Day 1

Correct Answer: D. Sudden decrease in urine output to 15 mL/hr

Rationale:
A decrease in urine output may indicate decreased renal perfusion or the onset of cardiogenic shock, both of which require immediate intervention. Options A–C are common post-op findings and should be monitored, but they are not immediately life-threatening.

Correct Answer: B. Tachycardia, heat intolerance, weight loss

Rationale:
Hyperthyroidism increases metabolic rate, resulting in signs such as tachycardia, heat intolerance, weight loss, increased appetite, nervousness, and diaphoresis. The other options describe symptoms more consistent with hypothyroidism.

Correct Answer: C. Assisting a stable patient with a bed bath

Rationale:
Option A: Incorrect – Assessment of new or unstable patients must be done by an RN.
Option B: Incorrect – Medication administration is within the RN and LPN scope, not UAP.
Option C: Correct – UAPs can assist with activities of daily living (ADLs) like bathing.
Option D: Incorrect – Teaching and reinforcing require knowledge and judgment; RNs may delegate reinforcement to an LPN, but not to a UAP.

Correct Answer: C. “Your baby will receive the hepatitis B vaccine shortly after birth.”

Rationale:
The hepatitis B vaccine is the first vaccine given to newborns, usually within 12 to 24 hours after birth, to help prevent perinatal transmission of the virus.

Correct Answer: C. Severe blood or fluid loss reducing circulating volume

Rationale:
Hypovolemic shock occurs when there is a significant loss of blood or body fluids, leading to decreased preload, reduced cardiac output, and impaired tissue perfusion. This can result from trauma, surgery, burns, or severe dehydration.

Correct Answer: B. 16 breaths per minute

Rationale:
The normal respiratory rate for a healthy adult at rest is 12 to 20 breaths per minute. Rates below 12 or above 20 may indicate a respiratory issue that requires further assessment.

Correct Answer: B. 0.5 mL IM

Rationale:
The standard adult dose of tetanus toxoid (TT) is 0.5 mL intramuscularly (IM), typically given in the deltoid muscle. It is not given subcutaneously or orally.

Correct Answer: C. Clean the wound, apply a sterile dressing, and report the finding to the healthcare provider immediately.

Rationale:
Diabetic patients are at high risk for infections and delayed wound healing, especially in the feet due to peripheral neuropathy and poor circulation. Immediate care and provider notification are necessary to prevent complications such as infection or amputation.

Correct Answer: B. Reposition the patient and assess for signs of impaired circulation or nerve compression.

Rationale:
Prolonged immobility in intubated patients can lead to nerve compression and circulatory issues, causing numbness. Repositioning is a non-invasive, priority comfort measure that addresses the likely cause. Analgesics and sedation are not the first line unless pain is present. Ignoring or dismissing the symptom, or changing oxygen without assessment, is inappropriate.

Correct Answer: C. Provide the patient with a communication board or writing tools.

Rationale:
Using a communication board or writing tools empowers the patient to express specific needs clearly and independently. While blinking and mouthing words may help in some cases, they are limited and may lead to misinterpretation. Involving the family can be supportive, but it should not replace direct communication between nurse and patient when possible.

Correct Answer:
A. The ETT is secured at the 28 cm mark at the patient’s lips, with symmetrical chest rise and bilateral breath sounds.

Rationale:
For adult males, proper ETT depth is typically 22–28 cm at the lips. Symmetrical chest rise and bilateral breath sounds confirm that the tube is not inserted too far (e.g., into one mainstem bronchus) or too shallow (e.g., in the esophagus). Other choices indicate improper placement.

Correct Answer: B. Notify the healthcare provider immediately about the elevated blood pressure.

Rationale:
This patient is experiencing a hypertensive crisis, which can lead to stroke or organ damage. The priority action is to notify the provider immediately so that antihypertensive treatment can be initiated. While delegation of routine vitals or reassessment is appropriate in some cases, critical vital signs must be addressed by the RN first.

Correct Answer: C. To prevent nausea and vomiting

Rationale:
Metoclopramide is an antiemetic commonly used to prevent or treat nausea and vomiting, especially in patients undergoing chemotherapy or postoperatively. It works by increasing gastric motility and blocking dopamine receptors in the chemoreceptor trigger zone of the brain.

