Question 1

EKG Interpretation – Atrial Fibrillation A nurse is reviewing a patient’s telemetry strip and notes an irregularly irregular rhythm, absent P waves, and a narrow QRS complex. The patient is alert but reports mild fatigue. What is the nurse’s priority action?

Accepted Answer

Answer reason: The findings indicate atrial fibrillation, and the patient appears hemodynamically stable (alert with only mild fatigue). In stable cases, the immediate nursing priority is to escalate care for medical management focused on rate control and prevention of thromboembolism, with anticoagulation commonly indicated based on stroke-risk assessment. Synchronized cardioversion is generally prioritized for unstable patients (e.g., hypotension, ischemic chest pain, acute heart failure, altered mental status) or selected scenarios under provider direction. CPR and atropine are not indicated because there is no evidence of pulselessness or symptomatic bradycardia.
Category reason: This is a patient-care prioritization question about nursing actions in response to a dysrhythmia and hemodynamic stability, which fits NCLEX Physiological Adaptation (Hemodynamics).

Question 2

During pericardiocentesis, intravenous fluids are given in order to.............?

Accepted Answer

Answer reason: Removing pericardial fluid can abruptly change preload and cardiac output in a patient who may already have compromised filling (e.g., tamponade physiology). Intravenous fluids help support venous return and stabilize hemodynamics during and immediately after the procedure. The primary intent is preventing hypotension and cardiovascular collapse rather than hydration, infection prevention, or nutrition.
Category reason: This item focuses on a procedure-related nursing/clinical intervention to maintain cardiovascular stability during pericardiocentesis, which is a hemodynamic management problem rather than foundational anatomy alone.

Question 3

A nurse in the ICU is caring for a client with a new diagnosis of septic shock. Which intervention should the nurse prioritize?

Accepted Answer

Answer reason: Septic shock causes profound vasodilation and capillary leak leading to relative hypovolemia and inadequate tissue perfusion, so restoring intravascular volume is the immediate priority to support blood pressure and organ perfusion. Initial management is rapid administration of isotonic crystalloids (e.g., 30 mL/kg) while closely monitoring response (MAP, urine output, lactate). Antibiotics are time-critical and should be given early, but hemodynamic stabilization with fluids is the first action that addresses the life-threatening perfusion deficit. Vasopressors are typically started if hypotension persists after adequate fluid resuscitation, and diagnostic imaging should not delay resuscitation.
Category reason: This is a nursing prioritization question focused on immediate stabilization of a shock state and optimizing perfusion and blood pressure, which is hemodynamic management in critical care.

Question 4

A client with septic shock has a mean arterial pressure (MAP) of 55 mmHg. Which medication should the nurse prepare to administer?

Accepted Answer

Answer reason: A MAP of 55 mmHg indicates inadequate tissue perfusion in septic shock and requires prompt vasopressor support after (or alongside) fluid resuscitation to restore perfusion pressure. A first-line vasopressor in septic shock is used to increase systemic vascular resistance and raise MAP to a typical target of at least 65 mmHg. The other choices either lower blood pressure (vasodilator), reduce circulating volume (diuretic), or decrease heart rate/contractility (beta-blocker), which can worsen hypotension and shock.
Category reason: This question tests immediate nursing management of shock by selecting an intervention to correct hypotension and restore perfusion, which is a hemodynamic adaptation issue in acute illness.

Question 5

A pregnant woman in labor shows signs of supine hypotensive syndrome. What should the nurse do?

Accepted Answer

Answer reason: This relieves aortocaval compression by the gravid uterus, improving venous return and cardiac output and thereby correcting maternal hypotension. Improved maternal perfusion also supports uteroplacental blood flow and fetal oxygenation. Elevating the head can worsen venous return, and keeping the client supine perpetuates the cause even if oxygen is applied. Knee-chest is not the first-line maneuver for this condition and is less practical during labor compared with left lateral positioning.
Category reason: This question tests an immediate nursing intervention to correct a hemodynamic instability (supine hypotension from aortocaval compression) in a laboring client, which is a patient-care decision under Physiological Adaptation—Hemodynamics.

