1 :

1630:

The client reports shortness of breath, gradually increasing over past 3 days.

Client sitting in tripod position. Labored breathing. Shallow, rapid breaths. Decreased breath sounds of lower bases bilaterally. Fine inspiratory crackles of upper lobes bilaterally. No pleural friction rub. No cyanosis. Client reports pain level as 5 on a scale of 0 to 10.

S1 S2, no murmurs or extra heart sounds. Radial and pedal pulses +1 bilaterally. No edema of lower extremities. No jugular venous distension or ascites.

1715:

Client reports productive purulent cough, chills, fever, fatigue, and pain with coughing. Client reports pain level as 7 on a scale of 0 to 10.

1600:

Temperature 38.2Β°C (100.8Β°F)

Heart rate 110/min

Respiratory rate 30/min

Blood pressure 96/66 mm Hg

Oxygen saturation 89% on room air

1700:

Temperature 38.5Β°C (101.3Β°F)

Heart rate 118/min

Respiratory rate 32/min

Blood pressure 90/60 mm Hg

Oxygen saturation 94% on oxygen at 2 L/min via nasal cannula


Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate the provider to prescribe,and.


Hint : πŸ€¦β€β™‚οΈLook for diagnostic studies that identify both the severity of infection and the specific causative organism.

Correct Answers

  • Blank 1 Correct Option: complete blood count
  • Blank 2 Correct Option: sputum culture and sensitivity
  • Blank 3 Correct Option: blood cultures

Rationale :

🦠The client’s fever, purulent sputum, crackles, tachypnea, and hypoxemia strongly suggest an acute bacterial respiratory infection such as pneumonia.

πŸ§ͺA complete blood count evaluates the white blood cell count, which helps determine the severity of the infectious and inflammatory response.

πŸ”¬A sputum culture and sensitivity identifies the respiratory pathogen and determines which antibiotic therapy is most effective.

🩸Because the client has hypotension, tachycardia, and fever, blood cultures are appropriate to evaluate possible bacteremia or sepsis, ideally before antibiotics are administered.

πŸ“ŒCore Message

A client with suspected severe bacterial pneumonia should undergo CBC, sputum culture, and blood cultures to evaluate infection severity and guide antimicrobial treatment.

2 :

Hint : πŸ§ƒConsider how physical activity lowers blood glucose and what nutritional measure can reduce the risk of a dangerous drop.

Correct Answers:

  • "I will eat a carbohydrate snack before exercising.”


Rationale :

🍌A carbohydrate snack before exercise can help prevent exercise-induced hypoglycemia, particularly for clients using insulin.

⚑Exercise increases glucose utilization by skeletal muscles and can enhance insulin sensitivity, causing blood glucose to decrease.

⏰Clients should generally avoid exercising during the peak action of insulin because this increases the risk for hypoglycemia.

🚫Exercise should also be avoided when significant ketones are present, because physical activity can worsen hyperglycemia and ketosis.


πŸ“ŒCore Message

Clients using insulin may need carbohydrate intake before exercise to reduce the risk of exercise-related hypoglycemia.

3 :

Hint : πŸ‘€Focus on the finding suggesting the abdomen is becoming acutely tense or inadequately decompressed.

Correct Answers:

  • Abdominal rigidity


Rationale :

🚨Abdominal rigidity after bowel surgery can indicate inadequate gastric or intestinal decompression, possible obstruction, or developing peritoneal irritation.

🧴An NG tube connected to low intermittent suction is intended to remove gastrointestinal secretions and reduce abdominal distention after surgery.

🟒Greenish-yellow drainage is an expected appearance because gastric drainage may contain bile and gastrointestinal secretions.

πŸ§ͺAn aspirate pH below 5 supports gastric placement, making this finding consistent with appropriate tube positioning and function.


πŸ“ŒCore Message

Abdominal rigidity in a postoperative client with an NG tube may indicate inadequate gastrointestinal decompression and requires prompt assessment.

4 :

Hint : 🌿Consider fruits known to have cross-reactive proteins with natural rubber products.

Correct Answers:

  • Avocados


Rationale :

πŸ₯‘An allergy to avocado is associated with latex-fruit syndrome, in which structurally similar proteins trigger cross-reactive allergic responses.

🧀Individuals with latex allergy can also react to foods such as banana, kiwi, avocado, and chestnut.

πŸ‘‰The reaction occurs because certain plant proteins share antigenic similarities with proteins found in natural rubber latex.

⚠️Identifying these food allergies can help nurses recognize clients who might be at increased risk for a latex hypersensitivity reaction during procedures.


πŸ“ŒCore Message

An avocado allergy can indicate increased risk for latex hypersensitivity because of cross-reactive plant proteins.

5 :

Hint : ❄️Choose the intervention that controls early inflammation and edema without stressing the injured ligament.

Correct Answers:

  • Apply ice on the ankle for 20 min intervals.


Rationale :

🧊Applying ice for approximately 20 minutes at a time during the acute period reduces pain, swelling, and inflammation following an ankle sprain.

🩹Cold causes local vasoconstriction, which helps reduce tissue edema and bleeding into injured tissues.

🦢Elevation is also beneficial, but the extremity should generally be raised above heart level, rather than specifically above the head.

⚠️Persistent numbness or tingling can suggest compromised neurovascular status and should not be considered an expected finding.


πŸ“ŒCore Message

Acute ankle sprains are initially managed with intermittent cold therapy to decrease pain and swelling.

