1. A nurse is caring for a client immediately after a large-volume paracentesis (5 liters removed) for ascites. Fifteen minutes later, the client becomes dizzy, and vital signs show blood pressure 84/50 mmHg (baseline 128/76 mmHg) and heart rate 118 beats/min. What is the priority nursing action?
Reduction of Risk Potential
A.Place the client supine, increase IV fluid rate, and notify the provider
B.Assist the client to a sitting position and offer oral fluids
C.Apply an abdominal binder and reassess in one hour
D.Administer the scheduled dose of furosemide
Show answerAnswer
A. Place the client supine, increase IV fluid rate, and notify the provider
Rapid removal of large volumes of ascitic fluid can cause a fluid shift from the vasculature into the peritoneal space, leading to hypovolemia and hypotension. The nurse should place the client supine to improve venous return, increase IV fluids to restore volume, and notify the provider promptly to prevent hypovolemic shock.
2. A client recovering from severe diarrhea for the past 3 days reports generalized muscle weakness and leg cramps. The nurse notes hypoactive bowel sounds and an ECG showing flattened T waves with a prominent U wave. Which laboratory finding does the nurse expect?
Physiological Adaptation
A.Serum sodium of 152 mEq/L
B.Serum calcium of 12.0 mg/dL
C.Serum potassium of 2.9 mEq/L
D.Serum magnesium of 3.0 mg/dL
Show answerAnswer
C. Serum potassium of 2.9 mEq/L
Prolonged diarrhea causes significant potassium loss through the GI tract, leading to hypokalemia. Classic manifestations include muscle weakness, hypoactive bowel sounds/ileus, and ECG changes of flattened T waves with a U wave; normal serum potassium is 3.5–5.0 mEq/L, so 2.9 mEq/L is low.
3. A nurse is caring for a client receiving mechanical ventilation for acute respiratory distress syndrome (ARDS). Which ventilator strategy is most consistent with current lung-protective guidelines?
Physiological Adaptation
A.High tidal volumes with high FiO2
B.High tidal volumes with low PEEP
C.Low tidal volumes with adequate PEEP
D.Permissive hyperventilation to normalize PaCO2
Show answerAnswer
C. Low tidal volumes with adequate PEEP
Lung-protective ventilation for ARDS uses low tidal volumes (approximately 6 mL/kg of predicted body weight) with adequate PEEP to prevent alveolar collapse and minimize ventilator-induced lung injury, while permitting mild hypercapnia (permissive hypercapnia, not hyperventilation).
4. After a percutaneous liver biopsy, a client is positioned on the right side. Thirty minutes later, the client reports increasing abdominal pain radiating to the right shoulder. Blood pressure has decreased from 122/76 mmHg to 100/60 mmHg, and heart rate has increased from 84/min to 112/min. Which action should the nurse take first?
Reduction of Risk Potential
A.Administer acetaminophen for the referred shoulder pain
B.Reposition the client to the left side for comfort
C.Encourage deep breathing to relieve the shoulder discomfort
D.Assess for signs of intra-abdominal bleeding and notify the health care provider
Show answerAnswer
D. Assess for signs of intra-abdominal bleeding and notify the health care provider
Referred right shoulder pain from diaphragmatic irritation, combined with falling blood pressure and rising heart rate after a liver biopsy, indicates possible intra-abdominal hemorrhage, a critical complication requiring immediate assessment and provider notification.
5. An alert and oriented client with end-stage renal disease refuses a scheduled hemodialysis session, stating, 'I'm tired of this, I don't want treatment today.' The nurse has explained the risks of refusing. What is the nurse's next best action?
Management of Care
A.Contact the client's healthcare proxy to override the decision
B.Administer the treatment because refusal could be life-threatening
C.Ask a family member to convince the client to accept dialysis
D.Document the refusal and the client's understanding of the risks, then notify the physician
Show answerAnswer
D. Document the refusal and the client's understanding of the risks, then notify the physician
A competent adult has the legal right to refuse treatment even if it may be life-threatening, after being informed of the risks. The nurse's role is to document the informed refusal and notify the physician, not to override the decision or coerce the client.
6. A client with chronic low back pain asks the nurse for a non-pharmacologic method to help manage pain during physical therapy sessions. Which technique should the nurse suggest?
Basic Care and Comfort
A.Guided imagery focusing on a peaceful, relaxing scene during the session
B.Holding the breath during painful movements to build tolerance
C.Distracting the client with complex mental math problems during exercise
D.Taking a hot shower immediately before starting the exercises
Show answerAnswer
A. Guided imagery focusing on a peaceful, relaxing scene during the session
Guided imagery is an evidence-based cognitive-behavioral technique that reduces the perception of pain by redirecting attention to calming mental images, and it can be used concurrently with physical activity.
