Question

A nurse is caring for a client who has a full code status. The client has experienced cardiac arrest and has activity on the electroencephalogram. Which of the following nursing interventions should the nurse perform?

Answer 1

Correct Answers:

The nurse should begin full cardiopulmonary resuscitation CPR immediately.

Rationale :

🔴 A client with full code status must receive full resuscitative measures immediately when cardiac arrest occurs.

🔴 CPR should not be delayed because early chest compressions and ventilation improve the chance of survival.

🔴 The presence of activity on the electroencephalogram does not change the need to respond to cardiac arrest.

🔴 Full CPR includes chest compressions, airway support, rescue breathing, rhythm assessment, and emergency response activation.

🔴 The nurse should follow basic life support and facility emergency protocols without waiting for additional confirmation.

Begin chest compressions but hold rescue breathing.

🔴CPR for a full-code client includes both circulation and ventilation support when indicated.

🔴Holding rescue breathing would provide incomplete resuscitation.

Hold cardiopulmonary resuscitation until orders are confirmed.

🔴A client with full code status already has clear direction for resuscitation.

🔴Delaying CPR can reduce survival and worsen neurologic outcomes.

Perform a head-to-toe assessment.

🔴A head-to-toe assessment is not the priority during cardiac arrest.

🔴The nurse must begin emergency resuscitation immediately.

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Answer 2

Correct Answers:

Client broke hip 24hr ago due to tall

Rationale :

🔵 The background section of I-SBAR-R includes relevant history and events that explain the client’s current condition.

🔵 Reporting that the client broke the hip 24 hours ago due to a fall provides important context for the postoperative total hip replacement.

🔵 Background information helps the receiving nurse understand why the client required surgery and what risk factors may affect recovery.

🔵 A recent fall may also guide monitoring for injury complications, mobility concerns, pain, and fall-risk precautions.

🔵 This information supports safe continuity of care during handoff communication.

Client requests a change in prescribed diet.

🔵This is a current request or concern, not background information.

🔵It would fit better under situation or recommendation depending on the report.

Client reports pain a 6 on 0 to 10 pain scale.

🔵Pain level is part of the client’s current assessment.

🔵It reflects present status rather than past clinical background.

Request prescription for oxygen administration.

🔵This is a recommendation because it asks the provider or next nurse to take action.

🔵It is not historical background information.

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Answer 3

Correct Answers:

Ask a clinical question regarding CAUTIS.

Rationale :

🟢 The first step in evidence-based practice is to ask a clear, focused clinical question.

🟢 A well-developed question guides the search for evidence and keeps the project focused on reducing catheter-associated urinary tract infections.

🟢 Nurses often use the PICOT format to identify the population, intervention, comparison, outcome, and timeframe.

🟢 Asking the clinical question first helps determine what evidence is needed before searching or implementing changes.

🟢 This step supports safe, organized, and research-based improvement in patient care.

Review the information gathered about reducing CAUTIs.

🟢Reviewing information happens after evidence has been collected.

🟢The nurse must first identify the clinical question that guides the review.

Look for credible sources of evidence to reduce CAUTIs.

🟢Searching for evidence is an important EBP step.

🟢It occurs after the nurse develops a focused clinical question.

Implement recommendations to reduce CAUTIs.

🟢Implementation occurs after evidence is found, appraised, and applied to practice.

🟢Starting with implementation skips the required planning and evidence review steps.

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Answer 4

Correct Answers:

Psychological distress

Rationale :

🟣 Psychological distress is a potential complication of a chronic wound because long-term wounds can affect quality of life.

🟣 Chronic wounds may cause pain, odor, drainage, limited mobility, sleep disruption, and social isolation.

🟣 These effects can lead to anxiety, depression, embarrassment, frustration, and reduced self-esteem.

🟣 The nurse should assess both the physical wound and the client’s emotional coping.

🟣 Holistic wound care includes pain control, infection prevention, nutrition support, mobility promotion, and psychosocial support.

Electrolyte abnormalities

🟣Electrolyte abnormalities are not a common direct complication of a chronic wound.

🟣They may occur with severe fluid loss or systemic illness, but this is not the best answer here.

Fluid volume overload

🟣Chronic wounds are not typically associated with fluid volume overload.

🟣Fluid overload is more commonly related to heart failure, kidney disease, or excessive fluid intake.

