"can you believe we graduate in a year"
Patient Name:Jaden Flood
Age: 68 years
Medical History: Hypertension, Hyperlipidemia, Type 2 Diabetes
Chief Complaint: Shortness of breath and chest discomfort
Background:
Jaden presents to the emergency department with increasing shortness of breath over the past 3 days, especially when walking short distances. He also reports mild chest discomfort described as pressure, worsened with exertion and relieved with rest. She denies any recent fever or cough. On examination, he appears fatigued, with cool extremities and mild pedal edema.
Vital Signs:
Temperature: 98.6°F (37°C)
Heart Rate: 108 bpm
Respiratory Rate: 24 breaths/min
Blood Pressure: 148/88 mmHg
O2 Saturation: 90% on room air
Labs and Diagnostics:
BNP: 610 pg/mL (↑)
Troponin I: Normal
EKG: Sinus tachycardia, no ST elevation
Chest X-ray: Cardiomegaly and mild pulmonary congestion
Clinical Impression:
Jaden is suspected of having congestive heart failure (CHF) exacerbation with impaired gas exchange due to pulmonary congestion.
Which nursing intervention is most appropriate to improve oxygenation in this patient with suspected congestive heart failure?
A. Place the patient in a supine position to improve circulation
B. Encourage fluid intake to promote kidney perfusion
C. Elevate the head of the bed and apply supplemental oxygen
D. Administer a high-carbohydrate diet to increase energy
Option C is correct because elevating the head of the bed (semi-Fowler’s or Fowler’s position) reduces venous return and improves diaphragmatic expansion, aiding oxygenation. Supplemental oxygen improves SpO₂ in hypoxic patients.
Option A is incorrect; placing the patient supine can worsen breathing in CHF due to fluid overload and pulmonary congestion.
Option B is inappropriate during fluid overload; CHF patients often require fluid restriction, not encouragement.
Option D has no direct benefit on oxygenation and may increase metabolic workload.
1. What is a key characteristic of critical thinking in nursing?
**Correct Answer:** C
**Rationale:** Critical thinking involves open-mindedness, continual inquiry, and analyzing each unique patient situation.
11. What is third-spacing?
Answer: C
Rationale: Third-spacing involves fluid being trapped in non-functional spaces such as tissues, reducing circulating volume.
8. What fluid movement process is driven by hydrostatic pressure in capillaries?
Answer: C
Rationale: Filtration is driven by hydrostatic pressure and occurs in the capillaries and kidneys.
7. Select all that apply: What are symptoms of hypokalemia?
Answer: A, C, D
Rationale: Hypokalemia presents with cardiac issues, lethargy, urinary retention, and muscle weakness (not twitching).
Q5. Which intervention is used as a last resort for managing severe constipation?
Answer: C. Digital stool removal
Rationale: Digital removal is the last resort if enemas and other methods fail.
Which are common symptoms of hypoxia?
Answers: A. Restlessness, C. Cyanosis
Rationale: Symptoms of hypoxia include restlessness and cyanosis; increased LOC is not typical—hypoxia often decreases LOC.
What is the primary goal of ventilation?
A. To expel nitrogen from the lungs
B. To balance body temperature
C. To maintain PaCO2 between 35-45mmHg and PaO2 between 95-100mmHg
D. To increase blood pH
Answer: C. To maintain PaCO2 between 35-45mmHg and PaO2 between 95-100mmHg
Rationale: Proper ventilation ensures normal blood gas levels, vital for tissue oxygenation and acid-base balance.
Q3. Which organisms can cause infection?
Answer: All of the above
Rationale: All listed organisms—bacteria, viruses, fungi, and protozoa—can cause infections.
5. Which hormone is most responsible for regulating serum calcium levels?
Answer: C
Rationale: Parathyroid hormone (PTH) is crucial in maintaining calcium balance in the body.
Q1. Which of the following best defines an infection?
Answer: A process where a pathogen invades tissue and grows within the host
Rationale: Infection results when a pathogen invades tissue and begins growing within the host, unlike colonization which lacks tissue invasion.
10. Which of the following describes the difference between physical dependence and addiction?
**Correct Answer:** C
**Rationale:** Addiction includes behavioral signs such as hoarding or doctor shopping, whereas physical dependence is physiological.
4. Which of the following sensory disorders is characterized by sudden episodes of vertigo and tinnitus?
**Correct Answer:** B
**Rationale:** Ménière’s disease affects the inner ear and leads to symptoms such as vertigo, tinnitus, and fluctuating hearing loss.
Which node is responsible for initiating the electrical impulse in the heart?
Answer: B. SA node
Rationale: The SA node, also known as the sinoatrial node, acts as the natural pacemaker of the heart, initiating electrical impulses.
A nurse is assessing a client who is suspected to have hypovolemia. Which of the following findings would the nurse expect?
A. Bounding pulse
B. Neck vein distention
C. Dry mucous membranes
D. Increased blood pressure
Correct Answer: C. Dry mucous membranes
Rationale:
Dry mucous membranes are a common sign of fluid volume deficit (hypovolemia) due to decreased circulating fluid.
