Preview Extract
ATI ADVANCED MED SURG PROCTORED 2019 EXAM
GUIDE
1.
A nurse in a burn treatment center is caring for a client who is admitted with
severe burns to both lower extremities and is pending an escharotomy. The client’s spouse
asks the nurse what the procedure entails. Which of the following nursing statements is
appropriate?
a. “large incisions will be made in the eschar to improve circulation”
b. “ I can call the doctor back here if you want me to”
c. “a piece of skin will be removed and grafted over the burned area”
d. “dead tissue will be surgically removed”
Answer: a. “large incisions will be made in the eschar to improve circulation”
Rationale:
An escharotomy involves making incisions through the eschar (a thick, dry, leathery scab
or burn covering) to improve circulation and prevent compartment syndrome.
2.
A nurse is monitoring the fluid replacement of a client who has sustained burns.
Which of the following fluids is used in the first 24 hours following a burn injury?
a. 5% dextrose in water
b. 5% dextrose in normal saline
c. normal saline
d. lactated ringers
Answer: d. lactated ringers
Rationale:
Lactated Ringer's solution is preferred for fluid resuscitation in the first 24 hours
following a burn injury because it closely resembles the electrolyte composition of plasma
and helps maintain circulating blood volume.
3.
A nurse is caring for a client who has full-thickness burns all over 75% of his
body. Which of the following methods is appropriate to accurately monitor the
cardiovascular system?
a. auscultate cuff blood pressure
b. palpate pulse pressure
c. obtain a central venous pressure
d. monitor the pulmonary artery pressure
Answer: c. obtain a central venous pressure
Rationale:
Monitoring central venous pressure (CVP) provides an accurate assessment of fluid status
and cardiac function in clients with extensive burns, helping guide fluid resuscitation and
prevent complications like hypovolemic shock.
4.
A nurse is assessing the depth and extent of a client who has severe burns to the
face, neck, and upper extremities. Which of the following factors is the first priority when
assessing the severity of the burn?
a. Age of the client
b. Associated medical history
c. Location of the burn
d. Cause of the burn
Answer: c. Location of the burn
Rationale:
The location of the burn is crucial in determining its severity, especially burns to the face,
neck, and upper extremities, which can compromise airway, breathing, and circulation and
require immediate attention.
5.
A client arrives at the emergency dept following an explosion at the chemical
plant. He has deep partial and full-thickness chemical burns over more than 25 % of his
body surface area. What is the nurse’s priority intervention?
a. Initiate fluid resuscitation
b. Medication for pain
c. Administer antibiotics
d. Maintain a patent airway
Answer: d. Maintain a patent airway
Rationale:
In a client with burns, especially involving the airway, maintaining a patent airway is the
priority to ensure adequate oxygenation and prevent respiratory compromise.
6.
A nurse is caring for a client who came the emergency dept reporting chest pain.
The provider suspects a myocardial infarction. While waiting for the laboratory to report
the client’s troponin levels, the client asks what this blood test will show. The nurse
should explain that troponin is
a. An enzyme that indicates damage to brain, heart, and skeletal muscle tissues
b. A protein whose levels reflect the risk for coronary artery disease
c. A heart muscle protein that appears in the bloodstream when there is damage to the
heart
d. A protein that helps transport oxygen throughout the body
Answer: c. A heart muscle protein that appears in the bloodstream when there is damage
to the heart
Rationale:
Troponin is a protein found in heart muscle cells. Elevated levels in the bloodstream
indicate damage to the heart muscle, such as in a myocardial infarction.
7.
A nurse is assessing a client who has disseminated intravascular coagulation
(DIC). Which of the following should the nurse expect in the findings?
a. Excessive thrombosis and bleeding
b. Progressive increase in platelet production
c. Immediate sodium and fluid retention
d. Increased clotting factors
Answer: a. Excessive thrombosis and bleeding
Rationale:
DIC is characterized by widespread activation of clotting factors, leading to both
thrombosis (clot formation) and bleeding (consumption of clotting factors and platelets).
8.
A nurse is about to administer warfarin (Coumadin) to a client who has atrial
fibrillation. When the client asks what his medication will do, which of the following is an
appropriate nursing response?
a. It helps convert atrial fibrillation to sinus rhythm
b. Is dissolves clots in the bloodstream
c. It slows the response of the ventricles to the fast atrial impulses
d. It prevents strokes in clients who have atrial fibrillation
Answer: d. It prevents strokes in clients who have atrial fibrillation
Rationale:
Warfarin is an anticoagulant that helps prevent the formation of blood clots, reducing the
risk of stroke in clients with atrial fibrillation.
9.
A nurse in a cardiac care unit is caring for a client with acute heart failure. Which
of the following findings should the nurse expect?
a. Decreased brain natriuretic peptide (BNP)
b. Elevated central venous pressure (CVP)
c. Decreased pulmonary pressure
d. Increases urinary output
Answer: b. Elevated central venous pressure (CVP)
Rationale:
Acute heart failure can lead to increased pressure in the heart and central venous system,
reflected by an elevated CVP.
10.
A client comes into the ED reporting nausea and vomiting that worsens when
lying down and without relief from antacids. The provider suspects acute pancreatitis.
Which of the following lab test results should the nurse expect to see if the client has
acute pancreatitis?
a. Decreased WBC
b. Increased serum amylase
c. Decreased serum lipase
d. Increased serum calcium
Answer: b. Increased serum amylase
Rationale:
Acute pancreatitis is characterized by elevated levels of serum amylase and lipase,
enzymes released by the pancreas when it is inflamed or damaged.
11.
A nurse in the ICU is caring for a client who has acute respiratory distress
syndrome (ARDS) and is receiving mechanical ventilation via an endotracheal tube. The
provider plans to extubate her within the next 24 hours. Which of the following is an
important criterion for extubating the client?
a. Ability to cough effectively
b. Adequate tidal volume without manually assisted breaths
c. No indication of infection
d. No need for supplemental oxygen
Answer: b. Adequate tidal volume without manually assisted breaths
Rationale:
Adequate tidal volume without the need for manually assisted breaths indicates that the
client is able to maintain sufficient ventilation on their own, which is an important
criterion for extubation.
12.
A nurse is caring for a client following a CT scan with dye who suffered from an
anaphylactic reaction. Which of the following conditions requires a priority nursing
response?
a. Urticaria
b. Stridor
c. Tachypnea
d. Angioedema
Answer: b. Stridor
Rationale:
Stridor, a high-pitched sound heard during inspiration, indicates upper airway obstruction
and requires immediate attention to ensure the airway remains patent.
13.
A nurse is caring for a female client who came in to the ED reporting shortness of
breath and pain in the lung area. Her heart rate is 110/min, respiratory rate 40/min, and
blood pressure 140/80 mm Hg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg,
PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority
intervention?
a. Prepare for mechanical ventilation
b. Administer oxygen via face mask
c. Prepare to administer a sedative
d. Monitor for pulmonary embolism
Answer: b. Administer oxygen via face mask
Rationale:
The priority is to improve oxygenation. The client's low PaO2 and SaO2 indicate
hypoxemia, which requires immediate intervention to improve oxygen delivery.
14.
A nurse is monitoring a client who has just had a thoracentesis to remove pleural
fluid. Which of the following clinical manifestations indicate a complication that requires
notifying the provider immediately?
a. Serosanguineous drainage from the puncture site
b. Discomfort at the puncture site
c. Increased heart rate
d. Decreased temperature
Answer: c. Increased heart rate
Rationale:
An increased heart rate can indicate hypovolemia or another complication such as
pneumothorax, which requires prompt notification of the provider.
