Question

A nurse is preparing to infuse a 250-mL unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should

adjust the flow rate to deliver how many drops per minute? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 1

Correct Answers:

31

Rationale :

💠Flow rate (gtt/min)=(250mL×15gtt/mL)÷120min =3750÷120=31.25 💠Rounded to the nearest whole number: 31 gtt/min

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Answer 2

Correct Answers:

100

Rationale :

📌mL/hr=Total volume to infuse (mL)÷Time (hr)

📌Step-by-step:

Volume = 50 mL

Time = 30 minutes = 0.5 hours

📌mL/hr=50÷0.5=100

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Answer 3

Correct Answers:

Begin chest compressions

Rationale :

🟢 Immediate chest compressions are the priority in any unresponsive client with no pulse or signs of circulation, as per Basic Life Support (BLS) guidelines.

🟢 The critical goal is to maintain perfusion to the brain and vital organs, especially in the first minutes following cardiac arrest.

🟢 Calling for help (code blue) and initiating CPR (starting with compressions) should precede all other interventions to maximize survival.

🟢 Other actions, such as applying the AED or using a bag valve mask, are done after compressions have begun or by other members of the code team.

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Answer 4

Correct Answers:

Swollen and enlarged veins

Rationale :

🟩 Peripheral venous disease (PVD) primarily affects the veins' ability to return blood to the heart, leading to venous stasis and valvular incompetence.

🟩 This causes venous distention, leading to swollen, enlarged, and twisted veins, especially visible in the lower legs (varicosities).

🟩 Clients may also experience edema, a feeling of heaviness, and skin changes such as thickened, brownish skin around the ankles from hemosiderin deposits.

🟩 Unlike peripheral arterial disease (PAD), venous disease does not typically present with shiny skin or hair loss, which are arterial findings.

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Answer 5

Correct Answers:

Elevated

Rationale :

🟨 According to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines, a blood pressure reading of systolic 120–129 mm Hg and diastolic less than 80 mm Hg is categorized as Elevated blood pressure.

🟨 This client’s BP of 124/79 mm Hg meets that exact criterion: systolic between 120–129, and diastolic under 80.

🟨 While not considered hypertensive yet, clients in this category are at higher risk of progressing to Stage 1 hypertension if preventive measures aren’t taken.

🟨 Lifestyle interventions such as dietary changes, physical activity, sodium restriction, and regular monitoring are encouraged to prevent advancement.

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Answer 6

Correct Answers:

Lower back or groin pain

Rationale :

🔶 Abdominal aortic aneurysm (AAA) often develops silently but may present early with dull, steady pain in the lower back, abdomen, or groin due to pressure from the expanding aneurysm.

🔶 This pain occurs as the aneurysm compresses adjacent structures like lumbar nerves or tissues in the retroperitoneal space, even before rupture.

🔶 It is a key early symptom that warrants urgent imaging (typically ultrasound or CT) to confirm diagnosis and determine the size and risk of rupture.

🔶 Prompt identification of this symptom is essential, as a rupture can lead to life-threatening hemorrhage with high mortality.

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Answer 7

Correct Answers:

Dull. aching calf pain

Rationale :

🔵 Dull, aching pain in the calf, particularly after vascular surgery or immobility, is a classic sign of deep vein thrombosis (DVT). This pain may worsen with walking or dorsiflexion of the foot due to venous obstruction.

🔵 The pain results from inflammation and venous congestion caused by the thrombus impairing blood flow.

🔵 This symptom is especially significant in postoperative clients, who are at increased risk due to immobility, endothelial injury, and hypercoagulability.

🔵 Immediate evaluation and intervention (e.g., Doppler ultrasound, anticoagulant therapy) are necessary to prevent pulmonary embolism, a serious complication of DVT.

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Answer 8

Correct Answers:

Rapid accumulation of fluid around the heart causes hemodynamic changes to occur.

Rationale :

🔴 Phase II cardiac tamponade is characterized by a rapid accumulation of pericardial fluid, which increases intrapericardial pressure and impairs the heart’s ability to fill during diastole.

