1 :

0900:

Client is admitted to the unit with a diagnosis of pneumonia. IV of 0.9% sodium chloride infusing into 20-gauge peripheral IV located in the left hand at 90 mL/hr.

1300:

Client has not voided since admission. Bladder is distended and palpable. Provider notified.

1330:

Prescription obtained for intermittent catheterization.

1300:

Bladder scan indicates a volume of 480 mL.

0900:

Temperature 37.4Β° C (99.4Β° F)

Heart rate 98/min

Respiratory rate 20/min

Blood pressure 144/80 mm Hg

The nurse is planning care for the client. Complete the following sentence by using the lists of options. After providing perineal care and donning sterile gloves, the nurse should firstfollowed by.

Hint : 🧀The nurse must follow a sterile technique that avoids introducing bacteria into the urinary tract.

Correct Answers

  • Blank 1 Correct Option: clean the urethral meatus with antiseptic
  • Blank 2 Correct Option: slowly insert the catheter through the urethral meatus
Rationale :

🧴Cleaning the urethral meatus with antiseptic prevents ascending infections by reducing microbial presence.

πŸ§ͺInserting the catheter slowly ensures minimal trauma and confirms sterile technique is maintained during catheterization.

⚠️This stepwise approach aligns with aseptic protocols and prevents catheter-associated urinary tract infections (CAUTIs).

🧼These practices are critical especially in clients with urinary retention, as seen with the 480 mL bladder scan finding.

πŸ“ŒCore Message

Proper aseptic sequence during catheterization is essential to prevent infection and trauma in clients with urinary retention.

2 :

Day 1

The client has left-sided weakness and is unable to ambulate without full assistance. 2+ pedal pulses present and equal bilaterally.

Day 2

Area of swelling and tenderness noted to back of right calf. Pedal pulses present and equal bilaterally. nurse is caring for a client who had a stroke.

Day 1

Platelets 165,000/mmΒ² (150,000 to 400,000/mmΒ³) 

Prealbumin level 23 mg/dl (15 to 36 mg/dl) 

Complete the following sentence using the lists of options. Shit! The client is at risk for developingdue to their.

Hint : πŸ§β€β™‚οΈInactivity after a stroke increases the danger of vascular complications in the extremities.

Correct Answers

  • Blank 1 Correct Option: Deep vein thrombosis
  • Blank 2 Correct Option: Immobility
Rationale :

πŸ’β€β™‚οΈImmobility after a stroke significantly reduces venous return, increasing the risk of DVT, especially in lower extremities.

πŸ›οΈThe new finding of swelling and tenderness in the calf supports venous stasis and possible clot formation.

🧬Although labs like platelets and prealbumin are within safe ranges, the primary issue is circulatory stasis.

🩺Prompt recognition is essential to prevent complications like pulmonary embolism, a life-threatening condition.

πŸ“ŒCore Message

Immobility after stroke leads to venous stasis, which increases the risk of deep vein thrombosis.

3 :

0800:

Client 1 is admitted with right hip pain following a fall. Client 2 has a history of hyperlipidemia. Client 3 has a history of congestive heart failure. Client 4 has hypertension and a new prescription for furosemide. Client 5 has a stage 2 pressure injury on the sacrum. Client 6 is admitted with a new diagnosis of diabetes mellitus.

1400:

Client 1: Right hip x-ray with fractured femoral neck

Client 2: HDL 40 mg/dL (greater than 45 mg/dL)

Client 3: Chest x-ray: Pulmonary edema

Client 4: Potassium 3.4 mEq/L (3.5 to 5.0 mEq/L)

Client 5: Prealbumin 12 mg/dL (15 to 36 mg/dL)

Client 6: Glycosylated hemoglobin 9% (Good diabetic control less than 7%)

Complete the following sentence by using the lists of options. The first client the nurse should assess isfollowed by.

Hint : πŸ“ŠAlways assess clients with airway or electrolyte-related complications before others with chronic or stable conditions.

Correct Answers

  • Blank 1 Correct Option: Client 3
  • Blank 2 Correct Option: Client 4
Rationale :

🌬️Client 3 has pulmonary edema, which is a life-threatening condition and indicates fluid overload, needing urgent respiratory support.

πŸ§ͺClient 4 has hypokalemia (K⁺ 3.4 mEq/L) and is receiving furosemide, which can worsen electrolyte imbalance, leading to dysrhythmias.

πŸ“‰These conditions demand priority assessment as they can rapidly deteriorate into cardiac or respiratory emergencies.

⏱️Early detection can prevent further complications, aligning with ABC prioritization.