Correct Answer: C. Atropine sulfate

Rationale:
Atropine sulfate is the first-line medication for symptomatic bradycardia. It works by blocking the parasympathetic influence on the heart, thereby increasing heart rate. Epinephrine may be used if atropine is ineffective. Lidocaine and amiodarone are used for ventricular arrhythmias, not bradycardia.

Correct Answer: D. Glomerular filtration rate (GFR)

Rationale:
While BUN, serum creatinine, and urine output provide useful information, GFR is the most accurate and reliable indicator of overall kidney function. It reflects how well the kidneys are filtering the blood and is used to stage kidney disease.

Correct Answer: D. Assess the patient’s understanding of blood sugar monitoring and meal planning.

Rationale:
While all options may be appropriate in long-term care, the most important immediate nursing intervention is to assess his understanding. Since he skips meals and experiences dizziness (possible hypoglycemia), evaluating his knowledge is critical for safety and appropriate management. Teaching and support can follow after this baseline is established.

Correct Answer: C. Uncompensated metabolic acidosis

Rationale:
The ABG shows low pH (acidemia), low HCO₃⁻ (indicating metabolic cause), and normal PaCO₂ (no respiratory compensation yet), consistent with uncompensated metabolic acidosis. This is common in CKD due to the kidneys’ inability to excrete hydrogen ions and regenerate bicarbonate.

Correct Answer: B. Hypoventilation caused by opioid sedation

Rationale:
The ABG indicates acute respiratory acidosis (low pH, high PaCO₂, normal HCO₃⁻). Opioids like morphine can depress the respiratory center, leading to hypoventilation and CO₂ retention. This is common in sedated postoperative ICU patients.

Correct Answer: C. Prepare to administer IV calcium gluconate as ordered

Rationale:
The patient is showing signs of severe hyperkalemia (muscle weakness, arrhythmias, ECG changes). IV calcium gluconate stabilizes the cardiac membrane and helps prevent life-threatening arrhythmias. It is the priority intervention while other treatments (e.g., insulin, diuretics, dialysis) are prepared.

Correct Answer: D.
Rationale:

The most appropriate client for a newly licensed nurse is one with a predictable and stable condition. Option D presents a stable post-operative client who requires routine care and is preparing for transfer, making this the safest assignment. The other clients require advanced assessment, critical thinking, or emergency response skills that are more appropriate for experienced nurses.

Correct Answer:
B. Peripheral neuropathy

Rationale:
Isoniazid can cause peripheral neuropathy, especially in patients who are malnourished or have diabetes. This is due to interference with vitamin B6 (pyridoxine) metabolism. Supplementation with vitamin B6 is often recommended. Orange-colored urine is more commonly associated with rifampin, another anti-tuberculosis drug. Bradycardia and hypoglycemia are not typical side effects of isoniazid.

Correct Answer: C. Complaints of epigastric pain and visual disturbances

Rationale:
Epigastric pain and visual disturbances (like blurred vision or seeing spots) are signs of worsening preeclampsia and may indicate impending eclampsia, which can lead to seizures. This requires immediate intervention, possibly administration of magnesium sulfate and preparation for delivery.

Correct Answer: C. Tall, peaked T waves and widened QRS complex

Rationale:
Hyperkalemia (elevated serum potassium) affects cardiac conduction and is commonly associated with tall, peaked T waves, widened QRS complexes, and flattening or loss of P waves in severe cases. The progression of ECG changes can indicate worsening hyperkalemia and risk for cardiac arrest.

Correct Answer: B. Abdominal aortic aneurysm (AAA) rupture

Rationale:
This patient’s presentation—sudden severe abdominal and back pain, hypotension, and a pulsatile abdominal mass—is classic for a ruptured abdominal aortic aneurysm. This is a medical emergency that requires immediate intervention.

Correct Answer: B. Skin temperature and color of the affected leg

Rationale:
Assessing skin temperature and color helps evaluate for deep vein thrombosis (DVT), which is a potentially serious complication of unilateral leg swelling. Warmth, redness, and tenderness could indicate DVT, which requires prompt intervention.

Correct Answer: B. Advise the patient to change positions slowly to prevent orthostatic hypotension.