Altered hemoglobin A1C

🟣An elevated hemoglobin A1C can contribute to poor wound healing in diabetes.

🟣It is usually a risk factor for chronic wounds rather than a complication caused by the wound.

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Answer 5

Correct Answers:

Decreased cardiac output

Rationale :

🫁 In tension pneumothorax, air accumulates under pressure in the pleural space and shifts mediastinal structures.

🫁 Tracheal deviation indicates severe pressure buildup and displacement of the heart, lungs, and great vessels.

🫁 This pressure compresses the vena cava, reducing venous return to the heart.

🫁 Reduced venous return decreases ventricular filling and leads to decreased cardiac output.

🫁 This is a life-threatening emergency that requires rapid decompression and chest tube placement.

Increased venous return

🫁Tension pneumothorax decreases venous return because pressure compresses the great vessels.

🫁Increased venous return would not be expected in this condition.

Respiratory alkalosis

🫁Early hyperventilation can sometimes lower carbon dioxide levels, but this is not the key expected result following tracheal deviation.

🫁The major danger is impaired circulation from decreased venous return.

Dilated ventricles

🫁Tension pneumothorax does not primarily cause dilated ventricles.

🫁It limits cardiac filling by compressing thoracic structures and reducing blood return to the heart.

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Answer 6

Correct Answers

Blank 1 Correct Option: cardiac status
Blank 2 Correct Option: purging episodes

Rationale :

💓 The nurse should first address cardiac status because the client has hypokalemia with a potassium level of 2.9 mEq/L and a weak, thready pulse of 122/min.

💓 Low potassium can cause dangerous cardiac dysrhythmias, muscle weakness, and impaired cardiac conduction, making this the highest priority.

💓 The client’s repeated vomiting causes loss of potassium, chloride, and fluid, which increases the risk for dehydration, tachycardia, and cardiovascular collapse.

💓 After stabilizing cardiac status, the nurse should address the client’s purging episodes because purging is the ongoing behavior causing the electrolyte imbalance and physical complications.

💓 Managing purging includes safety monitoring, therapeutic communication, electrolyte replacement, nutritional support, and treatment of the underlying eating disorder.

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Answer 7

Correct Answers:

A client who has left-sided stroke reports severe headache and is manifesting confusion.

Rationale :

🧠 A client with a stroke who develops a severe headache and confusion should be assessed first because these findings can indicate worsening neurologic status.

🧠 Severe headache with acute confusion may suggest increased intracranial pressure, hemorrhagic conversion, cerebral edema, or neurologic deterioration.

🧠 This client requires immediate assessment of level of consciousness, pupils, vital signs, motor strength, speech, and airway protection.

🧠 Early recognition of neurologic decline is critical because delayed intervention can lead to permanent brain injury or death.

🧠 Using priority principles, this client is the most unstable because the symptoms indicate a possible acute change in cerebral perfusion.

A client who has Graves’ disease has a heart rate of 100/min and reports tremors.

🧠A heart rate of 100/min with tremors is expected with Graves’ disease due to increased thyroid hormone activity.

🧠This client needs monitoring, but the findings are not as urgent as acute neurologic deterioration.

A client who has diabetes insipidus has an intake of 1,500 mL and an output of 1,600 mL in 24 hr.

🧠This intake and output are nearly balanced, so it does not show severe fluid loss at this time.

🧠Diabetes insipidus becomes urgent when there is excessive urine output, dehydration, hypernatremia, or hypotension.

A client who has type 2 diabetes mellitus has a blood glucose level of 120 mg/dL.

🧠A blood glucose level of 120 mg/dL is only mildly elevated from the listed reference range.

🧠It is not an immediate priority compared with severe headache and confusion in a stroke client.

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Answer 8

Correct Answers:

Pancreatic cancers are classified as either endocrine pancreatic cancer or exocrine pancreatic cancer.

Rationale :

🟣 Pancreatic cancers are classified into exocrine pancreatic cancer and endocrine pancreatic cancer based on the type of pancreatic cells involved.

🟣 Exocrine tumors are the most common type and usually arise from the ductal cells that help transport digestive enzymes.

🟣 Endocrine tumors, also called pancreatic neuroendocrine tumors, arise from hormone-producing cells of the pancreas.

🟣 This classification is important because tumor type affects symptoms, treatment options, prognosis, and disease progression.

