Cardiac & Respiratory
A client with left-sided heart failure is most likely to exhibit which symptom?
What are dyspnea and pulmonary crackles?
A stroke patient has right-sided weakness. Which side should food be placed in the mouth?
What is the left (unaffected) side?
What lab must be monitored for a client on warfarin?
What is INR?
Respecting a client’s decision to refuse treatment reflects which ethical principle?
What is autonomy?
The RN is delegating to a UAP on a med-surg unit. Which task is appropriate? A. Perform and teach finger-stick glucose for a newly diagnosed client B. Administer a pre-procedure enema to a client with syncope history C. Assist a stable POD-2 total knee arthroplasty client to ambulate 50 ft with a gait belt per the RN mobility plan D. Monitor a client 30 min after IV morphine for respiratory depression
What is C ambulation of a stable client
Which lab test best confirms an acute myocardial infarction?
What is troponin I or T?
What is the priority assessment for a client with a spinal cord injury at C4?
What is respiratory effort?
Which adverse effect of furosemide requires immediate attention?
What is muscle weakness/cramps (hypokalemia)?
Which leadership style focuses on group input and shared decision-making?
What is democratic leadership?
Four clients are awaiting assessment. Who should the RN see first?
A. COPD, wheezes, SpO₂ 90% on 2 L NC, reports baseline dyspnea
B. Post-op cholecystectomy 2 hr ago, BP 88/54, HR 122, cool clammy skin
C. DKA with glucose 320 mg/dL, thirsty, on IV fluids as ordered
D. Ischemic stroke 24 hr, mild confusion at baseline, BP 150/88
What is B?
Rationale: Signs of shock/hemorrhage (hypotension, tachycardia, cool clammy) take priority (ABCs/unstable > stable).
A COPD patient is receiving O₂ at 6 L/min via nasal cannula. What is the priority action?
What is reduce the O₂ flow rate to avoid suppressing hypoxic drive?
A head injury client has clear nasal drainage. What is the priority nursing action?
What is test the fluid for glucose (possible CSF leak)?
A client on digoxin reports nausea and blurred vision. What is the priority action?
What is hold the dose and notify the provider?
Reporting unsafe staffing levels demonstrates which professional role?
What is advocate?
The RN is supervising UAP. Which UAP report requires immediate RN intervention?
A. Continuous bubbling noted in the water seal chamber of a chest tube
B. Foley output 20 mL/hr for 2 hr in a stable post-op client
C. POD-1 hip client refuses incentive spirometer
D. C. difficile patient is in contact precautions
What is A?
Rationale: Continuous bubbling in the water seal = air leak, an urgent system issue requiring RN assessment; the others are important but less emergent.
A client has chest pain unrelieved by nitroglycerin. What is the nurse’s priority action?
What is administering morphine as prescribed?
Which electrolyte imbalance is most associated with renal failure?
What is hyperkalemia?
What teaching is essential for a client prescribed lithium?
What is maintain consistent sodium and fluid intake?
What is the first step in conflict resolution between two staff members?
What is identify the source of conflict?
Which assignment is most appropriate for the LPN under RN supervision?
A. New GI bleed, initiating blood transfusion and titrating oxygen
B. Stable HF client: scheduled oral furosemide, daily weights, I&O
C. Fresh tracheostomy POD-0: first trach dressing/assessment
D. Chest pain patient awaiting troponin results and ECG changes
What is B?
Rationale: LPN cares for stable clients with predictable outcomes and routine meds; new/unstable, initial assessments, and high-risk interventions are RN.
In a client with a pulmonary embolism, which intervention takes priority?
What is administering oxygen immediately?
A client with increased ICP is restless and agitated. What is the first nursing action?
What is raise the head of bed to 30 degrees?
A client prescribed gentamicin develops decreased urine output. What should the nurse do?
What is report immediately (nephrotoxicity)?
A nurse manager reviews incident reports to identify patterns and improve care. What type of QI activity is this?
What is root cause analysis?
Mass-casualty START triage at the hospital entrance—who gets the Immediate (Red) tag?
A. Open femur fracture; RR 36, cap refill 5 sec, does not obey commands
B. >70% TBSA full-thickness burns; agonal breaths
C. Forearm laceration, bleeding controlled, ambulatory
D. Unresponsive and apneic; airway repositioned—still apneic
What is A?
Rationale: START: RR >30, cap refill >2 sec, cannot follow commands = Red (immediate). B/D = Expectant (Black); C = Minor (Green).