Question

A client presents to the emergency department with ankle pain and swelling following a basketball injury. Which intervention should the nurse implement first?

Answer 1

Correct Answers:

Transport the client to have x-rays

Rationale :

🦴A thorough assessment must always come before treatment in the nursing process, especially following a traumatic injury.

🧊Although applying ice and elevating the ankle can help reduce swelling and pain, these are interventions that should occur after a definitive diagnosis is made.

✅X-rays are essential to determine whether there is a fracture, dislocation, or soft tissue injury, guiding further care such as casting, surgery, or conservative management.

🧠Without confirming the nature and severity of the injury through imaging, any pharmacological or supportive interventions may be inappropriate or even harmful.

📌Core message

Initial diagnostic imaging is essential after injury to determine the extent of damage and guide appropriate treatment safely.

Answer 2

Correct Answers

Apply oxygen via nasal cannula [ Appropriate ]
Implement seizure precautions [ Not Appropriate ]
Ambulate the client in the hallway [ Not Appropriate ]
Strict intake and output measurements [ Appropriate ]
Administer diuretics [ Appropriate ]
Administer 0.9% sodium chloride at 150 mL/hr [ Not Appropriate ]
Weigh the client every day [ Appropriate ]
Potassium chloride 60 mEq intravenous push [ Not Appropriate ]

Rationale :

👳‍♀️The client is presenting with acute decompensated heart failure, as evidenced by shortness of breath, pink frothy sputum, bilateral crackles, and significant weight gain.

💧Appropriate actions include applying oxygen to address hypoxia, implementing strict intake and output to monitor fluid status, administering diuretics to reduce fluid overload, and daily weights to trend fluid retention.

🚷Seizure precautions are not warranted unless there is active or suspected neurological involvement such as seizures or severe hyponatremia with symptoms.

💉Administering potassium chloride IV push is dangerous and contraindicated, as it can cause fatal dysrhythmias; potassium should be given diluted and slowly.

🚶Ambulating a client with dyspnea, severe edema, and tachycardia could worsen oxygenation and is inappropriate without stabilization.

📌Core message

Client care should focus on fluid reduction and oxygen support while avoiding unnecessary activity or dangerous medication routes.

Answer 3

Correct Answers:

Paresthesia in the feet

Rationale :

🦶Clients with peripheral artery disease experience poor arterial blood flow, especially to the lower extremities, leading to symptoms like paresthesia, pain, and pallor.

🩹They are not likely to present with large draining ulcers, which are more typical of venous insufficiency.

🧱Thick, hardened skin is characteristic of chronic venous disease, not PAD, which typically involves shiny, thin skin with hair loss.

✅A capillary refill of 2 seconds is normal, and not an expected finding in PAD, where delayed refill is more likely due to impaired perfusion.

📌Core message

PAD causes decreased arterial perfusion, often leading to numbness or tingling in the extremities.

Answer 4

Correct Answers:

Creatinine level of 2.9 mg/dL

Rationale :

🧪A creatinine level of 2.9 mg/dL indicates significant renal impairment, which may reflect hypertensive nephropathy or other acute kidney injury.

👨‍🦲In a client with hypertension, elevated creatinine suggests end-organ damage that must be addressed to prevent progression to renal failure.

💡While a serum sodium of 134 mEq/L is slightly low, it is not critical and often asymptomatic.

📈The blood pressure of 132/82 mm Hg and BUN of 9 mg/dL are within acceptable or mildly abnormal ranges and do not require urgent action.

📌Core message

A markedly elevated creatinine in a hypertensive patient may signal organ damage requiring immediate attention.

Answer 5

Correct Answers:

Hemoglobin of 11.5 g/dL

Rationale :

💉A successful PRBC transfusion is measured by increased hemoglobin levels, as the primary goal is to improve oxygen-carrying capacity.

📊A hemoglobin of 11.5 g/dL shows a clear improvement in anemia and confirms the effectiveness of the transfusion.

