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100
Your patient has returned from a peripheral artery bypass for the treatment of peripheral arterial disease. The nurse will make it PRIORITY to do:
Assess the surgical site for excessive drainage
Assess and grade lower extremity pulses bilaterally
Apply compression stockings
Elevate the lower extremity above heart level
2: Assess and grade lower extremity pulses bilaterally
Rationale: The first step in the nursing process is always to assess. When approaching priority questions always look for the options that are to assess. When you look at this question, that eliminates 2 options right away. When deciding between 1 and 2, understanding that PAD is a problem of circulation will direct you to the correct answer. A nurses assesses circulation by checking pulses.
100
A client has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The health care provider's choice of antibiotics would be primarily based on what diagnostic test?
1. Echocardiography
2. Blood cultures
3. Cardiac aspiration
4. Complete blood count
2- Blood cultures
Rationale- Treatment of endocarditis infection starts with broad-spectrum antibiotics and then is narrowed down by blood culture specificity. The question is asking specifically about antibiotic intervention for endocarditis which should lead you to option 2.
100
As a nurse, which statement is incorrect regarding an informed consent signed by a patient?
The nurse is responsible for obtaining the consent for surgery
Patients under 18 years of age may need a parent or legal guardian to sign a consent form
The nurse can witness the client signing the consent form
It is the nurse’s responsibility to ensure the patient has been educated by the physician about the procedure before informed consent is obtained
1-The nurse is responsible for obtaining consent for surgery
Rationale- The way to think about this concept is the nurse is not the one responsible for performing the surgery. The nurse is also not responsible for making the decision for the patient to have surgery. The nurse's role is advocate, making sure the patient understands what they have consented to and it is what they want.
100
A nurse is caring for a client who is 12 hours post op following a total hip arthroplasty. Which of the following actions should the nurse take?
Maintain adduction of the client’s legs
Encourage range of motion of the hip up to 120 degrees
Place a pillow between the client’s legs
Keep the client’s hips internally rotated
3- Place a pillow between the client's legs
Rationale- This question requires you to understand hip precautions- No bending at the waist greater than 90 degrees, no crossing of the legs (adduction), no internal rotation of the hip. It is helpful to remember that the name of the wedge pillow commonly used in post-op hip patients is called the Abductor Pillow.
*To remember adduction versus abduction, remember ABduction- Away from Body
100
A client who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments?
1. Integumentary assessment
2. Assessment for signs of hemorrhage
3. Neurologic assessment
4. Assessment of respiratory status
4- Assessment of respiratory status
Rationale- All of the above are important to assess on a patient that has been exposed to Anthrax because it can cause symptoms that affect all of the above symptoms, however respiratory status is always top priority.
200
Your patient’s blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST?
Low-dose corticosteroids
Crystalloids IV fluid bolus
Norepinephrine
2 units of Packed Red Blood Cells
2- Crystalloids IV fluid bolus
Rationale- Remember the sepsis bundle. Fluids, blood cultures, broad-spectrum antibiotics
200
A nurse working in the emergency department is caring for a client who reports nausea and vomiting for the past three days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?
Heart rate 110/min
Blood pressure 138/90 mmHg
Urine Specific Gravity 1.020
BUN 15mg/dL
1- Heart rate 110/min
Rationale- 110 bpm is an abnormal VS, normal HR is 60 to 100. This patient is slightly tachycardic indicating the body is under stress. The less fluids available in the body aka dehydration/fluid volume deficit, the faster the heart has to beat to perfuse the body.
200
A nurse is caring for a group of clients. Which client should the nurse make a referral to physical therapy for?
A client receiving preoperative teaching for right knee arthroplasty
Client stating that they are having difficulty obtaining a walker for at home use
Client reporting that there is an increase in pain following their left hip arthroplasty
Client having emotional difficulty accepting that they have a prosthetic leg
1- A client receiving preoperative teaching for right knee arthroplasty
Rationale- Option 1 is appropriate for PT. Option 2 needs a referral to care management. Option 3 should be in touch with their medical team for pain management. Option 4 is appropriate for a referral to psych and social to help get in touch with support groups.
