Question 1

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding?

Accepted Answer

Answer reason: A decreasing Glasgow Coma Scale score indicates worsening neurologic function and reduced level of consciousness. A drop from 5 to 3 represents a significant decline and can signal increasing intracranial pressure, brain herniation risk, or progression of the underlying injury. While a GCS of 8 or less often prompts airway protection considerations, the question asks for the best interpretation of the score change itself. Therefore, the most accurate nursing interpretation is clinical deterioration requiring urgent reassessment and escalation of care.

Question 2

The nurse notes that the client's mechanical ventilator is set to control mode. The nurse understands that this setting will achieve which action?

Accepted Answer

Answer reason: This decreases respiratory muscle workload and oxygen consumption, which is the core rationale for using a control mode in patients who need full ventilatory support. Modes that allow spontaneous respirations or patient-initiated breaths are more consistent with assisted or synchronized intermittent mandatory ventilation rather than pure control mode. The idea of intentionally hyperventilating to ensure oxygenation is incorrect because oxygenation is primarily driven by FiO2 and PEEP, while excessive ventilation mainly lowers PaCO2 and can cause harm.

Question 3

A patient is admitted to the hospital with a myocardial infarction (MI). When assessing the patient for pain, the nurse is most likely to observe referred pain in what location?

Accepted Answer

Answer reason: Myocardial ischemia commonly refers pain to the left shoulder/arm due to shared segments (often T1–T5) and involvement of the intercostobrachial nerve distribution. This makes upper chest, jaw, neck, and left shoulder/arm classic referral sites in MI assessments. In contrast, the sternum is a typical primary chest pain location rather than a referred site, and the head or left lower abdominal quadrant are not typical MI referral patterns.

Question 4

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client?

Accepted Answer

Answer reason: Fluid in the alveoli and small airways produces inspiratory crackles that are typically bilateral and often most prominent at the dependent lung bases. Frothy, pink-tinged sputum is classic for pulmonary edema from capillary transudation mixed with small amounts of blood. Clear vesicular sounds would not match edema, and stridor would indicate upper-airway obstruction rather than alveolar flooding.

Question 5

What is the major goal of nursing care for a client with heart failure and pulmonary edema?

Accepted Answer

Answer reason: Pulmonary edema from heart failure creates an immediate oxygenation/ventilation problem due to fluid in the alveoli, so airway and breathing take priority. Nursing goals therefore focus first on improving gas exchange (e.g., positioning, oxygen/ventilatory support, and rapid response to therapies like diuretics/vasodilators as ordered). While improving cardiac output and reducing edema are important, they are longer-range objectives and do not address the most urgent threat of hypoxemia. Comfort measures are supportive but cannot supersede stabilizing respiration in an acute pulmonary edema presentation.

Question 6

A client is admitted with a pulmonary embolus. The nurse assesses restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety. Arterial blood gases indicate respiratory alkalosis and hypoxemia. When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority?

Accepted Answer

Answer reason: Pulmonary embolus causes acute ventilation–perfusion mismatch, decreasing perfusion to ventilated alveoli and leading to hypoxemia, which is the immediate life-threatening problem. The assessment and ABGs (one-word dyspnea, restlessness, tachycardia, hypoxemia with respiratory alkalosis from hyperventilation) point to compromised oxygenation requiring priority interventions (oxygen, positioning, rapid response to worsening status). Pain and anxiety are important but are secondary consequences of inadequate oxygen delivery and should be addressed after stabilizing gas exchange. Activity intolerance is also downstream of impaired oxygenation and is not the initial priority when hypoxemia is present.

Question 7

The nurse has completed some child and family education for a child diagnosed with thalassemia. The medical plan of treatment includes blood transfusions when the anemia reaches a severe point. Which statement by the parents indicates a need for further education?

Accepted Answer

Answer reason: " Thalassemia is an inherited hemoglobin synthesis disorder causing chronic microcytic anemia that is not due to iron deficiency, so routine iron supplementation is inappropriate unless iron deficiency is confirmed. Children receiving repeated transfusions are at risk for iron overload, making extra iron potentially harmful. Parental statements about monitoring for pallor and planning rest reflect appropriate recognition of anemia symptoms and energy conservation needs. The inheritance statement is also consistent with the common autosomal recessive pattern (both parents typically carriers in major forms).

Question 8

A nurse is caring for an adult patient with myasthenia gravis. Which of the following nursing diagnosis is a priority?