Question 6

A client with cardiogenic shock is on norepinephrine infusion. Which change indicates improved perfusion?

Accepted Answer

Answer reason: B. Urine output of 40 mL/hr Adequate renal output reflects improved renal blood flow and end-organ perfusion in shock, and a typical goal is at least ~30 mL/hr in many adults. Norepinephrine is titrated to restore perfusing pressure; improved urine output is a practical bedside indicator that perfusion is improving. The other choices suggest persistent hypoperfusion or inadequate blood pressure support (cool/clammy skin, low MAP, and low systolic pressure).
Category reason: This item tests nursing evaluation of end-organ perfusion and response to vasoactive therapy in cardiogenic shock, which is a hemodynamic management judgment.

Question 7

A laboring client receives an epidural and develops BP 80/40 mmHg. What is the priority action?

Accepted Answer

Answer reason: Epidural anesthesia can cause sympathetic blockade leading to vasodilation and sudden maternal hypotension, which threatens uteroplacental perfusion and fetal oxygenation. The fastest initial nursing intervention is to increase circulating volume with an IV fluid bolus to improve preload and blood pressure. Trendelenburg is not routinely recommended due to limited benefit and potential respiratory compromise, and stopping the epidural does not correct the acute hemodynamic drop. Oxytocin can worsen hypotension and should not be initiated as a response to epidural-related hypotension.
Category reason: This is a patient-care priority question about responding to acute maternal hypotension after an epidural, focusing on stabilizing circulation and perfusion, which fits Hemodynamics under Physiological Adaptation.

Question 8

Which artery is best for assessing arterial pulse during shock?

Accepted Answer

Answer reason: In shock, peripheral vasoconstriction reduces blood flow to distal arteries, making pulses like radial and dorsalis pedis weak or absent early. Central pulses are more reliably palpated when perfusion is compromised, so checking a central artery better reflects core circulation. The carotid pulse remains detectable longer and provides a faster, more accurate assessment of severe hypotension.
Category reason: This item tests nursing assessment of circulation during shock and selection of the most reliable pulse site, which is hemodynamic monitoring in an acute clinical scenario.

Question 9

A nurse is caring for a client who underwent pericardiocentesis. Which finding indicates a successful response?

Accepted Answer

Answer reason: Pericardiocentesis relieves cardiac tamponade by removing pericardial fluid and restoring ventricular filling. As intrapericardial pressure falls, right-sided filling pressures decrease, which is reflected by a lower CVP. The other findings listed (distant heart sounds, pulsus paradoxus, and narrow pulse pressure) are classic signs of ongoing tamponade or impaired cardiac output rather than improvement.
Category reason: This item tests nursing interpretation of post-procedure hemodynamic response after pericardiocentesis, focusing on improved cardiac filling and pressure changes, which aligns with Hemodynamics under Physiological Adaptation.

Question 10

An epidural was placed 10 min ago. The client now reports nausea; BP is 80/40 mm Hg; FHR baseline 100. What is the initial nursing action?

Accepted Answer

Answer reason: This presentation immediately after epidural placement is most consistent with sympathetic blockade causing maternal hypotension, decreased uteroplacental perfusion, and fetal bradycardia. The priority is rapid maternal resuscitation by optimizing venous return/uterine displacement and expanding intravascular volume to improve blood pressure and fetal oxygenation. Provider notification may follow, but stabilizing hemodynamics is the first nursing action. Oxytocin and pushing would worsen fetal status by increasing uterine activity or delaying correction of hypoperfusion.
Category reason: This question tests immediate nursing management of acute maternal hypotension and fetal bradycardia after epidural, focusing on hemodynamic stabilization and patient-care interventions.

Question 11

What position is best for a patient experiencing hypovolemic shock?

