Ten minutes after starting a transfusion of packed red blood cells, a patient reports chills and back pain. Which additional finding would confirm the nurse's suspicion of an acute hemolytic transfusion reaction?
Pruritic rash
Nasal congestion
Seizure
Hypotension
✓
Correct Answer
Hypotension
Acute hemolytic transfusion reactions are marked by the quick presentation of low back pain, fever/chills, tachycardia, tachypnea, and/or hypotension. Seizure, pruritic rash, and nasal congestion are not typically associated.
Question 2
The nurse is caring for a patient who appears to develop an acute transfusion reaction while receiving blood products. What is the nurse's priority action?
Send the blood products back to the blood bank
Stop the transfusion
✓
Administer epinephrine
Call the provider
Correct Answer
Stop the transfusion
The priority action for a nurse who suspects a transfusion reaction is to immediately stop the transfusion.
Question 3
After a blood transfusion begins, the patient begins wheezing, reports dyspnea, and experiences hypotension with a decreased oxygen saturation. What does the nurse know to be the likely cause?
Hemolytic transfusion reaction
Septic shock
Anaphylactic transfusion reaction
✓
Transfusion associated metabolic acidosis
Correct Answer
Anaphylactic transfusion reaction
A patient with wheezing, dyspnea, hypotension, and decreased oxygen saturation during the course of a blood transfusion should be evaluated for an anaphylactic transfusion reaction.
Question 4
Following IV therapy the patient develops erythema, warmth, pain, and red streak along the skin with a "cordlike" vein. Which complication should the nurse expect?
Anaphylaxis
Medication extravasation
Infiltration
Phlebitis
✓
Correct Answer
Phlebitis
Phlebitis is an IV complication which may cause erythema, warmth, pain, cordlike veins, and/or a red streak along the skin.
Question 5
A nurse is caring for a client with diabetes mellitus type II. When reviewing the client's labs, what value(s) would the nurse anticipate?
Fasting blood glucose = 130 mg/dL
✓
Casual blood glucose = 190 mg/dL
HgbA1C = 7.5%
Oral glucose tolerance test = 160 mg/dL
Correct Answer
Fasting blood glucose = 130 mg/dL
Abnormal lab results that may indicate the presence of diabetes include: casual blood glucose ≥ 200 mg/dL, fasting blood glucose ≥ 126 mg/mL, glucose ≥ 200 mg/dL with OGTT, and/or HgbA1C ≥ 6.5%.
Question 6
The nurse is reviewing localized signs of a surgical site infection in a postoperative client with a student nurse. Which of the following symptoms if stated by the student nurse would require follow up?
Fever
✓
Purulent drainage
Erythema
Induration
Correct Answer
Fever
Although a sign of infection, fever is a systemic finding, not a localized sign of infection.
Question 7
The nurse is developing a plan of care regarding a risk of developing myxedema coma. For which of the following client diagnoses would this be appropriate? Select all that apply.
Untreated hypothyroidism
Thyroid nodule, resulting in excess production of T3 and T4
Urinary tract infection in a patient with hypothyroidism
Abrupt discontinuation of levothyroxine
✓
Correct Answer
Abrupt discontinuation of levothyroxine
Myxedema coma is life-threatening hypothyroidism. It is often caused by untreated hypothyroidism, infection, illness, or abrupt discontinuation of levothyroxine. Excess T3 and T4 results in hyperthyroidism (vs. hypothyroidism).
Question 8
The nurse is reviewing potential vitamin deficiencies with a client diagnosed with cystic fibrosis. Which of the following vitamins if stated by the nurse would require follow up?
Vitamin C
✓
Vitamin K
Vitamin D
Vitamin A
Correct Answer
Vitamin C
Cystic fibrosis may cause a deficiency in fat soluble vitamins (i.e., Vitamins A, D, E, and K). It should not impact an individual's ability to absorb water-soluble vitamins.
Question 9
The nurse is reviewing causes of ventilator low pressure alarms with a new nurse. Which cause if stated by the new nurse as resulting in a low pressure alarm would require follow up?
Cuff leak
Equipment disconnection
Patient coughing
✓
Tube displacement
Correct Answer
Patient coughing
Low pressure alarms are typically a result of a leak or a disconnect. A patient coughing would trigger a high pressure alarm.
Question 10
The nurse is reviewing medication typically used to treat tuberculosis with a nursing student. Which of the following medications if stated by the nursing student would require follow up?
Isoniazid
Rifampin
Phenazopyridine
✓
Pyrazinamide
Correct Answer
Phenazopyridine
The four most common medications used to treat tuberculosis are rifampin, isoniazid, pyrazinamide, and ethambutol. Phenazopyridine is used to treat pain associated with urinary tract infections.
Question 11
The nurse is reviewing migraine headaches with a student nurse. Which of the following statements made by the student would require follow up?
They are made better by pacing
✓
They may be preceded by an aura
They may be accompanied by vomiting
Photophobia may be present
Correct Answer
They are made better by pacing
Migraine headaches may be characterized by unilateral throbbing headache, nausea and vomiting, aura, photophobia, phonophobia, and are made better by lying still in a dark, quiet environment.
Question 12
The nurse is reviewing instructions with a client prior to their EEG scheduled for tomorrow. Which of the following if stated by the client would require follow up?
Wash hair
Arrive sleep deprived
Avoid stimulants
Remain NPO
✓
Correct Answer
Remain NPO
Prior to an EEG a patient should wash their hair, arrive sleep deprived, avoid stimulants, and avoid sedatives. There is no need to remain NPO.
Question 13
A nurse is reviewing care for a client with a traumatic brain injury and the presence of symptoms associated with Cushing's triad. When discussing with a student nurse, which of the following symptoms if stated as a Cushing's triad would require follow up?
Bradycardia
Irregular breathing
Tachycardia
✓
Systolic hypertension
Correct Answer
Tachycardia
Systolic hypertension (widened pulse pressure), bradycardia, and irregular breathing are part of Cushing's triad.
Question 14
The nurse is reviewing hyperglycemia symptoms with a client recently diagnosed with diabetes mellitus. Which of the following symptoms if stated by the client would require follow up?
Polyphagia
Polyplegia
✓
Polyuria
Polydipsia
Correct Answer
Polyplegia
Hyperglycemia can cause polydipsia (i.e., excessive thirst), polyphagia (i.e., excessive hunger), and polyuria (i.e., excessive urination). Polyplegia (i.e., paralysis of many muscles) is not an expected finding.
Question 15
The nurse is reviewing signs of hypocalcemia with a student nurse. Which of the following symptoms if stated by the student nurse would require follow up?
Peaked T-waves on EKG
✓
Circumoral numbness/tingling
Trousseau's sign
Chvostek's sign
Correct Answer
Peaked T-waves on EKG
Hypocalcemia is marked by positive Chvostek's and Trousseau's signs, muscle spasms, numbness/tingling in the lips and fingers, and GI upset. Peaked T-waves on EKG is a possible finding associated with hyperkalemia.
