1 :

The client has a history of a seizure disorder. 

0800

The client is alert and oriented to person, place, and time. Seizure precautions are in place. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside. 

1000

Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands. 

1004

Client's jerking contractions of arms and legs stopped. Client is confused and lethargic. Bilateral breath sounds clear. Oxygen applied 3 L/min via nasal cannula. Oxygen saturation 95%. 

Complete the following sentence by using the lists of options. At 1000, the nurse enters the client's room. The first action the nurse should take is to followed by

Hint : During seizures, protect airway first

Correct Answers

  • Blank 1 Correct Option: turn the client on their side.
  • Blank 2 Correct Option: loosening the client's gown
Rationale :

✅ Turn the client on their side — FIRST

🌻 During a generalized tonic-clonic seizure, the immediate priority is maintaining the client's airway and safety.

🌻 Turning the client onto their side allows saliva and oral secretions to drain from the mouth.

🌻 Side-lying positioning decreases the risk of aspiration while the client is unconscious and unable to protect the airway.

🌻 The nurse should protect the client's head from injury and remove nearby objects that could cause harm.

🌻 The nurse should not restrain the client's extremities because restraint can cause musculoskeletal injury.

🌻 Nothing should be placed inside the client's mouth because this can cause oral trauma, broken teeth, or airway obstruction.

🌻 The nurse should also note the time the seizure begins and its characteristics while maintaining safety.

🌻 Therefore, turning the client onto their side is the first action.

✅ Loosen the client's gown — SECOND

🌻 After positioning the client safely, the nurse should loosen restrictive clothing, particularly around the neck and chest.

🌻 Loosening the gown helps prevent clothing from interfering with respiratory movement and ventilation.

🌻 Maintaining adequate breathing is especially important during a generalized seizure because respiratory effectiveness can temporarily decrease.

🌻 The nurse should continue observing the client's respiratory status and seizure activity.

🌻 Oxygen and suction equipment should remain readily available, as they already are in this client's room.

🌻 Following cessation of the seizure, the nurse should assess airway, breathing, oxygen saturation, neurologic status, and injuries.

🌻 Postictal confusion and lethargy are expected after a generalized tonic-clonic seizure.

🌻 Therefore, loosening the client's gown appropriately follows side-lying positioning.

❌ Observe the progression of the seizure

🏵️ The nurse should observe and time the seizure, but airway protection and physical safety take priority.

🏵️ Observation occurs while immediate safety interventions are being implemented.

❌ Document the seizure event

✳️ Documentation is important but should occur after the client's immediate airway and safety needs have been addressed.

✳️ The nurse should document seizure onset, duration, movements, consciousness, incontinence, and postictal findings.

❌ Reorient the client

🧿 Reorientation is appropriate during the postictal period when the client is confused and recovering consciousness.

🧿 It is not the priority while the client is actively experiencing generalized seizure activity.

❌ Administer anticonvulsant medications

🍊 Rescue anticonvulsant medication may be required for prolonged or recurrent seizures according to prescribed protocols.

🍊 This seizure stops after approximately 4 minutes, so immediate positioning and airway protection take priority among the available choices.

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2 :

The client has a history of a seizure disorder. 

0800

The client is alert and oriented to person, place, and time. Seizure precautions are in place. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside. 

1000

Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands. 

1004

Client's jerking contractions of arms and legs stopped. Client is confused and lethargic. Bilateral breath sounds clear. Oxygen applied 3 L/min via nasal cannula. Oxygen saturation 95%. 

Complete the following sentence by using the lists of options. At 1000, the nurse enters the client's room. The first action the nurse should take is to followed by

Hint : During seizures, protect airway first

Correct Answers

  • Blank 1 Correct Option: turn the client on their side.
  • Blank 2 Correct Option: loosening the client's gown
Rationale :

✅ Turn the client on their side — FIRST

🌻 During a generalized tonic-clonic seizure, the immediate priority is maintaining the client's airway and safety.

🌻 Turning the client onto their side allows saliva and oral secretions to drain from the mouth.

🌻 Side-lying positioning decreases the risk of aspiration while the client is unconscious and unable to protect the airway.

🌻 The nurse should protect the client's head from injury and remove nearby objects that could cause harm.

