Question

A nurse is caring for a client.

Answer 1

Correct Answers:

History of hypertension
History of hyperlipidemia
Cholesterol level
History of rheumatoid arthritis

Rationale :

History of hypertension

✏️ Hypertension is a major risk factor for cardiovascular disease.

✏️ Persistently elevated blood pressure damages the vascular endothelium and increases stress on arterial walls.

✏️ This vascular injury contributes to the development and progression of atherosclerosis.

✏️ Hypertension also increases the workload placed on the heart, particularly the left ventricle.

✏️ Long-term pressure overload can contribute to left ventricular hypertrophy and impaired cardiac function.

✏️ Hypertension substantially increases the risk of coronary artery disease, myocardial infarction, heart failure, and stroke.

✏️ Effective blood-pressure management is therefore an important component of cardiovascular risk reduction.

✏️ The documented history of hypertension represents an important heart disease risk factor.

History of hyperlipidemia

✏️ Hyperlipidemia involves abnormal elevations of lipids in the bloodstream.

✏️ Excess circulating lipids can accumulate within arterial walls and contribute to atherosclerotic plaque formation.

✏️ Progressive atherosclerosis can narrow the coronary arteries and reduce myocardial blood supply.

✏️ Plaque disruption can promote thrombosis and result in an acute coronary syndrome.

✏️ Lipid abnormalities are therefore strongly associated with the development of coronary artery disease.

✏️ Management commonly includes dietary modification, physical activity, weight management, and prescribed lipid-lowering therapy.

✏️ Lipid levels should be monitored to determine the effectiveness of cardiovascular risk-reduction strategies.

✏️ A history of hyperlipidemia therefore increases the client's risk for heart disease.

Cholesterol level: 250 mg/dL

✏️ The client's total cholesterol of 250 mg/dL exceeds the listed desirable level of less than 200 mg/dL.

✏️ Elevated cholesterol contributes to the accumulation of lipid-containing atherosclerotic plaques within arteries.

✏️ Coronary atherosclerosis can progressively reduce the amount of oxygenated blood reaching the myocardium.

✏️ Significant arterial narrowing can contribute to angina and myocardial ischemia.

✏️ Plaque rupture can also trigger thrombus formation and potentially cause myocardial infarction.

✏️ A complete lipid profile can further characterize cardiovascular risk by evaluating LDL, HDL, and triglycerides.

✏️ Reducing elevated atherogenic cholesterol is an important strategy for preventing atherosclerotic cardiovascular disease.

✏️ The documented cholesterol level is therefore an abnormal finding associated with increased cardiovascular risk.

History of rheumatoid arthritis

✏️ Rheumatoid arthritis (RA) is a chronic systemic inflammatory disorder associated with increased cardiovascular risk.

✏️ Persistent systemic inflammation can contribute to endothelial dysfunction and accelerate atherosclerotic processes.

✏️ Individuals with RA have an increased incidence of atherosclerotic cardiovascular disease.

✏️ Chronic inflammation can affect both the blood vessels and cardiovascular system beyond the joints affected by RA.

✏️ Cardiovascular risk can become particularly important when RA occurs alongside traditional risk factors such as hypertension and hyperlipidemia.

✏️ Appropriate management of inflammatory disease and traditional cardiovascular risk factors can help reduce overall cardiovascular morbidity.

✏️ Nurses should therefore consider chronic inflammatory disorders when evaluating a client's overall heart disease risk profile.

✏️ The client's history of rheumatoid arthritis represents an additional cardiovascular risk factor.

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Answer 2

Correct Answers

Blank 1 Correct Option: place the client in a private room
Blank 2 Correct Option: apply supplemental oxygen

Rationale :

Place the client in a private room

👉 The client has findings strongly suggestive of active pulmonary tuberculosis, including persistent cough, fever, night sweats, weight loss, and positive TB testing.

👉 Pulmonary tuberculosis can spread through airborne droplet nuclei when an infected person coughs, speaks, or sneezes.

👉 The client should be placed promptly in an airborne infection isolation room (AIIR), which is a private negative-pressure room.

👉 Rapid isolation limits exposure of other clients, visitors, and healthcare personnel to potentially infectious particles.

👉 Healthcare personnel entering the room should use an appropriately fitted N95 respirator or higher-level respiratory protection.

👉 The client should wear a surgical mask during necessary transport outside the isolation room.

👉 Infection-control measures should begin when active pulmonary TB is suspected rather than waiting for additional diagnostic confirmation.

👉 Immediate airborne isolation is therefore one of the first nursing priorities for this client's suspected communicable respiratory infection.

Apply supplemental oxygen

👉 The client's oxygen saturation of 88% on room air indicates clinically significant hypoxemia.

