1.Easy
Which pain scale is designed for infants and young children who cannot describe their pain?
- AThe Morse Fall Scale
- BThe Glasgow Coma Scale
- CThe Braden Scale
- DThe FLACC scale
2.Easy
What is the normal baseline fetal heart rate?
- A60–100/min
- B160–220/min
- C110–160/min
- D40–60/min
3.Easy
In priority questions, what does an “unstable” patient mean?
- AA patient who takes more than five different medications
- BA patient whose condition is changing or hard to predict
- CA patient who has a long-term illness such as diabetes
- DA patient who is anxious and tearful about tomorrow’s surgery
4.Medium
On the first day after abdominal surgery, a patient has a temperature of 37.9 °C and reduced breath sounds at the lung bases. Which nursing action is most helpful?
- AGive a cough suppressant so that the incision is not strained
- BRestrict oral fluids so that the lungs do not fill up with extra fluid
- CEncourage deep breathing, coughing and use of the incentive spirometer
- DKeep the patient lying flat in bed to rest the incision fully
5.Medium
An Rh-negative mother has just given birth to an Rh-positive baby. What does the nurse expect to give the mother?
- ANo treatment is needed
- BA dose of the hepatitis B vaccine instead
- CRh immunoglobulin within 72 hours
- DVitamin K to the mother
6.Medium
A nurse teaches a patient with COPD pursed-lip breathing. Which statement shows a need for further teaching?
- A“I will breathe in through my mouth and out quickly through my nose.”
- B“I will breathe out slowly through pursed lips.”
- C“I will breathe in slowly through my nose.”
- D“I will make my breath out about twice as long as my breath in.”
7.Hard
During birth, the baby’s head delivers but the shoulders do not follow. What should the nurse do first?
- APush firmly on the top of the uterus (fundal pressure)
- BHelp with the McRoberts position and give suprapubic pressure as directed
- CAsk the mother to stop pushing and wait an hour
- DPull hard on the baby’s head and neck to free the trapped shoulders quickly
8.Hard
During a busy shift, four tasks are due. Which should the nurse do first?
- AFirst dose of IV antibiotic for a patient with suspected sepsis
- BHelp a stable patient fill in tomorrow’s menu card
- CUpdate the nursing care plan before the managers’ audit
- DGive a routine daily vitamin tablet that is due at the same time
Answer key
- 1. D · The FLACC scale
- 2. C · 110–160/min
- 3. B · A patient whose condition is changing or hard to predict
- 4. C · Encourage deep breathing, coughing and use of the incentive spirometer
- 5. C · Rh immunoglobulin within 72 hours
- 6. A · “I will breathe in through my mouth and out quickly through my nose.”
- 7. B · Help with the McRoberts position and give suprapubic pressure as directed
- 8. A · First dose of IV antibiotic for a patient with suspected sepsis
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