A & B are signs of fluid overload (hypervolemia).
D is incorrect because hypovolemia typically causes hypotension, not hypertension.
A nurse is teaching a community safety class. Which of the following scenarios represents the greatest immediate risk to oxygenation and requires emergency action?
A. A 20-year-old child accidentally locked inside a parked car on a warm day with child safety locks engaged
B. A 5-year-old playing in the backyard with a minor scrape on the knee
C. A toddler crying in a high chair while waiting for a snack
D. A child refusing to wear a helmet while riding a tricycle in the driveway
✅ Correct Answer: A. A 20-year-old child accidentally locked inside a parked car on a warm day with child safety locks engaged
📚 Rationale:
3. A patient with obstructive sleep apnea might benefit most from which intervention?
**Correct Answer:** A
**Rationale:** CPAP provides continuous airway pressure, helping prevent airway collapse in obstructive sleep apnea.
13. What solution is used to rapidly expand circulatory volume?
Answer: C
Rationale: D10W is a hypertonic solution that helps rapidly increase blood volume.
4. Which reasoning approach moves from the general to the specific?
**Correct Answer:** B
**Rationale:** Deductive reasoning moves from general principles to specific situations.
6. Which condition results in cells swelling due to fluid movement?
Answer: B
Rationale: Hypotonic solutions cause water to enter cells, making them swell.
Q8. Select all that apply: What are treatments for infection?
Answer: ['Antibiotics for bacteria', 'Antifungals for fungi', 'Antimicrobials for protozoans', 'Antipyretics for symptom relief']
Rationale: These treatments are specific to pathogen types. Antihistamines are not used to treat bacterial infections.
🩺 Case Study: Fluids and Electrolytes
Patient Name: Brianna
Age: 76 years
Medical History: Chronic kidney disease (CKD) Stage 3, Hypertension, Heart failure
Chief Complaint: Confusion and muscle weakness
Background:
Brianna was brought to the emergency department by her daughter due to increased confusion, muscle cramps, and fatigue over the last 2 days. Her daughter reports that he has been drinking large amounts of water because she "felt dehydrated." She is currently on a low-sodium diet and takes furosemide (Lasix) for his heart failure.
Vital Signs:
Blood Pressure: 102/68 mmHg
Heart Rate: 98 bpm
Respiratory Rate: 20 bpm
Temperature: 98.2°F (36.8°C)
Oxygen Saturation: 96% on room air
Laboratory Results:
Sodium (Na⁺): 125 mEq/L (↓)
Potassium (K⁺): 4.2 mEq/L (normal)
BUN: 22 mg/dL
Creatinine: 1.6 mg/dL
Clinical Impression:
The patient is experiencing hyponatremia, likely due to excessive free water intake and diuretic use in the setting of renal insufficiency.
📘 NCLEX-Style Question
Which nursing intervention is most appropriate for managing this patient's electrolyte imbalance?
A. Encourage the patient to drink more water to maintain hydration
B. Administer a hypotonic IV solution such as 0.45% NS
C. Place the patient on seizure precautions and monitor sodium levels closely
D. Restrict sodium intake to prevent fluid retention
✅ Correct Answer: C. Place the patient on seizure precautions and monitor sodium levels closely
📚 Rationale:
Option C is correct because severe hyponatremia (< 125 mEq/L) can lead to neurological symptoms such as confusion and seizures. Safety and close monitoring are priorities.
Option A is incorrect because excess water intake can worsen hyponatremia by diluting sodium levels further.
Option B is incorrect; hypotonic solutions can worsen hyponatremia. Hypertonic solutions (e.g., 3% NS) may be considered in severe cases under close supervision.
Option D is inappropriate; the patient is already hyponatremic. Further sodium restriction could exacerbate the electrolyte imbalance.
Which conditions can affect chest wall movement?
Answers: A. Pregnancy, B. Obesity, D. Trauma
Rationale: Pregnancy, obesity, and trauma physically restrict chest wall movement, impairing effective respiration.
9. A positive Chvostek's sign is indicative of which electrolyte imbalance?
A. Hypercalcemia
B. Hypocalcemia
C. Hyperkalemia
D. Hyponatremia
Answer: B
Rationale: Chvostek's sign indicates neuromuscular irritability seen in hypocalcemia.
12. What electrolyte imbalance is most associated with chronic alcoholism?
Answer: B
Rationale: Chronic alcoholism commonly leads to low magnesium levels (hypomagnesemia).
Q5. Healthcare-associated infections (HAIs) are commonly caused by which of the following?
Answer: Antibiotic administration
Rationale: HAIs often result from invasive procedures, antibiotic administration, MDROs, and breaks in infection control.
3. What is a common cause of hyperkalemia?
Answer: C
Rationale: Renal disease reduces potassium excretion, leading to elevated serum K+.
14. Which electrolytes are commonly monitored for cardiac dysrhythmias?
Answer: A, B, C
Rationale: Imbalances in Ca, K, and Mg can all affect heart rhythm; sodium is more associated with fluid balance.