7. A client has had a nasogastric tube to continuous suction for 3 days. Arterial blood gas results are: pH 7.52, PaCO2 46 mmHg, HCO3 32 mEq/L, PaO2 90 mmHg. How should the nurse interpret these results?
Reduction of Risk Potential
A.Uncompensated respiratory alkalosis
B.Uncompensated metabolic acidosis
C.Compensated respiratory acidosis
D.Partially compensated metabolic alkalosis
Show answerAnswer
D. Partially compensated metabolic alkalosis
The pH (7.52) is elevated, indicating alkalosis. The elevated HCO3 (32, normal 22–26) confirms a metabolic cause from loss of gastric HCl via NG suction. The elevated PaCO2 (46, normal 35–45) shows the lungs are hypoventilating to retain CO2 as compensation. Because the pH remains abnormal despite compensation, this is a partially compensated metabolic alkalosis.
8. A client arrives in the emergency department after a stab wound to the right chest. The nurse notes absent breath sounds on the right, tracheal deviation to the left, jugular venous distention, and a blood pressure of 78/50 mm Hg. Which intervention should the nurse anticipate as the priority?
Physiological Adaptation
A.Administer a 500 mL bolus of normal saline
B.Prepare for immediate needle decompression of the chest
C.Apply a three-sided occlusive dressing to the wound
D.Obtain a portable chest x-ray to confirm the diagnosis
Show answerAnswer
B. Prepare for immediate needle decompression of the chest
Tracheal deviation, absent breath sounds, JVD, and hypotension indicate a tension pneumothorax, a life-threatening emergency caused by air trapped in the pleural space compressing the heart and great vessels. Needle decompression must be performed immediately to relieve pressure before any diagnostic imaging or fluid resuscitation.
9. A client receiving continuous enteral tube feeding at 60 mL/hr through a gastrostomy tube has a gastric residual volume (GRV) of 520 mL when checked per facility protocol. What should the nurse do first?
Basic Care and Comfort
A.Continue the feeding as ordered since GRV is not clinically significant
B.Increase the feeding rate to help empty the stomach faster
C.Stop the feeding, hold for 1 hour, and reassess the GRV before resuming
D.Discontinue the feeding permanently and notify the provider immediately
Show answerAnswer
C. Stop the feeding, hold for 1 hour, and reassess the GRV before resuming
A GRV greater than 500 mL indicates delayed gastric emptying and risk for aspiration; facility protocols typically direct the nurse to hold the feeding temporarily and reassess before resuming, rather than immediately discontinuing or increasing the rate.
10. A nurse is caring for a client on the first postoperative day after abdominal surgery. Before assisting the client out of bed for the first time, which action is the priority?
Basic Care and Comfort
A.Administer the scheduled pain medication and wait 4 hours before ambulating
B.Instruct the client to perform 10 deep knee bends before standing
C.Have the client dangle at the edge of the bed for a few minutes before standing
D.Ask the client to stand up quickly to minimize discomfort during the transfer
Show answerAnswer
C. Have the client dangle at the edge of the bed for a few minutes before standing
Dangling the legs at the bedside allows the client's cardiovascular system to adjust to the upright position, reducing the risk of orthostatic hypotension and falls before standing. Standing quickly increases fall risk, waiting 4 hours delays needed mobility to prevent complications like DVT, and deep knee bends are inappropriate and unsafe post-op.
11. A client with a history of Addison disease is admitted after abruptly stopping oral hydrocortisone 2 days ago. The client is lethargic, hypotensive, and reports severe abdominal pain. Which prescription should the nurse anticipate as the priority?
Physiological Adaptation
A.IV insulin and dextrose infusion
B.IV hydrocortisone and normal saline bolus
C.Oral fludrocortisone and potassium supplement
D.IV vasopressin and fluid restriction
Show answerAnswer
B. IV hydrocortisone and normal saline bolus
This presentation is an Addisonian (adrenal) crisis caused by abrupt corticosteroid withdrawal, resulting in life-threatening hypotension and shock from cortisol deficiency. Priority treatment is immediate IV corticosteroid replacement (hydrocortisone) along with aggressive isotonic fluid resuscitation to correct hypovolemia and hypotension.
12. A client taking warfarin for atrial fibrillation has an INR of 5.5 and reports no bleeding. The target INR range for this client is 2-3. Which action should the nurse anticipate?
