Question

A nurse is teaching a client who is to begin chemotherapy about a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include in the teaching?

Answer 1

Correct Answers:

“We can draw blood samples from the PICC for diagnostic tests."

Rationale :

🟠A peripherally inserted central catheter (PICC) provides long-term venous access for therapies such as chemotherapy, antibiotics, or parenteral nutrition.

🟠Blood samples can be safely drawn from a PICC line, reducing the need for repeated peripheral venipuncture and preserving fragile peripheral veins.

🟠The catheter tip is placed in the superior vena cava, allowing for both infusion of vesicant drugs and withdrawal of blood without damaging smaller veins.

🟠Sterile technique and proper flushing protocols are essential when drawing blood from a PICC to prevent infection and maintain catheter patency.

🟠This teaching reduces client anxiety by explaining that routine lab work can be done through the PICC, making treatment less invasive.

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Answer 2

Correct Answers:

Use a bed alarm.

Rationale :

🟢Clients with dementia and wandering behaviors are at high risk for falls and injuries due to impaired judgment and disorientation.

🟢A bed alarm provides an early warning when the client attempts to leave the bed unassisted, allowing staff to intervene promptly.

🟢This intervention is a safety measure that does not restrict mobility or autonomy, unlike restraints, and promotes dignity in dementia care.

🟢Bed alarms are part of a fall-prevention protocol widely used in medical-surgical units, especially for high-risk populations such as elderly clients with cognitive impairment.

🟢By ensuring early detection of movement, the nurse can redirect and reorient the client, preventing accidents while maintaining a therapeutic environment.

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Answer 3

Correct Answers

Restrict the client's fluid Intake to 2 L per day. [ Anticipated ]
Weigh the client daily. [ Anticipated ]
Increase the dosage of furosemide. [ Anticipated ]
Begin a 24-hr urine collection for the client. [ Nonessential ]
Hold the client's metoprolol. [ Contraindicated ]
Decrease the client's oxygen to 1 L/min via nasal cannula. [ Contraindicated ]

Rationale :

Restrict fluids to 2 L/day

💧The client shows acute fluid overload—a weight increase of 1.8 kg (≈1.8 L) in 24 hr indicates retained volume that strains the heart.

💧A 2-L/day restriction directly reduces intravascular volume and preload, easing ventricular stretch and improving pulmonary congestion.

💧The trend to SpO₂ 90% on 2 L/min suggests fluid-related gas-exchange impairment; limiting fluids helps improve oxygenation by decreasing interstitial/alveolar fluid.

💧Elevated BNP 400 pg/mL confirms ventricular volume/pressure overload, supporting the need for strict fluid control.

💧Fluid restriction is a core heart-failure order aligned with guideline-based care to prevent further edema, dyspnea, and rehospitalization.

Daily weights

💧 Daily weights are the most sensitive indicator of fluid status; a rapid change reflects volume shifts long before exam findings do.

💧 The client’s +1.8 kg in 24 hr signals ~1.8 L retained—actionable data for titrating diuretics and fluids.

💧 Weighing same scale, time, and clothing provides reliable trend data to evaluate response to therapy.

💧Objective weight trends help the team anticipate decompensation and intervene early, reducing risk of pulmonary edema and falls from dyspnea.

💧 In HF pathways, daily weights are a high-priority safety measure and an essential discharge-teaching point to detect relapse.

Increase furosemide dose

💧 Furosemide (loop diuretic) promotes rapid diuresis, lowering preload and relieving pulmonary/interstitial fluid that’s driving the SpO₂ decline.

💧The combination of rising weight, SpO₂ 90% on 2 L, and elevated BNP indicates the current dose is insufficient for present congestion.

💧Augmenting the dose helps reduce dyspnea, crackles, and edema, improving gas exchange and cardiac efficiency.

💧The client’s K⁺ 3.8 mEq/L and concurrent KCl supplementation support safe up-titration with continued electrolyte/renal monitoring.

💧Timely escalation of diuretics is evidence-based HF management, often preventing progression to acute decompensated HF.

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Answer 4

Correct Answers

Blank 1 Correct Option: Meningitis
Blank 2 Correct Option: Initiate neurological checks 2hr and Decrease environmental stimuli.
Blank 3 Correct Option: Temperature and Lactate level.

Rationale :

Condition: Meningitis

⏺️The cluster of high fever (39.2 °C/102.6 °F), persistent severe headache (7/10), photophobia, and positive nuchal rigidity are hallmark signs of meningeal inflammation.