Accepted Answer

Answer reason: This position promotes venous return from the lower extremities, improving preload and supporting cardiac output and blood pressure during acute volume loss. It can be implemented quickly while definitive treatment (rapid isotonic fluids and control of bleeding) is initiated. Full Trendelenburg is not recommended because it can impair diaphragmatic excursion and worsen ventilation without proven benefit. High Fowler’s would further decrease venous return and can worsen hypotension.
Category reason: This item tests nursing management of acute shock by choosing a positioning intervention to support circulation and tissue perfusion, which aligns with hemodynamic stabilization in Physiological Adaptation.

Question 12

Scenario: A patient's BP drops to 85/50 mmHg two hours after surgery. Urine output is 10 mL/hour. Q. What should the nurse do first?

Accepted Answer

Answer reason: Hypotension with oliguria shortly after surgery strongly suggests acute hypovolemia, most concerning for hemorrhage. The immediate nursing priority is to quickly assess for a correctable cause by checking the surgical site/dressing (and other bleeding signs) before implementing interventions that could mask ongoing blood loss. Increasing IV fluids may be needed, but identifying and stopping bleeding is essential to restore effective circulating volume and prevent shock. Furosemide would worsen hypovolemia, and rapid response is appropriate if the patient is unstable after initial focused assessment and immediate notifications/interventions are initiated.
Category reason: This item tests urgent postoperative nursing assessment and hemodynamic stabilization decisions (recognizing possible hemorrhage causing hypotension and low urine output), which is a patient-care judgment task under Physiological Adaptation.

Question 13

A client in the ER has cool, clammy skin, weak pulse, and hypotension after a severe abdominal injury. What is the priority action?

Accepted Answer

Answer reason: B. Initiate IV fluid resuscitation These findings after major abdominal trauma are consistent with hypovolemic shock from internal hemorrhage, so restoring circulating volume and perfusion is the immediate priority (ABCs/hemodynamic stabilization). Rapid IV access with isotonic crystalloids (and preparation for blood products as indicated) supports blood pressure and tissue oxygen delivery while definitive hemorrhage control is arranged. Pain medication and leg elevation do not address the primary life-threatening problem, and CT should be delayed until the client is stabilized.
Category reason: This is a priority nursing action in an emergency trauma/shock scenario focused on stabilizing perfusion and blood pressure, which aligns with hemodynamic management under Physiological Adaptation.

Question 14

A patient with an implanted pacemaker reports feeling dizzy and has a heart rate of 42 bpm. What is the first action?

Accepted Answer

Answer reason: This presentation suggests symptomatic bradycardia, where the immediate priority is to determine hemodynamic stability (perfusion) by checking for hypotension and other signs of poor perfusion. Vital-sign assessment guides urgency and next steps (e.g., atropine and/or pacing) and helps identify imminent instability. If hypotension is present, escalation to ACLS bradycardia interventions is indicated; if stable, further evaluation of pacemaker function can follow.
Category reason: This question tests immediate nursing assessment and prioritization in a potentially unstable bradycardic patient, focusing on perfusion/hemodynamic status and first action before interventions.

Question 15

A nurse is assessing a postpartum client who delivered vaginally 1 hour ago. Which finding is most concerning?

Accepted Answer

Answer reason: Deviation to the right commonly indicates a distended bladder, which prevents effective uterine contraction and increases bleeding risk. This finding requires prompt nursing action (fundal massage and bladder emptying) and close assessment of lochia/vitals for hemorrhage. By contrast, moderate lochia rubra at 1 hour postpartum and a firm, midline fundus are expected findings, and perineal swelling/discomfort is common after vaginal birth unless there are signs of expanding hematoma or shock.

Question 16

A nurse is reviewing the fetal monitor strip and sees late decelerations with each contraction. What is the first action?

Accepted Answer

Answer reason: Side-lying positioning reduces aortocaval compression, improves maternal venous return and cardiac output, and increases uteroplacental perfusion to optimize fetal oxygen delivery. Increasing oxytocin would worsen uterine activity and further decrease placental blood flow, making fetal compromise more severe. Supplemental oxygen and notifying the provider are appropriate next steps if decelerations persist, but the fastest first intervention is maternal repositioning to improve perfusion.

Question 17

Adequacy of fluid replacement in hypovolemic shock can be assessed through ..............?

