CELBAN Reading Comprehension 2 — Questions and Answers
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?
- To prevent dehydration from furosemide
- To manage fluid overload in a patient with compromised kidney or heart function (Correct answer)
- To reduce the frequency of urination for patient comfort
- To ensure accurate measurement of IV fluid administration
Correct answer: To manage fluid overload in a patient with compromised kidney or heart function
Fluid restriction combined with furosemide (a diuretic) indicates management of fluid overload, commonly seen in heart failure or renal insufficiency.
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?
- Anterior wall
- Lateral wall
- Inferior wall (Correct answer)
- Posterior wall
Correct answer: Inferior wall
ST-segment elevation in leads II, III, and aVF indicates an inferior myocardial infarction, typically caused by right coronary artery occlusion.
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?
- Administer it as scheduled since the scan is after the dose time
- Hold the dose and document the reason per the MAR instruction (Correct answer)
- Crush and dissolve in water to give before NPO begins
- Substitute with insulin coverage instead
Correct answer: Hold the dose and document the reason per the MAR instruction
The MAR explicitly instructs to hold metformin before contrast imaging due to the risk of contrast-induced nephropathy and lactic acidosis.
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?
- Stage II
- Stage III (Correct answer)
- Stage IV
- Unstageable
Correct answer: Stage III
Visible subcutaneous fat with full-thickness skin loss but no exposed bone, tendon, or muscle is consistent with Stage III pressure injury.
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?
- 'Have you thought about quitting smoking?'
- 'You've shown real commitment by coming to this appointment.'
- 'It sounds like you feel stuck between wanting to quit and enjoying smoking.' (Correct answer)
- 'Let me summarize what we've discussed today.'
Correct answer: 'It sounds like you feel stuck between wanting to quit and enjoying smoking.'
Reflective listening involves mirroring the patient's feelings or thoughts back to them, demonstrating understanding without judgment.
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?
- 1030
- 1130 (Correct answer)
- 1200
- By end of shift
Correct answer: 1130
The policy requires incident reporting within 2 hours; fall occurred at 0930, so the report must be filed by 1130.
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?
- Wait another week to see if symptoms resolve on their own
- Apply an over-the-counter antibiotic ointment and monitor
- Contact the healthcare provider as these are signs listed in the handout (Correct answer)
- Go directly to the emergency department without calling first
Correct answer: Contact the healthcare provider as these are signs listed in the handout
Warmth and purulent (yellow) drainage within 30 days match the listed infection signs, and the handout instructs patients to contact their provider.
CELBAN Reading Comprehension 2
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?