200
The nurse is caring for a patient who has severe chest pain after working outside on a hot day and is brought to the ED. The nurse administers nitroglycerin to help alleviate chest pain. What side effect should concern the nurse the most?
1. Dry mucous membranes
2. HR of 88 bpm
3. BP 86/58
4. Complaints of headache
3- BP 86/58
Rationale- Dry mucous membranes, hypotension and headache are expected side effects of Nitroglycerin. Hypotension is the only side effect that has the potential to be life-threatening.
200
A nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). Which of the following QRS changes should the nurse expect to see on the clients ECG?
- narrower than usual QRS complexes
- Much greater amplitude than the usual QRS complexes
- same polarity as the usual QRS complexes.
- immediate resumption of the usual rhythm.
2- Much greater amplitude than the usual QRS complexes
Rationale- The QRS complexes have greater amplitude in height and depth in client’s with PVCs than normal
300
A nurse is caring for a client who is who is having a seizure. Which of the following interventions is the nurse’s priority?
Loosen clothing around their neck
Check pupillary responses
Turn client on their side
Move furniture away from the client
3- Turn client on their side
Rationale- Priority in an acute situation is always the ABCs (airway, breathing, circulation.) When someone is seizing, risk for aspiration is high because the patient does not have control of their secretions. Always start by turning them from supine to their side and have suction ready.
*Every patient room should always have 2 suction set ups no matter the scenario*
300
The nurse is caring for a patient with hypercholesterolemia who has been prescribed atorvastatin. What serum levels should be monitored in this patient?
1. CBC
2. Blood Cultures
3. Na and K levels
4. Liver Enzymes
4- Liver Enzymes
Rationale- Atorvastatin is metabolized by the liver. The other options don't have anything to do with this drugs metabolism.
300
The nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include in teaching?
Keep the client’s personal care items in the bathroom
Keep the overhead lights on in their bedroom while the client is sleeping
Remind the client to scan their complete range of vision during ambulation
Secure the client’s extension cords under their carpeting
3- Remind the client to scan their complete range of vision during ambulation
Rationale- Right off the bat you can eliminate options that don't have to do with vision. Then you need to understand that hemianopsia means that the patient cannot see out of the half their visual field in each eye hence the need to scan back and forth as they walk to avoid obstacles.
300
A nurse is caring for a client who has a brain stem injury. Which of the following physiologic functions should the nurse monitor?
1. Understanding speech
2. Respiratory effort
3. Decision-making ability
4. temperature control.
2- Respiratory effort
Rationale- The nurse should monitor the respiratory effort of a client who has an injury to the brain stem. The medulla in the brain stem controls the respiratory center.
300
Select the patient below who is at MOST risk for complications following a burn:
A 42-year-old male with partial-thickness burns on the front of the right and left arms and legs
A 25-year-old female with partial-thickness burns on the front of the head and neck and front and back of the torso
A 36-year-old male with full-thickness burns on the front of the left arm
A 10-year-old with superficial burns on the right leg
A 25-year-old female with partial-thickness burns on the front of the head and neck and front and back of the torso
Rationale: When approaching burn questions focus on the area the burn effects and the body-surface-area(BSA). In answer 2, the area is the head, neck, back and torso. This option is by far the most BSA and proximity to the airway make it the most prone to serious complications or fatality.
400
A nurse is caring for a client from whom the respiratory therapist has just removed the endotracheal tube. which of the following actions should the nurse take first?
- Instruct the client to cough.
- Administer oxygen via face mask.
- Evaluate the client for stridor.
- Keep the client in semi to high-Fowler’s position.
3- Evaluate the client for stridor
Rationale- The first action the nurse should take using the nursing process is to assess the client. After exhumation, the nurse should continuously evaluate the client’s respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation.
400
The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate?