Which of the following are considered hypertonic solutions?
A. 3% sodium chloride
B. D5W (5% dextrose in water)
C. D5NS (5% dextrose in 0.9% normal saline)
D. 0.45% sodium chloride
E. D10W (10% dextrose in water)
Correct Answers: A, C, E
Rationale:
A: 3% sodium chloride is a hypertonic solution used to treat severe hyponatremia.
C: D5NS is hypertonic because dextrose is added to isotonic saline.
E: D10W is hypertonic and provides calories as well as free water.
B: D5W is isotonic in the bag but becomes hypotonic in the body as dextrose is metabolized.
D: 0.45% NS is a hypotonic solution.
Q2. Which of the following are potential complications of chronic urinary catheterization? (Select all that apply)
Answer: A, B, D
Rationale: Chronic catheter use can lead to infection (urosepsis), renal disease, and bladder stones. Retention is typically managed, not caused. Hypotension is unrelated.
A nurse is caring for a patient with sensorineural pain due to peripheral neuropathy. Which of the following descriptions best characterizes this type of pain?
A. Aching and cramping in the muscles after activity
B. Sharp, burning pain along a nerve pathway
C. Dull, localized joint pain worsened with movement
D. Pain relieved by repositioning and rest
Correct Answer: B. Sharp, burning pain along a nerve pathway
Rationale:
Sensorineural pain is often described as sharp, burning, tingling, or shooting, and it follows the path of affected nerves—common in conditions like diabetic neuropathy or sciatica.
A describes muscular pain.
C refers to somatic pain from joints or musculoskeletal issues.
D aligns more with mechanical pain like pressure or ischemic pain, not sensorineural.
15. Which type of fluid solution includes blood products like albumin and packed RBCs?
A. Hypotonic solution
B. Crystalloid solution
C. Colloid solution
D. Isotonic solution
Answer: C
Rationale: Colloid solutions consist of large molecules like blood products that do not dissolve completely.
Q10. Passive immunity involves:
Answer: Receiving antibodies from another source
Rationale: Passive immunity is gained through transfer of antibodies, such as through placenta or immunoglobulin administration.
1. Which of the following best describes the function of the circadian rhythm in relation to sleep?
**Correct Answer:** B
**Rationale:** The circadian rhythm is regulated by the hypothalamus and aligns the sleep-wake cycle with the 24-hour day-night cycle.
🩺 Case Study: GI/GU
Patient Name:Cloey Clark
Age: 52 years
Medical History: Type 2 Diabetes, Hypertension
Chief Complaint: Lower abdominal pain and urinary urgency
Background:Cloey presents to the clinic complaining of burning sensation while urinating, frequent urge to void, and lower abdominal discomfort for the past 2 days. She also reports that her urine has a strong odor and appears cloudy. She denies flank pain or fever. She has a history of recurrent urinary tract infections (UTIs).
Vital Signs:
Temperature: 99.4°F (37.4°C)
Blood Pressure: 136/84 mmHg
Heart Rate: 88 bpm
Respiratory Rate: 16 bpm
O2 Saturation: 98% on room air
Urinalysis Results:
Positive for nitrites
Positive leukocyte esterase
Bacteria present
WBCs: Increased
Clinical Impression:
Cloey is diagnosed with an uncomplicated urinary tract infection. The provider has prescribed oral antibiotics and increased fluid intake.
📘 NCLEX-Style Question
Which of the following instructions should the nurse include when teaching Maria how to prevent future urinary tract infections?
A. "Take baths instead of showers to keep the area clean."
B. "Wipe from back to front after using the restroom."
C. "Void immediately after sexual intercourse."
D. "Limit fluid intake to avoid frequent urination."
✅ Correct Answer: C. "Void immediately after sexual intercourse."
📚 Rationale:
Option C is correct because voiding after intercourse helps flush out bacteria that may have entered the urethra, reducing the risk of infection.
Option A is incorrect; showers are preferred over baths for UTI prevention, as baths can introduce bacteria to the urinary tract.
Option B is incorrect; wiping from front to back is the correct method to prevent fecal bacteria from entering the urethra.
Option D is incorrect; increasing fluid intake is encouraged to help flush bacteria from the urinary system—not limiting it.
Answer: To localize and eliminate the injurious agent
Rationale: Inflammation is the body's localized response to injury or infection to contain and remove the threat.
1. Which of the following is a characteristic of intracellular fluid (ICF)?
Answer: D
Rationale: ICF is high in potassium and found within cells, especially in skeletal muscle mass.
2. Which of the following are components of the nursing process? (Select all that apply)
**Correct Answer:** A, B, D, E
**Rationale:** The nursing process includes Assessment, Diagnosis, Planning, Implementation, and Evaluation. Reflection is a tool used in developing critical thinking but not a step in the process.
Which condition is characterized by inadequate alveolar ventilation?
Answer: C. Hypoventilation
Rationale: Hypoventilation refers to insufficient air entering the alveoli, which can lead to elevated CO2 and decreased O2.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which nursing intervention is most appropriate to promote effective gas exchange?