🌻 The nurse should not restrain the client's extremities because restraint can cause musculoskeletal injury.

🌻 Nothing should be placed inside the client's mouth because this can cause oral trauma, broken teeth, or airway obstruction.

🌻 The nurse should also note the time the seizure begins and its characteristics while maintaining safety.

🌻 Therefore, turning the client onto their side is the first action.

✅ Loosen the client's gown — SECOND

🌻 After positioning the client safely, the nurse should loosen restrictive clothing, particularly around the neck and chest.

🌻 Loosening the gown helps prevent clothing from interfering with respiratory movement and ventilation.

🌻 Maintaining adequate breathing is especially important during a generalized seizure because respiratory effectiveness can temporarily decrease.

🌻 The nurse should continue observing the client's respiratory status and seizure activity.

🌻 Oxygen and suction equipment should remain readily available, as they already are in this client's room.

🌻 Following cessation of the seizure, the nurse should assess airway, breathing, oxygen saturation, neurologic status, and injuries.

🌻 Postictal confusion and lethargy are expected after a generalized tonic-clonic seizure.

🌻 Therefore, loosening the client's gown appropriately follows side-lying positioning.

❌ Observe the progression of the seizure

🏵️ The nurse should observe and time the seizure, but airway protection and physical safety take priority.

🏵️ Observation occurs while immediate safety interventions are being implemented.

❌ Document the seizure event

✳️ Documentation is important but should occur after the client's immediate airway and safety needs have been addressed.

✳️ The nurse should document seizure onset, duration, movements, consciousness, incontinence, and postictal findings.

❌ Reorient the client

🧿 Reorientation is appropriate during the postictal period when the client is confused and recovering consciousness.

🧿 It is not the priority while the client is actively experiencing generalized seizure activity.

❌ Administer anticonvulsant medications

🍊 Rescue anticonvulsant medication may be required for prolonged or recurrent seizures according to prescribed protocols.

🍊 This seizure stops after approximately 4 minutes, so immediate positioning and airway protection take priority among the available choices.

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3 :

0900

Client admitted to the unit for decreased sensation and mobility in lower extremities. Client has a history of diabetes mellitus.

1200

Client has urinary and fecal incontinence. Condom catheter and absorbent pad placed under the client. 

0900

Intake: 180 mL water 25% breakfast 

Output: 200 mL loose stool 

1200

Intake: 240 mL juice 10% lunch 

Output: 150 mL urine 150 mL loose stool

The nurse is planning the client's care. Which of the following actions should the nurse include? Select the 4 actions the nurse should include in the plan of care.

Answer Options

Hint : Protect skin from pressure and moisture

Correct Answers:

  • Reposition the client every 3 hr.
  • Request a consult with a registered dietitian.
  • Provide a support pressure-redistribution surface.
  • Use a moisture barrier ointment after cleaning the client's skin.

Rationale :

✅ Reposition the client every 3 hr.

🌼 The client has decreased lower-extremity sensation and mobility, which significantly increases the risk for pressure injury.

🌼 Reduced sensation means the client may not recognize discomfort caused by prolonged pressure.

🌼 Limited mobility also prevents the client from independently changing position to relieve pressure.

🌼 Regular repositioning reduces sustained pressure over bony prominences such as the sacrum, hips, and heels.

🌼 Position changes also promote tissue perfusion and decrease localized ischemia.

🌼 The nurse should inspect the skin during repositioning for redness, warmth, discoloration, or breakdown.

🌼 Repositioning frequency should be individualized according to the client's condition and the support surface being used.

🌼 Therefore, scheduled repositioning is an appropriate pressure-injury prevention intervention.

✅ Request a consult with a registered dietitian.

🏵️ The client is consuming only 25% of breakfast and 10% of lunch, indicating inadequate nutritional intake.

🏵️ Poor nutrition increases the risk for skin breakdown and impaired wound healing.

🏵️ Adequate protein is particularly important for maintaining skin integrity and repairing damaged tissue.

🏵️ Sufficient calories are necessary to prevent the body from using protein stores for energy.

🏵️ The client's loose stools also increase the risk of fluid and nutrient losses.

🏵️ A registered dietitian can evaluate caloric, protein, fluid, and micronutrient requirements while considering the client's diabetes mellitus.

