WorksheetsNCM 112 Lec Special Exam (Prelims)
Total questions: 99
Worksheet time: 52mins
A patient with a severe nasal fracture is bleeding heavily and breathing with difficulty. What is the nurse’s priority intervention?
Apply pressure to carotid arteries.
Suction continuously for comfort.
Insert an NG tube.
Maintain airway patency, position upright, apply ice, prepare for packing.
A 70-year-old man reports chest pain radiating to left arm. ECG: ST depression. Troponin: normal. Which diagnosis is most likely?
NSTEMI
Stable angina
STEMI
Variant angina
A 44-year-old woman scheduled for thyroidectomy is anxious and refuses to remove her wedding ring before surgery, insisting it is “for good luck.” As the circulating nurse, what is the most appropriate action?
Remove the ring forcibly and store it in the OR safe.
Tape the ring securely to the finger and document its presence.
Cancel the surgery until the patient consents to remove it.
Ignore it since it has sentimental value.
A patient with chest pain is given thrombolytic therapy. Thirty minutes later, he complains of severe back pain and hematuria. What should the nurse do first?
Encourage fluids.
Continue infusion but monitor closely.
Stop the thrombolytic infusion immediately and notify the provider.
Give additional aspirin.
A 45-year-old male presents with severe obstructive sleep apnea (OSA) confirmed by polysomnography. The physician recommends continuous positive airway pressure (CPAP), but the patient insists he prefers oxygen therapy at night instead. As the nurse, which is the most appropriate evaluation of this patient’s preference?
Oxygen therapy is safer and equally effective in treating OSA
Oxygen therapy will reduce both apnea episodes and cardiac risks
CPAP addresses airway obstruction, while oxygen alone does not
Patient autonomy overrides medical recommendations
A client undergoing emergency appendectomy is placed on NPO status. The client insists on drinking water because of a very dry mouth. Which instruction best explains the reason for NPO?
Instrument, sponge, and needle counts, and specimen labeling
The availability of postoperative blood test
Patient's allergies
The surgical site and procedure
A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause?
Decreased cardiac output
Coronary Arteriosclerosis
Decreased cardiac contractility
Infarction of the Myocardium
A 70-year-old patient with chronic bronchitis presents with increased sputum production, chronic cough, and cyanosis. Which term best describes this clinical presentation?
Silent chest
Pink puffer
Tripod position
Blue bloater
A 66-year-old male with a 30-pack-year history presents with progressive dyspnea, barrel chest, and pursed-lip breathing. Which COPD type is described?
Chronic bronchitis
Asthma
Pulmonary fibrosis
Emphysema
A 52-year-old heavy smoker presents with persistent hoarseness, sore throat, and difficulty swallowing for the past 3 months. The physician suspects laryngeal cancer.
A 48-year-old woman is scheduled for laparoscopic cholecystectomy. During the pre-op teaching, the nurse explains that CO₂ insufflation will be used. The patient asks why. Which explanation best helps the patient understand the purpose of insufflation?
Carbon dioxide prevents infection inside the abdomen.
CO₂ is used to numb the surgical area so you won’t feel pain.
Insufflation creates space in the abdomen to allow visualization and instrument movement.
CO₂ causes muscle relaxation systemically, making anesthesia easier.
A 45-year-old female scheduled for elective laparoscopic cholecystectomy arrives at the preoperative holding area. The nurse is conducting a preoperative assessment and notices that the patient states she has not removed her wedding ring due to fear of losing it. The nurse recalls that jewelry should be removed before surgery to prevent injury. Which is the primary rationale for removing jewelry before surgery?
It can harbor microorganisms that may contaminate the surgical wound
It may cause burns if electrocautery is used during surgery
It can cause damage to the surgical drapes and sterile field
It may be misplaced or lost during the procedure
A nurse is reviewing the informed consent form with a 39-year-old patient scheduled for thyroidectomy. The patient states, "I signed the paper but I don’t understand the risks." What is the nurse’s best immediate action?