πŸ“ŒCore Message

Clients with fluid overload and electrolyte disturbances should be assessed first due to potential life-threatening complications.

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4 :

0950:

A male client transferred to room from PACU following abdominal surgery. Report received that estimated blood loss in the procedure was 1200 mL. Client is alert and talking. Lung sounds clear, heart regular rate and rhythm, hypoactive bowel sounds. Sequential compression devices in place and peripheral pulses palpable and equal bilaterally. Client can feel and wiggle toes.

1025:

Called to room. Client appears agitated. The client states, "I feel like something is wrong." Lung sounds clear, increased rate and depth of respirations noted. Client rates incisional pain as 5 on a scale of 0 to 10. Surgical dressing dry and intact. Hypoactive bowel sounds. Peripheral pulses palpable and strong, capillary refill time (CRT) less than 3 seconds, equal sensation bilaterally.

0950:

Heart rate 82/min

Respiratory rate 16/min

Blood pressure 104/68 mm Hg

Oxygen saturation 95% on 1 L/min nasal cannula

1025:

Heart rate 104/min

Respiratory rate 24/min

Blood pressure 108/70 mm Hg

Oxygen saturation 90% on 1 L/min nasal cannula

1025:

Postoperative labs received

WBC count 10,800/mmΒ² (5,000 to 10,000/mmΒ³)

Hgb 8.3 g/dL (14 to 18 g/dL)

Hct 32% (42 to 52%)

Drag words from the choices below to fill in each blank in the following sentence. The nurse should first follow up on the client'sand.

Hint : πŸ“‰When a client shows mental status changes alongside falling oxygen levels, consider the risk of hypoxia or shock.

Correct Answers

  • Blank 1 Correct Option: Oxygen saturation
  • Blank 2 Correct Option: Behavioral findings
Rationale :

πŸ“‰Oxygen saturation drop to 90% despite oxygen therapy may suggest hypoxemia or early signs of hypovolemic shock post-op.

😟Client’s agitation and β€œfeeling something is wrong” are behavioral changes, often early signs of deteriorating perfusion or oxygenation.

πŸ’‰The blood loss of 1,200 mL and Hgb 8.3 g/dL place the client at risk for hypoxia and decreased tissue oxygenation.

⚠️These findings require immediate intervention to prevent clinical decompensation.

πŸ“ŒCore Message

Agitation and decreased oxygen saturation are early indicators of postoperative hypoxia or blood loss complications.

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5 :

Day 1

0800:

The client is postoperative following a hip arthroplasty.

Day 1

0800:

Potassium 4.2 mEq/L (3.5 to 5.0 mEq/L)

Sodium 139 mEq/L (136 to 145 mEq/L)

Glucose 100 mg/dL (74 to 106 mg/dL)

Day 1

1200:

Client is resting in bed with an abductor pillow in place. Repositioned every 2 hr. Peripheral IV in left arm infusing dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr. Client reports pain as 8 on a scale of 0 to 10. Oxycodone 10 mg PO administered.

1400:

Client is sleeping and is easily aroused. Client reports pain as 5 on a scale of 0 to 10.

Oxycodone 10 mg PO every 4 hr PRN

Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developingdue to.

Hint : πŸ’ŠCertain analgesics can slow the digestive system, increasing risk for GI complications.

Correct Answers

  • Blank 1 Correct Option: Constipation
  • Blank 2 Correct Option: opioid use
Rationale :

πŸ’ŠOpioids, such as oxycodone, slow gastrointestinal motility, increasing the risk of constipation postoperatively.

πŸͺ‘This is a common side effect and must be monitored, especially in patients recovering from hip surgery who may have limited mobility.

πŸ’€Sedation and immobility further aggravate the issue, making bowel care essential.

⚠️Prophylactic measures like stool softeners are often required to prevent bowel obstruction or discomfort.

πŸ“ŒCore Message

Opioid use increases the likelihood of constipation, especially in immobile postoperative clients.

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6 :

1000:

Client is 6 hrs postoperative following an appendectomy. Bilateral breath sounds are shallow but clear and present throughout. Abdomen soft, nondistended, bowel sounds hypoactive. Right lower quadrant abdominal dressing dry and intact. Urinary catheter removed in PACU. Client reports pain as 8 on a scale of 0 to 10. Morphine 4 mg IV administered as prescribed. Client wearing sequential compression device.

1200:

Voided 350 mL of clear yellow urine. Abdominal dressing remains dry and intact. Abdomen soft, nondistended, bowel sounds hypoactive. Pedal pulse is even bilaterally, no edema noted in the bilateral extremities. Client drowsy. Reports pain as 2 on a scale of 0 to 10.

