1st exam rle 10.

What ECG finding is indicative of a

second-degree AV block type 1
1. If a prolong QP interval can increase (Wenckebach)?
the risk of which of the following
-Progressive lengthening of the PR
arrhythmias?
interval until a QRS is dropped.
-Ventricular tachycardia.
11. What is a common cause of a
2. How is the heart rate calculated from prolonged PR interval?
an ECG strip?
-First-degree AV block.
-count the number of QRS complexes
12. What is the primary reason for a
in a 10 second interval and multiply by
reduced amplitude of the R-wave in V1?
6
-Right ventricular hypertrophy.
3. In which condition is the ST segment
typically elevated? 13. Which ECG finding is the hallmark of
hyperkalemia?
-myocardial infarction
-Peaked T-waves.
4. In which situation would you expect to
see a low voltage URS complex? 14. Which interval measures the time
from the beginning of atrial
-Pericardial Effusion
depolarization to the beginning of
5. What does a U wave on an ECG ventricular depolarization?
typically indicate?
-PR interval.
-Hypokalemia or bradycardia
15. Which lead is considered the most
6. What does the P wave on an ECG important for diagnosing ischemia and
represent? infarction?

-Atrial depolarization -Lead V1.

7. What does the QRS complex 16. Which of the following ECG findings
represent? is most characteristic of atrial
fibrillation?
-Ventricular depolarization
-Absent P waves with irregularly
8. What does the T-wave on an ECG
spaced QRS complexes.
represent?
17. A patient with a pH of 7.40, PaCO2 of
-Ventricular repolarization
38 mmHg, and HCO3 of 24 mEq/L is
9. What ECG finding is associated with considered to be in:
right atrial enlargement?
-Normal state.
-Peaked P-wave in lead 2
18. A patient’s ABG result shows a pH of 34. A patient is receiving 1,000 ml of IV
7.50, PaCO2 of 30 mmHg, and HCO3 of fluids every 12 hours. What is the total
24 mEq/L. This indicates: amount of IV fluids administered in 24
hours?
-Respiratory alkalosis.
-B. 2,000 ml.
27. Which of the following parameters is
primarily used to assess the efficacy of 35. A patient is receiving intravenous
ventilation in an ABG analysis? fluids at a rate of 75 ml per hour. How
much fluid will the patient receive in 8
-B. PaCO2.
hours?
28. Which of the following would be a
A. 600 ml.
common cause of metabolic acidosis?
35. Pt is receiving intravenous fluids at a
-A. Diabetic ketoacidosis.
rate of 75 ml per hour. How much fluid
29. Which value indicates metabolic will the patient receive in 8 hours?
alkalosis in an ABG?
600 ml
-C. HCO3 30 mmol/L
36. Pt voids 500 ml of urine and has 200
30. A nurse is assessing a patient who ml of diarrhea. How much fluid has the
has been admitted with dehydration. patient's loss?
Which of the following findings would
-700 ml
indicate that the patient is experiencing
a positive fluid balance? 37. Pt w/ a fluid intake of 1200 ml and an
output of 1500 ml over 24 hours is
-C. Edema in the extremities.
experiencing
31. A nurse notices that a patient's intake
-Dehydration
and output are not matching. What is the
most appropriate initial action? 38. Pt urine output is measured 1500 ml
over 24 hrs. What is this rate considered?
-A. Recalculate the intake and output.
-Normal
32. A patient has a urinary output of 250
ml in the last 4 hours. How many ml per 39. How is fluid intake typically recorded
hour is the patient's average urine in a medical chart?
output?
-In milliliters.
-B. 75 ml per hour.
40. How should a nurse document fluid
33. A patient has an intake of 800 ml of intake from a feeding tube?
water, 200 ml of milk, and 250 ml of juice.
-As part of enteral intake.
What is the total fluid intake?

-A. 1,250 ml.

