Reproduction/
Clotting
Clotting
A postpartum client delivered vaginally 1 hour ago. The nurse notes heavy vaginal bleeding and a boggy uterus that deviates to the right. The client’s bladder is palpable.
What is the priority nursing action?
A. Administer Oxytocin IV infusion
B. Perform fundal massage
C. Assist the client to void
D. Administer Methylergonovine IM
Correct answer: B
Rationale (short): Boggy uterus = uterine atony → massage immediately to stop bleeding.
A client arrives to the ED with chest pain rated 8/10. The nurse notes the client is diaphoretic, anxious, and reports the pain started while resting. Vital signs: BP 88/54, HR 110. The client has a prescription for Nitroglycerin PRN.
What is the priority nursing action?
A. Administer nitroglycerin
B. Administer Aspirin
C. Apply oxygen
D. Reassess pain in 5 minutes
Correct answer: B
Rationale (short): Nitroglycerin is contraindicated with SBP < 90, so give aspirin first for suspected ACS.
A client with anorexia nervosa is admitted and begins nutritional therapy. On day 3, the client develops weakness, edema, and confusion.
What is the priority nursing action?
A. Increase caloric intake
B. Slow the rate of feeding
C. Encourage exercise
D. Administer diuretics
Correct answer: B
Rationale (short): Signs of refeeding syndrome → slow feeding to prevent cardiovascular collapse.
A client 6 hours post–hip fracture repair reports severe pain unrelieved by opioids and increasing tightness in the thigh. What is the priority action?
A. Reposition the client
B. Apply ice to the surgical site
C. Notify the provider immediately
D. Reassess in 30 minutes
Answer: C
Rationale: Pain unrelieved by opioids + pressure = possible compartment syndrome → requires immediate intervention.
(SATA) Which findings indicate neurovascular compromise? (Select all that apply)
A. Pallor
B. Tingling
C. Strong pulses
D. Cool extremity
E. Delayed cap refill
Answers: A, B, D, E
Rationale: These indicate decreased perfusion and nerve involvement.
A client on methadone has a respiratory rate of 7/min. What is priority?
A. Stimulate client
B. Administer naloxone
C. Reassess later
D. Give oxygen only
Answer: B
Rationale: Opioid-induced respiratory depression → naloxone first.
(SATA) Which are appropriate teaching points for naltrexone? (Select all that apply)
A. Avoid opioids
B. Can cause withdrawal
C. Safe with opioid use
D. Blocks opioid effects
E. Causes euphoria
Answers: A, B, D
Rationale: Naltrexone blocks opioids and can trigger withdrawal.
A newborn’s heart rate is 150 bpm, blood glucose is 50 mg/dL, and respirations pause for 10 seconds occasionally.
What should the nurse do?
A. Initiate resuscitation
B. Notify provider
C. Continue to monitor
D. Administer oxygen
Correct answer: C
Rationale (short): All values are within normal newborn limits.
A client with a history of CAD reports chest pain that has become more frequent, lasts longer, and now occurs at rest. The pain is not fully relieved by nitroglycerin.
How should the nurse interpret these findings?
A. Stable angina
B. Unstable angina
C. Non-cardiac chest pain
D. Myocardial infarction
Correct answer: B
Rationale (short): Unpredictable + at rest + worsening = unstable angina.
A nurse is reviewing labs for a malnourished client. Which lab best reflects recent nutritional intake?
A. Albumin
B. Prealbumin
C. Hemoglobin
D. Hematocrit
Correct answer: B
Rationale (short): Prealbumin changes quickly → reflects recent intake.
A client on bedrest develops unilateral calf swelling, warmth, and pain. What is the priority nursing action?
A. Massage the calf
B. Ambulate the client
C. Apply compression stockings
D. Maintain bedrest and notify provider
Answer: D
Rationale: Suspected DVT → prevent embolization; no massage or ambulation.
A client in traction—what requires intervention?
A. Weights hanging freely
B. Ropes aligned
C. Weights resting on the floor
D. Client centered in bed
Answer: C
Rationale: Traction must remain continuous.
A client begins Suboxone therapy. Which outcome indicates effectiveness?
A. Increased sedation
B. Reduced cravings
C. Euphoria
D. Increased appetite
Answer: B
Rationale: Suboxone reduces cravings without producing euphoria.
Priority in alcohol withdrawal?
A. Prevent seizures
B. Improve sleep
C. Reduce anxiety
D. Encourage fluids
Answer: A
Rationale: Seizures are life-threatening.