🧪The RBC count of 2.1 million cells/mcL is still low and suggests anemia persists, making it a poor indicator of success.

🧬Platelet count and clotting times like PTT are not relevant indicators of PRBC transfusion success, as they pertain more to platelet and plasma transfusions.

📌Core message

Rising hemoglobin levels confirm that a red blood cell transfusion achieved its intended effect.

Answer 6

Correct Answers:

A client with a blood pressure of 174/90mmHg complaining of chest discomfort.

Rationale :

✅Chest discomfort with elevated blood pressure may indicate acute coronary syndrome or myocardial infarction, requiring immediate evaluation.

📈Though all the clients have elevated blood pressures, chest symptoms take priority due to the risk of life-threatening cardiac events.

💊Proteinuria and elevated creatinine are concerning but not immediately life-threatening, making them lower in urgency.

🤕A headache alone with hypertension is a common symptom and does not automatically suggest a crisis unless severe or accompanied by neurological signs.

📌Core message

Chest pain in a hypertensive client must be assessed first due to the risk of cardiac emergency.

Answer 7

Correct Answers:

Temperature

Rationale :

✅A temperature of 102.9°F (39.4°C) in a client with a PICC line and purulent drainage suggests a central line-associated bloodstream infection (CLABSI), which is a medical emergency.

🦠Sepsis can develop rapidly from line infections, especially in clients on TPN, which provides a rich medium for bacterial growth.

🥗Anorexia and mild sodium/glucose imbalances are less urgent and can be monitored or managed after infection risk is addressed.

🚨Prompt action, including blood cultures, antibiotics, and possible line removal, is essential to prevent deterioration.

📌Core message

Fever with a central line and drainage strongly indicates infection and demands immediate action.

Answer 8

Correct Answers:

Evaluate the client for facial drooping.

Rationale :

🧠A blood pressure this high (hypertensive crisis) significantly increases the risk of stroke, so neurological assessment is the top priority.

👁‍🗨Assessing for facial drooping, arm weakness, or slurred speech helps detect early signs of a cerebrovascular event.

💬Pain rating and bowel sounds are not urgent priorities compared to potential neurologic compromise.

🧪Renal labs can be reviewed later, but identifying neurologic deterioration is time-sensitive.

📌Core message

Stroke assessment should be immediate in hypertensive crisis with signs like severe headache.

Answer 9

Correct Answers:

Use liquid medications instead of pills if available
Verify that medications can be safely crushed

Rationale :

🧴Liquid medications are preferred for PEG tubes to reduce the risk of clogging and improve absorption.

💊If liquid forms are unavailable, it’s vital to confirm whether pills can be crushed safely, as some (e.g., extended-release) must not be altered.

🪑The head of bed should be elevated at least 30 to 45 degrees, not just 20°, to prevent aspiration.

🧪Tube placement should be checked before each use, not just daily, to avoid complications.

🥣Medications should not be mixed with enteral formulas as this may cause interactions or clog the tube.

📌Core message

PEG medication safety relies on using liquid forms or verified crushable tablets and avoiding tube obstruction.

Answer 10

Correct Answers:

Allergic

Rationale :

🌸Pruritus and hives shortly after transfusion are classic signs of a mild allergic reaction, often due to sensitivity to donor plasma proteins.

💉Allergic reactions typically present with skin symptoms only, unlike hemolytic reactions, which involve fever, chills, and back pain.

💨Circulatory overload causes dyspnea, hypertension, and crackles, not pruritus.

✅A febrile reaction typically includes fever and chills but not itching or hives.

📌Core message

Mild allergic transfusion reactions cause pruritus and hives, distinguishing them from other serious reactions.

Potential actions	Appropriate	Not Appropriate
Apply oxygen via nasal cannula
Implement seizure precautions
Ambulate the client in the hallway
Strict intake and output measurements
Administer diuretics
Administer 0.9% sodium chloride at 150 mL/hr
Weigh the client every day
Potassium chloride 60 mEq intravenous push

1 :
A client presents to the emergency department with ankle pain and swelling following a basketball injury. Which intervention should the nurse implement first?

