Question 1

Scenario: A patient with COPD is receiving 5L/min of oxygen via nasal cannula and is drowsy. Q. What should the nurse do first?

Accepted Answer

Answer reason: In COPD, excessive supplemental oxygen can worsen hypercapnia and lead to CO2 narcosis, presenting as increasing drowsiness or decreased mental status. The priority is to reduce oxygen to a low-flow target and promptly escalate care while reassessing oxygenation and ventilation (e.g., pulse oximetry, respiratory effort, and likely ABGs). Increasing oxygen delivery or abruptly stopping oxygen are unsafe because they can respectively worsen CO2 retention or cause hypoxemia.
Category reason: This item tests immediate nursing action in response to a potentially life-threatening change (altered mental status) during oxygen therapy in a COPD patient, requiring clinical judgment about ventilation/oxygenation management rather than recalling isolated basic science facts.

Question 2

A client presenting with a blood pressure of 188/123 mmHg is admitted to the emergency department for atrial fibrillation (AFib) with tachycardia. What is the nurse's initial action?

Accepted Answer

Answer reason: A beta-blocker provides effective rate control and also helps address the markedly elevated blood pressure, improving hemodynamic stability. Immediate synchronized cardioversion is generally reserved for patients who are unstable (e.g., hypotension, ischemic chest pain, acute heart failure, shock) rather than those with severe hypertension. Warfarin is for stroke prevention and is not an initial ED action for acute rate control, and digoxin has a slower onset and is less effective for rapid rate control in high-sympathetic states.

Question 3

A nurse is collecting data from an infant who has respiratory syncytial virus (RSV). Which of the following findings should the nurse expect?

Accepted Answer

Answer reason: Nasal congestion and runny nose are expected early findings in infants due to mucosal edema and increased secretions. By contrast, barrel chest suggests chronic hyperinflation (e.g., long-standing obstructive disease), not an acute RSV course. Clubbing indicates chronic hypoxemia over time, and vesicles on the trunk point toward varicella or other vesicular exanthems rather than RSV.

Question 4

A nurse is assessing a client with left-sided heart failure. Which finding should the nurse expect?

Accepted Answer

Answer reason: This promotes fluid movement into alveoli and interstitial spaces, producing pulmonary congestion and auscultated crackles. Dyspnea, orthopnea, and crackles are therefore expected findings on assessment. In contrast, peripheral edema, jugular venous distention, and hepatomegaly are more characteristic of systemic venous congestion seen in right-sided heart failure.

Question 5

The nurse instructs a client diagnosed with COPD about how to perform pursed lip breathing. Which of the following statements by the client to the nurse indicates further teaching is necessary?

Accepted Answer

Answer reason: ” Pursed-lip breathing works by creating back-pressure during exhalation to prevent airway collapse and reduce air trapping in COPD, and it should be done with slow, controlled inhalation followed by prolonged exhalation through pursed lips. Adding an intentional breath-hold can increase air trapping and dyspnea and is not part of the standard technique taught for COPD symptom relief. A key teaching point is that exhalation should be longer than inhalation (often 1:2), and pursing the lips like whistling supports that. Using abdominal muscles to assist exhalation can be appropriate as a supportive strategy, but the breath-hold is the unsafe/incorrect component here.

Question 6

A client with C4 spinal cord injury is at greatest risk for?

Accepted Answer

Answer reason: At the C4 level, diaphragmatic function may be compromised and intercostal/abdominal muscle weakness markedly reduces cough effectiveness, creating a high risk of hypoventilation, atelectasis, and respiratory failure. This threat is immediate and life-threatening, making it the greatest risk compared with gastrointestinal complications like ileus or stress ulcer. Neurogenic shock can occur with high-level injuries, but it is typically an acute early complication and not as consistently the overriding ongoing risk as respiratory failure in a C4 injury.

Question 7

A nurse is caring for a patient who had a right-sided stroke. Which finding would the nurse expect?

