Imm/Infl/Infec.
A patient undergoing chemotherapy for cancer is at risk for which type of immune dysfunction?
A. Exaggerated immune response
B. Suppressed immune response
C. Autoimmune response
D. Acute inflammatory response
B. Suppressed immune response
Rationale: Chemotherapy weakens the immune system, increasing susceptibility to infections due to suppressed immunity.
Which assessment finding indicates early hypoxia?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Hypotension
B. Restlessness
Rationale: Early signs of hypoxia include restlessness, anxiety, and tachycardia.
Which symptom is most concerning in a patient with peripheral artery disease (PAD)?
A. Leg pain when walking
B. Cool, pale extremities
C. Decreased capillary refill
D. Absent pedal pulses
D. Absent pedal pulses
Rationale: Absent pulses indicate severe ischemia requiring immediate intervention
What is the primary goal of evidence-based practice in nursing?
A. Reduce staff workload
B. Improve patient outcomes
C. Decrease hospital costs
D. Eliminate the need for protocols
B. Improve patient outcomes
Rationale: Evidence-based practice ensures care is supported by research to enhance outcome
Social & Economic Factors Affecting Health
Which of the following is an example of a social determinant of health?
B
Rationale: Social determinants of health include factors like food security, housing, and access to healthcare, which impact overall health.
Which assessment finding would indicate a localized inflammatory response? (Select all that apply)
A. Redness
B. Swelling
C. Fever
D. Warmth
E. Pain
A, B, D, E
Rationale: Local inflammation presents with redness, swelling, warmth, and pain, while fever is a systemic response.
A patient with COPD has a low oxygen saturation level. What is the priority nursing intervention?
A. Increase oxygen to 6 L/min
B. Encourage pursed-lip breathing
C. Withhold bronchodilators
D. Position the patient in a supine position
B. Encourage pursed-lip breathing
Rationale: Pursed-lip breathing improves CO2 elimination and enhances oxygenation in COPD patients.
What is the priority intervention for a patient experiencing chest pain due to myocardial infarction?
A. Administer nitroglycerin
B. Encourage deep breathing
C. Increase activity level
D. Provide high-sodium diet
A. Administer nitroglycerin
Rationale: Nitroglycerin dilates coronary arteries and improves blood flow to the heart.
Which intervention is most effective in preventing healthcare-associated infections?
A. Wearing gloves
B. Hand hygiene
C. Disinfecting surfaces weekly
D. Avoiding patient contact
B. Hand hygiene
Rationale: Hand hygiene is the single most effective method to prevent infections in healthcare.
A nurse is caring for a low-income client who is unable to afford prescribed medications. Which intervention is most appropriate?
C
Rationale: Community resources can help clients afford medications, ensuring adherence and optimal health outcomes.
A patient with pneumonia has an elevated WBC count and fever. Which nursing intervention is most appropriate?
A. Administer prescribed antibiotics
B. Encourage bed rest only
C. Withhold fluids
D. Limit oxygen therapy
A. Administer prescribed antibiotics
Rationale: Bacterial pneumonia requires antibiotics to treat infection and prevent complications.
A nurse is educating a patient on preventing postoperative atelectasis. What should be included? (Select all that apply)
A. Use an incentive spirometer
B. Ambulate frequently
C. Avoid deep breathing
D. Maintain bed rest
E. Perform coughing exercises
A, B, E
Rationale: Deep breathing, coughing, and mobility help prevent atelectasis by promoting lung expansion.
Which lab test is most specific for diagnosing heart failure?
A. Troponin
B. BNP (B-type natriuretic peptide)
C. Lipid panel
D. PT/INR
B. BNP (B-type natriuretic peptide)
Rationale: BNP is elevated in heart failure due to fluid overload and cardiac stress.
Which of the following strategies improves patient safety in healthcare settings? (Select all that apply.)
A, B, D, E
Rationale: Using patient identifiers, hand hygiene, teamwork, and fall precautions enhance safety. Barcode scanning should never be bypassed.
Which population is at greatest risk for experiencing health disparities?
C
Rationale: Lack of insurance and financial strain contribute to health disparities, limiting access to necessary care.
A patient with rheumatoid arthritis is experiencing joint pain and swelling. Which type of inflammation is occurring?
A. Acute
B. Chronic
C. Localized
D. Systemic
B. Chronic
Rationale: Rheumatoid arthritis is a chronic inflammatory disease causing prolonged inflammation and joint damage.
Which diagnostic test is used to measure oxygenation and acid-base balance?
A. Chest X-ray
B. Pulmonary function test
C. Arterial blood gas (ABG)
D. Complete blood count
C. Arterial blood gas (ABG)
Rationale: ABGs assess oxygen, CO2, and pH levels to evaluate gas exchange.
A patient with atrial fibrillation is prescribed warfarin. What should the nurse include in patient education?
A. Eat a consistent amount of leafy greens
B. Take aspirin with warfarin
C. Avoid routine blood testing
D. Stop taking the medication if feeling well
: A. Eat a consistent amount of leafy greens
Rationale: Vitamin K intake affects warfarin effectiveness, so intake should remain stable.
A nurse is caring for a client at risk for falls. Which intervention should the nurse implement?
B
Rationale: A clutter-free environment reduces fall risks. The bed should be in the lowest position, grip socks should be worn, and bed alarms should remain activated.
Which intervention best addresses health disparities in underserved communities?
B
Rationale: Preventative care reduces long-term health disparities by addressing health issues early.
What is the priority nursing intervention for a patient in septic shock?
A. Administer antihistamines
B. Monitor glucose levels
C. Initiate IV fluids and antibiotics
D. Encourage ambulation
C. Initiate IV fluids and antibiotics
Rationale: Early sepsis treatment includes aggressive fluid resuscitation and antibiotics to manage infection and prevent organ failure.
What is the priority intervention for a patient with signs of deep vein thrombosis (DVT)?
A. Massage the affected leg
B. Keep the leg in a dependent position
C. Administer anticoagulants as prescribed
D. Encourage vigorous ambulation
C. Administer anticoagulants as prescribed
Rationale: Anticoagulants prevent clot progression and reduce embolism risk.
Which is an example of a nursing-sensitive quality indicator?
A. Physician prescribing practices
B. Hospital-acquired infections (HAIs)
C. Radiology test results
D. The number of surgeries performed in a hospital
B
Rationale: HAIs are preventable and directly influenced by nursing care, making them a nursing-sensitive quality indicator.
A nurse is educating a group of community members on the impact of health literacy. Which statement by a participant indicates a need for further teaching?
C
Rationale: Patients should actively participate in their healthcare by asking questions and making informed decisions.