Your Free Practice Questions
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Which assessment finding in a client with a suspected pelvic fracture requires immediate nursing intervention?
💡 Rationale:
Pelvic fractures are frequently associated with injury to the bladder or urethra. Hematuria is a sign of internal trauma and must be reported immediately to prevent further urological damage. While other signs are expected, hematuria indicates a serious internal complication.
Which patient demonstrates an understanding of orthostatic hypotension precautions after starting a new antihypertensive medication?
💡 Rationale:
Sitting on the side of the bed allows the body's baroreceptors to adjust to postural changes, reducing the risk of syncope and falls caused by rapid changes in systemic vascular resistance.
An adult patient arrives with a suspected stroke. The patient reports symptoms began 2 hours ago. What is the most important diagnostic test to perform immediately?
💡 Rationale:
A non-contrast head CT is essential to differentiate between ischemic and hemorrhagic stroke, which dictates whether the patient is a candidate for fibrinolytic therapy.
A nurse is caring for a client with asthma. Which of the following findings are indicative of an impending respiratory failure? Select all that apply.
💡 Rationale:
A 'silent chest' signifies complete airflow obstruction; a decreased RR indicates fatigue; and inability to speak shows severe distress. Inspiratory wheezing is common in asthma but not as grave as the other signs of respiratory failure.
A nurse is managing a client on TPN who reports sudden onset of chills, fever, and tachycardia. What is the nurse's priority action?
💡 Rationale:
TPN is an ideal medium for bacterial growth. Sudden onset of fever and chills in a client receiving TPN suggests catheter-related bloodstream infection (CRBSI). The priority is to stop the infusion to prevent further systemic seeding while notifying the provider for orders.
A nurse is caring for a client who is NPO following bowel surgery. The provider orders the initiation of Total Parenteral Nutrition (TPN). Which nursing action is the highest priority before starting the infusion?
💡 Rationale:
TPN is hypertonic and must be infused into a high-flow central vein to prevent vessel damage. Verifying the central line placement via X-ray is the critical safety step before initiating the infusion to prevent complications such as extravasation.
An elderly patient with a history of recurrent urinary tract infections (UTIs) is admitted with confusion and fever. The nurse notes the patient is positive for Clostridioides difficile. Which nursing action is most appropriate?
💡 Rationale:
C. difficile spores are resistant to alcohol-based hand sanitizers; soap and water must be used to physically remove the spores. Contact precautions are required to prevent environmental spread.
A patient with a history of heart failure is receiving furosemide. The nurse reviews the patient's morning laboratory results and notes a potassium level of 3.0 mEq/L. Which action should the nurse take first?
💡 Rationale:
A potassium level of 3.0 mEq/L is hypokalemic and puts the patient at risk for life-threatening cardiac arrhythmias. The nurse must notify the provider to obtain orders for replacement. Administering furosemide would worsen the hypokalemia. Dietary changes are secondary to medical correction.
A nurse is providing discharge teaching to a client following a Cesarean birth. Which statement by the client indicates an understanding of the discharge instructions?
💡 Rationale:
Post-cesarean, clients are instructed to limit lifting to nothing heavier than the newborn to prevent abdominal strain and promote incision healing. Sexual activity should wait until the 6-week follow-up, and incision care should be gentle rather than scrubbing.
A patient diagnosed with diabetes mellitus has a foot ulcer that has not responded to conservative treatment after 4 weeks. What is the priority nursing intervention?
💡 Rationale:
Consulting a wound care specialist is essential for complex wounds that are not healing, especially in diabetic patients who require specialized care. Increasing wound care frequency might not address underlying issues, while patient education is crucial but secondary to immediate intervention. Antibiotics may not be necessary if there is no evidence of infection.
A 62-year-old male is brought to the emergency department after experiencing chest pain that radiates to his left arm. He is diaphoretic and appears anxious. What is the most important initial nursing action?
