Fundamentals
This is the minimum number of seconds the CDC recommends for hand washing with soap and water.
20 seconds
A client's serum potassium is 6.8 mEq/L. Name the earliest ECG change the nurse should expect to see.
Peaked (tall, narrow, tent-shaped) T waves
Name the five rights of medication administration.
Right client, right drug, right dose, right route, right time
A client with a chest tube has no fluctuation (tidaling) in the water-seal chamber. Name the two possible causes.
Lung re-expansion or tubing obstruction/kink.
A client says 'I just don't want to be here anymore.' Name the therapeutic communication technique the nurse should use first, and give an example of an appropriate opening response.
Use an open-ended clarifying question — example: 'Tell me more about what you mean by that' or 'Are you having thoughts of harming yourself?'
A client's urine output is 25 mL/hour for the past 3 hours. State whether this is adequate or inadequate, and identify the minimum acceptable urine output per hour for an adult.
Inadequate — minimum is 30 mL/hour
Name the primary mechanism that causes pitting edema in a client with right-sided heart failure.
Increased venous hydrostatic pressure — blood backs up into systemic veins, forcing fluid into interstitial tissues
A client on heparin infusion needs anticoagulation monitoring. Name the specific lab value used to monitor heparin therapy and its therapeutic range.
aPTT (activated partial thromboplastin time) — therapeutic range is 1.5 to 2.5 times the control value (approximately 60–100 seconds)
A client with COPD has ABGs showing pH 7.29, PaCO2 68, HCO3 32, PaO2 54. Name the acid-base disorder and the correct oxygen delivery device.
Partially compensated respiratory acidosis — Venturi mask at 24–28% FiO2.
A client with schizophrenia tells the nurse the news anchor on TV is sending secret messages meant specifically for them. Name the psychiatric term for this symptom.
Delusion of reference
A nurse is using SBAR. When reporting 'the client's BP has dropped to 82/50, heart rate is 128, and he appears diaphoretic,' which letter of SBAR does this represent?
S — Situation
A client with type 1 diabetes presents with deep, rapid breathing and fruity-smelling breath. Name this breathing pattern, the acid-base disorder causing it, and the substance responsible for the fruity odor.
Kussmaul respirations — caused by metabolic acidosis (DKA) — fruity odor from acetone (ketones)
A client prescribed metformin is scheduled for a contrast CT scan tomorrow. State exactly what the nurse must do with the metformin and why.
Hold metformin 48 hours before and 48 hours after the contrast procedure — contrast dye can cause AKI, leading to metformin accumulation and potentially fatal lactic acidosis
A client returns from thyroidectomy and the nurse inflates a BP cuff above systolic for 3 minutes. The hand and fingers flex into a spasm. Name this sign, what it indicates, and the priority intervention.
Trousseau's sign — hypocalcemia from parathyroid damage — administer IV calcium gluconate.
A client is being discharged on lithium carbonate. Name the two most important dietary and fluid instructions the nurse must give.
Maintain consistent daily sodium intake and drink 2–3 liters of fluid per day
A nurse has four clients: one with SpO2 of 87%, one with pain rated 7/10, one requesting a bedpan, and one whose family wants discharge education. Using Maslow's hierarchy, name the client who must be seen first and state the specific physiological reason.
The client with SpO2 87% — hypoxia threatens oxygenation, the most basic survival need
A client with SIADH has a serum sodium of 118 mEq/L and a urine osmolality of 520 mOsm/kg. In one sentence explain why urine is concentrated while serum sodium is low, and name the two priority nursing interventions.
Excess ADH forces the kidneys to reabsorb free water, diluting serum sodium while producing inappropriately concentrated urine — priority interventions are fluid restriction and seizure precautions
A client receiving IV vancomycin develops sudden flushing, redness across the face and upper chest, and hypotension. Name this reaction and state the correct nursing intervention.
Red Man Syndrome — slow the infusion rate and administer diphenhydramine (Benadryl)
A client receiving doxorubicin asks why they need periodic echocardiograms.
Doxorubicin causes cumulative, dose-dependent cardiotoxicity that can lead to heart failure.
A nurse notices a client on the psychiatric unit has been giving away personal belongings, saying goodbye to peers, and is unusually calm after days of distress. Name the behavioral pattern this represents and state the priority nursing action.
Suicidal behavioral warning signs — place the client on 1:1 observation and notify the provider immediately.
A client is ordered contact precautions. State two pieces of PPE the nurse must don before entering the room, and identify the correct order for removing them.
Gloves and gown — remove gloves first, then gown (gloves are most contaminated); perform hand hygiene after each step
A client with chronic kidney disease has a phosphorus of 6.8 mg/dL, calcium of 7.9 mg/dL, and PTH of 380 pg/mL. In one sentence, explain why PTH is elevated in CKD.
Failed kidneys cannot activate vitamin D, causing hypocalcemia, which triggers the parathyroid glands to release excess PTH
A client is on digoxin and furosemide. Their potassium level comes back at 3.0 mEq/L. Explain the specific danger this combination creates and name the priority nursing action.
Hypokalemia potentiates digoxin toxicity — hold digoxin, notify the provider, and anticipate potassium replacement
A client presents with sudden pleuritic chest pain, JVD, tachycardia, and clear lung sounds bilaterally. Name the suspected diagnosis.
Massive pulmonary embolism — the clot obstructs the right side of the heart, causing right heart failure and JVD, while the left side and lungs remain unaffected.
A client with schizophrenia on long‑term haloperidol suddenly develops severe muscle rigidity, diaphoresis, and confusion. The provider is unavailable. What is the priority nursing action?
Hold the antipsychotic and prepare to treat for neuroleptic malignant syndrome