Ask the surgeon to return and clarify the procedure with the patient
Re-explain the risks of the procedure in detail
Cancel the surgery until the patient fully understands the procedure
Continue preparing the patient for surgery since the form was already signed
A patient complains of severe flank pain radiating to the groin, nausea, and hematuria. The nurse suspects renal calculi. Which diagnostic test is most accurate for detecting urinary stones?
Abdominal X-ray (KUB)
Ultrasound
Intravenous pyelogram (IVP)
Non-contrast helical CT scan
A 45-year-old post-MI patient is enrolled in cardiac rehabilitation. The nurse is asked to design a program to maximize recovery. Which is the BEST plan?
Focus only on stress management to reduce myocardial oxygen demand
Encourage immediate vigorous exercise to restore endurance quickly
Develop a phased plan: start with light activity, gradually increase as tolerated, and include emotional support
Restrict the patient to bedrest for several weeks to prevent recurrence
A 45-year-old with pulmonary embolism (PE) has sudden pleuritic chest pain and hypoxemia. The nurse knows V/Q mismatch causes hypoxia in PE. Which statement best explains V/Q mismatch in PE?
Oxygen diffusion across the alveolar membrane is increased in PE.
Perfusion is reduced to ventilated alveoli because of blocked pulmonary vessels.
Alveoli are flooded with fluid preventing ventilation but perfusion continues.
There is increased ventilation with decreased perfusion due to airway obstruction.
A 72-year-old man with acute kidney injury from dehydration is on IV fluids. After 24 hours, urine output improved to 40 mL/hr, serum creatinine decreased from 3.2 to 1.8 mg/dL, and BUN dropped from 48 to 25 mg/dL. How should the nurse evaluate the effectiveness of therapy?
By assessing urine output
By checking serum creatinine levels
By monitoring BUN levels
By evaluating patient symptoms
A patient with pernicious anemia presents with pallor, fatigue, and glossitis. Which nutrient deficiency causes pernicious anemia?
Vitamin B12
Iron
Folic acid
Vitamin C
A 25-year-old male with a history of allergic rhinitis presents with sudden shortness of breath, inspiratory stridor, and swelling of the lips and tongue after eating peanuts. What is the most likely cause of the patient’s acute respiratory distress?
Laryngeal carcinoma
Epiglottitis
Asthma exacerbation
Anaphylactic reaction with airway obstruction
A 58-year-old woman with NSTEMI (non–ST elevation myocardial infarction) is admitted to the coronary care unit. She is started on oxygen, aspirin, clopidogrel, and IV heparin. The resident suggests starting thrombolytic therapy. As the nurse evaluating this plan, what is the best response?
Suggest discontinuing aspirin before giving thrombolytics
Agree because all myocardial infarctions require thrombolytics
Question the order because thrombolytics are contraindicated in NSTEMI
Administer as ordered because the patient is high risk
A nurse is caring for a client with laryngeal cancer scheduled for laryngectomy. Which early symptom most often leads to medical consultation?
Painful swallowing
Persistent hoarseness
Severe dyspnea
Hemoptysis
A 55-year-old woman underwent thyroidectomy. Four hours postop, she complains of difficulty breathing, stridor, and hoarseness. The nurse administered humidified O2 and notified the surgeon. The surgeon arrives after 15 minutes, performs suctioning, and orders emergency tracheostomy setup. How should the nurse evaluate her prior interventions?
Excessive — humidified oxygen is contraindicated in upper airway obstruction
Appropriate — nurse initiated airway support and activated surgical team immediately
Inadequate — nurse should have waited for surgeon before applying oxygen
Unsafe — suctioning should have been performed immediately by the nurse instead of waiting
A young woman presents with fatigue and paresthesias. Labs: Hgb 8.5 g/dL, MCV 110 fL, decreased B12 level. The nurse explains the mechanism of neurologic symptoms. Which explanation is best?
Anemia causes direct pressure on nerves.
Iron deficiency causes neurotoxicity.
Low vitamin D causes nerve dysfunction.
Low B12 causes peripheral nerve demyelination leading to paresthesias.
