Title RECALLS 8 - NP3 - SC ✅

C. Inconclusive D. Definitive and requiring a repeat test 30. The parent of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks you why antibiotics were not prescribed by the doctor. How should you respond? A. “The child may be allergic to antibiotics.” B. “The child is too young to receive antibiotics.” C. “Antibiotics are not indicated unless a bacterial infection is present.” D. “The child still has the maternal antibodies from birth and does not need antibiotics.” 31. You are an emergency department nurse evaluating a patient who has experienced a blunt trauma to the chest. Which sign would suggest that the patient may have a pneumothorax? A. A low respiratory rate B. Diminished breath sounds C. The presence of a barrel chest D. A sucking sound at the site of injury Situation: The nurse is preparing for an upcoming shift and decides to review her knowledge on various medications. She focuses on understanding the indications, side effects, and proper administration techniques for commonly used drugs in her unit. 32. A patient is prescribed guaifenesin. How would the nurse know the patient understands the correct way to take this medication if the patient describes which specific action? A. Take an extra dose if fever develops B. Take the medication with meals only C. Increase water intake when taking the medication D. Decrease the amount of daily fluid intake 32. The nurse is getting ready to administer intravenous naloxone to a patient with an opioid overdose. What supportive medical equipment should the nurse ensure is available at the patient’s bedside? A. Nasogastric tube B. Paracentesis tray C. Resuscitation equipment D. Central line insertion tray 33. Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? A. Platelet count B. Neutrophil count C. Liver function tests D. Complete blood count 34. A patient is about to start a 6-month course of isoniazid therapy. What should the nurse plan to teach the patient to do during their treatment? A. Use alcohol in small amounts only. B. Report yellow eyes or skin immediately. C. Increase intake of Swiss or aged cheeses. D. Avoid vitamin supplements during therapy. 35. The nurse has provided a patient on ethambutol with information about the medication. How can the nurse confirm that the patient understands the instructions if the patient says they will promptly report which specific symptom? A. Impaired sense of hearing B. Gastrointestinal side effects C. Orange-red discoloration of body secretions D. Difficulty in discriminating the color red from green 36. A patient with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. Which lab result would signal to the nurse that the patient is receiving an effective therapeutic dose? A. Prothrombin time of 12.5 seconds B. Activated partial thromboplastin time of 28 seconds C. Activated partial thromboplastin time of 60 seconds D. D. Activated partial thromboplastin time longer than 120 seconds 37. The nurse provides discharge instructions to a patient with atrial fibrillation who is taking warfarin sodium. Which statement by the patient shows they require further education? A. “I will avoid alcohol consumption.” B. “I will take coated aspirin for my headaches.” C. “I will take my pills every day at the same time.” D. “I have already called my family to pick up a MedicAlert bracelet.” Answer: B 38. The home health care nurse is visiting a patient with hypertension and high LDL cholesterol, whose serum cholesterol level is 420 mg/dL (11 mmol/L). The patient is prescribed warfarin, and the nurse provides education about the medication. Which statement by the patient indicates that further teaching is needed? A. “Constipation and bloating might be a problem.” B. “I’ll continue to watch my diet and reduce my fats.” C. “Walking a mile each day will help the whole process.” D. “I’ll continue my nicotinic acid from the health food store.” 39. For a patient receiving intravenous heparin therapy for atrial fibrillation, which medication should the nurse ensure is readily available on the nursing unit? A. Vitamin K B. Protamine sulfate C. Potassium chloride D. Aminocaproic acid 40. A patient on daily digoxin has a serum potassium level of 3 mEq/L (3 mmol/L) and reports anorexia. The cardiologist orders a serum digoxin level test. Which digoxin level would the nurse identify as being outside the therapeutic range? A. 0.5 ng/mL (0.63 nmol/L) B. 0.8 ng/mL (1.02 nmol/L) C. 0.9 ng/mL (1.14 nmol/L) D. 2.2 ng/mL (2.8 nmol/L) Situation: Nurse Evelyn is caring for the patients diagnosed with COPD. The following questions are regrading this condition. 41. Nurse Evelyn is assessing a patient newly diagnosed with COPD. The patient reports a chronic cough with sputum production. What assessment finding would she expect in this patient? A. Clear, thin sputum B. Pink, frothy sputum C. Yellow-green, thick sputum D. Rust-colored sputum 42. A patient with COPD is prescribed an inhaled corticosteroid. Nurse Evelyn instructs the patient on how to use the inhaler properly. Which statement by the patient indicates the need for further teaching? A. “I should rinse my mouth with water after using the inhaler.” B. “I will use the inhaler before using my bronchodilator.” C. “I will press down on the inhaler while I breathe in deeply.” D. “I should wait at least 1 minute between puffs if instructed to take more than one.” 43. A patient with COPD is receiving supplemental oxygen therapy. Which observation would indicate that the patient might be experiencing oxygen toxicity? A. Cyanosis of the lips and fingertips B. A decreased respiratory rate C. Complaints of dry cough and substernal discomfort D. Decreased oxygen saturation levels 44. A patient with COPD is experiencing increased shortness of breath and has a history of frequent exacerbations. Nurse Evelyn is reviewing the patient’s medications. Which class of medication would she expect to be prescribed to help manage this patient’s symptoms? A. Antihistamines B. Antibiotics C. Bronchodilators D. Antivirals 45. A patient with COPD is participating in pulmonary rehabilitation. Nurse Evelyn is educating the patient about lifestyle changes to improve their condition. Which lifestyle modification would she most likely recommend? A. Increase daily intake of caffeine B. Engage in regular physical activity C. Avoid all dietary fats D. Limit fluid intake to prevent congestion 3 | Page
