1 :

Hint : 🦠 RSV = contact isolation

Correct Answers:

  • Use a designated stethoscope when caring for the toddler.


Rationale :

🟩 RSV is primarily spread through direct contact with respiratory secretions, making contact precautions essential.

🟩 Using dedicated medical equipment like a stethoscope prevents cross-contamination between clients.

🟩 This strategy is part of standard infection control protocols for preventing nosocomial RSV infections.

🟩 Since RSV is not airborne, an N95 mask and negative-pressure room are not required, but meticulous contact precautions are.


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2 :

Hint : 🔥Mania = high energy, needs calories

Correct Answers:

  • Provide high-calorie nutritional supplements.


Rationale :

🟧 Clients experiencing acute mania are often too distracted to sit through full meals, increasing the risk for malnutrition.

🟧 Offering nutrient-dense, high-calorie snacks allows for sufficient intake without requiring extended sitting periods.

🟧 The goal is to prevent weight loss and dehydration during periods of excessive activity.

🟧 Simple, high-calorie options maintain nutritional status and energy balance when traditional meals are impractical.


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3 :

Hint : 💉Bleeding risk before scope

Correct Answers:

  • Clopidogrel


Rationale :

🟥 Clopidogrel is an antiplatelet agent that interferes with blood clotting and poses a high risk for bleeding.

🟥 Before invasive procedures like a colonoscopy, it is important to notify the provider about any medication that affects hemostasis.

🟥 Continuing clopidogrel could lead to gastrointestinal hemorrhage, especially if polyp removal or biopsy is performed.

🟥 This makes it the highest priority medication to report among others listed, ensuring safe procedural outcomes.


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4 :

Day 1, 0630:

Coronary artery bypass graft surgery x 4 grafts.

Day 3, 0730:

Alert and oriented to person, place, and time. Follows simple commands. Clear speech. Clear lung sounds bilaterally. Chest tubes bilaterally x 4 in pleural and pericardial space. Continuous suction at -20 cm H20. No air bubbling in the water seal chamber. Tidaling present. Chest tube dressings are clean, dry, and intact.

Normal sinus rhythm, S1, S2, no murmurs or extra heart sounds noted. No jugular venous distension. Pedal and radial pulses + 2 bilaterally. Pedal edema + 2 lower right leg. Pedal edema + 1 of lower left leg. Right leg dressing is clean, dry, and intact.

Day 3, 1130:

Atrial fibrillation noted on the ECG, rate 136/min. S1, S2, present, irregular, no murmurs or extra heart sounds noted on auscultation. Reports no chest pain or shortness of breath. Client alert and oriented, speech clear, moves all extremities. Lungs clear bilaterally to auscultation. Chest tubes patent. All dressings clean, dry, and intact.

Day 3, 0730:

Temperature 37.0 C (98.70 F)

Heart rate 88/min

Respiratory rate 22/min

Blood pressure 136/88 mm Hg

Oxygen saturation 94% on room air

Pain level 6 on a scale of 0 to 10

Day 3, 1130:

Temperature 37.720 C (99.890 F)

Heart rate 136/min

Respiratory rate 26/min

Blood pressure 110/76 mm Hg

Oxygen saturation 92% on room air

Pain level 5 on a scale of 0 to 10

Day 3, 0730:

Chest tube drainage: 40 mL

Day 3, 0930:

Chest tube drainage: 40 mL

Day 3, 1 130:

Chest tube drainage: 30 mL

Day 3, 1330:

Chest tube drainage: 30 ML


Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing as evidenced by their


Hint : 🧠 A-fib rhythm + stroke risk

Correct Answers

  • Blank 1 Correct Option: stroke
  • Blank 2 Correct Option: cardiac rhythm

Rationale :

Stroke

🔵 A stroke is a possible complication of atrial fibrillation, which can cause emboli to form in the atria and travel to the brain.

🔵 The irregular rhythm reduces effective atrial contraction, promoting blood stasis and clot formation.

🔵 In postoperative clients, especially after cardiac surgery, this risk increases, making stroke a high-priority concern.

Cardiac rhythm

🔵 The new onset of atrial fibrillation is a key finding that signals the client’s risk for cerebral embolism.

🔵 Identifying this rhythm early allows the care team to start anticoagulation or rhythm control measures.

🔵 Prompt action based on cardiac rhythm findings is essential for stroke prevention and stabilization.


