"Nailed It!"
Which assessment finding indicates worsening intracranial pressure?
A. Decreased blood pressure
B. Sluggish pupillary response
C. Restlessness relieved by repositioning
D. Mild nausea
✅ Answer: B
💡 Rationale: Changes in pupillary response signal increased pressure on cranial nerves.
A nurse is reviewing the health history of a client who is being screened for colorectal cancer. Which factor in the client’s history places the client at highest risk for developing colorectal cancer?
A. History of frequent urinary tract infections
B. Chronic ulcerative colitis for 15 years
C. Past infection with Helicobacter pylori
D. History of gallstones and cholecystectomy
✅ Correct Answer: B. Chronic ulcerative colitis for 15 years
💡 Rationale:
Long-term inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease cause chronic inflammation of the colon, increasing the risk of colorectal cancer.
The nurse is caring for a client with leukemia who is transitioning to palliative care. Which nursing action is most appropriate to determine what the client wants for her care?
A. Ask the family members to describe what they believe the client would want.
B. Provide information about treatment options and ask the client which she prefers.
C. Ask the client to describe her goals and priorities for the remainder of her care.
D. Explain that the healthcare team will make care decisions based on her condition.
✅ Correct Answer: C. Ask the client to describe her goals and priorities for the remainder of her care.
💡 Rationale:
Palliative care emphasizes patient-centered decision-making that honors individual values, preferences, and quality-of-life goals. The nurse’s role is to facilitate open, compassionate communication that allows the client to express her wishes.
A nurse is caring for a client with acute lymphocytic leukemia (ALL) who is prescribed immunotherapy. Which statement best describes the mechanism of action of immunotherapy?
A. Directly kills cancer cells by damaging their DNA
B. Stimulates the client’s immune system to recognize and attack cancer cells
C. Prevents cancer cells from dividing by interfering with mitosis
D. Replaces damaged bone marrow with healthy stem cells
✅ Correct Answer: B. Stimulates the client’s immune system to recognize and attack cancer cells
💡 Rationale:
Immunotherapy works by enhancing the body’s immune response against cancer cells. Unlike chemotherapy or radiation, it does not directly kill cancer cells, but it helps the immune system identify and destroy malignant cells, which is particularly useful in hematologic cancers like ALL.
Question:
The nurse is caring for a client with acute myeloid leukemia (AML) receiving myelosuppressive chemotherapy. The client has developed anemia, neutropenia, and thrombocytopenia. Which of the following best explains the cause of these findings?
A. Chemotherapy suppresses red blood cell production only in the spleen.
B. Chemotherapy destroys rapidly dividing bone marrow cells, leading to pancytopenia.
C. Chemotherapy increases platelet aggregation, resulting in decreased circulation.
D. Chemotherapy enhances immune function, causing increased cell turnover.
✅ Correct Answer: B. Chemotherapy destroys rapidly dividing bone marrow cells, leading to pancytopenia.
Rationale:
Myelosuppressive (cytotoxic) chemotherapy targets rapidly dividing cells, which include not only cancer cells but also the rapidly dividing hematopoietic cells in the bone marrow. This results in bone marrow suppression and subsequent pancytopenia—a decrease in all three blood cell lines: red blood cells (anemia), white blood cells (neutropenia), and platelets (thrombocytopenia).
A nurse is caring for a client with acute myeloid leukemia receiving cytotoxic chemotherapy. The client’s laboratory results show:
Which nursing intervention should the nurse prioritize?
A. Encourage the client to perform daily walking exercises to maintain strength.
B. Administer fresh fruits and vegetables to promote immune health.
C. Use strict aseptic technique during all invasive procedures.
D. Administer the influenza vaccine immediately.
✅ Correct Answer: C. Use strict aseptic technique during all invasive procedures.
Rationale:
The client’s WBC of 1,000/mm³ indicates severe neutropenia, placing them at high risk for infection. Infection prevention is the top nursing priority in pancytopenic clients receiving chemotherapy. The nurse must use strict aseptic technique, perform frequent hand hygiene, and avoid exposure to infectious agents.
A nurse is caring for a client receiving radiation therapy who has developed skin breakdown at the treatment site. Which nursing intervention is most appropriate to promote skin healing and prevent further irritation?