15.
A group of college students was attending a weekend football rally when one of
the students stumbled and fell into the bonfire. Although several friends quickly
intervened, the client sustained partial-thickness burns to both lower legs, chest, and both
forearms. Which of the following is the priority nursing action when the client is brought
to the ED?
a. Cover the burned area with sterile gauze
b. Inspect mouth for signs of inhalation injury
c. Administer intravenous pain medication
d. Draw blood for a CBC
Answer: b. Inspect mouth for signs of inhalation injury
Rationale:
Inhalation injury can be life-threatening. The priority is to assess the airway for any signs
of compromise due to smoke or heat inhalation.
16.
A triage nurse in an emergency dept is caring for a client who has gunshot wound
to the right side of the chest. The nurse notices a thick dressing on the chest and a sucking
noise coming from the wound. The client has a blood pressure of 100/60 mm Hg, a weak
pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions
should the nurse take initially?
a. Raise the foot of the bed to a 90-degree angle
b. Remove the dressing to inspect the wound
c. Prepare to insert a central line
d. Administer oxygen via nasal cannula
Answer: b. Remove the dressing to inspect the wound
Rationale:
The presence of a sucking noise suggests a possible tension pneumothorax, which can be
life-threatening. Removing the dressing to inspect the wound allows for immediate
intervention if tension pneumothorax is present.
17.
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The
client’s heart rate increases from 86/min to 110/min and becomes irregular. The nurse
should know that the client requires which of the following?
a. A cardiology consult
b. Less frequent suctioning
c. An antidysrhythmic medication
d. Pre-oxygenation prior to suctioning
Answer: d. Pre-oxygenation prior to suctioning
Rationale:
The client's increased heart rate and irregular rhythm may indicate hypoxia, a common
complication of endotracheal suctioning. Pre-oxygenation helps minimize the risk of
hypoxia during the suctioning procedure.
18.
The nurse is caring for a client who is receiving a blood transfusion. The
transfusion started 30 minutes ago at a rate of 100 mL/hr. The client begins to complain of
low back pain and headache and is increasingly restless. What is the first nursing action?
a. Stop the transfusion, disconnect the blood tubing, and begin a primary infusion of
normal saline solution
b. Slow the infusion and evaluate the vital signs and the client’s history of transfusion
reactions
c. Slow the infusion of blood and begin infusion of normal saline solution from the Y
connector.
d. Recheck the unit of blood for correct identification numbers and crossmatch
information
Answer: a. Stop the transfusion, disconnect the blood tubing, and begin a primary
infusion of normal saline solution
Rationale:
The client's symptoms are consistent with a transfusion reaction. The first action is to stop
the transfusion and initiate supportive care, including administering normal saline to
maintain intravascular volume.
19.
A client with a diagnosis of disseminated intravascular coagulation (DIC) has the
following assessment findings: blood pressure of 76/56, temperature 102.6 degrees, resp.
24 breath/min., with complaints of severe neck and back pain. Which nursing action
should the nurse implement first?
a. Administer acetaminophen (Tylenol) PO.
b. Administer ibuprofen (Motrin) PO.
c. Draw coagulation study blood work in the AM
d. Give morphine sulfate IV
Answer: d. Give morphine sulfate IV
Rationale:
The priority is to manage the client's severe pain. Morphine sulfate can help relieve the
client's discomfort while other interventions are implemented.
20.
The nurse administering albuterol (Proventil) via a metered-dose inhaler (MDI) to
a client who has a history of coronary artery disease is now in congestive heart failure.
What side effects will be particularly important to observe for when the client takes the
medication?
a. Tremors and central nervous system stimulation
b. Tachycardia and chest discomfort
c. Development of oral candidiasis
d. An increase in blood pressure
Answer: b. Tachycardia and chest discomfort
Rationale:
Albuterol can cause tachycardia (rapid heart rate) and may exacerbate chest discomfort in
clients with coronary artery disease and congestive heart failure. These side effects should
be monitored closely.
21.
The nurse is assessing a client who is on a ventilator and has an endotracheal tube
in place. What data confirms that the tube has migrated too far into the trachea?
a. Decreased breath sounds are heard over the left side of the chest
b. Increased rhonchi are present at the lung bases bilaterally
c. Ventilator pressure alarm continues to sound
d. Client is able to speak and coughs excessively
Answer: c. Ventilator pressure alarm continues to sound
Rationale:
When the endotracheal tube is inserted too far into the trachea, the tip can press against
the tracheal wall, causing increased airway pressure and triggering the ventilator pressure
alarm.
22.
What is the desired action of dopamine (Intropin) when administered in the
treatment of shock?
a. It increases myocardial contractility
b. It is associated with fewer severe allergic reactions
c. It causes rapid vasodilation of the vascular bed
d. It supports renal perfusion by dilation of the renal arteries
Answer: a. It increases myocardial contractility
Rationale:
Dopamine is used in shock to increase myocardial contractility and improve cardiac
output.
23.
The nurse is monitoring an IV infusion of sodium nitroprusside (Nirpride). Fifteen
minutes after the infusion is started, the client’s BP goes from 190/120 mm Hg to 120/90
mm Hg. What is the priority nursing action?
a. Recheck the BP and call the doctor
b. Decrease the infusion rate and recheck the blood pressure in 5 minutes
c. Stop the medication and keep the IV open with D5W.
d. Assess the client’s tolerance of the current level of BP
Answer: b. Decrease the infusion rate and recheck the blood pressure in 5 minutes
Rationale:
A rapid decrease in blood pressure may indicate that the medication is being administered
too quickly. Decreasing the infusion rate can help stabilize the blood pressure.
24.
Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock.
Before administering the drug, the nurse should make sure that the client has:
a. A heart rate of less than 120 beats/min
b. Urine output of at least 30 mL/hr.
c. Received adequate anticoagulation
d. Been receiving adequate IV fluid replacement
Answer: d. Been receiving adequate IV fluid replacement
Rationale:
Before administering norepinephrine, it is important to ensure that the client has received
adequate IV fluid replacement to address hypovolemia and improve tissue perfusion.
25.
The client returns to his room after a thoracotomy. What will the nursing
assessment reveal if hypovolemia from excessive blood loss is present?
a. CVP of 3 cm H20 and urine output of 20 mL/hr
b. Jugular vein distention with the head elevated 45 degrees
c. Chest tube drainage of 50 mL/hr in the first 2 hours
d. Persistent increased BP and increased pulse pressure
Answer: b. Jugular vein distention with the head elevated 45 degrees
Rationale:
Jugular vein distention can indicate hypovolemia, as the body attempts to compensate for
decreased blood volume by increasing venous return to the heart.
26.
The nurse is performing an assessment and finds the client has cold, clammy skin,
pulse of 130 beats/min and weak, blood pressure of 84/56 mm Hg, and urinary output of
20 mL for the past hour. The nurse would interpret these findings as suggestive of which
pathophysiology?
a. Reduction of circulation to the coronary arteries, thus increasing the preload
b. Decreased glomerular filtration rate, resulting in volume overload
c. Stimulation of the sympathetic nervous system, causing severe vasoconstriction
d. Decrease in cardiac output and inadequate tissue perfusion
Answer: d. Decrease in cardiac output and inadequate tissue perfusion
Rationale:
The client's symptoms indicate poor tissue perfusion, likely due to a decrease in cardiac
output. Cold, clammy skin, tachycardia, hypotension, and decreased urinary output are
signs of inadequate tissue perfusion.