Accepted Answer

Answer reason: These deficits lead to unsafe behaviors such as overestimating abilities and disregarding limitations, which is a classic nursing assessment finding. In contrast, expressive aphasia and agraphia are more typical of dominant (usually left) hemisphere strokes affecting Broca’s area. Motor weakness from a right-sided stroke would more typically be left-sided, making right-sided hemiplegia/facial droop inconsistent.

Question 8

A nurse is caring for a client with a traumatic brain injury. Which finding indicates increased intracranial pressure and requires immediate action?

Accepted Answer

Answer reason: Anisocoria with sluggish response suggests impaired cerebral perfusion and possible impending herniation, which is a time-critical emergency requiring rapid escalation (neuro assessment, airway/oxygenation support, notify provider/rapid response). Normal vital signs like a pulse of 88 and BP 110/70 do not indicate increased ICP by themselves, and a GCS of 15 reflects intact neurologic function. This finding is therefore the most specific and urgent indicator among the options.

Question 9

A 16-year-old comes into the ER following a motor vehicle accident. The client is dyspnic and has severe pain. The left chest is sucked in during inspiration and it bulges out during expiration. The nurse understands these are symptoms most suggestive of which of the following?

Accepted Answer

Answer reason: Paradoxical chest wall movement after blunt trauma indicates an unstable segment of the rib cage that moves opposite to normal ventilation mechanics. The described “sucked in” on inspiration and “bulges out” on expiration is classic paradoxical motion from multiple adjacent rib fractures, leading to impaired ventilation and dyspnea. Severe pain is also consistent because rib fractures destabilize the chest wall and limit effective breathing. Pneumothorax more typically presents with unilateral decreased breath sounds and pleuritic pain rather than visible paradoxical inward/outward chest wall motion.

Question 10

Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?

Accepted Answer

Answer reason: An ICP of 20 mm Hg is elevated, so an intervention that can rapidly reduce intracranial volume is appropriate in the acute setting when ordered/indicated. Barbiturates may be used for refractory intracranial hypertension but are not a routine first nursing intervention and require close hemodynamic monitoring. Fluid restriction is not a standard immediate measure for elevated ICP and can worsen cerebral perfusion if it leads to hypotension.

Question 11

The nurse is caring for a 90-year-old female with a diagnosis of Parkinson's disease. Which of the following symptoms does the nurse expect to find?

Accepted Answer

Answer reason: A resting tremor classically appears as a “pill-rolling” movement of the fingers, often accompanied by bradykinesia and rigidity. A steady gait is unlikely because Parkinson’s typically causes shuffling steps, reduced arm swing, and postural instability. Decreased vision and bilateral hand edema are not hallmark features of Parkinson’s and would prompt evaluation for other conditions.

Question 12

You are caring for a resident and note bilateral course crackles, jugular vein distention, and a productive cough during your assessment. These are signs/symptoms of?

Accepted Answer

Answer reason: Bilateral coarse crackles indicate alveolar/interstitial fluid, while jugular venous distention reflects increased right-sided filling pressures/volume. A productive cough can occur as pulmonary edema fluid mixes with airway secretions. By contrast, acute pneumothorax typically causes sudden unilateral decreased breath sounds and respiratory distress rather than JVD with bilateral crackles (except in tension physiology).

Question 13

An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?

Accepted Answer

Answer reason:  Pneumothorax introduces air into the pleural space, preventing full lung expansion and reducing ventilation on the affected side. This produces decreased or absent breath sounds over the involved area on auscultation, a key assessment finding after blunt chest trauma. A low respiratory rate is not a typical early sign because patients more commonly develop tachypnea from hypoxia and increased work of breathing. A sucking sound suggests an open (penetrating) chest wound with air movement through the chest wall rather than a classic blunt-trauma pneumothorax finding.

Question 14

A male client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannula. The client’s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client’s respiratory status. Which complication may arise if the client receives a high oxygen concentration?