A. Encourage the client to lie flat during rest periods
B. Administer high-flow oxygen via non-rebreather mask
C. Instruct the client in pursed-lip breathing techniques
D. Limit fluid intake to prevent pulmonary congestion
Correct Answer: C. Instruct the client in pursed-lip breathing techniques
Rationale:
C: Pursed-lip breathing helps improve gas exchange by promoting airway opening and reducing air trapping, a key issue in COPD.
A: Lying flat can impair lung expansion and worsen dyspnea in COPD patients.
B: High-flow oxygen can suppress the hypoxic respiratory drive in some COPD patients—oxygen should be titrated carefully.
D: Adequate hydration helps loosen mucus secretions; limiting fluids is not generally recommended unless otherwise indicated (e.g., heart failure).
Which of the following are true regarding second intention wound healing? (Select all that apply)
A. Edges are approximated
B. There is increased scarring
C. The risk of infection is greater
D. Healing time is longer
E. It is typically used for surgical incisions
Answer: B, C, D
Rationale: Secondary intention involves longer healing, greater risk of infection, and more scarring. Edges are not approximated.
5. Which medication would be most appropriate for managing mild pain due to inflammation?
**Correct Answer:** C
**Rationale:** Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) effective for mild to moderate inflammatory pain.
10. Select all that apply: What are symptoms of hypercalcemia?
Answer: A, B, D
Rationale: Hypercalcemia can cause muscle weakness, bone pain, and kidney stones. Tetany is a symptom of hypocalcemia.
Q1. Which layer of the skin is responsible for producing melanin?
Answer: C. Epidermis
Rationale: Melanin is produced in the epidermis, giving the skin its color.
5. Select all the ways a nurse can develop critical thinking skills:
**Correct Answer:** A, C, D
**Rationale:** Reflective journaling, collaboration with colleagues, and concept mapping are effective ways to enhance critical thinking.
Which factors can affect oxygenation?
Answers: A. Age, B. Stress, C. Medications
Rationale: Age, stress, and medications can influence oxygenation, while sun exposure does not directly affect cardiopulmonary function.
Q10. Which are appropriate nursing interventions for maintaining healthy elimination in patients? (Select all that apply)
Answer: A, C, D
Rationale: Exercise, bowel training, and cautious use of medications are important. Low fluid intake and ignoring incontinence are inappropriate.
A nurse is caring for a postoperative patient who suddenly becomes restless and anxious. Which of the following should the nurse suspect?
A. Hypoglycemia
B. Hyperkalemia
C. Hypoxia
D. Hypervolemia
Correct Answer: C. Hypoxia
Rationale:
Restlessness and anxiety are early signs of hypoxia, as the brain is very sensitive to changes in oxygen levels.
A (Hypoglycemia) can cause similar symptoms but usually also includes shakiness, diaphoresis, and confusion.
B (Hyperkalemia) more commonly affects cardiac rhythm and causes muscle weakness.
D (Hypervolemia) may cause signs like crackles, edema, and hypertension—not acute anxiety or restlessness.
Which of the following can decrease lung compliance?
A. Pulmonary fibrosis
B. Emphysema
C. Increased surfactant
D. Decreased alveolar surface tension
Answers: A. Pulmonary fibrosis, B. Emphysema
Rationale: Both pulmonary fibrosis and emphysema can impair the lung's ability to expand, reducing compliance.
Q9. Which practice is essential to prevent infection transmission in healthcare?
Answer: Hand hygiene
Rationale: Hand hygiene is one of the most effective practices in preventing the spread of infections in healthcare settings.
Q4. Which of the following are functions of the skin? (Select all that apply)
Answer: A, C, D, E
Rationale: Skin helps in sensing, regulating temperature, protecting organs, and assisting in vitamin D activation. It does not directly regulate blood pressure.
6. Select all that apply: Which factors can influence a patient's sensory function?
**Correct Answer:** A, B, C, E
**Rationale:** Sensory function is influenced by age, presence of meaningful stimuli, the environment, and social interaction.
7. What is the primary goal of using a pain assessment tool?
**Correct Answer:** C
**Rationale:** Pain is subjective, and assessment tools help understand the patient's personal experience with pain.
Q6. Which of the following is NOT a factor influencing infection prevention and control?
Answer: Weather
Rationale: Age, stress, and nutritional status are personal health factors. Weather, while indirectly relevant, is not a primary factor.
Which of the following statements about the flow of blood through the heart are true?
A. The pulmonary vein carries oxygenated blood to the heart.
B. Blood in the right atrium is oxygen-rich.
C. The left ventricle pumps blood into the systemic circulation.
D. The tricuspid valve lies between the left atrium and left ventricle.
E. Blood moves from the lungs to the heart via the pulmonary vein.
Correct Answers: A, C, E
Rationale:
A: Correct – the pulmonary vein is one of the few veins that carries oxygenated blood, bringing it from the lungs to the left atrium.