A 74-year-old man with type 2 diabetes and coronary artery disease is scheduled for abdominal surgery. The nurse must create a perioperative risk reduction plan. Which plan is MOST appropriate?
Teach deep breathing and coughing exercises and notify anesthesia about his comorbidities
Prepare the patient for surgery without additional interventions to avoid stress
Avoid patient teaching because it will increase anxiety
Focus only on pain management strategies postoperatively
A 68-year-old female with recurrent UTIs is being evaluated for postmenopausal vaginal atrophy. The nurse explains how estrogen relates to UTIs. Which statement best describes this relationship?
Decreased estrogen alters vaginal flora and mucosa, increasing susceptibility to UTIs.
Estrogen increases urine acidity, preventing bugs from growing.
Estrogen causes urinary retention leading to infections.
Estrogen directly kills bacteria in the bladder.
A patient with chronic kidney disease asks why he is always tired. The nurse recalls that fatigue is commonly due to:
Electrolyte imbalance
Anemia secondary to low erythropoietin
Fluid retention
Uremic toxins in the blood
A child with RSV bronchiolitis has increased work of breathing, intercostal retractions, and oxygen saturation 89% on room air. The provider orders humidified oxygen and frequent suctioning. Which rationale best explains suctioning in this condition?
Suctioning is primarily to prevent bacterial superinfection.
It reduces the need for oxygen therapy permanently.
Suctioning increases airway secretions, making cough more effective.
Removing secretions improves airway patency and gas exchange in small airways.
A patient with sickle cell disease asks the nurse what triggers a crisis. The nurse correctly answers:
Low iron intake
Increased serum calcium
Exposure to cold, dehydration, infection
Low protein diet
A 72-year-old patient with emphysema shows a barrel chest, prolonged expiration, and use of accessory muscles. Which pathophysiology underlies this finding?
Destruction of alveolar walls
Excess surfactant production
Airway hyperresponsiveness
Pulmonary embolism
A 62-year-old man with chronic hoarseness and a 40-pack-year smoking history presents for laryngoscopy. The nurse explains vocal cord biopsy may be performed. Which patient education statement best shows understanding of why biopsy is needed?
Tissue biopsy determines whether abnormal lesions are cancerous.
A biopsy checks if voice problems are due to reflux only.
Biopsy will permanently improve your voice.
Biopsy eliminates the need for follow-up care.
A 70-year-old man underwent abdominal aortic aneurysm repair. On the second postoperative day, the nurse observes: BP 88/60 mmHg, HR 124 bpm, urine output 15 ml/hr, skin cool/clammy. The physician ordered rapid IV fluids and vasopressors. After 1 hour, BP remains low and urine output does not improve. Which nursing evaluation is MOST appropriate?
Fluid resuscitation should be stopped because of risk of overload
Current interventions are effective; continue monitoring only
Interventions are inadequate; likely hypovolemic shock is unresolved and requires immediate escalation
Vasopressor infusion alone is sufficient for stabilization
A 63-year-old patient with a history of hypertension and hyperlipidemia presents with chest pain radiating to the left arm. The nurse anticipates diagnostic studies for myocardial infarction (MI). Which cardiac biomarker is most specific for myocardial infarction?
CK-MB
Troponin I or T
Myoglobin
LDH
A 22-year-old African American male presents with severe pain in his back and legs. He has a history of sickle cell anemia. Which complication is most likely responsible for his symptoms?
Acute vaso-occlusive crisis
Iron deficiency anemia
Osteoarthritis
Rheumatoid arthritis
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways?
Accompanied by shortness of breath
Lasts less than 15 minutes
No relief from taking nitroglycerin
Pain occurs without known cause
A patient with chronic kidney disease (CKD) has anemia treated with epoetin alfa. The patient asks why this medication is used. Which is the best explanation?
It corrects vitamin B12 deficiency.
It provides iron to build red blood cells.
It stimulates the bone marrow to produce more red blood cells by replacing erythropoietin.
It removes toxins that suppress production of red cells.
A patient with severe nasal fracture is bleeding heavily and breathing with difficulty. What is the nurse’s priority intervention?
