CELBAN Reading Comprehension 2

Question 1

A nursing care plan states: 'Monitor fluid intake and output every 4 hours; restrict oral fluids to 1,000 mL/day; administer furosemide 40 mg IV as ordered.' What is the PRIMARY purpose of the fluid restriction?

Accepted Answer

To manage fluid overload in a patient with compromised kidney or heart function

Answer

To prevent dehydration from furosemide

Answer

To reduce the frequency of urination for patient comfort

Answer

To ensure accurate measurement of IV fluid administration

Question 2

A passage reads: 'The patient is a 68-year-old male presenting with diaphoresis, pallor, and substernal chest pain radiating to the left arm. 12-lead ECG reveals ST-segment elevation in leads II, III, and aVF.' Based on this, which area of the heart is most likely affected?

Accepted Answer

Inferior wall

Answer

Anterior wall

Answer

Lateral wall

Answer

Posterior wall

Question 3

A medication administration record (MAR) notes: 'Metformin 500 mg PO BID with meals — HOLD if patient is NPO or scheduled for contrast imaging.' A nurse finds the patient is scheduled for a CT scan with contrast at 1400. What should the nurse do with the 1200 metformin dose?

Accepted Answer

Hold the dose and document the reason per the MAR instruction

Answer

Administer it as scheduled since the scan is after the dose time

Answer

Crush and dissolve in water to give before NPO begins

Answer

Substitute with insulin coverage instead

Question 4

A clinical article states: 'Pressure injuries are staged I through IV, with unstageable wounds also recognized. Stage II involves partial-thickness skin loss with exposed dermis, while Stage III involves full-thickness skin loss without exposed fascia.' A patient's wound shows subcutaneous fat visible but no bone, tendon, or muscle. Which stage is this?

Accepted Answer

Stage III

Answer

Stage II

Answer

Stage IV

Answer

Unstageable

Question 5

A nursing journal excerpt reads: 'Motivational interviewing (MI) is a collaborative, person-centered approach that elicits and strengthens motivation for change. Core skills include open-ended questions, affirmations, reflective listening, and summarizing (OARS).' Which response BEST demonstrates reflective listening?

Accepted Answer

'It sounds like you feel stuck between wanting to quit and enjoying smoking.'

Answer

'Have you thought about quitting smoking?'

Answer

'You've shown real commitment by coming to this appointment.'

Answer

'Let me summarize what we've discussed today.'

Question 6

A policy document states: 'All incidents involving patient falls must be documented in the incident reporting system within 2 hours of occurrence. A post-fall assessment must be completed by the RN, and the attending physician notified immediately if injury is suspected.' A patient is found on the floor at 0930 with a complaint of hip pain. By what time must the incident report be filed?

Accepted Answer

1130

Answer

1030

Answer

1200

Answer

By end of shift

Question 7

A discharge teaching handout reads: 'Signs of wound infection include increased redness, warmth, swelling, purulent discharge, and fever above 38°C. Contact your healthcare provider if any of these signs appear within 30 days of surgery.' A patient calls 10 days post-op reporting the wound feels warm and there is yellow drainage. What should the nurse advise?

Accepted Answer

Contact the healthcare provider as these are signs listed in the handout

Answer

Wait another week to see if symptoms resolve on their own

Answer

Apply an over-the-counter antibiotic ointment and monitor

Answer

Go directly to the emergency department without calling first