27.
The nurse applies a Nitro-Dur patch on a client who has undergone cardiac
surgery. What nursing observation indicates that a Nitro-Dur patch is achieving the
desired effect?
a. Chest pain is completely relieved
b. Client performs activities of daily living without chest pain
c. Pain is controlled with frequent changes of patch
d. Client tolerates increased activity without pain
Answer: b. Client performs activities of daily living without chest pain
Rationale:
The desired effect of a Nitro-Dur patch is to reduce chest pain (angina) during activities of
daily living. If the client can perform these activities without chest pain, the patch is likely
achieving its desired effect.
28.
The V/S of a client with Cardiac disease are as follows: BP 102/76 mm Hg, Pulse
52, RR 16. Atropine is administered IV push. What nursing assessment indicates a
therapeutic response to the medication?
a. Pulse rate has increased to 70 beats/min
b. Systolic BP has increased by 20
c. Pupils are dilated
d. Oral secretions have decreased
Answer: a. Pulse rate has increased to 70 beats/min
Rationale:
Atropine is given to increase heart rate. An increase in pulse rate from 52 to 70 beats/min
indicates a therapeutic response to the medication.
29.
An older adult client comes into ER stating that he has no appetite, is nauseated,
his heart feels funny and has noticed a haziness in his vision. The client states that he has
been taking an antihypertensive drug and digitalis for more than a year. Based on the
presenting symptoms, what would be the priority nursing action?
a. Obtain an order for an EKG and serum potassium and digitalis levels
b. Perform a neurological assessment to determine whether he has one side weakness.
c. Assess lungs for decreased breath sounds and/or adventitious breath sounds.
d. Obtain an order for an EKG
Answer: a. Obtain an order for an EKG and serum potassium and digitalis levels
Rationale:
The client's symptoms are suggestive of digitalis toxicity. Obtaining an EKG and serum
potassium and digitalis levels will help confirm this diagnosis and guide further treatment.
30.
The nurse is administering alteplase to a client who has been diagnosed with acute
coronary syndrome. What are important nursing implications for this medication?
a. Monitor the ECG for dysrhythmias
b. Place the client on bleeding precautions
c. Monitor urine output hourly
d. Monitor for activity tolerance
Answer: b. Place the client on bleeding precautions
Rationale:
Alteplase is a thrombolytic agent that can increase the risk of bleeding. Placing the client
on bleeding precautions, such as avoiding invasive procedures and using caution with
sharp objects, is important to prevent bleeding complications.
31.
The nurse is caring for a client who underwent cardiac catheterization 1 hour ago.
What is an important nursing measure at this time?
a. Measure urinary output hourly and maintain continuous cardiac monitoring
b. Encourage client to perform slow pressure exercise of the affected side to promote
circulation.
c. Maintain pressure over catheter insertion site and determine distal circulation status.
d. Evaluate apical pulse and determine presence of pulse deficit.
Answer: c. Maintain pressure over catheter insertion site and determine distal circulation
status.
Rationale:
Maintaining pressure over the catheter insertion site helps prevent bleeding and assessing
distal circulation status helps ensure adequate perfusion.
32.
The nurse in a cardiac stepdown unit has received a hand-off shift report for these
clients. Which client should be assessed first?
a. a client who has just returned from a coronary arteriogram with placement of an
intracoronary stent.
b. A client who is in heart failure and has gained 2 pounds in the last 24 hours.
c. a client with endocarditis who has a temperature elevation of 100°F and pulse 100
beats/min
d. A client who was cardioverted from atrial fib 24 hours ago and has had 3 atrial
premature beats.
Answer: a. a client who has just returned from a coronary arteriogram with placement of
an intracoronary stent.
Rationale:
The client who has just returned from a coronary arteriogram with placement of an
intracoronary stent needs immediate assessment for any signs of complications such as
bleeding or thrombosis.
33.
What ECG changes would reflect myocardial ischemia in a client who has been
admitted for observation after experiencing an episode of chest pain?
a. Prolonged PR interval
b. Wide QRS complex
c. ST-segment elevation or depression
d. Tall, peak T-waves
Answer: c. ST-segment elevation or depression
Rationale:
ST-segment elevation or depression indicates myocardial ischemia or injury and is a
common finding in clients with acute coronary syndromes.
34.
A new employee at a facility needs a hepatitis vaccine. Which statement reflects
accurate understanding of the immunization?
a. "I need to get 6 shots of hep C"
b. "Once I receive the Hep vaccine I will always be immune"
c. "I will receive 3 injections over a period of months, which should protect me from hep
B"
d. "Hep vaccine is an oral vaccine with live attenuated virus"
Answer: c. "I will receive 3 injections over a period of months, which should protect me
from hep B"
Rationale:
The hepatitis B vaccine is typically administered in a series of three injections to provide
immunity against the virus.
35.
While talking with a client with a diagnosis of end-stage liver disease. The nurse
notices the client is unable to stay awake and seems to fall asleep in the middle of a
sentence. The nurse recognizes these symptoms to be indicative of what condition?
a. Hyperglycemia
b. Increased bile production
c. Increased blood ammonia levels
d. Hypocalcemia
Answer: c. Increased blood ammonia levels
Rationale:
In end-stage liver disease, the liver is unable to metabolize ammonia, leading to increased
blood ammonia levels, which can cause altered mental status and drowsiness.
36.
The nurse is caring for a client with chronic hep B. What will the teaching plan for
this client include?
a. Use a condom for sexual intercourse
b. Report any clay-colored stools.
c. Eat a high protein diet
d. Perform daily urine bilirubin checks
Answer: a. Use a condom for sexual intercourse
Rationale:
Chronic hepatitis B can be transmitted through sexual contact, so using a condom is
important to prevent the spread of the virus.
37.
A patient with massive trauma and possible spinal cord injury is admitted to the
emergency department (ED). Which finding by the nurse will help confirm a diagnosis of
neurogenic shock?
a. Cool clammy skin
b. Inspiratory crackles
c. Apical heart rate of 48 beats/min
d. Temperature 101.2°F
Answer: a. Cool clammy skin
Rationale:
Neurogenic shock is characterized by peripheral vasodilation and can lead to cool,
clammy skin due to decreased vascular tone.
38.
A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours.
The pulse rate is 120, and the central venous and pulmonary artery wedge pressure are 4.
Which of these orders by the healthcare provider will the nurse question?
a. Give furosemide (Lasix) 40 mg IV
b. Increase normal saline infusion to 150 mL/hr
c. Administer hydrocortisone (SoluCortef) 100 mg IV
d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr
Answer: a. Give furosemide (Lasix) 40 mg IV
Rationale:
In septic shock, maintaining adequate fluid volume is crucial. Given the patient's low
urine output and signs of shock, administering a diuretic like furosemide would further
decrease fluid volume, which is not indicated.
39.
After receiving 1000 mL of normal saline, the central venous pressure for a patient
who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The
nurse will anticipate the administration of which of the following?
a. Nitroglycerin (Tridil)
b. Sodium nitroprusside (Nipride)
c. Drotrecogin alpha (Xigris)
d. Norepinephrine (Levophed)
Answer: d. Norepinephrine (Levophed)
Rationale:
Norepinephrine is a vasopressor that can increase blood pressure in patients with septic
shock by increasing peripheral vascular resistance.
40.