⏺️The client’s lethargy and malaise signal central nervous system involvement and possible evolving encephalopathy.

⏺️Tachycardia (115/min) with relative hypotension (98/64 mm Hg) fits a systemic inflammatory response that can accompany infectious meningitis.

⏺️The note “awaiting CT” aligns with standard workup to exclude mass effect before lumbar puncture when meningitis is suspected.

⏺️Early recognition of infectious meningitis is critical because rapid progression to raised ICP, seizures, and septic shock can occur without prompt, targeted management.

Actions

Initiate neurological checks 2 hr

⏺️Frequent neuro checks trend level of consciousness, orientation, pupils, and motor response, enabling early detection of rising ICP or neurologic decline.

⏺️Meningitis can deteriorate rapidly, so q2-hr monitoring of GCS, pupils, strength, and new focal deficits provides actionable changes for escalation.

⏺️Trending findings guides timely interventions (e.g., airway protection, anticonvulsants, hyperosmolar therapy) to prevent secondary brain injury.

⏺️Establishing a baseline and documenting serial changes improves team communication and decision-making for diagnostics and treatments.

⏺️Close surveillance also helps evaluate the response to therapy (antimicrobials/fluids) and the emergence of complications such as seizures.

Decrease environmental stimuli

⏺️ Photophobia and phonophobia are common; darkened, quiet rooms directly reduce headache and meningeal irritation.

⏺️Lowering stimuli limits sympathetic surges (tachycardia/blood pressure spikes) that can increase cerebral metabolic demand and ICP.

⏺️Minimizing interruptions and clustering care support rest, improving comfort without sedatives that could mask neuro changes.

⏺️ Reducing agitation diminishes Valsalva-like responses (cough/strain) that transiently raise intracranial pressure.

⏺️Environmental control is an immediate, low-risk intervention that supports analgesia and other definitive treatments.

Parameters

Temperature

⏺️ Fever is a core marker of infectious activity; trending temperature assesses treatment effectiveness once antimicrobials are initiated.

⏺️ Persistent hyperthermia increases cerebral metabolic rate, potentially worsening ICP and neurological outcomes.

⏺️ Regular monitoring guides antipyretic use and cooling strategies, balancing comfort with cerebral protection.

⏺️Temperature trends correlate with other markers (e.g., WBC, hemodynamics), informing ongoing sepsis surveillance.

⏺️Documenting response (defervescence vs. spikes) helps differentiate therapeutic success from treatment failure or complications.

Lactate level

⏺️ Serum lactate reflects tissue hypoperfusion and the severity of sepsis, a frequent complication of bacterial meningitis.

⏺️Elevated lactate (>2 mmol/L) indicates anaerobic metabolism and correlates with worse outcomes, prompting aggressive resuscitation.

⏺️Serial lactate trends assess response to IV fluids and antibiotics, confirming improving perfusion or signaling deterioration.

⏺️Integrating lactate with vital signs and mental status provides a comprehensive view of global perfusion and neurologic risk.

⏺️ Early normalization of lactate supports effective source control and guides titration of hemodynamic support if needed.

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Answer 5

Correct Answers

Blank 1 Correct Option: Hyperthyroidism
Blank 2 Correct Option: Initiate hydration therapy and Place client on telemetry.
Blank 3 Correct Option: Neurological Status and Cardiac dysrhythmias.

Rationale :

Condition: Hyperthyroidism

🔷 Markedly elevated T3 (310 ng/dL) and T4 (25 mcg/dL) with suppressed TSH (0.1 mU/mL) are diagnostic for hyperthyroidism, matching the client’s hypermetabolic presentation.

🔷 The constellation of fever, tachycardia/palpitations, hypertension, tremor, nervousness/insomnia, diarrhea, and weight loss despite good appetite are classic thyrotoxicosis findings.

🔷 Recent infection (influenza) is a well-known trigger that can precipitate thyroid storm, explaining the acute worsening over hours.

🔷 Hypoxemia (SpO₂ 89%) with crackles and tachypnea reflects increased oxygen demand and cardiac workload driven by excess thyroid hormone, risking cardiopulmonary decompensation.

🔷 Prompt recognition is essential because untreated thyroid storm can rapidly progress to arrhythmias, heart failure, hyperthermia, delirium, and shock; early targeted management reduces morbidity and mortality.

