Sepsis
A patient develops a urinary tract infection after 4 days of hospitalization. The nurse identifies this as which type of infection?
a) Iatrogenic
b) Health care–associated (HAI)
c) Communicable
d) Colonization
A: b) HAI
Rationale: Infections not present at admission but occurring in a health care setting are HAIs. Iatrogenic refers to infections caused by a procedure, colonization is presence without disease.
Which statement correctly reflects a nursing diagnosis rather than a medical diagnosis?
a) Pneumonia related to bacterial infection
b) Ineffective Airway Clearance related to thick secretions
c) Myocardial Infarction related to coronary artery blockage
d) Diabetes Mellitus related to impaired insulin secretion
Answer: b) Ineffective Airway Clearance related to thick secretions
Rationale: Nursing diagnoses focus on patient responses, not medical conditions.
Which task is appropriate for a nurse to delegate to a nursing assistant (UAP)?
a) Teaching a patient how to self-administer insulin
b) Assessing a patient’s pain after ambulation
c) Taking and recording vital signs for a stable patient
d) Evaluating whether a patient’s wound has healed
Answer: c) Taking and recording vital signs for a stable patient
Rationale: Delegation follows the “5 rights.” UAPs can collect routine, stable data but cannot assess, teach, or evaluate.
The nurse is reviewing a patient’s blood pressure readings: 150/94, 148/92, and 152/96 mmHg. Which interpretations are correct? (Select all that apply.)
A. The patient has hypotension
B. The patient has stage 2 hypertension
C. The readings should be confirmed on another day
D. This is an isolated elevated blood pressure
E. The patient is at increased risk for cardiovascular complications
Answer: B, C, E
Rationale: Repeated high BP indicates hypertension and requires confirmation on separate days. Hypertension increases CV risk.
Q: Which order is incomplete?
a) Acetaminophen 650 mg PO q6h PRN pain
b) Morphine sulfate IV q4h
c) Oxycodone 5 mg PO q6h PRN pain
d) Ibuprofen 400 mg PO q8h PRN fever
A: b) Morphine sulfate IV q4h
Rationale: Missing dose and route frequency details—must include full components.
Q: Which patient is most at risk for infection?
a) 30-year-old post-appendectomy
b) 85-year-old with diabetes and indwelling Foley catheter
c) 45-year-old with hypertension
d) 60-year-old with controlled asthma
A: b) 85-year-old with diabetes and Foley catheter
Rationale: Age, chronic illness, and invasive devices ↑ infection risk.
A nurse notices that a patient is restless, diaphoretic, and reporting difficulty breathing. According to Tanner’s Clinical Judgment Model, which step is the nurse demonstrating?
a) Interpreting
b) Responding
c) Noticing
d) Reflecting
Answer: c) Noticing
Rationale: Recognizing cues and changes in patient condition is Noticing. Interpreting is making sense of the cues, responding is taking action, and reflecting occurs afterward.
The nurse evaluates a patient with the nursing diagnosis of “Ineffective Airway Clearance” and notes the patient’s cough is productive, O2 sat improved, and lung sounds clear. What should the nurse do next?
a) Continue current interventions indefinitely
b) Discontinue the care plan for this diagnosis
c) Document findings but keep the diagnosis
d) Modify the plan with new interventions
Answer: b) Discontinue the care plan for this diagnosis
Rationale: When goals are met, discontinue the plan. If unmet, modify.
A patient suddenly becomes diaphoretic, pale, and reports “I feel faint.” Vital signs: BP 78/40, HR 132 bpm, RR 26. What should the nurse do first?
A. Recheck vital signs in 5 minutes
B. Place patient in supine position with legs elevated
C. Call the healthcare provider
D. Administer antipyretic medication
Answer: B. Place patient in supine position with legs elevated
Rationale: This is symptomatic hypotension with tachycardia. Positioning improves venous return to support perfusion.
Q1: Convert 150 lbs to kilograms.
Q2: How many mL in 3 cups?
A1: 150 ÷ 2.2 = 68.2 kg
A2: 3 × 240 mL = 720 mL
Q: Which assessment finding suggests a systemic infection rather than localized?
a) Redness and swelling at incision site
b) Purulent wound drainage
c) Fever of 101°F and chills
d) Tenderness at surgical site
A: c) Fever of 101°F and chills
Rationale: Systemic infections produce whole-body responses like fever, fatigue, elevated WBC.
Which of the following is a correctly written PES nursing diagnostic statement?
a) Risk for Falls related to unsteady gait as evidenced by patient using a cane
b) Acute Pain related to surgery as evidenced by grimacing and pain 8/10
c) Pneumonia related to lung infection as evidenced by cough and fever
d) Impaired Gas Exchange due to COPD
Answer: b) Acute Pain related to surgery as evidenced by grimacing and pain 8/10
Rationale: Correct PES: Problem + Etiology (nursing-related) + Signs/Symptoms. (a is incorrect—risk dx should not have s/s, c uses medical dx, d vague “due to”).
The nurse finds that a patient who is scheduled for an appendectomy is crying and infers that the patient is crying because of anxiety over the surgery and needed hospital admission. Which action is appropriate for the nurse to take?
Question 3 options:
a) The nurse infers that the patient is frightened of surgery.
b) The nurse ignores it, because such behavior is normal.
c) The nurse infers that the patient does not want to be admitted to a hospital.
d) The nurse validates the inference by asking the patient about the crying behavior.