C: Correct – the left ventricle pumps oxygen-rich blood into the aorta and systemic circulation.
E: Correct – pulmonary veins return blood from the lungs to the heart.
B: Incorrect – the right atrium contains deoxygenated blood.
D: Incorrect – the tricuspid valve is between the right atrium and right ventricle; the mitral (bicuspid) valve is between the left atrium and left ventricle.
What is the intrinsic rate of the SA node?
Answer: B. 60-100 bpm
Rationale: The SA node generates impulses at a normal rate of 60-100 beats per minute under resting conditions.
🩺 Case Study: Oxygenation Emergency — Trapped in Vehicle
Patient Name:Cloey Clark
Age: 20 years
Medical History: Asthma (mild intermittent)
Chief Complaint: Shortness of breath, dizziness
Scenario:
Cloey, a 20-year-old college student, accidentally becomes trapped inside a parked car after getting into the back seat of a friend’s vehicle to retrieve a backpack. The child safety locks engaged automatically, and the car doors could not be opened from the inside. Her phone battery had died, and the car was parked outside in direct sunlight on a hot summer afternoon (90°F/32°C).
Cloey was found 45 minutes later by a passerby, who noticed signs of distress through the window and called 911. EMS arrived and broke a window to remove Cloey from the vehicle. Upon removal, Cloey was confused, sweating profusely, breathing rapidly, and had a rapid heart rate.
Initial Assessment (Post-Rescue):
Temperature: 102.2°F (39°C)
Heart Rate: 128 bpm
Respiratory Rate: 30 breaths/min
Blood Pressure: 98/58 mmHg
O2 Saturation: 89% on room air
Skin: Flushed, hot, diaphoretic
Mental status: Disoriented, lethargic
Intervention:
Cloey received high-flow oxygen via non-rebreather mask, was cooled with ice packs and IV fluids, and transported to the ED for further care. He was diagnosed with heat exhaustion complicated by hypoxia due to poor ventilation and high temperature exposure.
📘 NCLEX-Style Question
What is the nurse's priority intervention upon Jordan’s arrival to the emergency department?
A. Administer an antipyretic to reduce his fever
B. Obtain a complete medical history and allergy list
C. Apply a cooling blanket and reassess temperature in 1 hour
D. Maintain high-flow oxygen therapy and monitor airway status
✅ Correct Answer: D. Maintain high-flow oxygen therapy and monitor airway status
📚 Rationale:
Option D is correct. The priority is to support oxygenation and airway management, especially since the patient has low oxygen saturation, tachypnea, and signs of heat-induced hypoxia. Airway compromise due to heat exhaustion or altered mental status could become critical.
Option A is secondary. Antipyretics like acetaminophen are not typically effective for hyperthermia due to environmental exposure.
Option B is important, but not a priority in a time-sensitive, life-threatening emergency.
Option C is inappropriate due to delayed reassessment; the patient requires continuous monitoring and immediate cooling interventions, not hourly checks.
2. Select all that apply: Which of the following are examples of isotonic solutions?
Answer: A, B, C
Rationale: D10W is a hypertonic solution; the others are isotonic and help maintain fluid balance.
4. What does the P wave in a normal ECG represent?
Answer: B
Rationale: The P wave indicates atrial contraction as part of the normal cardiac cycle.
Q9. Which of the following is a risk factor for pressure ulcers?
Answer: C. Bony prominence
Rationale: Pressure ulcers commonly develop over bony prominences.
Q6. A patient with an ileostomy is at greatest risk for:
Answer: A. Skin breakdown around the stoma
Rationale: Stoma care is critical in ileostomy patients to prevent skin complications.
Q7. What is colonization?
Answer: Presence of microorganisms without tissue damage
Rationale: Colonization refers to the presence and growth of microorganisms without tissue invasion or damage.
Which of the following are expected assessment findings in a patient with hypokalemia?
A. Muscle weakness
B. Abdominal cramping
C. Flat or inverted T waves
D. Irregular heartbeat
E. Hyperactive reflexes
Correct Answers: A, C, D
Rationale:
A: Correct – muscle weakness is a classic symptom of hypokalemia.
C: Correct – flat or inverted T waves are an ECG sign of hypokalemia.
D: Correct – arrhythmias are a serious risk in hypokalemia.
B: Incorrect – abdominal cramping is more common in hyperkalemia.
E: Incorrect – hypokalemia often leads to hyporeflexia, not hyperreflexia.
A patient is admitted with dehydration. The provider orders 0.9% normal saline (NS) IV. What is the primary reason for administering this solution?
A. To provide free water and promote renal excretion
B. To replace electrolytes rapidly
C. To expand the intravascular volume without altering serum osmolality
D. To reduce cellular edema by shifting fluid into the intravascular space
Correct Answer: C
Rationale: 0.9% normal saline is an isotonic solution, which means it has the same osmolality as blood plasma. It is used to expand intravascular volume without causing fluid shifts into or out of cells.
(A) Describes hypotonic solutions like 0.45% NS.
(B) While NS contains sodium and chloride, it's not considered an electrolyte replacement solution like LR.