41. If a pt fluid intake is 2,500 ml and the 50. Which of the following should be
fluid output is 2,200 ml, what is the pt included in the measurement of fluid
fluid balance? output?

-Positive 300 ml. - Nasogastric Tube Drainage

42. What is the primary purpose of

measuring intake and output in a
2nd EXAM RLE
patient? A nurse is assessing the AV fistula site
-To monitor fluid balance and keep before dialysis. Which finding requires
deep function immediate attention?

43. What is the recommended method - Absence of bruit

for recording fluid intake and output in a A nurse is assessing the chest tube
hospital setting? drainage system and notices that the
- Accurate and timely documentation. fluid and water-sealed chamber rises
and falls with the patient's respiration.
44. What should a nurse do if a patient
What is the appropriate action?
has a sudden increase in fluid output?
- Document the finding as normal
- Monitor for signs of dehydration.
A nurse is caring for a patient on a non-
45. Monitoring a patient with heart
rebreather mask who has a PO2 of
failure. What is the primary concern?
58mmHg. What is the nurse's best
-Fluid balance leading to edema. action?

46. Which measurement should the -Call the healthcare provider for
nurse use to most accurately assess the further evaluation
patient's fluid retention over a 24-hour
A nurse is caring for a patient who is
period?
receiving oxygen therapy via a nasal
-Daily weights cannula and begins to exhibit signs of
respiratory distress the patient's oxygen
47. Which of the following is a common
saturation is 92% but they are anxious
sign of fluid overload?
and struggling to breathe. What should
-Edema. the nurse do first?

48. Which of the following is included in -Reassess the patient delivery device
the measurement of fluid intake?
A nurse is caring for a patient with a chest
- Blood transfusions. tube the patient accidentally pulls the
chest tube out. What is the nurse's
49. Which of the following is not
immediate action?
considered a fluid output?

-Medication
-Cover the insertion site with a sterile suspects dialysis disequilibrium
occlusive dressing tape on a three- syndrome or DDS. What is the nurse's
side first action?

A nurse is caring for a patient with an ETT. -Slow the dialysis flow rate and notify
Which of the following interventions is the healthcare provider
essential to prevent ventilatory-
A patient receiving hemodialysis
associated pneumonia or VAP?
develops muscle cramps during the
-Elevate the head of the bed to 30-45 procedure. What is the most appropriate
degrees intervention?

A nurse is caring for a patient with an ETT -Decrease the ultra-filtration rate
and mechanical ventilation. Which of the
A patient receiving oxygen therapy via a
following assessments indicates the
simple mask at eight liters per minute
need for suctioning?
complains of feeling claustrophobic and
-Ronchi heard over the lung feels anxious. What is the best nursing
intervention?
A nurse monitoring the output from a
patient chest tube following a motor -Reassure the patient and explore
vehicle accident. Which findings would alternative mask options
prompt the nurse to notify the healthcare
A patient undergoing hemodialysis has a
provider immediately?
potassium level of 6.2 mcg per liter.
-A total of 150 ml of drainage in the first Which of the following should the nurse
hour anticipate?

A nurse is providing oral care to a patient -Prepare the patient for immediate
with an endotracheal tube. What is the dialysis
primary reason for this intervention?
A patient undergoing peritoneal dialysis
- To prevent the development of or PD has an outflow that is cloudy. What
ventilatory-associated pneumonia is the nurse's most appropriate action?

A patient on continuous ambulatory -Notify the healthcare provider

peritoneal dialysis or CAPD has gained immediately
two kilograms since the last treatment.
A patient who is receiving peritoneal
What is the nurse's most appropriate
dialysis complains of abdominal pain.
intervention?
What is the nurse's first action?
-Use a dialysate with a higher glucose
-Assess the color and clarity of the
concentration
dialysate outflow
A patient receiving hemodialysis
A patient with a chest tube following a
complains of nausea, headache, and
pneumothorax experienced continuous
restlessness during treatment. The nurse
bubbling in the water seal chamber. -Suction the tracheostomy as needed
What is the most likely cause of the
A patient with an ETT begins coughing
observation?
vigorously during suctioning. What is the
-The drainage system has a leak nurse's most appropriate action?