🏵️ Nutritional interventions can be individualized to improve intake while maintaining appropriate blood glucose management.

🏵️ Therefore, a dietitian consultation is indicated to address this important pressure-injury risk factor.

✅ Provide a support pressure-redistribution surface.

✳️ A pressure-redistribution surface helps distribute the client's body weight across a larger surface area.

✳️ This reduces concentrated pressure over vulnerable bony prominences.

✳️ The client's immobility and sensory impairment place them at particularly high risk for pressure injuries.

✳️ Specialized mattresses and overlays can reduce both pressure and shear forces.

✳️ A support surface does not eliminate the need for regular repositioning and skin assessment.

✳️ The nurse should ensure that bedding remains smooth, dry, and free of wrinkles to further reduce friction.

✳️ The client's sacral and perineal areas require particular attention because of urinary and fecal incontinence.

✳️ Therefore, using a pressure-redistribution surface is an appropriate preventive intervention.

✅ Use a moisture barrier ointment after cleaning the client's skin.

🧿 The client has both urinary and fecal incontinence, creating frequent exposure of the skin to moisture and irritants.

🧿 Prolonged moisture causes maceration, weakening the skin and increasing susceptibility to breakdown.

🧿 Stool contains digestive enzymes that can further damage the perineal and sacral skin.

🧿 The skin should be cleaned promptly and gently after each episode of incontinence.

🧿 A moisture barrier ointment forms a protective layer between the skin and urine or stool.

🧿 Barrier products help prevent incontinence-associated dermatitis and reduce further skin irritation.

🧿 The nurse should avoid aggressive rubbing because friction can damage already vulnerable tissue.

🧿 Therefore, applying a moisture barrier after cleansing is an important component of the client's skin-protection plan.

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4 :

Day 1, 1630

Tympanic temperature 36.6° C (97.8° F) 

Respiratory rate 18/min 

Oxygen saturation 100% on room air,

Heart rate 78/min 

Blood pressure 132/84 mm Hg 

Day 2, 0815

Tympanic temperature 37.4° C (99.3° F)

Respiratory rate 20/min

Oxygen saturation 96% on room air 

Heart rate 88/min 

Blood pressure 152/88 mm Hg 

Day 1, 1630

Admitted from acute facility via ambulance transport. Alert, oriented. Equal bilateral muscle strength. Respiratory rate even, unlaboured. Lungs clear to auscultation. Gauze dressing noted to left hip arthroplasty site, dry and intact with scant sanguineous drainage. Client has a light skin tone. Mild edema and yellow-purple ecchymosis noted around borders of dressing. Pedal pulses +3 bilaterally. Vital signs obtained. 

Day 2, 0815

Called to room by assistive personnel to assess client. Client is slow to respond verbally but responds appropriately. Client reports feeling food stuck in their mouth; vocal quality is somewhat hoarse. Mild weakness noted on client's left side. Vital signs obtained, will notify provider.

0800

Metoprolol 50 mg PO BID 

Digoxin 0.125 mg PO daily 

Enoxaparin 40 mg subcutaneous daily through postoperative day 14 

2000

Simvastatin 40 mg PO daily at bedtime 

Complete the following sentence by using the lists of options. The client is at risk for as evidenced by the client's

Hint : New neurologic deficits increase aspiration risk

Correct Answers

  • Blank 1 Correct Option: aspiration
  • Blank 2 Correct Option: neurological status
Rationale :

✅ Correct Answer: Aspiration

🌻 The client is at significant risk for aspiration because several new findings suggest impaired swallowing and airway protection.

🌻 The report that food feels stuck in the mouth indicates difficulty controlling or moving food safely through the oral phase of swallowing.

🌻 A hoarse vocal quality after eating can be a warning sign of pharyngeal dysfunction or material entering near the airway.

🌻 The client is also slow to respond verbally, which suggests an acute neurologic change that can reduce protective reflexes.

🌻 New left-sided weakness is especially concerning for a possible stroke, which commonly causes dysphagia.

🌻 Dysphagia allows food, liquids, or saliva to enter the trachea and lungs instead of moving safely into the esophagus.

🌻 Aspiration can lead to airway obstruction, hypoxemia, aspiration pneumonitis, or aspiration pneumonia if not recognized promptly.

