Preview Extract
1. A nurse is reviewing the ABG results of a patient who the provider suspects has metabolic
acidosis. Which of the following results should the nurse expect to see?
a. pH 26
c. PaO2 45
Answer: a. pH < 7.35
Rationale:
Metabolic acidosis is characterized by a low pH (below 7.35) due to the accumulation of acid or
loss of bicarbonate in the body. Other indicators include a decreased HCO3- level (< 22 mEq/L),
not an increased one.
2. A client is experiencing shortness of breath, fatigue, and jugular vein distention. The nurse
auscultates a third heart sound (S3). What should the nurse anticipate as the cause of these signs
and symptoms?
a. Myocardial infarction
b. Pulmonary embolism
c. Cardiac tamponade
d. Heart failure
Answer: d. Heart failure
Rationale:
Shortness of breath, fatigue, jugular vein distention, and an S3 are signs and symptoms of heart
failure resulting from the decreased pumping ability of the heart and increased fluid volume.
3. A nurse is caring for a client in the emergency department who was just admitted with chest
pain, possible acute coronary syndrome. Which of the following actions should the nurse take
first?
a. Draw blood for cardiac enzyme monitoring
b. Administer sublingual nitroglycerin
c. Auscultate heart sounds
d. Insert an IV catheter
Answer: b. Administer sublingual nitroglycerin
Rationale:
Administering sublingual nitroglycerin helps to reduce chest pain by dilating the coronary
arteries and improving blood flow to the heart muscle. This intervention should be prioritized to
relieve the client's symptoms and prevent further myocardial damage.
4. A nurse is caring for a client who is experiencing ventricular tachycardia with a pulse. The
rapid response team is at the bedside. What electrical intervention should be used to correct this
dysrhythmia?
a. Defibrillation
b. Synchronized cardioversion
c. Pacemaker insertion
d. Transcutaneous pacing
Answer: b. Synchronized cardioversion
Rationale:
Synchronized cardioversion is the electrical management of choice for ventricular tachycardia
with a pulse, as it delivers a timed electrical shock to the heart to restore normal rhythm. This is
different from defibrillation, which is used for pulseless rhythms.
5. A nurse is caring for an adult client who is experiencing delayed wound healing. Which of the
following interventions should the nurse take?
a. Apply a wet-to-dry dressing
b. Administer prophylactic antibiotics
c. Monitor serum albumin levels and notify provider if below 3.5 g/dL
d. Restrict fluid intake
Answer: c. Monitor serum albumin levels and notify provider if below 3.5 g/dL
Rationale:
Monitoring serum albumin levels is crucial because low albumin indicates poor nutritional
status, which can impair wound healing. Albumin levels below 3.5 g/dL suggest the need for
nutritional intervention to support recovery.
6. A nurse is teaching a client who has pre-dialysis end-stage kidney disease about diet. Which of
the following instructions should the nurse include?
a. Increase intake of foods high in potassium.
b. Reduce intake of foods high in potassium.
c. Limit fluid intake.
d. Increase protein intake.
Answer: b. Reduce intake of foods high in potassium.
Rationale:
Pre-dialysis end-stage kidney disease indicates that the client's kidneys are not functioning
properly. Potassium can build up to dangerous levels in the blood with kidney disease. Therefore,
reducing intake of foods high in potassium is crucial to prevent hyperkalemia, which can lead to
serious complications such as irregular heart rhythms.
7. A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's
morning blood glucose level as 210 mg/dL instead of 120 mg/dL. Based on this error, she
administered the insulin dose appropriate for a reading over 200 mg/dL before the client's
breakfast. Which of the following actions should the nurse take first?
a. Give the client 15 to 20 g of carbohydrates.
b. Monitor the client for hypoglycemia.
c. Complete an incident report.
d. Notify the nurse manager.
Answer: b. Monitor the client for hypoglycemia.
Rationale:
Since the nurse administered the insulin dose appropriate for a reading over 200 mg/dL when the
actual reading was 120 mg/dL, there is a risk of hypoglycemia. Therefore, the nurse should first
monitor the client for signs and symptoms of hypoglycemia, such as sweating, trembling,
confusion, and irritability.
