1 :

1100

Client has history of type 2 diabetes mellitus and hypertension. Client admitted for pneumonia. Client reports occasional productive cough. headache. and rates their pain as 4 on a scale of 0 to 10. Respirations are even and non-labored. Scattered rhonchi in bilateral lung fields. Heart rate regular.

1200

Temperature 38.2Β°C (100.8Β°F)

Heart rate 104/min

Respiratory rate 20/min

Blood pressure 90/70 mm Hg

Oxygen saturation 97% on room air

1200

Capillary glucose 64 mg/dL (74 to 106 mg/dl)

1100

Metoprolol extended release SO mg PO twice daily, administer the first dose at noon.

Insulin aspart 10 units subcut before meals, administer the first dose at noon.


Complete the following sentence by using the lists of options. The nurse should address the client’sfollowed by blank2].


Hint : πŸ”Address the finding that can most rapidly impair brain function before focusing on circulation concerns.


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Distractor Analysis :

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2 :

1100

Temperature 36.4Β°C (97.5Β°F)

Heart rate 58/min

Respiratory rate 20/min

Blood pressure 98/64 mm Hg

Oxygen saturation 97% on room air

 

1115

Temperature 36.4Β°C (97.5Β°F)

Heart rate 64/min

Respiratory rate 22/min

Blood pressure 104/70mm Hg

Oxygen saturation 96% on room air

1130

Sodium 140 mEq/L (136 to 145 mEq/L)

Potassium 6 mEq/L (3.5 to 5 mEq/L)

BUN 18 mg/dL (10 to 20 mg/dL)

Creatinine 0.8 mg/dL (0.5 to 1 mg/dL)

Hgb 14 g/dL (12 to 16 g/dL)

Hct (37% to 47%)

1100

Client reports muscle weakness and tingling in their hands and face. Client is alert to person, place, time, and situation. Speech clear. Heart rate irregular. Radial pulse +3 bilateral. Respirations even and nonlabored. Scattered rhonchi posterior bases. Abdomen rounded and nondistended. Bowel sounds hyperactive in all 4 quadrants. Skin warm dry and intact. Capillary refill less than 2 seconds. Turgor elastic. No edema present.

 

1115

Labs, vital signs, and ECG were obtained. Urinalysis collection is pending. Client is being transferred to the medical-surgical unit.

1130

ECG: Peaked T waves with absent P waves. Rate is 58/min.


For each potential provider prescription. click to specify if the prescription is appropriate or inappropriate for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.


Provider Prescription Appropriate Inappropriate
Administer hydralazine IV.
Administer sodium polystyrene rectally.
Administer calcium gluconate IV.
Administer insulin IV.
Administer potassium chloride IV.

Hint : πŸ”Focus on treatments that either protect the heart or lower potassium levels.

Correct Answers

  • Administer hydralazine IV. [ Inappropriate ]
  • Administer sodium polystyrene rectally. [ Appropriate ]
  • Administer calcium gluconate IV. [ Appropriate ]
  • Administer insulin IV. [ Appropriate ]
  • Administer potassium chloride IV. [ Inappropriate ]

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Distractor Analysis :

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3 :

Day 1

Temperature 36.9Β°C (98.4Β°F)

Heart rate 106/min

Blood pressure 120/76 mm Hg

Respiratory rate 22/min

 

Day 10

Temperature 36.3Β°C (97.3Β°F)

Heart rate 82/min

Blood pressure 110/66 mm Hg

Respiratory rate 20/min

Day 1

Client is seeing provider for routine medical checkup. Client reports shortness of breath and edema in legs. Provider prescribes digoxin 0.125 mg PO daily for heart failure. Client has no known allergies.

 

Day 10

Follow-up visit with provider. Client indicates they have noticed an increase in daily urinary output since last visit. Client states, "l am not having as much difficulty breathing, and my legs are not as swollen."

Day 1

Potassium level 4.2 mEq/L (3.5 to 5 mEq/L)

 

Day 10

Potassium level 3.2 mEq/L (3.5 to S mEq/L)

Digoxin level 0.8 ng/mL (0.8 to 2 ng/mL)


For each potential client finding. click to specify if the finding is expected or unexpected for the client following their prescribed therapy. There must be at least 1 selection in every row. There does not need to be a selection in every column.


Potential Finding expected Unexpected
Current heart rate
Reported urinary concern
Reported current leg findings
Current potassium level
Digoxin level

Hint : 🍌Pay close attention to the electrolyte that strongly influences digoxin safety.

Correct Answers

  • Current heart rate [ expected ]
  • Reported urinary concern [ expected ]
  • Reported current leg findings [ expected ]
  • Current potassium level [ Unexpected ]
  • Digoxin level [ expected ]

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Distractor Analysis :

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4 :

0620

Client admitted to the ED with reports of crushing chest pain, shortness of breath, and nausea and vomiting. Client reports symptoms began approximately 45 minutes ago while eating breakfast. 12-lead ECG performed and shows ST-segment elevation in 4 leads.

 

0630

Two 18-gauge IV catheters inserted into right and left forearm.

0623

Blood pressure 138/78 mm Hg

Heart rate 98/min

Respiratory rate 18/min

Temperature 37.2Β°C (99Β°F)

Oxygen saturation 95% on room air

 

0640

Blood pressure 136/80 mm Hg

Heart rate 96/min

Respiratory rate 20/min

Temperature 37.2Β°C (99Β°F)

Oxygen saturation 96% on room air

0625

Troponin 0.67 ng/mL (less than 0.03 ng/mL)


Which of the following medications would the nurse expect the physician to prescribe for this client? Select All That Apply.


Answer Options

Hint : 🚨Think about the standard emergency medications used to treat an acute coronary artery blockage.

Correct Answers:

  • No Correct Answers Available !


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5 :

1400

Client is admitted for the management of deep vein thrombosis of their lower extremity. Client has received IV anticoagulant therapy.

 

1600

Client is scheduled for discharge. Will provide education to the client about the self-administration of medication.

1400

Discharge to home. Enoxaparin 40 mg subcut twice daily for 2 weeks. Use prefilled syringes. Client to self-administer. Nursing to provide education to client about self-administration of medication before discharge.


Select the 3 statements the nurse should make.


Answer Options

Hint : πŸ“Think about the correct technique for a subcutaneous anticoagulant injection.

Correct Answers:

  • No Correct Answers Available !


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6 :

Hint : πŸ₯”Think about which medication can raise potassium levels.

Correct Answers:

  • No Correct Answers Available !


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7 :

Hint : ⏰Focus on the timing between chemotherapy and the medication.

Correct Answers:

  • No Correct Answers Available !


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8 :

Hint : 🚿Think about the main action of ADH in the kidneys.

Correct Answers:

  • No Correct Answers Available !


Rationale :

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9 :

Hint : 🩹Consider why nutrients might bypass the digestive system.

Correct Answers:

  • No Correct Answers Available !


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10 :

Hint : ⚑Think about the electrolyte this medication is designed to remove.

Correct Answers:

  • No Correct Answers Available !


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Distractor Analysis :

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Total Questions: 10

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