1 :

Hint : 🫃Relieve vena cava pressure

Correct Answers:

  • Position the Client on her Side.


Rationale :

🌟 At 36 weeks gestation, the gravid uterus can compress the inferior vena cava when the client lies flat, reducing venous return and causing symptoms like nausea, dizziness, and hypotension.

🌟 This is known as supine hypotensive syndrome, and it impairs both maternal circulation and fetal oxygenation.

🌟 Turning the client to the left lateral position relieves the compression, restores cardiac output, and alleviates nausea by improving uteroplacental perfusion.

🌟 This is the safest and most immediate action to protect both maternal and fetal well-being.


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2 :

0400

Client is alert and Oriented x3, states I will be glad when my Surgery is over. Ambulated to bathroom Without assistance, Voided 300 mL of clear yellow urine. Client is NPO Client has peripheral IV inserted into right hand with lactated Ringer's infusing. No edema at IV insertion site

0600

Bedside glucose monitor was 210mg/dl (74 to 106 mg/dL)

Regular Insulin was administered per provider prescription.

0630:

Client is disoriented to time. place, and situation. Client is unable to follow verbal commands or answer simple questions. The client is diaphoretic. Skin is cool to touch. Client hands have fine tremors.

Type 2 diabetes mellitus x5 years that has been controlled with metformin. Recently, regular insulin has been added.

Admitted for total knee replacement

0400:

Temperature 37.2° C (99° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 150/90 mm Hg

Oxygen saturation 96% on room air

Medical Administration record

10 units subcutaneous regular insulin


After reviewing the assessment findings, whichof the following actions should the nurse take? Select the 2 actions the nurse should take.


Answer Options

Hint : 🩸Check sugar + anticipate treatment

Correct Answers:

  • Anticipate prescription glucagon.
  • Check the client blood glucose level


Rationale :

✾ The client is showing clinical signs of hypoglycemia (disorientation, tremors, cool skin) despite a previously elevated glucose reading. Insulin effects can peak after administration, causing rapid glucose drops.

✾ The first action is to check the current blood glucose level to confirm hypoglycemia, since symptoms strongly suggest it.

✾ The second action is to anticipate a prescription for glucagon, which is used when the client is symptomatic and unable to consume oral glucose or if they become unconscious.

✾ These are both priority interventions based on the symptoms, timing of insulin administration, and glucose fluctuation risk.

✾ Other options (orthostatic BP check, cooling blanket, IV insulin) are not indicated or may worsen the situation.


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3 :

Hint : 💊Antihistamine for hives

Correct Answers:

  • Diphenhydramine.


Rationale :

✪ Urticaria following antibiotic administration indicates a mild to moderate allergic reaction, often mediated by histamine release.

✪ Diphenhydramine, an H1 histamine receptor blocker, is the first-line treatment to reduce itching, swelling, and redness.

✪ It stabilizes the allergic response and may prevent progression to anaphylaxis if given early.

✪ It is essential for managing skin manifestations of hypersensitivity reactions, particularly with medications.


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4 :

Hint : 📱Medication adherence support

Correct Answers:

  • Using an electronic messaging system to remind clients when to take medications’


Rationale :

✬ Tertiary prevention involves minimizing complications and improving treatment compliance in those already diagnosed with a chronic disease like HIV.

✬ Medication reminders via digital systems support treatment adherence and help prevent disease progression and resistance.

✬ This action improves long-term outcomes and reduces hospitalization risks.

✬ It is a client-specific intervention aimed at enhancing management of the existing condition.


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5 :

Hint : ⚖️Task delegation requires training

Correct Answers:

  • You can delegate this task if the AP has been trained to use our scales."


Rationale :

⭐ Weighing clients is a non-invasive, routine task appropriate to delegate if the assistive personnel (AP) is trained and competent in using the equipment.

⭐ Delegation is appropriate when the task does not involve initial assessment, clinical judgment, or evaluation.

⭐ The nurse retains responsibility for interpreting the weight data as part of the nursing process.

⭐ Ensuring proper training maintains safety and accuracy in care delivery.


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6 :

Cient hospitalized following a motor vehicle crash. Open fracture to right femur. Reduction Of fracture and internal fixation device used to stabilize. Splint applied.

Day 2. 0830.