(D) Refers to hypertonic solutions, not isotonic.
🩺 Case Study: Oxygenation/Cardiac
Patient Name: James Thompson
Age: 68 years
Medical History: Hypertension, Hyperlipidemia, Type 2 Diabetes
Chief Complaint: Shortness of breath and chest discomfort
Background:
James presents to the emergency department with increasing shortness of breath over the past 3 days, especially when walking short distances. He also reports mild chest discomfort described as pressure, worsened with exertion and relieved with rest. He denies any recent fever or cough. On examination, he appears fatigued, with cool extremities and mild pedal edema.
Vital Signs:
Temperature: 98.6°F (37°C)
Heart Rate: 108 bpm
Respiratory Rate: 24 breaths/min
Blood Pressure: 148/88 mmHg
O2 Saturation: 90% on room air
Labs and Diagnostics:
BNP: 610 pg/mL (↑)
Troponin I: Normal
EKG: Sinus tachycardia, no ST elevation
Chest X-ray: Cardiomegaly and mild pulmonary congestion
Clinical Impression:
James is suspected of having congestive heart failure (CHF) exacerbation with impaired gas exchange due to pulmonary congestion.
Which nursing intervention is most appropriate to improve oxygenation in this patient with suspected congestive heart failure?
A. Place the patient in a supine position to improve circulation
B. Encourage fluid intake to promote kidney perfusion
C. Elevate the head of the bed and apply supplemental oxygen
D. Administer a high-carbohydrate diet to increase energy
✅ Correct Answer: C. Elevate the head of the bed and apply supplemental oxygen
📚 Rationale:
Option C is correct because elevating the head of the bed (semi-Fowler’s or Fowler’s position) reduces venous return and improves diaphragmatic expansion, aiding oxygenation. Supplemental oxygen improves SpO₂ in hypoxic patients.
Option A is incorrect; placing the patient supine can worsen breathing in CHF due to fluid overload and pulmonary congestion.
Option B is inappropriate during fluid overload; CHF patients often require fluid restriction, not encouragement.
Option D has no direct benefit on oxygenation and may increase metabolic workload.
Q3. Which type of wound healing involves delayed closure, often due to infection or poor circulation?
Answer: C. Tertiary intention
Rationale: Tertiary intention healing is delayed closure, typically for infected or high-risk wounds.
Q2. Select all that apply: Which are symptoms of infection?
Answer: ['Fever', 'Nasal congestion', 'Sore throat', 'Vomiting']
Rationale: These are common symptoms of infection. Joint flexibility is not typically a sign of infection.
9. Which intervention is least appropriate for postoperative care following a corneal transplant?
**Correct Answer:** B
**Rationale:** Ice packs should not be used directly on the eye after corneal transplant due to the risk of increased IOP.
2. Select all that apply: Which conditions can be complications of chronic sleep deprivation?
**Correct Answer:** A, C, D
**Rationale:** Chronic sleep deprivation has been linked to multiple health risks including hypertension, stroke, and obesity.
Q8. Which maneuver may be used by clients with chronic urinary retention to promote voiding?
Answer: B. Valsalva maneuver
Rationale: The Valsalva and Crede’s maneuvers may assist in voiding.
What is the major muscle of inspiration?
Answer: C. Diaphragm
Rationale: The diaphragm is the primary muscle involved in inspiration, and it is controlled by the phrenic nerve.
Which of the following best describes the correct order of blood flow through the heart starting from the vena cava?
A. Right atrium → Right ventricle → Pulmonary artery → Lungs → Pulmonary vein → Left atrium → Left ventricle → Aorta
B. Right atrium → Pulmonary artery → Right ventricle → Lungs → Pulmonary vein → Left atrium → Aorta → Left ventricle
C. Vena cava → Right atrium → Right ventricle → Pulmonary vein → Lungs → Pulmonary artery → Left atrium → Left ventricle
D. Vena cava → Right atrium → Right ventricle → Aorta → Lungs → Pulmonary vein → Left atrium → Left ventricle
Correct Answer: A
Rationale: Blood returns from the body via the vena cava into the right atrium, flows to the right ventricle, and is pumped through the pulmonary artery to the lungs. Oxygenated blood returns via the pulmonary vein to the left atrium, then to the left ventricle, and finally through the aorta to the rest of the body.
A patient reports seeing 'halos' around lights and has elevated intraocular pressure. Which condition is most likely?
A. Cataracts
B. Retinal detachment
C. Glaucoma
D. Age-related macular degeneration
**Correct Answer:** C
**Rationale:** Glaucoma involves increased IOP and symptoms such as halos around lights and vision changes.
At the 'Commitment' level of critical thinking, a nurse:
A. Relies completely on expert advice.
B. Requires validation from peers before acting.
C. Accepts accountability for decisions made independently.
D. Follows a checklist without analyzing the situation.
**Correct Answer:** C
**Rationale:** The 'Commitment' level is characterized by independent decision-making and accountability.
Which artery supplies blood to the right side of the heart?