Rationale:
Levodopa can cause side effects such as orthostatic hypotension, nausea, and dyskinesia. Changing positions slowly can help reduce dizziness related to blood pressure changes. High-protein meals can interfere with levodopa absorption, and the medication should never be stopped or doses changed without medical supervision.

Correct Answer: B. ALT 155 U/L

Rationale:
Alanine aminotransferase (ALT) is an enzyme found in the liver. An elevated ALT level indicates liver cell injury, which is a hallmark of drug-induced liver disease. Acetaminophen, especially in high doses, is known to cause hepatotoxicity. The other values are within normal limits and not specific to liver damage.

Correct Answer: B. Edrophonium (Tensilon)

Rationale:
Edrophonium is used in the Tensilon test to help differentiate myasthenia gravis from other causes of facial weakness, including Bell’s palsy. Although it doesn’t confirm Bell’s palsy directly, it helps rule out other neuromuscular causes. Bell’s palsy is typically diagnosed clinically, but the Tensilon test is useful when myasthenia gravis is in the differential.

Correct Answer: B. It is associated with chronic hypoxia and may indicate long-standing pulmonary disease.

Rationale:
Clubbing of the fingers is a physical finding associated with chronic hypoxia and is often seen in patients with long-standing pulmonary diseases such as COPD, cystic fibrosis, or lung cancer. It results from increased connective tissue and vascularity in the distal digits. It is not a normal part of aging, nor is it an early sign of peripheral arterial disease or typically caused by vitamin deficiencies.

Correct Answer: C. Kaposi’s sarcoma

Rationale:
Kaposi’s sarcoma is a vascular tumor associated with human herpesvirus-8 (HHV-8), commonly seen in immunocompromised individuals such as those with HIV/AIDS. It typically presents as painless, violaceous nodules or plaques, often on the lower extremities, and may be associated with edema due to lymphatic obstruction. The chronic progression and increase in lesion number support this diagnosis.

Correct Answer: C. Productive cough with shortness of breath

Rationale:
Patients with myocarditis already have compromised cardiac function. Amiodarone can cause pulmonary toxicity, and symptoms like cough and shortness of breath may indicate worsening myocarditis or a developing pulmonary complication (e.g., pneumonitis or pulmonary fibrosis). This finding is the priority due to the potential for rapid deterioration.

Bradycardia (HR 58 bpm) and nausea are common side effects.
Photosensitivity is also expected but not urgent.

Correct Answer: A. Document the finding as a known side effect of the medication.

Rationale:
Amiodarone can cause a bluish-gray skin discoloration, especially on areas exposed to sunlight, such as the face. This is a known adverse effect of long-term therapy, not necessarily an indication to discontinue the medication.

Patients should be advised to use sun protection to prevent worsening. Although it may be distressing cosmetically, it is not typically harmful.

Correct Answer: D. Unexplained bruising on the body

Rationale:
While all symptoms can be associated with a lupus flare, unexplained bruising may indicate a more serious complication such as thrombocytopenia (low platelet count), which can lead to increased bleeding risk. This finding requires immediate evaluation. The malar rash (butterfly rash), fever, and weight loss are common in lupus flares but are less immediately life-threatening than potential bleeding disorders.

Correct Answer: C) E-cigarette or Vaping Associated Lung Injury (EVALI)

Rationale:
E-cigarette or Vaping Associated Lung Injury (EVALI) is a condition linked to the use of e-cigarettes or vaping products, presenting with symptoms such as cough, shortness of breath, and chest pain. This condition has been increasingly recognized, especially in young adults, and may lead to serious respiratory complications.

While acute bronchitis and pneumonia can present with similar symptoms, EVALI is the most likely diagnosis related to vaping. COPD typically occurs with long-term smoking, not vaping alone.

Correct Answer: C. Return the blister cards to the pharmacy and hold administration.

Rationale: The nurse’s priority is patient safety. Medications with incorrect labels must not be administered. They should be returned to the pharmacy for correction and verification before any administration. Administering them or correcting labels independently without proper verification can lead to serious medication errors. Notifying the supervisor is appropriate but not the immediate priority.

Correct Answer: C. “I will have a large plate of spaghetti with marinara sauce for dinner.”

Rationale: Tomato-based sauces, like marinara on spaghetti, are acidic and can aggravate GERD symptoms.