Accepted Answer

Answer reason: Administering a high oxygen concentration can remove this hypoxic respiratory drive, decreasing ventilatory effort and leading to hypoventilation that may progress to apnea. High FiO2 can also worsen V/Q mismatch and increase PaCO2, further depressing consciousness and respirations. The other options do not represent the classic primary risk of excessive oxygen in CO2 retainers; for example, respiratory alkalosis is more associated with hyperventilation rather than oxygen-induced hypoventilation.

Question 15

The nurse in charge is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

Accepted Answer

Answer reason: In emphysema, loss of elastic recoil leads to dynamic small-airway collapse during exhalation and air trapping. Pursed-lip breathing creates a mild back-pressure (PEEP) in the airways during exhalation, helping splint the bronchioles open. This improves expiratory flow, reduces air trapping, and can relieve dyspnea. A common distractor is prolonging inspiration; this technique primarily targets exhalation by lengthening it and maintaining airway patency.

Question 16

After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must?

Accepted Answer

Answer reason: This action supports mobilization of secretions and improves ventilation in the remaining lung, which is especially important after lung resection. Routine clamping is unsafe because it can rapidly cause a tension pneumothorax if an air leak is present. Milking a chest tube is generally avoided unless specifically ordered because it can create excessive negative pressure and tissue trauma and is not a routine nursing care requirement.

Question 17

A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

Accepted Answer

Answer reason: An SpO2 of 88% with acute dyspnea indicates significant hypoxemia requiring rapid delivery of a high fraction of inspired oxygen. A non-rebreather mask can provide the highest oxygen concentration among the listed devices when run at high flow with the reservoir bag inflated, making it most likely to quickly improve oxygenation. Lower-flow devices such as a nasal cannula or simple mask may not deliver sufficient FiO2 in this setting to reverse symptoms promptly. A face tent is typically used for patients who cannot tolerate a mask and provides variable, generally lower oxygen concentrations, so it is less effective for urgent correction of hypoxemia.

Question 18

The nurse in charge formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea in a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include:

Accepted Answer

Answer reason: Excess body mass increases metabolic workload and the energy cost of movement, which raises oxygen consumption and can worsen dyspnea in chronic bronchitis. Obesity also reduces chest wall compliance and can impair diaphragmatic excursion, making ventilation less efficient and further increasing the work of breathing. For a client with activity intolerance from inadequate oxygenation, minimizing modifiable factors that increase oxygen demand is a key teaching goal. In contrast, encouraging adequate nutrition and smaller meals is often helpful, but fluid amount alone is not the primary driver of increased oxygen demand in this scenario unless it contributes to other complications.

Question 19

Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the following reasons best explains why?

Accepted Answer

Answer reason: Diuresis lowers intravascular volume, which decreases venous return and pulmonary vascular congestion, reducing the work of breathing in chronic bronchitis with possible cor pulmonale/fluid retention. With less cardiopulmonary workload, overall tissue oxygen consumption and the required oxygen delivery decrease, easing dyspnea. This is the primary physiologic rationale for using diuretics in COPD patients who retain fluid rather than expecting a direct “lung-opening” effect. A common distractor is that diuresis “improves respiratory function” directly; in COPD it mainly helps by unloading the heart and reducing congestion, not by reversing airflow obstruction.

Question 20

A nurse is caring for a client with severe mitral regurgitation and decreased cardiac output. The nurse assesses the client for mental status changes. What is the rationale for this intervention?

Accepted Answer

Answer reason: Severe mitral regurgitation decreases effective forward stroke volume, so even if total stroke volume is high, end-organ perfusion may still be compromised. Mental status assessment is therefore an early, sensitive indicator of worsening hemodynamic status and impending decompensation. Medication effects can contribute to confusion, but in this scenario the priority rationale is detecting decreased cerebral perfusion from low cardiac output.

Question 21

When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching?

Accepted Answer

Answer reason: Limiting sodium decreases fluid retention and helps control blood pressure, reducing the risk of volume overload complications. High-potassium foods are not routinely encouraged because renal impairment can reduce potassium excretion and raise the risk of hyperkalemia. Protein is often moderated rather than emphasized to limit nitrogenous waste while maintaining adequate nutrition.

