1 :

3 days ago:

Client presents to the surgical center for perioperative teaching and instructions. Client is scheduled for a cholecystectomy next week. Preoperative teaching reinforced regarding respiratory and physical functioning, anticipated length of stay, surgical preparation, and management of pain. Labs, vital signs, and ECG obtained. Provider obtained consent for surgery. Client is to return to surgical center in 3 days for scheduled surgery.

Today, 0900:
Client presents to surgical center for scheduled cholecystectomy. Client reports anxiety, and pain as 2 on a scale of 0 to 10. Client is requesting information about risks and benefits of surgery. Client is alert to person, place, time, and situation. Client reports last meal was this morning at 0730 and consisted of toast, coffee, and scrambled eggs. Client reports performing chlorhexidine shower this morning. Heart rate regular and fast, no murmurs or gallops. Radial pulse +3 bilaterally. Respirations even and nonlabored. Lungs clear anterior and posterior. Abdomen soft, rounded, and nondistended, no tenderness. Bowel sounds active in all 4 quadrants. Client reports formed bowel movement yesterday. Bladder nondistended; continent. Reports no difficulty with urinating. Skin warm, dry, and intact. Capillary refill less than 2 seconds. Turgor without tenting. No edema present.

3 days ago:

Temperature 37.10 C (98.80 F)

Heart rate 82/min

Respiratory rate 20/min

Blood pressure 126/74 mm Hg

Oxygen saturation 97% on room air

Today, 0900:

Temperature 37.40 C (99.30 F)

Heart rate 110/min

Respiratory rate 20/min

Blood pressure 158/96 mm Hg

Oxygen saturation 92% on room air

3 days ago:

CBC: WBC count 9,800/mm3 (5,000 to 10,OOO/mm3)

Hemoglobin 11 g/dL (12 to 16 g/dL)

Hematocrit (37% to 47%)

Platelet count 140,000/mm3 (150,000 to 400,000/mm3)

Type and Cross: O negative

ECG: Normal sinus rhythm, heart rate 88/min

Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report to the provider.

Answer Options

Hint : 🩺 Pre-op red flags

Correct Answers:

  • Oxygen saturation
  • Client's PO intake
  • Blood pressure
  • WBC count
  • Platelet count

Rationale :

🔷 Oxygen saturation decreased to 92%, indicating potential hypoxia or respiratory compromise

🔷 PO intake before surgery violates NPO guidelines, increasing aspiration risk

🔷 Blood pressure of 158/96 mm Hg is elevated and may cause perioperative complications

🔷 WBC count of 9,800 is near upper normal but not critical; however, paired with elevated vitals, may suggest inflammatory response

🔷 Platelet count of 140,000 is below normal, increasing the risk of bleeding during surgery

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2 :

Day 1, 1100:

Client admitted from emergency department with a new diagnosis of pneumonia. Confirmed by chest x-ray and laboratory results. Client reports dyspnea and exhibits shortness of breath at rest. Client is hypoxic, confirmed by oxygen saturation. Placed on oxygen at 2 L/min via nasal cannula. Congested cough, sputum specimen obtained and sent to the laboratory. Crackles heard on auscultation, breath sounds diminished. IV initiated in left forearm with 22-gauge angiocath for intermittent antibiotic therapy and further treatment.

Day 2, 1500:

Client remains hypoxic. Less dyspnea noted at rest, extreme shortness of breath noted on exertion. Receiving intermittent IV medications. IV site without manifestations of infection or infiltration.

Day 1, 1100:

Temperature 39.10 C (102.40 F)

Heart rate 102/

Respiratory rate 26/min

Blood pressure 122/80 mm Hg

Oxygen saturation 86% on room air

Weight 90.7 kg (200 lb)

Day 2, 1200:

Temperature 380 C (100.40 F)

Heart rate 100/min

Respiratory rate 22/min

Blood pressure 120/74 mm Hg

Oxygen saturation 88% on nasal cannula at 2 L/min

Day 3, 1200:

Temperature 37.20 C (990 F)

Heart rate 90/min

Respiratory rate 20/min

Blood pressure 120/72 mm Hg

Oxygen saturation 91 % on nasal cannula at 3 L/min

Day 4, 1500:

Temperature 37.20 C (990 F)

Heart rate 92/min

Day 1, 1500:

Cefazolin 500 mg every 12 hr IV

Dexamethasone 15 mg every 6 hr IV

Day 3. 1200:

Discontinue dexamethasone 15 mg every 6 hr IV

Prednisone 40 mg PO daily

Day 4, 1500:

Discontinue cefazolin 500 mg every 12 hr IV
 

Day 4, 1500:

Discharge prescriptions:

Cephalexin 500 mg PO every 6 hr for 5 days

Prednisone 40 mg PO daily for 5 days

Home oxygen 3 L/min via nasal cannula.

