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Potential Test Questions. Interventions/ Rationales.

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5 Potential Test Questions

1.A nurse is assessing a patient in the ED who was recently involved in a motorcycle accident for increased intracranial pressure. Which of the flowing should the nurse observe as signs and symptoms of increased pressure? (Select all the apply)
A.Restlessness and irritability
B.Pinpoint pupils
C.Urinary incontinence
D.Severe headache

Answers: A, B, D

2.A male adolescent is brought into the ED via stretcher who was recently involved in a physical altercation with a fellow classmate. The paramedic reports off to the nurse that the adolescent had recently lost consciousness but is currently responsive, reports BP to be 154/98, Pulse 58, Respirations 8 and O2 Stat 83%. What is the priority assessment for the nurse to make?
A.Ask the patient how long he was unconscious for
B.Obtain current B/P
C.Asses for pupillary changes
D.Determine current respiratory status

Answer: D

3.A three year old, male is brought to the clinic with what is suspected to be muscular dystrophy. What diagnostic test would most likely be ordered?
A.CBC with differential
B.Muscle biopsy
C.Serum Calcium

Answer: B

4.A female client is concerned about her current weight. She weighs 153 pounds and is 5’2. Based on her BMI by weight and height the nurse could explain to her that she falls under what category?
B.Normal weight
C.Over weight

Answer: C

5.A lumbar puncture is being performed to confirm what is thought to be bacterial meningitis. Which abnormal finding is found to be confirmation of bacterial meningitis?
A.Elevated protein
B.Clear appearance of the CSF
C.Decreased WBC
D.Elevated glucose

Answer: A

Clinical Experience

My patient was a 33 year old female with end stage anorexia nervosa. When admitted she coded and tested positive for cocaine, had been drinking heavily and was diagnosed with aspiration pneumonia. She was 5’4 and 94 pounds. Immobile due to neuropathy of her legs and feet therefore subsequently developed a stage 1 pressure ulcer on her coccyx.

Perfusion: Ineffective Peripheral Tissue Perfusion

I: Assess presence, location, and degree of swelling or edema formation.
R: Useful in identifying edema in involved extremity/ location.

I: Note client’s nutritional and fluid status.
R: Weight loss makes ischemic tissue more prone to breakdown.

I: Recommend or provide foot and ankle exercises when unable to move freely.
R: Promote peripheral circulation and limit complications associated with poor perfusion and tissue injury.

Cellular Regulation: Impaired Gas Exchange

I: Note respiratory rate, depth, use of accessory muscles, pursed lip breathing and areas of pallor and cyanosis.
R: To evaluate degree of compromise
I: Encourage frequent position changes and deep-breathing and coughing exercises.
R: Promotes optimal chest expansion and drainage of secretions.
I: Emphasize the importance of nutrition.
R: Improve stamina and reduces the work of breathing.

INR of 4

A patient with an INR of 4 would most likely lead a nurse or healthcare professional to suspect they are on Coumadin. A therapeutic INR level for Coumadin in 2.0-3.0, therefore this patient INR puts him/her at risk for bleeding

Risk for Bleeding

I: Review laboratory data.
R: To determine the presence of disorders that could cause bleeding.
I: Use soft toothbrush for oral care.
R: Reduce the risk of injury to the oral mucosa.
I: Promote dietary measure for foods high in Vitamin K.
R: Promotes blood clotting.

Sources for Interventions and Rationales: Nurse’s pocket Guide. Edition 12.


You have awesome questions. I like the ones you made up better than mine. Don't doubt yourself! You will make a wonderful nurse one day.

3Potential Test Questions. Interventions/ Rationales.  Empty Re: Lauren on Mon Nov 14, 2011 7:27 pm


That is so sad that someone so young has such bad habits that has ultimately caused her health to decline so rapidly. Sad


Oh wow that is such a sad, shocking story considering her age. U put up some great questions, u go with the select all that apply! Smile


What an interesting, and sad, patient Lauren. Did she have a psych evaluation on her chart? Were they just treating her pneumonia, or was she also being seen by a Dietician and Psychiatrist?

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