1 :

The client is a 77-year-old male with mitral valve stenosis and heart failure (HF).

Initial Assessment:

Heart rate: 63 beats/minute

Respiratory rate: 22 breaths/minute

Blood pressure: 142/99 mm Hg

Oxygen saturation: 94% on 2 L/minute oxygen via nasal cannula

Follow-up Assessment:

Heart rate: 72 beats/minute

Respiratory rate: 21 breaths/minute

Blood pressure: 122/85 mm Hg

Oxygen saturation: 95% on 2 L/minute oxygen via nasal cannula

Initial Findings:

Heart monitor shows atrial fibrillation

Client is sleepy but awakes easily and follows commands

Pulses 1+ in all extremities

Mild edema noted to both legs

Wheezes heard in all lung fields upon auscultation

Productive cough with pink-tinged mucus

Follow-up Findings:

Heart monitor shows normal sinus rhythm

Client is awake and following commands

Ate 50% of lunch tray

Pulses 1+ in all extremities

Breath sounds clear and equal

Potassium: 3.1 mEq/L

Prothrombin time/International normalized ratio (INR): 2.2

Urine output: 600 mL since 0800

Admit to the cardiac floor

Heart healthy diet with protein supplement shakes

Out of bed with assistance

Place on a cardiorespiratory monitor

Vital signs every 4 hours

Apply oxygen 2 L/minute via nasal cannula to keep oxygen saturation greater than 93%

Monitor potassium level, prothrombin time/INR every 6 hours

Furosemide 30 mg IV push (IVP) every 12 hours

Propranolol 10 mg PO every 8 hours

Warfarin 10 mg PO every 12 hours

Initial Notes:

Heart monitor shows atrial fibrillation. Client is sleepy but awakes easily and follows commands. Pulses 1+ in all extremities. Mild edema noted to both legs. Wheezes heard in all lung fields upon auscultation. Has a productive cough with pink-tinged mucus

Follow-up Notes:

Heart monitor shows normal sinus rhythm. Client is awake and following commands. Ate 50% of lunch tray. Pulses 1+ in all extremities

Review the exhibits and click to mark whether each assessment finding represents a therapeutic result of the furosemide administered, a non-therapeutic side effect, or an unrelated finding.

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

Hint : 🧾Look for the value that reflects whether the medication reduced excess volume.

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 :

πŸ’ŠFurosemide 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.

πŸ§ͺHypokalemia 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.

πŸ“ŒCore 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.

2 :

44-year-old male

Anterior-posterior spinal fusion surgery 3 days ago

The client is a 44-year-old male who had an anterior-posterior spinal fusion 3 days ago. Today, upon assessment, the client was found awake and alert. Breath sounds were clear and equal, with a regular and rhythmic heart rate. Bowel sounds were noted to be hypoactive, and the client's abdomen was visibly distended. The client reported not having had a bowel movement since the surgery. Skin was observed to be pink and well-perfused, with capillary refill taking less than 3 seconds. The surgical dressing was found to be clean and intact. The client reported a pain level of 8 on a 0-10 numeric pain scale, for which morphine was administered as ordered. However, the client expressed dissatisfaction with the current dosage and requested a higher dose of morphine due to uncontrolled pain. In response to this, the healthcare provider was promptly notified.

Out of bed 3 times per day with physical therapy

Ibuprofen 600 mg PO every 6 hours PRN for pain 4 or less on a 0 to 10 pain scale

Morphine 1 mg IM every 4 hours PRN for pain greater than 4 on a 0 to 10 pain scale

Temperature: 98.5Β° F (37Β° C) orally

Heart rate: 83 beats/minute

Respiratory rate: 19 breaths/minute

Blood pressure: 122/77 mm Hg

Oxygen saturation: 100% on room air

Abdomen distended

Bowel sounds hypoactive

Skin pink and well-perfused

Capillary refill less than 3 seconds

Surgical dressing clean and intact

The client is experiencing uncontrolled pain and has not had a bowel movement since the surgery. Which actions should the nurse take to assess the client's progress? Select all that apply.

Answer Options

Hint : πŸͺ‘Focus on actions that support bowel function and gather relevant bowel history safely within nursing scope.

Correct Answers:

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

Rationale :

πŸ’ŠOpioid 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.

πŸ—£οΈ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.

β›”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.

πŸ“ŒCore 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.