💡 Rationale:
The immediate priority in a patient with chest pain is to assess the cardiac status using a 12-lead ECG. This will help to identify any acute myocardial infarction or arrhythmias. While administering nitroglycerin and aspirin is important, these actions should follow the initial cardiac assessment. Starting IV access is also needed, but without the ECG, the nurse lacks critical information for further treatment decisions.
A nurse is caring for a patient who is undergoing chemotherapy. The patient's absolute neutrophil count (ANC) is 450/mm3. Which of the following is the priority nursing intervention?
💡 Rationale:
An ANC below 500/mm3 indicates severe neutropenia, making the patient highly susceptible to infection. Implementing neutropenic precautions (reverse isolation) is the priority. The other options do not address the immediate risk of opportunistic infection.
A patient with a history of chronic pancreatitis is complaining of severe epigastric pain. Which medication order should the nurse question?
💡 Rationale:
Traditionally, Morphine was avoided in pancreatitis due to the belief that it caused Sphincter of Oddi spasms; while still debated, current evidence-based practice favors alternatives like Hydromorphone. Pancrelipase, Octreotide, and antacids are standard supportive treatments.
A 32-year-old patient presents with severe dysmenorrhea. After conservative management with NSAIDs fails, the healthcare provider suspects endometriosis. Which diagnostic procedure is considered the 'gold standard' for a definitive diagnosis of endometriosis?
💡 Rationale:
While ultrasound and MRI can suggest endometriosis, the gold standard for definitive diagnosis is direct visualization of the endometrial lesions via laparoscopy and confirmation through tissue biopsy.
During a routine health assessment, a nurse evaluates a 30-year-old woman with a family history of hyperparathyroidism. Which finding would indicate a need for further investigation?
💡 Rationale:
B is correct as muscle weakness and abdominal pain can be indicative of hyperparathyroidism due to elevated calcium affecting muscle and renal function. A is not alarming; a healthful lifestyle may not necessitate further investigation. C suggests a healthy lifestyle and thus does not warrant concern. D shows that hyperparathyroidism usually leads to elevated calcium levels, and normal levels require closer monitoring considering the family history.
A patient with infective endocarditis is admitted for intravenous antibiotic therapy. Which assessment finding should the nurse prioritize to report to the healthcare provider immediately?
💡 Rationale:
A new or changing heart murmur in a patient with endocarditis can indicate the development of valvular vegetation or leaflet destruction, potentially leading to acute heart failure. This requires immediate hemodynamic evaluation.
A patient with a history of heart failure is admitted with shortness of breath and peripheral edema. Which assessment finding is the most reliable indicator of worsening fluid volume status?
💡 Rationale:
Daily weight is the most sensitive and accurate indicator of fluid volume status changes in heart failure patients. A gain of 2 to 3 pounds in 24 hours often reflects significant fluid retention before physical symptoms like edema or crackles become profound.
An elderly client is admitted with an acute delirium. Which safety assessment is most critical to include in the plan of care?
💡 Rationale:
For a client with delirium, impulsivity and impaired judgment create a high risk for falls, wandering, or self-harm. Addressing the environment and cognitive orientation is essential to prevent injury in a disoriented patient.
A client presents with a sudden onset of sharp, pleuritic chest pain and shortness of breath. The nurse assesses the client and finds absent breath sounds on the right side. Which hypothesis is most likely?
💡 Rationale:
Absent breath sounds combined with acute pleuritic pain are classic signs of a pneumothorax. Pulmonary edema typically presents with crackles; bronchitis with rhonchi; and MI with crushing pain, not absent breath sounds.
A nurse is educating a patient with Type 2 Diabetes about the importance of regular foot care. Which statement by the patient indicates a need for further teaching?
💡 Rationale:
The statement about wearing sandals indicates a misunderstanding of foot care. Closed shoes are generally safer and provide more protection against injuries that can lead to ulcerations, especially in diabetic patients who may have sensory deficits. The other statements reflect good practices for foot care in a diabetic patient. Further education should focus on the importance of protective footwear.
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