GI
Prolonged vomiting causes:
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory acidosis
d. Respiratory alkalosis
A. Metabolic alkalosis
Explanation:
• Prolonged vomiting leads to the loss of gastric acid (HCl).
• This loss of hydrogen ions causes the blood to become more alkaline.
• The kidneys attempt to compensate, but the primary disturbance is metabolic alkalosis.
Why not the others?
• Metabolic acidosis ❌ → Caused by conditions like diarrhea (loss of bicarbonate), DKA, or renal failure.
• Respiratory acidosis ❌ → Caused by hypoventilation (e.g., COPD, drug overdose).
• Respiratory alkalosis ❌ → Caused by hyperventilation (e.g., anxiety, high altitude).
Which of the following is a classic finding in a patient with chronic bronchitis?
A. Barrel chest
B. Hypercapnia
C. Cyanosis ("blue bloater")
D. Kussmaul respirations
C. Cyanosis ("blue bloater")
Explanation:
• A. Barrel chest → More characteristic of emphysema ("pink puffer"), due to hyperinflation of the lungs.
• B. Hypercapnia → Can occur in chronic bronchitis, but it is not the classic hallmark finding.
• C. Cyanosis ("blue bloater") → Classic descriptor for chronic bronchitis patients. They often present with hypoxemia and cyanosis due to impaired gas exchange and mucus plugging.
• D. Kussmaul respirations → Seen in diabetic ketoacidosis (DKA), not chronic bronchitis.
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
A. “Do you have trouble affording your medications?”
B. “You are lucky; most people get severe morning headaches.”
C. “Most people with hypertension do not have symptoms.”
D. “You need to take your medicine or you will get kidney failure.”
C. “Most people with hypertension do not have symptoms.”
Rationale:
• Hypertension is often called the “silent killer” because most individuals do not experience noticeable symptoms, even when blood pressure is dangerously high.
• The nurse’s role is to provide education and clarification, helping the client understand that the absence of symptoms does not mean the condition is harmless.
A 58-year-old patient with type 2 diabetes, is admitted with blood glucose of 320 mg/dL and reports frequent urination and thirst. He is prescribed regular insulin subcutaneously before meals. Which nursing action is most important before administering the insulin?
A. Ensure the patient has eaten at least half of their meal
B. Check the patient’s blood pressure
C. Confirm the patient’s blood glucose level
D. Assess the patient’s potassium level
C. Confirm the patient’s blood glucose level
Rationale:
• A. Ensure the patient has eaten at least half of their meal → This is more relevant for rapid-acting insulins (like lispro or aspart), which act quickly and can cause hypoglycemia if food isn’t consumed. Regular insulin has a slower onset (30–60 minutes), so verifying food intake is important but not the priority.
• B. Check the patient’s blood pressure → Not directly related to insulin administration.
• C. Confirm the patient’s blood glucose level → Correct. Insulin dosing is based on the patient’s current blood glucose. Administering insulin without checking could cause inappropriate dosing and hypoglycemia.
• D. Assess the patient’s potassium level → Insulin can lower potassium by driving it into cells, but routine potassium checks are not required before every subcutaneous dose. This is more critical in IV insulin therapy (e.g., for DKA).
The primary action of nitroglycerin in angina is to:
A. Increase heart rate
B. Decrease preload and afterload
C. Increase myocardial oxygen demand
D. Promote clot dissolution
B. Decrease preload and afterload
Explanation:
• Nitroglycerin is a vasodilator that primarily works by relaxing vascular smooth muscle.
• It causes venodilation, which reduces venous return (preload), and arterial dilation, which reduces systemic vascular resistance (afterload).
• By lowering both preload and afterload, nitroglycerin decreases myocardial oxygen demand, which helps relieve angina.
The patient comes into the ED with bloody stool and abdominal pain
What is Ulcerative Colitis?
A nurse is educating a patient with cystic fibrosis about managing their condition. The nurse explains that chest physiotherapy (CPT) is used primarily for what purpose?