Question 16
The nurse is caring for a client with sickle cell anemia experiencing a vaso-occlusive crisis. Which of the following analgesics does the nurse anticipate administering?
Hydromorphone
✓
Ketorolac
Ibuprofen
Acetaminophen
Correct Answer
Hydromorphone
Patients with sickle cell anemia experiencing vaso-occlusive crisis should be treated with opioid analgesics such as hydromorphone, morphine, or fentanyl. Non-opioid analgesics such as acetaminophen, ibuprofen, or ketorolac are not indicated for this type of pain.
Question 17
The nurse is caring for a client experiencing chest pain that occurs with exercise or at rest and has increased in duration, frequency, or severity over time. Which diagnosis does the nurse anticipate?
Microvascular angina
Variant (Prinzmetal's) angina
Stable angina
Unstable angina
✓
Correct Answer
Unstable angina
Unstable angina occurs with exercise or at rest and increases in duration, frequency and/or severity over time.
Question 18
The nurse has received an order to strain a client's urine. Which renal disorder is this client likely experiencing?
Urolithiasis
✓
Acute Kidney Injury
Nephrotic Syndrome
Glomerulonephritis
Correct Answer
Urolithiasis
Urolithiasis is the presence of stones within the urinary tract. The nurse should strain all of the patient's urine to find the stones. The stones should be sent to the lab for analysis.
Question 19
A nurse is caring for a client diagnosed with acute kidney injury (AKI). The client had a urine output of 150 mL during the last 12 hours. Which stage of AKI does the nurse anticipate this client is experiencing?
Onset
Oliguria
✓
Diuresis
Recovery
Correct Answer
Oliguria
Urine output of <400mL/day is the oliguria stage of AKI.
Question 20
The nurse is providing education to a client with osteoporosis. Which type of exercise should the nurse include as a recommendation?
Riding a bicycle
Using resistance bands while seated
Walking
✓
Swimming
Correct Answer
Walking
Patients with osteoporosis should engage in weight-bearing exercise, such as walking. Swimming, riding a bicycle, and the use of resistance bands while seated are all examples of non-weight-bearing exercise.
Question 21
The nurse is caring for a client diagnosed with osteomalacia. Which of the following treatment orders does the nurse anticipate for this client?
Buck's traction
Continuous passive motion
Vitamin D supplementation
✓
Phototherapy
Correct Answer
Vitamin D supplementation
The primary treatment for osteomalacia is supplementation of vitamin D.
Question 22
The nurse is providing client education on the terminology used in staging their tumor. How should the nurse define the use of "N"?
Number of regional lymph nodes involves
✓
Severity of neoplastic disease
Neurogenic involvement
Level of nodular appearance
Correct Answer
Number of regional lymph nodes involves
The "N" value when staging a tumor represents the number of regional lymph nodes involved.
Question 23
The nurse is caring for a client experiencing hepatic encephalopathy. Which of the following medications does the nurse anticipate administering to remove excess ammonia?
Insulin
Lactulose
✓
Psyllium husk
Calcium gluconate
Correct Answer
Lactulose
Lactulose is a laxative which also works to remove excess ammonia.
Question 24
The nurse is assessing a client who complains of cyanotic, cold, numb, and painful fingers when exposed to cold or stress. Which of the following diagnoses does the nurse anticipate?
Venous insufficiency
Compartment syndrome
Raynaud's phenomenon
✓
Sjogren's syndrome
Correct Answer
Raynaud's phenomenon
Raynaud's phenomenon results in peripheral vasospasm causing cold, cyanotic, numb, and/or painful fingers after exposure to cold or stress.
Question 25
The nurse is developing a plan of care for a patient at risk for the development of rheumatic fever. Which of the following diagnoses would increase that risk?
Consumption of raw or undercooked meat
Cellulitis infection with methicillin-resistant Staphylococcus aureus
Family history of rheumatic fever
Respiratory infection with group A Streptococci
✓
Correct Answer
Respiratory infection with group A Streptococci
Respiratory infection with group A beta-hemolytic Streptococci (GABHS) is a key factor in the development of rheumatic fever.
Question 26
The nurse is preparing to assist with synchronized cardioversion. Which of the following arrhythmias does the nurse anticipate is this client's diagnosis?
Pulseless ventricular tachycardia
Supraventricular tachycardia
✓
Ventricular fibrillation
Asystole
Correct Answer
Supraventricular tachycardia
Synchronized cardioversion is indicated for a patient in SVT. Patients in pulseless ventricular tachycardia and ventricular fibrillation should receive defibrillation. Patients in asystole should receive CPR.
Question 27
A nurse is caring for a client with a venous thromboembolism (VTE). While discussing contributing factors to VTE development with a student nurse, which of the following symptoms if stated by the student nurse as one of Virchow's triad would require follow up?
Hypercoagulability
Endothelial injury
Impaired blood flow
Hypocoagulability
✓
Correct Answer
Hypocoagulability
The three parts of Virchow's triad are endothelial injury, impaired blood flow, and hypercoagulability.
Question 28
The nurse is reviewing causes of metabolic acidosis with a student nurse. Which of the following potential causes if stated by the student nurse would require follow up?
Diarrhea
Kidney failure
Diabetic ketoacidosis
Hyperglycemic hyperosmolar state
✓
Correct Answer
Hyperglycemic hyperosmolar state
Diarrhea, kidney failure, and DKA may all cause metabolic acidosis. Hyperglycemic hyperosmolar state does not result in an acid/base imbalance.
Question 29
The nurse is reviewing the use of synchronized cardioversion with a student nurse. Which of the following arrhythmias if stated by a the student as appropriate for synchronized cardioversion would require follow up?
Pulseless ventricular tachycardia
✓
Supraventricular tachycardia
Atrial fibrillation with rapid ventricular response
Stable ventricular tachycardia
Correct Answer
Pulseless ventricular tachycardia
Synchronized cardioversion is indicated for the treatment of SVT, stable ventricular tachycardia, and atrial fibrillation with rapid ventricular response. Patients with pulseless ventricular tachycardia should receive defibrillation.
Question 30
The nurse is reviewing the use of defibrillation with a student nurse. Which of the following arrhythmias if stated by a the student as appropriate for defibrillation would require follow up?
Pulseless electrical activity
✓
Coarse ventricular fibrillation
Fine ventricular fibrillation
Pulseless ventricular tachycardia
Correct Answer
Pulseless electrical activity
Defibrillation is indicated for pulseless ventricular tachycardia and ventricular fibrillation (both coarse and fine). Patients in pulseless electrical activity should receive CPR, not defibrillation.
Question 31
The nurse is caring for a client who is to undergo a thoracentesis procedure. What position should the nurse assist the client into while preparing for this procedure?
Trendelenburg
Prone
Left lateral recumbent
Sitting upright with arms on an overbed table
✓
Correct Answer
Sitting upright with arms on an overbed table
A patient receiving a thoracentesis to drain fluid from the lungs should be positioned sitting upright with the arms supported on pillows or an overbed table.