1. Hypermagnesemia
2. Hyponatremia
3. Hypocalcemia
4. Hyperkalemia
3- Hypocalcemia
Rationale- Symptoms of hypocalcemia include Chvostek's and Trousseau's sign. I remember Chvostek by word association: Chvostek-Cheek-Calcium
400
A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first?
1. Document the client's intake and output.
2. Scan the bladder with a portable ultrasound.
3. Pour warm water over the client's perineum.
4. Perform a straight catheterization.
2- Scan the bladder with a portable ultrasound.
Rationale- Assessment is always the first step in the nursing process. Option 2 is an assessment. You need the data of bladder volume perform in order to know which intervention to perform.
400
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?
1. The chest tube is draining serosanguineous fluid at 65 mL/hr
2. The client tolerates gentle milking of the tubing.
3. Bubbling in the water seal chamber has ceased.
4. There is tidaling in the water seal chamber.
3- Bubbling in the water seal chamber has ceased.
Rationale- Bubbling immediately following insertion can be a normal finding like the scenario in this question. Development of bubbling unexpectedly, however, is indication of an air leak, make sure all connections are secure. Tidaling corresponds to the patients respirations. A chest tube should never be milked; can cause damage to lung tissue by creating high negative pressure. Greater than 50mL/hr of output is considered large volume output and the provider should be notified.
400
A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication?
1. Decreased heart rate
2. Crackles heard on auscultation
3. Increased urinary output
4. Decreased deep tendon reflexes
2- Crackles heard on auscultation
Rationale- Option 2 is the only negative side effect of the options provided. Mannitol is a diuretic used to reduce ICP. Due to the fluid shifts caused by the drug to reduce ICP, fluid can travel to the lung tissues presenting as crackles on auscultation aka pulmonary edema.
500
A triage nurse is in the emergency department when several hundred clients who were just injured in a train collision arrive a the facility for treatment. Which of the following clients require immediate treatment?
1. a client who has neck pain and was transported to the facility on a backboard.
2. a client who has epigastric and left arm pain and is diaphoretic.
3. a client who has nasal orbital ecchymosis and respiratory rate of 16/min.
4. a client who has abdominal pain and is 2 months pregnant.
2- a client who has epigastric and left arm pain and is diaphoretic
Rationale- the nurse should apply the unstable versus stable priority framework. A report of a severe epigastric and L arm pain accompanied by diaphoresis is a classic manifestation of a MI, which is life-threatening and requires immediate treatment.
500
A nurse is assessing a client who sustained a recent head injury. Which of the following should the nurse recognize as a manifestation of increased ICP.
1. Widened pulse pressure.
2. tachycardia
3. periorbital edema
4. decreased urine output.
1- Widened pulse pressure
Rationale- A widening of the pulse pressure is a manifestation of increased ICP. Other manifestations include pupil changes, change in LOC, and N/V
500
A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?
1. Anorexia and jaundice
2. Bronchospasm and urticaria
3. Hypertension and bounding pulse
4. Low back pain and apprehension
4- Low back pain and apprehension
Rationale- A hemolytic transfusion reaction is caused by ABO incompatibility which leads to hemolysis of the RBCs. The components of the RBCs that are released leads to kidney tissue damage, activation of the coagulation cascade and lead to systemic vasoconstriction and shock
500
The nurse and the other members of the team are caring for a client who converted to ventricular fibrillation (VF). The client was defibrillated unsuccessfully and the client remains in VF. The nurse should anticipate the administration of what medication?
1. Epinephrine
2. Lidocaine
3. Amiodarone
4. Sodium bicarbonate
1- Epinephrine
Rationale- Both epinephrine and amiodarone are critical care medications that are used during codes to try to get the heart out of fatal rhythms. Epinephrine is the first line drug and amiodarone is used next if epi is unsuccessful.
500
A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.)
Expressive aphasia
Visual spatial deficits
2- Visual Spatial Deficits 3- Left Hemianopia 5- One-sided neglect (specifically- L-sided weakness)