3 :

The client is resting in bed, grimacing. Swelling and bruising are present. The left arm is cool. The nurse reviews the orders and plans initial steps for caring for the client.

Day 1, 1930: Admit client to surgical unit.

Day 1, 2305: Prepare client for surgery.

Initiate peripheral IV access.

Morphine 2 mg IV, once, now.

Oxycodone 7.5 mg PO every 4 hours, PRN for pain greater than 5 on 0 to 10 scale.

Acetaminophen 500 mg PO every 4 hours, PRN for pain greater than 2 on 0 to 10 scale.

0.9% sodium chloride 100 mL/hr continuous IV infusion.

Enoxaparin 30 mg SUBQ every 12 hours.

X-ray of left shoulder and right knee, STAT.

Computed tomography (CT) of brain, STAT.

Complete blood count (CBC) and complete metabolic panel (CMP).

Knee x-ray, 3 views: No osseous abnormality. Osteoarthropathy of the patellofemoral compartment.

Computed tomography (CT) brain: No acute intracranial abnormality.

Shoulder x-ray, 3 views: Fracture of left humeral head/neck junction. Bony impaction with comminution is noted. The fracture extends to the shoulder joint. Significant displacement of the fracture at the humeral head/neck junction is seen. There is a bony offset of the fracture fragment most pronounced in the neck region.

Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

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

Hint : 🎯Focus on assessing perfusion and surgical siteβ€”not unrelated symptoms.

Correct Answers

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

πŸ–οΈ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.

πŸ“ŒCore 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.

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4 :

A 68-year-old male, with a history of bilateral total hip arthroplasty two years ago, presents to the emergency department (ED) by ambulance. The client reports he simply slipped today and did not feel lightheaded or dizzy before the fall. He returned home from the store and was putting his groceries away. He dropped a can and bent over to pick it up. He lost his balance and fell face-forward, hitting his head on the wall and his left shoulder on the floor. Reports pain mainly in his shoulder. However, he also notes pain in his right knee. Additionally, the client reports he feels nauseated and tired.

Day 1, 1820: 

Client is resting in bed, grimacing. Reports intense pain and the inability to move his left arm. He is guarded. Shoulder swelling and bruising are present. Left arm is cool to the touch. Collarbone appears out of alignment on the left side.

Temperature: 98.1Β° F(36.7Β° C)

Heart rate: 88 beats/minute

Respiratory rate: 18 breaths/minute

Blood pressure: 136/90 mm Hg

Oxygen saturation: 95% on room air

Weight: 344 lb (156.1 kg)

Height: 6 ft 2 in (182.8 cm)

Body mass index (BMI): 46.67 kg/mΒ²

Pain rating: 10 on a 0 to 10 scale, sharp, constant pain in the left arm; pain rating of 3 on a 0 to 10 pain scale, dull, achy pain in the right knee

The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Answer Options

Hint : πŸ–‹οΈPrioritize findings that may indicate compromised circulation, nerve involvement, or unstable fractures.

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.

πŸ’ͺDecreased 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.

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

πŸ“ŒCore Message

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

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5 :

The client is a 44-year-old female who was admitted for an abdominal abscess and sepsis. She has been intubated with mechanical ventilatory support for the last 2 weeks. The client will start ventilator weaning today. She is currently on pressure support of 25 cm water (H2O) with no mandatory breaths and a fraction of inspired oxygen (FiO2) of 35%.

The nurse has been decreasing the pressure support by 4 cm H2O every hour. The following changes were noted:

At 0400, the pressure support was decreased to 21 cm H2O.

At 0500, the pressure support was decreased to 17 cm H2O.

At 0600, the pressure support was decreased to 13 cm H2O.

At 0700, the pressure support was decreased to 9 cm H20.

At 0800, the pressure support was decreased to 5 cm H2O.

At 0900, the pressure support was decreased to 1 cm H20.

At 1000, the pressure support was decreased to 0 cm H2O.

At 1100 and 1200, the pressure support remained at 0 cm H2O.

The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

Answer Options

Hint : πŸ‘€Look for signs that the patient is ready for breathing independently after mechanical ventilation.

Correct Answers:

  • Set up supplemental oxygen delivery
  • Gather supplies for extubation

Rationale :

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

πŸ› οΈGathering extubation supplies is essential because the client has tolerated 0 cm Hβ‚‚O pressure support for 2 hours, suggesting readiness for extubation.