Question 32
The nurse is reviewing chest tubes with a student nurse as they assess a client's chest tube drainage system. The student nurse notes tidaling in the water seal chamber. Which of the following statements would be accurate if used to describe the cause of the tidaling?
An air leak
Too little suction
Too much suction
The patient's breathing
✓
Correct Answer
The patient's breathing
Tidaling refers to the gentle movement of the water seal caused by pressure changes related to a patient's breathing. This is an expected finding.
Question 33
The nurse is assessing a client's chest tube collection system. In which area does the nurse expect to see continuous bubbling?
Within the chest tube
Suction control chamber
✓
Water seal chamber
At the insertion site
Correct Answer
Suction control chamber
Continuous bubbling within the suction control chamber demonstrates that the suction is working appropriately. Continuous bubbling is an unexpected finding anywhere else in the closed system.
Question 34
The nurse is caring for a client with a chest tube. The chest tube has become disconnected from the drainage system. What is the nurse's priority action?
Place the end of the tube in sterile water
✓
Remove the chest tube from the patient
Assess the patient's respiratory status
Call the provider
Correct Answer
Place the end of the tube in sterile water
Although the nurse should alert the provider and assess the patient's respiratory status, the priority action is to place the end of the tube into sterile water to maintain the water seal and prevent additional complications.
Question 35
The nurse is caring for a client experiencing massive proteinuria, frothy urine, edema, and weight gain. Which diagnosis should the nurse anticipate?
Nephrotic syndrome
✓
Glomerulonephritis
Hemolytic uremic syndrome
Renal tubular acidosis
Correct Answer
Nephrotic syndrome
Nephrotic syndrome is marked by massive proteinuria (resulting in frothy urine), edema due to protein loss, and weight gain as a result of fluid retention.
Question 36
A male client reports urinary frequency, hesitancy, and post-void dribbling. When reviewing the client's lab results, the nurse notes which lab result is indicative of benign prostatic hyperplasia?
PSA = 6 ng/mL
✓
Creatinine = 1.2 mg/dL
WBC = 4,000/mm3
BUN = 6 mg/dL
Correct Answer
PSA = 6 ng/mL
A patient with benign prostatic hyperplasia may have an increased prostate specific antigen level (PSA >4), increased WBCs if a UTI is present, and increased BUN and/or creatinine if the kidneys are involved.
Question 37
The nurse is caring for a client who has experienced a spinal injury. The nurse would be concerned about neurogenic shock if the injury is above what level?
S1
C5
L3
T6
✓
Correct Answer
T6
Neurogenic shock is marked by hypotension, bradycardia, and temperature instability and most commonly occurs with a spinal injury above T6.
Question 38
A nurse is caring for a patient with suspected lyme disease. The patient presents with a ring-shaped, bullseye lesion. Which stage of lyme disease does this finding indicate?
Stage III
Stage II
Unstageable
Stage I
✓
Correct Answer
Stage I
Stage I lyme disease symptoms include a ring-shaped, bullseye lesion and flu-like symptoms.
Question 39
A patient has burns on their anterior trunk and entire right arm. Using the rule of nines, what percentage of the patient's body surface area is affected by the burn?
22.50%
18%
36%
27%
✓
Correct Answer
27%
Using the rule of nines, each arm is 9%. The anterior trunk is 18%. So the total percentage is 9 + 18 = 27%.
Question 40
The nurse is caring for a client experiencing a painful, unilateral vesicular rash that runs along a dermatome. The nurse anticipates diagnosis of which virus?
Measles
Rubeola
Herpes zoster
✓
Rubella
Correct Answer
Herpes zoster
Herpes zoster, often known as shingles, may cause a painful, unilateral vesicular rash that runs along a dermatome.
Question 41
The nurse should anticipate airborne precautions for a patient with which of the following conditions?
The nurse is providing education to a client with a new diagnosis of herpes simplex virus. Which statement by the nurse would be best to include in this teaching?
There is no difference in spread or symptoms between HSV-1 and HSV-2
HSV-1 is typically spread through contaminated saliva, HSV-2 is typically spread by sexual contact
✓
HSV-1 lesions typically appear on the genitals, HSV-2 lesions typically appear on the mouth and lips
HSV-1 can be cured, but HSV-2 cannot be cured
Correct Answer
HSV-1 is typically spread through contaminated saliva, HSV-2 is typically spread by sexual contact
HSV-1 is typically spread by direct contact with contaminated saliva. The lesions occur on the mouth and/or lips. HSV-2 is spread primarily by sexual contact and causes genital lesions. Both are incurable.
Question 43
A nurse is caring for a patient with a chief complaint of an itchy scalp and hair loss. The nurse notes a ring shaped rash on the patient's head during the initial assessment. Which infection does the nurse suspect?
Tinea cruris
Tinea pedis
Tinea corporis
Tinea capitis
✓
Correct Answer
Tinea capitis
Tinea capitis occurs on the head. It is more commonly known as ringworm.
Question 44
The nurse assesses a patient for pressure injuries and notes a partial thickness pressure injury with an exposed dermis. How should the nurse document this finding?
Stage 3
Unstageable
Stage 1
Stage 2
✓
Correct Answer
Stage 2
A stage 2 pressure injury is marked by a partial thickness erosion through the epidermis with exposed dermis.
Question 45
A wound care nurse has assessed a pressure injury that has partial thickness skin loss and a moist, red wound base. What stage is this wound?
Stage 4
Stage 3
Stage 2
✓
Stage 1
Correct Answer
Stage 2
Stage 2 wounds have partial thickness skin loss, exposed dermis, and can be red/moist or have a serous-filled blister.
Question 46
A nurse receives the lab results for a patient and notes that the CD4 lymphocytes are decreased. Which disorder does this patient likely have?
Hashimoto's disease
Pulmonary hypertension
HIV
✓
Lupus
Correct Answer
HIV
HIV is a common cause of decreased CD4 lymphocytes.
Question 47
The nurse is assisting a client receiving brachytherapy. Which of the following interventions made by a previous nurse would require follow up?
Keep the patient's door closed at all times
Have the patient wear a dosimeter badge
✓
Limit visitors to 30 minutes
Keep a lead-lined container in the room
Correct Answer
Have the patient wear a dosimeter badge
The nurse, not the patient, should wear a dosimeter badge. All other options are indicated when caring for a patient receiving brachytherapy.
Question 48
The nurse identifies that a patient with which of the following is at an increased risk for developing cervical cancer?
Gonorrhea
Syphilis
HPV infection
✓
Chlamydia
Correct Answer
HPV infection
Infection with the human papillomavirus (HPV) is the primary risk factor for developing cervical cancer.
Question 49
A nurse is caring for a patient with syphilis. The nurse assesses the patient and notes the patient has a rash on their hands and feet. Which stage of syphilis is this patient experiencing?
