Question 1

The nurse is caring for a client with pneumonia. Which nursing intervention is the priority?

Accepted Answer

Answer reason: In pneumonia, airway and gas exchange are the priority. Encouraging deep breathing and coughing mobilizes secretions and improves ventilation, addressing ABCs. Other options are supportive but not as urgent for oxygenation.

Question 2

Ayelech is a 30 years old G5P4 woman admitted in labour ward with history of 32 weeks gestation, mild vaginal bleeding and abdominal pain. On physical examination her blood pressure is 150/100 mmHg, abdomen is tense, tender and hard. Fetal heart sounds are not audible. The diagnosi of Ayelech is?

Accepted Answer

Answer reason: Painful vaginal bleeding with a tense, tender, hard uterus and absent fetal heart tones is classic for placental abruption. Placenta previa typically presents with painless bleeding and a soft uterus; vasa previa bleeding is fetal and often after ROM; preterm labour does not explain these findings.

Question 3

Which of the following findings is associated with right-sided heart failure?

Accepted Answer

Answer reason: Right-sided heart failure causes systemic venous congestion and dependent edema; when supine at night, improved renal perfusion leads to nocturnal diuresis. Dyspnea and lung crackles are typical of left-sided HF; daytime oliguria is not the characteristic finding asked.

Question 4

A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to?

Accepted Answer

Answer reason: BP 180/96 in pregnancy suggests severe hypertension/preeclampsia risk. The immediate priority is maternal stabilization and reducing stimuli to lower BP and prevent seizures; a calm environment addresses this. Diet review and analgesics are not priorities, and fetal assessment follows maternal stabilization.

Question 5

A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for?

Accepted Answer

Answer reason: In labor, clients with sickle cell disease are at risk for vaso-occlusion precipitated by hypoxia. Providing supplemental oxygen helps prevent sickling. Fluid restriction is contraindicated (hydration is important). Transfusion and Cesarean are not routine unless there are specific indications.

Question 6

A 32-year-old mother is diagnosed with hypothyroidism. Which nursing diagnosis is the highest priority?

Accepted Answer

Answer reason: Severe hypothyroidism can cause marked bradycardia and decreased myocardial contractility, which directly threaten perfusion and oxygen delivery. Cardiac compromise poses the greatest immediate risk compared with cold intolerance, slowed cognition, or fatigue.

Question 7

The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with?

Accepted Answer

Answer reason: Expressive (Broca’s) aphasia impairs language output, leading to difficulty speaking and writing, while comprehension is relatively preserved. Options C and D reflect apraxia/agnosia, not expressive aphasia; B reflects receptive aphasia.

Question 8

A client with increased intracranial pressure is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of the hyperventilation is to?

Accepted Answer

Answer reason: Hyperventilation lowers PaCO2, causing cerebral vasoconstriction and reduced cerebral blood volume, thereby decreasing cerebral blood flow and intracranial pressure.

Question 9

Which of the following is not an appropriate nursing diagnosis related to appendicitis?

Accepted Answer

Answer reason: Acute pain and risk for infection after rupture are core concerns in appendicitis, and patient education needs justify deficient knowledge. Disturbed body image is not typically relevant to acute appendicitis care, making it the least appropriate diagnosis.

Question 10

For a client in hepatic coma, which outcome would be the most appropriate?

Accepted Answer

Answer reason: Hepatic coma (hepatic encephalopathy) is primarily a neurologic alteration; the most appropriate outcome is improvement in mental status to orientation x3. The other options are unrealistic or not primary: oral intake is contraindicated in coma, albumin synthesis does not improve acutely, and absence of ecchymoses is unrelated to resolving encephalopathy.

Question 11

A patient is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse include in the care plan for the client?

Accepted Answer

Answer reason: Acute pancreatitis requires pancreatic rest: keep the client NPO and use NG suction to reduce gastric contents and pancreatic stimulation. Other options address different conditions (variceal bleeding, ascites) or are appropriate later in recovery.

Question 12

A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?

Accepted Answer

Answer reason: Acute pancreatitis management includes gastric decompression with an NG (Levine) tube to reduce vomiting and pancreatic stimulation. BP q15 min and continuous cardiac monitoring are not routine unless unstable; dressing changes are unrelated.

Question 13

The nurse would teach a client with Raynaud's phenomenon that it is MOST important to?