Pharmacological and Parenteral Therapies
A.Increase the warfarin dose to reach the target range faster
B.Administer the next scheduled warfarin dose as ordered
C.Administer protamine sulfate immediately
D.Hold warfarin and prepare to administer vitamin K as ordered
Show answerAnswer
D. Hold warfarin and prepare to administer vitamin K as ordered
An INR of 5.5 is significantly above the therapeutic range of 2-3 and places the client at high risk for spontaneous bleeding. The nurse should anticipate holding the warfarin dose and administering vitamin K (phytonadione), the antidote for warfarin, as ordered.
13. A client with a T4 spinal cord injury reports a sudden severe pounding headache. Assessment reveals blood pressure 210/122 mmHg, heart rate 48/min, and flushing above the level of injury. Which action should the nurse take first?
Physiological Adaptation
A.Notify the provider immediately and await orders
B.Check for bladder distention and a kinked urinary catheter
C.Place the client in a supine position
D.Administer the prescribed antihypertensive medication
Show answerAnswer
B. Check for bladder distention and a kinked urinary catheter
These findings indicate autonomic dysreflexia, a life-threatening emergency in clients with spinal cord injury at T6 or above, most commonly triggered by bladder distention. The nurse should first identify and remove the noxious stimulus, such as a distended bladder or kinked catheter, before administering medications.
14. A client with a spinal cord injury at T6 reports a sudden severe pounding headache. Assessment reveals blood pressure 210/120 mmHg, heart rate 48 beats/min, and flushing above the level of injury. What should the nurse do first?
Reduction of Risk Potential
A.Administer a PRN dose of an antihypertensive medication
B.Lower the head of the bed to a flat position
C.Check the urinary catheter for kinks or bladder distension
D.Notify the provider and wait for further orders
Show answerAnswer
C. Check the urinary catheter for kinks or bladder distension
These findings indicate autonomic dysreflexia, a life-threatening emergency triggered by a noxious stimulus below the level of injury—most commonly bladder distension. The nurse's first action is to sit the client up and check for and relieve the underlying cause, such as a kinked catheter or full bladder, before giving medication.
15. A charge nurse is making assignments for the shift. Which client is most appropriate to assign to a licensed practical nurse (LPN) working under RN supervision?
Management of Care
A.A client requiring initial teaching about a new tracheostomy
B.A client who was just admitted with new-onset chest pain
C.A client with a stable colostomy who needs pouch reinforcement
D.A client receiving a first-time blood transfusion
Show answerAnswer
C. A client with a stable colostomy who needs pouch reinforcement
LPNs can care for stable clients with established plans of care, including reinforcing an existing colostomy pouch. New admissions requiring assessment, first-time blood administration, and initial teaching all require RN-level judgment and are outside the LPN scope in most jurisdictions.
16. A client with pneumonia has a temperature of 38.6°C (101.5°F), respiratory rate of 24/min, white blood cell count of 14,000/mm3, productive cough, and new-onset confusion with a blood pressure of 88/50 mmHg. Which finding should prompt the nurse to notify the provider immediately as a priority indicator of possible septic shock?
Physiological Adaptation
A.Temperature of 38.6°C (101.5°F)
B.White blood cell count of 14,000/mm3
C.Productive cough
D.Blood pressure of 88/50 mmHg
Show answerAnswer
D. Blood pressure of 88/50 mmHg
Hypotension in the setting of suspected infection indicates possible progression to septic shock, a medical emergency requiring immediate fluid resuscitation and vasopressor support. While fever, leukocytosis, and altered mentation support a diagnosis of sepsis, hypotension signals hemodynamic instability that requires urgent action.
17. A nurse reviews morning laboratory results for four clients. Which result requires the nurse to notify the health care provider immediately?
Reduction of Risk Potential
A.Potassium 6.2 mEq/L
B.Glucose 112 mg/dL
C.Calcium 9.4 mg/dL
D.Sodium 138 mEq/L
Show answerAnswer
A. Potassium 6.2 mEq/L
Normal potassium is 3.5–5.0 mEq/L; a level of 6.2 mEq/L indicates severe hyperkalemia, which can cause life-threatening cardiac dysrhythmias (peaked T waves, widened QRS) and requires immediate provider notification and treatment. The other values are within or near normal limits.
18. A nurse notices that a coworker has slurred speech, unsteady gait, and the smell of alcohol on their breath before starting a shift. What is the nurse's priority action?