A. Apply scented lotion to keep the skin moisturized.
B. Clean the area daily with alcohol and cover with a tight dressing.
C. Gently cleanse the area with mild soap and lukewarm water, then pat dry.
D. Expose the area to direct sunlight for 15 minutes daily to aid healing.
✅ Correct Answer: C. Gently cleanse the area with mild soap and lukewarm water, then pat dry. Rationale:
Radiation therapy damages both cancer cells and healthy skin tissue, often leading to radiation dermatitis. The nurse should promote gentle skin care, avoid trauma, and use nonirritating, mild cleansers. The area should be kept clean, dry, and protected.
A nurse is caring for a client undergoing radiation therapy. Which of the following nursing precautions is most appropriate to protect the nurse from radiation exposure?
A. Spend extended time with the client to provide emotional support.
B. Bath the patient after the treatment
C. Limit time spent near the radiation source.
D. Wear sterile gloves and mask when entering the client’s room.
✅ Correct Answer: C. Limit time spent near the radiation source.
Rationale:
For clients receiving internal (sealed-source) radiation therapy, nurses must follow the principles of time, distance, and shielding (i.e., a iron apron)
A nurse is caring for a postoperative client who has not voided in 6 hours and has a distended bladder upon palpation. What is the most appropriate initial nursing action?
A. Notify the healthcare provider to insert an indwelling catheter.
B. Encourage the client to drink more fluids.
C. Perform a bladder scan to assess for urinary retention.
D. Apply a warm compress to the lower abdomen to stimulate urination.
✅ Correct Answer: C. Perform a bladder scan to assess for urinary retention.
Rationale:
The nurse should first confirm urinary retention before intervening. A bladder scan is a noninvasive, accurate way to determine the amount of urine retained and helps guide whether catheterization is necessary.
A nurse is caring for a client who had a left mastectomy with lymph node removal and now has lymphedema in the left arm. Which nursing action is most appropriate to help prevent complications?
A. Measure blood pressure and draw blood from the left arm only.
B. Elevate the left arm on a pillow above the level of the heart.
C. Apply a heating pad to the affected arm to reduce swelling.
D. Restrict movement of the left arm to prevent further injury.
✅ Correct Answer: B. Elevate the left arm on a pillow above the level of the heart.
Rationale:
Elevation of the affected arm promotes lymphatic drainage and reduces swelling. The nurse should also avoid blood pressure measurements, venipunctures, or injections in the affected arm to prevent trauma and infection.
A nurse is teaching a patient about polycystic ovary syndrome (PCOS). Which statement accurately describes PCOS?
A. It is a condition in which the ovaries stop producing hormones entirely.
B. It is a hormonal disorder characterized by irregular periods, excess androgen levels, and polycystic ovaries.
C. It is an infection of the ovaries caused by bacteria.
D. It only affects postmenopausal women.
Answer:
B. It is a hormonal disorder characterized by irregular periods, excess androgen levels, and polycystic ovaries. Rationale:
PCOS is a common endocrine disorder in people with ovaries, marked by hormonal imbalances (including excess androgens), ovulatory dysfunction (irregular or absent periods), and polycystic ovaries seen on ultrasound. It is not caused by infection and can affect women of reproductive age, not just postmenopausal women.
A nurse is counseling a patient with polycystic ovary syndrome (PCOS) on lifestyle modifications. Which recommendation should the nurse include as a primary intervention?
A. Increase sedentary activities to reduce stress on the ovaries
B. Follow a balanced diet, engage in regular exercise, and maintain a healthy weight
C. Avoid all carbohydrates completely
D. Use herbal supplements as the first-line treatment
B. Follow a balanced diet, engage in regular exercise, and maintain a healthy weight
Rationale: Lifestyle modifications, including diet, exercise, and weight management, are the first-line interventions for managing PCOS. These changes help improve insulin sensitivity, regulate menstrual cycles, reduce androgen levels, and decrease long-term metabolic risks.
A nurse is caring for a patient with a hepatobiliary disorder. The patient’s blood pressure is low. In which situation should the nurse anticipate administering a fluid bolus?
A. The patient is experiencing mild nausea.
B. The patient has mild jaundice without hypotension.
C. The patient has hypotension and signs of poor perfusion.
D. The patient is reporting mild right upper quadrant discomfort.
C. The patient has hypotension and signs of poor perfusion.
Rationale:
A fluid bolus is indicated when a patient shows low blood pressure and evidence of inadequate perfusion (e.g., weak pulse, cool extremities, low urine output). Mild symptoms like nausea, jaundice, or mild discomfort alone do not warrant a fluid bolus. In hepatobiliary disorders, careful monitoring of fluid status is essential due to potential fluid shifts and liver dysfunction.