Which of these findings is the best indicator that the fluid resuscitation for a
patient with hypovolemic shock has been successful?
a. Hemoglobin is within normal limits
b. Urine output is 60 mL over the last hour
c. Pulmonary artery wedge pressure (PAWP) is 10 mmHg
d. Mean arterial pressure (MAP) is 55 mm Hg
Answer: d. Mean arterial pressure (MAP) is 55 mm Hg
Rationale:
Mean arterial pressure (MAP) is a better indicator of tissue perfusion than individual
blood pressure measurements. A MAP of 55 mm Hg indicates that the patient's tissues are
receiving adequate perfusion.
41.
Which interventions will the nurse include in the plan of care for a patient who has
cardiogenic shock?
a. Avoid elevating head of bed
b. Check temperature every 2 hours
c. Monitor breath sounds frequently
d. Assess skin for flushing and itching
Answer: c. Monitor breath sounds frequently
Rationale:
In cardiogenic shock, the heart's ability to pump blood is impaired, leading to inadequate
tissue perfusion. Monitoring breath sounds can help assess for pulmonary congestion, a
common complication in cardiogenic shock.
42.
Which assessment is most important for the nurse to make in order to evaluate
whether treatment of a patient with anaphylactic shock has been effective?
a. Pulse rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
Answer: c. Blood pressure
Rationale:
In anaphylactic shock, blood pressure is often significantly decreased due to widespread
vasodilation. Monitoring blood pressure is crucial to assess the effectiveness of treatment
in restoring adequate perfusion.
43.
When caring for the patient who has septic shock, which assessment finding is
most important for the nurse to report to the health care provider?
a. BP 92/56 mm Hg
b. Skin cool and clammy
c. Apical pulse 118 beats/min
d. Arterial oxygen saturation 91%
Answer: b. Skin cool and clammy
Rationale:
Cool and clammy skin is indicative of poor perfusion, a hallmark of septic shock. This
finding indicates inadequate tissue oxygenation and should be reported promptly for
further evaluation and intervention.
44.
During change-of-shift report, the nurse learns that a patient has been admitted
with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which
finding is most important for the nurse to report to the HCP?
a. Decreased bowel sounds
b. Apical pulse 110 beats/min
c. Pale, cool, and dry extremities
d. New onset of confusion and agitation
Answer: d. New onset of confusion and agitation
Rationale:
New onset of confusion and agitation can indicate worsening dehydration or electrolyte
imbalances, which are serious complications that require immediate attention.
45.
A patient is admitted to the burn unit with burns to the upper body and head after a
garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased
and no wheezes are audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again
b. Notify the HCP and prepare for endotracheal intubation
c. Document the results and continue to monitor the patient’s respiratory rate
d. Reposition the patient in high-Fowler’s position and reassess breath sounds
Answer: b. Notify the HCP and prepare for endotracheal intubation
Rationale:
Decreased lung sounds and the absence of wheezes could indicate airway obstruction or
worsening respiratory status, necessitating immediate intervention such as intubation.
46.
During the emergent phase of burn care, which nursing action will be most useful
in determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor
b. Monitor daily weight
c. Assess mucous membranes
d. Measure hourly urine output
Answer: d. Measure hourly urine output
Rationale:
Hourly urine output is a critical indicator of fluid status in burn patients. Adequate urine
output indicates adequate renal perfusion and fluid resuscitation.
47.
After receiving change-of-shift report, which of these patients should the nurse
assess first?
a. A patient with smoke inhalation who has wheezes and altered mental status
b. A patient with full-thickness leg burns who has a dressing change scheduled
c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain
d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at
500 mL/hr
Answer: a. A patient with smoke inhalation who has wheezes and altered mental status
Rationale:
Wheezes and altered mental status in a patient with smoke inhalation could indicate
airway compromise or respiratory distress, requiring immediate assessment and
intervention.
48.
The RN observes all of the following actions being taken by a staff nurse who has
floated to the unit. Which action requires that the RN intervene?
a. The nurse uses latex gloves when applying antibacterial cream to a burn wound
b. The float nurse obtains burn cultures when the patient has a temp of 101* F
c. The float nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before
a dressing change
d. The float nurse calls the health care provider for an insulin order when a nondiabetic
patient has an elevated serum glucose
Answer: d. The float nurse calls the health care provider for an insulin order when a
nondiabetic patient has an elevated serum glucose
Rationale:
Administering insulin to a nondiabetic patient with elevated serum glucose is
inappropriate and could result in hypoglycemia. The RN should intervene to prevent this
potential harm.
49.
A client with cervical neck fracture is admitted to the intensive care unit. Which
findings would the nurse recognize as indicative of spinal shock?
a. Spasticity, neuromuscular irritability, hyperreflexia
b. Flaccidity and lack of sensation below the level of spinal cord lesion.
c. Autonomic dysreflexia with neurogenic bladder symptoms
d. Muscular spasticity and loss of motor reflexes in all parts of the body below the level of
spinal cord lesion.
Answer: b. Flaccidity and lack of sensation below the level of spinal cord lesion.
Rationale:
Spinal shock is characterized by flaccidity and loss of sensation below the level of the
spinal cord lesion due to temporary loss of reflex activity.
*know T2-T3: paraplegic*
50.
A client with T6 spinal cord injury is being discharged. The PT is concerned about
autonomic dysreflexia. S/S include the following:
a. Dialated pupils
b. Sudden vomiting and diarrhea
c. drop in BP and pulse
d. Diaphoresis above the level of the lesion
Answer: c. drop in BP and pulse
Rationale:
Autonomic dysreflexia is characterized by a sudden increase in blood pressure and a drop
in pulse rate. It is a medical emergency that requires immediate attention.
51.
A woman has been recently diagnosed with systemic lupus and shares with the
nurse, "I want to get pregnant, but I don’t know how I will tolerate pregnancy because I
have lupus." Which response is best?
a. Most women find that they feel better when they are pregnant
b. How long have you been in remission?
c. Women with lupus frequently have slightly longer gestation
d. Its best to become pregnant within the first 6 months of diagnosis
Answer: b. How long have you been in remission?
Rationale:
The duration of remission is an important factor in determining the potential risks of
pregnancy in women with lupus. Women are generally advised to be in remission for at
least 6 months before attempting pregnancy.
52.
The nurse is assessing the patency of an arteriovenous fistula and suspects clotting
in the fistula if which findings are noted? Select all that apply
a. presence of a thrill on palpation over the fistula
b. Absence of a bruit on auscultation over the fistula
c. Presence of a pulse in the extremity below the fistula
d. Complaints of tingling or discomfort in the extremity
e. Warm hand and fingers in the extremity in which the fistula is located.
Answer: b. Absence of a bruit on auscultation over the fistula
d. Complaints of tingling or discomfort in the extremity
Rationale:
A bruit is a whooshing sound heard over the fistula indicating blood flow. Its absence may
indicate clotting. Complaints of tingling or discomfort can also indicate compromised
blood flow due to clotting.
53.
Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal
failure. The client asks the nurse about the purpose of the medication. The appropriate
response would be which of the following?
a. It is used to lower your blood pressure
b. It is used to treat anemia
c. It will help to increase the potassium levels in your body
d. It is an anticonvulsant medication given to all clients after dialysis to prevent seizure
activity.
Answer: b. It is used to treat anemia
Rationale:
Epoetin alfa is a medication used to stimulate the production of red blood cells and treat
anemia, which is common in chronic renal failure due to decreased production of
erythropoietin by the kidneys.
54.