Latent
Secondary
✓
Tertiary
Primary
Correct Answer
Secondary
A rash on the hands and feet is indicative of the secondary stage of syphilis. The patient may also experience flu-like symptoms during this stage.
Question 50
A nurse is educating a patient on peritoneal dialysis. Which of the following findings could indicate peritonitis?
Lower extremity myalgia
Dyspnea at rest
Constipation
Cloudy dialysate
✓
Correct Answer
Cloudy dialysate
Peritonitis is a possible complication of peritoneal dialysis. The first sign that a patient may have peritonitis is cloudy or bloody dialysate outflow.
Question 51
A nurse caring for a patient with glomerulonephritis understands that due to an increase in membrane permeability the patient will have:
An increased GFR and oliguria
A decreased GFR and oliguria
✓
An increased GFR and polyuria
A decreased GFR and polyuria
Correct Answer
A decreased GFR and oliguria
A patient with glomerulonephritis will have a decreased glomerular filtration rate leading to oliguria.
Question 52
Which bacteria is the most common cause of a urinary tract infection?
Klebsiella terrigena
Escherichia coli
✓
Group A streptococcus
Streptococcus pneumoniae
Correct Answer
Escherichia coli
E. coli is the most common pathogen responsible for urinary tract infections.
Question 53
A nurse is caring for an elderly patient who has new onset confusion, urinary frequency, and cloudy foul-smelling urine. The provider orders a urinalysis. Which result would indicate the patient has a urinary tract infection?
Positive for protein.
Negative for leukocyte esterase, nitrites, and bacteria
Negative for leukocyte esterase and nitrites
Positive for leukocyte esterase and nitrites
✓
Correct Answer
Positive for leukocyte esterase and nitrites
Urinary tract infection urinalysis results may include: positive for leukocyte esterase, nitrites, bacteria, white blood cells, and hematuria.
Question 54
A nurse is providing care for a patient experiencing incontinence of small amounts of urine when coughing, sneezing, or laughing. The nurse should provide teaching to this patient on which type of incontinence?
Stress incontinence
✓
Overflow incontinence
Urge incontinence
Functional incontinence
Correct Answer
Stress incontinence
Stress incontinence is caused by a weak pelvic floor. It results in small urine loss when sneezing, coughing, or laughing. Kegel exercises, weight loss, and vaginal cone therapy are all treatment options for stress incontinence.
Question 55
A nurse is caring for a patient with renal irregularities. The patient's urinalysis results indicate a urine specific gravity of 1.225. Which finding would the nurse expect to assess?
Bloody urine
Concentrated urine
✓
Dilute urine
Normal appearing urine
Correct Answer
Concentrated urine
The normal range for urine specific gravity is 1.010 - 1.025. A high urine specific gravity will result in concentrated urine. A low urine specific gravity will result in dilute urine.
Question 56
The nurse assesses a patient who has Cullen's sign, Turner's sign, and severe left upper quadrant pain. The nurse identifies the patient as having symptoms of which disorder?
Cholecystitis
Pancreatitis
✓
Appendicitis
Colitis
Correct Answer
Pancreatitis
Pancreatitis is marked by severe LUQ pain and may also result in the presence of Cullen's and Turner's signs.
Question 57
The nurse is caring for a client diagnosed with ulcerative colitis. Which of the following symptoms does the nurse anticipate the client may report?
12 liquid stools yesterday
✓
Weight gain
Flank pain
No bowel movement for 4 days
Correct Answer
12 liquid stools yesterday
Patients with ulcerative colitis have continuous ulcerations in the colon causing 10 - 20 liquid stools per day.
Question 58
When palpating a patient's abdomen, the nurse notes it to be painful, rigid, and "board-like." Which condition might this patient be experiencing?
Intussusception
Cholecystitis
Peritonitis
✓
Primary biliary cholangitis
Correct Answer
Peritonitis
Inflammation of the lining of the abdomen, known as peritonitis, is likely to present with a painful, rigid, board-like abdomen.
Question 59
A patient diagnosed with appendicitis has been experiencing 8/10 pain, but tells the nurse "I actually feel a lot better all of a sudden." What is the nurse's priority action?
Notify the provider
✓
Take the patient's temperature
Assess the patient's WBC
Administer acetaminophen instead of morphine
Correct Answer
Notify the provider
Sudden relief of pain in a patient with appendicitis may indicate appendiceal rupture, a true medical emergency. The nurse should immediately alert the provider, as this patient likely requires emergent surgery.
Question 60
The nurse is caring for a client who has reported experiencing abdominal pain approximately 2-3 hours after eating and is worse at night. Which type of ulcer does the nurse suspect the client may have?
Esophageal
Gastric
Duodenal
✓
Jejunal
Correct Answer
Duodenal
Patients with duodenal ulcers are likely to report pain 2 - 3 hours after eating which is worse at night.
Question 61
The nurse is caring for a client who has reported experiencing abdominal pain approximately 15-30 minutes after eating and is worse during the day. Which type of ulcer does the nurse suspect the client may have?
Duodenal
Jejunal
Gastric
✓
Esophageal
Correct Answer
Gastric
Patients with gastric ulcers are likely to report pain 15 - 30 minutes after eating which is worse during the day.
Question 62
The nurse is caring for a client experiencing a hyperglycemic hyperosmolar state. Which finding does the nurse anticipate assessing?
Kussmaul's respirations
Ketonuria
Elevated blood sugar
✓
Metabolic acidosis
Correct Answer
Elevated blood sugar
HHS is a form of hyperglycemia marked by elevated blood sugar, polydipsia, polyuria, and polyphagia. Unlike DKA, the patient will not present with metabolic acidosis, ketonuria, or Kussmaul's respirations.
Question 63
The nurse is educating a client regarding their type II diabetes mellitus diagnosis. Which of the following is most likely the goal for their hemoglobin A1C?
< 6.5%
< 5.5%
< 7%
✓
< 10%
Correct Answer
< 7%
For a patient with type 2 diabetes mellitus, the goal for their hemoglobin A1C is for it to be below 7%.
Question 64
The nurse is caring for a client who has experienced damage to the parathyroid gland during a thyroidectomy. Which of the following electrolyte imbalances does the nurse understand may occur?
Hypercalcemia
Hyperkalemia
Hypocalcemia
✓
Hypomagnesemia
Correct Answer
Hypocalcemia
Damage to the parathyroid gland may results in hypocalcemia.
Question 65
When reviewing labs for a patient with primary hypothyroidism, which lab value does the nurse expect to be increased?
T3
T4
TSH
✓
Thyroxine
Correct Answer
TSH
A patient with primary hypothyroidism will have an increased thyroid stimulating hormone value, as the anterior pituitary gland attempts to compensate for the low T3/T4 values produced by the thyroid.
Question 66
The nurse is reviewing signs of Cushing's disease with a student nurse. Which of the following symptoms if stated by the student nurse would require follow up?