Accepted Answer

Answer reason: In hypovolemic shock, adequate fluid replacement should restore organ perfusion, typically reflected by improving urine output toward at least ~0.5 mL/kg/hr in adults. Blood pressure can normalize late or be temporarily supported by compensatory vasoconstriction, so it is less reliable as an early marker of adequacy. Skin turgor is nonspecific and distal pulses can improve with vasomotor changes without confirming end-organ perfusion.

Question 18

Which of the following is the initial treatment goal for Cardiogenic Shock?

Accepted Answer

Answer reason: Improving oxygen supply to the myocardium helps reverse ischemia, supports contractility, and can interrupt the downward spiral of worsening pump failure. Measures that achieve this include supplemental oxygen/ventilatory support as needed, maintaining adequate blood pressure with vasoactive agents, and rapid treatment of the underlying cause (e.g., revascularization in MI). Correcting hypoxia and acidosis are supportive targets, but they are downstream consequences; the initial treatment goal is to improve myocardial oxygen delivery and perfusion to stabilize hemodynamics.

Question 19

A client has developed atrial fibrillation with a ventricular response rate of 150 beats per minute. The nurse should assess the client for which associated signs or symptoms?

Accepted Answer

Answer reason: Decreased cardiac output commonly presents with hypotension and cerebral hypoperfusion symptoms such as lightheadedness or dizziness. Nursing assessment should focus on hemodynamic stability and perfusion indicators because instability can require urgent rate control or cardioversion. Hypertension/headache is less consistent with tachyarrhythmia-related low output, and flat neck veins are not an expected primary finding. Nausea/vomiting may occur with many conditions but is not the hallmark assessment cue for hemodynamic compromise from rapid AF.

Question 20

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiologic change does the nurse attribute the decreased blood pressure?

Accepted Answer

Answer reason: The resulting venous and arterial vasodilation decreases venous return (preload) and systemic vascular resistance, which lowers blood pressure quickly after the block. While high spinal levels can also reduce heart rate by affecting cardioaccelerator fibers (T1–T4), the primary immediate mechanism for hypotension is peripheral vasodilation with pooling. Chemoreceptor response is not the typical driver of acute post-spinal hypotension in this setting.

Question 21

Client has a craniotomy for a meningioma for what response should the nurse assess the client in the postanesthesia care unit?

Accepted Answer

Answer reason: A narrowing pulse pressure suggests worsening hemodynamic instability and, in the neuro postoperative context, can be an ominous sign associated with increased intracranial pressure and impending herniation physiology, prompting urgent reassessment and provider notification. Immediate PACU monitoring focuses on vital-sign trends, level of consciousness, and signs of cerebral hypoperfusion because these change quickly and require time-sensitive intervention. In contrast, wound infection is typically a later complication and dehydration is not the most specific or immediate PACU threat after intracranial surgery.

Question 22

The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to?

Accepted Answer

Answer reason: A drop to about 30 mL/hr is oliguria, which is an early sign of low forward flow and potential cardiogenic shock in this context. Lower cardiac output decreases renal blood flow and glomerular filtration rate, triggering sympathetic/RAAS-mediated sodium and water retention and further lowering urine output. Dehydration or diminished blood volume are possible causes of oliguria, but in an ICU patient immediately post-MI the most likely new cause is hemodynamic compromise. Established renal failure is typically a later or persistent consequence rather than the most likely immediate driver of an acute post-MI urine output decline.

Question 23

The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to?

Accepted Answer

Answer reason: Direct, firm pressure is the fastest first-line nursing action to promote hemostasis while maintaining graft integrity. Reinforcing and elevating can be supportive after initial control, but it delays the critical step of stopping the bleed. Removing the dressing risks disrupting clots and worsening bleeding, and elastic bandages may compromise perfusion to the bypassed extremity.

Question 24

A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first?

Accepted Answer

Answer reason: In preeclampsia with rising blood pressure, an immediate, noninvasive intervention that can improve maternal hemodynamics and fetal oxygenation is the priority. Checking urine protein and monitoring urine output are important assessments for disease severity and renal perfusion, but they do not address the acute hemodynamic compromise as quickly as repositioning. Taking a temperature is not a priority response to worsening hypertension in this context unless infection is suspected.