Insert an NG tube
Maintain airway patency, position upright, apply ice, prepare for packing.
Apply pressure to carotid arteries.
Suction continuously for comfort.
A 76-year-old male with BPH has acute urinary retention (bladder palpable). What should the nurse anticipate?
Prepare for catheterization to relieve retention.
Apply warm compress only.
Encourage oral fluids.
Observe and document without action.
A 70-year-old man underwent abdominal aortic aneurysm repair. On the second postoperative day, the nurse observes: BP 88/60 mmHg, HR 124 bpm, urine output 15 ml/hr, skin cool/clammy. The physician ordered rapid IV fluids and vasopressors. After 1 hour, BP remains low and urine output does not improve. Which nursing evaluation is MOST appropriate?
Current interventions are effective; continue monitoring only
Fluid resuscitation should be stopped because of risk of overload
Vasopressor infusion alone is sufficient for stabilization
Interventions are inadequate; likely hypovolemic shock is unresolved and requires immediate escalation
A 70-year-old male presents with difficulty initiating urination, weak stream, and nocturia. The physician suspects benign prostatic hyperplasia (BPH). Which diagnostic test is most commonly used to evaluate BPH?
Cystoscopy
Digital rectal examination (DRE)
Intravenous pyelogram
Urine culture
A 48-year-old coal miner is diagnosed with chronic interstitial lung disease (pulmonary fibrosis). He asks why he becomes more short of breath with exercise even though his lungs look “stiff” on imaging. Which nurse explanation best demonstrates understanding of restrictive lung disease physiology?
Your lungs have more air and can hold more oxygen during exercise.
Only the airways are affected; muscles are weak.
This condition increases cardiac output to compensate, so breathlessness is unrelated.
Your lungs cannot expand normally, reducing total lung capacity and diffusion surface, so exertional oxygen transfer falls.
A 60-year-old man with acute pulmonary embolism (PE) receives anticoagulation and oxygen therapy. After 8 hours, he remains tachycardic (HR 120 bpm), dyspneic, and has O2 sat 86% despite 6 L/min nasal cannula. Which is the MOST accurate nursing evaluation?
Airflow alone with acute pulmonary embolism requires anticoagulation and oxygen therapy. After 8 hours, he remains tachycardic (HR 120 bpm), dyspneic, and has O2 sat 86% despite 6 L/min nasal cannula. Which is the MOST accurate nursing evaluation?
After 8 hours, he remains tachycardic, dyspneic, and has O2 sat 86% despite 6 L/min nasal cannula. Which is the MOST accurate nursing evaluation?
A patient with acute coronary syndrome is receiving IV nitroglycerin. BP drops from 110/70 to 80/50. What should the nurse do?
Increase the infusion rate.
Stop the nitroglycerin infusion immediately.
Notify the surgeon to perform angioplasty.
Give another dose of aspirin.
A patient with pneumonia is admitted with fever, chills, and a productive cough. The nurse recalls that the definitive diagnostic test for pneumonia is:
Chest X-ray
Sputum culture and sensitivity
ABG analysis
White blood cell count
A 23-year-old patient with asthma develops wheezing and shortness of breath after exposure to dust. His peak flow is 45% of personal best. The nurse applies the asthma action plan. What is the best action?
Start IV antibiotics.
Encourage relaxation and delay meds.
Send the patient home without treatment.
Give rescue inhaler (short-acting beta agonist) and reassess.
A patient is admitted with acute laryngeal edema from allergic reaction. He is restless, stridorous, and hypoxic. What is the nurse’s best immediate action?
Place the patient flat to improve airway.
Apply cool mist therapy.
Prepare for emergency intubation or tracheostomy while giving O₂.
Give oral fluids for hydration.
A patient with chest pain is given thrombolytic therapy. Thirty minutes later, he complains of severe back pain and hematuria. What should the nurse do first?
Stop the thrombolytic infusion immediately and notify the provider.
Continue infusion but monitor closely.
Give additional aspirin.
Encourage fluids.