Accepted Answer

Answer reason: By ABC priorities, maintaining a patent airway and effective clearance of secretions outweighs safety, psychosocial, or comfort diagnoses. Weak cough, dysphagia, and pooling secretions increase aspiration and respiratory failure risk, making this the most time-sensitive nursing problem. Injury risk and coping issues are important but are addressed after oxygenation/airway stability. Pain is not typically the primary or most dangerous manifestation compared with respiratory compromise.

Question 9

A patient complains to the nurse that she leaks urine while exercising. All other assessment data is normal, so the nurse suspects that this problem is?

Accepted Answer

Answer reason: Urine leakage triggered by increased intra-abdominal pressure (e.g., exercise, coughing, laughing) reflects urethral sphincter or pelvic floor weakness rather than a neurologic or psychogenic cause. With otherwise normal assessment data, the most likely mechanism is inadequate urethral closure during physical stress. Reflex incontinence is typically associated with neurologic lesions causing involuntary detrusor contractions and does not require exertion as a trigger. Anxiety or being “out of shape” are not recognized primary etiologies for exertional urine loss in standard continence classifications.

Question 10

A client is being treated for heart failure with diuretic therapy. Which of the following assessments BEST indicates to the nurse that the client's condition is improving?

Accepted Answer

Answer reason: In heart failure, excess intravascular volume leads to pulmonary congestion, producing crackles; effective diuresis should reduce this fluid and improve breath sounds. A decrease in crackles directly reflects improving pulmonary edema and better gas exchange. Stable weight may still indicate persistent fluid overload if the patient started above dry weight, so it is less specific for improvement. A lower systolic blood pressure can reflect reduced cardiac output or over-diuresis and is not a reliable indicator of clinical improvement. Urine output of 1,500 mL/day can be normal and does not by itself confirm decongestion if intake is also high or edema persists.

Question 11

The nurse is admitting a client with heart failure-related fluid overload. Identify the order of nursing priorities. All options must be used?

Accepted Answer

Answer reason: The nurse must first determine work of breathing, breath sounds (crackles), oxygen saturation, and signs of distress to guide urgency and immediate interventions. After assessment, supplemental oxygen is implemented to treat hypoxemia while additional stabilization steps proceed. Vital signs and cardiac monitoring help quantify hemodynamic status and detect dysrhythmias, and IV access enables prompt diuretic therapy to reduce preload and pulmonary congestion.

Question 12

The client with heart failure states the need to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding?

Accepted Answer

Answer reason: Needing multiple pillows to sleep is a classic description of positional dyspnea relieved by sitting upright, which defines orthopnea. Paroxysmal nocturnal dyspnea instead involves sudden episodes of severe breathlessness that awaken the client after being asleep, not simply requiring extra pillows at bedtime. Dyspnea at rest and dyspnea on exertion describe activity-related severity but do not capture the key positional pattern described.

Question 13

A child is admitted in a sickle cell crisis. What treatment should the nurse anticipate being most helpful in reducing the painful crisis? Choose One?

Accepted Answer

Answer reason: Aggressive oral/IV fluids decrease viscosity and improve perfusion, helping limit further sickling and reducing ischemic pain. Supplemental oxygen is helpful when hypoxemia is present, but it is not the most broadly effective first-line measure for pain reduction in an uncomplicated painful crisis. Antibiotics are indicated only when infection is suspected, and bedrest alone does not address the underlying hemoconcentration contributing to vaso-occlusion.

Question 14

The nurse is performing her routine physical assessment on a patient with Cushing's syndrome. Which of the following assessment findings is the nurse most likely to discover?

Accepted Answer

Answer reason: This finding is a classic, high-yield physical assessment clue that aligns with chronic hypercortisolism. Hyperkalemia and hypotension are more consistent with adrenal insufficiency (low cortisol/aldosterone), not Cushing syndrome. Hypoglycemia is also unlikely because cortisol typically raises blood glucose, so patients more often exhibit hyperglycemia than adrenergic symptoms of low glucose.

Question 15

A mother reports to the pediatric nurse that her 3-year-old child coughs at night and at times until he vomits. The symptoms have not improved over the past 2 months despite multiple over-the-counter cough medications. What should the nurse explore related to a possible etiology?