The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

Answer Options

Hint : 💨Oxygen and meds safety

Correct Answers:

  • Take steroid medication in the morning.
  • Take antibiotic medication with or without food.
  • Ensure the oxygen delivery system is at least 8 feet from any heat source.
  • Store the oxygen cylinder wrench with the oxygen tank.

Rationale :

🔹 Morning administration of steroids mimics natural cortisol rhythm and minimizes insomnia

🔹 Cephalexin may be taken with or without food, improving compliance

🔹 Keeping oxygen away from heat prevents combustion or fire risk

🔹 Storing the wrench with the tank allows for quick shutoff in emergencies

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3 :

Day 1:

Collecting client data on food safety. Raw meats and raw vegetables are prepared together on one cutting board. Refrigerator is set to 6.70 C (440 F) Leftovers are discarded after 7 days in refrigerator. Frozen foods are defrosted on the countertop. Client washes hands for 10 seconds before cooking. Leftovers are refrigerated after sitting on the countertop for 3 Reinforced client teaching about food safety. Follow-up visit scheduled in 2 weeks.

Day 14:

At client's home to collect follow-up data on food safety. Uses one cutting board to prepare raw meats and a different cutting board to prepare raw vegetables. The refrigerator is set to 5.60 C (420 F). Leftovers are discarded after 2 days in refrigerator. Frozen foods are defrosted in the refrigerator. Client washes hands for 1 5 seconds before cooking. Leftovers are refrigerated after sitting on the countertop for 2 hr.

Select the 4 findings that indicate an understanding of the reinforced teaching.

Answer Options

Hint : 🥕 Home food safety rules

Correct Answers:

  • Use of cutting board
  • Refrigerator temperature
  • Defrosting of frozen foods
  • Amount of time washing hands.

Rationale :

🧼 Separate cutting boards prevent cross-contamination

🧼 Refrigerator set to ≤ 5.6°C (42°F) maintains food preservation standards

🧼 Defrosting food in refrigerator reduces bacterial growth compared to countertop defrosting

🧼 Washing hands for ≥ 15 seconds ensures adequate hand hygiene

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4 :

Day 1, 1630:

Medication Administration Record

Metoprolol 50 mg PO BID

Simvastatin 40 mg PO daily at bedtime


Medication Administration Record

Metoprolol 50 mg PO BID

Simvastatin 40 mg PO daily at bedtime

Day 1, 1630:

Tympanic temperature 36.6 C (97.80 F

Respiratory rate 18/min

Heart rate 78/min

Blood pressure 132/84 mm Hg

Oxygen saturation 100% on room air

Day 2, 0815:

Tympanic temperature 37.40 C (99.30

Respiratory rate 20/min

Heart rate 88/ mi n

Blood pressure 152/88 mm Hg

Oxygen saturation 96% on room air

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

Hint : 🥣Silent swallow risks

Correct Answers

  • Blank 1 Correct Option: aspiration
  • Blank 2 Correct Option: dysphagia
Rationale :

🟢 Hoarse voice, food pocketing, and weakness indicate risk for aspiration

🟢 Dysphagia is supported by client's report of food stuck and hoarseness

🟢 Intervention is needed before advancing oral intake or therapy to prevent aspiration pneumonia

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5 :

6 months ago:

Client present today for annual examination. Reports lack of

sleep and increased stress due to moving and starting a new

job.

Today, 1400:

Client presents to office today with reports of fatigue. Client

states they have difficulty sleeping without drinking four or five

beers a night. Client reports, "l sometimes get headaches along  

with nausea and vomiting. I have been busy with my new job, so

I have been eating a lot of fast food, and I've gained 15 pounds."

Today, 1445:

Provider notified of laboratory results.

6 months ago:

Temperature 37.20 C (990 F)

Heart rate 82/min

Respiratory rate 18/min

Blood pressure 132/68 mm Hg

Oxygen saturation 98% on room air

Today, 1400:

Temperature 36.80 C (98.20 F)

Heart rate 100/min

Respiratory rate 22/min

Blood pressure 162/90 mm Hg

Oxygen saturation 95% on room ai

Today, 1445:

Sodium 148 mEq/L (136 to 145 mEq/L)

Potassium 3.7 mEq/L (3.5 to 5 mEq/L)

BUN 16 mg/dL (1 0 to 20 mg/dL)

Creatinine 0.8 mg/dL (0.5 to 1 mg/dL)

WBC count 8,000/mm3 (5,000 to 10,000/mm3)

HDL 38 mg/dL (greater than 45 mg/dL)

LDL 210 mg/dL (less than 130 mg/dL)

Total cholesterol 248 mg/dL (less than 200 mg/dL)

A nurse is caring for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.

Answer Options

Hint : 🔎Dietary targets for heart

Correct Answers:

  • Keep daily fat intake to less than 35%.
  • Place on 2,300 mg sodium diet.
  • Limit alcohol intake to 2 drinks per day.