Question 25

During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to

Accepted Answer

Answer reason: In a client with cardiomyopathy, inadequate preload or mild dehydration can further reduce stroke volume and worsen symptoms, so increasing oral fluids is an appropriate initial nursing instruction when no signs of fluid overload are described. Reassessing blood pressure after fluid intake checks whether the hemodynamic changes improve and helps determine if further evaluation is needed. Fluid restriction would be expected to aggravate hypotension and dizziness unless the problem were clearly fluid overload or hyponatremia, which is not indicated here.

Question 26

The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care?

Accepted Answer

Answer reason: Urine output is a rapid, continuous bedside indicator of renal perfusion and overall cardiac output, and trending it hourly helps identify early hemodynamic deterioration or post–cardiac arrest syndrome. A drop in output can signal inadequate circulating volume, low forward flow, or evolving acute kidney injury, prompting timely fluid, vasoactive, or perfusion-focused interventions. By comparison, white blood count and scheduled glucose checks are not as immediate or sensitive for real-time perfusion status, and intermittent temperature monitoring is supportive but less critical than perfusion assessment in the acute phase.

Question 27

A patient is admitted to the intensive care unit with disseminated intravascular coagulation (DIC) associated with a gram-negative infection. Which assessment information has the most immediate implications for the patient's care?

Accepted Answer

Answer reason: Hypoxemia is an immediate airway/breathing threat that requires rapid intervention to prevent respiratory failure and worsening tissue hypoxia. In DIC from gram-negative sepsis, microthrombi and capillary leak can rapidly impair gas exchange and precipitate ARDS, making a low SpO2 an urgent sign to address with oxygenation/ventilation support and escalation of care. While absent peripheral pulses and mottling suggest poor perfusion/shock, oxygenation at 87% represents an immediately measurable, treatable instability affecting vital organ oxygen delivery. Chest pain is concerning for ischemia or PE, but the immediate priority is correcting inadequate oxygenation and assessing for evolving respiratory compromise.

Question 28

A nurse is caring for a postpartum patient who is experiencing heavy vaginal bleeding. The nurse notes the patient's blood pressure is dropping. What should the nurse prioritize?

Accepted Answer

Answer reason: Heavy postpartum bleeding with a falling blood pressure indicates evolving hypovolemic shock, so immediate hemodynamic stabilization is the priority (ABC/circulation). Rapid IV isotonic fluids support perfusion while the team simultaneously evaluates and treats the hemorrhage source. Assessing fundal tone is important for identifying uterine atony, but it does not correct the immediate life-threatening hypotension. Notifying the provider and preparing for transfusion are appropriate next steps, but initial nursing action should focus on restoring circulating volume and preventing further decompensation.

Question 29

The nurse is assessing a septic patient with hypotension and tachycardia. The nurse reviews the patient's lab results and expects an elevation of?

Accepted Answer

Answer reason: When cells shift toward anaerobic metabolism, lactate rises, making it a key marker of shock severity and a target for resuscitation trends. Elevated lactate supports concern for septic shock and guides urgency of fluids, vasopressors, and ongoing reassessment. In contrast, platelets more commonly decrease in sepsis due to consumption/DIC risk rather than increase.

Question 30

The nurse provides care for a client diagnosed with prerenal acute kidney injury. Which action will the nurse perform first?

Accepted Answer

Answer reason: Prerenal acute kidney injury is caused by decreased renal perfusion, so immediate hemodynamic assessment is the priority to identify hypotension or shock that requires rapid intervention. Blood pressure directly reflects circulating volume and perfusion pressure, which drive glomerular filtration and urine output. An indwelling catheter may be needed to trend urine output, but it does not correct the primary problem and is not the first step unless obstruction is suspected. Daily weights are useful for ongoing fluid balance monitoring but are less urgent than evaluating and stabilizing perfusion.

Question 31

A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock?

