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Medical Examination CCNS .
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CCNS PDF DEMO:
QUESTION NO: 1
Which of the following findings, if identified in a patient who is being treated for hypovolemic shock, should
indicate to the nurse that the treatment is having the desired effect?
A. Pulse oximeter reading of 99%
B. Temperature of 98.4oF
C. Urine output of 30 mL/hr
D. CVP of 40 mmHg
Answer: C
Explanation: A finding, if identified in a patient who is being treated for hypovolemic shock, that should
indicate to the nurse that the treatment is having the desired effect, is a urine output of 30 mL/hr.
Management of hypovolemic shock includes monitoring of fluid balance. A diminished urinary output is
characteristic, thus fluid replacement therapy would adequately perfuse the kidneys and increase urine
output.
QUESTION NO: 2
During a nursing staff meeting, the nurses determine that they will make sure all vital signs are reported
and charted within 15 minutes following assessment. This is an example of:
A. Group Decision Making
B. Group Identity
C. Group patterns of interaction
D. Group leadership
Answer: B
Explanation: Ascertaining that the staff completes a task on time and that all members agree the task is
important is a characteristic of group identity.
QUESTION NO: 3
A 20-year-old patient was diagnosed with neutropenia. When teaching the patient and his family, the
nurse should include the avoidance of:
A. Using suppositories or enemas
B. Using a filter mask
C. Performing oral hygiene after every meal
D. Performing perineal hygiene after each bowel movement
Answer: A
Explanation: When teaching the patient and his family, the nurse should include the avoidance of using
suppositories or enemas. A neutropenic patient is at high risk for infection, especially from bacterial infection of the gastrointestinal and respiratory tract.
QUESTION NO: 4
Baby Boy Holiday was admitted to the unit due to cancer of the esophagus. The laboratory values show a
hemoglobin of 7g/dL, hematocrit of 25%, and RBC count of 2.5 million/mm3. Considering the data, an appropriate nursing diagnosis for the patient at this time would be:
A. Risk for injury related to possible metastasis and subsequent airway obstruction
B. Imbalanced nutrition; less than body requirements related to dysphagia
C. Ineffective airway clearance related to tumor growth and metastasis
D. Acute pain related to pressure of the tumor on surrounding tissues and nerves
Answer: B
Explanation: Considering the data, an appropriate nursing diagnosis for the patient at this time would be
imbalanced nutrition; less than body requirements related to dysphagia. The decreased hemoglobin and
hematocrit levels and RBC count may be a result of malnutrition; also, cancer of the esophagus can cause dysphagia and anorexia.
QUESTION NO: 5
On a visit to an older adult who has a chronic heart failure, the nurse observes that the infant lies quietly in
a crib and barely has basic needs attended. The older adult is the primary caregiver to the infant. The nurse should:
A. Advise purchasing appropriate toys designed for this age level
B. Inform the older adult that the infant will be retarded if not stimulated
C. Explain the need for the family to hire a mother's helper for the home
D. Initiate a referral to an appropriate agency to assess the need for a home health aide
Answer: D
Explanation: The nurse should initiate a referral to an appropriate agency to assess the need for a home
health aide. This will ensure that a thorough assessment of the family's needs is made and the appropriate assistance is initiated.
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Updated: May 25, 2022