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- The nurse is teaching a client recently diagnosed with rheumatoid arthritis (RA) about home care and management of symptoms. What should the nurse encourage the client to do at home? Select all that apply. A Allow periods of rest in the afternoon B Perform range of motion exercises daily C Place a pillow under the knees at night before sleeping D Use heating packs to relax stiff joints as needed - correct answer ✅A, B, D A Patient presents with a butterfly shaped erythematous rash around the bridge of the nose and cheeks. This is a sign of what autoimmune disease? A Graves' disease B Systemic Lupus Erythematosus C Crohn's disease D Multiple sclerosis - correct answer ✅B
- A client has an arm cast and reports that it feels really tight, and the fingers are puffy. What is the nurse's best response?
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A Elevate your arm on two pillows and apply ice to the cast B Continue to take ibuprofen (Motrin) until the swelling subsides C It is normal for a new cast to feel a little tight for the first few days D Please come to the clinic today to have your arm checked by the health care provider - correct answer ✅B
- A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse's first intervention? A Assess pedal pulses. B Apply oxygen by nasal cannula. C Increase the IV flow rate. D Document the finding. - correct answer ✅A The patient has been diagnosed with a fractured hip. Which of the following findings did the patient have, that is the most typical sign for a fractured hip? A Pain in the hip and affected leg B Diminished sensation in the affected leg
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A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer a recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for A STAT computer tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consultation. - correct answer ✅A Which of the following values is considered normal for ICP?
- 0 to 10 mm Hg
- 25 mm Hg
- 35 to 45 mm Hg
- 60 to 75 mm Hg - correct answer ✅ 1
- Which of the following are expected signs and symptoms of a left sided ischemic stroke? Select all that apply.
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A. right sided facial numbness B. Left sided weakness C. Difficulty walking or holding balance D. Headache E.A&O X 4 - correct answer ✅A, C, D *Which of the following are early signs and symptoms of increased intracranial pressure (ICP)? Select all that apply a. change in LOC b. Increased urinary output c. Weakness in one extremity or one side d. Pupillary changes e. Weight loss - correct answer ✅A, C, D *A Patient has just been transferred to the PACU after surgery. What should be the nurse's priority action? A Early ambulation.
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B After the pain becomes severe and other relaxation techniques have failed C When the patient experiences pain rating of "9" on a 1-10 pain scale D When there is no pain, but it is time for the medication to be administered - correct answer ✅A A client develops malignant hyperthermia. What client symptoms would the nurse most likely observe as the first indicator of the disorder? A Tetanus-like jaw movements B Generalized muscle rigidity C Heart rate over 150 beats per minute D Body temperature increase of 1-2 degrees celsius - correct answer ✅C A nurse is educating a client about the importance of understanding her post op needs. The nurse knows that the client understands with which response?
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A "I can sign the consent for the procedure after the procedure when I'm about to go home" B "If I am given anesthesia or a sedative during the procedure, my husband will have to drive us home" C I will learn the exercises to prevent clots after the procedure D I will wait til the pain is severe before asking for medication. - correct answer ✅B A patient has undergone a recent surgery after a stroke and is admitted to the PACU. Their vitals are HR: 86, RR: 27, BP: 141/88, Temp: 99.2 F. What common post-op complication can be seen with these vitals? A Atelectasis B Shock C DVT D Myocardial Infarction - correct answer ✅A The primary objective in the immediate postoperative period is: A Controlling nausea and vomiting B Monitoring hypotension
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A nurse is caring for a patient who received abdominal surgery 3 hours ago. During their assessment, the nurse notes that the client, who was previously stable, now appears to be hypotensive (BP of 90/54), anxious, and has cool, clammy skin. Which of the following does the nurse consider is the most likely cause of the client change in condition? A The patient is showing signs of an allergic reaction to anastasia B The patient is showing early signs of infection C The patient is experiencing atelectasis D The patient is showing early signs of shock - correct answer ✅D *A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which of the following recommendations is appropriate. A. Wear loosely woven clothing for added ventilation B. Apply sunscreen only after going in the water C. Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure
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D. Avoid peak exposure hours from 9am to 1pm - correct answer ✅C
- A cancer pt has had a rapid decrease in WBCs and is placed on neutropenic precautions. What precautions should the nurse take? Select all that apply. A. Wash hands upon entering the room and wear gloves. B. Bring the client flowers to brighten the room. C: Allow family members to visit so the client does not become lonely. D: Make sure the client does not have any raw fresh fruits and vegetables. E: Place the client in a private room. F: Use communal vital machines to assess vital signs. - correct answer ✅A,D,E The nurse is teaching a 17 yo client and the client's family about what to expect with high dose chemotherapy and the effects of neutropenia. What should the nurse teach as the most reliable early indicator of infection in a neutropenic client? A. Dyspnea
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B. Acute pain r/t Intermittent claudication C.Decreased mobility r/t venous insufficiency D.acute pain r/t vasculitis - correct answer ✅B *2. The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurse's postoperative plan of care should include what intervention? A Early ambulation and leg exercises B Cessation of the oral contraceptives until 3 weeks postoperative C Doppler ultrasound of peripheral circulation twice daily D Dependent positioning of the patient's extremities when at rest - correct answer ✅A A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? A The lack of exercise, which is the main cause of PAD.