Accepted Answer

Answer reason: This commonly manifests as altered mental status, including restlessness and confusion. In contrast, hypertension and bounding pulses are more consistent with increased cardiac output or high systemic vascular resistance without pump failure; cardiogenic shock typically trends toward hypotension and weak, thready pulses. Although heart rate may vary depending on infarct location and conduction involvement, neurologic changes from hypoperfusion are a key expected finding as shock progresses.

Question 32

If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe?

Accepted Answer

Answer reason: Cardiogenic shock is pump failure leading to low cardiac output and systemic hypoperfusion. The kidneys are highly sensitive to decreased renal blood flow, so urine output drops early and is a key clinical marker of inadequate perfusion (often

Question 33

A nurse is caring for a patient with a blood pressure of 80/50 mmHg after a myocardial infarction. What is the priority action?

Accepted Answer

Answer reason: This finding requires prompt escalation for rapid evaluation and potential orders for vasoactive support, urgent diagnostics, and management of complications (e.g., dysrhythmia, mechanical failure). Waiting 15 minutes to recheck risks delaying life-saving treatment in an unstable patient. Trendelenburg is not recommended for shock management and can worsen respiratory status; giving fluids may be inappropriate in cardiogenic shock and should be guided by provider-directed hemodynamic assessment.

Question 34

The nurse is monitoring a postpartum client who is bleeding for signs of shock. Which indicates an early sign of shock?

Accepted Answer

Answer reason: A jump in heart rate to 124 bpm in a bleeding postpartum client indicates the body is attempting to preserve cardiac output despite falling circulating volume. A small decrease in blood pressure can still be within normal variation and may not reflect decompensation due to compensatory vasoconstriction. Mild postpartum cramping and a low-grade temperature can be expected findings and are not specific indicators of shock.

Question 35

A nurse is caring for a 35-year-old client who has been diagnosed with hypovolemic shock as a result of severe hemorrhage. In which position should the nurse place this client to promote optimal circulation?

Accepted Answer

Answer reason: Lying flat with legs elevated (modified shock position) promotes venous return from the lower extremities to the heart and can transiently improve blood pressure and tissue perfusion while definitive therapies (oxygen, IV fluids/blood) are initiated. Trendelenburg is no longer recommended routinely because it can impair ventilation, increase aspiration risk, and does not reliably improve hemodynamics. Sims’ and left side-lying positions do not optimize venous return for shock management.

Question 36

A nurse in a maternity unit has received the following information about assigned clients. The nurse should first assess the client who is at?

Accepted Answer

Answer reason: 32 weeks gestation, has placenta previa, and has a 1 cm (0.4 in) area of bright red blood on the perineal pad. Placenta previa can cause sudden, painless, bright-red bleeding and can rapidly progress to significant maternal hemorrhage and fetal compromise, so it requires immediate assessment and escalation of care. Even a small visible amount of bleeding may underestimate ongoing or concealed blood loss, making rapid evaluation of vital signs, fetal status, and bleeding trend essential. By comparison, gestational hypertension with 2+ reflexes is not the hyperreflexia (3+ to 4+) concerning for impending eclampsia, so it is less urgent than active bleeding. Worsening back pain with preterm labor is important but is typically less immediately life-threatening than possible placenta previa hemorrhage, and hyperemesis with several emesis episodes is usually addressed after stabilizing higher-risk conditions.

Question 37

A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the health care provider?

Accepted Answer

Answer reason: Postanesthesia priorities focus on ABCs and maintaining adequate perfusion; a large acute systolic drop suggests hemodynamic instability that may indicate bleeding, hypovolemia, or excessive anesthetic/analgesic effect. A change from 130 to 90 mm Hg is clinically significant and requires prompt provider evaluation and possible interventions (e.g., fluid resuscitation, assessment for hemorrhage). In contrast, pushing out an oral airway usually indicates improving level of consciousness and return of protective reflexes. Snoring respirations and shallow breathing can reflect partial obstruction or residual sedation and often require immediate nursing actions (repositioning, airway support, oxygen) but are not as definitive for a serious systemic complication as a marked hypotensive trend.