Accepted Answer

Answer reason: Environmental allergens/irritants (e.g., pet dander, dust mites, smoke) are common triggers and identifying exposures is a key etiologic assessment for persistent symptoms despite OTC cough remedies. This option directly targets a plausible cause that would change management (trigger avoidance and evaluation for asthma therapy). A butterfly rash points toward systemic lupus erythematosus, which does not fit the isolated chronic nocturnal cough pattern. Pyloric stenosis presents in early infancy with projectile vomiting rather than a 3-year-old’s chronic nighttime cough.

Question 16

A client with emphysema requires oxygen therapy. How does the nurse administer oxygen therapy to this client?

Accepted Answer

Answer reason: In chronic COPD/emphysema, oxygen is administered in a controlled, titrated manner to correct hypoxemia while minimizing the risk of worsening hypercapnia. A target saturation range of about 88–92% is commonly recommended unless a different goal is ordered, making titration to at least 88% the safest general nursing approach. Adjusting oxygen “based on dyspnea” is inappropriate because work of breathing does not reliably reflect oxygenation and can lead to excessive FiO2. A fixed liter-flow limit (e.g., ≤3 L/min) is not evidence-based for all patients and can under-treat hypoxemia or fail to match the ordered delivery device/FiO2.

Question 17

A patient on mechanical ventilation is placed on SIMV mode with a rate of 10, FIO2 50%, TV 700. The blood gases were pH 7.12, CO2 80, HCO3 29 and paO2 45 mm Hg. To correct the acid/base imbalance, what ventilator changes does the nurse expect?

Accepted Answer

Answer reason: The ABG shows severe acidemia with markedly elevated PaCO2 (80) and only mild metabolic compensation (HCO3 29), indicating inadequate ventilation as the primary problem. Increasing the set respiratory rate on SIMV increases minute ventilation and decreases PaCO2, improving pH. Increasing FiO2 would address hypoxemia (low PaO2) but does not correct hypercapnia-driven acidosis, and reducing tidal volume would worsen CO2 retention.

Question 18

A nurse cares for a client with a traumatic chest injury causing flail chest. Which distinctive characteristic of flail chest does the nurse find on assessment?

Accepted Answer

Answer reason: During inspiration, negative intrathoracic pressure pulls the unstable segment inward while the rest of the chest rises; during expiration it bulges outward, producing the hallmark paradoxical movement. This impaired mechanics reduces effective ventilation and increases work of breathing, making the finding distinctive on assessment. Tracheal deviation is more characteristic of tension pneumothorax, while bloody sputum can occur with pulmonary contusion but is not the defining sign of a flail segment.

Question 19

A nurse cares for a group of clients with acid-base imbalances. Which client does the nurse assess first?

Accepted Answer

Answer reason: Airway and breathing threats take priority because impaired ventilation and hypoxemia can rapidly progress to respiratory failure and dysrhythmias. An SpO2 of 89% on room air in emphysema indicates clinically significant hypoxemia with inadequate gas exchange, and respiratory acidosis suggests CO2 retention requiring prompt assessment of work of breathing, mental status, and need for oxygen/ventilatory support. By comparison, the renal-failure client is already slated for dialysis soon and is not described as unstable right now. The DKA client’s potassium is low and important to address, but without immediate airway/breathing compromise it is typically managed urgently after rapid assessment, whereas active hypoxemia requires first priority evaluation.

Question 20

What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?

Accepted Answer

Answer reason: This volume expansion and activation of the renin-angiotensin-aldosterone system commonly lead to elevated blood pressure on admission. While fatigue or lassitude can occur with renal inflammation and uremia, they are nonspecific findings compared with the characteristic fluid-related blood pressure change. Vomiting and diarrhea are not typical primary admitting findings and would more strongly suggest a gastrointestinal illness or another cause of fluid loss.

Question 21

A client recovering from total hip arthroplasty performed 6 hours ago has an oxygen saturation of 84%. The nurse performs what action first?

Accepted Answer

Answer reason: An SpO2 of 84% is severe hypoxemia, so the priority is to immediately improve airway patency and ventilation using the least invasive, fastest intervention. Upright positioning increases chest expansion, reduces diaphragmatic splinting after surgery, and can rapidly improve oxygenation while further assessment and treatments are prepared. Simply auscultating delays correction of hypoxia and does not treat the problem. Oxygen and coached deep breathing/coughing are appropriate next steps, but positioning is typically performed first because it can be implemented instantly and supports both ventilation and secretion clearance.

