Question

A nurse is caring for a 77-year-old male client.

Answer 1

Correct Answers

Potassium 3.1 mEq/L [ Non-therapeutic side effect ]
Prothrombin time/International normalized ratio (INR) 2.2 [ Unrelated finding ]
Urine output: 600 mL [ Therapeutic result ]

Rationale :

💊Furosemide is a loop diuretic that promotes potassium loss, and a potassium level of 3.1 mEq/L indicates hypokalemia, a known non-therapeutic side effect.

🧪Hypokalemia is a common risk with loop diuretics and can lead to cardiac dysrhythmias if not addressed promptly.

🧾An INR of 2.2 reflects the effect of warfarin therapy, not furosemide, so it is an unrelated finding in this context.

🚽Increased urine output is a desired response to furosemide and indicates it is working to reduce fluid overload in heart failure.

📌Core Message

Furosemide’s therapeutic effect is seen in increased urine output, it commonly causes hypokalemia as a non-therapeutic side effect, and has no effect on INR, which is related to warfarin.

Answer 2

Correct Answers:

Administer a stool softener
Ask the client about their normal bowel routine

Rationale :

💊Opioid medications like morphine commonly cause constipation as a side effect due to reduced gastrointestinal motility, so administering a stool softener is an appropriate and preventive nursing action.

🗣️Asking about the client’s normal bowel habits helps determine whether the current constipation is a deviation from baseline, allowing for more informed assessment and individualized interventions.

⛔Holding the next meal without a medical order is inappropriate unless the client is actively nauseous, vomiting, or being prepped for a procedure, none of which are present here.

❌Performing a digital rectal exam is an invasive procedure and requires a provider’s order, especially post-spinal surgery, where spinal precautions must be followed.

⚠️Discontinuing morphine is outside the nurse’s scope of practice; it must be evaluated and adjusted by the prescribing provider based on the client's pain needs and clinical status.

📌Core Message

The nurse should support bowel function by giving a stool softener and assessing the client’s normal bowel routine, while avoiding invasive procedures or medication changes without provider input.

Answer 3

Correct Answers

Check capillary refill on bilateral upper extremities. [ Indicated ]
Administer ondansetron 4 mg IV. [ Contraindicated ]
Inspect the bandage for drainage. [ Indicated ]

Rationale :

🖐️Checking capillary refill on both upper extremities is indicated because the client has a cool left arm, which may signal circulatory impairment from the humeral fracture.

🚫Ondansetron administration is contraindicated since there is no evidence of nausea or vomiting, and giving it without cause may result in unnecessary medication exposure.

🩹Inspecting the bandage for drainage is indicated as part of standard postoperative assessment to check for bleeding, infection, or wound complications, especially with recent trauma and swelling.

🦴The significant fracture and arm symptoms require vascular assessment and wound monitoring, not unrelated symptom management.

📌Core Message

The nurse should assess circulation and inspect the bandage based on signs of possible vascular compromise, while ondansetron is inappropriate without symptoms like nausea.

Answer 4

Correct Answers:

Bone misalignment
Decreased range of motion
Left arm that is cool to touch
Swelling at the site of injury
Intense pain reported by client

Rationale :

🦴Bone misalignment is a critical finding as it suggests a displaced fracture, which may require immediate intervention.

💪Decreased range of motion may indicate nerve or joint damage, especially relevant in a patient with prior orthopedic history.

🧊Coolness of the left arm signals compromised circulation, a potentially urgent vascular issue.

✍️Swelling at the injury site is common with fractures but still requires monitoring to rule out compartment syndrome.

🔥Intense pain suggests significant trauma and must be addressed to avoid poor healing outcomes or functional impairment.

📌Core Message

Investigate bone misalignment, extreme pain, cool extremities, swelling, and limited motion as they may indicate neurovascular compromise or fracture instability.