A client with an ECG reading showing sinus bradycardia has a blood pressure of
47/28 mmHg. Which drugs does the nurse expect the physician to order for this client?
a. Lidocaine (Xylocaine)
b. Atropine sulfate
c. Isoproterenol hydrochloride (Isuprel)
d. Epinephrine
Answer: b. Atropine sulfate
Rationale:
Atropine sulfate is the drug of choice for treating symptomatic bradycardia. It works by
blocking the parasympathetic nervous system, leading to increased heart rate and
improved cardiac output.
55.
Chemical cardioversion is prescribed for the client with atrial fibrillation. The
nurse who is assisting in preparing the client would expect that which medication specific
for chemical cardioversion will be needed?
a. Nitroglycerin
b. Nifedipine (Procardia)
c. Lidocaine (Xylocaine)
d. Amiodarone (Cordarone)
Answer: d. Amiodarone (Cordarone)
Rationale:
Amiodarone is commonly used for chemical cardioversion in atrial fibrillation due to its
antiarrhythmic properties.
56.
A nurse assesses a comatose, head-injured client and finds flexion of the arms,
wrists, and fingers and adduction of the upper extremities. Which of the following
describes these findings?
a. Stroke
b. Epileptic Seizure
c. Decorticate posturing
d. Decerebrate posturing
Answer: c. Decorticate posturing
Rationale:
Decorticate posturing is characterized by flexion of the arms, wrists, and fingers, and
adduction of the upper extremities. It is indicative of damage to the corticospinal tract.
57.
The client diagnosed with ARDS is transferred to the intensive care department
and placed on a ventilator. Which intervention should the nurse implement first?
a. Confirm that the ventilator settings are correct
b. Verify that the ventilator alarms are functioning properly
c. Assess the respiratory status and pulse oximeter reading.
d. Monitor the client's arterial blood gas results.
Answer: c. Assess the respiratory status and pulse oximeter reading.
Rationale:
Assessing the respiratory status and pulse oximeter reading will provide immediate
information about the client's oxygenation status and ventilatory needs.
58.
The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then
attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the
cause of the alarm and takes what initial action?
a. Administer oxygen
b. Check the client’s vital signs
c. Ventilate the client manually
d. Start cardiopulmonary resuscitation
Answer: c. Ventilate the client manually
Rationale:
If the cause of the alarm cannot be determined immediately, the nurse should manually
ventilate the client to ensure adequate oxygenation and ventilation.
59.
The client is admitted to the ED with chest trauma. Which signs/symptoms would
the nurse expect to assess that support the diagnosis of pneumothorax?
a. Bronchovesicular lung sounds and friction rub
b. Absent breath sounds and tachypnea
c. Nasal flaring and lung consolidation
d. Symmetrical chest expansion and bradypnea.
Answer: b. Absent breath sounds and tachypnea
Rationale:
Absent breath sounds on the affected side and tachypnea are indicative of pneumothorax
due to the loss of negative pressure in the pleural space.
60.
A nurse is planning care for a client with a chest tube attached to a Pleur-Evac
drainage system. The nurse includes which interventions in the plan? (Select all that
apply)
a. Clamping the chest tube intermittently
b. Changing the client’s position frequently
c. Maintaining the collection chamber below the client’s waist
d. Adding water to the suction control chamber as it evaporates.
e. Taping the connection between the chest tube and the drainage system.
Answer: b. Changing the client’s position frequently
c. Maintaining the collection chamber below the client’s waist
e. Taping the connection between the chest tube and the drainage system.
Rationale:
Changing the client’s position helps facilitate drainage, maintaining the collection
chamber below the client’s waist prevents backflow of drainage, and taping the
connection between the chest tube and the drainage system prevents accidental
disconnection.
61.
A client has a total serum calcium level of 7.5 mg/dl. Which clinical
manifestations would the nurse expect to note on assessment of the client? (Select all)
a. Constipation
b. Muscle twitches
c. Hypoactive bowel sounds
d. Hyperactive deep tendon reflexes
e. Positive Trousseau’s sign and positive Chvostek’s sign
f. Prolonged ST interval and QT interval on ECG
Answer: b. Muscle twitches
d. Hyperactive deep tendon reflexes
e. Positive Trousseau’s sign and positive Chvostek’s sign
Rationale:
Hypocalcemia (total serum calcium level of <8.5 mg/dl) can lead to muscle twitching,
hyperactive deep tendon reflexes, and positive Trousseau’s and Chvostek’s signs.
Constipation and hypoactive bowel sounds are not typically associated with
hypocalcemia. Prolonged ST and QT intervals on ECG are associated with hypocalcemia
but are not clinical manifestations noted on assessment.
62.
The client diagnosed with rule-out myocardial infarction is experiencing chest
pain while walking to the bathroom. Which action should the nurse implement first?
a. Administer sublingual nitroglycerin.
b. Obtain a STAT electrocardiogram
c. Have the client sit down immediately
d. Assess the client’s vital signs.
Answer: c. Have the client sit down immediately
Rationale:
When a client is experiencing chest pain, the immediate action is to have the client sit or
lie down to reduce the workload on the heart and minimize myocardial oxygen demand.
63.
The nurse is caring for a client diagnosed with ARDS who is on a ventilator.
Which interventions should the nurse implement? (Select all)
a. Assess the client’s level of consciousness
b. Monitor client's urine output
c. Perform passive range of motion exercises
d. Maintain intravenous fluids as ordered
e. Place the client with the head of bed flat
Answer: a. Assess the client’s level of consciousness
b. Monitor client's urine output
d. Maintain intravenous fluids as ordered
Rationale:
In caring for a client with ARDS, it is important to assess the level of consciousness as
changes can indicate hypoxia, monitor urine output to assess renal perfusion, and
maintain intravenous fluids to support hemodynamic stability. Passive range of motion
exercises and positioning the client with the head of the bed flat are not specific
interventions for ARDS.
64.
The nurse is assessing a client experiencing motor loss as a result of a left-sided
cerebrovascular accident (CVA). Which clinical manifestations would the nurse
document?
Answer: The most common motor dysfunction of a CVA is paralysis of one side of the
body, hemiplegia; in this case with a left-sided CVA, paralysis would affect the right side.
Ataxia is an impaired ability to coordinate movement.
The nurse would document the following clinical manifestations:
• Hemiplegia: Paralysis of one side of the body, in this case, affecting the right side due to
a left-sided CVA.
• Ataxia: Impaired ability to coordinate movement.
Rationale:
Motor loss is a common manifestation of a cerebrovascular accident (CVA), also known
as a stroke. In a left-sided CVA, motor dysfunction typically affects the right side of the
body due to the contralateral organization of the brain. Hemiplegia refers to paralysis of
one side of the body and is a common motor dysfunction seen in strokes. Ataxia is another
possible manifestation, characterized by a lack of coordination in movement. These
clinical manifestations would be documented by the nurse to assess and monitor the
client's condition following the CVA.
65.
When teaching a client about the expected outcomes after intravenous
administration of furosemide, the nurse would include which outcome?
a. Increased blood pressure
b. Increased urine output
c. Decreased pain
d. Decreased PVCs
Answer: b. Increased urine output
Rationale:
Furosemide is a diuretic that increases urine output by inhibiting the reabsorption of
sodium and water in the kidneys. Increased urine output is an expected outcome of
furosemide administration. Increased blood pressure, decreased pain, and decreased PVCs
are not typically associated with furosemide administration.
66.
