Recognizing Cues
The nurse assesses a client with chronic heart failure. Which finding is most consistent with left-sided heart failure?
A. Jugular venous distention
B. Bilateral crackles and orthopnea
C. Hepatomegaly and ascites
D. Dependent lower-extremity edema
Answer: B
Rationale: Left-sided heart failure causes pulmonary congestion, resulting in crackles, dyspnea, orthopnea, low oxygen saturation, and paroxysmal nocturnal dyspnea. The other findings are more consistent with right-sided systemic congestion.
A client has coffee-ground emesis, melena, heart rate 118/min, blood pressure 88/54 mm Hg, and cool, clammy skin. How should the nurse interpret these findings?
A. The client is developing hypovolemic shock from gastrointestinal blood loss.
B. The client is experiencing a vagal response caused by vomiting.
C. The client has a bowel obstruction with fluid shifting.
D. The client is experiencing a medication-related allergic reaction.
Answer: A
Rationale: Coffee-ground emesis and melena indicate upper GI bleeding. Hypotension, tachycardia, weakness, and cool, clammy skin indicate decreased circulating volume and possible hypovolemic shock.
The nurse receives reports on four clients. Which client should be assessed first?
A. A client with stable angina whose pain resolved after one nitroglycerin tablet
B. A client with heart failure who has 2+ ankle edema at the end of the day
C. A client with crushing chest pain unrelieved by nitroglycerin and new diaphoresis
D. A client with hypertension who reports a mild headache and blood pressure of 148/88 mm Hg
Answer: C
Rationale: Crushing chest pain unrelieved by nitroglycerin with diaphoresis suggests acute myocardial infarction and requires immediate assessment and intervention. The other findings are less immediately life-threatening.
A hospitalized client suddenly develops dyspnea, chest pain, tachycardia, and an oxygen saturation of 84%. Which action should the nurse take first?
A. Encourage the client to cough forcefully.
B. Assist the client to ambulate.
C. Elevate the head of the bed and administer oxygen.
D. Apply a warm compress to the affected leg.
Answer: C
Rationale: The priority is supporting oxygenation and ventilation. The nurse should position the client upright, administer oxygen, remain with the client, and activate the emergency response or notify the provider.
A client with thyroid storm has received prescribed treatment. Which finding best indicates that treatment has been effective?
A. Temperature decreases from 40°C to 37.8°C (104°F to 100°F) and heart rate decreases from 148 to 96/min
B. The client develops increasing agitation and diarrhea.
C. The client’s systolic blood pressure decreases to 78 mm Hg.
D. The client develops new atrial fibrillation.
Answer: A
Rationale: Improvement is indicated by decreasing hyperthermia, tachycardia, agitation, and cardiovascular instability. Hypotension, dysrhythmias, and worsening neurological or gastrointestinal symptoms indicate deterioration.
A postoperative client suddenly reports shortness of breath and sharp chest pain. Which additional findings support the nurse’s suspicion of a pulmonary embolism? Select all that apply.
A. Tachycardia
B. Tachypnea
C. Hemoptysis
D. Bradycardia
E. Unilateral absent bowel sounds
F. Decreased oxygen saturation
Answers: A, B, C, F
Rationale: Pulmonary embolism commonly presents with sudden dyspnea, chest pain, tachypnea, tachycardia, hypoxemia, anxiety, cough, and possible hemoptysis. Bradycardia and altered bowel sounds are not characteristic findings.
A septic client has oozing from IV sites, petechiae, hematuria, a decreasing platelet count, and an elevated D-dimer. Which explanation best accounts for these findings?
A. Platelets and clotting factors are being consumed by widespread clot formation.
B. The bone marrow has abruptly stopped producing red blood cells.
C. Excessive vitamin K production has caused spontaneous bleeding.
D. The kidneys are excreting excessive amounts of clotting factors.
Answer: A
Rationale: DIC causes widespread activation of coagulation. Platelets and clotting factors are consumed in forming microthrombi, leaving inadequate clotting components available to stop bleeding.
A client with kidney failure has a potassium level of 6.8 mEq/L (Elevated). Which finding is the highest priority?
A. Increased bowel sounds
B. Muscle weakness
C. Peaked T waves
D. Tingling of the fingers
Answer: C
Rationale: Peaked T waves indicate cardiac conduction effects of hyperkalemia and place the client at risk for fatal ventricular dysrhythmias. Cardiac instability takes priority over gastrointestinal and neuromuscular findings.