8. A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of
the following interventions should the nurse include in the plan of care?
a. Check urine specific gravity.
b. Monitor blood glucose levels.
c. Administer insulin.
d. Restrict fluid intake.
Answer: a. Check urine specific gravity.
Rationale:
Diabetes insipidus is characterized by the excretion of large amounts of diluted urine, leading to
dehydration and electrolyte imbalances. Checking urine specific gravity helps assess the
concentration of urine, which is typically low in diabetes insipidus. Monitoring urine specific
gravity can help determine the effectiveness of treatment and the client's hydration status.
9. A nurse is caring for a client admitted with wheezing and coughing due to an allergic reaction
to a newly prescribed medication. Which of the following medications should be administered
first?
a. Aminophylline 500 mg IV.
b. Cromolyn 20 mg via nebulizer.
c. Methylprednisolone 100 mg IV.
d. Albuterol 3 mL via nebulizer.
Answer: d. Albuterol 3 mL via nebulizer.
Rationale:
Albuterol is a bronchodilator that helps relieve wheezing and coughing by opening up the
airways. It is the first-line treatment for acute bronchospasm in allergic reactions. Administering
albuterol first can help improve the client's breathing and reduce the severity of symptoms.
10. A nurse is caring for a female client in the emergency department who reports shortness of
breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago
and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure
140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3
20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?
a. Administer oxygen via face mask.
b. Perform a chest x-ray.
c. Administer pain medication.
d. Start intravenous (IV) fluids.
Answer: a. Administer oxygen via face mask.
Rationale:
The client's symptoms, including shortness of breath and low oxygen levels (PaO 2 60 mm Hg),
indicate a potential respiratory problem. Administering oxygen via face mask can help improve
oxygenation and relieve respiratory distress, which is the priority in this situation.
11. A nurse is caring for a client following repair of a fracture. Which of the following findings
should alert the nurse that the client is experiencing compartment syndrome? (Select all that
apply.)
a. The affected area is pale
b. Pulselessness
c. Numbness, burning, and tingling
d. Bruising to the affected area
e. Increased pain unrelieved by elevation or pain medication
Answer: e. Increased pain unrelieved by elevation or pain medication
c. Numbness, burning, and tingling
a. The affected area is pale
b. Pulselessness
Rationale:
Compartment syndrome is a serious condition that can occur after a fracture. It is characterized
by increased pressure within a muscle compartment, which can lead to tissue damage. Signs and
symptoms include increased pain unrelieved by elevation or pain medication, numbness,
tingling, or burning sensations, pale or cool skin, pulselessness, and severe cases may have
bruising.
12. A nurse is administering a tap water enema to a client who is constipated. During the
administration of the enema, the client states he is having abdominal cramps. Which of the
following actions should the nurse take to relieve the client's discomfort?
a. Stop the enema administration
b. Raise the height of the solution container
c. Encourage the client to take deep breaths
d. Lower the height of the solution container
Answer: d. Lower the height of the solution container
Rationale:
Lowering the height of the solution container will slow the flow rate of the enema solution,
which can help alleviate the client's abdominal cramps. It allows the solution to enter the colon at
a slower rate, reducing discomfort.
13. A client is diagnosed with left homonymous hemianopsia following a stroke. Which of the
following actions should the nurse take when caring for this client?
a. Place the client's bedside table on the left side of the bed
b. Use the clock method to describe the location of items on the client's tray
c. Place the wheelchair on the left side of the client
d. Place the call light on the left side of the bed
Answer: b. Use the clock method to describe the location of items on the client's tray
Rationale:
Left homonymous hemianopsia results in the loss of the left visual field in both eyes. Using the
clock method (e.g., "Your glass of water is at 3 o'clock on your tray") helps the client locate
objects based on their remaining visual field, which is to the right.
14. A nurse is caring for a client who is at risk for shock. Which of the following findings is the
earliest indicator that this complication is developing?
a. Decreased urine output
b. Hypotension
c. Cool, clammy skin
d. Narrowing pulse pressure
Answer: d. Narrowing pulse pressure
Rationale:
In a client at risk for shock, narrowing pulse pressure (the difference between systolic and
diastolic blood pressure) is an early indicator of inadequate perfusion. As shock progresses, other
signs such as tachycardia, hypotension, and altered mental status may also be present.