The patient’s plan to eat a large plate of spaghetti with marinara sauce shows a need for further teaching.

The other options are appropriate dietary and lifestyle modifications for managing GERD.

Correct Answer: C. Report the findings to child protective services.

Rationale:
Facial bruising in a child, especially at different stages of healing, raises concern for potential child abuse. The nurse is legally mandated to report suspected abuse. While notifying the provider and involving a social worker are appropriate, the priority action is to report to the proper authorities to ensure the child’s safety.

Correct Answer: B. Administer naloxone as prescribed

Rationale:
The patient is showing classic signs of opioid-induced respiratory depression. Naloxone is the priority intervention to reverse the opioid effects and restore adequate respiratory function.

Correct Answers: A, B, and E

Rationale:
A. Have emergency reintubation equipment at the bedside → Always prepare for potential airway compromise after extubation.

B. Suction the oropharynx and endotracheal tube → Helps clear secretions to prevent aspiration and facilitate breathing.

E. Provide supplemental oxygen immediately after extubation → Supports oxygenation as the patient adjusts to breathing independently.

Incorrect Options:
C. Instruct the patient to hold their breath during extubation → The patient should be encouraged to cough and take deep breaths after extubation to clear secretions and promote ventilation.
D. Place the patient in a supine position → The patient should be in a semi-Fowler’s or high Fowler’s position to aid in lung expansion and prevent aspiration.

Correct Answer: B. Blood pressure and heart rate

Rationale: Albumin is a colloid solution used for volume expansion in hypovolemia. Since it increases intravascular volume rapidly, the nurse must monitor for signs of fluid overload, such as hypertension and tachycardia, before administration.

Correct Answer: C. Crackles in the lungs

Rationale: Mannitol is an osmotic diuretic used to reduce ICP by drawing fluid from brain tissues into the bloodstream, leading to increased urine output. However, a potential complication is pulmonary edema due to fluid overload. Crackles in the lungs indicate fluid accumulation and require immediate intervention.

Correct Answer: C. Remove and inspect the suction catheter for patency.

Rationale:
If suctioning is ineffective and no secretions are being removed, the first action should be to assess the patency of the suction catheter, as it may be blocked. Increasing suction pressure or instilling saline without checking for a blockage can worsen the situation. Notifying the respiratory therapist is appropriate if troubleshooting fails, but immediate action by the nurse is required first.

Correct Answers:
✅ A. The patient must be alert and able to follow commands to protect their airway.
✅ C. A spontaneous tidal volume of at least 6 mL/kg indicates adequate respiratory effort.
✅ E. Normal ABG values suggest adequate gas exchange and ventilation.

Incorrect Answers:
❌ B. A positive cuff leak test (airflow around the deflated cuff) suggests minimal airway swelling, which is preferred for safe extubation.
❌ D. A respiratory rate of 35 bpm is too high and may indicate respiratory distress.
❌ F. If a patient requires sedation to tolerate the tube, they may not have the ability to manage their own airway after extubation.

Correct Answer: C) “I will increase my oxygen flow rate if I feel more short of breath.”

Rationale: Clients with COPD should not increase their oxygen flow rate without consulting their healthcare provider, as high levels of oxygen can suppress their respiratory drive.

Correct Answer: C. “Since the kidney is from a pig, my body will not recognize it as foreign and won’t attack it.”

Rationale:
The immune system recognizes pig tissue as foreign, even if genetically modified, and can mount a rejection response. Immunosuppressive therapy is required to reduce this risk. Xenotransplantation is still in experimental stages, and rejection remains a significant challenge.

Correct Answer: C. Implement fall precautions and assist with mobility as needed

Rationale:
The priority intervention is to prevent further falls and injuries. Since Theresa has already sustained a fracture, ensuring her safety by implementing fall precautions is the most immediate concern. While educating her on medication adherence, increasing Calcium and Vit. D intake, and referring her to physical therapy are important, they are secondary to preventing additional harm.