Buffalo hump
Bronze skin color
✓
Moon face
Fluid retention
Correct Answer
Bronze skin color
Patients with Cushing's syndrome may have a "buffalo hump," a rounded "moon face," and fluid retention. Bronze skin color is seen in Addison's disease.
Question 67
The nurse is providing client education to a client with Addison's disease. Which of the following potential related alterations if stated by the client would require follow up?
Hyperglycemia
Hyperkalemia
✓
Hypocalcemia
Hypernatremia
Correct Answer
Hyperkalemia
Hypocalcemia, hypernatremia, and hyperglycemia are expected findings in a patient with Addison's disease. This patient would likely have hypokalemia, not hyperkalemia.
Question 68
The nurse is reviewing signs of Addison's disease with a student nurse. Which of the following symptoms if stated by the student nurse would require follow up?
Fluid retention
✓
Hypotension
Hypoglycemia
Bronze skin color
Correct Answer
Fluid retention
Patients with Addison's disease may have weakness, fatigue, weight loss, bronze skin color, hypotension, dehydration, and hypoglycemia.
Question 69
Excess ADH resulting in small amounts of concentrated urine and fluid volume excess is indicative of which endocrine disorder?
Addison's disease
Diabetes insipidus
Diabetic ketoacidosis
SIADH
✓
Correct Answer
SIADH
Syndrome of inappropriate antidiuretic hormone (SIADH) results in the patient only producing small amounts of concentrated urine and demonstrating fluid volume excess.
Question 70
Insufficient ADH resulting in large amounts of dilute urine is indicative of which endocrine disorder?
Diabetic ketoacidosis
Diabetes insipidus
✓
SIADH
Cushing's disease
Correct Answer
Diabetes insipidus
Diabetes insipidus results in the patient producing large amounts of dilute urine.
Question 71
The nurse is caring for a client who reports experiencing a sweet-tasting drainage from their nose and a headache. The nurse notes a halo-sign when assessing the drainage. Which of the following is most likely occurring?
Nosebleed
Cerebrovascular accident
Cerebrospinal fluid leakage
✓
Sinus infection
Correct Answer
Cerebrospinal fluid leakage
CSF leakage may be indicated by a halo sign in the drainage (clear in the center, yellow on the edges), sweet-tasting drainage, presence of glucose in the drainage, and a headache.
Question 72
A patient experiences malignant hyperthermia. Which medication does the nurse anticipate administering?
Dantrolene
✓
Flumazenil
Naloxone
Baclofen
Correct Answer
Dantrolene
Dantrolene, a skeletal muscle relaxant, is indicated in the emergent treatment of malignant hyperthermia.
Question 73
The nurse ensures that a wrench or screwdriver is always present for a patient in which type of traction?
Skin traction
Halo traction
✓
Buck's traction
Bryant's traction
Correct Answer
Halo traction
A wrench or screwdriver should be present in case of emergency for any patient in Halo traction.
Question 74
The nurse is providing education to a client who is going to be having a cast placed. How should the nurse instruct the client to relieve itching under the cast?
Wrap an ace bandage around the cast tightly
Take diphenhydramine around the clock
Blow cool air from a hair dryer under the cast
✓
Use a ruler to scratch underneath the cast
Correct Answer
Blow cool air from a hair dryer under the cast
The patient should be educated to never use a ruler or other object to scratch underneath the cast. Instead, blowing cool air under the cast with a hair dryer may be beneficial.
Question 75
A patient has undergone a fasciotomy. Which complication did this patient likely experience?
Osteomyelitis
Femur fracture
Avascular necrosis
Compartment syndrome
✓
Correct Answer
Compartment syndrome
Compartment syndrome is a condition marked by elevated pressure within and around muscles which may require a fasciotomy to relieve this build up of pressure.
Question 76
The nurse is caring for a client experiencing an acute gout attack. Which medication does the nurse anticipate administering?
Colchicine
✓
Febuxostat
Allopurinol
Promethazine
Correct Answer
Colchicine
Colchicine is a medication indicated in the treatment of acute gout. Allopurinol and febuxostat are indicated in the treatment of chronic gout. Promethazine is an antiemetic unrelated to the treatment of gout.
Question 77
The nurse should educate a patient to engage in which of the following activities following a hip arthroplasty?
Bend at the waist to put on shoes
Avoid use of a pillow between the knees when sleeping
Use an elevated toilet seat
✓
Cross ankles when sitting
Correct Answer
Use an elevated toilet seat
Following a hip arthroplasty a patient should not allow hip flexion past 90 degrees, should avoid low chairs, should not cross ankles or legs, use an elevated toilet seat, and sleep with a hip abductor pillow between knees.
Question 78
Which condition is marked by unilateral joint pain, Heberden's nodes and Bouchard's nodes?
Rheumatoid arthritis
Osteoarthritis
✓
Scoliosis
Raynaud's
Correct Answer
Osteoarthritis
Osteoarthritis is a progressive musculoskeletal disorder marked by unilateral joint pain along with Heberden's and Bouchard's nodes.
Question 79
Which condition is marked by bilateral joint pain, morning stiffness, swan neck deformity, and boutonniere deformity?
Ankylosing spondylitis
Rheumatoid arthritis
✓
Scleroderma
Osteoarthritis
Correct Answer
Rheumatoid arthritis
Rheumatoid arthritis is an autoimmune condition marked by bilateral joint pain, morning stiffness, and swan neck/boutonniere deformities.
Question 80
A patient is experiencing tinnitus, unilateral sensorineural hearing loss, and vertigo. What diagnosis does the nurse anticipate?
Cerumen impaction
Ménière's disease
✓
Otitis media
Bell's palsy
Correct Answer
Ménière's disease
Ménière's disease is a condition marked by tinnitus, unilateral sensorineural hearing loss, and vertigo.
Question 81
A patient comes into the emergency room stating they are having trouble seeing. The patient states "It's like a curtain has been pulled over my eye". Which eye disorder does the nurse expect this patient to have?
Macular degeneration
Open angle glaucoma
Closed angle glaucoma
Retinal detachment
✓
Correct Answer
Retinal detachment
Retinal detachment causes floaters, flashing lights, and a sudden painless feeling of a curtain being pulled over the visual field.
Question 82
A nurse is caring for a patient who has had a loss of central vision. The nurse understands this is a sign of which eye disorder?
Open angle glaucoma
Retinal detachment
Closed angle glaucoma
Macular degeneration
✓
Correct Answer
Macular degeneration
Macular degeneration results in loss of central vision.
Question 83
A nurse is caring for a patient who has had a gradual increase in intraocular pressure. The nurse understands this is a sign of which eye disorder?
Open angle glaucoma
✓
Retinal detachment
Closed angle glaucoma
Macular degeneration
Correct Answer
Open angle glaucoma
Open angle glaucoma occurs when there is an overproduction of aqueous humor or obstruction of outflow. This results in a gradual increase of intraocular pressure.