Actions

Initiate Hydration Therapy

🔷 Severe insensible losses from fever/diaphoresis plus gastrointestinal losses from diarrhea create intravascular volume depletion in hyperthyroidism.

🔷 Isotonic IV fluids restore preload and tissue perfusion, supporting delivery of oxygen to meet the elevated metabolic rate.

🔷 Adequate hydration helps protect renal function and facilitates clearance of catabolic by-products generated by the hypermetabolic state.

🔷 Volume repletion reduces the risk of lactic acidosis and shock, stabilizing hemodynamics while other definitive therapies (e.g., beta-blockade/antithyroid agents) are initiated.

🔷 Careful, titrated fluid administration is necessary given crackles/possible congestion; the goal is euvolemia with frequent reassessment of lungs, vitals, and urine output.

Place Client on Telemetry

🔷 Excess thyroid hormone increases β-adrenergic activity, predisposing to atrial fibrillation, SVT, and other cardiac dysrhythmias—a leading cause of deterioration in thyroid storm.

🔷 Continuous telemetry enables immediate detection of rate/rhythm changes, guiding timely beta-blocker titration or advanced interventions if instability occurs.

🔷 The client’s HR 125/min, palpitations, and chest pain indicate high arrhythmic risk and potential myocardial oxygen supply-demand mismatch.

🔷 Telemetry trend data (e.g., rate response to therapy, recurrence of ectopy) provides objective feedback on treatment effectiveness.

🔷 Coupled with strict vital-sign surveillance, telemetry improves early recognition of hemodynamic compromise and prevents unexpected cardiac events.

Parameters

Cardiac Dysrhythmias

🔷 Thyrotoxicosis is strongly associated with atrial fibrillation and rapid ventricular responses, which can precipitate hypotension, ischemia, or heart failure.

🔷 Continuous rhythm assessment verifies rate control and identifies conversion or worsening that might require urgent management.

🔷 Monitoring allows correlation of fever control, hydration, and beta-blockade with improvements in heart rate variability and rhythm stability.

🔷 Early detection of new ischemic changes or QT abnormalities reduces risk of ventricular arrhythmias.

🔷 Documenting dysrhythmia trends informs decisions about escalation, such as antiarrhythmic therapy or higher-level care.

Neurological Status

🔷 Agitation, anxiety, and insomnia can evolve into delirium, seizures, or coma in thyroid storm, reflecting worsening cerebral metabolic stress.

🔷 Serial assessments of LOC, orientation, pupils, and behavior track response to therapy and signal impending crisis requiring rapid intervention.

🔷 Neurologic monitoring complements temperature and hemodynamic data to gauge overall systemic control of the hypermetabolic state.

🔷 Worsening neuro signs may indicate hyperthermia, hypoxemia, or hypoperfusion, prompting reassessment of oxygenation, fluids, and medications.

🔷 Clear documentation of neuro trends enhances interprofessional communication and guides safe sedation/analgesia choices that won’t mask deterioration.

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Answer 6

Correct Answers:

Decontaminate hands with an alcohol-based hand rub after taking the client’s pulse.

Rationale :

⭐ Clients with immunodeficiency disorders are highly susceptible to infection, so strict hand hygiene is the most effective prevention strategy.

⭐ After performing direct client care activities such as taking a pulse, alcohol-based hand rub is appropriate if the hands are not visibly soiled.

⭐ Alcohol-based rubs are proven to be effective at reducing transient microorganisms quickly and are recommended by the CDC and WHO in healthcare settings.

⭐ Hand hygiene is always performed before and after contact with clients, after removing gloves, and after touching client surroundings.

⭐ This practice minimizes the risk of healthcare-associated infections (HAIs) and protects both the client and healthcare personnel.

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Answer 7

Correct Answers

Blank 1 Correct Option: Upper GI bleed
Blank 2 Correct Option: Test stools for occult blood.
Blank 3 Correct Option: Hemoglobin & hematocrit and Blood pressure.

Rationale :

Condition: Upper GI Bleed

🔶 The combination of coffee-ground emesis over two days followed by a large bright-red hematemesis (~1 cup) strongly indicates an active upper GI source (stomach or proximal duodenum).

🔶 Hypotension (89/52) with sinus tachycardia (115/min) and lethargy/dizziness signals volume depletion from acute blood loss, consistent with ongoing hemorrhage.