🌻 Therefore, aspiration is the most important risk because the client is showing direct evidence of impaired swallowing and possible acute neurologic dysfunction.

✅ Correct Evidence: Neurological status

🌻 The client's new neurologic findings provide the strongest evidence for the aspiration risk.

🌻 Mild left-sided weakness suggests possible focal neurologic impairment, such as an acute cerebrovascular event.

🌻 Stroke or other neurologic injury can impair the cranial nerves and muscles responsible for chewing, swallowing, and airway protection.

🌻 The client's slow verbal responses represent a change from the previous day, when the client was alert, oriented, and neurologically intact.

🌻 The newly hoarse voice can indicate weakness or dysfunction of structures involved in swallowing and phonation.

🌻 The complaint that food is remaining in the mouth suggests impaired oral motor coordination, which is frequently associated with neurologic dysfunction.

🌻 These findings warrant keeping the client NPO until swallowing safety is evaluated, along with prompt provider notification and a swallow assessment.

🌻 Therefore, the client's neurological status is the clearest evidence supporting the risk for aspiration.

❌ Sepsis

🏵️ The client does not demonstrate strong evidence of systemic infection, such as significant fever, hypotension, or marked respiratory deterioration.

🏵️ The postoperative bruising and mild edema described around the incision can occur following surgery and do not independently establish sepsis.

❌ Tachycardia

✳️ The client's heart rate is 88/min, which is within the expected adult range and does not represent tachycardia.

✳️ The more urgent concern is the client's new focal neurologic and swallowing abnormalities.

❌ Decreased platelet count

🧿 Enoxaparin can rarely cause heparin-induced thrombocytopenia, making platelet monitoring important during therapy.

🧿 No platelet results, abnormal bleeding, or other findings are provided to indicate that thrombocytopenia is currently developing.

❌ Cardiovascular findings

🍊 The client's blood pressure has increased to 152/88 mm Hg, but the cardiovascular findings do not explain the immediate aspiration risk.

🍊 Left-sided weakness, altered responsiveness, hoarseness, and swallowing difficulty provide much stronger evidence of neurologic dysfunction.

❌ Oxygenation

🌸 The client's oxygen saturation is 96% on room air, which does not indicate significant current hypoxemia.

🌸 Aspiration risk is evident before oxygenation deteriorates because the client already demonstrates swallowing impairment.

❌ Enoxaparin medication

🌼 Enoxaparin increases bleeding risk and can rarely cause thrombocytopenia, but it does not directly explain the client's aspiration risk.

🌼 The client's neurologic changes and dysphagia are the findings that specifically indicate impaired airway protection.

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5 :

Hint : 💧Diuretics increase urine production

Correct Answers:

  • "This can be caused by the use of a diuretic medication."

Rationale :

🌸 Polyuria refers to the production and excretion of an abnormally large volume of urine, generally more than about 3 L/day in adults.

🌸 Diuretic medications increase urine production by promoting renal excretion of sodium and water.

🌸 Medications such as loop and thiazide diuretics decrease renal sodium reabsorption, causing more sodium and water to remain in the urine.

🌸 The increased amount of water eliminated by the kidneys results in increased urinary volume.

🌸 Other common causes of polyuria include diabetes mellitus, diabetes insipidus, excessive fluid intake, and certain kidney disorders.

🌸 The nurse should distinguish polyuria from urinary frequency, because frequency involves urinating often without necessarily increasing the total daily urine volume.

🌸 Clients taking diuretics should be monitored for excessive fluid loss and abnormalities such as dehydration, hypotension, and electrolyte disturbances.

🌸 Therefore, identifying diuretic medication use as a cause of polyuria demonstrates correct understanding.

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6 :

Hint : Advocacy protects client safety and rights

Correct Answers:

  • Client advocate

Rationale :

🧿 A client advocate protects the client's safety, rights, dignity, and well-being during healthcare delivery.

🧿 The nurse manager is observing the newly licensed nurse specifically to ensure that straight catheterization is performed safely and correctly.

🧿 Direct observation allows the manager to intervene if the nurse performs an action that could cause injury, infection, or unnecessary discomfort.

🧿 Straight catheterization requires strict aseptic technique to decrease the risk of introducing microorganisms into the urinary tract.