Question 84
The nurse should educate a patient to avoid which of the following activities following cataract surgery?
Wearing glasses
Increasing dietary fiber
Blowing their nose
✓
Taking stool softeners
Correct Answer
Blowing their nose
Patients should avoid activities that could increase intraocular pressure following cataract surgery (e.g., blowing nose, bending at the waist, lifting > 10 pounds, wearing tight collars, straining with bowel movements).
Question 85
Within how many hours of symptom onset must the nurse administer thrombolytics to a patient experiencing an ischemic stroke?
Three
✓
One
Six
Twelve
Correct Answer
Three
Patients with ischemic stroke must receive thrombolytics within three hours of symptom onset.
Question 86
A nurse is caring for a patient who has recently had a stroke affecting the left side of their brain. Which of the following signs/symptoms would the nurse expect to be present?
Overestimation of abilities
Poor judgement
Inability to speak or understand language
✓
Left-sided weakness
Correct Answer
Inability to speak or understand language
A stroke affecting the left hemisphere of the brain may cause the patient to have difficulty speaking and understanding language. Overestimation of abilities, poor judgement and impulse control, and left-sided weakness are associated with a stroke that affects the right hemisphere.
Question 87
A patient has complained of tingling in their feet. The nurse assesses this patient and notes symmetric paralysis. The patient states it began at their feet and has been moving up. Which disorder is this a characteristic of?
Myasthenia gravis
Stroke
Guillain-barre syndrome
✓
Spinal cord injury
Correct Answer
Guillain-barre syndrome
Guillain-barre syndrome is an autoimmune disorder that affects the peripheral nervous system. It causes a sudden onset of weakness and paralysis beginning at the feet and moving upward.
Question 88
Which autoimmune disorder is characterized by the development of plaque in the white matter of the central nervous system?
Transverse myelitis
Myasthenia gravis
Multiple sclerosis
✓
Chiari malformation
Correct Answer
Multiple sclerosis
Multiple sclerosis is an autoimmune disorder which causes the development of plaque in the white matter of the central nervous system.
Question 89
A patient with a spinal cord injury presents with extreme hypertension, severe headache, blurred vision, and diaphoresis. The nurse anticipates which diagnosis?
Autonomic dysreflexia
✓
Sepsis
Neurogenic shock
Meningitis
Correct Answer
Autonomic dysreflexia
Autonomic dysreflexia is a complication of spinal cord injury characterized by extreme hypertension, severe headache, blurred vision, and diaphoresis.
Question 90
A nurse is caring for a patient with a spinal cord injury. The nurse is assessing the patient and notes extreme hypertension and diaphoresis. What should be the nurse's first action?
Administer antihypertensives.
Check to see if the patient's urinary catheter is kinked.
Sit the patient up and loosen any restrictive clothing.
✓
Monitor the patient's blood pressure.
Correct Answer
Sit the patient up and loosen any restrictive clothing.
Extreme hypertension and diaphoresis after a spinal cord injury is indicative of autonomic dysreflexia. The first action the nurse should take is to sit the patient up and loosen any restrictive clothing.
Question 91
Following a motor vehicle collision, a patient experiences neurogenic shock. Which of the following is the nurse likely to observe in this patient?
Pain below the level of the injury
Jaundice
Muscle rigidity
Hypotension
✓
Correct Answer
Hypotension
Neurogenic shock is marked by hypotension, bradycardia, and temperature instability.
Question 92
A nurse is caring for a patient with Alzheimer's. The nurse is providing discharge teaching to the patient and family. Which of the following is important for the family to do to keep the patient safe at home?
Place door locks where the patient can easily reach them
Allow the patient to have a flexible schedule
Remove throw rugs from the home
✓
Remove bright lighting from the home
Correct Answer
Remove throw rugs from the home
For a patient with Alzheimer's disease, it is important to remove throw rugs from the home as they are a tripping hazard. The patient should have a structured schedule, door locks should be out of reach/sight, and the home should be well lit especially around stairs.
Question 93
The nurse is aware that which disorder is characterized by the formation of beta-amyloid deposits and neurofibrillary tangles in the brain?
Amyotrophic lateral sclerosis
Huntington's disease
Alzheimer's disease
✓
Parkinson's disease
Correct Answer
Alzheimer's disease
Alzheimer's disease is a progressive and irreversible neurological condition marked by beta-amyloid deposits and neurofibrillary tangles in the brain.
Question 94
The nurse assesses a patient who presents with muscle rigidity, persistent tremor, and a festinating gait. Which condition does the nurse identify is the likely cause for these findings?
Brown-Sequard syndrome
Parkinson's disease
✓
Neurogenic shock
Cerebrovascular accident
Correct Answer
Parkinson's disease
Parkinson's disease is a progressive neurodegenerative disorder characterized by muscle rigidity, tremor, and a festinating (i.e., slow, shuffling) gait.
Question 95
Which isolation precautions are required for a patient with suspected or confirmed bacterial meningitis?
Protective
Universal
Airborne
Droplet
✓
Correct Answer
Droplet
Patients with suspected or confirmed bacterial meningitis should be placed in droplet precautions.
Question 96
Which disorder is characterized by positive Kernig's and Brudzinski's signs and nuchal rigidity?
Spinal cord injury
Meningitis
✓
Subarachnoid hemorrhage
Appendicitis
Correct Answer
Meningitis
Patients with meningitis will demonstrate nuchal rigidity and positive Kernig's and Brudzinski's signs.
Question 97
A patient with suspected meningitis is unable to straighten their leg when their hip is flexed to 90 degrees due to severe stiffness in the hamstrings. This indicates the patient is positive for which sign?
Trousseau's sign
Brudzinski's sign
Chvostek's sign
Kernig's sign
✓
Correct Answer
Kernig's sign
A positive Kernig's sign is when the patient has extreme tightness of the hamstrings and is unable to straighten the leg when the hip is flexed at 90 degrees. This is a sign of meningitis.
Question 98
The nurse is caring for a client who reports experiencing a type of seizure characterized by day dreaming, eye fluttering, or picking at their clothes. Which diagnosis does the nurse anticipate?
Absence seizure
✓
Focal seizure
Grand mal seizure
Tonic clonic seizure
Correct Answer
Absence seizure
An absence seizure may cause the patient to look as though they are daydreaming, having fluttering of the eyes, or performing repetitive motions such as picking at clothes.
Question 99
The nurse is assessing a patient with cluster headaches and expects they will report which of the following symptoms?
Nasal congestion
✓
Vomiting
Phonophobia
Pain gets better by lying down
Correct Answer
Nasal congestion
Cluster headaches are characterized by severe unilateral non-throbbing headache, facial sweating, and nasal congestion and are made better by pacing/movement.
Question 100
A patient demonstrates difficulty coordinating muscle movements and maintaining posture and balance. The nurse anticipates a history of injury to which part of the brain?
