Question

A nurse is caring for a client.

Answer 1

Correct Answers

Blank 1 Correct Option: administer oxygen at 2L/min via nasal cannula
Blank 2 Correct Option: administer sublingual nitroglycerin

Rationale :

💨The client’s oxygen saturation has dropped from 97% to 92%, indicating a reduction in oxygen delivery to the myocardium, a potential sign of acute coronary syndrome.

❤️Oxygen should be administered at 2L/min via nasal cannula to correct hypoxia and support myocardial function during ischemia.

💊The client is also experiencing increased chest pain (now 7/10) and shortness of breath, which are signs of worsening ischemia.

💥Nitroglycerin is a first-line treatment for angina because it causes vasodilation, reducing cardiac workload and increasing coronary perfusion.

📌Core Message

Administer oxygen for hypoxia and nitroglycerin to relieve ischemic chest pain in suspected acute coronary syndrome.

Answer 2

Correct Answers

Blank 1 Correct Option: transient tachypnea of the newborn
Blank 2 Correct Option: Hypoglycemia

Rationale :

👶The newborn displays tachypnea with grunting and mild retractions, which are hallmark signs of transient tachypnea of the newborn (TTN)—common after cesarean delivery.

💁‍♂️Cesarean birth leads to retained fetal lung fluid, causing delayed clearance and temporary respiratory distress.

👉The infant's weight is 4200 g (9 lb 4 oz), classifying them as macrosomic, increasing their risk for hypoglycemia due to elevated insulin production.

⚠️Hypoglycemia in newborns can present subtly, and tachypnea can be one of the early indicators, requiring prompt monitoring.

📌Core Message

Large-for-gestational-age infants are at risk for TTN and hypoglycemia, especially after cesarean birth.

Answer 3

Correct Answers:

"I should keep the medication in the original container."

Rationale :

💊Dabigatran is highly sensitive to moisture and should remain in its original manufacturer’s container with the desiccant to maintain drug stability.

⚠️Removing the capsule or storing it outside its original packaging increases risk of degradation, leading to reduced effectiveness.

🚫It should not be crushed or opened, as this increases bioavailability and bleeding risk.

🧊Refrigeration is not recommended, as it can expose the medication to condensation and moisture, compromising its efficacy.

📌Core Message

Dabigatran must stay in its original container to prevent moisture damage and ensure medication potency.

Answer 4

Correct Answers:

Caregiver reporting client acting differently than usual
Witnessing their family's death
Client experiences nightmares
Smoking marijuana to clear their mind

Rationale :

🧠The caregiver’s concern that the client is “acting differently” suggests significant emotional or behavioral changes, which warrant mental health evaluation.

💔Witnessing the death of immediate family is a severe traumatic event that can lead to acute stress disorder (ASD) or post-traumatic stress disorder (PTSD).

🌙Recurrent nightmares and disturbed sleep are classic symptoms of trauma-related disorders and should be assessed for impact on function.

🚬Using marijuana to cope is a sign of maladaptive behavior, indicating the client is struggling to manage emotions in a healthy manner and is at risk for substance misuse.

📌Core Message

Immediate follow-up is needed for behavioral changes, trauma exposure, nightmares, and substance use following a traumatic event.

Answer 5

Correct Answers:

Choose a vein that is palpable and straight.

Rationale :

🩸A palpable and straight vein is optimal for IV catheter insertion because it is easier to access and reduces the risk of complications like infiltration or phlebitis.

🖐️Selecting the nondominant arm is preferred to preserve function and avoid discomfort.

🚫A tourniquet should be applied above, not below, the site to aid in venous engorgement.

⬇️Lowering the arm before insertion promotes venous filling, whereas elevation would reduce blood flow, making vein visualization harder.

📌Core Message

Use a palpable, straight vein on the nondominant arm for safe IV access.

Answer 6

Correct Answers:

Use soap and water to provide perineal care.
Empty the drainage bag when it is half full
Revive the need for the indwelling urinary catheter daily

Rationale :

🧼Soap and water are recommended for perineal hygiene to prevent bacterial colonization near the catheter site.

🛑Emptying the drainage bag when half full prevents backflow of urine, a major contributor to catheter-associated UTIs (CAUTIs).

📅Reviewing the need for continued catheter use daily allows for timely removal, minimizing duration and UTI risk.

🚫Changing catheter tubing every 3 days is not evidence-based unless there is leakage or contamination.

🚱Encouraging 3000 mL/day fluid intake contradicts the provider’s fluid restriction order due to heart failure.

🚫Placing the bag on the bed raises risk of reflux and infection; it should always be below bladder level.

