Nursing and Medical Scenarios Quiz

The nurse is administering a transfusion of packed RBCs. Which interventions should the nurse implement? Select all that apply.

• Verify the client has signed consent

• Obtain the blood from the laboratory

• Assess the IV site for size and patency

• Start the transfusion slowly

• Check the blood with another nurse at the bedside

A client undergoing assessment of cranial nerve VIII is likely to have which of the following included in his examination?

• Babinski and Kernig signs

• Weber, Rinne, and Romberg test

• Snellen and Ishihara charts

• Whispered voice and pupillary light reflex

A nurse is caring for a client recently diagnosed with hypothyroidism. The client noticed thinning hair

and a change in bowel movements from everyday to every other day. She also reports a new preference

for warmer environments and a profound decrease to her energy levels. Which of the following nursing

diagnoses would be priority for this client?

• Disturbed body image related to physical appearance changes

• Chronic pain related to muscle cramping

• Risk for imbalanced nutrition: more than body requirements

• Activity intolerance related to insufficient physiologic energy

The client in the medical units begins to experience a severe anaphylactic reaction after an initial dose of

IV penicillin, an antibiotic. Which intervention would least likely be implemented as an immediate

response to this development?

• Establish airway and provide oxygen

• Administer IM epinephrine

• Start IV line and administer normal saline

• Request and obtain a routine chest x-ray

Which of the following clients is most at risk for developing a deep vein thrombosis?

• A 22-year-old postpartum client 2 days after delivery

• A 76-year-old male client on bedrest for pneumonia

• A 40-year-old client who smokes and uses oral contraceptives

• A 55-year-old client with atrial fibrillation taking anticoagulants

A nurse’s forearm is splattered with blood while inserting an IV catheter. Which action should the nurse take?

• Wash the forearm with soap and water

• Apply alcohol-based sanitizer only

• Notify the client’s physician

• Cover the area with a sterile bandage

A nurse is admitting a client who has influenza accompanied by severe nausea and vomiting. Client

reports numbness and tingling of the toes and fingers. The nurse should recognize the client is

experiencing which of the following acid-base imbalances?

• Respiratory acidosis

• Metabolic acidosis

• Metabolic alkalosis

• Mixed respiratory/metabolic alkalosis

A client has a nasogastric tube following a subtotal gastrectomy. What should the nurse do?

• Monitor for nausea, vomiting, and abdominal distention

• Remove the NG tube if the patient reports discomfort

• Clamp NG tube to encourage bowel sounds

• Administer laxatives every 6 hours

A nurse is caring for a client with emphysema. Which of the following would the nurse NOT expect to assess?

• Use of accessory muscles

• Barrel-shaped chest

• Deep respirations

• Decreased breath sounds

A client on an inpatient psychiatric unit angrily says to a nurse “ Peter is not cleaning up after himself in

the community bathroom. You need to address the problem.” Which is the appropriate nursing response?

• I will talk to Peter for you.

• Just clean up after him this time.

• Ignore it—he’ll eventually stop.

• I can see that you are angry. Let’s discuss ways to approach Peter with your concerns.