Corpus callosum
Cerebellum
✓
Frontal lobe
Pons
Correct Answer
Cerebellum
The cerebellum is responsible for posture, balance, and coordination of muscle movements. Injury to this area would likely result in difficulty with these actions.
Question 101
A nurse is caring for a patient with damage to part of the frontal lobe and has a referral for a speech therapist. Which part of the brain could have been damaged to require this referral?
Parietal lobe
Broca's area
✓
Wernicke's area
Occipital lobe
Correct Answer
Broca's area
Broca's area controls speech function. If this area was damaged, a patient may benefit from working with a speech therapist.
Question 102
A nurse is caring for a patient who was recently diagnosed with anemia. The nurse receives an order for the patient to receive intranasal cyanocobalamin. Based on this treatment, which type of anemia does the patient most likely have?
Aplastic
Pernicious
✓
Hemolytic
Iron-deficiency
Correct Answer
Pernicious
Pernicious anemia occurs with a lack of intrinsic factor in the gastric mucosa, which impairs B12 absorption. The treatment is cyanocobalamin (B12).
Question 103
Which type of shock does the nurse anticipate occurring when caring for a patient with extreme blood loss following a gunshot wound?
Hypovolemic shock
✓
Neurogenic shock
Septic shock
Cardiogenic shock
Correct Answer
Hypovolemic shock
Patients with extreme blood loss will experience hypovolemic shock.
Question 104
The nurse is caring for a client diagnosed with septic shock. Which of the following findings would the nurse anticipate?
Hypotension
✓
Bradycardia
Bradypnea
Hypertension
Correct Answer
Hypotension
Patients with septic shock typically have hypotension, tachycardia, tachypnea, and either hyper or hypothermia. Hypertension, bradycardia, and bradypnea are not expected findings in septic shock.
Question 105
Following a peripheral bypass graft, which complication is characterized by numbness, pain with passive movement, edema, and taut skin?
Avascular necrosis
Compartment syndrome
✓
Osteomyelitis
Cellulitis
Correct Answer
Compartment syndrome
Compartment syndrome is a condition marked by pain, pallor, pulselessness, paresthesias, and swelling of the affected area.
Question 106
A patient has been diagnosed with primary hypertension and wonders what caused it. Which of the following factors would the nurse include in an explanation of the causes of primary hypertension?
Stress
✓
Kidney disease
Hyperthyroidism
Cushing's syndrome
Correct Answer
Stress
Primary hypertension can be caused by family history, stress, obesity, smoking, and high sodium intake. Secondary hypertension is caused by disease or medication use.
Question 107
The nurse is assessing a client's cardiovascular system and notes muffled heart sounds, a paradoxical pulse, and jugular vein distention. What diagnosis does the nurse anticipate?
The nurse is auscultating heart sounds on a client diagnosed with pericarditis. Which of the following sounds does the nurse anticipate hearing?
S3
Friction rub
✓
S4
Murmur
Correct Answer
Friction rub
A friction rub is likely to be auscultated in a patient with pericarditis.
Question 109
A nurse is reviewing client teaching with a client who just received a pacemaker. The client asks what it means if their pacemaker is synchronous. Which of the following would be the best response by the nurse?
A synchronous pacemaker fires only when the heart's intrinsic rate falls below a certain rate
✓
A synchronous pacemaker fires when the patient activates it on a device
An synchronous pacemaker fires only when the heart's intrinsic rate rises above a certain rate
A synchronous pacemaker fires at a constant rate
Correct Answer
A synchronous pacemaker fires only when the heart's intrinsic rate falls below a certain rate
A synchronous pacemaker fires only when the heart's intrinsic rate falls below a certain predetermined rate. The other type of pacemaker is asynchronous which fires at a constant rate regardless of the heart's electrical activity.
Question 110
The nurse is providing education to a client scheduled for a cardioversion. Which medication should the nurse anticipate teaching the client to take for at least three weeks prior to the procedure?
Corticosteroid
Anticoagulant
✓
NSAID
Adrenergic agonist
Correct Answer
Anticoagulant
Prior to a scheduled cardioversion a patient should be appropriately anticoagulated to prevent accidental dislodging of a blood clot during the procedure.
Question 111
A client's telemetry alarm notifies the nurse that they are experiencing asystole. The nurse assesses the client and finds no pulse. What is the nurse's priority action?
Initiate CPR
✓
Obtain a 12-lead EKG
Defibrillate the patient
Call the provider
Correct Answer
Initiate CPR
A patient in asystole requires immediate initiation of CPR. While the provider should be contacted, the nurse should immediately begin CPR. Defibrillation and obtaining an EKG are not appropriate interventions for asystole.
Question 112
A nurse is reviewing care for a patient with a pulse experiencing ventricular tachycardia with a nursing student. Which of the following interventions suggested by the student nurse would require follow up?
Defibrillation
✓
Antiarrhythmics
Cardioversion
Correction of electrolyte imbalances
Correct Answer
Defibrillation
Treatment for VT with a pulse includes: cardioversion, antiarrhythmics, and correction of electrolyte imbalances. Defibrillation is indicated for pulseless ventricular tachycardia.
Question 113
An emergency room nurse is caring for a patient. The patient goes into ventricular fibrillation. What intervention is appropriate?
Cardioversion
CPR
Digoxin
Defibrillation
✓
Correct Answer
Defibrillation
Defibrillation is the treatment for ventricular fibrillation. Remember defib vfib!
Question 114
An emergency room nurse is caring for a patient. The patient goes into asystole. Which action should the nurse take first?
Defibrillate the patient with 360J
Administer 1 mg atropine
Begin chest compressions
✓
Call the provider
Correct Answer
Begin chest compressions
While the provider should be contacted, the nurse's priority is to immediately begin CPR. Defibrillation and administration of atropine are not indicated at this time.
Question 115
The nurse is providing client education to a client regarding their increased risk for blood clots. For which atrial dysrhythmia diagnosis would this education be appropriate?
Atrial tachycardia
Atrial fibrillation
✓
Supraventricular tachycardia
Atrioventricular nodal reentrant tachycardia
Correct Answer
Atrial fibrillation
Atrial fibrillation puts patients at risk for the development of blood clots due to ineffective blood flow through the atria causing pooling in the left atrial appendage.
Question 116
A patient presents to the emergency room stating that they had such severe heartburn that they took an entire bottle of antacids. Which acid/base imbalance does the nurse anticipate this patient may now be experiencing?
Respiratory alkalosis
Metabolic alkalosis
✓
Respiratory acidosis
Metabolic acidosis
Correct Answer
Metabolic alkalosis
An overdose of an antacid may result in metabolic alkalosis due to too much of a base being introduced to the patient's system.
Question 117
A nurse is caring for a diabetic patient who has been hospitalized for diabetic ketoacidosis (DKA). The nurse understands that which acid-base imbalance typically occurs with DKA?
Respiratory acidosis
Metabolic alkalosis
Metabolic acidosis
✓
Respiratory alkalosis
Correct Answer
Metabolic acidosis
DKA causes ketones to build up in the bloodstream, leading to metabolic acidosis.