👉 Supplemental oxygen should be initiated to increase available oxygen and support adequate tissue oxygenation.

👉 The respiratory rate of 24/min further demonstrates increased respiratory demand.

👉 Crackles, scattered wheezes, and productive coughing indicate substantial pulmonary involvement.

👉 The nurse should administer oxygen using an appropriate delivery device and monitor the client's oxygen saturation and respiratory status.

👉 Response to therapy should include assessment of respiratory effort, mental status, skin color, and SpO₂.

👉 Persistent or worsening hypoxemia may require escalation of respiratory support and prompt healthcare-provider evaluation.

👉 Correcting the client's impaired oxygenation is an immediate ABC priority and should occur promptly.

❌ Encourage fluid intake

👉 Adequate hydration can help thin respiratory secretions and support overall fluid balance during febrile illness.

👉 Fluid intake should be encouraged when appropriate based on the client's clinical status and ability to tolerate oral fluids.

👉 Hydration does not immediately address the client's airborne transmission risk or significant hypoxemia.

❌ Obtain a sputum culture

👉 Sputum testing is important for evaluating suspected active pulmonary tuberculosis and identifying the causative organism.

👉 Appropriate respiratory specimens may be obtained for acid-fast bacilli testing, molecular testing, and culture as prescribed.

👉 Specimen collection can occur after immediate measures have been initiated to protect against transmission and stabilize oxygenation.

❌ Determine the client's exposure to tuberculosis

👉 Assessing potential TB exposure provides valuable epidemiologic information and can help identify possible transmission sources and contacts.

👉 Exposure history includes close contact with individuals who have known or suspected active tuberculosis and other relevant risk factors.

👉 Collecting additional history does not immediately correct an existing physiologic problem or prevent ongoing airborne exposure.

❌ Provide the client with an incentive spirometer

👉 An incentive spirometer promotes sustained maximal inspiration and can help prevent or treat certain forms of pulmonary atelectasis.

👉 Its use requires adequate patient participation and repeated controlled deep inspirations.

👉 It does not provide immediate treatment for the client's oxygen saturation of 88%.

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Answer 3

Correct Answers

Blank 1 Correct Option: falls
Blank 2 Correct Option: postural hypotension

Rationale :

Falls

🌸 Falls are the priority risk because the client demonstrates a substantial decrease in blood pressure when moving to a standing position.

🌸 The blood pressure decreases from 138/62 mm Hg lying to 92/40 mm Hg standing.

🌸 Such a marked decrease can reduce cerebral perfusion when the client stands or begins walking.

🌸 Reduced cerebral perfusion can cause dizziness, lightheadedness, weakness, blurred vision, or syncope.

🌸 These manifestations can significantly impair balance and increase the likelihood of a fall-related injury.

🌸 Immediate nursing precautions can include assisting with ambulation and encouraging slow position changes.

🌸 The nurse should reassess orthostatic vital signs and evaluate the client for symptoms during position changes and mobility.

🌸 Preventing a fall is a priority because an episode of hypotension can produce an immediate safety threat.

Postural hypotension

🌸 Postural hypotension, also called orthostatic hypotension, occurs when blood pressure falls significantly after assuming an upright position.

🌸 This client demonstrates a systolic decrease from 138 mm Hg lying to 92 mm Hg standing.

🌸 The diastolic pressure also decreases from 62 mm Hg to 40 mm Hg.

🌸 This change substantially exceeds the commonly used diagnostic threshold of a decrease of at least 20 mm Hg systolic or 10 mm Hg diastolic after standing.

🌸 Orthostatic hypotension can produce inadequate cerebral blood flow, particularly during standing and ambulation.

🌸 The client may consequently experience dizziness, weakness, visual changes, or syncope.

🌸 The client's prescribed furosemide can contribute to volume depletion and hypotension and should be considered during further assessment.

🌸 The documented positional blood-pressure changes therefore provide clear evidence of postural hypotension and explain the increased fall risk.

❌ Impaired skin integrity

🌸 Urinary incontinence can expose the skin to prolonged moisture and increase the risk of maceration and skin breakdown.

🌸 Regular perineal care, moisture management, and skin assessment are important for maintaining skin integrity.

🌸 This represents an important ongoing concern requiring preventive nursing care.

❌ Hypoglycemia

🌸 Hypoglycemia generally refers to an abnormally low blood glucose concentration, commonly below 70 mg/dL.

🌸 The client's fasting glucose is 110 mg/dL, which is within the laboratory reference range provided.

🌸 Monitoring glucose remains important because the client has type 2 diabetes mellitus.