A patient with heart failure is on furosemide. He suddenly complains of muscle weakness. Labs show K⁺ 2.9 mmol/L. What is the nurse’s best action?
Give an additional diuretic dose.
Notify the physician and prepare to give potassium replacement.
Encourage more fluid intake.
Document finding only.
A patient is admitted with acute laryngeal edema from allergic reaction. He is restless, stridorous, and hypoxic. What is the nurse’s best immediate action?
Prepare for emergency intubation or tracheostomy while giving O₂.
Apply cool mist therapy.
Give oral fluids for hydration.
Place the patient flat to improve airway.
During a mastectomy, the scrub nurse observes that the sterile field was accidentally contaminated by the surgeon’s gown sleeve. What should the nurse do?
Ignore it since the contamination is minor.
Replace contaminated instruments and report to the circulating nurse immediately.
Continue surgery but document later.
Tell another scrub nurse to cover the contamination.
A sickle cell patient presents with acute chest pain, fever, and cough. The nurse should suspect:
Acute chest syndrome
Pulmonary embolism
Pneumothorax
Asthma exacerbation
A 62-year-old woman scheduled for colectomy has the following labs: Hgb 8.5 g/dL, Hct 26%, Platelets 180,000/μL, INR 1.0. She reports fatigue and shortness of breath with exertion. Which is the priority nursing action before surgery?
Encourage high-protein diet to increase hemoglobin
Proceed with surgery since INR and platelets are normal
Anticipate need for blood transfusion before surgery
Inform patient that fatigue is expected in surgery patients
A patient in PACU after abdominal surgery suddenly becomes restless, with SpO₂ dropping to 86% despite O₂ at 4 L/min NC. Breath sounds are diminished on the right. What should the nurse do first?
Reposition patient and assess for airway obstruction, prepare for possible chest x-ray.
Administer opioid analgesic.
Notify the surgeon immediately.
Increase O₂ flow to 10 L/min.
A patient with asthma presents with severe wheezing, RR 36, use of accessory muscles, and SpO₂ 88% despite nebulized bronchodilator. Which complication is the nurse most concerned about?
Aspiration pneumonia
Pulmonary fibrosis
Pleural effusion
Status asthmaticus with risk of respiratory failure
A 76-year-old male with BPH has acute urinary retention (bladder palpable). What should the nurse anticipate?
Apply warm compress only.
Encourage oral fluids.
Prepare for catheterization to relieve retention.
Observe and document without action.
The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?
Numbness and tingling in the distal extremities
Unequal peripheral pulses between extremities
Visible clubbing of the fingers and toes
Reddened extremities with muscle atrophy
A patient with asthma is using a peak flow meter. He records 55% of his personal best before exercise. What should the nurse advise?
Proceed with exercise as normal.
Use short-acting beta agonists before exercise.
Take long-acting corticosteroid now.
Ignore since below 80% is acceptable.
A 72-year-old man with acute kidney injury from dehydration is on IV fluids. After 24 hours, urine output improved to 40 mL/hr, serum creatinine decreased from 3.2 to 1.8 mg/dL, and BUN dropped from 48 to 25 mg/dL. How should the nurse evaluate the effectiveness of therapy?
Effective — urine output and labs indicate improving renal perfusion and function
Ineffective — renal recovery is not possible in AKI
Partially effective — output improved but creatinine should be normal by now
Ineffective — fluid therapy is causing worsening renal function
A male patient with BPH complains of nocturia and weak stream. The provider orders a postvoid residual (PVR) ultrasound. What interpretation indicates urinary retention requiring intervention?
PVR 20 mL — normal
PVR 50 mL — equivocal
PVR 200 mL — significant retention
PVR 5 mL — significant retention
A client scheduled for elective hip arthroplasty asks about DVT prevention. The nurse explains interventions. Which statement by the nurse demonstrates correct understanding of evidence-based prophylaxis?
Antibiotics given before surgery prevent blood clots.
Keeping the affected leg elevated and immobile is the best prevention.
We will avoid early ambulation for 48 hours to reduce bleeding risk.