Question 118
A patient is extremely nervous about an upcoming procedure, and is experiencing a panic attack. What type of acid/base imbalance can occur as a result?
Respiratory acidosis
Metabolic alkalosis
Metabolic acidosis
Respiratory alkalosis
✓
Correct Answer
Respiratory alkalosis
A decrease in carbon dioxide caused by hyperventilation can result in respiratory alkalosis.
Question 119
Following surgery, a patient is experiencing severe pain when taking a deep breath, causing them to breathe more shallowly. What type of acid/base imbalance can occur as a result?
Metabolic alkalosis
Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
✓
Correct Answer
Respiratory acidosis
An increase in carbon dioxide caused by hypoventilation can result in respiratory acidosis.
Question 120
A nurse is caring for a patient with an acid-base imbalance. The patient was hyperventilating due to panic-level anxiety. Which imbalance is most likely occurring in this patient?
Respiratory acidosis
Metabolic alkalosis
Metabolic acidosis
Respiratory alkalosis
✓
Correct Answer
Respiratory alkalosis
Respiratory alkalosis can be caused by hyperventilation due to fear, anxiety, high altitude, salicylate toxicity, trauma, or pain.
Question 121
The nurse receives an order to administer 0.45% NaCl and encourage water intake. Which electrolyte imbalance does the nurse anticipate as this client's diagnosis?
Hypokalemia
Hypernatremia
✓
Hyperkalemia
Hyponatremia
Correct Answer
Hypernatremia
A patient experiencing hypernatremia may require additional oral water intake and administration of 0.45% NaCl (i.e., half normal saline) to help correct this electrolyte imbalance.
Question 122
A nurse is caring for a client with exhibiting positive Chvostek's sign, positive Trousseau's sign, and muscle spasms. Which of the following electrolyte imbalances does the nurse anticipate as the client's diagnosis?
Hypercalcemia
Hypocalcemia
✓
Hypernatremia
Hyponatremia
Correct Answer
Hypocalcemia
Signs of hypocalcemia include a positive Chvostek's sign, positive Trousseau's sign, muscle spasms, GI upset, and tingling/numbness of the lips or fingers.
Question 123
The nurse is caring for a client with an endotracheal tube. When planning the client's care, how often should the nurse anticipate repositioning the tube to prevent the development of a pressure injury?
Every 2 days
Every 24 hours
✓
Every 8 hours
Every 12 hours
Correct Answer
Every 24 hours
A patient's endotracheal tube should be repositioned every 24 hours to decrease the risk of developing a medical-device related pressure injury.
Question 124
The nurse is reviewing causes of ventilator high pressure alarms with a new nurse. Which cause if stated by the new nurse as resulting in a high pressure alarm would require follow up?
A leak in the tubing
✓
A kink in the tubing
Patient biting the ET tube
Patient coughing
Correct Answer
A leak in the tubing
High pressure ventilator alarms may be caused by pulmonary edema, pneumothorax, bronchospasm, biting, coughing, secretions, and kinks in the tubing. A leak in the tubing would cause a low pressure alarm.
Question 125
When caring for a patient diagnosed with unilateral lung disease, how should the nurse position this patient?
Laterally with the unaffected lung down
✓
Laterally with the unaffected lung up
Trendelenburg
Supine
Correct Answer
Laterally with the unaffected lung down
A patient with unilateral lung disease should be positioned side lying with their "good lung" (i.e., unaffected lung) down to increase airflow to the affected lung.
Question 126
How does the nurse expect a patient's trachea will be affected in the late stages of a right-sided pneumothorax?
Tracheal deviation to the left
✓
Tracheal bulging
Tracheal deviation to the right
Trachea will be midline
Correct Answer
Tracheal deviation to the left
In the late stages of pneumothorax, the trachea may deviate to the unaffected side. With right-sided pneumothorax, the patient would have tracheal deviation to the left.
Question 127
A patient presents with accumulation of fluid in the pleural space. What is this condition known as?
Pulmonary hypertension
Pulmonary edema
Pleural effusion
✓
Pneumothorax
Correct Answer
Pleural effusion
Pleural effusion is an accumulation of fluid in the pleural space.
Question 128
Upon percussion of the lungs of a patient with pneumothorax, what does the nurse expect to hear?
Dullness
Resonance
Tympany
Hyperresonance
✓
Correct Answer
Hyperresonance
Hyperresonance is heard over areas with large amounts of air, such as in the chest of a patient with pneumothorax.
Question 129
A patient reports having hemoptysis, night sweats, and weight loss over the past month. The patient should be evaluated further for which condition?
Influenza
Pneumonia
HIV
Tuberculosis
✓
Correct Answer
Tuberculosis
Purulent and/or bloody sputum (i.e., hemoptysis), night sweats, weight loss, lethargy, and cough lasting 3+ weeks are all potential signs of tuberculosis.
Question 130
The nurse is providing client education regarding pulmonary hypertension that has led to right ventricular enlargement and failure. Which disease process is the nurse describing?
Heart failure with reduced ejection fraction
Systolic heart failure
Cor pulmonale
✓
Diastolic heart failure
Correct Answer
Cor pulmonale
Cor pulmonale is a condition of right heart failure caused by pulmonary hypertension.
Question 131
The nurse is caring for a client with chronic obstructive pulmonary disorder (COPD). Which of the following findings does the nurse anticipate assessing?
Increased PaO2
Increased SpO2
Decreased PaCO2
Increased PaCO2
✓
Correct Answer
Increased PaCO2
Patients with COPD are likely to have a decreased PaO2, increased PaCO2, and decreased SpO2
Question 132
The nurse is educating a patient on how to use a peak flow meter. Which reading should the nurse educate a patient to record?
The middle number
The lowest number
The highest number
✓
The average of the three
Correct Answer
The highest number
When using a peak flow meter, the patient should record the highest of the three readings.
Question 133
Which of the following should the nurse identify as a late sign of hypoxia?
Pallor
Hypotension
✓
Tachypnea
Tachycardia
Correct Answer
Hypotension
Late signs of hypoxia include decreased LOC, bradycardia, bradypnea, hypotension, cyanosis, dysrhythmias, and lactic acidosis. The other options listed are early signs of hypoxia.
Question 134
Which of the following should the nurse identify as an early finding of hypoxia?
Irritability
✓
Cyanosis
Bradycardia
Decreased LOC
Correct Answer
Irritability
Early signs of hypoxia include restlessness, irritability, tachycardia, tachypnea, hypertension, and pallor. The other options listed are late signs of hypoxia.
Question 135
How does the nurse identify that a patient is ready to eat or drink following a bronchoscopy?
Patient is alert and oriented
GCS of 15
90 minutes have passed
Return of the gag reflex
✓
Correct Answer
Return of the gag reflex
Following a bronchoscopy a patient should be kept NPO until the gag reflex returns in order to reduce the risk for aspiration.