A patient with a chest tube following a -Withdraw the suction catheter and
thoracotomy has 200 ml of bright red provide oxygen
drainage and a first hour after surgery.
A patient with an ETT has a sudden
What is the most appropriate action by
decreased in oxygen saturation and
the nurse?
diminished breath sounds on the left
-Notify the healthcare provider side. What is the nurses FIRST action?
immediately
-Check the ETT placement
A patient with a chest tube post-
A patient with an oxygen saturation 88%
lobectomy has 400 ml of dark red
is receiving oxygen via nasal cannula at 3
drainage over the past 24 hours. What is
liter per minute. The healthcare provider
the nurse's most appropriate action?
changed it into a venturi mask. What is
-Document the finding as normal the primary rationale for this
Intervention?
A patient with a chest tube reports
increased shortness of breath, and the -To provide a precise execution of
nurse notices that the chest tube has oxygen
become disconnected from the drainage
A patient with chronic kidney disease is
system. What is the nurse's priority
scheduled for hemodialysis. Which of
action?
the following medications should the
-Submerge the chest tube in sterile nurse withhold before the procedure?
water.
-Antihypertensive
A patient with a new tracheostomy
A patient with COPD is on 4 liters per
suddenly becomes anxious and
minute of oxygen via nasal cannula. The
diaphoretic. The nurse assessed the
patient reports increased shortness of
tracheostomy and find the tube had
breath. What is the nurse's best action?
dislodged. What is the nurse FIRST
action? - Assess the patient's respiratory
status and oxygen saturation
-Assess the patient's respiratory
status A patient with COPD receiving oxygen at
home via nasal cannula. The nurse
A patient with a tracheostomy tube is at
educates the patients about oxygen
risk of airway obstruction. What is the
therapy safety. Which statement that the
best nursing intervention to prevent this
patients indicate the need for further
complication?
teaching?
- “ I can apply lotion to my skin if I get The nurse is assisting in the reposition of
dry areas around my nose” the patient with an ETT. Which of the
following is the most important nursing
A patient with pneumonia is receiving
intervention?
oxygen therapy via nasal cannula but
their oxygen saturation remains 86%. -Verify tube placement by auscultating
The nurse assesses the patient and finds the lung sounds
the patient is using accessory muscles
The nurse is caring for a patient with on
to breath. What should the nurse do
continuous oxygen via nasal cannula at 5
next?
liter per minute. The patient reports
-Call a rapid response dryness and discomfort in the nasal
passages. What is the nurse's most
During a routine check of a patient with
appropriate nursing intervention?
ETT, the nurse observed that the ETT was
dislodged. What is the nurse's -Attach a humidifier
immediate action?
The nurse is caring for a patient who just
-Manually ventilate the patient with a returned from hemodialysis. Which of
bag valve mask the following assessments required
immediate intervention?
During chest tube care the nurse notices
that the drainage stops abruptly. What -The patients report dizziness
should the nurse do first?
The nurse is caring for a patient with a
-Assess the patients respiratory status tunnel dialysis catheter. Which of the
following practices is essential to
During tracheostomy care, the nurse
prevent infection?
notices bright red blood and secretions.
What is the nurse-appropriate nursing -Maintain sterile technique on
action? assessing the catheter