15. A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and
diarrhea. Which of the following findings should the nurse expect?
a. Hyperactive bowel sounds
b. Increased urine output
c. Muscle weakness
d. Hypertension
Answer: c. Muscle weakness
Rationale:
Hypokalemia, or low potassium levels, can lead to muscle weakness, especially in the legs. Other
common manifestations of hypokalemia include fatigue, muscle cramps, and cardiac
dysrhythmias.
16. A nurse is providing teaching for a client who has experienced an acute episode of gastritis.
Which of the following instructions should the nurse include in the teaching?
a. Avoid drinking alcohol
b. Eat spicy foods to promote healing
c. Take nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief
d. Avoid taking prescribed antibiotics on an empty stomach
Answer: a. Avoid drinking alcohol
Rationale:
Alcohol can irritate the stomach lining and worsen gastritis symptoms. Therefore, it is important
for the client to avoid drinking alcohol to prevent further irritation and promote healing of the
stomach lining.
17. A nurse at an outpatient surgery center is providing discharge teaching to a client and his
spouse following surgical removal of a cataract. Which of the following should the nurse include
in the teaching?
a. The client should avoid using the affected eye for reading or watching television
b. The client should wear dark glasses while outdoors
c. The client should avoid using the prescribed eye drops
d. The client should resume normal activities immediately
Answer: b. The client should wear dark glasses while outdoors
Rationale:
After cataract surgery, the client's eyes may be sensitive to light. Wearing dark glasses while
outdoors can help protect the eyes from bright sunlight and promote healing. The client should
also follow the prescribed regimen for eye drops and avoid using the affected eye for reading or
watching television as directed by the healthcare provider.
18. A nurse is assessing a client who has a puncture wound on his foot. Which of the following
findings is a manifestation of acute osteomyelitis?
a. Localized erythema
b. Swelling
c. Warmth
d. Purulent drainage
Answer: a. Localized erythema
Rationale:
Acute osteomyelitis is an infection of the bone that can occur as a complication of a puncture
wound. Localized erythema (redness) around the wound site can be a sign of inflammation and
infection in the bone. Other signs and symptoms of acute osteomyelitis include swelling,
warmth, tenderness, and possibly purulent drainage from the wound.
19. A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following
findings should the nurse identify as a manifestation of increased intracranial pressure?
a. Irritability
b. Bradycardia
c. Hypotension
d. Hyperreflexia
Answer: a. Irritability
Rationale:
Increased intracranial pressure (ICP) can lead to changes in mental status, including irritability,
confusion, and restlessness. Other signs of increased ICP include headache, vomiting, changes in
vision, and altered level of consciousness. Bradycardia and hypotension are not typically
associated with increased ICP, while hyperreflexia may occur in response to increased ICP but is
not as specific as irritability.
20. When caring for a client with a chest tube, the nurse notes continuous bubbling in the chest
tube water seal chamber. What does this indicate?
a. An air leak
b. Proper functioning of the chest tube
c. Presence of blood in the chest tube
d. Inadequate suction pressure
Answer: a. An air leak
Rationale:
Continuous bubbling in the chest tube water seal chamber indicates an air leak in the system.
This could be from the chest tube insertion site, the connection between the tubing and the
drainage system, or from the lung tissue itself. Identifying and correcting the source of the air
leak is important to prevent complications such as pneumothorax.
21. A nurse in an emergency department is caring for a client who had a seizure and became
unresponsive after stating she had a sudden, severe headache and vomiting. The client’s vital
signs are as follows: BP 198/100 mmHg, pulse of 82/min, respirations of 24/min, and a temp of
100.8 F. Which of the following neurologic disorders should the nurse suspect?
a. Migraine headache
b. Ischemic stroke
c. Hemorrhagic stroke
d. Transient ischemic attack (TIA)
Answer: c. Hemorrhagic stroke
Rationale:
The sudden, severe headache, vomiting, and altered level of consciousness are consistent with
symptoms of a hemorrhagic stroke, which occurs due to bleeding in the brain. The elevated
blood pressure (BP) is also a common finding in hemorrhagic stroke. Ischemic stroke and TIA
typically do not present with such sudden, severe headache and vomiting.