Management of Care
A.Report the observation immediately to the nurse manager or supervisor
B.Wait until after the shift to see if the coworker's condition improves
C.Say nothing and monitor the coworker's client care throughout the shift
D.Confront the coworker privately and tell them to go home
Show answerAnswer
A. Report the observation immediately to the nurse manager or supervisor
The nurse has a legal and ethical duty to protect client safety, which requires immediately reporting suspected impairment to a supervisor so the situation can be addressed through proper channels, such as removing the coworker from patient care duties. Confronting alone, ignoring, or waiting places clients at risk of harm.
19. A client returns from spinal fusion surgery with an order to maintain strict spinal alignment. Which technique should the nurse use when repositioning this client in bed?
Basic Care and Comfort
A.Have the client push up with the arms to reposition independently
B.Use a logrolling technique with at least two staff members
C.Ask the client to bend the knees and pivot the hips while turning
D.Raise the head of the bed to 90 degrees before turning the client
Show answerAnswer
B. Use a logrolling technique with at least two staff members
Logrolling keeps the spine in a straight line and prevents twisting of the vertebral column, which is essential after spinal fusion surgery. Two or more staff members are needed to move the head, trunk, and legs as one unit.
20. A nurse enters a client's room to insert a urinary catheter for a scheduled procedure. The client, who is alert and oriented, states, 'No one explained why I need this or what it involves.' The nurse proceeds to insert the catheter anyway because it was ordered by the physician. Which tort has the nurse most likely committed?
Management of Care
A.Negligence
B.Defamation
C.False imprisonment
D.Battery
Show answerAnswer
D. Battery
Battery is unauthorized physical contact with a person without consent. Because the client expressed lack of understanding and did not give informed consent for the procedure, proceeding with the catheter insertion constitutes battery.
21. A nurse is providing perineal care to a female client with an indwelling urinary catheter. Which technique is correct?
Basic Care and Comfort
A.Cleanse from the urinary meatus outward toward the rectum, using a clean area of the cloth for each stroke
B.Scrub vigorously back and forth over the meatus and catheter insertion site to remove all debris
C.Use the same area of the washcloth for the entire perineal cleansing to reduce the number of supplies needed
D.Cleanse from the rectal area toward the urinary meatus to remove the most contaminated area first
Show answerAnswer
A. Cleanse from the urinary meatus outward toward the rectum, using a clean area of the cloth for each stroke
Perineal care should proceed from the least contaminated area (urinary meatus) to the most contaminated area (rectum), using a clean section of cloth or a new wipe for each stroke to prevent introducing bacteria into the urinary tract. Cleansing from the rectum toward the meatus, reusing the same cloth area, or scrubbing back and forth all risk transferring pathogens into the urethra, increasing catheter-associated UTI risk.
22. A nurse applies bilateral wrist restraints to an alert, fully oriented client who has been frequently requesting help to get out of bed. The nurse applies the restraints without a physician's order because the unit is short-staffed and the nurse is concerned about falls. Which legal concept best describes this situation?
Management of Care
A.False imprisonment, because the client's freedom of movement was restricted without justification or a proper order
B.Battery, because the restraints involve unauthorized physical contact with the client
C.Negligence, because the nurse failed to meet the general standard of care
D.Assault, because the client was threatened with physical restraint
Show answerAnswer
A. False imprisonment, because the client's freedom of movement was restricted without justification or a proper order
False imprisonment occurs when a competent client's freedom of movement is restricted without legal justification, such as applying restraints to an alert, oriented client without a valid order or documented clinical indication. Restraints used purely for staff convenience rather than an assessed safety need constitute an unjustified restriction of liberty.
23. A school nurse examines a 6-year-old child and notices multiple bruises in various stages of healing on the child's back and buttocks, along with the child's reluctance to discuss how the injuries occurred. What is the nurse's priority legal obligation?
Management of Care
A.Confront the parents directly about the suspected abuse
B.Wait until the injuries are reassessed at the next scheduled visit
C.Ask the child's teacher to investigate the home situation first
D.Document the findings and report the suspected abuse to child protective services
Show answerAnswer
D. Document the findings and report the suspected abuse to child protective services
Nurses are mandatory reporters of suspected child abuse. The nurse must objectively document findings and report to the appropriate child protective agency; investigation is not the nurse's role.
24. A charge nurse is delegating blood glucose monitoring to a UAP for four clients. Which client's blood glucose check is inappropriate to delegate to the UAP?