A. Left coronary artery
B. Circumflex artery
C. Right coronary artery
D. Carotid artery
Answer: C. Right coronary artery
Rationale: The right coronary artery specifically supplies the right side of the heart including the right atrium and ventricle.
🩺 Case Study: Oxygenation Emergency — Trapped in Vehicle
Patient Name:Cloey Clark
Age: 20 years
Medical History: Asthma (mild intermittent)
Chief Complaint: Shortness of breath, dizziness
Scenario:
Cloey, a 20-year-old college student, accidentally becomes trapped inside a parked car after getting into the back seat of a friend’s vehicle to retrieve a backpack. The child safety locks engaged automatically, and the car doors could not be opened from the inside. Her phone battery had died, and the car was parked outside in direct sunlight on a hot summer afternoon (90°F/32°C).
Cloey was found 45 minutes later by a passerby, who noticed signs of distress through the window and called 911. EMS arrived and broke a window to remove Cloey from the vehicle. Upon removal, Cloey was confused, sweating profusely, breathing rapidly, and had a rapid heart rate.
Initial Assessment (Post-Rescue):
Temperature: 102.2°F (39°C)
Heart Rate: 128 bpm
Respiratory Rate: 30 breaths/min
Blood Pressure: 98/58 mmHg
O2 Saturation: 89% on room air
Skin: Flushed, hot, diaphoretic
Mental status: Disoriented, lethargic
Intervention:
Cloey received high-flow oxygen via non-rebreather mask, was cooled with ice packs and IV fluids, and transported to the ED for further care. He was diagnosed with heat exhaustion complicated by hypoxia due to poor ventilation and high temperature exposure.
📘 NCLEX-Style Question
What is the nurse's priority intervention upon Jordan’s arrival to the emergency department?
A. Administer an antipyretic to reduce his fever
B. Obtain a complete medical history and allergy list
C. Apply a cooling blanket and reassess temperature in 1 hour
D. Maintain high-flow oxygen therapy and monitor airway status
✅ Correct Answer: D. Maintain high-flow oxygen therapy and monitor airway status
📚 Rationale:
Option C is inappropriate due to delayed reassessment; the patient requires continuous monitoring and immediate cooling interventions, not hourly checks.
🩺 Case Study: Oxygenation Emergency — Trapped in Vehicle
Patient Name:Cloey Clark
Age: 20 years
Medical History: Asthma (mild intermittent)
Chief Complaint: Shortness of breath, dizziness
Scenario:
Cloey, a 20-year-old college student, accidentally becomes trapped inside a parked car after getting into the back seat of a friend’s vehicle to retrieve a backpack. The child safety locks engaged automatically, and the car doors could not be opened from the inside. Her phone battery had died, and the car was parked outside in direct sunlight on a hot summer afternoon (90°F/32°C).
Cloey was found 45 minutes later by a passerby, who noticed signs of distress through the window and called 911. EMS arrived and broke a window to remove Cloey from the vehicle. Upon removal, Cloey was confused, sweating profusely, breathing rapidly, and had a rapid heart rate.
Initial Assessment (Post-Rescue):
Intervention:
Cloey received high-flow oxygen via non-rebreather mask, was cooled with ice packs and IV fluids, and transported to the ED for further care. He was diagnosed with heat exhaustion complicated by hypoxia due to poor ventilation and high temperature exposure.
Which of the following assessment findings in Jordan indicates that his oxygenation status is deteriorating and requires immediate intervention?
A. Temperature of 100.8°F (38.2°C) and mild confusion
B. Respiratory rate of 18 with slight fatigue
C. O₂ saturation of 85% with increasing lethargy
D. Heart rate of 90 bpm and alert but anxious
Which of the following assessment findings in Jordan indicates that his oxygenation status is deteriorating and requires immediate intervention?
A. Temperature of 100.8°F (38.2°C) and mild confusion
B. Respiratory rate of 18 with slight fatigue
C. O₂ saturation of 85% with increasing lethargy
D. Heart rate of 90 bpm and alert but anxious
✅ Correct Answer: C. O₂ saturation of 85% with increasing lethargy
📚 Rationale:
🩺 Case Study: Myocardial Infarction (MI)
Patient Name:Bald Nathan
Age: 33 years
Medical History: Type 2 Diabetes, Hypertension, Smoking history (1 pack/day), Hyperlipidemia
Chief Complaint: Chest pain radiating to the left arm
Background:
Mr. Clean arrives at the emergency department complaining of severe chest pain that started 45 minutes ago while he was mowing the lawn. He describes the pain as a “tight pressure” that radiates to his left arm and jaw. He is diaphoretic, nauseated, and short of breath. He took one aspirin tablet at home and called EMS.
Vital Signs:
BP: 92/56 mmHg
HR: 116 bpm
RR: 22 breaths/min
SpO₂: 94% on room air
Temp: 98.1°F (36.7°C)
12-Lead EKG Findings:
ST elevation in leads II, III, and aVF
Labs:
Troponin I: Elevated at 4.3 ng/mL
CK-MB: Elevated
Potassium: 4.0 mEq/L
Blood glucose: 212 mg/dL
Clinical Impression:
ST-Elevation Myocardial Infarction (STEMI), likely inferior wall MI. The patient is being prepared for emergent cardiac catheterization.