Question 22

A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Farenheit orally. What finding would the nurse expect?

Accepted Answer

Answer reason: Pneumonia with a temperature of 102.3°F is consistent with an acute infectious process where this expected thermoregulatory response is present. Bradycardia is unlikely because fever typically produces tachycardia. Mental confusion and hypotension can occur with worsening hypoxemia or sepsis, but they are not the expected finding in an otherwise straightforward febrile presentation.

Question 23

The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention?

Accepted Answer

Answer reason: In congestive heart failure, pulmonary congestion can rapidly progress to acute pulmonary edema, making hypoxemia an immediate life-threatening finding requiring prompt intervention (e.g., oxygen, positioning, escalation of care). Crackles and nocturia are common CHF manifestations but are not as immediately dangerous as a saturation in the mid-80s. Diaphoresis can signal distress, but without objective hypoxemia it is less specific for imminent decompensation than a critically low SpO2.

Question 24

The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal?

Accepted Answer

Answer reason: When a failing ventricle is dilated and less compliant, rapid passive filling in early diastole produces a low-frequency “ventricular gallop” best heard with the bell at the apex (left-sided failure) or lower sternal border (right-sided failure). This finding aligns directly with CHF physiology and is a common expected assessment finding alongside crackles and peripheral edema. In contrast, an apical click suggests mitral valve prolapse, and a split S2 is more related to conduction/respiratory variation than fluid-overloaded ventricular dysfunction.

Question 25

A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?

Accepted Answer

Answer reason: This pulmonary congestion produces crackles (rales) on inspiration, especially at the lung bases, and is a classic expected assessment finding. Chest pain is not a defining CHF assessment finding and more strongly suggests ischemia/acute coronary syndrome as an alternative priority problem. A heart murmur may be present if valvular disease is an underlying cause, but it is not as directly consistent with acute fluid overload in CHF as crackles are.

Question 26

The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?

Accepted Answer

Answer reason: Fecal impaction can compress the urethra/bladder neck and trigger acute retention, making it a time-sensitive finding that requires prompt provider notification and bowel management. Infrequent voiding is expected with retention and is not the urgent “new cause” to escalate. Burning with urination suggests UTI, which is important but is typically less immediately reversible as an obstructive precipitant than impaction in the setting of retention.

Question 27

The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?

Accepted Answer

Answer reason: A cool, pale extremity suggests acute arterial occlusion with threatened limb perfusion, a time-sensitive emergency requiring rapid assessment and escalation to prevent tissue loss. This finding indicates impaired circulation (often with pain, pulselessness, paresthesia) and has higher immediate morbidity risk than nonspecific GI changes or appetite decrease. Tachypnea can indicate cardiopulmonary stress, but an acutely ischemic limb in this context is a classic high-priority complication needing urgent intervention.

Question 28

A child with Tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give priority attention to?

Accepted Answer

Answer reason: Preoperative nursing priority follows ABCs, making airway/breathing status and adequacy of oxygenation the first focus to detect hypoxemia and prevent hypercyanotic (tet) spells. Focused assessment includes baseline SpO2 trends, work of breathing, cyanosis severity, and signs of worsening hypoxia that would require urgent intervention or escalation. Infection prevention and nutrition are important for surgical readiness, but they do not supersede the need to identify and manage compromised oxygenation. Developmental surveillance is appropriate long-term, yet it is not the priority when a potentially life-threatening cardiopulmonary issue is present.

Question 29

A client is admitted for COPD. Which findin would require the nurse's immediate attention?

Accepted Answer

Answer reason: Neurologic changes signal inadequate cerebral oxygenation and require immediate assessment of airway, breathing, oxygen saturation, and ABGs with prompt escalation of respiratory support as needed. In contrast, cough with sputum or a low-grade fever may suggest infection but is typically less immediately life-threatening than altered mentation. Nausea and vomiting are concerning but do not usually indicate imminent ventilatory compromise in this context unless aspiration risk is present.