Accepted Answer

Answer reason: Nicotine is a potent vasoconstrictor that worsens the digital ischemia of Raynaud’s; cessation is the most critical intervention. Other measures are helpful but less impactful.

Question 14

The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which of the following nursing diagnoses would be MOST appropriate for this client based on this assessment data?

Accepted Answer

Answer reason: Assessment shows crackles, pleuritic pain, and inability to take a deep breath to cough effectively. These directly indicate retained secretions with an ineffective cough, best matching the diagnosis of ineffective airway clearance.

Question 15

The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be MOST effective in removing respiratory secretions?

Accepted Answer

Answer reason: Adequate hydration thins and loosens respiratory secretions, making them easier to expectorate. Cough suppressants reduce the cough needed to clear secretions; bed rest does not promote clearance; chest physiotherapy helps but hydration is the most effective foundational measure.

Question 16

A 60-year-old female is diagnosed with hypothyroidism; which symptom should the nurse assess for?

Accepted Answer

Answer reason: Hypothyroidism slows metabolic processes, leading to weight gain and other findings like bradycardia and constipation. Tachycardia and diarrhea are more consistent with hyperthyroidism; nausea is nonspecific.

Question 17

A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have?

Accepted Answer

Answer reason: Testicular cancer commonly presents with a painless mass or a feeling of heaviness in the scrotum/testicle. Discoloration is not typical; priapism (sustained painful erection) and erectile dysfunction are not characteristic early findings.

Question 18

A male client is admitted with a spinal cord injury at level C4. The client asks the nurse how the injury is going to affect his sexual function. The nurse would respond?

Accepted Answer

Answer reason: At C4 injury, the sacral reflex arc (S2–S4) remains intact, allowing reflexogenic erections with genital stimulation, but normal sexual function and ejaculation are often impaired. Therefore, erections will be possible.

Question 19

A client is experiencing spinal shock; what bladder function should the nurse expect?

Accepted Answer

Answer reason: In spinal shock there is flaccidity and areflexia below the level of injury, producing an atonic bladder with urinary retention. Spastic/reflex bladder appears later after shock resolves.

Question 20

The home care nurse is performing an assessment of a client with pneumonia secondary to chronic pulmonary disease. Which of the following goals is MOST appropriate?

Accepted Answer

Answer reason: Pneumonia causes impaired gas exchange resulting in hypoxemia; the primary nursing goal is to maintain and improve oxygenation. Peripheral circulation oxygenation and bicarbonate correction are not priority goals, and ventilation is secondary to ensuring adequate oxygenation.

Question 21

Which of the following nursing actions has the HIGHEST priority in caring for the client with hypoparathyroidism?

Accepted Answer

Answer reason: Hypoparathyroidism causes hypocalcemia, which can precipitate life‑threatening cardiac dysrhythmias. Using ABCs and safety first, planning to manage dysrhythmias is the highest priority over teaching, infection prevention, or routine lab review.

Question 22

The nurse is caring for a newborn who has just been diagnosed with hypospadias. After discussing the defect with the parents, the nurse should expect that?

Accepted Answer

Answer reason: Hypospadias is typically corrected with staged urethroplasty when the infant can tolerate surgery; circumcision is deferred to preserve foreskin tissue, repair is not delayed to school age, and appearance may not be completely normal initially.

Question 23

The PRIMARY nursing diagnosis for a client with congestive heart failure with pulmonary edema is?

Accepted Answer

Answer reason: In CHF with pulmonary edema, the fundamental problem is decreased cardiac output. Improving cardiac output is the primary goal; doing so reduces pulmonary congestion and secondarily improves gas exchange and fluid status. Pain and fluid excess are consequences, not the primary diagnosis.

Question 24

A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings?

Accepted Answer

Answer reason: Low T3/T4 with elevated TSH indicates hypothyroidism, which decreases metabolic activity and presents with lethargy and cold intolerance; diarrhea and heat intolerance suggest hyperthyroidism.

Question 25

A nurse is caring for an older adult male patient diagnosed with benign prostatic hyperplasia (BPH). Which of the following clinical findings is most characteristic of BPH?

Accepted Answer

Answer reason: BPH leads to enlargement of the prostate gland, compressing the urethra and causing obstructive urinary symptoms. Hesitancy—difficulty initiating urination—is one of the earliest and most characteristic signs of urethral compression in BPH.