-Call the physician Immediately The nurse is caring for a patient with ETT
(endotracheal tube) who is receiving
The nurse Assessing the patient
oxygen therapy, the patient's oxygen
receiving oxygen therapy, the patient has
saturation suddenly drops to 84%. What
developed drowsiness and increased
is the nurse's first action?
respiratory rate. What complication
should the nurse suspect? -Assess the tube placement and
patency
- Hypercapnia
The nurse is educating a patient with a
The nurse is assessing the patient with
tracheostomy on how to communicate.
an ETT. What finding would require
Which method is most appropriate for a
immediate intervention?
patient who is alert and oriented?
- The patient is biting the ETT
-Use a communication board
The nurse is preparing to suction a too high. What complication could lead
patient with a tracheostomy. Which to?
action is the priority before beginning the
- Tracheonecrosis
procedure?
When changing a tracheostomy dressing
-Check the suction equipment
the nurse observes skin irritation around
The nurse is preparing to suction a the stomach. What is the most
patient with an ETT. Which of the appropriate action?
following techniques is the most
-Clean the area with normal saline and
important to prevent hypoxia during
apply a protective barrier
suctioning?
When teaching a family member how to
-Hyperventilate the patient before and
perform tracheostomy care. Which
after suctioning
instructions are most important?
The nurse is providing education to a
- Sterile technique is essential when
patient with a chest tube. Which
cleaning the inner cannula
statement by the patient needs further
teaching? A patient with a tracheostomy is unable
to clear secretions by coughing. Which
- “ I can __ the test tube temporarily
nursing action is most appropriate?
with water”
-Perform Tracheostomy Suctioning
The nurse is providing tracheostomy care
to a patient. Which action by the nurse
minimizes the risk of infection?
3rd exam
-Apply sterile gauze during procedure 1. To prevent fluid overload

The nurse notices that a patient with - Isotonic

tracheostomy showing signs of 2. A patient with anemia is receiving a
respiratory distress. What is the nurse blood transfusion. What type of IV
first action? solution is typically used to administer
-Suction the tracheostomy tube blood transfusion.

The nurse observes that the chest tube - Normal Saline

dressing is loose and there is visible air 3. A patient with cerebral edema in need
leaking from around the insertion site. of solution to reduce ICP. Which of the
What is the nurse's best action? following IV solutions would be most
-Clean the area with normal saline and appropriate
apply a protective barrier - Dextrose 10% water
When assessing an a Endotracheal tube
the nurse finds that the cuff pressure is
4. A patient with hyponatremia need to 13. When might albumin used in IV
replace sodium. Which of the following therapy?
IV solution would be most appropriate?
- To replace blood loss
- Dextrose 5% normal saline
14. When would the hypertonic solution
5. A pt with severe dehydration is in need be used?
with rapid fluid replacement. Which if
- To reduce cerebral edema
the following IV solutions would be most
appropriate? 15. Which of the following a nurse should
do if the patient is receiving IV fluids is
- Plain normal saline
experiencing a fluid overload?
6. What is a potential complication of
- Slow the infusion rate and inform the
excessive fluid replacement therapy.
physician
- Fluid overload
16. Which of the following is a common
7. What is the most common type of IV indication for IV therapy?
catheter used for short term therapy.
- Inability to swallow
- over the needle catheter
17. Which of the following is the late sign
8. What is the primary difference of fluid overload?
between cold blood and pack red blood
- Pulmonary crackles (BONUS)
cells
18. Which of the following is a nursing
- the presence of plasma
intervention to prevent fluid and
9. What is the primary function of electrolytes imbalances in the patient
colloids in IV therapy receiving IV therapy

- to expand blood volume - Monitor intake and output

10. What is the primary goal of fluid and 19. Which of the following is a potential
electrolyte replacement therapy complication of IV therapy?

- to maintain homeostasis - Phlebitis

11. What is the primary focus of IV 20. Which of the following is the
therapy preventive measure to avoid fluid
overload?
- to deliver fluids and medication
directly - all of the above

12. What is the proper technique of 21. Which of the following is not a type of
assessing IV site infiltration? colloids?