Question 30

The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which finding is most likely to occur?

Accepted Answer

Answer reason: When forward flow drops, neurohormonal activation promotes sodium and water retention, raising venous pressures and causing dependent fluid accumulation. This makes swelling in the legs/ankles a common accompanying finding. Nail clubbing is associated with chronic hypoxemia (e.g., longstanding lung disease or cyanotic heart disease), not typical acute CHF decompensation. Chest pain can occur with ischemia but is not the most expected linked sign of volume overload indicated by crackles.

Question 31

A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data, what is the first nursing action?

Accepted Answer

Answer reason: These ABGs show hypoxemia (PaO2 70) with low SaO2 (87%) and respiratory alkalosis from hyperventilation (low PaCO2) commonly seen with pulmonary embolism. Applying supplemental oxygen is an immediate independent nursing intervention to improve oxygen delivery while other treatments are arranged. Notifying the provider is important, but it should occur after initiating immediate measures that stabilize oxygenation; calming the client does not address the physiologic threat.

Question 32

The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?

Accepted Answer

Answer reason: In late stages, respiratory muscle failure leads to hypoventilation manifested by shallow breathing and reduced tidal volume, often preceding hypercapnia and respiratory acidosis. Cognitive status is typically preserved, so confusion is not an expected primary finding unless secondary to CO2 retention or infection. Visual field loss suggests a focal cortical or optic pathway lesion rather than ALS. Generalized tonic-clonic seizures are not characteristic of ALS and would prompt evaluation for an alternate or additional neurologic disorder.

Question 33

A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?

Accepted Answer

Answer reason: In the immediate post-op setting, hypoventilation from residual anesthetics/opioids can cause falling oxygenation before obvious visual signs appear. Cyanosis is a late sign that typically requires more significant desaturation and may be hard to detect reliably. A pulse oximetry value of 92% reflects reduced saturation but is not as early as the physiologic compensation of rising heart rate, and abnormal breath sounds indicate a possible cause rather than an early systemic response.

Question 34

While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?

Accepted Answer

Answer reason: " In chronic heart failure, diuretics are a long-term therapy used to manage ongoing fluid retention and reduce symptoms like edema and dyspnea. This response correctly explains that the medication is continued to control the underlying tendency to accumulate fluid rather than for a fixed short course. Suggesting the client will need less medication simply because they urinate more misunderstands the purpose of the drug and could promote unsafe self-titration. Referring the client back to the provider is non-therapeutic here because the nurse can safely reinforce the general expectation of continued therapy while still encouraging follow-up for individualized changes.

Question 35

A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client

Accepted Answer

Answer reason: Progression from end-expiratory, lower-pitched wheezing to high-pitched wheezing throughout exhalation reflects more diffuse and severe airway narrowing. This suggests deterioration in asthma control and a higher risk of fatigue and impending respiratory compromise if not treated promptly. Needing suctioning is more consistent with coarse crackles/rhonchi from secretions rather than a changing wheeze pattern, and hyperventilation does not specifically explain the shift in wheeze timing and pitch.

Question 36

During the beginning shift assessment of a client with asthma and is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?

Accepted Answer

Answer reason: An SpO2 of 89% indicates inadequate oxygenation despite supplemental oxygen via nasal cannula, making it the most urgent unreported finding to address. This should trigger rapid reassessment of work of breathing, lung sounds, and response to bronchodilators, and may require increasing oxygen delivery and notifying the provider/RT. Wheezing and tachypnea are common in asthma exacerbations and help grade severity, but the low saturation provides objective evidence of impaired gas exchange. Signs of dehydration are important but are not as immediately life-threatening as hypoxemia in an asthmatic client.

Question 37

While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to?