A client arrives at the emergency department with deep partial thickness burns
over 15% of his body. At admission, his vital signs are blood pressure 100/50 mm Hg,
heart rate 130 beats/minute, and respiratory rate 20 breaths/minute. Which nursing
interventions are appropriate for this client? Select all that apply
a. Starting an IV infusion of lactated Ringers solution
b. Administering 6 mg of morphine IV
c. Administering tetanus prophylaxis as ordered
Answer: a. Starting an IV infusion of lactated Ringers solution
c. Administering tetanus prophylaxis as ordered
Rationale:
For a client with burns covering 15% of the body, starting an IV infusion of lactated
Ringers solution is essential for fluid resuscitation. Administering tetanus prophylaxis is
important to prevent tetanus infection. Administering morphine may be appropriate for
pain management, but the dose should be based on the client's weight and pain level.
Applying a dry, sterile dressing to the burns and elevating the burned extremities are
appropriate interventions but may not be the priority at this time. Inserting a nasogastric
tube for feeding is not indicated in the immediate care of a client with burns.
67.
If dietary trays are usually brought to the nursing unit at 8:00 am, the nurse should
plan to administer intermediate-acting insulin (Humulin N) 40 units SQ to the client
between
Answer: 6:30 am and 7:00 am.
Rationale:
Intermediate-acting insulin, such as Humulin N, is typically administered 30 to 60
minutes before meals to ensure that it is working when the client's blood glucose levels
begin to rise after eating. Administering the insulin between 6:30 am and 7:00 am allows
it enough time to start working before the client receives their meal at 8:00 am, helping to
control their blood glucose levels effectively.
68.
What ECG changes would reflect myocardial ischemia in a client who has been
admitted for observation after experiencing an episode of chest pain?
Answer: ST segment elevation or depression
Rationale:
ST segment elevation or depression on an electrocardiogram (ECG) can indicate
myocardial ischemia. These changes in the ST segment are often seen in conditions such
as unstable angina or myocardial infarction (heart attack) and reflect abnormalities in the
electrical activity of the heart muscle due to inadequate blood flow. Identifying these
changes is crucial for diagnosing and managing ischemic heart disease.
69.
The client with acute renal failure has a serum potassium level of 6.0 mEq/L. The
nurse would plan which of the following as a priority action?
a. Place the client on a cardiac monitor
b. Administer kayexalate as ordered
c. Prepare the client for hemodialysis
d. Encourage increased oral fluid intake
Answer: a. Place the client on a cardiac monitor
Rationale:
A serum potassium level of 6.0 mEq/L is considered elevated (normal range is typically
3.5-5.0 mEq/L) and can lead to serious cardiac arrhythmias, including potentially fatal
ventricular fibrillation. Therefore, the priority action is to place the client on a cardiac
monitor to closely monitor their cardiac rhythm.
70.
The nurse is caring for a client who underwent cardiac catheterization 1 hour ago.
What is an important nursing measure at this time?
Answer: Maintain pressure over catheter insertion site and determine distal circulation
status.
Rationale:
After cardiac catheterization, it is important to maintain pressure over the catheter
insertion site to prevent bleeding and hematoma formation. Assessing distal circulation is
also crucial to ensure that blood flow to the extremity is not compromised, which could
indicate complications such as arterial occlusion or thrombosis.
71.
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The
client’s heart rate increases to 110 beats/min and becomes irregular. The nurse should
know that the client requires:
Answer: Oxygenate prior to suctioning.
Rationale:
An increase in heart rate and irregular heart rhythm during endotracheal tube suctioning
can indicate hypoxemia (low oxygen levels). It is essential to oxygenate the client before
suctioning to prevent further hypoxemia and potential cardiac complications. Proper
oxygenation ensures that the client's oxygen needs are met during the suctioning
procedure.
72.
A client comes into the ER with complaints of midsternal chest pain radiating to
the neck and left arm, which is unrelieved by sublingual nitroglycerin. An
electrocardiogram (ECG) is obtained. What observation on the ECG or on the cardiac
monitor would indicate to the nurse the need to immediately notify the physician?
a. PR impulse 0.20 sec
b. Tachycardia rate of 125 beat of premature
c. Premature ventricle beat
d. An ST segment elevation from the isoelectric baseline.
Answer: d. An ST segment elevation from the isoelectric baseline.
Rationale:
An ST segment elevation on the ECG is indicative of acute myocardial infarction (heart
attack) and requires immediate medical attention. This finding suggests that there is
inadequate blood flow to a part of the heart, which can lead to serious complications if not
addressed promptly.
73.
A client begins to complain of chills and discomfort after about 50ml of packed
red blood cells. The best nursing action at this time is to
a. Discontinue the transfusion and move the IV and restart IV transfusion at another site.
b. Compare the VS now and what they were before the transfusion began.
c. STOP THE TRANSFUSION AND MAINTAIN A PATENT LINE WITH NORMAL
SALINE solution and new tubing.
d. Slow down the transfusion blood and dilute with normal saline solution.
Answer: c. STOP THE TRANSFUSION AND MAINTAIN A PATENT LINE WITH
NORMAL SALINE solution and new tubing.
Rationale:
The client's symptoms suggest a possible transfusion reaction, such as a febrile nonhemolytic reaction or bacterial contamination. Stopping the transfusion, maintaining a
patent IV line with normal saline, and notifying the healthcare provider are appropriate
actions to take in this situation. Further assessment and monitoring are necessary to
ensure the client's safety.
74.
The vital signs of a client with cardiac disease are as follows: blood pressure of
103/78 mm Hg, heart rate _____ beats/min, and respiratory rate of 16 breaths/min.
Atropine is administered IV push. What nursing assessment indicates a therapeutic
response to the medication?
Answer: Pulse rate has increased to 70 beats/min.
Rationale:
Atropine is a medication used to increase heart rate, particularly in cases of bradycardia.
An increase in heart rate from the baseline indicates a therapeutic response to atropine, as
it suggests the medication is effectively increasing the heart rate.
75.
Order rocephen 1g over 30minutes Q6H. Supply 1g/100mL. How many mL per
hour will the nurse infuse? Round the nearest whole number.
Answer: 200 mL/hr.
Rationale:
To calculate the mL per hour for the infusion, you first need to determine the total volume
to be infused in 30 minutes, which is 100 mL (1g/100mL). Then, to find the mL per hour,
you divide the total volume by the time in hours (30 minutes is 0.5 hours): 100 mL / 0.5
hours = 200 mL/hr.
76.
The nurse is caring for a client who is 1 day postoperative following an open
thoracotomy. The client is receiving oxygen mist at 40 percent. The O2 saturation
measured by pulse oximeter was 83%. ABG results are pH 7.31, PaCO2 93 mmHg,
HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?
Answer: Position client in high-Fowler's and encourage use of incentive spirometer and
coughing.
Rationale:
The client's ABG results indicate respiratory acidosis, with an elevated PaCO2.
Positioning the client in high-Fowler's can help improve ventilation. Encouraging the use
of incentive spirometer and coughing can also help improve ventilation and assist in
clearing secretions, which can improve oxygenation.
77.
The diabetic educator is teaching a class on Diabetes Type 1 and is discussing sick
day rules. Which interventions should the diabetes counselor include in the teaching?
(Select all that apply)
a. Take diabetic medication even if unable to eat the client’s normal diet.
b. If unable to eat, drink liquids equal to the client’s normal diet.
c. Test the blood glucose levels and test the urine ketones once a day and keep a record.
Answer:
a. Take diabetic medication even if unable to eat the client’s normal diet.
b. If unable to eat, drink liquids equal to the client’s normal diet.
c. Test the blood glucose levels and test the urine ketones once a day and keep a record.