Question 38

A patient with decreased perfusion to the lower extremities most likely has?

Accepted Answer

Answer reason: Left ventricular pump failure lowers stroke volume and mean arterial pressure, which directly reduces blood delivery to dependent extremities. In contrast, increased preload may occur as a consequence of heart failure but does not by itself explain poor distal perfusion, and hypertension typically reflects increased afterload rather than low flow. Right atrial obstruction would primarily impede venous return and cause systemic venous congestion (e.g., JVD, edema) rather than primarily causing diminished arterial perfusion to the legs.

Question 39

The nurse is caring for a client who received a kidney transplant 12 hours ago. Which of the following findings would require immediate follow-up?

Accepted Answer

Answer reason: A BP of 89/52 is clinically significant hypotension and demands prompt assessment (mental status, heart rate, drainage/bleeding, I&O) and provider notification/intervention to prevent graft ischemia. By contrast, brisk urine output can be expected early from osmotic diuresis and improved renal function, and pink-tinged urine may occur from surgical/urothelial irritation. Mild electrolyte abnormalities can occur and are important but are not typically the most time-critical threat compared with unstable blood pressure.

Question 40

The nurse is caring for a client with a myocardial infarction experiencing tachycardia and coughing up frothy, pink-tinged sputum. Which finding would the nurse expect upon lung auscultation?

Accepted Answer

Answer reason: Frothy, pink-tinged sputum in the setting of acute myocardial infarction strongly suggests acute pulmonary edema from left ventricular failure with increased pulmonary capillary hydrostatic pressure. Fluid accumulating in the alveoli causes alveolar collapse and reopening during inspiration, producing fine inspiratory crackles (rales), typically starting at the lung bases and potentially progressing upward. Wheezing can occur in “cardiac asthma,” but it is less characteristic than crackles for alveolar fluid. Rhonchi are more consistent with large-airway secretions (e.g., bronchitis), and globally diminished sounds are more typical of effusion, severe airflow limitation, or pneumothorax rather than acute alveolar flooding.

Question 41

Which of the following is a sign of hypovolemic shock?

Accepted Answer

Answer reason: As compensation fails or the volume loss worsens, systemic perfusion cannot be maintained and hypotension develops as a key hemodynamic sign. Tachycardia (not bradycardia) and cool, clammy skin are typical compensatory findings early, while blood pressure may drop later as shock progresses. Renal perfusion falls, so urine output decreases rather than increases.

Question 42

The patient is experiencing post-operative tachycardia with low blood pressure. The nurse should be most concerned about which of the following surgical complications?

Accepted Answer

Answer reason: Ongoing bleeding can rapidly progress to hypovolemic shock, making it the most time-critical and life-threatening complication among the choices. Infection is less likely to present primarily with hypotension and tachycardia early post-op without fever or other signs, whereas bleeding can occur abruptly. Wound dehiscence and a localized hematoma may occur, but they do not best explain systemic hemodynamic instability unless associated with significant blood loss.

Question 43

A nurse is caring for a client in labor who has an epidural. The nurse notes repetitive late decelerations on the fetal monitor strip. The client's blood pressure is 88/50 mmHg. What is the nurse's priority intervention?

Accepted Answer

Answer reason: The fastest, most direct corrective action is to restore maternal circulating volume and blood pressure with an IV fluid bolus to improve placental blood flow. Oxygen can be an adjunct, but it does not address the primary cause when hypotension is driving the fetal tracing change. Supine positioning worsens aortocaval compression and can further reduce venous return and uteroplacental perfusion.

Question 44

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102 degree F (38.8degree C). What priority concern related to elevated temperatures does a nurse consider when notifying the health care provider about the client's temperature?

Accepted Answer

Answer reason: Fever raises metabolic demand and oxygen consumption, which increases sympathetic stimulation with tachycardia and higher myocardial workload. In a post-CABG patient, this increased demand can precipitate ischemia, dysrhythmias, and hemodynamic instability, making it the key priority concern to communicate. Diaphoresis is an expected accompanying symptom but is not the major physiologic threat compared with increased cardiac workload. Cerebral edema is not a typical implication of uncomplicated postoperative fever, and hemorrhage more commonly causes hypotension/tachycardia and falling hemoglobin rather than hyperthermia as a primary sign.

