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1. A clinical nurse specialist notes that a patient is demonstrating signs and symptoms of blood transfusion
reaction. The nurse immediately stops the blood transfusion and then does what??

A) Monitor intake and output every 15 minutes
B) Sends a urine specimen to the laboratory
C) Obtains blood pressure in both arms
D) Hangs a bag of normal saline using a new IVF tubing

2. An adult patient was admitted with a definitive diagnosis of portal hypertension and ascites. The physician
ordered 2 "units" of salt-poor albumin intravenously. The nurse educates the patient and his immediate
relatives that the purpose of salt-poor albumin is to:

A) Increase storage of protein
B) Temporarily divert the blood flow away from the liver
C) Provide parenteral nutrients
D) Elevate the circulating blood volume

3. When a mother of a pediatric patient who is admitted to the intensive care unit with multiple injuries sees
her child for the first time, she cries out that she didn't mean to hurt her baby. The nurse should:

A) Advise the relative to visit and comfort the mother
B) Respond by saying "you must feel guilty after you hurt your baby"
C) Call the child abuse hotline and report a possible case of abuse
D) Offer support by saying "this must be difficult for you"

4. On initial morning rounds, the neonatal nurse discovers baby Sean has blood glucose of 35 mg/dl. What
immediate course of action should be taken?

A) Feed him immediately
B) Give him insulin
C) All of the above
D) Give him water

5. A nurse assesses the communication patterns of a five-month-old infant. The nurse determines that the
infant is demonstrating the highest level of developmental achievement expected if the infant:

A) Uses monosyllabic babbling
B) Uses simple words, such as "mama"
C) Coos when comforted
D) Links syllables together

問題與答案：