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5 :

Hint : 👶Misreading baby's cues

Correct Answers:

  • Viewing the newborn's actions to be uncooperative


Rationale :

🟨 Misinterpreting a newborn's cues, such as crying or turning away, as intentional noncompliance may reflect impaired bonding.

🟨 This perception could indicate emotional detachment or postpartum mood disturbance.

🟨 Effective maternal-infant bonding involves understanding and responding appropriately to developmentally normal behaviors.

🟨 The nurse should support the client through education and emotional reassurance to encourage healthy attachment.


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6 :
A
B
C

Hint : 🫀Aortic valve = 2nd ICS, RSB


Rationale :

🟥 The aortic valve is best auscultated at the second intercostal space, right sternal border, which is labeled as Point A in the image.

🟥 This location allows the clearest transmission of aortic valve closure sounds (S2) during the cardiac cycle.

🟥 Using the diaphragm of the stethoscope at this spot provides high-frequency sound detection, ideal for valvular assessment.

🟥 Accurate stethoscope placement is essential to differentiate aortic murmurs from other valvular abnormalities.


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7 :

6 Months Ago:

Client reports daytime fatigue for 3 to 4 months. Drinks 1 to 2 cups of coffee early in the morning. Work schedule 0800 to 1600. Client exercises at the gym on the way home from work. usual bedtime is 2330; awakens at 0630.

Today:

Client reports difficulty falling asleep at night. then awakening 1 to 2 hr after falling asleep. Has daytime fatigue. Recently changed work schedule. Works 1200 to 2000. Exercises at the gym on the way home from work and eats dinner after they shower. usual bedtime is 2330; awakens at 0700. Client reports that they turn off phone at 2230 every night. Client drinks 2 to 3 cups of coffee early in the morning.

6 Months Ago:

Hct (37% to 47%)

Hgb 9 g/dL (12 to 16 g/dL)

Today:

Hct 38% (37% to 47%)

Hgb 13 g/dL (12 to 16 g/dL)

8 Months Ago:

Ethinyl estradiol/desogestrel 1 tablet PO daily for contraception

6 Months Ago:

Ferrous sulfate 120 mg PO twice daily 1 hr before meals for iron Supplementation


Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.


Answer Options

Hint : 🛏️ Late food + exercise = poor sleep

Correct Answers:

  • Evening meal
  • Exercise schedule


Rationale :

Evening meal:

🟨 Eating dinner after late-night workouts and showers may delay digestion and disrupt circadian rhythm, contributing to poor sleep quality.

🟨 Eating large meals close to bedtime activates metabolism and keeps the body alert, interfering with sleep onset.

🟨 Adjusting meal timing to at least 2–3 hours before bed can improve rest.

Exercise schedule:

🟨 Exercising after 8:00 PM stimulates catecholamine release, which can increase alertness and body temperature.

🟨 Late evening physical activity can delay melatonin release, which is critical for natural sleep induction.

🟨 Shifting workouts earlier in the day can optimize sleep efficiency.


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8 :

Hint : 💨 early hypoxia

Correct Answers:

  • Restlessness


Rationale :

🟦 Restlessness is an early and classic sign of hypoxia, as the brain responds to insufficient oxygen by increasing cerebral excitability.

🟦 Clients may exhibit irritability, anxiety, or agitation before changes in vital signs or oxygen saturation occur.

🟦 Recognizing restlessness early enables prompt intervention, such as adjusting oxygen flow or positioning.

🟦 Other signs like cyanosis or seizures are late findings and indicate more severe hypoxia.


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9 :

Hint : 🛁Bathing + seizure = danger

Correct Answers:

  • The preschooler takes tub baths independently.


Rationale :

🟥 A child with epilepsy should not take tub baths alone, as a seizure in water poses a risk for drowning or head injury.

🟥 Supervision is essential during bathing to ensure safety and immediate intervention if a seizure occurs.

🟥 Showers under observation or sponge baths are safer alternatives for seizure-prone children.


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10 :

Hint : ❤️Crackles = left heart strain

Correct Answers:

  • Bilateral lung crackles


Rationale :

🟩 Crackles in both lungs reflect pulmonary congestion, a hallmark of left-sided heart failure.

🟩 The left ventricle's reduced efficiency leads to blood backing up into the pulmonary circulation, causing fluid accumulation.

🟩 These findings warrant immediate provider notification, as they indicate impaired oxygen exchange and worsening heart function.

🟩 Other signs like JVD and edema reflect right-sided failure, not left-sided.


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Total Questions: 10

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