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B The likelihood that heavy alcohol intake is a significant risk factor for PAD. C Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD - correct answer ✅C *Your patient reports experiencing dull and achy sensations in the lower extremities. You note that the lower extremities have edema and brownish pigmentation. Pulses are present bilaterally and the extremities feel warm to the touch. To help alleviate the patient's symptoms, the nurse will position the lower extremities in the? A Dependent position B Horizontal position C Elevated position above heart level D Knee-flexed position - correct answer ✅C The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left
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recognize as the most significant contributing factors to the development of COPD? Select all that apply. a) "I have been drinking alcohol almost daily since age 20" b) "I have been overweight for as long as I can remember." c) "I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year" d) "I know I eat too much fast food" e) "I was a car mechanic for about 40 years and had my own garage." - correct answer ✅C,E A patient is being treated at the hospital for a severe asthma exacerbation. When providing patient education, which of the following signs and symptoms would the nurse tell the client to monitor for that are characteristic of an asthma attack? Select all that apply. a) Dehydration b) Wheezing c) Bradycardia d) Chest tightness
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e) Dyspnea - correct answer ✅B,D,E An older client presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? A) It would not be beneficial for this client. B) It would help decrease the bronchospasm. C) It would clear up the density in the bases of the client's lungs. D) It would decrease the client's pain on inspiration. - correct answer ✅B The nurse is caring for a patient with a chest tube. The nurse knows that the drainage system is working correctly if she observes? A) Continuous bubbling in the water seal chamber. B) Intermittent bubbling in the water seal chamber. C) No bubbling appears in the suction chamber
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C shortness of breath D coughing E paresthesia - correct answer ✅A,C,D A 73 year old male is admitted from the ED after a fall. Suddenly he describes a deep pain on the side of his abdomen and his back. His blood pressure drops, and he is experiencing some lightheadedness on top of 10/10 pain. What might this patient be experiencing, and how could it be treated? A Myocardial Infarction; MONA B Coronary artery disease; Statin and dietary modifications C Abdominal aortic aneurysm; surgery D Acute renal failure; dialysis - correct answer ✅C Which ECG finding is most indicative of a severe myocardial infarction? A Wide QRS segment B Peaked T wave C Peaked P wave
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D ST segment elevation` - correct answer ✅D The client's underlying heart rhythm is sinus rhythm, but the rhythm is irregular because of occasional early beats. The configuration of the P waves is normal, except the P wave of the early beat does not look the same as the others. The morphology of the QRS complex is the same for all beats. The heart rate is 66 beats per min, and the blood pressure is normal. How should the nurse interpret this finding? A Sinus tachycardia B Normal sinus rhythm C Sinus rhythm with premature atrial contractions (PACs) D Sinus bradycardia with premature ventricular - correct answer ✅C The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? A. Administer sublingual nitroglycerin B. Obtain a stat 12 lead EKG