Question 26

An older adult male client is being evaluated for benign prostatic hyperplasia (BPH). Which assessment finding is MOST characteristic of BPH?

Accepted Answer

Answer reason: Prostate enlargement compresses the urethra, producing classic lower urinary tract symptoms, with hesitancy being an early and defining manifestation.

Question 27

A nurse is caring for a patient with hepatic encephalopathy due to liver failure. Which intervention should be included in the patient’s care plan?

Accepted Answer

Answer reason: Lactulose converts ammonia into ammonium and promotes its excretion through the stool, directly reducing the neurotoxicity that drives hepatic encephalopathy. It is the primary, most effective, and most urgent intervention.

Question 28

A nurse is caring for a patient diagnosed with acute pancreatitis. Which intervention should be included in the patient’s care plan?

Accepted Answer

Answer reason: Acute pancreatitis causes significant third-spacing of fluids, leading to dangerous hypovolemia. Early and aggressive IV fluid resuscitation is the most critical intervention to prevent shock and organ failure.

Question 29

Clay is an 8-year-old boy diagnosed with heart failure. Which of the following shows that he is strictly following the directed therapeutic regimen?

Accepted Answer

Answer reason: In pediatric heart failure, effective therapy should improve perfusion and nutrition, allowing the child to achieve appropriate growth for age. Normal weight for age indicates adequate caloric intake and improved cardiac output with reduced fluid overload. A pulse

Question 30

Which of the following contributes most to the debilitation of an individual during a course of chemotherapy?

Accepted Answer

Answer reason: Pain is one of the most debilitating symptoms experienced during chemotherapy because it significantly affects mobility, sleep, nutrition, and overall functional ability. While alopecia and gastrointestinal disturbances are distressing, pain has the greatest direct impact on daily activities and quality of life.

Question 31

What is the primary goal of treatment for a patient with congestive heart failure (CHF)?

Accepted Answer

Answer reason: In CHF, the failing heart cannot pump sufficient blood to meet metabolic demands. The overarching treatment goal is to improve forward flow, thereby increasing cardiac output. Diuresis to reduce fluid retention and afterload reduction to lower blood pressure are strategies used to achieve this goal but are not the primary end in themselves. Heart rate control may help by optimizing filling time, yet the central objective remains improving cardiac output.

Question 32

UTI mainly affects ____?

Accepted Answer

Answer reason: A urinary tract infection occurs when bacteria invade the urethra, bladder, ureters, or kidneys—structures belonging to the urinary system. The other options are unrelated organ systems not involved in UTIs.

Question 33

Which of the following is used to deliver high concentrations of oxygen to patients?

Accepted Answer

Answer reason: Among the listed devices, an oxygen tent is used to provide an oxygen-enriched environment and can deliver relatively high oxygen concentrations, especially in pediatric settings. A nasal cannula provides low-flow oxygen, typically delivering lower FiO2. A simple face mask delivers moderate concentrations, while a Venturi mask is designed for precise, controlled FiO2 (often moderate) rather than the highest possible concentration. Therefore, the best answer for high concentrations from these options is the oxygen tent.

Question 34

Which is an example of a nursing diagnosis?

Accepted Answer

Answer reason: A nursing diagnosis describes a patient response to a health condition that nurses can address through independent nursing interventions, using standardized NANDA-style phrasing. "Ineffective breathing pattern" is a classic nursing diagnosis focusing on the patient’s ventilation pattern and can be improved with nursing assessment, positioning, breathing exercises, and monitoring. Asthma, diabetes mellitus, and heart failure are medical diagnoses (diseases) made by providers and treated primarily with medical therapies.

Question 35

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?

Accepted Answer

Answer reason: The client’s immediate presentation is disorientation and confusion, indicating an acute change in cognition that can signal a medical emergency (e.g., delirium, intoxication/withdrawal, hypoxia, infection, head injury). In nursing priorities, unstable physiologic/neurologic status and impaired cognition that threatens safety take precedence over longer-term psychosocial or functional concerns. While homelessness and suspiciousness require follow-up planning, they do not supersede the urgent need to address and evaluate the acute confusion. Therefore, the priority problem is acute confusion.

Question 36

A nurse is assessing a preschooler who has HIV. Which of the following manifestations should the nurse expect?