A. To prevent respiratory infections.
B. To strengthen the diaphragm and intercostal muscles.
C. To mobilize and clear thick, tenacious secretions.
D. To reduce the inflammation of the airways.
C. To mobilize and clear thick, tenacious secretions → CPT uses percussion, vibration, and postural drainage to loosen mucus so it can be expectorated, improving airway clearance
Which lab value is most specific for myocardial injury?
A. CK‑MB
B. Troponin I
C. Myoglobin
D. BNP
B. Troponin I
Explanation:
• Troponin I (and Troponin T) are the most specific biomarkers for myocardial injury. They are proteins found in cardiac muscle and are released into the bloodstream when myocardial cell damage occurs.
• Troponins rise within 3–6 hours after injury, peak at 12–24 hours, and remain elevated for up to 7–10 days, making them highly useful for both early and late detection.
• A. CK‑MB → More specific than total CK, but still found in skeletal muscle. Less specific than troponins.
• C. Myoglobin → Rises very early (within 1–2 hours), but it is not specific to cardiac muscle (also found in skeletal muscle).
• D. BNP → Reflects ventricular stretch/heart failure, not myocardial necrosis.
Troponin I is the gold standard for diagnosing myocardial infarction due to its high specificity and sensitivity
Which assessment data does the nurse anticipate in a client diagnosed with osteomalacia?
Low estrogen
Lack of Vitamin D
Elevated blood sugar
Decreased bone mass
2. lack of vitamin d
Think of osteomalacia = “soft bones” from vitamin D deficiency, while osteoporosis = “porous bones” from low bone mass (often estrogen-related).
A nurse is assessing a patient’s jugular venous pressure. The nurse should:
A. Position the patient supine with head elevated 30–45 degrees
B. Measure the highest point of pulsation when the patient is standing
C. Expect normal JVP to be visible 7 cm above the sternal angle
D. Assess JVP immediately after the patient has been exercising
A. Position the patient supine with head elevated 30–45 degrees
Explanation
• Jugular venous pressure (JVP) is assessed with the patient lying supine, head of bed elevated 30–45 degrees.
• This position allows venous pulsations to be visible in the neck without being exaggerated or absent.
• The vertical distance from the sternal angle to the highest point of venous pulsation is measured. Normal JVP is ≤3 cm above the sternal angle (not 7 cm).
Which finding is most concerning in a patient with a suspected abdominal aortic aneurysm (AAA)?
A. Mild abdominal discomfort
B. Pulsatile mass in the upper abdomen
C. Sudden onset of severe back pain
D. Slight increase in blood pressure
C. Sudden onset of severe back pain
Explanation
• In a patient with a suspected abdominal aortic aneurysm (AAA), the most concerning finding is sudden, severe back or abdominal pain.
• This symptom suggests impending rupture or actual rupture, which is a life-threatening emergency requiring immediate intervention.
A patient is admitted with suspected pulmonary tuberculosis (TB). What is the priority infection control measure?
A. Placing the patient on droplet precautions.
B. Placing the patient in a private room with negative airflow.
C. Wearing a surgical mask when entering the patient's room.
D. Cohorting the patient with other patients who have TB.
B. Placing the patient in a private room with negative airflow
• TB patients must be placed in an airborne infection isolation room (AIIR) with negative pressure to prevent spread of infectious particles.
For TB, always think “Airborne = Alone + Airflow + N95.”
• Alone → Private room
• Airflow → Negative pressure
• N95 → Respirator for staff
Mr. Lewis, 68 years old, presents with chest pain radiating to his left arm, diaphoresis, and shortness of breath. ECG shows ST elevation in leads II, III, and aVF. Troponin levels are elevated.
What 2 immediate nursing actions should be taken?
Acute Inferior Wall Myocardial Infarction (STEMI)
• ST elevation in leads II, III, and aVF indicates infarction in the inferior wall of the left ventricle, typically due to occlusion of the right coronary artery (RCA).
• Elevated troponin confirms myocardial injury.
Two Immediate Nursing Actions
1. Administer Oxygen and Nitroglycerin (per protocol and orders)
• Oxygen helps improve myocardial oxygen supply.