(SATA) A postpartum client is 2 hours after delivery. The nurse notes heavy bleeding, a boggy uterus, and tachycardia. Which interventions should the nurse implement?
A. Perform fundal massage
B. Assist client to void
C. Place client supine with legs elevated
D. Administer Oxytocin
E. Reassess in 15 minutes
F. Start IV fluids
Correct answers: A, B, D, F
Rationale (short): Uterine atony → massage + empty bladder + oxytocin + fluids for volume support.
(SATA) A client with left-sided heart failure is being assessed. Which findings should the nurse expect?
A. Crackles
B. Orthopnea
C. Peripheral edema
D. Pulmonary edema
E. Jugular vein distention
F. Dyspnea
Correct answers: A, B, D, F
Rationale (short): Left-sided HF → lung congestion (crackles, dyspnea, orthopnea, pulmonary edema).
(SATA) A client with bulimia nervosa is being evaluated. Which findings are expected?
A. Swollen parotid glands
B. Near-normal weight
C. Severe weight loss
D. Electrolyte imbalance
E. Loss of tooth enamel
F. Bradycardia
Correct answers: A, B, D, E
Rationale (short): Bulimia → normal weight + purging effects (teeth, glands, electrolytes).
(SATA) A nurse is caring for a client at risk for pressure injuries. Which interventions are appropriate? (Select all that apply)
A. Reposition every 2 hours
B. Massage bony prominences
C. Keep skin clean and dry
D. Use pressure-relieving mattress
E. Limit protein intake
Answers: A, C, D
Rationale: Prevent breakdown with repositioning, moisture control, and pressure relief; avoid massage and ensure adequate nutrition.
A postop hip replacement client attempts to cross their legs while in bed. What is the nurse’s priority action?
A. Educate the client on hip precautions later
B. Apply sequential compression devices
C. Raise the head of the bed
D. Reposition using an abduction pillow
Answer: D
Rationale: Prevents hip dislocation — priority safety intervention.
A client taking disulfiram drinks alcohol. What should the nurse expect?
A. Sedation
B. Euphoria
C. Flushing and nausea
D. Bradycardia
Answer: C
Rationale: Disulfiram causes aversive reaction with alcohol.
Best response to relapse?
A. “Why did you relapse?”
B. “Let’s identify triggers”
C. “You failed treatment”
D. “Try harder next time”
Correct Answer: B
"Let's identify triggers" is the most therapeutic response
A client on Heparin develops a platelet count of 90,000/mm³.
What should the nurse do?
A. Continue medication
B. Hold medication and notify provider
C. Administer vitamin K
D. Increase dose
Correct answer: B
Rationale (short): Low platelets → suspect HIT → stop heparin immediately.
A client with pulmonary embolism suddenly becomes restless and reports a feeling of impending doom.
What is the nurse’s best interpretation?
A. Anxiety related to hospitalization
B. Expected response to pain
C. Early sign of hypoxia
D. Side effect of medication
Correct answer: C
Rationale (short): Restlessness + doom = early hypoxia sign.
A client with Diabetes Insipidus is being assessed. Which finding indicates the condition is worsening?
A. Urine output of 5 L/day
B. Sodium level of 150 mEq/L
C. Increased thirst
D. Dry mucous membranes
Correct answer: B
Rationale (short): Hypernatremia = worsening dehydration → priority.
A client reports tingling and numbness after cast placement. What is the priority?
A. Elevate above heart
B. Administer pain meds
C. Loosen dressing and assess
D. Apply heat
Answer: C
Rationale: Early neurovascular compromise → relieve pressure.
A newborn diagnosed with developmental hip dysplasia is placed in a Pavlik harness. Which action by the parent requires immediate correction?
A. Checking skin under straps daily
B. Removing the harness for bathing
C. Keeping hips in flexion and abduction
D. Reporting redness to provider
Answer: B
Rationale: The harness must remain on continuously unless prescribed otherwise; removal can disrupt hip alignment.
A client on naltrexone reports opioid use. What should the nurse expect?
A. Increased euphoria
B. No effect
C. Withdrawal symptoms
D. Sedation
Answer: C
Rationale: Naltrexone blocks opioids → precipitates withdrawal.
A client taking disulfiram asks if they can use mouthwash containing alcohol. What is the best response?