📌Core Message

Preventing CAUTIs involves daily catheter assessment, perineal care, and avoiding overfilled drainage bags.

Answer 7

Correct Answers

Hypercapnia [ Malignant hyperthermia ]
Wheezes [ Latex allergy ]
Tachycardia [ Malignant hyperthermia ; Latex allergy ; Hypovolemic shock ]
Muscle rigidity [ Malignant hyperthermia ]
Urticaria [ Latex allergy ]

Rationale :

💁‍♂️Hypercapnia is a key early sign of malignant hyperthermia, due to rapid muscle metabolism and CO₂ production.

🌬️Wheezing is commonly associated with anaphylaxis due to latex allergy, causing bronchospasm.

💓Tachycardia occurs in all three conditions due to compensatory mechanisms or systemic responses like shock or stress.

💪Muscle rigidity, especially in the jaw and chest, is a hallmark sign of malignant hyperthermia.

🌡️Urticaria is a classic skin reaction to latex exposure, signaling a hypersensitivity response.

📌Core Message

Malignant hyperthermia presents with hypercapnia and rigidity, while latex allergy shows urticaria and wheezing; tachycardia is common in all three.

Answer 8

Correct Answers:

"You can receive the immunization for influenza at any time during your pregnancy."

Rationale :

🦠The inactivated influenza vaccine is safe during all trimesters and protects against maternal and neonatal complications.

🚫Live vaccines, like rubella and varicella, are contraindicated during pregnancy due to risk of fetal harm.

💉Hepatitis B vaccination is also safe and recommended for pregnant individuals if indicated.

📆The varicella vaccine should be given postpartum, not during pregnancy.

📌Core Message

The inactivated flu vaccine is safe during pregnancy, unlike live vaccines such as MMR or varicella.

Answer 9

Correct Answers:

Assist the adolescent in applying for Medicaid.

Rationale :

💵Medicaid offers comprehensive financial support for pregnant individuals, covering prenatal care, delivery, and postpartum services.

🧍‍♀️Respecting adolescent autonomy is vital; direct involvement of parents should only occur with consent.

🧠Referrals to mental health are important if psychological distress is present, but this scenario focuses on financial concerns.

👶Advising adoption is not within the nurse's role; the nurse should support informed decision-making rather than dictate outcomes.

📌Core Message

Medicaid is the appropriate referral for financial concerns in pregnant adolescents needing prenatal care.

Answer 10

Correct Answers:

"The estimated blood loss was 250 milliliters."

Rationale :

🩸Estimated blood loss (EBL) is a critical piece of information during handoff communication because it informs the receiving nurse about the client's hemodynamic stability and potential need for fluid replacement or monitoring.

🧾Unlike subjective or non-clinical information (e.g., board membership), EBL is a clinical detail directly affecting postoperative care.

🧠The report of uncomplicated intubation, although potentially relevant, does not provide actionable information for ongoing care unless complications occurred.

🔢The number of sponges used is part of intraoperative safety checks, but this detail is typically documented in the OR record, not prioritized in postoperative handoff unless there are discrepancies.

📌Core Message

Include estimated blood loss in PACU-to-floor handoff to guide postoperative monitoring and fluid balance decisions.

1 :
A nurse is caring for a client.

Correct Answers

2 :
A nurse is caring for a newborn.

Correct Answers

3 :
A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching?

4 :
A nurse is caring for a client in a clinic.

Answer Options

5 :
A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

6 :
A nurse is caring for a client in the medical-surgical unit.

Answer Options

7 :
A nurse is caring for a client who is postoperative following a right hip arthroplasty.

Correct Answers

8 :
A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?

9 :
A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?

10 :
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Option	Malignant hyperthermia	Latex allergy	Hypovolemic shock
Hypercapnia
Wheezes
Tachycardia
Muscle rigidity
Urticaria

1 : A nurse is caring for a client.

Correct Answers

2 : A nurse is caring for a newborn.

Correct Answers

3 : A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching?

4 : A nurse is caring for a client in a clinic.

Answer Options

5 : A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

6 : A nurse is caring for a client in the medical-surgical unit.

Answer Options

7 : A nurse is caring for a client who is postoperative following a right hip arthroplasty.

Correct Answers

8 : A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?

9 : A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?

10 : A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

1 :
A nurse is caring for a client.

2 :
A nurse is caring for a newborn.

3 :
A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching?

4 :
A nurse is caring for a client in a clinic.

5 :
A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

6 :
A nurse is caring for a client in the medical-surgical unit.

7 :
A nurse is caring for a client who is postoperative following a right hip arthroplasty.

8 :
A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?

9 :
A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?

10 :
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?