• Nitroglycerin reduces preload/afterload, decreasing myocardial oxygen demand and relieving chest pain.
2. Prepare and Administer Aspirin (chewable) and Notify Provider/Activate Cardiac Cath Team
• Aspirin reduces platelet aggregation, limiting clot progression.
• Rapid communication ensures timely reperfusion therapy (PCI or thrombolytics if PCI unavailable).
A 17-year-old with type 1 diabetes arrives in the ER with abdominal pain, fruity breath odor, and rapid breathing. Blood glucose is 480 mg/dL, and arterial blood gas shows pH 7.25. Which is the nurse’s priority intervention?
A. Administer IV potassium
B. Start IV insulin infusion
C. Give oral hypoglycemic medication
D. Encourage oral fluids
This scenario describes diabetic ketoacidosis (DKA) in a patient with type 1 diabetes:
• Abdominal pain, fruity breath odor, rapid breathing (Kussmaul respirations)
• Blood glucose 480 mg/dL
• Metabolic acidosis (pH 7.25)
Option Analysis:
• A. Administer IV potassium → Potassium replacement is important because insulin drives potassium into cells, but potassium is replaced after insulin therapy is started and once levels are checked. It is not the first priority.
• B. Start IV insulin infusion
• Priority intervention. Insulin is needed to stop ketone production, lower blood glucose, and correct acidosis. This is the immediate life-saving treatment.
Teaching tip:
In DKA, think priorities:
• Fluids (IV fluids first to correct dehydration),
• Insulin (IV infusion to stop ketone production),
• K+ (potassium monitoring/replacement once insulin is started).
A nurse is providing education to a patient with a history of recurrent kidney stones. Which preventative measures should the nurse include in the teaching? (Select all that apply)
A. Increase daily fluid intake.
B. Limit consumption of high-oxalate foods.
C. Decrease calcium intake.
D. Maintain a low-sodium diet.
E. Avoid excessive caffeine intake.
Correct Answers:
A. Increase daily fluid intake
B. Limit consumption of high-oxalate foods
D. Maintain a low-sodium diet
E. Avoid excessive caffeine intake
Signs of appendicitis: (Select all that apply)
a. RLQ pain
b. Fever
c. Rebound tenderness
d. Nausea
e. Rovsing's sign
ABCDE
A nurse is assessing a patient experiencing an acute asthma attack. The patient is no longer wheezing and appears lethargic. What is the nurse's priority action?
A. Document the absence of wheezing as a positive sign.
B. Administer a sedative to reduce the patient's anxiety.
C. Recognize this as a "silent chest" and prepare for intubation.
D. Encourage the patient to cough to clear the airway.
C. Recognize this as a "silent chest" and prepare for intubation
• A “silent chest” means air is barely moving, signaling impending respiratory failure. Immediate preparation for advanced airway management and mechanical ventilation is critical.
A 72 years old male patient has a history of hypertension and presents with fatigue, ankle swelling, and orthopnea. BNP levels are elevated.
What condition is suspected?
Congestive Heart Failure (CHF)
Explanation
• BNP (B-type natriuretic peptide) is released by the ventricles in response to increased stretch and pressure.
• Elevated BNP levels are highly suggestive of heart failure, especially when paired with clinical signs.
• Key symptoms in this case:
• Fatigue → reduced cardiac output.
• Ankle swelling (peripheral edema) → fluid retention due to right-sided involvement.
• Orthopnea → difficulty breathing when lying flat, classic for left-sided heart failure.
• Left = Lungs → pulmonary symptoms (dyspnea, crackles, pink sputum).
• Right = Rest of body → systemic symptoms (edema, ascites, JVD).
A nurse is reviewing lab results for a patient with Cushing's syndrome. What is a key expected finding?
A. Hyperglycemia
B. Hypoglycemia
C. Hyponatremia
D. Hypotension
Explanation:
• Cushing’s syndrome involves excess cortisol, which increases gluconeogenesis and insulin resistance, leading to elevated blood glucose. Hyperglycemia → Correct. Cushing’s syndrome involves excess cortisol, which ince.
