go to the comfort room

Obtain consent form

Q36 Score: 1

A client with fibromyalgia

A client with phantom limb pain

A client with progressive pancreatic cancer

A client with trigeminal neuralgia

Q37 Score: 1

Aspartate aminotransferase

Lactic acid dehydrogenase

Hydroxybutyric dehydrogenase

Creatine phosphokinase

Q38 Score: 1

Therapeutic touch

Use of heat and cold applications

Meditation

Transcutaneous electrical nerve stimulation (TENS

Q40 Score: 1

Explain all the possible interventions that may cause the client to worry.

Establish trusting relationship by giving his medication on time.

Stay with the client during pain episodes.

Promote client’s sense of control and participation in pain control by listening to his concerns.

Q41 Score: 1

Treatment is based on client goals.

A multidisciplinary approach is needed.

The client must be believed about perceptions of own pain.

Drug side effects must be prevented and managed.

Q42 Score: 1

Flattened neck veins when client is in supine position

Full and bounding pedal and post-tibial pulses

Pitting edema located in feet, ankles, and calves

Shallow respirations with crackles on auscultation

Q43 Score: 1

Simple description pain intensity scale

0-10 numeric pain scale

Faces pain-rating scale

McGill-Melzack pain questionnaire

Q45 Score: 1

Nausea or vomiting

Abdominal pain or diarrhea

Hallucinations or tinnitus

Lightheadedness or paresthesia

Q46 Score: 1

Amitriptyline (Elavil)

Corticosteroids

Methylphenidate (Ritalin)

Lorazepam (Ativan)

Q47 Score: 1

Bilateral inspiratory and expiratory crackles

Absence of breaths sound in the right thorax

Inspiratory wheezes in the right thorax

Bilateral pleural friction rub

Q48 Score: 1

Regular insulin

Glipizide (Glucotrol)

Repaglinide (Prandin)

Metformin (Glucophage)

Q49 Score: 1

Last case

In between cases

According to availability of anesthesiologist

According to the surgeon’s preference

Q51 Score: 1

Observe the dressing and type and odor of drainage if any

Get patient’s consent

Wash hands

Request the client to expose the incision wound

Q52 Score: 1

Make a note in the nurse’s file and continue to observe clinical performance.

Refer the new nurse to the in-service education department.

Quiz the nurse about knowledge of pain management.

Give praise for the correct dose and time and discuss the deficits in charting.

Q54 Score: 1

perioperative anxiety and stress

delayed coagulation time

delayed wound healing

postoperative respiratory dysfunction

Q55 Score: 1

check for presence underwear

check for presence dentures

check patient’s blood studies

check baseline vital signs