Rationale :

🥗 Elevated cholesterol levels require reduced fat intake to prevent progression of atherosclerosis

🥗 Blood pressure of 162/90 warrants sodium restriction to avoid fluid retention and worsening hypertension

🥗 Moderation of alcohol improves cardiovascular function and prevents additional sleep disturbances

🥗 Excessive alcohol also contributes to dyslipidemia and elevated triglycerides

🥗 These interventions align with heart-healthy diet guidelines for hypertension and hyperlipidemia

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6 :

1 050:

Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. Client reports that pain began in the mid abdominal region during the night. This morning the pain intensified and localized to the right lower quadrant region. Pain continues to intensify, rebound tenderness noted. Client reports vomiting one time after eating a piece of toast at 0600 with continued feelings of nausea. Peripheral IV to the left forearm with IV fluids infusing.

1 200: Informed consent obtained by the surgeon performing the procedure. Placed in the client's medical record. Client expresses concerns about potential complications that could result from the surgery.

Upon admission to emergency department (ED), 0945:

Temperature 38.30 C (100.90 F)

Heart rate 102/min

Respiratory rate 22/min

Blood pressure 122/80 mm Hg

Oxygen saturation 96% on room air

Pain reported as 6 on a scale of 0 to 10

Upon admission to medical-surgical department, 1050: 

Temperature 38.40 C (101.10 F)

Heart rate 104/min

Respiratory rate 22/min

Blood pressure 124/80 mm Hg

Oxygen saturation 96% on room air

Pain reported as 8 on a scale of 0 to 10

1050:

Received influenza vaccine 1 month ago.

Thyroid disease, taking levothyroxine for 14 years.

History of cholecystectomy 3 years ago.

Denies alcohol or illegal drug use. Reports smoking

approximately six cigarettes per day for the past 10 years.

Allergic to shellfish, latex, and penicillin.

Select the 3 findings that require follow-up prior to surgery.

Answer Options

Hint : 🔎Pre-op safety trio

Correct Answers:

  • Dietary intake
  • Informed consent
  • Allergies

Rationale :

🩺 Eating before surgery violates NPO protocol, increasing aspiration risk under anesthesia

🩺 Informed consent must be verified as legally valid, especially if sedation occurred before signing

🩺 Allergies to latex, iodine, shellfish, or medications must be known to prevent anaphylactic reactions

🩺 Nurses are responsible for flagging any safety concerns to the surgical team

🩺 These preoperative checks prevent perioperative complications and legal issues

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7 :

0800:

The client is alert and oriented to person, place, and time.

Seizure pads placed on the client's bed. 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.

1 004:

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

The client has a history of a seizure disorder

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 followed by

Hint : 🔎 Side, then summon

Correct Answers

  • Blank 1 Correct Option: turn the client to their side
  • Blank 2 Correct Option: call for assistance
Rationale :

🌀 Turning the client prevents aspiration and airway blockage during seizure activity

🌀 Positioning supports drainage of secretions and prevents tongue obstruction

🌀 Calling for help brings staff to assist with airway management and protect from injury

🌀 Both actions are part of seizure precautions before initiating medication or documentation

🌀 The nurse must prioritize immediate client safety above all else

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8 :

Hint : 🔎 Sodium lost through GI

Correct Answers:

  • Hyponatremia

Rationale :

🧊 Diarrhea and vomiting cause loss of sodium-rich fluids, leading to hyponatremia

🧊 Low sodium causes mental status changes, fatigue, and muscle weakness

🧊 Sodium levels should be monitored with basic metabolic panels (BMP)

🧊 Prompt identification helps prevent seizures or neurological deterioration

🧊 Fluid and sodium replacement is critical to restore electrolyte balance

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9 :

Hint : 🔎 Support, don’t steer

Correct Answers:

  • "How will you discuss this decision with your loved ones?"

Rationale :
🗣️ This response promotes autonomy and reflection, essential in therapeutic communication 🗣️ It invites the client to express thoughts and involve family in a supportive way 🗣️ Avoids giving advice or expressing judgment about the client’s end-of-life decision 🗣️ Encourages emotional processing, respecting the client’s values and choices 🗣️ Therapeutic responses help build trust and reduce defensiveness
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10 :

Hint : 🔎 Finger side + gloves only

Correct Answers:

  • Prick the Side of the client's finger,
  • Apply clean gloves.

Rationale :

🩸 Pricking the side of the finger avoids nerve endings and reduces discomfort

🩸 The sides of the fingertip have better blood flow and fewer pain receptors than the center

🩸 Applying clean gloves ensures standard precautions and protects both the nurse and client from contamination

🩸 Gloves are required for any blood or body fluid exposure, including capillary blood draws

🩸 Avoid squeezing the finger excessively, which can cause hemolysis and inaccurate readings

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Total Questions: 10

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