Correct Answer: B. RN and C. LPN/LVN

Rationale:
When delegating client transport, the charge nurse must consider stability, potential complications, and the scope of practice of the team members.
RN: Can assess and manage a chest tube if complications arise.
LPN/LVN: Can transport a stable patient with a chest tube, as they are trained to monitor for issues but may need RN supervision in some settings.
Transport Tech, Radiology Tech, UAP: Not appropriate for this task because they are not trained to monitor or manage a chest tube if an emergency occurs.
Since the client has a chest tube, even though they are stable, a licensed nurse (RN or LPN/LVN) should be responsible for transport to ensure safety in case of complications like tube dislodgement or drainage issues.

Correct Answer: B) The patient acuity levels on the medical-surgical unit.

Rationale: The charge nurse must first assess the acuity levels of the patients on the unit to ensure that the unit remains adequately staffed to provide safe patient care. While experience and preferences may be considered, patient safety and appropriate staffing distribution are the priority.

In a healthcare context, patient acuity refers to the severity and intensity of a patient’s medical condition or illness.

Correct Answer: A) Obtain the patient’s baseline vital signs.

Rationale:
Before administering PRBCs, the nurse must obtain the patient’s baseline vital signs to monitor for potential transfusion reactions.
Blood products should only be primed with 0.9% Normal saline, not Lactated Ringer’s (B is incorrect).
PRBCs should be started slowly (usually 2 mL/min for the first 15 minutes) to monitor for reactions before increasing the rate (C is incorrect).
Ambulation is not a priority before transfusion (D is incorrect).

Correct Answer: B) Place the patient in protective (reverse) isolation.
Rationale:
A WBC count of 3,000/mm³ is indicative of Leukopenia (low WBC count), increasing the patient’s risk for infection. The priority intervention is to protect the patient from potential sources of infection by implementing protective (reverse) isolation. Other interventions, such as monitoring for fever and ensuring hydration, are important but not the first priority.

Correct Answer: C. “I can stop taking this medication once my blood pressure is normal.”

Rationale: Clonidine is a centrally acting alpha-2 agonist that lowers blood pressure. It should not be stopped abruptly, as this can cause rebound hypertension, which may be severe. Patients should take it as prescribed, even if their blood pressure improves, and consult their provider before making any changes.

Correct Answer: B. Heart rate of 54 beats per minute.

Rationale:

Nicardipine is a Calcium channel blocker that causes vasodilation and is used to manage severe hypertension. A significant concern is bradycardia, which may indicate excessive cardiac suppression. While a controlled reduction in blood pressure is expected, and mild headaches or flushing are common side effects, a heart rate below 60 bpm warrants further evaluation.

Correct Answer: B. The ventilator allows the patient to breathe spontaneously between set breaths without additional support.

Rationale:

SIMV mode

• Delivers a preset number of ventilator breaths, but allows the patient to take spontaneous breaths between them without additional ventilator assistance (unless pressure support is added).
• This mode helps maintain respiratory muscle strength and promotes weaning from mechanical ventilation.

Correct Answer: C) Initiate IV fluids and monitor vital signs closely

Rationale: This patient has classic signs of a ruptured ectopic pregnancy (sudden severe abdominal pain, dizziness from hypotension, and referred shoulder pain due to diaphragmatic irritation from internal bleeding). Hypovolemic shock is the primary concern, so the nurse must initiate IV fluids, monitor vital signs, and ensure emergency interventions.

Option A is incorrect because while surgery is likely needed, the immediate priority is stabilizing the patient to prevent further deterioration.
Option B is incorrect because Methotrexate (a medical treatment for ectopic pregnancy) is only used in unruptured ectopic pregnancies.
Option D is incorrect because a pregnancy test is not the priority in a patient with a known positive test and life-threatening symptoms.

Correct Answer: B) Start chest compressions at a rate of at least 100-120 per minute.

Rationale:
The priority in adult CPR is to initiate high-quality chest compressions immediately when a patient is unresponsive, pulseless, and not breathing.

According to the American Heart Association (AHA) guidelines, compressions should be started immediately at a depth of at least 2 inches (5 cm) and a rate of 100-120 per minute.

Option A is incorrect because calling for help and retrieving a defibrillator is important, but chest compressions should not be delayed. CPR should be initiated immediately while help is on the way.

Option C is incorrect because in adult CPR, chest compressions should be started first before rescue breaths (C-A-B sequence: Compressions → Airway → Breathing).

Option D is incorrect because a pulse check should take no more than 10 seconds before starting compressions. Delaying compressions worsens survival outcomes.