Answer: D
A nurse is caring for a 70-year-old patient with COPD who requires supplemental oxygen. Which intervention is most important for the nurse to include in the patient’s teaching plan?
a) Encourage the patient to increase oxygen flow rate when short of breath.
b) Remind the patient not to smoke near oxygen equipment.
c) Instruct the patient to lie flat to promote lung expansion.
d) Teach the patient to remove oxygen when ambulating to prevent tripping.
Correct Answer: b) Remind the patient not to smoke near oxygen equipment.
Rationale: Oxygen safety is a priority. Smoking near oxygen is a fire hazard. Patients with COPD should never self-adjust oxygen flow rates, should sit upright to ease breathing, and should keep oxygen on during activity as tolerated.
The provider orders morphine 2 mg IV every 4 hours PRN pain. The vial is labeled 10 mg/mL.
How many milliliters will the nurse administer per dose?
(Round to the nearest hundredth)
a) 0.15 mL
b) 0.2 mL
c) 0.25 mL
d) 0.3 mL
Final answer: 0.20 mL (0.2 mL)
Rationale: divide required mg by vial concentration. Because the value is <1, your rounding rule specifies two decimal places.
Q: The nurse educates a community group about the importance of vaccines. Which statement shows understanding?
a) “Vaccines help cure infections.”
b) “Vaccines strengthen the immune system by preventing certain diseases.”
c) “If I am healthy, I don’t need vaccines.”
d) “Vaccines are only important for children.”
A: b) Vaccines strengthen the immune system…
Rationale: Immunizations prevent, not cure, disease and protect both individuals and communities.
The nurse is caring for four patients. Which should the nurse see first?
a) Patient with acute pain rating 9/10
b) Patient with O2 saturation of 84% on room air
c) Patient requesting discharge teaching
d) Patient with stage II pressure ulcer
Answer: b) Patient with O2 saturation of 84% on room air
Rationale: Apply ABC: Airway and Breathing issues take priority over pain, teaching, or skin integrity.
A nurse is assessing an adult patient’s vital signs: Temp 101.6°F, HR 110 bpm, RR 22, BP 118/76, SpO₂ 95%. Which finding requires the nurse’s immediate follow-up?
A. Blood pressure
B. Heart rate
C. Temperature
D. Oxygen saturation
Answer: C. Temperature
Rationale: A temperature of 101.6°F indicates fever (pyrexia). Although HR is slightly elevated (tachycardia), it is expected with fever. Oxygen saturation is normal.
The nurse is teaching a patient how to perform incentive spirometry after abdominal surgery. Which domain of learning does this teaching primarily address?
a) Cognitive
b) Affective
c) Psychomotor
d) Motivational interviewing
Correct Answer: c) Psychomotor
Rationale: Using incentive spirometry involves hands-on skill performance, which is psychomotor learning. Cognitive learning involves understanding, while affective learning involves values and attitudes.
The provider orders heparin 7,500 units SC every 12 hours. The vial is labeled 10,000 units/mL.
How many milliliters will the nurse administer per dose?
(Round to the nearest hundredth)
a) 0.25 mL
b) 0.50 mL
c) 0.75 mL
d) 1 mL
c) 0.75 mL
Rationale: Heparin is high-risk, so accuracy is critical. The nurse calculates using dose ÷ concentration and rounds to two decimal places when under 1 mL.
Which procedure requires surgical asepsis?
a) Administering an IM injection
b) Emptying a Foley catheter drainage bag
c) Inserting a urinary catheter
d) Providing a bed bath
A: c) Inserting a urinary catheter
Rationale: Surgical asepsis eliminates all microorganisms—required for invasive procedures.
Which statement represents a SMART expected outcome for the nursing diagnosis “Impaired Physical Mobility”?
a) Patient will demonstrate improved strength by discharge.
b) Patient will ambulate 25 feet with a walker within 24 hours.
c) Patient will verbalize understanding of need for exercise.
d) Patient will not fall during hospitalization.
Answer: b) Patient will ambulate 25 feet with a walker within 24 hours.
Rationale: SMART = Specific, Measurable, Attainable, Realistic, Time-limited.
Which of the following patients are at risk for tachycardia? (Select all that apply.)
A. Patient with fever
B. Patient receiving beta-blockers
C. Patient with hypovolemia
D. Patient with anxiety
E. Patient with hypothermia
Answer: A, C, D
Rationale: Fever, low fluid volume, and anxiety increase HR. Beta-blockers lower HR. Hypothermia decreases HR (bradycardia).
A patient is admitted with pneumonia and reports shortness of breath. Assessment reveals oxygen saturation of 85%, productive cough, and crackles in bilateral lung bases. Which priority nursing intervention should the nurse implement first?
a) Administer oxygen as prescribed.
b) Teach pursed-lip breathing techniques.
c) Encourage fluid intake of 2000 mL/day.
d) Schedule chest physiotherapy.
Correct Answer: a) Administer oxygen as prescribed.
Rationale: The patient has hypoxemia (SpO₂ 85%). The priority intervention is to administer oxygen to correct impaired gas exchange. Other interventions (breathing techniques, fluids, chest physiotherapy) support long-term improvement but are not immediate priorities.
A child weighs 66 lb. The provider orders acetaminophen 15 mg/kg PO every 6 hours. The medication is available as 160 mg/5 mL suspension.
How many milliliters will the nurse administer per dose?
(Round to the nearest tenth)
a) 10.8 mL
b) 12.5 mL
c) 14.0 mL
d) 15.6 mL
Final answer: 14.1 mL per dose
Rationale: convert pounds → kg, compute total mg, divide by mg/mL to get mL. Round final result only to one decimal because it is ≥1.