NURSING BOARD EXAM PRACTICE IV – Care of Clients with Physiologic and Psychosocial Alterations

NURSING BOARD EXAM PRACTICE IV – Care of Clients with Physiologic and Psychosocial Alterations

June 2008 Nursing Licensure Examination (NLE)
June 2008 NP4 Nursing Board Exam Answer Key
Nursing Board Exams Questions 31-40

Situation - The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a dissecting aneurysm of the aorta.

31. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it?

A. 6 hours

B. 1 hour

C. 4 hours

D. 2 hours

32. What should you do FIRST before you administer blood transfusion?

A. verify client identity and blood product, serial number, blood type, cross matching results, expiration date

B. verify client identity and blood product serial number, blood type, cross matching results, expiration date with another nurse

C. check IV site and use appropriate BT set and needle

D. verify physician’s order

33. As WQ’s nurse, what will you do AFTER the transfusion has started?

A. add the total amount of blood to be transfused to the intake and output

B. discontinue the primary IV of Dextrose 5% Water

C. check the vital signs every 15 minutes

D. stay with WQ for 15 minutes to note for any possible BT reactions

34. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions are:

A. oliguria and jaundice

B. urticaria and wheezing

C. hypertension and flushing

D. headache, chills, fever

35. In case WQ will experience an acute hemolytic reaction, what will be your PRIORITY intervention?

A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physician

B. stop the blood transfusion and monitor the patient closely

C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank

D. immediately stop the BT, notify the blood bank and administer antihistamines

Situation - The kidneys have very important excretory, metabolic, erythropoietic functions. Any disruptions in the kidney’s functions can cause disease. As a nurse it is important that you understand the rationale behind the treatment regimen used.

36. PL, who is in acute renal failure, is admitted to the Nephrology Unit. The period of oliguria usually lasts for about 10 days. Which assessment parameter for kidney function will you use during the oliguric phase?

A. urine output directly related to the amount of IV fluid infused

B. urine output is less than 400 ml/24 hours

C. urine output of 30-60 ml/hour

D. no urine output, kidneys in a state of suspension

37. During the shock phase, what is the effect of the rennin-aldosterone-angiotensin system on renal function?

A. increased urine output, increased absorption of sodium and water

B. decreased urine output, decreased absorption of sodium and water

C. increased urine output, decreased absorption of sodium and water

D. decreased urine output, increased absorption of sodium and water

38. As you are caring for PL who has acute renal failure, one of the collaborative interventions you are expected to do is to start hypertonic glucose with insulin infusion and sodium bicarbonate to treat:

A. hyperkalemia

B. hypercalcemia

C. hypokalemia

D. hypernatremia

39. BN, 40 year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis in his left arm. What diet instructions will you need to reinforce prior to his discharge?

A. drink plenty of water

B. restrict your salt intake

C. monitor your fruit intake and eat plenty of bananas

D. be sure to eat meat every meal

40. BN, is also advised not to use salt substitute in the diet because:

A. salt substitute contain potassium which must be limited to prevent arrhythmias

B. limiting salt substitutes in the diet prevents a buildup of waste products in the blood

C. fluid retention is enhanced when salt substitutes are included in the diet

D. a substance in the salt substitute interferes with fluid transfer across the capillary membrane