NCM 121

1.       It is type of order that is to be carried out immediately.

• A.      Standing order

• B.      Single order

• C.      STAT order

• D.      PRN order

2.       The most accurate method of identifying a client before during administration is by:

• A.      Asking the client to state his name.

• B.      Calling the client by his name

• C.      Asking a relative to identify the client

• D.      Checking the identification band/bracelet of the client.

3.       How many MLs of air can cause air embolism in a client receiving intravenous injection?

• A. 100ML

• B. 5ML

• C. 10ML

• D. 50ML

       The client receiving blood transfusion experiences rashes, pruritus, and dyspnea. Which of the following is the best initial nursing action?

• A.      Stop the transfusion

• B.      Notify the Physician

• C.      Document the observation

• D.       Start an IV Line of normal saline.

5.    During blood transfusion, which of the following nursing actions are incorrect?

1.       Check crossmatching and blood typing before blood transfusion.

2.       Two nurses should check the label of the blood transfusion.

3.       Warm blood by placing it under running water.

4.       Administer Lactated Ringers in dextrose 5% before, during and after blood transfusion.

5.       Administer blood transfusion for 4 hours.

• A.      1,2

• B. 2,3

• C. 3,4

• D. 5

6.   The client receiving blood transfusion experience rashes, difficulty of breathing. Which of the following is the best initial nursing action?

• A.      Stop the transfusion

• B.      Notify the physician

• C.      Document the observation

• D.       Start an IV line of normal saline solution.

A client had a laminectomy and spinal fusion yesterday. Which statement is to be excluded from your plan of care?

• A.      Before log rolling, place a pillow under the client’s head and a pillow between the client’s legs.

• B.      Before log rolling, remove the pillow from under the client’s head and use no pillows between the client’s legs.

• C.      Keep the knees slightly flexed while the client is lying in a semi-Fowler’s position in bed.

• D. .      Keep a pillow under the client’s head as needed for comfort.

The nurse is caring for a 54-year-old female patient on the first postoperative day after a Roux-en-Y gastric bypass procedure. Which assessment finding should be reported immediately to the surgeon?

• A. Bilateral crackles audible at both lung bases

• B. Redness, irritation, and skin breakdown in skinfolds

• C. Emesis of bile-colored fluid past the nasogastric (NG) tube

• D. Use of patient-controlled analgesia (PCA) several times an hour for pain

Which information will the nurse prioritize in planning preoperative teaching for a patient undergoing a Roux-en-Y gastric bypass?

• A. Educating the patient about the nasogastric (NG) tube

• B. . Instructing the patient on coughing and breathing techniques

• C. Discussing necessary postoperative modifications in lifestyle

• D. Demonstrating passive range-of-motion exercises for the legs

A patient is being transferred to your unit with acute cholecystitis. In report the transferring nurse tells you that the patient has a positive Murphy's Sign. You know that this means:*

• A. The patient stops breathing in when the examiner palpates under the ribs on the right upper side of the abdomen at the midclavicular line.

• B. . The patient stops breathing out when the examiner palpates under the ribs on the right upper side of the abdomen at the midclavicular line.

• C. The patient verbalizes pain when the lower right quadrant is palpated.

• D. The patient reports pain when pressure is applied to the right lower quadrant but then reports an increase in pain intensity when the pressure is released.