Question 45

You are caring for a client who is admitted after a thermal burn injury. The client's vital signs are the following: blood pressure: 72/48. Heart rate: 152 beats/min. Respiratory rate: 26/min. He is pale in color and you are unable to feel his pedal pulses. Which action will the nurse take first?

Accepted Answer

Answer reason: Immediate isotonic fluid resuscitation restores circulating volume, improves tissue perfusion, and reduces the risk of progression to organ failure. Assessments like Doppler pulses or ECG do not correct the life-threatening hemodynamic instability and would delay definitive stabilization. A Foley catheter is important for monitoring resuscitation adequacy, but it is secondary to initiating rapid volume replacement when the patient is in overt shock.

Question 46

A client is experiencing signs and symptoms of coronary artery disease. What should be the nurse’s first priority?

Accepted Answer

Answer reason: Myocardial ischemia results from an imbalance between oxygen supply and demand, so the immediate priority is to improve oxygen delivery to the heart and reduce workload to prevent infarction and dysrhythmias. Early actions that support this goal include rest, positioning to decrease cardiac demand, oxygen as ordered, and rapid assessment of pain, vital signs, and ECG changes to guide urgent treatment. Anxiety reduction is supportive but does not address the life-threatening physiologic problem driving symptoms. Nitroglycerin can relieve ischemic chest pain, but it is a specific intervention that follows the overarching priority of optimizing myocardial oxygenation and requires safety checks (e.g., blood pressure) before administration.

Question 47

The nurse anticipates that a client with right-sided heart failure will exhibit which of the following?

Accepted Answer

Answer reason: Reduced kidney blood flow triggers neurohormonal responses (RAAS and sympathetic activation) that promote sodium and water retention, further lowering urine output. Therefore, decreased urine output is an expected manifestation, especially as congestion worsens. In contrast, polyuria is more consistent with diuretic effect or improved cardiac output rather than decompensated right-sided failure.

Question 48

Signs of increased intracranial pressure (ICP) include?

Accepted Answer

Answer reason: Increased ICP reduces cerebral perfusion and can transmit pressure to the optic nerve sheath, producing optic disc swelling on funduscopic exam. This finding is a classic objective sign of elevated intracranial pressure, particularly when it is sustained rather than acute and rapidly fatal. The other options conflict with expected Cushing response physiology, where systolic blood pressure tends to rise and pulse pressure widens while heart rate typically decreases (not increases). Therefore, optic disc edema is the best indicator among the choices.

Question 49

Which client problem is priority for the client with a cardiac dysrhythmia?

Accepted Answer

Answer reason: Cardiac dysrhythmias primarily threaten perfusion by reducing effective ventricular filling and/or ejection, making decreased cardiac output the most immediate life-threatening problem. Prioritization follows ABCs and circulation: maintaining adequate blood pressure and end-organ perfusion prevents shock, syncope, and ischemia. Impaired gas exchange can occur secondarily (e.g., pulmonary edema) but typically results from inadequate pump function rather than being the primary problem in dysrhythmia. Knowledge deficit and activity intolerance are important but are non-urgent compared with stabilizing hemodynamics.

Question 50

The nurse is aware that a client who has just experienced a myocardial infarction (MI) is most at risk for developing?

Accepted Answer

Answer reason: Acute myocardial ischemia and infarction create electrically unstable myocardium that is highly prone to ventricular ectopy and malignant rhythms, especially in the first 24–48 hours. These dysrhythmias can occur abruptly even when symptoms are improving, making them the most immediate and common early complication nurses monitor for on continuous ECG. Heart failure and cardiogenic shock are also possible but typically depend on infarct size and degree of left ventricular dysfunction, making them less universally likely than rhythm disturbances. Pericarditis is a later complication (often days after MI) and is not the most likely immediate risk right after an MI.

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