🟣 Client education should include that pancreatic cancer may be difficult to detect early because symptoms often appear after disease has progressed.

Pancreatic cancer is distinguished based on the layers of the pancreas.

🟣Pancreatic cancer is not classified by layers in the way some gastrointestinal cancers are staged by wall invasion.

🟣It is mainly described by cell type, location, stage, and spread.

The pancreas’s location increases the risk that cancer will spread into nearby structures and blood vessels.

🟣This statement is true about pancreatic cancer because the pancreas lies close to major blood vessels and nearby organs.

🟣However, the best classification-focused teaching point is that pancreatic cancers are grouped as exocrine or endocrine.

Pancreatic cancer typically develops from a polyp.

🟣Pancreatic cancer does not typically develop from a polyp.

🟣Polyps are more commonly associated with cancers such as colorectal cancer.

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Answer 9

Correct Answers:

Stay with the client.
Place the client in a room close to the nurses' station.
Offer the client a caffeinated beverage.

Rationale :

Stay with the client

🟠 The nurse should stay with the client because the client is experiencing symptoms consistent with an acute manic episode and is severely agitated.

🟠 Staying with the client allows the nurse to provide continuous observation, reduce risk for harm, and intervene quickly if the client becomes unsafe.

🟠 The client is pacing, refusing to sit, and has not slept or taken medications for at least 2 days, which increases the risk for exhaustion and impulsive behavior.

🟠 A calm nursing presence can help decrease environmental stimulation and support emotional regulation.

🟠 Safety is the priority because manic clients can have poor judgment, increased activity, and reduced ability to recognize physical needs.

Place the client in a room close to the nurses’ station

🟠 Placing the client near the nurses’ station allows frequent monitoring and rapid intervention if agitation escalates.

🟠 This location supports safety while avoiding unnecessary isolation or restraint.

🟠 The client is alert and oriented only x 2, which means close observation is needed due to impaired awareness and judgment.

🟠 A nearby room also helps staff monitor vital signs, hydration, nutrition, and behavioral changes.

🟠 The environment should remain low-stimulation, structured, and safe to reduce worsening manic behavior.

Offer the client finger foods

🟠 The nurse should offer finger foods because manic clients often cannot sit long enough to eat a full meal.

🟠 The client has not eaten for at least 2 days, increasing the risk for dehydration, hypoglycemia, weakness, and poor medication tolerance.

🟠 Portable, high-calorie foods allow the client to eat while moving and help meet nutritional needs.

🟠 Finger foods are especially appropriate when the client is pacing and unable to focus on structured meals.

🟠 Supporting nutrition is important because sustained manic activity greatly increases energy expenditure.

Offer the client a caffeinated beverage.

🟠Caffeine can worsen agitation, insomnia, tachycardia, and anxiety in a client experiencing mania.

🟠This client already has a heart rate of 110/min and has not slept for at least 2 days, so stimulation should be reduced.

Weigh the client daily.

🟠Daily weight can be useful for monitoring nutrition and hydration over time.

🟠It is not an immediate priority in the emergency setting for an acutely agitated manic client who needs safety, observation, and nutrition support first.

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Answer 10

Correct Answers:

Chronic cough
Sputum production
Dyspnea

Rationale :

Chronic cough

🫁 Chronic cough is one of the most common manifestations of COPD because long-term airway irritation causes persistent inflammation.

🫁 The cough is often related to chronic bronchitis, mucus hypersecretion, and impaired airway clearance.

🫁 Clients may report coughing that is worse in the morning or triggered by activity, smoke, cold air, or respiratory infection.

🫁 Chronic cough is clinically important because it reflects ongoing airway disease and may worsen during exacerbations.

🫁 The nurse should assess cough pattern, sputum characteristics, oxygenation, breath sounds, and signs of infection.

Sputum production

🫁 Sputum production is common in COPD because inflamed airways produce excess mucus.

🫁 Thick secretions can narrow the airways and make breathing more difficult.

🫁 Increased or changed sputum may indicate an acute COPD exacerbation or respiratory infection.

🫁 The nurse should note the amount, color, odor, and consistency of sputum.

🫁 Maintaining hydration, airway clearance, and prescribed inhaled therapy can help mobilize secretions.

Dyspnea

🫁 Dyspnea is a hallmark symptom of COPD and often becomes worse with exertion.

🫁 Airflow limitation, air trapping, and decreased gas exchange make breathing feel difficult.

