Practice Test Questions
16. A patient who had a head injury develops clear drainage from the nares. Which of these actions should a nurse take?
A. Pack the nares with sterile cotton
B. Collect the drainage specimen for culture
C. Gently suction the nares
D. Check the drainage for glucose
17. Which of these actions should a nurse take first when initiating cardiopulmonary resuscitation?
A. Determine responsiveness
B. Palpate carotid pulse
C. Begin chest compressions
D. Monitor respirations
18. A client is given instruction about collecting a mucus specimen forcytology. Which of these statements, if made by the client, would indicate correct understanding of the instructions?
A. “I will spit up the mucus after keeping my head lower than my body for afew minutes.”
B. “I will cough up the mucus into the container after a few deep coughs.”
C. “I will plan to collect the mucus before retiring for the night.”
D. “I will avoid drinking any liquids before coughing up the mucus from mychest.”
Rationales
16. Key: D Client Need: Physiologic Adaptation
D. Apositive test for glucose may indicate the presence of cerebrospinal fluid.
A. The nurse should not pack the nares of a patient with a head injury.
B. The drainage is clear and does not require a culture and sensitivity.
C. Nasal suctioning should not be undertaken in the patient with a suspected head injury.
17. Key: A Client Need: Management of Care
A. If the individual is responsive, CPR may not be necessary. This action should be carried out first.
B. Responsiveness should be determined first.
C. Compressions should not be started until responsiveness and breathing are determined.
D. Responsiveness should be established first followed by breathing.
18. Key: B Client Need: Safety and Infection Control
B. Expectoration of mucus requires deep coughing rather than “spitting”.
A. Deep coughing is required to produce a sputum specimen.
C. Mucus collection does not have to occur at night.
D. Liquids may facilitate expectoration of mucus.
来源：河南安琪新浪博客
16. A patient who had a head injury develops clear drainage from the nares. Which of these actions should a nurse take?
A. Pack the nares with sterile cotton
B. Collect the drainage specimen for culture
C. Gently suction the nares
D. Check the drainage for glucose
17. Which of these actions should a nurse take first when initiating cardiopulmonary resuscitation?
A. Determine responsiveness
B. Palpate carotid pulse
C. Begin chest compressions
D. Monitor respirations
18. A client is given instruction about collecting a mucus specimen forcytology. Which of these statements, if made by the client, would indicate correct understanding of the instructions?
A. “I will spit up the mucus after keeping my head lower than my body for afew minutes.”
B. “I will cough up the mucus into the container after a few deep coughs.”
C. “I will plan to collect the mucus before retiring for the night.”
D. “I will avoid drinking any liquids before coughing up the mucus from mychest.”
Rationales
16. Key: D Client Need: Physiologic Adaptation
D. Apositive test for glucose may indicate the presence of cerebrospinal fluid.
A. The nurse should not pack the nares of a patient with a head injury.
B. The drainage is clear and does not require a culture and sensitivity.
C. Nasal suctioning should not be undertaken in the patient with a suspected head injury.
17. Key: A Client Need: Management of Care
A. If the individual is responsive, CPR may not be necessary. This action should be carried out first.
B. Responsiveness should be determined first.
C. Compressions should not be started until responsiveness and breathing are determined.
D. Responsiveness should be established first followed by breathing.
18. Key: B Client Need: Safety and Infection Control
B. Expectoration of mucus requires deep coughing rather than “spitting”.
A. Deep coughing is required to produce a sputum specimen.
C. Mucus collection does not have to occur at night.
D. Liquids may facilitate expectoration of mucus.
来源：河南安琪新浪博客