Compression stockings, early ambulation, and ordered anticoagulants reduce DVT risk.
A 55-year-old woman with obstructive sleep apnea (OSA) is prescribed CPAP therapy. She asks how CPAP improves her condition. Which explanation is most accurate?
CPAP stimulates breathing centers in the brain.
CPAP keeps the upper airway open by providing positive pressure during sleep.
CPAP increases lung elasticity so you breathe easier.
CPAP prevents future development of asthma.
A 45-year-old man develops sudden pleuritic chest pain and dyspnea after a long flight. O2 sat 88% RA. What’s the immediate nursing action?
Give antibiotics immediately.
Insert NG tube.
Place the patient on high-flow O2 and notify the provider for PE workup.
Encourage ambulation to improve circulation.
A patient with pernicious anemia is confused and has paresthesias. Which intervention is most appropriate?
Prepare for lifelong vitamin B12 injections.
Restrict protein intake.
Give high-dose folic acid only.
Encourage oral iron supplements.
A 65-year-old man with COPD is admitted for colon surgery. On the morning of surgery, he is coughing up thick sputum with wheezing and oxygen saturation 89% of room air. What is the best nursing action?
Proceed with surgery as scheduled since anesthesia can manage oxygenation.
Encourage oral fluids and send the patient to OR.
Cancel surgery and send the patient home.
Notify surgeon/anesthesia and expect possible postponement for pulmonary optimization.
A patient with pneumonia is on antibiotics. On assessment, RR = 30, SpO2 90% with 6 L NC, accessory muscle use. What should the nurse anticipate?
Continue the same treatment.
Escalate oxygen delivery and prepare for possible intubation.
Give antitussive syrup.
Place supine for comfort.
A 45-year-old woman is admitted with pyelonephritis. She has flank pain, fever, and dysuria. Which nursing action is most appropriate?
Encourage fluid intake and administer antibiotics as ordered.
Restrict fluids to avoid overload.
Delay antibiotics until culture results.
Apply cold packs to relieve flank pain.
A patient in PACU after abdominal surgery suddenly becomes restless, with SpO2 dropping to 86% despite O2 at 4 L/min NC. Breath sounds are diminished on the right. What should the nurse do first?
Notify the surgeon immediately.
Increase O2 flow to 10 L/min.
Reposition patient and assess for airway obstruction, prepare for possible chest x-ray.
Administer opioid analgesic.
A patient with aplastic anemia is admitted with fever 38.7°C. WBC is 2,000/mm³. What is the nurse’s priority?
Give acetaminophen and observe.
Continue routine care without changes.
Send home for rest.
Place in protective isolation, monitor for infection, and notify the provider.
A 45-year-old woman is admitted with pyelonephritis. She has flank pain, fever, and dysuria. Which nursing action is most appropriate?
Restrict fluids to avoid overload.
Delay antibiotics until culture results.
Encourage fluid intake and administer antibiotics as ordered.
Apply cold packs to relieve flank pain.
During the immediate post-op period after mastectomy, the patient reports nausea. The nurse has an order for IV ondansetron. What is the correct action before administration?
Assess pain level
Confirm allergy history and check IV patency
Encourage oral fluids
Position the client flat for comfort
A post-op tonsillectomy child suddenly swallows frequently and becomes restless. What is the nurse’s priority action?
Document the behavior as normal recovery
Assess for possible postoperative hemorrhage
Encourage fluids to reduce throat dryness
Apply cold compress to the neck
A patient with left-sided HF is receiving IV furosemide. Which assessment finding best indicates the therapy is effective?
Decreased crackles in lungs
Decreased urine output
Increased peripheral edema
Elevated blood pressure
A 45-year-old man develops sudden pleuritic chest pain and dyspnea after a long flight. O2 sat 88% RA. What’s the immediate nursing action?
Encourage ambulation to improve circulation.
Give antibiotics immediately.
Insert NG tube.
Place the patient on high-flow O2 and notify the provider for PE workup.
A 5-year-old boy with epiglottitis suddenly becomes drooling, anxious, and sitting upright, refusing to lie down. Which interpretation is most accurate?