Accepted Answer

Answer reason: Children with HIV commonly have chronic gastrointestinal manifestations due to opportunistic infections and HIV-related enteropathy, leading to persistent diarrhea and malabsorption. This is a frequent, expected finding in pediatric HIV and may contribute to poor growth and dehydration risk. In contrast, generalized petechiae and jaundice are not the most typical expected baseline manifestations, and obesity is unlikely given the risk of wasting and failure to thrive.

Question 37

Which nursing intervention is most appropriate for a child with increased intracranial pressure (ICP)?

Accepted Answer

Answer reason: With increased ICP, nursing care should minimize stimuli that can increase cerebral metabolic demand and provoke spikes in intracranial pressure; a quiet, dim environment supports this. Encouraging coughing can raise intrathoracic pressure, impede venous return from the brain, and increase ICP. Trendelenburg positioning increases venous congestion in the head and can worsen ICP; head-midline with elevation is preferred. Rapid IV fluid boluses can increase cerebral edema and worsen intracranial pressure unless specifically ordered for hemodynamic instability.

Question 38

A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority?

Accepted Answer

Answer reason: Deep vein thrombosis directly impairs venous blood flow from the affected extremity, leading to venous congestion and reduced tissue perfusion. Addressing impaired peripheral tissue perfusion is the highest priority because it reflects the primary pathophysiologic problem and carries a risk of serious complications such as thrombus extension or embolization. Excess fluid volume and edema are secondary effects, and impaired gas exchange would only be a priority if pulmonary embolism were present.

Question 39

Which of the following is an early sign of hypoxia?

Accepted Answer

Answer reason: Restlessness is an early neurologic sign of hypoxia because the brain is highly sensitive to decreased oxygen and responds first with anxiety, agitation, and changes in mentation. Cyanosis is typically a late sign and may not appear until significant desaturation occurs. Bradycardia and hypotension are also later, decompensatory findings after prolonged or severe hypoxemia. Therefore, restlessness best reflects an early indicator of hypoxia.

Question 40

A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable intervention for the nurse to use to thin the client's secretions?

Accepted Answer

Answer reason: Humidified oxygen helps add moisture to inspired air, which loosens and thins thick tracheostomy secretions, making them easier to mobilize and suction. Chest physiotherapy may help mobilize secretions but does not directly thin tenacious secretions. Instilling or using saline as a lubricant for the suction catheter is not recommended as a routine practice due to risk of hypoxia and infection and does not reliably thin secretions. Pre-oxygenation with 100% oxygen is used to prevent hypoxemia during suctioning, not to thin secretions.

Question 41

A 32-year-old mother has bradycardia, weight gain, and is wearing two sweaters in warm weather. She is diagnosed with hypothyroidism. What is the priority nursing diagnosis?

Accepted Answer

Answer reason: In hypothyroidism, decreased metabolic rate commonly leads to bradycardia and reduced myocardial contractility, which can lower cardiac output. Using ABCs and physiologic stability prioritization, impaired circulation (decreased cardiac output) is a higher priority than comfort or psychosocial problems. While cold intolerance suggests risk for hypothermia, the more immediate and clinically significant problem from the findings provided is compromised cardiac output related to bradycardia. Therefore, the priority nursing diagnosis is decreased cardiac output r/t bradycardia.

Question 42

What is the main nursing priority during a sickle cell crisis?

Accepted Answer

Answer reason: In a vaso-occlusive sickle cell crisis, occlusion of microvasculature leads to severe pain and tissue ischemia; immediate priority is aggressive pain control and improving perfusion. Hydration (often IV fluids) reduces blood viscosity and helps decrease further sickling and supports renal perfusion. Encouraging ambulation is not a priority during acute severe pain and may worsen oxygen demand and discomfort. Iron supplements are not indicated (sickle cell anemia is not iron-deficiency), and restricting fluids can worsen dehydration and sickling.

Question 43

Nurse Kelly is assessing Maria, a patient on her first day postpartum. Upon examining Maria's fundus, Nurse Kelly observes that it is firm, positioned at the level of the umbilicus, but shifted to the right. What should Nurse Kelly do next?

Accepted Answer

Answer reason: A firm uterine fundus that is deviated to the right in the immediate postpartum period most commonly indicates a distended bladder. Bladder distention displaces the uterus and can interfere with uterine involution, increasing the risk of postpartum hemorrhage even if the fundus feels firm. The priority next nursing action is to assess for urinary retention (e.g., palpable bladder, inability to void) and facilitate emptying (assist to void or catheterize per protocol). The other options do not address the likely cause of fundal deviation.