🔴 As the pericardial space fills quickly, it causes compression of the atria and ventricles, leading to decreased stroke volume, hypotension, and shock.

🔴 This phase is marked by acute hemodynamic compromise, including jugular vein distention, muffled heart sounds, and pulsus paradoxus.

🔴 Immediate intervention (e.g., pericardiocentesis) is critical to relieve pressure and restore cardiac output.

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Answer 9

Correct Answers:

Have the client lie flat in bed.

Rationale :

🟥 After a cardiac catheterization, especially when the femoral artery is used, it is essential to keep the client lying flat with the affected leg extended to reduce the risk of bleeding or hematoma at the insertion site.

🟥 Lying flat promotes hemostasis at the arterial puncture site and prevents stress on the vessel wall, particularly within the first 4–6 hours post-procedure.

🟥 Elevating the head of the bed or flexing the leg may disrupt clot formation and increase the risk for retroperitoneal bleeding.

🟥 The client can be advanced to other positions only when hemostasis is confirmed and the provider gives clearance.

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Answer 10

Correct Answers:

Notify the provider of the client's allergy.

Rationale :

🔴 A shellfish allergy may indicate a potential iodine or contrast dye sensitivity, which is crucial because iodinated contrast media is often used during cardiac catheterization.

🔴 The provider must be notified immediately to assess the need for premedication (e.g., corticosteroids, antihistamines) or consider alternative imaging methods.

🔴 While attaching an allergy wristband is important, it does not address the urgent clinical risk posed by the potential for anaphylaxis during the procedure.

🔴 Prompt provider notification allows for safe planning and prevention of a life-threatening hypersensitivity reaction.

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Custom-N202 Exam 3~2025

No.

3 :
A critical care nurse finds a postoperative client unresponsive and calls for a code blue. Which of the following next actions should the nurse take?

4 :
A nurse is assessing a client who has peripheral venous disease. Which of the following findings should the nurse recognize as a manifestation of peripheral venous disease?

5 :
A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/79 mm Hg places him in which of the following categories?

6 :
A nurse is assessing a client who has a possible abdominal aortic aneurysm (AAA). Which of the following IS an early manifestation of an AAA?

7 :
A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?

8 :
A nurse is providing teaching to newly licensed nurses about cardiac tamponade. Which of the following should the nurse include when teaching about Phase II cardiac tamponade?

9 :
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

10 :
The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "l always get a rash when I eat shellfish." Which of the following is the priority nursing action?

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Custom-N202 Exam 3~2025

No.

3 : A critical care nurse finds a postoperative client unresponsive and calls for a code blue. Which of the following next actions should the nurse take?

4 : A nurse is assessing a client who has peripheral venous disease. Which of the following findings should the nurse recognize as a manifestation of peripheral venous disease?

5 : A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/79 mm Hg places him in which of the following categories?

6 : A nurse is assessing a client who has a possible abdominal aortic aneurysm (AAA). Which of the following IS an early manifestation of an AAA?

7 : A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?

8 : A nurse is providing teaching to newly licensed nurses about cardiac tamponade. Which of the following should the nurse include when teaching about Phase II cardiac tamponade?

9 : A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

10 : The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "l always get a rash when I eat shellfish." Which of the following is the priority nursing action?

3 :
A critical care nurse finds a postoperative client unresponsive and calls for a code blue. Which of the following next actions should the nurse take?

4 :
A nurse is assessing a client who has peripheral venous disease. Which of the following findings should the nurse recognize as a manifestation of peripheral venous disease?

5 :
A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/79 mm Hg places him in which of the following categories?

6 :
A nurse is assessing a client who has a possible abdominal aortic aneurysm (AAA). Which of the following IS an early manifestation of an AAA?

7 :
A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?

8 :
A nurse is providing teaching to newly licensed nurses about cardiac tamponade. Which of the following should the nurse include when teaching about Phase II cardiac tamponade?

9 :
A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

10 :
The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "l always get a rash when I eat shellfish." Which of the following is the priority nursing action?