Clients is alert to person, place, and time. Lung sounds diminished in the bases bilaterally. no adventitious sounds noted. Client denies Shortness of breath. Bowel sounds hypoactive x4 soft abdomen. Splint to right leg clean, dry, and intact. client rates pain as 6 on a scale of O to 10. Right foot warm to touch. no edema noted. Posterior tibial and dorsalis pedis pulses palpable and capillary refill to toes less than 2 seconds. Cient dent-es numbness or tingling to right foot.

Day 3.1200:

Client is alert to person, place, and time. Lung sounds clear.Client denies shortness of breath. Bowel sounds active in all 4 quadrants ,soft abdomen pain as 9 on a scale of 0 10 .Right foot  cool to touch, edema noted. unable to palpate posterior tibial and dorsalis pedis pulses, and capillary refill to toes greater then 2 seconds. Client reports numbness to right foot. Client unable to move toes or right foot, Splint to right leg intact, drainage.

Day 2.0830:

Temperature 36.8e C (98.2 e F)

Heart rate 90trnin

Respiratory rate 20/min

Blood pressure 132/84 mm Hg

Oxygen saturation on room air

Day 3. 0800:

Temperature 38.1' C (100.60 F)

Heart rate 98/min

Respiratory rate 24/min

BOOd pressure 128178 mm Hg

Oxygen saturation on room air.

Day 2

Hemoglobin 10 g/d[ (12 to 16 g/dL)

Hematocrit to 47%)

WBC count 14.000/mm (5.000 to 10,000/mm3)

Day 3

Hemoglobin 9.8 g/dL (12 to 16 g/dL)

hematocrit 329t (3796 to 47%)

WBC count 28.0001mmY (5.000 to 10.000/mrn3)


Drag words from the choices to fill blank of the following sentence. The client at risk for developing .


Hint : 🦵Neurovascular compromise signs

Correct Answers

  • Blank 1 Correct Option: Compartment syndrome.

Rationale :

✯ The client has decreased perfusion (cool foot, delayed cap refill, numbness, no pulses), indicating neurovascular compromise.

✯ These are hallmark signs of compartment syndrome, a surgical emergency caused by increased pressure in a closed muscle compartment.

✯ Early diagnosis is critical to prevent ischemia and permanent damage to nerves and muscles.

✯ Prompt action such as reporting to the provider and preparing for fasciotomy is essential.


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7 :

Hint : 📉Prolonged PR interval

Correct Answers:

  • First-degree atrioventricular block.


Rationale :

✭ A PR interval > 0.20 seconds (in this case, 0.35 seconds) on the ECG indicates a first-degree AV block.

✭ It reflects a delay in conduction from the atria to the ventricles, but each impulse still reaches the ventricles.

✭ Often asymptomatic, this rhythm is commonly associated with aging, medications, or ischemic heart disease.

✭ It requires monitoring but usually does not require immediate intervention unless symptomatic or progressive.


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8 :

Hint : 🍗Boost calories for CF

Correct Answers:

  • Provide a diet high in protein  and calories.


Rationale :

✰ Children with cystic fibrosis have increased metabolic demands and nutrient malabsorption, especially of fats and proteins.

✰ A high-calorie, high-protein diet helps support growth and prevent malnutrition, which is a common complication.

✰ Pancreatic enzyme replacement is also important, but diet is foundational to maintaining weight and energy.

✰ This recommendation supports overall health, lung function, and immune response in these clients.


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9 :

Hint : 🧾Standardized cost-effective care

Correct Answers:

  • Critical pathways should reduce health care costs.


Rationale :

✮ Critical pathways are structured multidisciplinary care plans that outline best practices and expected outcomes over a specific time frame.

✮ They aim to standardize care, reduce variation, and improve efficiency and quality, ultimately lowering healthcare costs.

✮ Variances can be managed but do not discontinue the pathway unless clinically necessary.

✮ They are created using evidence-based data, not solely from nursing notes.


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10 :

Hint : 🪑Prevent dizzy falls

Correct Answers:

  • Rise slowly when getting out of bed


Rationale :

✪ Furosemide is a loop diuretic that can cause volume depletion and orthostatic hypotension, increasing fall risk.

✪ Educating clients to rise slowly helps prevent dizziness or syncope.

✪ Clients also need to be taught about potential hypokalemia, but this specific action targets the most immediate safety risk.

✪ Monitoring for dehydration and electrolyte imbalances is also essential.


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Total Questions: 10

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