Unit 1: Test Taking Strategies
The nurse is caring for a hospitalized client with a diagnosis of heart failure who
suddenly complains of shortness of breath & dyspnea. The nurse should take what
IMMEDIATE action?
1: Administers oxygen to the client
2: Elevates the head of clients bed
3: Calls the HCP
4: Prepares to administer furosemide - ANS 2: Elevates head of clients bed
A
1 is WRONG because you need an order to administer oxygen
VI
The nurse is caring for a client who just returned from the recovery room after
undergoing abdominal surgery. The nurse should monitor for which EARLY sign of
hypovolemic shock?
TU
1: Sleepiness
2: Increased pulse rate
3: Increased depth of respiration
4: Increased orientation to surroundings - ANS 2: Increased pulse rate
IS
3 is WRONG because it is a sign that shock is progressing
OM
The nurse provides medication instructions to a client about digoxin (Lanoxin). Which
statement by the client indicates an understanding of its adverse effects?
1: Blurred vision is expected
2: If I am nauseated or vomiting I should stay on liquids and take some liquid antacids
3: This medication may cause headache & weakness but that is nothing to worry about
NA
4: If my pulse rate drops below 60, I should let my healthcare provider know - ANS 4:
If my pulse rate drops below 60, I should let my healthcare provider know
Digoxin: Cardiac glycoside
Main concern: Toxicity
JP
Adverse Effects: GI disturbances, neurological abnormalities, bradycardia, & ocular
disturbances
Strategies used to prioritize include
1?
2?
3? - ANS 1: ABC's (Airway, breathing, circulation)
2: Maslows Hierarchy of needs
, 3: Steps of nursing process
A client with a diagnosis of cancer is recieving morphine sulfate for pain. The nurse
should employ which PRIORITY action in the care of the client?
1: Monitor stools
2: Encourage fluid intake
3: Monitor urine output
4: Encourage the client to cought & breathe deeply - ANS 4: Encourage the client to
cought & breathe deeply
Rule Used: ABC's
A
Morphine sulfate - suppresses cough reflex & the respiratory reflex
VI
What is always the highest priority?
What is the exception to this rule? - ANS Airway is always the first priority.
The exception is the performance of CPR where CAB (circulation, airway, breathing)
TU
guidlines are followed.
Maslows Hierarchy of Needs - ANS 1: Basic physiological needs
2: Safety & security
IS
3: Love & belonging
4: Self- Esteem
5: Self- Actulization
OM
The nurse caring for a client experiencing dystocia dertermines that the PRIORITY is
which action?
1: Position change & provide comfort measures
2: Explanations to family members about what is happening to the client
NA
3: Monitoring for changes in the physical condition of the mother & fetus
4: Reinforcement of breathing techniques learned in childbirth prep classes - ANS 3:
Monitoring for changes in the physical condition of the mother & fetus
Rule Used: Maslow Hierarchy
JP
This answer addressed physiological needs of mother and fetus
Nursing Process - ANS 1: Assessment
2: Analysis
3: Planning
4: Implementation
5: Evaluation
The nurse is caring for a hospitalized client with a diagnosis of heart failure who
suddenly complains of shortness of breath & dyspnea. The nurse should take what
IMMEDIATE action?
1: Administers oxygen to the client
2: Elevates the head of clients bed
3: Calls the HCP
4: Prepares to administer furosemide - ANS 2: Elevates head of clients bed
A
1 is WRONG because you need an order to administer oxygen
VI
The nurse is caring for a client who just returned from the recovery room after
undergoing abdominal surgery. The nurse should monitor for which EARLY sign of
hypovolemic shock?
TU
1: Sleepiness
2: Increased pulse rate
3: Increased depth of respiration
4: Increased orientation to surroundings - ANS 2: Increased pulse rate
IS
3 is WRONG because it is a sign that shock is progressing
OM
The nurse provides medication instructions to a client about digoxin (Lanoxin). Which
statement by the client indicates an understanding of its adverse effects?
1: Blurred vision is expected
2: If I am nauseated or vomiting I should stay on liquids and take some liquid antacids
3: This medication may cause headache & weakness but that is nothing to worry about
NA
4: If my pulse rate drops below 60, I should let my healthcare provider know - ANS 4:
If my pulse rate drops below 60, I should let my healthcare provider know
Digoxin: Cardiac glycoside
Main concern: Toxicity
JP
Adverse Effects: GI disturbances, neurological abnormalities, bradycardia, & ocular
disturbances
Strategies used to prioritize include
1?
2?
3? - ANS 1: ABC's (Airway, breathing, circulation)
2: Maslows Hierarchy of needs
, 3: Steps of nursing process
A client with a diagnosis of cancer is recieving morphine sulfate for pain. The nurse
should employ which PRIORITY action in the care of the client?
1: Monitor stools
2: Encourage fluid intake
3: Monitor urine output
4: Encourage the client to cought & breathe deeply - ANS 4: Encourage the client to
cought & breathe deeply
Rule Used: ABC's
A
Morphine sulfate - suppresses cough reflex & the respiratory reflex
VI
What is always the highest priority?
What is the exception to this rule? - ANS Airway is always the first priority.
The exception is the performance of CPR where CAB (circulation, airway, breathing)
TU
guidlines are followed.
Maslows Hierarchy of Needs - ANS 1: Basic physiological needs
2: Safety & security
IS
3: Love & belonging
4: Self- Esteem
5: Self- Actulization
OM
The nurse caring for a client experiencing dystocia dertermines that the PRIORITY is
which action?
1: Position change & provide comfort measures
2: Explanations to family members about what is happening to the client
NA
3: Monitoring for changes in the physical condition of the mother & fetus
4: Reinforcement of breathing techniques learned in childbirth prep classes - ANS 3:
Monitoring for changes in the physical condition of the mother & fetus
Rule Used: Maslow Hierarchy
JP
This answer addressed physiological needs of mother and fetus
Nursing Process - ANS 1: Assessment
2: Analysis
3: Planning
4: Implementation
5: Evaluation