Answer 5

Correct Answers:

Set up supplemental oxygen delivery
Gather supplies for extubation

Rationale :

💨Setting up supplemental oxygen is appropriate as the client is transitioning off mechanical ventilation and may require support after extubation.

🛠️Gathering extubation supplies is essential because the client has tolerated 0 cm H₂O pressure support for 2 hours, suggesting readiness for extubation.

📈Increasing FiO₂ is not necessary since the current level is adequate at 35%, and there's no sign of hypoxia.

🚫Placing a nasogastric tube or offering ice chips is premature until airway protection and swallowing are confirmed post-extubation.

🗣️Suggesting ventilator mode changes is inappropriate here because the current weaning method appears to be effective.

📌Core Message

The nurse should prepare for extubation and arrange oxygen support as the client shows signs of ventilator weaning success.

Answer 6

Correct Answers

Blank 1 Correct Option: Postpartum hemorrhage

Rationale :

🩸Postpartum hemorrhage is suggested by anemia indicators—hemoglobin of 11 g/dL and RBC count of 3 million/mm³—which are below normal postpartum.

🧻Moderate lochia rubra with clots indicates ongoing bleeding, which can contribute to blood loss anemia.

🧪The client’s hematocrit (35%) is within range, but when combined with the other findings, it supports early-stage hemorrhage risk.

👶Other findings like a firm fundus and normal episiotomy site are reassuring, but they do not eliminate the risk of internal or ongoing bleeding.

📌Core Message

The client’s anemia, ongoing lochia, and lab trends indicate a risk for postpartum hemorrhage despite normal vital signs and fundus tone.

Answer 7

Correct Answers

I should have taken some allergy medications before going on the hike. [ Understanding ]
I have been very stressed out lately and should work on stress management. [ Understanding ]
I should have taken an extra dose of fluticasone-salmeterol. [ No understanding ]
I should have eaten a snack halfway through the hike. [ No understanding ]
My friend smoked cigarettes during the hike. [ Understanding ]

Rationale :

🧠Stress is a recognized asthma trigger, and acknowledging it demonstrates the client’s accurate understanding of how emotional factors can exacerbate symptoms.

💊Fluticasone-salmeterol is a maintenance inhaler and not meant for extra doses during acute symptoms, so this reflects poor understanding of its correct use.

🍽️Eating a snack does not prevent or contribute to asthma exacerbations, indicating a misunderstanding of relevant triggers.

🚬Secondhand smoke is a well-known environmental trigger, so the client correctly identifies this as an aggravating factor.

🌾Allergens can provoke asthma, especially outdoors, and taking allergy medications beforehand shows awareness of preventive management for allergy-induced asthma.

📌Core Message

The client demonstrates understanding of triggers like stress, smoke, and allergens, but shows misunderstanding about using a maintenance inhaler during an attack and irrelevant factors like eating.

Answer 8

Correct Answers:

Apply oxygen 1 L/minute
Give albuterol as ordered

Rationale :

🫁Oxygen therapy should be applied immediately to correct oxygen saturation below the prescribed threshold (91% < 94%), ensuring adequate oxygenation.

💨Albuterol is a short-acting beta-agonist used for acute bronchospasm, and the client's symptoms (wheezing, retractions, upright posture) demand urgent bronchodilation.

📊Vital signs and pulmonary function tests can wait a few minutes after stabilizing respiratory effort.

🍽️Providing food is not a priority when airway compromise is present.

📌Core Message

Oxygen and albuterol should be administered immediately to treat respiratory distress and low oxygen saturation in an asthma exacerbation.

Answer 9

Correct Answers:

The material contains a list with definitions of unfamiliar terms.
The material uses pictures to help illustrate complex ideas.
The material uses common words with few syllables.

Rationale :

📘Older adults benefit from education that uses clear, simple language and avoids medical jargon, making common words with few syllables most effective.

🖼️Visual aids help reinforce comprehension, especially when illustrating complex ideas, enhancing retention in those with cognitive or visual challenges.