Management of Care
A.A stable client with type 2 diabetes on routine oral medications
B.A client with well-controlled gestational diabetes performing routine home glucose checks
C.A client newly diagnosed with diabetic ketoacidosis who is on an insulin drip and requires frequent glucose trending with clinical correlation
D.A postoperative client with type 1 diabetes on a stable sliding-scale insulin regimen
Show answerAnswer
C. A client newly diagnosed with diabetic ketoacidosis who is on an insulin drip and requires frequent glucose trending with clinical correlation
UAPs can perform routine, stable blood glucose checks, but clients requiring clinical judgment, trending analysis, and correlation with changing insulin drip rates in an unstable condition like DKA require RN assessment and are not appropriate for delegation.
25. A nurse removes a client's central venous catheter from the subclavian site and applies an occlusive dressing. Immediately afterward, the client reports chest pain, becomes acutely anxious, and a churning sound is auscultated over the precordium. Oxygen saturation drops to 88%. Which action should the nurse take first?
Reduction of Risk Potential
A.Auscultate breath sounds bilaterally
B.Administer 100% oxygen by non-rebreather mask
C.Position the client on the left side in Trendelenburg's position
D.Call the rapid response team
Show answerAnswer
C. Position the client on the left side in Trendelenburg's position
These findings (chest pain, churning murmur, hypoxia, anxiety immediately after central line removal) indicate an air embolism. The immediate priority is to position the client in left lateral Trendelenburg's position, which traps air in the right atrium away from the pulmonary outflow tract, preventing it from traveling to the lungs. Oxygen and calling for help are important but secondary to positioning, which directly addresses the life-threatening mechanism.
Loss of gastric hydrochloric acid through NG suction or vomiting leads to metabolic alkalosis, with the lungs compensating by hypoventilating to retain CO2.
ROME: Respiratory Opposite, Metabolic Equal
NG suction/vomiting causes H+ loss, raising HCO3 and pH
Partial compensation exists when pH remains abnormal despite CO2 changes
A progressive accumulation of air in the pleural space that shifts the mediastinum and compresses the heart and great vessels, causing obstructive shock.
Having a client sit at the edge of the bed with legs dangling before standing allows time for cardiovascular compensation, reducing orthostatic hypotension risk during first ambulation.
A life-threatening exacerbation of adrenal insufficiency causing severe hypotension, hyponatremia, hyperkalemia, and hypoglycemia, often triggered by abrupt steroid withdrawal or stress.
Triggered by infection, stress, or abrupt corticosteroid discontinuation
Treatment: IV hydrocortisone + isotonic fluids + glucose as needed
Warfarin therapy is monitored using INR, with a typical therapeutic target of 2-3 for most indications; vitamin K is the antidote for excessive anticoagulation.
Therapeutic INR for AFib/DVT is usually 2-3
Vitamin K (phytonadione) reverses warfarin effect
INR >5 without bleeding often managed by holding dose ± oral vitamin K
A life-threatening syndrome in spinal cord injury above T6 caused by an unchecked sympathetic response to a noxious stimulus below the injury level, producing severe hypertension and bradycardia.
Most common trigger: bladder distention (kinked catheter, UTI)
First action: identify and remove the stimulus, sit client upright
LPNs care for stable clients with predictable outcomes, performing tasks such as reinforcing teaching, administering routine meds, and providing established care under RN supervision.
LPNs cannot perform initial assessments or admission histories
LPNs cannot administer blood products or IV push medications in most states
Stable, chronic, predictable clients are appropriate LPN assignments
Sepsis progresses to septic shock when infection causes persistent hypotension requiring vasopressors despite fluid resuscitation, along with organ dysfunction and altered mentation.
Nurses have an ethical and legal obligation to report suspected impairment (e.g., alcohol, drugs) in a colleague to a supervisor immediately to protect client safety.
Client safety is the priority, not workplace loyalty
Reporting must go through proper channels (supervisor, manager)
State boards often have peer assistance/diversion programs for impaired nurses
Perineal care should move from the urinary meatus (clean) toward the rectum (dirty), using a new area of cloth/wipe for each stroke to prevent catheter-associated urinary tract infection.
False imprisonment is the unjustified restriction of a client's freedom of movement without a proper order or legitimate safety indication, such as restraining an alert, oriented client for staff convenience.
Restraints require a physician's order and documented justification
Restraining a competent client without cause is false imprisonment
Different from battery (unauthorized touching) and assault (threat of harm)
Tasks requiring clinical judgment, assessment, or correlation with unstable conditions cannot be delegated to UAP, even if the task itself (like glucose checks) is routine.
UAPs can perform data collection on stable clients
RNs must retain tasks requiring assessment or judgment
Unstable clients (e.g., DKA, insulin drips) need RN oversight
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