A nurse is caring for a patient with acute pancreatitis who has an NG tube for gastric decompression. The tube becomes clogged. Which action should the nurse take to restore and maintain tube patency?
A. Forcefully flush the tube with 50 mL of water.
B. Use a syringe with gentle, intermittent irrigation using warm water or saline.
C. Remove and replace the NG tube immediately.
D. Clamp the tube for 1 hour and reassess.
Answer:
B. Use a syringe with gentle, intermittent irrigation using warm water or saline.
Rationale: To maintain NG tube patency, gentle, intermittent irrigation with warm water or saline is recommended. Forcing fluid can cause trauma or dislodge the tube
A nurse is caring for a patient with acute pancreatitis who is experiencing severe nausea and vomiting. How can the nurse help control the nausea?
A. Encourage the patient to eat small frequent meals.
B. Administer an NG tube for gastric decompression.
C. Give the patient spicy foods to stimulate digestion.
D. Encourage the patient to ambulate frequently.
B. Administer an NG tube for gastric decompression.
Rationale:
In acute pancreatitis, an NG tube can help relieve nausea and vomiting by removing gastric secretions and preventing further pancreatic stimulation. Eating or ambulating may worsen symptoms in acute phases, and spicy foods are contraindicated. The NG tube allows the pancreas to rest and helps prevent complications like aspiration.
Which organ has the ability to regenerate and repair itself after injury?
A. Heart
B. Brain and spinal cord
C. Liver
D. Kidneys
✅ Answer: C. Liver Rationale:The liver is unique among internal organs because it can regenerate functional tissue after injury or partial removal. Hepatocytes (liver cells) can divide and restore the liver to its normal size and function, provided the underlying structure remains intact.
Heart: Cardiac muscle cells (myocytes) cannot regenerate; damaged tissue becomes scar tissue. Brain and spinal cord: Neurons in the central nervous system have very limited regenerative capacity. Kidneys: Can repair minor tubular injury, but cannot regenerate lost nephrons once destroyed.
A nurse is teaching a client with acute hepatitis about activity levels. The nurse advises that it is okay to perform activities but emphasizes the importance of rest. What is the rationale for this instruction?
A. Rest prevents dehydration.
B. Rest promotes hepatocyte regeneration.
C. Rest reduces jaundice.
D. Rest prevents viral transmission.
B. Rest promotes hepatocyte regeneration. Rationale:
In acute hepatitis, liver cells (hepatocytes) are damaged by the infection or inflammation. Adequate rest supports the liver’s natural healing process and allows hepatocytes to regenerate more effectively. While hydration, monitoring jaundice, and infection control are important, the primary reason for rest is liver cell recovery.
A nurse is caring for a client who has been exposed to hepatitis B but already completed the hepatitis B vaccine series. What is the most appropriate immediate action?
A. Monitor the client for jaundice for the next 2 weeks.
B. Administer hepatitis B immune globulin (HBIG) within 24 hours of exposure.
C. Schedule the client for a booster dose of the hepatitis B vaccine in 6 months.
D. Teach the client to avoid alcohol for 1 week.
Answer:
B. Administer hepatitis B immune globulin (HBIG) within 24 hours of exposure.
Rationale:
Even if a client has completed the hepatitis B vaccine series, high-risk exposure (e.g., needle stick or blood contact) may still warrant post-exposure prophylaxis with HBIG, ideally within 24 hours. This provides immediate passive immunity while the body’s own vaccine-induced antibodies respond. Monitoring for symptoms, boosters, or lifestyle modifications do not provide immediate protection after exposure.
A nurse is caring for a client with acute cholecystitis. Which intervention should the nurse implement first?
A. Encourage the client to drink clear fluids to stay hydrated.
B. Administer a high-fat diet to stimulate bile flow.
C. Keep the client NPO to reduce gallbladder stimulation.
D. Apply a heating pad to the abdomen to relieve pain.
C. Keep the client NPO to reduce gallbladder stimulation. Rationale:
In acute cholecystitis, the gallbladder is inflamed. NPO status helps prevent stimulation of the gallbladder, which reduces pain and further inflammation. Hydration may be provided via IV fluids. High-fat foods can exacerbate symptoms. Heat may provide comfort but does not address the priority of reducing gallbladder stimulation.