Accepted Answer

Answer reason: A temperature of 38.5°C (101.1°F) on day 2 can be expected if there are no other signs of infection or clinical deterioration. The safest, appropriate nursing action is to provide ordered antipyretic therapy and continue monitoring for new symptoms (e.g., productive cough, dysuria, wound redness) that would shift concern toward infection. Immediate provider notification or broad cultures are not first-line solely for an expected post-MI fever without additional abnormal findings, and increasing fluids is supportive but does not address fever/pain control directly.

Question 38

Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?

Accepted Answer

Answer reason: "Pursed-lip breathing creates a mild positive end-expiratory pressure that slows exhalation and helps prevent premature small-airway closure in COPD. By maintaining airway patency during exhalation, it reduces air trapping and improves ventilation, which directly addresses dyspnea from obstructive physiology. The statement about preventing collapse of the small airways/alveolar units reflects this core mechanism. In contrast, benefits like less mouth dryness are incidental and not the primary clinical reason for using the technique.

Question 39

A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical unit after a cholecystectomy. When initial vital signs are taken the nurse notes a temperature of 94.8 degrees Fahrenheit. Which first nursing action is appropriate?

Accepted Answer

Answer reason: Initiating passive external warming and reassessing soon directly treats the likely cause while verifying response to the intervention. Simply continuing to monitor delays correction and can worsen shivering, increased oxygen demand, dysrhythmias, and coagulopathy. Calling the provider is not the first step when an effective nursing intervention is available and the situation is not yet refractory or unstable; provider notification is appropriate if the patient fails to rewarm or shows clinical deterioration.

Question 40

During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

Accepted Answer

Answer reason: Reduced chest wall expansion suggests decreased lung compliance, fatigue, or developing atelectasis/consolidation that is limiting tidal volume and effective gas exchange. In a client with Legionella pneumonia, this represents an acute deterioration that requires immediate assessment of oxygenation, respiratory effort, and need for escalation (e.g., supplemental O2, ABG, rapid response). Pleuritic pain and dry mucous membranes are important but are not as immediately life-threatening as a direct sign of failing ventilation. A respiratory rate dropping from very high to a still-elevated value can reflect improvement rather than impending collapse when considered alone.

Question 41

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 nursing diagnosis would be most appropriate for this client based on this assessment data?

Accepted Answer

Answer reason: The assessment highlights crackles (suggesting secretions in the affected lobe) and pleuritic pain preventing deep inspiration, which directly impairs cough effectiveness and secretion mobilization. This makes maintaining a patent airway and clearing sputum the most immediate, diagnosis-level problem addressed by nursing interventions (e.g., pain control, splinting, hydration, coughing/deep breathing strategies). “Impaired gas exchange” can occur in pneumonia, but the stem most strongly supports a secretion/cough problem rather than evidence of hypoxemia (e.g., low SpO2, cyanosis). Anxiety is not supported by the presented data and is not the priority physiologic issue described.

Question 42

The nurse is assessing a client with clinical manifestations of right ventricular heart failure (HF). Which of the following statements by the client would be consistent with this diagnosis?

Accepted Answer

Answer reason: " Right-sided heart failure causes systemic venous congestion due to impaired right ventricular pumping, leading to increased hydrostatic pressure in the peripheral venous system. This produces dependent edema, classically swelling in the feet/ankles (and may also cause weight gain, ascites, and hepatomegaly). In contrast, wet cough and marked exertional dyspnea are more typical of left-sided failure from pulmonary congestion. Burning leg pain with walking is more consistent with intermittent claudication from peripheral arterial disease rather than heart failure.

Question 43

The nurse performs a home visit on a client who delivered two days ago. The client states that she is bottle-feeding her infant. The nurse notes white, curd-like patches on the newborn's oral mucous membranes. The nurse should take which of the following actions?

Accepted Answer

Answer reason: White, curd-like plaques on a newborn’s oral mucosa are classic for oral candidiasis (thrush), an infectious alteration requiring antifungal therapy. The appropriate nursing action is to educate the caregiver that treatment is needed so the infection resolves and feeding discomfort is reduced. Checking blood glucose does not address this localized fungal finding, and changing formula will not eradicate Candida. Avoiding sleeping with a bottle is good preventive guidance for caries/otitis risk but does not treat the current oral infection.