🫁 Clients may use accessory muscles, tripod positioning, or pursed-lip breathing to improve ventilation.

🫁 Dyspnea can reduce activity tolerance and quality of life.

🫁 The nurse should monitor oxygen saturation, respiratory effort, breath sounds, and response to bronchodilator therapy.

Wheezing

🫁Wheezing can occur in COPD due to narrowed airways and bronchospasm.

🫁However, the most common core manifestations are chronic cough, sputum production, and dyspnea.

Chest tightness

🫁Chest tightness may occur during bronchospasm or respiratory distress.

🫁It is not typically listed among the most common defining manifestations of COPD.

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QLexNursing

1 :
A nurse is caring for a client who has a full code status. The client has experienced cardiac arrest and has activity on the electroencephalogram. Which of the following nursing interventions should the nurse perform?

2 :
A nurse is providing a handoff report using the introduction, Situation, background, assessment, recommendation. and readback (I-SBSR-R) for a client postoperative a total hip placement. Which of the following information should be included in the background component?

3 :
A nurse is using evidence-based practice (EBP) to decrease the Incidence of catheter-associated urinary tract infections (CAUTIs) on a unit. Which of the following actions should the nurse take first?

4 :
A nurse is caring for a client with a chronic wound. Which or the following is a potential complication of a chronic wound?

5 :
A nurse is assessing a client who has tension pneumothorax. Which of the following findings Should the nurse expect following tracheal deviation?

6 :
A nurse working in a mental health facility is admitting a client.

Correct Answers

7 :
A nurse has received report on a group of clients. Which of the following client clients should the nurse assess first?

8 :
A nurse is educating a client about a recent diagnosis of pancreatic cancer. Which of the following information should the nurse include in the client education?

9 :
A nurse is caring for a client in the emergency department (ED).

Answer Options

10 :
Which of the following are the most common manifestations of COPD? (Select all that apply.)

QLexNursing

1 : A nurse is caring for a client who has a full code status. The client has experienced cardiac arrest and has activity on the electroencephalogram. Which of the following nursing interventions should the nurse perform?

2 : A nurse is providing a handoff report using the introduction, Situation, background, assessment, recommendation. and readback (I-SBSR-R) for a client postoperative a total hip placement. Which of the following information should be included in the background component?

3 : A nurse is using evidence-based practice (EBP) to decrease the Incidence of catheter-associated urinary tract infections (CAUTIs) on a unit. Which of the following actions should the nurse take first?

4 : A nurse is caring for a client with a chronic wound. Which or the following is a potential complication of a chronic wound?

5 : A nurse is assessing a client who has tension pneumothorax. Which of the following findings Should the nurse expect following tracheal deviation?

6 : A nurse working in a mental health facility is admitting a client.

Correct Answers

7 : A nurse has received report on a group of clients. Which of the following client clients should the nurse assess first?

8 : A nurse is educating a client about a recent diagnosis of pancreatic cancer. Which of the following information should the nurse include in the client education?

9 : A nurse is caring for a client in the emergency department (ED).

Answer Options

10 : Which of the following are the most common manifestations of COPD? (Select all that apply.)

1 :
A nurse is caring for a client who has a full code status. The client has experienced cardiac arrest and has activity on the electroencephalogram. Which of the following nursing interventions should the nurse perform?

2 :
A nurse is providing a handoff report using the introduction, Situation, background, assessment, recommendation. and readback (I-SBSR-R) for a client postoperative a total hip placement. Which of the following information should be included in the background component?

3 :
A nurse is using evidence-based practice (EBP) to decrease the Incidence of catheter-associated urinary tract infections (CAUTIs) on a unit. Which of the following actions should the nurse take first?

4 :
A nurse is caring for a client with a chronic wound. Which or the following is a potential complication of a chronic wound?

5 :
A nurse is assessing a client who has tension pneumothorax. Which of the following findings Should the nurse expect following tracheal deviation?

6 :
A nurse working in a mental health facility is admitting a client.

7 :
A nurse has received report on a group of clients. Which of the following client clients should the nurse assess first?

8 :
A nurse is educating a client about a recent diagnosis of pancreatic cancer. Which of the following information should the nurse include in the client education?

9 :
A nurse is caring for a client in the emergency department (ED).

10 :
Which of the following are the most common manifestations of COPD? (Select all that apply.)