A client with diabetic ketoacidosis has a blood glucose of 624 mg/dL, blood pressure of 84/48 mm Hg, potassium of 5.2 mEq/L, and dry mucous membranes. Which prescribed intervention should the nurse implement first?
A. Begin an infusion of 0.9% sodium chloride.
B. Administer IV regular insulin.
C. Administer IV potassium chloride.
D. Restrict oral and IV fluids.
Answer: A
Rationale: Initial DKA management focuses on restoring circulation with isotonic IV fluid. Insulin follows fluid initiation. Potassium may initially be elevated but can fall rapidly after insulin begins, so it must be monitored rather than immediately replaced in this case.
A client with dysphagia following a stroke is receiving swallowing therapy. Which finding best indicates that the interventions are effective?
A. The client finishes meals quickly.
B. The client has clear lung sounds and no coughing during meals.
C. The client drinks thin liquids without using prescribed techniques.
D. The client pockets food in the affected side of the mouth.
Answer: B
Rationale: Absence of coughing, choking, wet vocal quality, fever, and abnormal lung sounds indicates improved swallowing safety and reduced aspiration risk.
A client who received rapid-acting insulin is diaphoretic, irritable, and having difficulty speaking. Which additional finding would the nurse expect?
A. Fruity breath odor
B. Blood glucose of 58 mg/dL
C. Kussmaul respirations
D. Warm, dry skin
Answer: B
Rationale: Diaphoresis, irritability, weakness, confusion, tachycardia, blurred vision, and difficulty speaking are manifestations of hypoglycemia. Fruity breath, Kussmaul respirations, and dehydration are more consistent with diabetic ketoacidosis.
A client admitted after severe vomiting has the following findings:
Which type of acute kidney injury is most likely?
A. Prerenal
B. Intrarenal
C. Postrenal
D. Chronic renal failure
Answer: A
Rationale: Severe fluid loss and hypotension decrease renal perfusion, producing prerenal AKI. Intrarenal AKI results from direct kidney tissue damage, while postrenal AKI results from urinary obstruction.
A client with a traumatic brain injury has the following changes:
Which hypothesis is the priority?
A. The client is developing neurogenic shock.
B. The client has increased intracranial pressure with possible brain herniation.
C. The client is experiencing opioid withdrawal.
D. The client is developing fluid volume deficit.
Answer: B
Rationale: Widening pulse pressure, bradycardia, irregular respirations, and declining consciousness are components of Cushing’s response and suggest severe increased ICP with possible herniation.
A client arrives 40 minutes after sudden onset of left-sided weakness and slurred speech. Which action should the nurse take first?
A. Give aspirin before diagnostic testing.
B. Determine the exact time the client was last known well.
C. Lower the blood pressure to less than 120/80 mm Hg.
D. Offer water to evaluate swallowing ability.
Answer: B
Rationale: Determining the last-known-well time is essential for identifying eligibility for reperfusion treatment. The client must remain NPO until swallowing is evaluated, and hemorrhage must be excluded before antiplatelet therapy is given.
A client with increased ICP received mannitol. Which finding best indicates a therapeutic response?
A. Urine output decreases to 10 mL/hr.
B. The client becomes more difficult to arouse.
C. Pupils become equal and reactive and the level of consciousness improves.
D. Blood pressure increases while the heart rate decreases.
Answer: C
Rationale: Improved neurological status and pupil response suggest decreased cerebral edema and ICP. Oliguria, worsening consciousness, and Cushing’s response indicate deterioration or ineffective treatment.
A client was struck in the temporal area during a motor vehicle crash. The client briefly lost consciousness, became alert and conversational, and is now increasingly drowsy. Which condition should the nurse suspect?
A. Concussion
B. Epidural hematoma
C. Chronic subdural hematoma
D. Ischemic stroke
Answer: B
Rationale: An epidural hematoma may cause an initial loss of consciousness followed by a lucid interval and then rapid neurological deterioration. It is commonly associated with arterial bleeding following temporal bone trauma.
A client reports bilateral hand pain, swelling of the metacarpophalangeal joints, fatigue, and morning stiffness lasting 2 hours. How should the nurse interpret these findings?
A. They are characteristic of osteoarthritis caused by cartilage degeneration.
B. They suggest systemic inflammatory rheumatoid arthritis.
C. They indicate an acute gout attack.
D. They are expected manifestations of osteoporosis.
Answer: B
Rationale: Rheumatoid arthritis commonly causes symmetrical joint inflammation, prolonged morning stiffness, fatigue, and systemic symptoms. Osteoarthritis typically worsens with activity and causes shorter periods of morning stiffness.