He is comfortable in tripod position, no intervention needed
Drooling indicates dehydration, encourage fluids
This indicates impending airway obstruction requiring immediate intervention
Child’s behavior is consistent with separation anxiety
A patient with pernicious anemia is confused and has paresthesias. Which intervention is most appropriate?
Restrict protein intake.
Give high-dose folic acid only.
Encourage oral iron supplements.
Prepare for lifelong vitamin B12 injections.
A 65-year-old man with COPD is admitted for colon surgery. On the morning of surgery, he is coughing up thick sputum with wheezing and oxygen saturation 89% of room air. What is the best nursing action?
Cancel surgery and send the patient home.
Proceed with surgery as scheduled since anesthesia can manage oxygenation.
Notify surgeon/anesthesia and expect possible postponement for pulmonary optimization.
Encourage oral fluids and send patients to OR.
A 23-year-old patient with asthma develops wheezing and shortness of breath after exposure to dust. His peak flow is 45% of personal best. The nurse applies the asthma action plan. What is the best action?
Start IV antibiotics.
Give rescue inhaler (short-acting beta agonist) and reassess.
Encourage relaxation and delay meds.
Send patients home without treatment.
A patient with heart failure is on furosemide. He suddenly complains of muscle weakness. Labs show K+ 2.9 mmol/L. What is the nurse’s best action?
Notify the provider and prepare to administer potassium supplementation.
Continue monitoring the patient without any intervention.
Administer a diuretic to increase urine output.
Encourage the patient to eat potassium-rich foods.
A 45-year-old man develops sudden pleuritic chest pain and dyspnea after a long flight. O2 sat 88% RA. What’s the immediate nursing action?
Encourage ambulation to improve circulation.
Give antibiotics immediately.
Insert NG tube.
Place the patient on high-flow O2 and notify the provider for PE workup.
A 45-year-old woman is admitted with pyelonephritis. She has flank pain, fever, and dysuria. Which nursing action is most appropriate?
Restrict fluids to avoid overload.
Encourage fluid intake and administer antibiotics as ordered.
Delay antibiotics until culture results.
Apply cold packs to relieve flank pain.
A patient with pneumonia is on antibiotics. On assessment, RR = 30, SpO2 90% with 6 L NC, accessory muscle use. What should the nurse anticipate?
Escalate oxygen delivery and prepare for possible intubation.
Give antitussive syrup.
Place supine for comfort.
Continue the same treatment.
Wilma knew that James have an adequate respiratory condition if she notices that
James’ respiratory rate is 18
James’ Oxygen saturation is 91%
There are frank blood suction from the tube
There are moderate amount of tracheobronchial secretions
The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?
Make inhalation longer than exhalation.
Exhale through an open mouth.
Use diaphragmatic breathing.
Use chest breathing.
A client with autoimmune thrombocytopenia and a platelet count of 800/uL develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery—this will go away on its own.” In considering her response to the client, the nurse must depend on the ethical principle of:
Autonomy
Advocacy
Justice
Beneficence
Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:
swelling
erythema
leukocytosis
pressure-like pain
Which of the following nursing responsibilities is essential in Mrs. Pichay who will undergo thoracentesis?
Support and reassure client during the procedure
Ensure that informed consent has been signed
Determine if client has allergic reaction to local anesthesia
Ascertain if chest x-rays and other tests have been prescribed and completed
Which of the following is not true with regards to informed consent?
It should describe different treatment alternatives
It should describe the client’s diagnosis
It should contain a thorough and detailed explanation of the procedure to be done
It should give an explanation of the client’s prognosis
Rosie, 57, who is diabetic is for debridement of an incision wound. When the circulating nurse checked the present IV fluid, she found out that there is no insulin incorporated as ordered. What should the circulating nurse do?
Communicate with the ward nurse to verify if insulin was incorporated or not
Double check the doctor’s order and call the attending MD
Communicate with the client to verify if insulin was incorporated
Incorporate insulin as ordered
The documentation of all nursing activities performed is legally and professionally vital. Which of the following should NOT be included in the patients chart?