🧿 Advocacy includes protecting clients when they may be unable to independently evaluate whether the care they receive meets appropriate standards of practice.

🧿 The manager's primary purpose in this situation is not performing the procedure but ensuring that the client's best interests and safety are protected.

🧿 Nurses function as advocates whenever they identify potential risks and take appropriate action to prevent client harm.

🧿 Therefore, the nurse manager is functioning in the role of client advocate.

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7 :

Hint : Secure oxygen cylinders upright

Correct Answers:

  • "You should store the oxygen tanks upright."

Rationale :

🌻 Oxygen cylinders should be stored upright and securely fastened in an appropriate stand or holder to prevent them from falling.

🌻 A damaged or broken cylinder valve can cause pressurized oxygen to escape rapidly, creating a serious physical safety hazard.

🌻 Oxygen itself is not flammable, but it supports combustion, causing fires to ignite and burn more rapidly.

🌻 Oxygen equipment should therefore be kept away from flames, sparks, heat sources, and smoking materials.

🌻 The client should place “No Smoking—Oxygen in Use” signs where appropriate in the home.

🌻 Electrical equipment used near oxygen should be in good condition to minimize the risk of sparks and fire.

🌻 The client should also follow the prescribed oxygen flow rate and never independently change the amount of oxygen delivered.

🌻 Therefore, storing oxygen tanks upright and secured demonstrates appropriate oxygen-equipment safety.

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8 :

Hint : Light bedtime snacks can promote sleep

Correct Answers:

  • Eat a light carbohydrate snack before bedtime.

Rationale :

🌼 A light carbohydrate snack before bedtime can be appropriate for a client experiencing insomnia.

🌼 A small snack can prevent hunger from interfering with the client's ability to fall asleep.

🌼 Appropriate choices can include crackers, toast, or a small serving of cereal, depending on dietary needs.

🌼 The snack should remain light, because a large or heavy meal close to bedtime can cause gastrointestinal discomfort and interfere with sleep.

🌼 Establishing a consistent bedtime routine also helps regulate the body's sleep-wake cycle.

🌼 The client should maintain a quiet, dark, comfortable sleeping environment and avoid stimulating activities before bedtime.

🌼 Caffeine, nicotine, alcohol, and excessive evening fluids should generally be avoided because they can disrupt sleep.

🌼 Therefore, eating a light carbohydrate snack before bedtime is the most appropriate recommendation.

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9 :

Hint : Prevent foot drop on affected side

Correct Answers:

  • Apply an orthotic boot to the client's left foot.

Rationale :

🌻 Left-sided hemiplegia causes paralysis or severe weakness of the muscles on the client's left side.

🌻 Immobility of the affected leg increases the risk for foot drop, which occurs when the foot remains in plantar flexion.

🌻 An orthotic boot helps maintain the affected foot in a neutral, functional position.

🌻 Proper positioning helps prevent plantar-flexion contractures and shortening of the Achilles tendon.

🌻 Maintaining appropriate alignment also facilitates safer mobility when the client begins transfer and gait rehabilitation.

🌻 The nurse should routinely remove the device as prescribed to assess skin integrity, circulation, and pressure areas.

🌻 Range-of-motion exercises should also be incorporated to maintain joint mobility and decrease contracture formation.

🌻 Therefore, applying an orthotic boot to the left foot is an appropriate intervention for left-sided hemiplegia.

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10 :

Hint : Cool swelling around IV means infiltration

Correct Answers:

  • Infiltration

Rationale :

🌸 Infiltration occurs when a nonvesicant IV solution unintentionally leaks from the vein into the surrounding tissue.

🌸 Taut and edematous skin around the peripheral IV site is a classic manifestation of infiltration.

🌸 Additional findings can include coolness, pallor, swelling, discomfort, and slowing or stopping of the infusion.

🌸 The affected extremity can become increasingly swollen as IV fluid accumulates in the interstitial tissue.

🌸 The nurse should stop the infusion immediately when infiltration is suspected.

🌸 The IV catheter should generally be removed after following appropriate facility and medication-specific procedures.

🌸 The affected extremity may be elevated, and an appropriate compress can be applied depending on the infused solution and protocol.

🌸 Therefore, taut, edematous tissue surrounding a peripheral IV site is most consistent with infiltration.

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