Situation: Annaliza, a senior nurse, is reviewing her knowledge regarding delegation and task management. 46. Annaliza, a nurse in a busy Philippine hospital is delegating tasks to a team of nurses and nursing assistants. Which task should she delegate to a nursing assistant? A. Administering intravenous medications B. Performing a comprehensive physical assessment C. Assisting a patient with daily activities and basic care D. Developing a care plan for a complex patient 47. The head nurse is reviewing the delegation process with a new nurse in a hospital in the Philippines. Which of the following principles should the nurse use to ensure effective delegation? A. Delegate tasks that require the nurse’s unique skills to unlicensed personnel B. Ensure that the delegatee has the necessary competence and training for the task C. Delegate all tasks to ensure that the workload is evenly distributed D. Only delegate tasks that are easy and can be done quickly 48. Nurse Annaliza is dealing with a situation where a nursing assistant is frequently late for their shift. What is the most appropriate action for the nurse manager to take? A. Ignore the lateness if it does not affect patient care B. Discuss the issue with the nursing assistant privately and address the pattern of lateness C. Reprimand the nursing assistant publicly to set an example D. Reassign the nursing assistant to a different shift without discussing the issue 49. Nurse Annaliza is preparing to delegate a complex wound dressing change. Which aspect of delegation is critical for ensuring that the task is performed safely? A. Verifying that the task is within the scope of practice for the delegatee B. Delegating the task without providing instructions C. Only providing verbal instructions without written guidelines D. Assuming that the delegatee knows how to perform the task without supervision 50. A nurse manager in the Philippines needs to prioritize tasks for a busy unit. Which of the following tasks should the nurse manager prioritize? A. Completing paperwork for routine audits B. Addressing a sudden change in a patient's condition C. Organizing a staff social event D. Conducting a review of patient satisfaction surveys Situation: A patient arrives at the emergency department accompanied by her son, who reports that about 30 minutes ago, his mother suddenly developed numbness and weakness in her left arm, along with slurred speech, while watching television. She has no history of head trauma. 51. The patient reports numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for a STAT computed tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consult. 52. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? A. Hemiparesis of the client’s left arm and apraxia. B. Paralysis of the right side of the body and ataxia. C. Homonymous hemianopsia and diplopia. D. Impulsive behavior and hostility toward family. 53. The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? A. Observe the client swallowing for possible aspiration. B. Position the client in a semi-Fowler’s position when sleeping. C. Place a suction setup at the client’s bedside during meals. D. Refer the client to an occupational therapist for evaluation. 54. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. Aspirin B. Timolol C. Heparin D. Streptokinase 55. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department? A. A 4-cm area of bright red drainage on the dressing. B. A weak pulse, shallow respirations, and cool pale skin. C. Pupils that are equal, react to light, and accommodate. D. Complaints of a headache that resolves with medication. 56. A client with a stroke is unable to speak but can understand spoken language. Which condition best describes this client’s speech difficulty? A. Receptive aphasia B. Expressive aphasia C. Global aphasia D. Wernicke’s aphasia 57. A patient is given a hairbrush but uses it to brush their teeth instead. This incorrect use of an object demonstrates which condition? A. Ataxia B. Apraxia C. Aphasia D. Agnosia 58. The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? A. Assess neurological status. B. Monitor pulse, respiration, and blood pressure. C. Initiate an intravenous access. D. Maintain an adequate airway 59. A patient admitted to the CCU was rushed to the hospital following a myocardial infarction. The patient has a history of hemorrhagic stroke. Which medication order would the nurse question? A. Alteplase (tPA) 15 mg IV bolus, then infusion as per protocol B. Oxygen at 2 L/min via nasal cannula C. Metoprolol 25 mg PO twice daily D. Morphine sulfate 2 mg IV every 2 hours PRN for chest pain Situation: Head injury is trauma to the scalp, skull, or brain from blunt or penetrating forces. It can be open (with fracture/penetration) or closed (without fracture), ranging from mild concussion to severe brain injury, and may lead to complications like increased intracranial pressure, cerebral edema, or secondary injury from hypoxia or hypotension. 60. The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as “high risk for immobility complications.” Which intervention would be included in the plan of care? A. Position the client with the head of the bed elevated at intervals. B. Perform active range-of-motion (ROM) exercises every four (4) hours. C. Turn the client every shift and massage bony prominences. D. Explain all procedures to the client before performing them. 61. An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first? A. Determine the identity of the client. B. Stop bleeding from open wounds. C. Check for a neck fracture. 4 | Page