6 :

Hint : 🧠Prioritize the action that prevents an initially reversible trauma injury from becoming permanent neurologic damage.

Correct Answers:

  • Stabilize the cervical spine.


Rationale :

🦴A client involved in a motor-vehicle crash should be assumed to have a potential cervical spine injury until it has been ruled out.

πŸ›‘οΈImmediate cervical stabilization prevents unnecessary neck movement that could worsen an unstable spinal injury and produce spinal cord damage.

🌬️During the trauma primary survey, airway management is performed while maintaining cervical spine protection.

πŸš‘Once spinal alignment is protected, the nurse can continue with oxygenation, circulation, vascular access, and temperature control based on the client’s findings.


πŸ“ŒCore Message

Following major trauma, immediate cervical spine protection is essential to prevent secondary spinal cord injury while the primary survey continues.

7 :

Hint : πŸ‘„Consider which intervention preserves a young infant’s normal feeding-related oral behavior despite nutrition being delivered through a tube.

Correct Answers:

  • Allow the infant to suck on a pacifier during feedings.


Rationale :

🧴Allowing a 3-month-old infant to use a pacifier during tube feeding provides nonnutritive sucking, which supports normal oral development.

πŸ‘ΆNonnutritive sucking can help the infant associate sucking with satiety and feeding, potentially improving later transition to oral feeding.

🦠Large amounts of formula should not remain in the feeding container for prolonged periods because this increases bacterial contamination risk.

πŸ’§A 30 mL water flush is generally excessive for a young infant and may contribute to inappropriate fluid administration.


πŸ“ŒCore Message

Nonnutritive sucking during tube feeding supports normal oral development and helps maintain the infant’s association between sucking and feeding.

8 :

Temperature: 37.5Β°C (99.5Β°F) 

Blood pressure: 96/60 mm Hg

Pulse: 124/min

Respiratory rate: 30/min (crying)

Height: 24 inches

Weight: 14.5 lb

Neurologic: PERL, follows pen light, alert and responsive, head circumference 43 cm. Anterior fontanel open, posterior fontanel closed, negative for tonic neck and Moro reflexes, cries when examined.

Ears-Nose-Throat: Intact palate, both lower central incisors, tonsils visible in back of oropharynx.

Respiratory: Respirations equal, lung sounds clear bilaterally.

Cardiovascular: S1 S2 heart sounds, no murmur, pulses +3.

Gastrointestinal: Abdomen round, non-distended, +bowel sounds all quadrants.

Genitourinary: Normal female genitalia, voiding in diaper.

Musculoskeletal: Moves all extremities equally, spontaneously.

Skin: Several ecchymotic areas on face, upper chest and extremities. One laceration measuring 2cm in length on scalp.

Developmental: Social smile, bears majority of weight when held in a standing position, able to hold a bottle, unable to sit without support.


Based on the assessment findings, the nurse should estimate the infant's age to be which of the following?


Answer Options

Hint : 🧸Match the infant’s tooth eruption, primitive-reflex disappearance, supported standing, and sitting ability with the expected developmental stage.

Correct Answers:

  • 6 months


Rationale :

🦷The presence of lower central incisors is consistent with eruption beginning around 6 months of age.

🧍An infant around this age can typically bear substantial weight when supported in a standing position and increasingly develops purposeful hand control.

🧴Being able to hold a bottle is consistent with developmental abilities emerging around the middle of the first year.

🧠The disappearance of the Moro and tonic neck reflexes, combined with inability to sit completely unsupported, also supports an age near 6 months.


πŸ“ŒCore Message

The combination of lower central incisors, disappearing primitive reflexes, supported weight bearing, and emerging bottle control is most consistent with a 6-month-old infant.

9 :

Hint : πŸ€¦β€β™‚οΈChoose the intervention that preserves IV access without exposing the client to additional incompatible blood products.

Correct Answers:

  • Infuse 0.9% sodium chloride IV.


Rationale :

🚨A suspected acute hemolytic transfusion reaction requires immediate discontinuation of the blood transfusion to prevent further exposure to incompatible blood cells.

πŸ’§The nurse should maintain IV access using 0.9% sodium chloride through new tubing so emergency medications and fluids can be administered safely.

🩸A hemolytic reaction can cause intravascular hemolysis, hypotension, acute kidney injury, and shock, making rapid intervention essential.

πŸ§ͺThe nurse should also notify the provider and blood bank while obtaining required blood and urine specimens according to facility protocol.


πŸ“ŒCore Message

During an acute hemolytic transfusion reaction, stop the blood immediately and maintain vascular access with 0.9% sodium chloride while initiating emergency evaluation.

10 :

Hint : 🧠Select the team member whose role focuses heavily on psychosocial resources and community referrals.

Correct Answers:

  • Social worker


Rationale :

🀝A social worker assists clients and families with psychosocial needs, counseling resources, and referrals for family therapy.

🏠Social workers evaluate family dynamics, community resources, financial concerns, and support systems that can affect health outcomes.

🧠They can coordinate referrals to qualified mental health professionals who provide individual, marital, or family counseling.

πŸ“žThe community health nurse therefore appropriately collaborates with the social worker when a client requests assistance accessing family therapy.


πŸ“ŒCore Message

A social worker is the appropriate interdisciplinary professional to coordinate access to family counseling and psychosocial services.

Total Questions: 10

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