22. A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of
the prostate (TURP). Which of the following is the priority finding for the nurse to report to the
provider?
a. Urinary output of 30 mL/hr
b. Complaints of bladder spasms
c. Output of burgundy-colored urine
d. Temperature of 99.6°F (37.6°C)
Answer: c. Output of burgundy-colored urine
Rationale:
Burgundy-colored urine may indicate bleeding, which can be a sign of hemorrhage following a
TURP. It is important to report this finding promptly to the provider for further evaluation and
management.
23. A nurse is caring for a client who has HIV. Which of the following laboratory values is the
nurse's priority?
a. Positive western blot test
b. CD4-T-cell count 180 cells/mm3
c. Platelets 150,000/mm3
d. WBC 5,000/mm3
Answer: b. CD4-T-cell count 180 cells/mm3
Rationale:
A CD4-T-cell count less than 200 cells/mm3 indicates severe immunosuppression in clients with
HIV and is a significant factor in determining the need for prophylactic treatment for
opportunistic infections. Therefore, this value is a priority for the nurse to report to the provider.
24. A nurse is teaching a client who has gastroesophageal reflux disease about managing his
illness. Which of the following recommendations should the nurse include in the teaching?
a. Limit fluid intake not r/t meals.
b. Chew on mint leaves to reduce indigestion
c. Avoid eating w/in 3 hrs of bedtime
d. Season foods w/black pepper
Answer: c. Avoid eating within 3 hours of bedtime
Rationale:
Avoiding eating within 3 hours of bedtime can help reduce symptoms of gastroesophageal reflux
disease (GERD) by allowing the stomach to empty before lying down, reducing the likelihood of
stomach contents refluxing into the esophagus. The other options are not recommended for
managing GERD.
25. A nurse in a provider's office is reviewing the laboratory results of a client who takes
furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The
nurse should monitor the client for which of the following complications?
a. Hyperkalemia
b. Hypokalemia
c. Hypermagnesemia
d. Hypomagnesemia
Answer: b. Hypokalemia
Rationale:
Furosemide is a loop diuretic that can cause potassium loss in the urine, leading to hypokalemia.
A potassium level of 3.3 mEq/L is below the normal range (3.5-5.0 mEq/L) and requires
monitoring for complications such as cardiac dysrhythmias. Hyperkalemia is an elevated
potassium level, which is not indicated in this scenario.
26. A nurse is caring for a client with who has hepatitis A. The client asks the nurse how he
might have contracted the virus. Which of the following is a question the nurse should ask the
client?
a. "Have you been to a third world country lately?"
b. "Have you had any recent blood transfusions?"
c. "Have you been sexually active with multiple partners?"
d. "Have you used intravenous drugs?"
Answer: a. "Have you been to a third world country lately?"
Rationale:
Hepatitis A is commonly contracted through consuming contaminated food or water, particularly
in developing countries where sanitation may be lacking. Asking about recent travel to such
regions can help identify the source of the infection.
27. A nurse is preparing a client for radiation treatment who is postoperative following a
mastectomy. The nurse should inform the client to expect which of the following adverse effects
from the treatment?
a. Hair loss
b. Fatigue
c. Nausea and vomiting
d. Skin irritation
Answer: b. Fatigue
Rationale:
Fatigue is a common side effect of radiation therapy, especially in clients who have undergone
surgery. It is important for the nurse to inform the client about this potential side effect so that
they can plan their activities accordingly and seek support if needed.
28. A nurse in a burn treatment center is caring for a client who is admitted with severe burns to
both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse
what the procedure entails. Which of the following nurse statements is appropriate?
a. "Large incisions will be made in the eschar to improve circulation."
b. "The burned tissue will be removed and replaced with skin grafts."
c. "The burned area will be cleaned and dressed with antimicrobial agents."
d. "The eschar will be left intact to protect the underlying tissue."
Answer: a. "Large incisions will be made in the eschar to improve circulation."
Rationale:
An escharotomy involves making incisions through the thick, dead tissue (eschar) that forms
over a burn wound. This is done to relieve pressure and improve circulation to the affected area,
which helps prevent further tissue damage and promotes healing.