Rationale:
a. Taking diabetic medication, even if the client is unable to eat their normal diet, helps
maintain blood glucose levels and prevents complications.
b. Drinking liquids equal to the client’s normal diet when unable to eat helps prevent
dehydration and maintains hydration levels.
c. Testing blood glucose levels and urine ketones once a day and keeping a record helps
monitor the client's condition and enables timely intervention if needed.
78.
The nurse is monitoring a client receiving peritoneal dialysis notes that the client’s
outflow is less than inflow. What action should the nurse take? (Select all that apply)
a. Reposition the client
b. Check for kinks in the tubing
c. Check for constipation
d. Check the dialysate temperature
Answer:
a. Reposition the client
b. Check for kinks in the tubing
c. Check for constipation
d. Check the dialysate temperature
Rationale:
a. Repositioning the client can help ensure proper drainage of dialysate and improve
outflow.
b. Checking for kinks in the tubing ensures that the dialysate can flow freely, allowing for
proper drainage.
c. Checking for constipation is important as it can cause pressure on the abdomen,
affecting the outflow of dialysate.
d. Checking the dialysate temperature ensures that it is within the appropriate range for
dialysis to occur effectively.
79.
The nurse is obtaining a health history from a client who is visiting the clinic with
complaints of a severe headache. The client provides the following data to the nurse based
on a review of systems. The nurse identifies the following as a modifiable risk for stroke?
(Select all the apply.)
a. SMOKING
b. ALCOHOL CONSUMPTION
c. DECREASED PHYSICAL ACTIVITY
d. OBESITY
Answer: a. SMOKING, b. ALCOHOL CONSUMPTION, c. DECREASED PHYSICAL
ACTIVITY, d. OBESITY
Rationale:
Smoking, alcohol consumption, decreased physical activity, and obesity are all modifiable
risk factors for stroke. Interventions aimed at reducing or eliminating these risk factors
can help lower the risk of stroke.
80.
The nurse is caring for a client diagnosed with ARDS who is on a ventilator.
Which intervention should the nurse implement? Select all that apply
a. Assess the client’s level of consciousness.
b. Monitor the client’s urine output.
c. Perform passive range of motion (ROM) exercises.
d. Maintain intravenous fluids as ordered.
Answer: a. Assess the client’s level of consciousness, b. Monitor the client’s urine output,
d. .Maintain intravenous fluids as ordered .
Rationale:
In caring for a client with ARDS who is on a ventilator, it is important for the nurse to
assess the client’s level of consciousness to monitor for changes in mental status that may
indicate a worsening condition. Monitoring urine output is essential to assess renal
function and fluid status. Maintaining intravenous fluids as ordered helps to ensure
adequate hydration and support hemodynamic stability. Passive range of motion (ROM)
exercises may not be appropriate for a client on a ventilator and should be avoided unless
specifically ordered by the healthcare provider.
81.
The nurse is performing an assessment on a client who has returned from the
dialysis unit following hemodialysis. The client is complaining of headache, nausea, and
is extremely restless. Which of the following is the most appropriate nursing action?
Answer: Notify the physician.
Rationale:
The client's symptoms of headache, nausea, and restlessness could indicate complications
from hemodialysis, such as disequilibrium syndrome or fluid or electrolyte imbalance. It
is important to notify the physician so that appropriate interventions can be initiated.
82.
The nurse determines that a client with diabetes mellitus is experiencing fat
breakdown for conversion to glucose if the client has elevated levels of which substance
in the urine?
Answer: Ketones.
Rationale:
When the body is breaking down fats for energy, ketones are produced. Ketones can be
detected in the urine in conditions such as diabetic ketoacidosis (DKA), which occurs
when there is a lack of insulin to properly use glucose for energy.
83.
The client is admitted to the ED with chest trauma. Which signs and symptoms
would the nurse expect to assess that supports the diagnosis of pneumothorax?
Answer: Absent breath sounds and tachypnea.
Rationale:
In pneumothorax, air enters the pleural space, causing the lung to collapse partially or
completely. This can result in absent breath sounds on the affected side due to lack of air
movement in the lung. Tachypnea (rapid breathing) may occur as the body tries to
compensate for decreased oxygenation.
84.
The nurse is caring for hospitalized clients. Which of the following clients is at
greatest risk for fluid volume deficit?
Answer: The client who has just been admitted has severe diarrhea and is febrile.
Rationale:
Severe diarrhea and fever can lead to fluid loss and increase the risk of fluid volume
deficit. Diarrhea results in the loss of water and electrolytes, while fever can increase fluid
loss through sweating.
85.
PT & INR for Coumadin, INR 2.8:
Answer: continue medication
Rationale:
An INR of 2.8 falls within the therapeutic range for patients on Coumadin (warfarin)
therapy for conditions like atrial fibrillation or deep vein thrombosis. This result indicates
that the patient's blood is anticoagulated appropriately, so continuing the medication is the
correct course of action.
86.
Hot spot:
Answer: apical pulse
Rationale:
The apical pulse is located at the apex of the heart and is typically assessed by
auscultation using a stethoscope. It is an important assessment for evaluating the heart
rate and rhythm.
87.
Hot spot:
Answer: T wave
Rationale:
The T wave on an electrocardiogram (ECG) represents ventricular repolarization.
Changes in the T wave can indicate various cardiac conditions and should be closely
monitored, especially in patients with cardiac issues.
88.
Hot spot:
Answer: P wave
Rationale:
The P wave on an ECG represents atrial depolarization, which is the electrical activation
of the atria before they contract. Changes in the P wave can indicate abnormalities in
atrial function.
89.
P wave:
Answer: atrial depolarization
Rationale:
The P wave represents the depolarization of the atria, which is the electrical activity that
precedes atrial contraction. It is an important part of the ECG waveform and helps assess
the function of the atria.
90.
Assessing response in an unconscious patient:
Answer: nail bed pressure (peripheral)
Rationale:
Assessing nail bed pressure in an unconscious patient is a quick and non-invasive way to
assess peripheral perfusion. A delayed or sluggish return of color after applying pressure
could indicate poor perfusion and may warrant further assessment or intervention.
91.
HbA1c considerations for about 3 months of glucose monitoring:
a. Less than 6% for nondiabetic
b. Diabetic controlled should be less than 7%
Answer: b. Diabetic controlled should be less than 7%.
Rationale:
The HbA1c test measures average blood glucose levels over the past two to three months.
For nondiabetic individuals, a level of less than 6% is considered normal. For diabetic
individuals, the goal is to keep the HbA1c level below 7% to reduce the risk of
complications.
92.
Sengstaken-Blakemore tube prevents bleeding (esophageal varices):
a. Triple lumen
b. Have scissors at the bedside
c. Provide oral and nasal care every 3 hours
d. Used to reduce bleeding
Answer: d. Used to reduce bleeding.
Rationale:
The Sengstaken-Blakemore tube is a device used to treat esophageal varices, which are
swollen veins in the esophagus that can bleed heavily. It works by applying pressure to
the bleeding veins, which helps to stop the bleeding. The tube is not a preventive measure
but rather a treatment for active bleeding.
93.
Planning rehabilitation for a stroke patient:
a. Assess functional status before developing plan
b. Walking, speaking, eating, ADLs
Answer: a. Assess functional status before developing plan.
Rationale:
Assessing the stroke patient's functional status is crucial before developing a
rehabilitation plan. This assessment includes evaluating the patient's ability to perform
activities of daily living (ADLs), such as walking, speaking, eating, and other functional
tasks. Understanding the patient's current abilities and limitations helps in setting
appropriate rehabilitation goals and designing an effective rehabilitation program.