Question 44

A client is diagnosed with congestive heart failure. Which of the following is a primary goal for this client?

Accepted Answer

Answer reason: The most global primary goal is to improve effective circulation by increasing forward cardiac output, which addresses symptoms like fatigue, renal hypoperfusion, and fluid retention. Lowering blood pressure can be helpful if afterload is high, but it is a means to the broader aim of improving perfusion rather than the primary endpoint in all clients. Increasing heart rate can worsen myocardial oxygen demand and reduce diastolic filling time, potentially decreasing stroke volume. Fluid restriction may be used to reduce congestion, but it is a supportive strategy and not as overarching as improving cardiac output.

Question 45

The nurse is performing an assessment on a 2-month-old infant with suspected pyloric stenosis. Which of the following assessments is consistent with this diagnosis?

Accepted Answer

Answer reason: On exam, the thickened pylorus can be felt as a small “olive-like” mass in the epigastric/right upper quadrant, especially after vomiting or feeding. Obstruction also produces visible gastric peristaltic waves and dehydration/weight loss over time, making vomiting a key consistent finding. In contrast, lower abdominal distention points more toward distal intestinal obstruction, and absence of vomiting would be inconsistent with pyloric stenosis.

Question 46

A nurse is caring for a patient diagnosed with Raynaud's disease. What symptom should the nurse expect to see when the patient has an acute attack?

Accepted Answer

Answer reason: During an acute attack, decreased peripheral blood flow produces pallor (white) and a cold sensation, and may later progress to cyanosis and then reactive hyperemia (red) as perfusion returns. This presentation is specific to distal extremity ischemia rather than generalized shivering. Other options describe nonspecific chills, neuromuscular twitching, or seizure-like findings, which do not match the classic peripheral vasospastic pattern.

Question 47

An RN is assessing a patient’s fundus 3 hours after delivery. The fundus is difficult to locate and boggy. The nurse’s initial action should be to?

Accepted Answer

Answer reason: Firm fundal massage helps stimulate uterine contraction and promotes uterine tone to reduce bleeding. This is the fastest independent action the nurse can take before escalating care or initiating ordered uterotonics. Calling the provider or starting oxytocin may be necessary next, but delaying immediate uterine stimulation increases hemorrhage risk.

Question 48

A 20-year-old female softball player presents to the emergency room with left shoulder pain on abduction and mild swelling. The nurse anticipates that the patient may have which of the following conditions?

Accepted Answer

Answer reason: Mild swelling can accompany soft-tissue inflammation or tearing even without gross deformity. A shoulder dislocation more often presents with obvious deformity, marked loss of range of motion, and significant pain after a distinct traumatic event. A fracture would typically follow significant trauma and is more likely to produce focal bony tenderness and pain with most shoulder movements rather than being most specific to abduction.

Question 49

A client with a chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest?

Accepted Answer

Answer reason: During inspiration the unstable segment is pulled inward while the rest of the chest expands, and during expiration it bulges outward, producing the hallmark paradoxical pattern. Cyanosis and dyspnea can occur but are nonspecific signs of impaired ventilation/oxygenation seen in many thoracic injuries. Hypotension more strongly suggests associated hemorrhage or obstructive shock (e.g., tension pneumothorax), not the defining assessment finding of flail chest.

Question 50

After open-heart surgery, a client develops a temperature of 102*F. The nurse notifies the physician because elevated temperatures:

Accepted Answer

Answer reason: In the immediate post–open-heart period, this rise in demand can reduce cardiac reserve and precipitate ischemia or hemodynamic instability, so it warrants prompt provider notification and evaluation for causes such as infection or atelectasis. The other options are not typical primary reasons for post-cardiac surgery fever escalation, and they do not capture the key hemodynamic risk. The nursing concern is the fever-driven stress on the heart and potential deterioration in perfusion.

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