Question 22

A nurse cares for a client admitted for a sickle cell crisis. Which intervention is the priority?

Accepted Answer

Answer reason: Supplemental oxygen increases oxygen delivery to tissues, especially if there is hypoxemia from acute chest syndrome or pain-related hypoventilation. Analgesics are essential but are addressed after ensuring adequate oxygenation/airway-breathing stability. Bed rest and positioning may reduce oxygen demand and discomfort, but they do not correct the underlying hypoxia risk in an acute crisis.

Question 23

A client has atrial fibrillation the nurse should monitor the client for?

Accepted Answer

Answer reason: These emboli can dislodge and travel to cerebral arteries, making ischemic stroke a key complication to monitor for. Monitoring for acute neurologic changes (e.g., unilateral weakness, facial droop, speech difficulty) is therefore the most clinically relevant surveillance priority. Cardiac arrest and ventricular fibrillation are not typical direct complications of atrial fibrillation itself, and heart block is a different conduction disturbance rather than the major thromboembolic risk emphasized with atrial fibrillation.

Question 24

A nurse is caring for a client who has pneumonia and thick secretions in his airway. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Airway clearance follows least-invasive-first and ABC priorities, promoting effective ventilation while mobilizing secretions. Deep breathing expands alveoli and improves oxygenation, and coughing is the most direct way to expectorate thick mucus using the client’s own airway reflexes. Suctioning is reserved for clients who cannot clear secretions independently or have evidence of obstruction because it is invasive and can cause hypoxemia and mucosal trauma. Chest physiotherapy and hydration can help loosen secretions but are supportive measures that do not immediately clear the airway as effectively as coached coughing.

Question 25

Tissue oxygenation is essential for a child with Sickle Cell Anemia. In order to promote oxygenation you need to carry out which of the following activities (The most important one)?

Accepted Answer

Answer reason: Adequate hydration decreases hemoconcentration, improves microcirculatory flow, and helps reduce vaso-occlusive sickling, making it the most impactful routine nursing action to support oxygen delivery. Avoiding low-oxygen environments is important, but dehydration is a very common, modifiable trigger that nurses can address continuously and proactively. Small frequent feeding is supportive care but does not directly improve oxygen-carrying delivery, and complete bed rest is not routinely required and can add other risks if used indiscriminately.

Question 26

The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?

Accepted Answer

Answer reason: Pulmonary edema reflects acute fluid overload in the lungs that threatens gas exchange, so the priority is rapid reduction of intravascular volume and pulmonary congestion. An IV loop diuretic produces faster diuresis and venodilation than oral measures, helping decrease preload and relieve crackles and dyspnea risk. Daily weights, I&O, and fluid restriction are important monitoring and longer-horizon management but do not address the immediate respiratory compromise signaled by bilateral moist crackles and rapid weight gain. Among the options, this intervention most directly treats the acute problem and prevents deterioration.

Question 27

A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant?

Accepted Answer

Answer reason: Handling and routine care such as diaper changes commonly triggers crying and agitation, which raises oxygen consumption and worsens work of breathing. Administering oxygen during this predictable stressor helps blunt desaturation and reduces cardiopulmonary strain. In contrast, sleep and being held are generally low-demand states unless the infant shows signs of distress, and a blood draw is a brief procedure that is not typically the most common trigger compared with routine caregiving that provokes crying.

Question 28

A 65-year-old male patient with emphysema and acute upper respiratory infection is admitted. Oxygen is ordered at 2 L/min. The reason for low-flow oxygen is to?

Accepted Answer

Answer reason: Delivering high concentrations of oxygen can reduce hypoxic stimulation and worsen hypoventilation, leading to rising PaCO2 and respiratory acidosis. A low-flow rate (e.g., 2 L/min via nasal cannula) helps achieve safer oxygenation targets while minimizing the risk of CO2 narcosis. Other options are not the primary safety rationale for limiting flow; humidification addresses secretion drying but does not explain choosing low-flow specifically in emphysema.

Question 29

A client is being admitted with a diagnosis of urolithiasis and ureteral colic. The nurse expects to note which finding on pain assessment?

Accepted Answer

Answer reason: The pain classically comes in waves and radiates from the flank toward the groin/genitalia due to shared sensory pathways (T10–L2) and the stone’s progression down the ureter. This pattern is more characteristic of ureteral obstruction than the steady, localized costovertebral discomfort seen with renal capsule distention or infection. Diffuse abdominal cramping suggests gastrointestinal sources rather than ureteral colic.