Baseline physical, emotional, and psychosocial data
Arguments between nurses and residents regarding treatment
Presence of prosthetic devices such as dentures, artificial limbs, hearing aid, etc.
Observed untoward signs and symptoms and interventions including contaminant intervening factors.
If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon?
Who is your assistant and anesthesiologist, and what is your preferred time and type of surgery?
Who is your internist?
Who are your anesthesiologist, internist, and assistant?
Who is your anesthesiologist?
A patient with unstable angina reports chest pain unrelieved by rest. The nurse administers nitroglycerin. What is the correct application of protocol if pain persists?
Switch to IM nitroglycerin after 1 dose.
Stop after 1 dose regardless of pain.
Continue giving indefinitely.
Give nitroglycerin sublingually every 5 minutes up to 3 doses, monitoring BP.
A 62-year-old man with laryngeal cancer will undergo a total laryngectomy. The patient is distressed about not being able to speak. As the nurse, which plan for alternative communication is MOST appropriate to develop before surgery?
Teach the patient to use hand signals only after surgery
Provide a whiteboard and introduce the use of electrolarynx or writing pads before surgery
Wait until after surgery to decide which device works best
Reassure the patient that speech therapy is not necessary since family can interpret his needs
A nurse teaches a patient with OSA about CPAP use. Which patient statement shows correct application of teaching?
I’ll only use CPAP when I feel very tired.
I can stop CPAP once my snoring improves.
I need to use CPAP every night to keep my airway open during sleep.
CPAP helps dissolve clots in my lungs.
A 5-year-old child with a history of asthma is admitted to the ER for severe bronchospasm. The physician orders nebulization and IV steroids. The child’s parents are anxious and panicked. As a nurse, which communication plan is BEST to create?
Restrict the parents from staying to avoid disturbing the team’s focus
Allow the parents to stay and explain the procedures being done
Assign a staff to talk to the parents outside the ER
Ask the parents to wait outside until the child is stabilized
A sickle cell patient presents with acute chest pain, fever, and cough. The nurse suspects acute chest syndrome. What should be done?
Send home with oral analgesics.
Restrict fluids and rest.
Delay antibiotics until WBC confirmed.
Give fluids, oxygen, antibiotics, and notify the provider immediately.
A patient with aplastic anemia is admitted with fever 38.7°C. WBC is 2,000/mm³. What is the nurse’s priority?
Give acetaminophen and observe.
Place in protective isolation, monitor for infection, and notify the provider.
Continue routine care without changes.
Send home for rest.
A 60-year-old woman underwent TURP (transurethral resection of prostate). Postoperatively, her urine is light pink with occasional clots. What should the nurse do?
Stop bladder irrigation immediately.
Call provider for hematuria.
Continue monitoring urine output/color, maintain irrigation flow.
Replace Foley catheter.
A patient with asthma is using a peak flow meter. He records 55% of his personal best before exercise. What should the nurse advise?
Proceed with exercise as normal.
Use short-acting beta agonists before exercise.
Take long-acting corticosteroid now.
Ignore since below 80% is acceptable.
A 63-year-old woman is scheduled for a radical mastectomy due to breast cancer. She expresses fear about the surgery and how she will look afterward. As the nurse assigned, you are tasked to develop a preoperative teaching plan that addresses her psychosocial and physical preparation. Which strategy is MOST appropriate?
Create a plan that includes wound care, arm exercises, and referral to a support group for body image
Reassure her repeatedly that "everything will be okay" to reduce anxiety
Teach only physical exercises to avoid overwhelming her before surgery
Delay patient teaching until the surgeon explains the details after surgery
A 60-year-old woman with congestive heart failure (CHF) is being discharged. The physician instructs the nurse to create a self-management teaching plan. Which is MOST appropriate?
Teach only medication administration because diet changes may be overwhelming
Encourage complete fluid restriction regardless of physician order
Emphasize rest and avoid discussing exercise tolerance
Create a plan including daily weight monitoring, sodium restriction, medication adherence, and when to seek help