Denies diabetes mellitus or peripheral vascular disease.

1000:

Temperature 36Β° C (96.8Β° F)

Blood pressure 118/56 mm Hg

Heart rate 92/min

Respiratory rate 18/min

Oxygen saturation 95% on room air

1200:

Temperature 37.2Β° C (99Β° F)

Blood pressure 104/56 mm Hg

Heart rate 62/min

Respiratory rate 12/min

Oxygen saturation 94% on room air.

Drag words from the choices below to fill in each blank in the following sentence. The client is most at risk of developingand.

Hint : πŸ›οΈPost-op patients with low activity and opioid use are more prone to respiratory and GI complications.

Correct Answers

  • Blank 1 Correct Option: Atelectasis
  • Blank 2 Correct Option: Paralytic ileus
Rationale :

🌬️Shallow breathing post-op places the client at risk for atelectasis, particularly without incentive spirometry.

🍽️Hypoactive bowel sounds and narcotic use can result in paralytic ileus, a serious post-op GI complication.

πŸ’€Drowsiness and reduced mobility further impair lung expansion and GI motility, making prevention strategies vital.

πŸ“‰Early detection of these issues supports recovery and prevents worsening complications.

πŸ“ŒCore Message

Postoperative immobility and opioid use put the client at risk for both atelectasis and paralytic ileus.

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7 :

Hint : πŸ§“With aging, changes in bladder function contribute significantly to infection risk.

Correct Answers:

  • Decreased bladder tone can cause urinary retention.

Rationale :

πŸ§“In older adults, bladder muscle tone decreases, reducing contractility, which leads to urinary retention.

πŸ’¦This retention can promote bacterial growth and increase the likelihood of UTIs.

πŸ”Residual urine is often left behind after voiding, providing a medium for pathogen multiplication.

⚠️Addressing urinary incontinence or retention early reduces the burden of recurrent infections.

πŸ“ŒCore Message

Decreased bladder tone in older adults can lead to urinary retention, increasing the risk for UTIs.

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8 :

Hint : πŸ“†The length of time spent in a caregiving role directly correlates with increased health risks for the caregiver.

Correct Answers:

  • Providing care for greater than 1 year

Rationale :

πŸ§“Prolonged caregiving, particularly for more than 1 year, increases the risk of caregiver fatigue, emotional distress, and even chronic illness due to cumulative stress.

πŸ’”Chronic caregiving often leads to role strain, neglect of personal health, and burnout, especially without adequate social support.

πŸ“‰Caregiver stress can result in poor immune function, depression, and decreased quality of life, placing both the caregiver and client at risk.

🧠This highlights the need for interventions like respite care, counseling, and health assessments for long-term caregivers.

πŸ“ŒCore Message

Long-term caregiving significantly increases a family caregiver’s emotional and physical health risks.

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9 :

Hint : 🧡Minimizing contact with elastic or rubber materials is vital when managing latex-sensitive clients.

Correct Answers:

  • Secure loose cords in stockinette with tape.

Rationale :

⚠️Clients with latex allergies are at high risk for anaphylactic reactions when exposed to latex-containing materials such as elastic cords.

πŸ“¦Stockinettes provide a latex-free barrier and securing cords with tape prevents exposure to rubber parts, ensuring allergy precautions are followed.

🚫Multidose vials often have latex stoppers, so piercing them repeatedly can introduce latex particlesβ€”this option is not safe.

πŸ•‘Scheduling surgery last increases exposure risk from residual latex particles in the room from earlier procedures.

πŸ“ŒCore Message

Use latex-free barriers like stockinettes and tape to protect clients with latex allergies during procedures.

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10 :

Hint : 🧠Advocacy always centers on honoring the client’s expressed values and decisions.

Correct Answers:

  • Informing the family of a deceased client of the client's wish to be an organ donor

Rationale :

πŸ—£οΈClient advocacy involves upholding the client’s autonomous decisions, even after death, such as respecting wishes to be an organ donor.

🧾The nurse ensures that legal and ethical rights are honored, even when it may be difficult for the family emotionally.

βš–οΈAdvocacy means promoting the client’s preferences, values, and rights when they cannot speak for themselves.

πŸ’ŠWhile documentation and reporting incidents are important, they are nursing responsibilities, not acts of client advocacy.

πŸ“ŒCore Message

Upholding a deceased client’s organ donation wish is a key act of client advocacy by the nurse.

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