A. “That is safe in small amounts.”
B. “Only if you rinse quickly.”
C. “Avoid it completely.”
D. “Use it every other day.”
Answer: C
Rationale: Even small alcohol exposure can trigger severe reaction.
A client with suspected DVT has a positive D-dimer.
What is the next step?
A. Start anticoagulants immediately
B. Confirm with venous ultrasound
C. Discharge client
D. Repeat test
Correct answer: B
Rationale (short): D-dimer is not definitive → confirm with ultrasound.
(SATA) A client is diagnosed with a pulmonary embolism. Which findings are expected?
A. Sudden dyspnea
B. Bradycardia
C. Tachycardia
D. Hemoptysis
E. Feeling of impending doom
F. Slow respirations
Correct answers: A, C, D, E
Rationale (short): PE → acute respiratory distress + tachycardia + hemoptysis + anxiety.
A client with Addison Disease presents to the ED. Which assessment finding is expected?
A. Hypertension
B. Hyperglycemia
C. Hyperkalemia
D. Weight gain
Correct answer: C
Rationale (short): Addison’s → low aldosterone → hyperkalemia.
You are assigned the following clients. Who do you assess first?
A. A client 2 days post–hip replacement reporting mild pain rated 3/10
B. A client with a cast reporting pain unrelieved by opioids and numbness
C. A client in alcohol withdrawal with tremors and anxiety
D. A client on methadone with a respiratory rate of 10/min
A nurse is assessing an infant for hip dysplasia. Which finding is most concerning?
A. Symmetrical thigh folds
B. Negative Barlow test
C. Limited hip abduction
D. Equal leg lengths
Answer: C
Rationale: Limited abduction is a key sign of hip dysplasia.
A client recovering from addiction asks about acamprosate. What is correct?
A. Causes aversion
B. Blocks opioids
C. Reduces cravings
D. Causes sedation
Answer: C
Rationale: Stabilizes neurotransmitters to reduce cravings.
A client starting buprenorphine reports sudden withdrawal symptoms. What is the most likely cause?
A. Medication allergy
B. Dose too high
C. Opioids still in system
D. Dehydration
Answer: C
Rationale: Buprenorphine can cause precipitated withdrawal if opioids are present.
(SATA) A client is receiving Heparin therapy. Which findings require immediate intervention?
A. Platelet count of 95,000/mm³
B. aPTT of 70 seconds
C. Hematuria
D. Black tarry stools
E. INR of 1.2
F. Minor bruising at injection site
Correct answers: A, C, D
Rationale (short): Bleeding + low platelets (HIT) = stop heparin; aPTT 70 is therapeutic.
A client being evaluated for tuberculosis has a positive skin test.
Which finding would confirm active TB disease?
A. No symptoms and normal chest X-ray
B. Positive sputum culture
C. Negative chest X-ray
D. Absence of cough
Correct answer: B
Rationale (short): Active TB requires positive sputum or imaging, not just skin test.
(SATA) A client is diagnosed with SIADH. Which findings are expected?
A. Hyponatremia
B. Decreased urine output
C. Polyuria
D. Confusion
E. Edema
F. Hypernatremia
Correct answers: A, B, D, E
Rationale (short): SIADH = water retention → low Na, low UOP, neuro changes, fluid overload.
A client has pain with passive movement of fingers. What does this indicate?
A. Normal healing
B. Nerve damage
C. Compartment syndrome
D. Muscle strain
Answer: C
Rationale: Hallmark early sign of compartment syndrome.
A nurse notes one leg appears shorter in an infant. What is the priority action?
A. Document as normal variation
B. Reassess in 1 week
C. Perform hip stability assessment
D. Notify provider immediately
Answer: C
Rationale: Leg length discrepancy suggests hip dysplasia → requires further assessment (Barlow/Ortolani).
A client misuses opioids and is prescribed Suboxone instead of buprenorphine alone. Why?
A. Stronger effect
B. Prevents withdrawal
C. Reduces abuse potential
D. Causes sedation
Answer: C
Rationale: Naloxone component discourages misuse.
Which patient should the nurse see first?
A. A client on methadone with a respiratory rate of 10/min who is difficult to arouse
B. A client experiencing alcohol withdrawal with tremors and anxiety
C. A client on disulfiram reporting flushing after accidental alcohol intake
D. A client taking naltrexone who reports mild nausea
Answer: A
Rationale:
Airway and breathing always come first. A client on methadone with respiratory depression and decreased LOC is at risk for respiratory arrest, making this the highest priority.