📖Providing a list of definitions helps explain unfamiliar terms, supporting understanding without requiring external reference.

🔤12-point font may be too small for clients with impaired vision; materials should typically use 14-point or larger for readability.

🎓Twelfth-grade reading level is too advanced; health materials should ideally be at a 5th to 6th-grade level for broad accessibility.

📌Core Message

Effective education for older adults should use simple language, visual aids, and defined terms to support comprehension and recall.

Answer 10

Correct Answers:

Report the complaint of eye pain to the surgeon.

Rationale :

🚨Severe eye pain after laser trabeculoplasty is not expected and could indicate increased intraocular pressure or complications, requiring immediate provider notification.

💉Administering an antiemetic is not a priority unless nausea or vomiting are present.

🛑Bilateral eye shields are not necessary unless there is photophobia, which isn’t reported here.

💊Prophylactic antibiotics may be prescribed, but initiating them without symptoms or orders is inappropriate.

📌Core Message

Acute eye pain post-laser trabeculoplasty may indicate serious complications and must be immediately reported to the surgeon.

Options	Therapeutic result	Non-therapeutic side effect	Unrelated finding
Potassium 3.1 mEq/L
Prothrombin time/International normalized ratio (INR) 2.2
Urine output: 600 mL

Options	Indicated	Contraindicated
Check capillary refill on bilateral upper extremities.
Administer ondansetron 4 mg IV.
Inspect the bandage for drainage.

Options	Understanding	No understanding
I should have taken some allergy medications before going on the hike.
I have been very stressed out lately and should work on stress management.
I should have taken an extra dose of fluticasone-salmeterol.
I should have eaten a snack halfway through the hike.
My friend smoked cigarettes during the hike.

1 :
A nurse is caring for a 77-year-old male client.

Correct Answers

2 :
A nurse is caring for a 44-year-old male client who had an anterior-posterior spinal fusion 3 days ago.

Answer Options

3 :
A nurse is caring for a client.

Correct Answers

4 :
A nurse is caring for a 68-year-old male client.

Answer Options

5 :
A nurse is caring for a 4-year-old female client.

Answer Options

6 :
A nurse is caring for patient.

Correct Answers

7 :
A nurse is caring for a patient.

Correct Answers

8 :
A nurse is caring for a 22-year-old female client.

Answer Options

9 :
When developing an educational program for older adult clients who are being discharged with new antihypertensive medications, which characteristics should the nurse ensure that the educational materials include? Select all that apply.

10 :
Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

1 : A nurse is caring for a 77-year-old male client.

Correct Answers

2 : A nurse is caring for a 44-year-old male client who had an anterior-posterior spinal fusion 3 days ago.

Answer Options

3 : A nurse is caring for a client.

Correct Answers

4 : A nurse is caring for a 68-year-old male client.

Answer Options

5 : A nurse is caring for a 4-year-old female client.

Answer Options

6 : A nurse is caring for patient.

Correct Answers

7 : A nurse is caring for a patient.

Correct Answers

8 : A nurse is caring for a 22-year-old female client.

Answer Options

9 : When developing an educational program for older adult clients who are being discharged with new antihypertensive medications, which characteristics should the nurse ensure that the educational materials include? Select all that apply.

10 : Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

1 :
A nurse is caring for a 77-year-old male client.

2 :
A nurse is caring for a 44-year-old male client who had an anterior-posterior spinal fusion 3 days ago.

3 :
A nurse is caring for a client.

4 :
A nurse is caring for a 68-year-old male client.

5 :
A nurse is caring for a 4-year-old female client.

6 :
A nurse is caring for patient.

7 :
A nurse is caring for a patient.

8 :
A nurse is caring for a 22-year-old female client.

9 :
When developing an educational program for older adult clients who are being discharged with new antihypertensive medications, which characteristics should the nurse ensure that the educational materials include? Select all that apply.

10 :
Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?