Which client should the nurse assess first?
A. A client with chronic kidney disease who reports generalized itching
B. A client with nephrolithiasis who reports flank pain rated 8/10
C. A client with pyelonephritis who has a temperature of 38.3°C (100.9°F)
D. A client with a urinary catheter who has no urine output for 2 hours and reports suprapubic pain
Answer: D
Rationale: No urinary output with suprapubic pain suggests acute urinary retention or catheter obstruction. The nurse must promptly restore urinary drainage and prevent bladder and renal injury.
A client with increased intracranial pressure is restless and has a declining level of consciousness. Which nursing action is appropriate?
A. Keep the client’s neck in a neutral position and elevate the head of the bed approximately 30 degrees.
B. Place the client in Trendelenburg position to improve cerebral perfusion.
C. Suction the client every hour for 30 seconds.
D. Flex the client’s hips to prevent sliding down in bed.
Answer: A
Rationale: Neutral neck alignment and head elevation promote cerebral venous drainage and may reduce ICP. Trendelenburg positioning, hip flexion, and prolonged or unnecessary suctioning can increase ICP.
A client with prerenal AKI is receiving IV fluids. Which finding best indicates improved renal perfusion?
A. Urine output increases to 40 mL/hr.
B. Serum potassium increases from 5.1 to 6.0 mEq/L.
C. Crackles develop in both lung bases.
D. Body weight increases by 2 kg in 24 hours.
Answer: A
Rationale: Urine output of at least 30 mL/hr generally indicates improved renal perfusion. Rising potassium, crackles, and rapid weight gain suggest worsening renal function or fluid overload.
A client arrives with suspected acute stroke. Which findings are most consistent with a left-hemispheric stroke? Select all that apply.
A. Aphasia
B. Right-sided weakness
C. Impulsive behavior
D. Difficulty with mathematical calculations
E. Left-sided neglect
F. Slow, cautious behavior
Answers: A, B, D, F
Rationale: A left-hemispheric stroke commonly causes aphasia, right-sided motor deficits, impaired analytical or mathematical abilities, and slow, cautious behavior. Right-hemispheric strokes are more associated with impulsivity and left-sided neglect.
A client developed right facial drooping and aphasia 45 minutes ago. The blood glucose is 42 mg/dL. Which conclusion should the nurse make?
A. The client has a confirmed ischemic stroke and should immediately receive alteplase.
B. The neurological changes may be caused by hypoglycemia and glucose should be corrected promptly.
C. The client is experiencing a hemorrhagic stroke caused by cerebral edema.
D. The findings are expected manifestations of a transient ischemic attack and require no emergency treatment.
Answer: B
Rationale: Hypoglycemia can mimic an acute stroke. Blood glucose must be assessed and corrected while the rapid stroke evaluation continues. Alteplase should not be administered until contraindications and stroke mimics are evaluated.
A client with a tibial fracture in a cast reports worsening pain despite opioid administration. The toes are pale, cool, and numb, and pain increases with passive movement. Which complication is the priority?
A. Fat embolism syndrome
B. Compartment syndrome
C. Osteomyelitis
D. Venous insufficiency
Answer: B
Rationale: Severe pain out of proportion to the injury, pain with passive movement, paresthesia, pallor, and coolness suggest compartment syndrome. This is a limb-threatening emergency requiring rapid intervention.
A client has severe flank pain radiating to the groin and microscopic hematuria. Which nursing action is most appropriate?
A. Restrict fluids until the stone passes.
B. Strain all urine and administer prescribed analgesics.
C. Place the client on strict bed rest.
D. Apply ice directly to the painful flank.
Answer: B
Rationale: Urine is strained to collect the stone for analysis. Pain medication and hydration are commonly used to promote comfort and stone passage unless fluid intake is contraindicated.
A client with acute gout receives prescribed anti-inflammatory treatment and dietary education. Which finding demonstrates that treatment has been effective?
A. The affected joint is less red and painful, and the client can tolerate light movement.
B. The client reports increased swelling after eating organ meats.
C. The serum uric acid level continues to increase.
D. The client limits fluid intake to decrease joint swelling.
Answer: A
Rationale: Reduced pain, warmth, redness, swelling, and improved joint movement indicate resolution of the acute inflammatory episode. Organ meats can increase purine intake, and adequate hydration is generally encouraged unless contraindicated.