• B. Hypoglycemia → Incorrect. Cortisol raises blood sugar, so hypoglycemia is not expected.
• C. Hyponatremia → Incorrect. Patients often have hypernatremia due to sodium and water retention from mineralocorticoid effects.
• D. Hypotension → Incorrect. Cortisol increases vascular sensitivity to catecholamines, so hypertension is more common.
A patient suddenly collapses in the hallway. The monitor shows chaotic electrical activity with no identifiable QRS complexes. The patient is unresponsive and pulseless. What is the nurse’s first action?
A. Administer amiodarone
B. Begin chest compressions
C. Check blood pressure
D. Prepare for synchronized cardioversion
B. Begin chest compressions
Explanation
• The monitor shows chaotic electrical activity with no identifiable QRS complexes, which describes ventricular fibrillation (VF).
• The patient is unresponsive and pulseless → this is a cardiac arrest.
• According to the ACLS algorithm, the first action is to initiate high-quality CPR (chest compressions) immediately.
• Defibrillation follows as soon as the defibrillator is available, but compressions must start right away to maintain minimal circulation until a shock can be delivered.
Complications of Crohn's disease: (Select all that apply.)
Fistulas
Abscesses
Bowel obstruction
Toxic megacolon
Perforation
Correct Answers:
Fistulas, Abscesses, Bowel obstruction, Perforation
Toxic megacolon is more commonly associated with ulcerative colitis, not Crohn’s.
What is concerning when a patient does the teach back method when learning about how to maintain a tracheostomy?
-I should wear a covering over the stoma
-I can go swimming as long as I keep the stoma under a water tight covering
-I should get a medical alert bracelet
-I need to make sure all my smoke detectors are working and get a carbon monoxide detector
What is the phrase, "I can go swimming as long as I keep the stoma under a water tight covering."
A patient presents with the following EKG strip and is found to be pulseless. Wide QRS complexes are noted. What is the nurse’s immediate priority intervention?
A. Defibrillation
B. Administer epinephrine IV
C. Begin synchronized cardioversion
D. Administer amiodarone IV
A. Defibrillation
Explanation
• A patient who is pulseless with wide QRS complexes on the EKG strip is most likely in pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF).
• The priority intervention in both rhythms is immediate defibrillation (unsynchronized shock) to restore a perfusing rhythm.
• This is part of the ACLS algorithm:
1. Check pulse → if pulseless, start CPR.
2. Defibrillate immediately if VT/VF is present.
3. Resume CPR for 2 minutes, then reassess rhythm.
4. Administer epinephrine and antiarrhythmics (amiodarone) later in the sequence, but defibrillation comes first
A nurse is assessing a patient for a suspected thyroid storm. Which findings are consistent with this condition? (Select all that apply)
A. Hyperthermia
B. Tachycardia
C. Hypotension
D. Restlessness and agitation
E. Bradycardia
Correct Answers:
A. Hyperthermia
B. Tachycardia
D. Restlessness and agitation
Teaching tip:
Think of thyroid storm as “everything speeds up and overheats”:
• Heat → Hyperthermia
• Heart → Tachycardia
• Head → Agitation, delirium
Which dietary instructions are appropriate for a patient with chronic kidney disease (CKD) who is not yet on dialysis? (Select all that apply)
A. Restrict sodium intake.
B. Restrict protein intake.
C. Increase potassium intake.
D. Restrict potassium intake.
E. Increase fluid intake.
A. Restrict sodium intake
B. Restrict protein intake
D. Restrict potassium intake
A. Restrict sodium intake.
• Helps control blood pressure and reduce fluid retention.
• B. Restrict protein intake.
• Before dialysis, protein restriction slows progression of kidney damage by reducing nitrogenous waste buildup. (Once on dialysis, protein needs increase.)
• C. Increase potassium intake.
• Dangerous. CKD patients often develop hyperkalemia because the kidneys cannot excrete potassium effectively.
• Fluids are usually restricted, not increased, to prevent overload since the kidneys cannot excrete excess fluid