Question 30

A client with intermittent claudication at rest asks the nurse about symptom relief. The nurse teaches which symptom relief measure?

Accepted Answer

Answer reason: Intermittent claudication at rest reflects severe peripheral arterial disease with critically reduced tissue perfusion; symptom relief focuses on improving arterial flow and reducing vasoconstriction. Nicotine causes peripheral vasoconstriction and promotes atherosclerotic progression, both of which worsen ischemic pain, so stopping smoking is a direct symptom-relief intervention. Elevating the legs above heart level further decreases arterial perfusion pressure to the feet and can intensify ischemic pain, whereas dependent positioning is typically more relieving. Cold compresses and tight wrapping can also reduce local perfusion and aggravate ischemia rather than relieve it.

Question 31

In performing a physical assessment of a client with chronic kidney disease (CKD), which finding should the nurse anticipate?

Accepted Answer

Answer reason: Extra intravascular volume can shift into the pulmonary interstitium and alveoli, producing inspiratory crackles on auscultation. CKD is also commonly associated with hypertension rather than hypotension, making a low blood pressure reading less expected. Glycosuria and polyphagia are classic findings of uncontrolled diabetes mellitus, which may cause CKD but are not anticipated CKD assessment findings by themselves.

Question 32

A client recovering from an exacerbation of left-sided heart failure had a problem with tolerating activity. The nurse determines that the client best tolerates mild exercise if the client exhibits which change in vital signs during activity?

Accepted Answer

Answer reason: An increase from 80 to 104 beats/min is a reasonable, expected exercise response and suggests the client is compensating adequately. In contrast, a drop in oxygen saturation to 91% indicates impaired gas exchange/pulmonary congestion and poor tolerance. A respiratory rate of 91 breaths/min or a large blood pressure decrease reflects significant distress or reduced perfusion and would signal the need to stop activity and reassess.

Question 33

The nurse is caring for a client with Guillain-Barré syndrome after a recent gastrointestinal illness. Monitoring for which symptom is a nursing care priority in this client?

Accepted Answer

Answer reason: Difficulty coughing and neck flexion weakness are red flags for bulbar/respiratory muscle involvement, signaling impending respiratory failure and need for frequent vital capacity/negative inspiratory force monitoring and possible ventilatory support. While autonomic dysfunction and ileus can occur, they are not as immediately life-threatening as loss of effective cough and ventilatory mechanics. A warm, tender swollen leg suggests DVT risk from immobility, but airway and breathing take priority.

Question 34

The parents of a toddler report that the client is having poor sleeping, intense perianal itching, and scratching. The nurse understands that this client is at the highest risk for which condition?

Accepted Answer

Answer reason: Nocturnal perianal pruritus with sleep disturbance in a young child is classic for pinworm infection due to female worms migrating to lay eggs around the anus at night, triggering intense itching and scratching. This presentation makes an intestinal helminth far more likely than malabsorptive disorders or protozoal diarrhea syndromes. Anal fissures can cause pain and bleeding with defecation, but they are not the typical cause of prominent nighttime itching. Giardiasis and celiac disease more commonly cause chronic diarrhea, steatorrhea, bloating, and weight issues rather than isolated perianal itching.

Question 35

While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 mL/h and oxygen at 2 L/min. The nurse should first?

Accepted Answer

Answer reason: Frequent PVCs after an MI can indicate myocardial irritability and risk for more dangerous dysrhythmias, so escalation for timely medical evaluation and treatment is the priority. A new pattern of 8 PVCs/min warrants prompt provider notification to assess for ischemia, electrolyte disturbances, and need for antiarrhythmic therapy or other interventions. Simply increasing IV fluids does not treat ventricular ectopy and may worsen cardiac workload. Increasing oxygen or giving analgesia may be appropriate depending on assessment (SpO2, chest pain), but the immediate action from the provided choices is to report the significant dysrhythmia.

Question 36

The nurse assesses a patient being treated after having an asthma attack. What symptoms would indicate to the nurse that the patient is not improving?