Question 44

A client with COPD is receiving oxygen at 4 L/min via nasal cannula. The nurse notices drowsiness and a drop in respiratory rate. What should the nurse do first?

Accepted Answer

Answer reason: In COPD, excessive supplemental oxygen can worsen hypercapnia and suppress the hypoxic respiratory drive, leading to somnolence and decreased respiratory rate. The first priority is to reduce the oxygen flow to the lowest level that maintains adequate oxygenation (typically targeting SpO2 about 88–92% per common COPD practice), while continuing close assessment. Increasing oxygen or placing a non-rebreather would likely worsen CO2 retention. Naloxone is only indicated for suspected opioid-induced respiratory depression, which is not suggested here.

Question 45

During labor, a woman's fetus shows late decelerations. What is the nurse's first action?

Accepted Answer

Answer reason: Late decelerations indicate uteroplacental insufficiency and fetal hypoxia during contractions. The priority first nursing action is intrauterine resuscitation by repositioning the client to the left lateral side to improve uterine blood flow and maternal-fetal perfusion. Increasing IV fluids may be a subsequent intervention if hypotension or decreased perfusion is suspected, but positioning is the immediate first step. Encouraging pushing can worsen fetal stress, and preparing for cesarean is not the initial action before attempting corrective measures and notifying the provider.

Question 46

A newborn's axillary temp is 35.5°C (95.9°F). What should the nurse do first?

Accepted Answer

Answer reason: An axillary temperature of 35.5°C indicates neonatal hypothermia, which can rapidly increase oxygen and glucose consumption and lead to respiratory distress and hypoglycemia. The priority first action is to stabilize temperature by providing external heat (radiant warmer) and then reassess to confirm response. Giving formula does not address the immediate thermoregulation problem, ice packs are unsafe and would worsen hypothermia, and notifying the neonatologist is not the first step when the nurse can initiate warming immediately.

Question 47

The nurse assesses a C-section client with a temperature of 100.4°F (38°C) at 24 hours postpartum. What is the best nursing action?

Accepted Answer

Answer reason: A low-grade fever (up to about 100.4°F/38°C) in the first 24 hours postpartum is commonly related to dehydration and physiologic changes rather than infection. Initial nursing management is supportive—promote hydration and mobilization to improve lung expansion and circulation and reduce atelectasis risk. Antibiotics or blood cultures are not indicated unless fever is higher, persistent beyond 24 hours, or accompanied by other signs of infection (uterine tenderness, foul lochia, wound changes). Therefore, encouraging ambulation and oral fluids is the best action.

Question 48

Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation?

Accepted Answer

Answer reason: Mitral regurgitation causes backflow of blood from the left ventricle into the left atrium during systole, increasing left atrial and pulmonary venous pressures. This leads to pulmonary congestion and decreased forward cardiac output, making exertional dyspnea a common presenting symptom. Confusion is nonspecific and more typical of significant hypoxia or low perfusion in advanced states, while elevated creatine phosphokinase suggests muscle injury (e.g., myocardial infarction) rather than valvular insufficiency. Chest pain is not a classic primary symptom of isolated mitral regurgitation and is more suggestive of ischemia or other cardiac etiologies.

Question 49

Which nursing intervention is the priority for a patient with increased intracranial pressure?

Accepted Answer

Answer reason: Elevating the head of the bed (typically ~30 degrees with the neck midline) promotes venous drainage from the brain, helping reduce intracranial pressure while supporting cerebral perfusion. Deep suctioning and coughing can increase intrathoracic pressure and stimulate coughing/gagging, which can transiently raise ICP and are not priority unless airway patency is threatened. Analgesics may help prevent pain-related ICP spikes, but positioning is an immediate, first-line nursing intervention to lower ICP risk safely.

Question 50

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which?

Accepted Answer

Answer reason: At 36 weeks’ gestation, the enlarged uterus can compress the inferior vena cava when the client is supine during fundal height measurement, decreasing venous return to the heart. This reduces cardiac output and cerebral perfusion, causing lightheadedness (supine hypotensive syndrome). Repositioning to the left lateral position typically relieves symptoms by reducing vena cava compression. The other options do not directly explain acute positional lightheadedness in late pregnancy.

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