📘 NCLEX-Style Question
Which of the following is the priority nursing action upon admission of a patient with suspected ST-elevation myocardial infarction (STEMI)?
A. Schedule the patient for an exercise stress test
B. Administer a high-protein meal to support cardiac recovery
C. Apply oxygen, initiate IV access, and prepare for cardiac catheterization
D. Monitor blood glucose hourly and hold cardiac medications
✅ Correct Answer: C. Apply oxygen, initiate IV access, and prepare for cardiac catheterization
📚 Rationale:
Option C is correct. In a suspected STEMI, the priority is to ensure oxygen delivery to the myocardium, establish IV access for medications (e.g., morphine, nitrates, anticoagulants), and prepare the patient for reperfusion therapy such as PCI (percutaneous coronary intervention).
Option A is inappropriate and contraindicated during an acute MI episode—stress testing increases cardiac workload and could worsen ischemia.
Option B is not a priority and may delay critical treatment. NPO status is typically maintained in case of emergency procedures.
Option D overlooks life-saving interventions for MI and focuses incorrectly on glucose alone.
The nurse is caring for a patient with hypervolemia. Which assessment findings support this diagnosis?
Select all that apply:
A. Crackles in the lungs
B. Weight gain
C. Increased hematocrit
D. Peripheral edema
E. Bradycardia
Correct Answers: A, B, D
Rationale:
📘 NCLEX-Style Question: Sodium Deficit
A 72-year-old patient with a history of heart failure and chronic kidney disease is admitted for altered mental status. Labs reveal a serum sodium of 119 mEq/L. The nurse notes that the patient is lethargic, has a bounding pulse, and bilateral crackles in the lungs. The provider orders 3% hypertonic saline. Which of the following is the most important nursing action?
A. Monitor serum potassium levels every 4 hours
B. Measure intake and output every 8 hours
C. Restrict oral sodium and fluid intake
D. Infuse hypertonic saline slowly while monitoring for signs of fluid overload
✅ Correct Answer: D. Infuse hypertonic saline slowly while monitoring for signs of fluid overload
📚 Rationale:
Option D is correct. This patient has severe hyponatremia (Na⁺ <120 mEq/L) and coexisting heart failure with fluid overload, making careful administration of 3% saline essential. Hypertonic saline must be administered cautiously, ideally via a central line, to avoid rapid sodium correction, which can cause central pontine myelinolysis. Additionally, fluid overload must be closely monitored due to underlying heart failure.
Option A is important but not the priority in managing a sodium deficit. Potassium shifts can occur, but sodium and fluid status take precedence here.
Option B is incorrect because q8h I&O monitoring is too infrequent in a patient receiving hypertonic saline and with fluid balance issues. More frequent monitoring (e.g., hourly) is standard.
Option C is inappropriate. While fluid restriction is part of treatment for dilutional hyponatremia, sodium should not be restricted in this patient who is already critically hyponatremic.
🩺 Case Study: Sleep Deprivation
Patient Name: Nathan Drake
Age: 28 years
Occupation: Night-shift ER nurse
Medical History: Anxiety, Mild depression
Chief Complaint: Difficulty concentrating, irritability, and headaches
Background:
Nathan presents to the clinic reporting persistent fatigue, irritability, and difficulty focusing at work over the past month. He says he often gets only 3–4 hours of sleep during the day due to noise, light, and family obligations. He frequently drinks energy drinks to stay awake during shifts. He admits to using his phone in bed, which delays his ability to fall asleep. His mood has also worsened, and he feels emotionally exhausted.
Assessment Findings:
Patient appears tired and distracted
Reports headaches and muscle tension
Mood is anxious and tearful
No signs of underlying physical illness
Clinical Impression:
Nathan is experiencing chronic sleep deprivation, negatively affecting her mental, emotional, and cognitive functioning.
📘 NCLEX-Style Question
Which nursing intervention would best promote improved sleep for Nathan?
A. Encourage him to exercise immediately before bedtime to promote fatigue
B. Recommend a glass of wine before bed to relax the nervous system
C. Educate him on establishing a consistent sleep routine and limiting screen time before bed
D. Advise him to take frequent naps throughout the night shift to make up for missed sleep
✅ Correct Answer: C. Educate her on establishing a consistent sleep routine and limiting screen time before bed
📚 Rationale:
Option C is correct. Creating a consistent bedtime routine and avoiding screens before bed helps regulate melatonin production and improve sleep quality.
Option A is incorrect. While exercise is beneficial for overall health, strenuous activity right before bed can stimulate the body and hinder sleep.
Option B is incorrect. Alcohol may induce sleep initially but disrupts REM cycles and leads to poorer sleep quality.
Option D is not ideal. Frequent naps during the shift may interfere with consolidated sleep cycles and lead to more fragmented rest.