πŸ“ˆIncreasing FiOβ‚‚ 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.

πŸ—£οΈSuggesting ventilator mode changes is inappropriate here because the current weaning method appears to be effective.

πŸ“ŒCore Message

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

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6 :

The client has clear yellow urine. Lochia rubra is moderate with small clots, and no foul odor is noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated.

Height: 5 ft 6 in (168 cm)

Weight: 140 lb (63.5 kg)

Oral intake: 100 mL

IV intake: 32.5 mL

Urine output: 150 mL

Blood loss output: 1/2 saturated pad

Red blood cells (RBC): 3 million/mm (3 x 10^6)

Hematocrit: 35%

Hemoglobin: 1 g/dL (110 g/L)

Reference Range

Red blood cells (RBC): 4.2 to 5.4 million/mm (4.2 to 5.4 x 10^6)

Hematocrit: 27 to 47%

Hemoglobin: 12.0 to 16.0 g/dL (120 to 160 g/L)

Please drag the condition from the choices above to fill in the blank in the sentence. Based on the client's history and physical, the nurse notes that this postpartum client is most at risk for developing

Hint : πŸ‘€Look at the blood values and bleeding pattern to determine the most likely complication.

Correct Answers

  • Blank 1 Correct Option: Postpartum hemorrhage
Rationale :

🩸Postpartum hemorrhage is suggested by anemia indicatorsβ€”hemoglobin of 11 g/dL and RBC count of 3 million/mmΒ³β€”which are below normal postpartum.

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

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

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

πŸ“ŒCore Message

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

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7 :

The client is admitted to the medical floor. She has been diagnosed with asthma and has had related symptoms at ages 14 and 16. She denies any other medical history.

The nurse begins client education and asks the client what potential asthma triggers may have been involved in her recent exacerbation.

"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."

Heart rate: 122 beats/minute

Blood pressure: 134/85 mm Hg

Oxygen saturation: 91% on room air

The client has mild subcostal retractions and is sitting in an upright position.

Wheezes are noted throughout the lung fields.

The client is pale.

She has strong peripheral pulses that are equal bilaterally.

Regular diet

Keep oxygen saturation greater than 94%

Fluticasone/Salmeterol 250/50 mcg 1 inhalation

For each statement, specify if the client has an understanding or no understanding of asthma triggers.

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.

Hint : 🎯Assess if the client identifies evidence-based triggers and uses medications appropriately.

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.

πŸ’ŠFluticasone-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.

πŸ“ŒCore 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.

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8 :

The client is a 22-year-old female with a history of asthma. She was diagnosed at the age of 4 years old and has 2 previous hospitalizations for asthma-related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week. She reports taking edible marijuana to relieve severe premenstrual symptoms.

The client came to the emergency department when she started having difficulty breathing on a hike. She took her usual dose of albuterol, but the symptoms did not resolve. The client's friend called an ambulance when they got back to the car because the client was unable to speak well enough to tell the 911 operator the client's location. The paramedics gave 2 more doses of albuterol en route. The client is pale, has subcostal retractions, and is sitting in an upright position. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122.

Admit to the medical floor

Vital signs every 4 hours

Perform peak expiratory flow test every 2 hours

Regular diet

Chest x-ray

Oxygen 1 L/minute nasal cannula, titrate to keep oxygen saturation greater than 94%

Fluticasone/Salmeterol 250/50 mcg 1 inhalation every 12 hours

Azithromycin 500 mg PO every day for 3 days

Diphenhydramine 25 mg PO every 12 hours

Albuterol 2.5 mg by nebulization now and every 4 hours PRN for wheezing

After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

Answer Options

Hint : ⏱️Prioritize actions that address airway obstruction and low oxygen levels first.

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.

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

πŸ“ŠVital 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.

πŸ“ŒCore Message

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

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9 :

Hint : πŸ“šKeep educational materials simple, visual, and easy to understand for older adults.

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 :

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

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

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

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

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

πŸ“ŒCore Message

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

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10 :

Hint : πŸ‘οΈPain deep in the eye after laser surgery is not normal and may signal a complication.

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.

πŸ’‰Administering an antiemetic is not a priority unless nausea or vomiting are present.

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

πŸ’ŠProphylactic antibiotics may be prescribed, but initiating them without symptoms or orders is inappropriate.

πŸ“ŒCore Message

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

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Total Questions: 10

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