Accepted Answer

Answer reason: In acute asthma, worsening airflow obstruction can progress to minimal air movement, producing very quiet or absent breath sounds (“silent chest”), which is an ominous sign of poor ventilation and impending respiratory failure. Effective treatment should improve air entry and reduce work of breathing; decreasing breath sounds suggests bronchospasm and air trapping are not resolving. Audible wheezing can sometimes lessen as the airway opens with treatment, but it can also disappear when airflow becomes critically reduced, so breath sound diminution is a more concerning indicator. Emotional distress is nonspecific, and a productive cough may occur as secretions mobilize and does not by itself signal deterioration.

Question 37

The nurse in charge of a patient with iron deficiency anemia is documenting care. Which nursing diagnosis is the most appropriate in the plan of care?

Accepted Answer

Answer reason: This physiologic problem aligns best with a diagnosis focused on impaired oxygenation rather than problems with breathing mechanics or secretion clearance. Ineffective airway clearance and ineffective breathing pattern are appropriate when obstruction, retained secretions, or altered ventilatory drive/mechanics are the primary issue, which is not implied by iron deficiency anemia. Deficient fluid volume is unrelated unless there is concurrent hemorrhage or dehydration, neither of which is described.

Question 38

A client who is 34 weeks pregnant is admitted to the labor and birth room with the diagnosis of preeclampsia. The client’s vital signs are as follows: blood pressure 149/92 mm Hg; pulse, 62 beats/min; respiratory rate, 18 breaths/min; temperature, 98.4°F (36.8°C). What is the priority intervention?

Accepted Answer

Answer reason: Preeclampsia management prioritizes optimizing uteroplacental perfusion and reducing maternal blood pressure effects without delaying immediate supportive care. Left lateral positioning decreases vena cava compression, improves venous return and cardiac output, and can improve renal and uterine blood flow, helping maternal-fetal oxygenation. A BP of 149/92 is elevated but not in the severe range (≥160/110) that typically drives urgent IV antihypertensive therapy, so medication is not the first immediate nursing action. Calling the provider may be appropriate after initial stabilization measures, and a cervical check is not the priority and may increase stimulation/stress without addressing the pathophysiologic risk.

Question 39

A client with heart failure exhibits fatigue and dyspnea on exertion. What is the priority nursing diagnosis for these findings?

Accepted Answer

Answer reason: When the heart cannot augment stroke volume and cardiac output with exertion, patients develop early fatigue and exertional shortness of breath as metabolic demand rises. While fluid overload can contribute to dyspnea, the stem does not highlight classic volume-excess cues (e.g., edema, weight gain, crackles) and the key symptom pairing points to pump failure. Impaired gas exchange is typically prioritized when there is evidence of alveolar-capillary compromise (resting hypoxemia, cyanosis, abnormal ABGs), which is not provided here.

Question 40

During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations, and a temperature of 103.2° F (39.6° C). The infant’s fontanel is more tense than at the last assessment. What should the nurse do first?

Accepted Answer

Answer reason: The findings (decreased responsiveness, bradycardia, increased blood pressure, irregular respirations, and a tense fontanel) are consistent with increased intracranial pressure and possible impending herniation, requiring immediate measures to promote cerebral venous drainage. Elevating the head of the bed helps reduce ICP quickly by improving venous outflow and decreasing intracranial blood volume. Calling the provider is essential, but it does not immediately address the life-threatening physiologic derangement while the nurse can intervene within scope. Treating fever may be supportive but is not the priority over stabilizing neurologic status and reducing ICP.

Question 41

The initial assessment of a newborn reveals a chest circumference of 34cm and an abdominal circumference of 31cm. The chest is asymmetrical and breath sounds are diminished on the left side. The nurse should give priority to?

Accepted Answer

Answer reason: g., pneumothorax or diaphragmatic hernia). Immediate oxygen support helps prevent hypoxemia and rapid decompensation while further evaluation and provider interventions are initiated. Abdominal auscultation or checking esophageal patency are secondary assessments that do not address the immediate threat to ventilation/oxygenation. Positioning may be helpful in some conditions but is not a substitute for promptly improving oxygenation when breath sounds are clearly reduced on one side.

Question 42

Mr. Killam has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement?

Accepted Answer

Answer reason: Nursing care should focus on improving ventilation and promoting CO2 elimination and airway clearance. Coughing and deep breathing increase alveolar ventilation, help mobilize secretions, and can reduce CO2 retention while supporting oxygenation. Low-flow oxygen may improve PaO2 but does not correct hypoventilation and can worsen CO2 retention in some chronic retainers if overused. Paper-bag breathing is used for respiratory alkalosis from hyperventilation and would be inappropriate here.

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