A nurse is caring for a client diagnosed with acute cholecystitis. Which of the following should the nurse include in counseling and assessment?
A. Teach the client that they may experience pain after eating fatty foods and assess for a positive Murphy’s sign.
B. Advise the client to increase high-fat foods to stimulate bile flow and check for jaundice only.
C. Tell the client that fatty foods have no impact on symptoms and focus only on fever.
D. Encourage the client to ignore abdominal pain and focus on physical activity.
A. Teach the client that they may experience pain after eating fatty foods and assess for a positive Murphy’s sign.
Rationale:
Clients with acute cholecystitis often develop pain after fatty meals because the gallbladder contracts and increases inflammation. The Murphy’s sign (pain on palpation of the right upper quadrant during inspiration) is a key clinical assessment finding. Education should focus on dietary management and recognition of symptoms. Options B, C, and D are inappropriate and could worsen the client’s condition
A nurse is caring for a client with cirrhosis. The client’s labs show low potassium (hypokalemia). Which statement about sodium polystyrene sulfonate (Kayexalate) is correct?
A. It is appropriate to give because it treats hypokalemia.
B. It is contraindicated because it treats hyperkalemia, and the client is already hypokalemic.
C. It can be given to promote liver regeneration.
D. It is used to prevent fluid overload in cirrhosis.
B. It is contraindicated because it treats hyperkalemia, and the client is already hypokalemic.
Rationale:
Sodium polystyrene sulfonate is a potassium-binding resin used to treat hyperkalemia, not hypokalemia. Clients with cirrhosis are often prone to hypokalemia due to diuretics or other factors. Administering Kayexalate in this case could worsen low potassium levels and lead to dangerous complications such as arrhythmias.
A nurse is caring for a client with cirrhosis who presents with a rigid, tender abdomen. Which life-threatening condition should the nurse suspect?
A. Hepatic encephalopathy
B. Spontaneous bacterial peritonitis
C. Esophageal varices
D. Portal hypertension
B. Spontaneous bacterial peritonitis
Rationale:
A rigid, tender abdomen in a client with cirrhosis may indicate spontaneous bacterial peritonitis (SBP), a potentially life-threatening infection of the ascitic fluid. Early recognition and prompt treatment with antibiotics are crucial to prevent sepsis and death. Other cirrhosis complications, like hepatic encephalopathy or esophageal varices, do not typically present with abdominal rigidity.
A nurse is caring for a client with cirrhosis and a history of hepatic encephalopathy who reports drinking 1 beer per night. What is the most appropriate nursing recommendation?
A. Continue drinking in moderation
B. Reduce alcohol to weekends only
C. Stop drinking completely
D. Switch to wine instead of beer
C. Stop drinking completely
Rationale:
Alcohol is hepatotoxic and can worsen liver damage in clients with cirrhosis. Even small amounts, like one beer per night, can precipitate hepatic encephalopathy or accelerate disease progression. Clients with liver disease should be advised to abstain from alcohol completely to protect remaining liver function.
A nurse is caring for a client with a cervical spinal cord injury. What is the major risk associated with this type of injury?
A. Impaired bowel and bladder function
B. Impaired mobility in lower extremities only
C. Impaired muscles needed for breathing
D. Loss of sensation in the fingers only
C. Impaired muscles needed for breathing
Rationale:
Cervical spinal cord injuries, particularly those at C1–C4, can affect the diaphragm and intercostal muscles, leading to respiratory compromise. This can result in respiratory failure, making airway management and ventilatory support a priority. While bowel, bladder, and limb function may also be affected, respiratory impairment is life-threatening and requires immediate attention.
A nurse is caring for a client with a spinal cord injury at T6 or above. The client reports facial flushing and sweating. What is the most likely cause?
A. Autonomic dysreflexia
B. Hypovolemic shock
C. Neurogenic shock
D. Spinal shock
A. Autonomic dysreflexia
Rationale:
Autonomic dysreflexia is a life-threatening condition that occurs in clients with spinal cord injuries at T6 or above. It is often triggered by bladder distension, bowel impaction, or other noxious stimuli. Classic signs include sudden severe hypertension, facial flushing, sweating above the level of injury, and headache. Prompt identification and intervention are crucial to prevent stroke, seizures, or death.