- Check for signs of redness and - Normal saline

swelling
22. Which type of IV solution is 29. A pt is receiving a blood transfusion
commonly used to treat dehydration and and is also prescribed with pain
electrolyte imbalances? medication. What is the most
appropriate time to administer the pain
- Crystalloids
medication
23. Why are IV solutions composed of
- it does not matter when the pain
water, dextrose, or electrolyte?
medication is administered
- to provide essential nutrients and
30. A pt is receiving a blood transfusion
maintain fluid balance
and is also prescribed with an antibiotic.
24. Why is it that electrolyte free water When is most appropriate time to
never be administered intravenously administer the antibiotic?

- it can cause hemolysis - after the blood transfusion

25. A pt is receiving a blood transfusion 31. A pt is receiving a blood transfusion

and begin to experience back pain and and is also prescribed with an
hemoglobinuria. What is the most likely anticoagulant. What is the most nursing
complication? intervention to prevent complications
associated with the combination blood
- hemolytic transfusion reaction
transfusion and anticoagulant therapy.
26. A pt is receiving a blood transfusion
- Monitor the patients coagulation
and begins to experience chills, fever,
time closely
and headache. What is the most likely
complication? 32. A pt is receiving a transfusion
dextran, a synthetic plasma expander.
- febrile non hemolytic transfusion
Which of the following side effect should
reaction
the nurse monitor
27. A pt is receiving a blood transfusion
- anaphylaxis
and begin to experience dyspnea,
tachycardia, and a cough. What is the 33. A pt is receiving a transfusion of
most likely complication? hetastarch a synthetic plasma expander.
Which of the following laboratory test
- Circulatory overload
should be monitored closely
28. A pt is receiving a blood transfusion
- BUN
and is also prescribed a diuretic. What is
the most important nursing intervention 34. A patient is scheduled to received a
to prevent complications associated blood transfusion. Which of the following
with the combination of blood is the most nursing intervention to
transfusion and diuretic therapy? prevent complication associated with
blood transfusion
- Monitor the pt blood pressure closely
- all of the above
35. What is the main advantage of using appropriate action to prevent
synthetic plasma expander . extravasation?

- all of the above - all of the above

36. What is the primary purpose of 42. A nurse successfully inserted an IV

plasma expander? catheter and is preparing to secure it.
Which of the following is the most
- to increase blood volume
appropriate method to secure the
37. Which of the following is the most catheter?
used plasma expander?
- Using commercial IV dressing with a
- Albumin clear window

38. A nurse is preparing to administer 43. A nurse is inserting an IV catheter to

blood transfusion. When priming the IV a patient. Which of the following is the
tubing with the use of Normal Saline, most appropriate position for the
what is the most appropriate volume to patient?
use?
- sitting upright with arm resting on
- 10 ml tool/armrest

39. A nurse is preparing to administer 44. A nurse is preparing to insert an IV

medication that is incompatible with catheter into the patients cephalic vein.
another medication, currently infusing Which of the following action should the
through the same IV catheter. What is the nurse take to prevent complications
most appropriate action to prevent associated with IV insertion.
precipitation?
- use a smaller gauge catheter for
- Flush the IV tubing with normal saline patient with fragile veins
between the two medications
45. A pt is ordered to receive one 1,000
40. A nurse is preparing to administer ml of 0.45% sodium chloride with a 20
medication through an existing IV meq of potassium chloride over 12 hr.
catheter. When priming the IV tubing with The IV tubing has a drp factor 15g/ml.
medication, what is the most What is correct IV flow rate
appropriate action to prevent air
- 21 g/m
embolism.
46. 1,000 ml sodium chloride, over 8 hrs.
- all of the above
Iv tubing 15 drp/ml. What is the IV flow
41. A nurse is preparing to administer rate
vesicant medication through IV catheter,
- 42 drp/min
when priming the IV tubing with
medication, what is the most 47. 5oo mg of gentamicin IV over 30 min.
40 ml. What is the correct IV flow rate
- 250 drp/min

48. 125 ml/hr.

- every 15 mins

49. one and a half hour

50. 2 unit pack rbc.

- 5 hrs