94.
Cranial nerve II:
Answer: Snellen test
Rationale:
Cranial nerve II, also known as the optic nerve, is responsible for vision. The Snellen test
is a common eye chart test used to measure visual acuity, which assesses the function of
the optic nerve.
95.
T2-T3:
Answer: Paraplegia
Rationale:
Injuries or damage to the spinal cord at the T2-T3 level can result in paraplegia, which is
the paralysis of the lower extremities. This occurs because the nerves below this level,
which control leg function, are affected.
96.
ICP:
Answer: no lumbar puncture
Rationale:
Increased intracranial pressure (ICP) can be a serious medical condition that requires
careful management. Performing a lumbar puncture (LP) in a patient with increased ICP
can potentially lead to herniation of the brain due to the pressure changes in the
cerebrospinal fluid. Therefore, an LP is contraindicated in patients with suspected or
known increased ICP.
97.
A nurse observing a closed chest tube drainage system in a postoperative 1-day
thoracotomy client notes continued bubbling in the suction chamber. What should the
nurse do?
a. Check the control outlet against the wall.
b. Observe all the connection tubing.
c. Continue to monitor the client's respiratory status.
d. Notify the MD of the observation.
Answer: c. Continue to monitor the client's respiratory status.
Rationale:
Continued bubbling in the suction chamber of a closed chest tube drainage system
indicates that the system is functioning correctly. The nurse should continue to monitor
the client's respiratory status to ensure there are no signs of respiratory distress or other
complications.
98.
A client admitted to the hospital reports recurrent flank pain, nausea, and vomiting
within 24 hours. Which of the following is the priority nursing action?
a. Administer pain medication.
b. Monitor intake and output.
c. Administer antiemetics.
d. Strain urine.
Answer: d. Strain urine.
Rationale:
The priority nursing action is to strain the client's urine to check for the presence of renal
calculi (kidney stones), which could be causing the symptoms of flank pain, nausea, and
vomiting. Identifying the presence of renal calculi is crucial for determining appropriate
interventions and preventing further complications.
99.
A nurse is caring for client who have type 1 DM. The nurse misread client
morning blood glucose level at 210 mg/dL instead of 120 mg/dL base on this error. She
admitted insulin dose of 200 mg/dL before client breakfast. Which of the nursing priority?
Answer: Monitor client for hypoglycemia
Rationale:
Administering an insulin dose based on a misread blood glucose level can result in
hypoglycemia, especially if the actual blood glucose level was 120 mg/dL rather than 210
mg/dL. Hypoglycemia can be dangerous and requires immediate attention. Therefore, the
priority nursing action would be to closely monitor the client for signs and symptoms of
hypoglycemia, such as sweating, tremors, irritability, and confusion, and to intervene
promptly if hypoglycemia occurs.
100.
A nurse is caring for a client who is scheduled for a colonoscopy. The client asks
the nurse if there will be a lot of pain during the procedure. Which of the following is an
appropriate nursing response?
a. No, you shouldn’t feel any pain because your rectum will be anesthetized.
b. You may be sedated, but you will feel discomfort during the instrument insertion.
c. Don’t worry.
d. [No answer provided]
Answer: b. You may be sedated, but you will feel discomfort during the instrument
insertion.
Rationale:
The nurse should provide an honest and accurate response to the client's question. While
the client may receive sedation to help with relaxation and discomfort, it is important to
inform them that they may still feel some discomfort during the procedure, especially
during the insertion of the colonoscope. Providing false reassurance (option A) or
dismissing the client's concerns (option C) is not appropriate in this situation. Option D is
not a valid response.
101.
A nurse is performing teaching for a client who has recently been diagnosed with
type 2 diabetes mellitus. The nurse should recognize that the client understood the
teaching. Identify hypoglycemia. (Select all)
a. Moist, clammy skin
b. Tachycardia
c. Polyuria
d. Polydipsia
e. Polyphagia
f. [No answer provided]
Answer: a. Moist, clammy skin
b. Tachycardia
e. Polyphagia
Rationale:
Hypoglycemia is characterized by symptoms such as moist, clammy skin (A), tachycardia
(B), and polyphagia (E). Polyuria (C) and polydipsia (D) are more commonly associated
with hyperglycemia. Option F is not a valid response.
102.
A nurse administered morphine 2 mg IV push after the client reported pain and
evaluated the client 15 minutes later. Which following adverse effects should the nurse
monitor for?
a. Pain scale level of 6 to 4
b. Sleepy but arousable when name called
c. O2 saturation 94%
d. Respiratory rate 8 bpm
Answer: d. Respiratory rate 8 bpm
Rationale:
Morphine is a potent opioid that can cause respiratory depression as an adverse effect. A
respiratory rate of 8 bpm is significantly low and indicates potential respiratory
depression, which is a serious adverse effect that requires immediate intervention. While
some level of pain relief (A) and sedation (B) are expected effects of morphine,
respiratory depression is a critical adverse effect. Oxygen saturation of 94% (C) is slightly
lower than normal but may not be directly related to the adverse effects of morphine.
103.
score.
A nurse assesses a client with a Glasgow Coma Scale score of 8. Describe the
a. Reflex alert client
b. Need for total nursing care
c. Client in deep coma
d. Stable neurological status
Answer: b. Need for total nursing care
Rationale:
A Glasgow Coma Scale (GCS) score of 8 indicates severe impairment of consciousness. A
score of 8 indicates that the client requires total nursing care due to the level of
consciousness impairment. A score of 8 does not indicate a reflex alert client (A), a client
in deep coma (C), or stable neurological status (D).
104.
A client is on a low-sodium diet and must reduce fluid intake. Which lunch option
should the client choose?
a. Tuna sandwich on wheat bread, can of cocktail fruit, salad, and soda
b. Grilled chicken sandwich on white bread, apple, salad, and iced tea
c. Grilled cheese sandwich and tomato soup
d. Ham and beans
Answer: c. Grilled cheese sandwich and tomato soup
Rationale:
A grilled cheese sandwich and tomato soup provide a low-sodium meal option. Tuna (A)
and ham (D) are typically high in sodium. Salad dressings and sodas (A) can also be high
in sodium. The grilled chicken sandwich (B) may be lower in sodium, but the bread and
salad dressing can still contribute to the sodium content.
105.
A client has had an acute myocardial infarction (MI), and cardiac enzymes are
obtained. What do cardiac enzymes identify?
a. Damage to the myocardium
b. Determine the size of the MI
c. Help to determine the location of the MI
d. [No answer provided]
Answer: a. Damage to the myocardium
Rationale:
Cardiac enzymes, such as troponin and creatine kinase-MB (CK-MB), are released into
the bloodstream when there is damage to the myocardium (heart muscle). Elevated levels
of these enzymes indicate myocardial damage, which is characteristic of a myocardial
infarction. Cardiac enzymes do not determine the size (B) or location (C) of the MI
directly. Option D is not a valid response.
106.
Administered DDAVP to client diagnosed with DI. Therapeutic effect:
Answer: Specific gravity (1.015)
Rationale:
DDAVP (Desmopressin) is a synthetic analogue of vasopressin used in the treatment of
central diabetes insipidus (DI). It works by increasing water reabsorption in the kidneys,
leading to a decrease in urine output and an increase in urine specific gravity. A specific
gravity of 1.015 is within the normal range (1.005-1.030), indicating that the medication
is having the intended therapeutic effect of reducing urine output and concentrating the
urine.
