Question

A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions.

Answer 1

Correct Answers:

Client 4

Rationale :

🎯Client 4 has a new diagnosis of heart failure, which presents an immediate risk of decompensation affecting circulation and oxygenation.

🎯According to the ABC priority framework, addressing conditions that impair breathing and perfusion takes precedence.

🎯Early intervention in heart failure is critical to prevent pulmonary edema or cardiogenic shock.

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Answer 2

Correct Answers:

Prepare for possible intubation and mechanical ventilation.
Monitor the client's blood glucose levels frequently.
Administer IV antibiotics as prescribed.
Ensure strict hand hygiene before and after client contact
Prepare to assist with a chest tube insertion.

Rationale :

⚫The client is exhibiting multiple signs of acute sepsis and respiratory compromise, which includes hypoxia (SpO₂ 85%), tachypnea, confusion, hypotension, and blood-tinged sputum along with a consolidated chest X-ray.

⚫These findings indicate rapid deterioration, requiring immediate and aggressive interventions to stabilize the client.

✅ Prepare for possible intubation and mechanical ventilation
The client’s severe hypoxia and altered mental status indicate potential respiratory failure.
Preparing for intubation is essential to protect the airway and ensure adequate oxygenation and ventilation, aligning with ABC (Airway, Breathing, Circulation) priorities.
✅ Monitor the client's blood glucose levels frequently
Clients with sepsis are prone to hyperglycemia due to stress and may also be on glucocorticoids.
Tight glucose control is necessary because uncontrolled blood glucose can worsen infection risk and impair immune function, thus delaying recovery.
✅ D. Administer IV antibiotics as prescribed
The cornerstone of sepsis treatment is the prompt administration of broad-spectrum IV antibiotics, which must be initiated within the first hour to improve survival rates. Delay in antibiotics is directly associated with increased mortality.
✅ Ensure strict hand hygiene before and after client contact
Infection control is critical in septic clients, particularly to prevent cross-contamination and protect immunocompromised individuals.
Strict hand hygiene is a first-line defense and is mandatory before and after any patient interaction.
✅ Prepare to assist with a chest tube insertion
The consolidation and blood-tinged sputum could suggest pleural effusion or empyema.
In such cases, the provider may insert a chest tube to drain fluid or pus, relieve respiratory distress, and allow lung re-expansion.
The nurse must be ready to assist and manage chest drainage systems.

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Answer 3

Correct Answers:

Obtain an electrocardiogram (ECG)

Rationale :

💎The client presents with chest tightness, shortness of breath, diaphoresis, elevated blood pressure, and confusion, which are hallmark signs of a myocardial infarction (MI) or acute coronary syndrome.

💎The priority nursing action is to obtain a 12-lead ECG, which helps identify ischemic changes or infarction patterns.

💎This diagnostic test guides immediate clinical decisions and is critical in preventing irreversible cardiac damage or death.

💎According to evidence-based guidelines, ECG should be obtained within 10 minutes of symptom onset in suspected MI cases.

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Answer 4

Correct Answers:

Tachycardia

Rationale :

🔹A heart rate of 110 beats per minute constitutes tachycardia, which may be an early indicator of a transfusion reaction or another adverse systemic response.

🔹Tachycardia is often the first sign of distress in clients receiving blood products and requires immediate assessment for other symptoms such as fever, chills, hypotension, or respiratory changes.

🔹Early recognition ensures timely intervention to prevent complications such as hemolysis, shock, or organ dysfunction.

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Answer 5

Correct Answers:

Administer the medication into the abdomen_

Rationale :

💎Subcutaneous heparin is best administered in the abdomen, at least 5 cm (2 inches) away from the umbilicus, due to its predictable absorption rate, availability of adequate fatty tissue, and lower risk of muscle damage or bruising.

💎Rotating injection sites in the abdomen minimizes tissue irritation and promotes consistent anticoagulant effectiveness.

💎This method follows best practice guidelines for safe and effective heparin administration.

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Answer 6

Correct Answers:

Gently press on the tragus of the patient's ear.

Rationale :

📌After instilling otic medication, gently pressing on the tragus helps move the solution deeper into the ear canal by creating slight pressure.

📌This enhances medication distribution, especially in older adults whose ear canals may be less responsive due to age-related changes.

📌This technique is safe, effective, and recommended for promoting full therapeutic benefit of ear drops.

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Answer 7

Correct Answers:

"We would consult the person appointed by your health care proxy to make decisions."

Rationale :

💥When a client has an advance directive and becomes unable to make health care decisions, the nurse must consult the person designated as the health care proxy.

💥This ensures that medical decisions reflect the client’s previously stated values and preferences, preserving autonomy and legal protection.

💥This aligns with the ethical principle of substituted judgment and complies with state and federal regulations surrounding advance care planning.

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Answer 8

Correct Answers:

Place a container for soiled linens inside the patient's room.

Rationale :

📌Placing the container for soiled linens inside the client’s room, particularly in isolation precautions, helps prevent cross-contamination and the spread of infection to other patients or healthcare areas.

📌This practice is aligned with standard and transmission-based precautions in infection control.

📌 It ensures that all contaminated materials are confined to the environment of care, maintaining safety for both clients and staff.

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Answer 9

Correct Answers:

"You should have a fecal occult blood test every year."

Rationale :

✍Annual fecal occult blood testing (FOBT) is a recommended colorectal cancer screening method for adults starting at age 45–50 who are at average risk.

✍This test detects microscopic blood in stool, which can be an early indicator of colon polyps or malignancy.

✍Early detection through screening significantly improves treatment outcomes and survival rates.

✍The nurse must emphasize the importance of routine annual screening for prevention and early intervention.

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Answer 10

Correct Answers:

Make sure two fingers can fit under the sleeves-

Rationale :

♦Sequential compression sleeves must be applied securely but not tightly.

♦Ensuring that two fingers fit under the sleeves confirms appropriate compression without restricting circulation.

♦This action promotes venous return and helps prevent deep vein thrombosis (DVT), especially in postoperative or immobile patients.

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QLexNursing

1 : A nurse in a medical-surgical unit is caring for six clients. The nurse needs to assess the clients based on their conditions.

Answer Options

2 : A 60-year-old male client is admitted to the medical-surgical unit_ The client is experiencing a worsening of symptoms over the last 24 hours_ The client's initial presentation was similar to previous days, but his condition has deteriorated.

Answer Options

3 : A 45-year-old female client is admitted to the emergency department with complaints of sudden shortness of breath and chest tightness_ She has a history of hypertension and diabetes.

Answer Options

4 : A nurse is attending to a patient who is receiving a unit of packed RBCs. The patient's vital signs at 0800 and 0815 are given .Heart rate of 110 bpm. Complete the following sentence using the list of options. The patient exhibits symptoms of?

5 : A nurse is instructing a patient on how to self-administer heparin. Which of the following instructions should the nurse include?

6 : A nurse is administering an Otic medication to an older adult patient. Which of the following actions should the nurse take to ensure the medication reaches the inner ear?

7 : A nurse is educating a terminally ill patient about declining resuscitation in a living will. The patient asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?

8 : A nurse is placing a patient on isolation precautions. The patient's diagnostic results at 1400 are given. Which of the following actions should the nurse take?

9 : A nurse in a clinic is caring for a middle-aged patient who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

10 : A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?