RN101
Home of the Registered Nurses (RN) and
Licensed Practical Nurses (LPN)

SITUATION I

 

Question 1:

Licensed Practical Nurse

 

Question 2:

Registered Nurse-8

Licensed Practical Nurse-3,4

PAB-1,2,5,6,7

 

SITUATION II

 

Question 1:

1. Teaching about food high in sodium

2. Explain the importance for alternating rest periods with exercise to the patient and family

3. Advise patient about limiting food high in salt and fluid

 

SITUATION  III

 

Question 1:

Ask the patient belief about narcotics and addiction

 

Question 2:

Encourage verbalization of his fears and past experiences

 

SITUATION IV

 

Question 1:

Show me where is your pain and describe how does it feel compare to yesterday. 

 

SITUATION V

 

4. Assisting the patient with oral hygiene.

 

SITUATION VI

1.MD

2.RN

3.RN

4.RN

5.LPN

6.MD

 

SITUATION VII

 

Question 1:

"Because feeding tubes are flexible, a guide wire or stylet is used to provide rigidity that facilitates positioning."

 

Question 2:

Pull the tube back and attempt to reinsert. 

 

Question 3:

1. Suction airway as needed
2. Remove feeding tube
3. Position patient on the side

 

Question 4:

Advance the tube until the mark is even with the naris and verify correct tube placement.

 

Question 5:

Call the physician; get an order to remove the feeding tube and insert a new feeding tube in the opposite naris.

 

Question 6:

A:3, B:4, C:2, D:1

 

SITUATION VIII

 

Question 1:

Assess the vital signs

 

Question 2:

Discontinue the transfusion

 

"A unit of blood should be administered within a 4 hour period of time. The nurse should discontinue the 
transfusion, document the findings and notify the blood bank. The agency policy will need to be followed concerning the documentation process and notification of appropriate personnel. Continuing the transfusion with the "open" unit will expose the client to an increased risk of injury."

 

SITUATION IX

 

Question 1:

Fluid overload

 

SITUATION X

 

Question 1:

Number 3

1. Oral surgeries are associated with transient bacteremia, and the client cannot donate for 72hours after an oral surgery.

2.The client cannot donate blood following rubella immunizations for one (1) month.
3. CORRECT: The client cannot donate blood for 6months after a pregnancy because of the nutritional demands on the mother.
4.Recent allergic reactions prevent donation because passive transference of hypersensitivity can occur. This client has an allergy that developed during childhood"

 

SITUATION XI

 

Question 1:

The solutions are not compatible (5% dextrose will hemolyze red cells)

 

Question 2:

1. Check the tubing for kinks

2. Reposition the client's wrist and elbow

 

SITUATION XII

Correct Answer: 3, 1, 4, 2, 5

3. This client may be chilling, indicating a potential rise in temperature. The nurse should assess the client and the temperature to see if interventions should be initiated based on a progression of the septicemia.

1. This client should be assessed to be sure that the client is stable because there was chest pain during the last shift.

4. The nurse should assess the client next because although confusion is expected, the nurse must determine whether any new situation is occurring.

2. This client has a psychosocial need but it must be addressed and steps implemented to resolve the problem.

5. A dressing change can take some time to complete. This is a physiological situation but not a life-threatening one and the nurse should see this client when he/she has time to perform the dressing change. 

 

SITUATION XIII

 

Question 1:

Assess pH of the aspirated contents

 

Question 2:

Flush with 30-50 ml water before and after feeding

 

SITUATION XIV

 

Question 1:

Mouth care

 

Question 2:

1. Explain that morphine does not cause death but effectively relieve pain and afford greater dignity in patient last days.

2. The change of LOC by the patient is not only caused by morphine neurotoxicity but also the progression of the illness of the patient.

 

SITUATION XV

 

Question 1:

1. Care focuses on controlling symptoms and relieving pain 

2. A multidisciplinary team provides care. (5) Bereavement care is provided to the family

 

Question 2:

1. Avoid people who have recently received attenuated vaccines 

2. Avoid activities that may cause bleeding

3. Wash hands frequently

4. Avoid crowded places, such as shopping malls

 

Question 3:

1. Fluctuations in the water-seal chamber occur when the client breathes

2. Intermittent bubbling occurs in the water-seal chamber

3. Gentle bubbling occurs in the suction control chamber

4. Drainage is collecting in the drainage chamber