2 :
A nurse is attending to a client.

Correct Answers

3 :
The nurse assesses the lower extremities of a client with peripheral artery disease (PAD). Which assessment finding should the nurse expect?

4 :
The nurse just received shift report on a client with hypertension and is reviewing the electronic health record. Which finding is most important to communicate to the healthcare provider?

5 :
The nurse is caring for a client with severe anemia who is receiving a transfusion of packed red blood cells (PRBCs). Which laboratory result indicates the transfusion was successful?

6 :
A nurse is receiving change-of-shift report on four clients with hypertension. Which client should the nurse assess first?

7 :
A nurse is attending to a client.

Answer Options

8 :
A client with a history of hypertension controlled with medication presents to the emergency department reporting a "pounding" headache and a home blood pressure reading of 242/124 mm Hg. What assessment should the nurse prioritize?

9 :
The nurse is preparing to administer medications to a client with a percutaneous endoscopic gastrostomy (PEG) tube. What action(s) should the nurse plan to take? (Select all that apply)

10 :
The nurse cares for a client receiving a unit of packed red blood cells (PRBCs). After the start of the transfusion, the client reports pruritus around the IV site, and the nurse notes hives across the client's chest. What transfusion reaction should the nurse suspect?

1 : A client presents to the emergency department with ankle pain and swelling following a basketball injury. Which intervention should the nurse implement first?

2 : A nurse is attending to a client.

Correct Answers

3 : The nurse assesses the lower extremities of a client with peripheral artery disease (PAD). Which assessment finding should the nurse expect?

4 : The nurse just received shift report on a client with hypertension and is reviewing the electronic health record. Which finding is most important to communicate to the healthcare provider?

5 : The nurse is caring for a client with severe anemia who is receiving a transfusion of packed red blood cells (PRBCs). Which laboratory result indicates the transfusion was successful?

6 : A nurse is receiving change-of-shift report on four clients with hypertension. Which client should the nurse assess first?

7 : A nurse is attending to a client.

Answer Options

8 : A client with a history of hypertension controlled with medication presents to the emergency department reporting a "pounding" headache and a home blood pressure reading of 242/124 mm Hg. What assessment should the nurse prioritize?

9 : The nurse is preparing to administer medications to a client with a percutaneous endoscopic gastrostomy (PEG) tube. What action(s) should the nurse plan to take? (Select all that apply)

10 : The nurse cares for a client receiving a unit of packed red blood cells (PRBCs). After the start of the transfusion, the client reports pruritus around the IV site, and the nurse notes hives across the client's chest. What transfusion reaction should the nurse suspect?

1 :
A client presents to the emergency department with ankle pain and swelling following a basketball injury. Which intervention should the nurse implement first?

2 :
A nurse is attending to a client.

3 :
The nurse assesses the lower extremities of a client with peripheral artery disease (PAD). Which assessment finding should the nurse expect?

4 :
The nurse just received shift report on a client with hypertension and is reviewing the electronic health record. Which finding is most important to communicate to the healthcare provider?

5 :
The nurse is caring for a client with severe anemia who is receiving a transfusion of packed red blood cells (PRBCs). Which laboratory result indicates the transfusion was successful?

6 :
A nurse is receiving change-of-shift report on four clients with hypertension. Which client should the nurse assess first?

7 :
A nurse is attending to a client.

8 :
A client with a history of hypertension controlled with medication presents to the emergency department reporting a "pounding" headache and a home blood pressure reading of 242/124 mm Hg. What assessment should the nurse prioritize?

9 :
The nurse is preparing to administer medications to a client with a percutaneous endoscopic gastrostomy (PEG) tube. What action(s) should the nurse plan to take? (Select all that apply)

10 :
The nurse cares for a client receiving a unit of packed red blood cells (PRBCs). After the start of the transfusion, the client reports pruritus around the IV site, and the nurse notes hives across the client's chest. What transfusion reaction should the nurse suspect?