❌ Metformin prescription

🌸 Metformin is commonly prescribed to improve glucose control in clients with type 2 diabetes mellitus.

🌸 When used alone, metformin has a relatively low likelihood of producing clinically significant hypoglycemia.

🌸 The client's current fasting glucose of 110 mg/dL does not demonstrate hypoglycemia.

❌ Urinary incontinence

🌸 Urinary incontinence increases exposure of perineal skin to moisture and irritants.

🌸 Persistent moisture can contribute to incontinence-associated dermatitis and impaired skin integrity.

🌸 Appropriate toileting assistance and skin protection are important components of the client's ongoing care.

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Answer 4

Correct Answers:

Prepare the client for a central venous line.

Rationale :

♦️ Parenteral nutrition containing 20% dextrose is a highly concentrated, hyperosmolar solution.

♦️ High-osmolarity PN can cause significant irritation and thrombophlebitis when infused through small peripheral veins.

♦️ A central venous catheter provides access to a large vein with rapid blood flow.

♦️ Rapid blood flow allows the concentrated PN solution to be quickly diluted in the circulation.

♦️ Central access is therefore appropriate for PN solutions containing high concentrations of dextrose and other nutrients.

♦️ The nurse should use strict aseptic technique when caring for the central venous access because PN therapy increases the risk of bloodstream infection.

♦️ The client's blood glucose, electrolytes, fluid status, weight, and other laboratory values should also be monitored throughout PN therapy.

♦️ Preparing the client for central venous access is therefore an appropriate component of the plan of care for this PN formulation.

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Answer 5

Correct Answers:

Determine the client's reading ability.

Rationale :

♦️ A total laryngectomy permanently removes the client's natural ability to produce voice through the larynx, making postoperative communication a major concern.

♦️ Immediately after surgery, the client will be unable to communicate using normal verbal speech.

♦️ Determining the client's reading ability helps the nurse identify which alternative communication methods will be effective.

♦️ Written instructions, communication boards, writing materials, and other visual communication strategies depend on the client's ability to read and understand written information.

♦️ Preoperative assessment allows the healthcare team to establish an individualized communication plan before speech is lost.

♦️ Effective communication is essential for the client to communicate pain, respiratory distress, needs, fears, and other concerns after surgery.

♦️ Establishing the client's baseline communication abilities also guides subsequent education about alternative speech methods.

♦️ Assessing reading ability is therefore the priority because effective postoperative communication and safety depend on identifying an appropriate communication method.

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Answer 6

Correct Answers:

Eyelashes that curl slightly outward.

Rationale :

🌼 Normal eyelashes are distributed along the eyelid margins and should curve slightly outward, away from the surface of the eye.

🌼 Outward-directed eyelashes help protect the eyes from dust, debris, and foreign particles.

🌼 The lashes should generally be evenly distributed without significant crusting, inflammation, or abnormal loss.

🌼 Eyelashes directed inward can rub against the cornea and conjunctiva, potentially causing irritation and corneal injury.

🌼 Inward turning of the eyelashes is known as trichiasis and requires further assessment.

🌼 The nurse should inspect the eyelashes together with the eyelids, conjunctiva, sclera, cornea, and pupils during an eye examination.

🌼 Normal eyelid and eyelash positioning contributes to effective protection and lubrication of the ocular surface.

🌼 Slightly outward-curving eyelashes are therefore an expected normal finding during an eye assessment.

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Answer 7

Correct Answers:

Activate the facility's fire alarm.

Rationale :

🌻 The nurse should follow the RACE sequence when responding to a fire in a healthcare facility.

🌻 RACE stands for Rescue, Alarm, Contain, and Extinguish/Evacuate.

🌻 Moving the client to safety completes the Rescue portion of the emergency response.

🌻 The next step is to activate the fire alarm so that the facility's emergency response system is initiated.

🌻 Activating the alarm alerts staff, emergency personnel, and other occupants that a fire emergency exists.

🌻 Prompt notification allows additional personnel to assist with containment, evacuation, and fire suppression.

🌻 The nurse should know the location of fire alarms, exits, extinguishers, and evacuation routes within the clinical area.

🌻 Activating the facility's fire alarm is therefore the appropriate action immediately after the client has been rescued from danger.

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Answer 8

Correct Answers:

Eat a light carbohydrate snack before bedtime.

Rationale :

🏵️ A light carbohydrate snack before bedtime can be incorporated into healthy sleep-hygiene practices for a client experiencing insomnia.

🏵️ A small snack can prevent hunger from interfering with the ability to fall asleep or remain asleep.

🏵️ Carbohydrates can increase the availability of tryptophan for transport into the brain.

🏵️ Tryptophan participates in the synthesis of serotonin and melatonin, which are involved in regulation of the sleep-wake cycle.