🔶 The low Hgb 9 g/dL and Hct 27% confirm significant blood-loss anemia, aligning with clinical signs of hypoperfusion (weak peripheral pulses).

🔶 Risk factors—chronic alcohol intake and smoking—increase the likelihood of peptic ulcer disease and gastritis, common causes of upper GI bleeding.

🔶 Hyperactive bowel sounds with abdominal tenderness further support a GI process, while clear lungs and adequate oxygenation point away from primary respiratory causes and focus attention on hemodynamic compromise from GI loss.

Action:

Test Stools for Occult Blood

🔶 Fecal occult blood testing (FOBT) detects ongoing or intermittent bleeding that may not be clinically visible, providing crucial data after an episode of hematemesis.

🔶 Serial positive occult tests indicate continued blood loss, prompting urgent escalation (e.g., endoscopy, transfusion strategy).

🔶 FOBT helps corroborate trends in Hgb/Hct, offering a low-risk, bedside adjunct to gauge whether bleeding is active, diminishing, or rebleeding.

🔶 In a patient with mixed emesis patterns (digested and fresh blood), stool testing refines the picture of total GI blood loss burden beyond what is seen in emesis alone.

🔶 Early documentation of occult bleeding supports timely GI consult and guides resuscitation targets while definitive therapy is arranged.

Parameters:

Hemoglobin & Hematocrit

🔶 Serial Hgb/Hct are the primary laboratory indicators for the severity and trajectory of acute GI hemorrhage.

🔶 Downward trends despite resuscitation signal ongoing bleeding and the need for more aggressive intervention (e.g., transfusion, endoscopic hemostasis).

🔶 Trending every 4–6 hours aligns with best practices for acute bleeding, allowing timely adjustments to fluids, blood products, and pharmacotherapy.

🔶 Coupling Hgb/Hct with clinical status (mental state, urine output, vitals) provides a comprehensive index of perfusion.

🔶 Stabilization or rise in values after treatment indicates hemostasis and effective resuscitation, supporting step-down in intensity of monitoring.

Blood Pressure

🔶 Systolic hypotension and narrowed pulse pressure in acute GI bleeding reflect decreased circulating volume and risk of shock.

🔶 Frequent BP checks (and continuous monitoring if available) detect hemodynamic instability early, guiding fluid boluses and transfusion thresholds.

🔶 A falling BP with a compensatory rise in HR indicates ongoing hemorrhage and the need for urgent escalation (rapid GI evaluation, vasoactive support if required).

🔶 BP trends, integrated with orthostatic measurements, help quantify volume responsiveness and resuscitation adequacy.

🔶 Stabilization of BP alongside symptom improvement (less dizziness, stronger pulses) marks resuscitative success while awaiting definitive hemostasis.

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Answer 8

Correct Answers:

58

Rationale :

✍️Step 1: Convert pounds to kilograms

160 lb÷2.2

☑️72.7 kg

✍️ Step 2: Apply the RDA protein requirement (0.8 g/kg/day)

72.7 kg×0.8 g/kg

☑️58.16 g/day

✍️Step 3: Round to nearest whole number

☑️58.16

☑️58 g/day

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Answer 9

Correct Answers:

Serum ammonia

Rationale :

🟢In advanced liver disease, the liver loses its ability to convert ammonia into urea for excretion.

🟢Elevated serum ammonia leads to hepatic encephalopathy, causing confusion, altered LOC, and even coma.

🟢Monitoring ammonia levels helps evaluate the progression of encephalopathy and the effectiveness of therapies such as lactulose.

🟢Other labs (e.g., LFTs, PT/INR, albumin) are also monitored, but ammonia directly reflects neurotoxicity risk.

🟢Prompt recognition of elevated ammonia prevents irreversible neurologic injury.

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Answer 10

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

Check the client’s airway and level of consciousness

🔷 In DKA, ABCs come first—severe metabolic acidosis and fatigue can depress mental status and threaten airway protection.

🔷 Assessing LOC (e.g., AVPU/GCS) verifies the client can maintain the airway, manage secretions, and protect against aspiration.

🔷 Kussmaul respirations may be present as a compensatory response; confirming airway patency and effective ventilation is essential before other measures.

🔷 Early airway assessment guides the urgency for oxygen support and potential airway escalation if the client deteriorates.

🔷 Prioritizing airway/LOC prevents secondary hypoxia, which worsens lactic acidosis and overall instability.

Assess vital signs to determine hydration status

🔷 DKA produces osmotic diuresis (polyuria), causing hypovolemia with tachycardia, hypotension, and poor perfusion—vital signs show its severity.

🔷 A full set (HR, BP, RR, SpO₂, temperature) plus orthostatic changes clarifies the volume deficit and the immediacy of resuscitation needs.

🔷 Identifying shock physiology guides fluid type, rate, and monitoring plan, preventing under- or over-resuscitation.

🔷 Baseline vitals provide a reference to evaluate the client’s response to therapy in the next steps.

🔷 Accurate hydration assessment reduces risks like renal hypoperfusion and electrolyte derangements that compound DKA.

Administer prescribed IV fluids

🔷 Isotonic crystalloids (e.g., 0.9% NS) are first-line to restore intravascular volume, improve tissue perfusion, and begin lowering serum glucose via dilution and improved renal clearance.

🔷 Early fluids blunt counter-regulatory hormones, enhance insulin sensitivity, and help correct the hyperosmolar state.

🔷 Volume repletion protects the kidneys, improves lactate clearance, and prepares for insulin initiation (often started after initial fluid bolus).

🔷 Fluid therapy also helps correct electrolyte shifts—particularly potassium, which must be watched closely as acidosis resolves.

🔷 Titration is guided by hemodynamics, urine output (≥0.5 mL/kg/hr), mental status, and serial labs to achieve euvolemia without overload.

Monitor for pulmonary edema

🔷 After aggressive fluids, clients—especially those with older age, renal impairment, or cardiac disease—are at risk for fluid overload.

🔷 Continuous reassessment of lung sounds (crackles), work of breathing, SpO₂, JVD, and daily weights detects early pulmonary congestion.

🔷 Watching for rising oxygen needs or new dyspnea prompts immediate adjustment of fluid rates and consideration of diuretics if indicated.

🔷 Careful balance prevents trading hypovolemia for cardiopulmonary compromise, a common pitfall in rapid resuscitation.

🔷 Integrating clinical findings with I&O and chest exam trends ensures safe progression from resuscitation to definitive metabolic management.

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Potential Prescription	Anticipated	Nonessential	Contraindicated
Restrict the client's fluid Intake to 2 L per day.
Weigh the client daily.
Increase the dosage of furosemide.
Begin a 24-hr urine collection for the client.
Hold the client's metoprolol.
Decrease the client's oxygen to 1 L/min via nasal cannula.

RN Adult Medical Surgical 2023 a

No.

1 :
A nurse is teaching a client who is to begin chemotherapy about a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include in the teaching?

2 :
A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

3 :
A nurse is caring for a client who has heart failure.

Correct Answers

4 :
A nurse is caring for a client who has just been admitted to the emergency department (ED).

Correct Answers

5 :
A nurse in an emergency department (ED) is caring for a client.

Correct Answers

6 :
A nurse is teaching a group of assistive personnel about performing hand hygiene when caring for a client who has an immunodeficiency disorder. Which of the following information should the nurse include in the teaching?

7 :
A nurse in the emergency department (ED) is caring for a client.

Correct Answers

9 :
A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client?

10 :
A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance, use all the steps.)

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RN Adult Medical Surgical 2023 a

No.

1 : A nurse is teaching a client who is to begin chemotherapy about a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include in the teaching?

2 : A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

3 : A nurse is caring for a client who has heart failure.

Correct Answers

4 : A nurse is caring for a client who has just been admitted to the emergency department (ED).

Correct Answers

5 : A nurse in an emergency department (ED) is caring for a client.

Correct Answers

6 : A nurse is teaching a group of assistive personnel about performing hand hygiene when caring for a client who has an immunodeficiency disorder. Which of the following information should the nurse include in the teaching?

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

Correct Answers

9 : A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client?

10 : A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance, use all the steps.)

1 :
A nurse is teaching a client who is to begin chemotherapy about a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include in the teaching?

2 :
A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

3 :
A nurse is caring for a client who has heart failure.

4 :
A nurse is caring for a client who has just been admitted to the emergency department (ED).

5 :
A nurse in an emergency department (ED) is caring for a client.

6 :
A nurse is teaching a group of assistive personnel about performing hand hygiene when caring for a client who has an immunodeficiency disorder. Which of the following information should the nurse include in the teaching?

7 :
A nurse in the emergency department (ED) is caring for a client.

9 :
A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client?

10 :
A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance, use all the steps.)