🏵️ Appropriate choices can include a small serving of crackers, cereal, or toast.

🏵️ The snack should remain light, because large or heavy meals close to bedtime can cause gastrointestinal discomfort and disrupt sleep.

🏵️ Establishing consistent bedtime routines and minimizing evening stimulants can further promote restorative sleep.

🏵️ A light carbohydrate snack is therefore an appropriate recommendation for promoting sleep onset and comfort.

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Answer 9

Correct Answers:

Gloves

Rationale :

♠️ Gloves are generally considered the most contaminated piece of personal protective equipment following direct patient care.

♠️ During a dressing change, the gloves can become contaminated through contact with the wound, drainage, dressings, or surrounding surfaces.

♠️ Removing the gloves first reduces the chance of transferring microorganisms to the nurse's hands, clothing, or other PPE.

♠️ Proper glove removal technique prevents the contaminated outer surfaces from contacting bare skin.

♠️ The nurse should avoid touching the outside of the gloves with unprotected hands during PPE removal.

♠️ After the remaining PPE is removed according to the appropriate sequence, the nurse should perform thorough hand hygiene.

♠️ Airborne precautions also require appropriate respiratory protection, such as a fitted N95 respirator, based on the infectious condition.

♠️ Removing the most heavily contaminated item first helps minimize cross-contamination and transmission of microorganisms.

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Answer 10

Correct Answers:

"I need to have a fire escape plan with my family."
"I need to check my medications for expiration dates."
"I will use the grab bars when getting in and out of the bathtub."

Rationale :

✅ “I need to have a fire escape plan with my family.”

🖊️ A fire escape plan helps household members know how to respond quickly and safely during a fire emergency.

🖊️ The plan should identify safe exits and escape routes from different areas of the home.

🖊️ Family members should know where to meet at a predetermined safe location outside the home.

🖊️ Practicing the escape plan can improve the family's ability to respond effectively during an actual emergency.

🖊️ Working smoke alarms should also be available and routinely tested throughout the home.

🖊️ Household members should understand that they should leave a burning building promptly rather than returning for personal belongings.

🖊️ Planning is particularly important when household members have mobility limitations or require assistance during evacuation.

🖊️ Developing and practicing a fire escape plan is therefore an important component of home fire safety.

✅ “I need to check my medications for expiration dates.”

🖊️ Regularly checking medication expiration dates is an important part of safe medication management in the home.

🖊️ Expired medications may have reduced potency, stability, or effectiveness.

🖊️ The client should periodically review prescription and over-the-counter medications stored in the home.

🖊️ Medication labels should remain clear and readable to reduce administration errors.

🖊️ Medications should be stored according to manufacturer instructions and protected from inappropriate heat, moisture, or light.

🖊️ Unneeded or expired medications should be discarded using recommended medication take-back or safe-disposal procedures.

🖊️ Maintaining an organized medication supply can help reduce medication errors and accidental ingestion.

🖊️ Checking expiration dates therefore demonstrates appropriate understanding of medication safety.

✅ “I will use the grab bars when getting in and out of the bathtub.”

🖊️ Grab bars provide a stable handhold when entering or exiting a bathtub or shower.

🖊️ Bathrooms are common locations for falls because water can make surfaces slippery.

🖊️ Using properly installed grab bars improves balance and stability during transfers.

🖊️ Grab bars should be securely attached to structural supports so they can safely bear the person's body weight.

🖊️ Additional bathroom precautions can include nonskid surfaces and adequate lighting.

🖊️ The client should avoid relying on towel racks because they are not designed to function as weight-bearing supports.

🖊️ Bathroom safety measures are particularly important for people with impaired strength, balance, or mobility.

🖊️ Using grab bars appropriately therefore helps reduce the risk of falls and fall-related injuries.

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QLexNursing

1 :
A nurse is caring for a client.

Answer Options

2 :
A nurse is caring for a client.

Correct Answers

3 :
A nurse is caring for a client.

Correct Answers

4 :
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

5 :
A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

6 :
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

7 :
A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?

8 :
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

9 :
A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?

10 :
A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

QLexNursing

1 : A nurse is caring for a client.

Answer Options

2 : A nurse is caring for a client.

Correct Answers

3 : A nurse is caring for a client.

Correct Answers

4 : A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

5 : A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

6 : A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

7 : A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?

8 : A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

9 : A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?

10 : A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

1 :
A nurse is caring for a client.

2 :
A nurse is caring for a client.

3 :
A nurse is caring for a client.

4 :
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

5 :
A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

6 :
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

7 :
A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?

8 :
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

9 :
A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?

10 :
A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)