Correct Answer: C) Dehydration due to gastrointestinal losses (vomiting, diarrhea).

Rationale:
Lactated Ringer’s (LR) is an isotonic crystalloid solution that contains electrolytes (sodium, potassium, calcium, and chloride) and lactate, which helps buffer mild metabolic acidosis. It is commonly used for fluid resuscitation in dehydration, burns, and surgery.

Option A is incorrect because LR contains potassium and may worsen hyperkalemia in patients with acute renal failure.
Option B is incorrect because LR contains lactate, which is converted to bicarbonate in the liver and may exacerbate metabolic alkalosis.
Option D is incorrect because normal saline (0.9% NaCl) is preferred in DKA, as the liver may not effectively convert lactate to bicarbonate in severe metabolic acidosis.

Correct Answer: B) Hypovolemia and mild hypoglycemia

Rationale:
D5LR is an isotonic solution with added dextrose, which provides fluid resuscitation, electrolytes, and a small amount of glucose. It is commonly used for hypovolemia (fluid loss) and can also help prevent hypoglycemia in patients needing maintenance fluids.

Option A is incorrect because D5LR is not the first choice for hypotensive shock or severe hyponatremia; Normal saline or Hypertonic saline is preferred.
Option C is incorrect because D5LR contains dextrose, which can worsen hyperglycemia in diabetic ketoacidosis (DKA). Instead, Normal saline or Lactated Ringer’s without dextrose is preferred.
Option D is incorrect because D5LR can contribute to fluid overload, making it inappropriate for patients with End-stage renal disease (ESRD).

Correct Answer: B) Displaying a grandiose sense of self-importance and lack of empathy for others

Rationale:
Patients with narcissistic personality disorder often have an exaggerated sense of self-importance, a need for excessive admiration, and a lack of empathy for others. They may also exhibit arrogant behaviors and believe they are superior to others.

Unlike individuals with borderline personality disorder (D), they typically do not fear abandonment. Mood swings with severe depression (C) are more characteristic of bipolar disorder. Intense guilt and self-blame (A) are more common in depression or obsessive-compulsive personality disorder.

Correct Answer: A) Administering high-dose aspirin and intravenous immunoglobulin (IVIG).

Rationale: The priority treatment for Kawasaki disease in the acute phase is high-dose aspirin and IVIG to reduce inflammation and prevent coronary artery complications.
–Aspirin is a non-steroidal anti-inflammatory drug (NSAID). It’s used to treat Kawasaki disease because: it can ease pain and discomfort. it can help reduce a high temperature.
–IVIG (intravenous immunoglobulin) is given in Kawasaki disease to reduce inflammation and prevent complications like coronary artery damage. It’s a key part of the treatment, often administered alongside aspirin.

Cool compresses (B) may provide comfort but are not the priority intervention.
Rest, not active play (C), is recommended to reduce strain on the heart.
Kawasaki disease primarily affects the cardiovascular system, not intracranial pressure (D).

Correct Answer: A) “Have you been exposed to sunlight for prolonged periods?”.

Rationale: Sun exposure is a known trigger for lupus flares, leading to increased symptoms such as rash, joint pain, and fatigue. Increased water intake (B) does not typically trigger lupus flares. While exercise (C) can impact fatigue, it is not a primary cause of SLE flares. High-protein foods (D) do not directly contribute to lupus exacerbations.

Correct Answer: C) Changing tracheostomy ties immediately after removing the old ones.

Rationale: The nurse should not remove old tracheostomy ties before securing new ones, as this could lead to accidental decannulation. Instead, one side of the ties should be replaced at a time.

Suctioning for no longer than 10–15 seconds (A) helps prevent hypoxia. Using sterile gloves (B) reduces infection risk. Assessing the stoma (D) is essential for early detection of complications.

Correct Answer: C) Instructing the patient to take deep breaths during catheter advancement.

Rationale:

• The patient should be instructed to hold their breath (Valsalva maneuver) during catheter advancement to prevent air embolism.
• Deep breathing could increase the risk of air embolism.
• Trendelenburg position (A) helps dilate the veins and reduce the risk of air embolism.
• Maintaining sterility (B) is essential to prevent infection.
• A chest X-ray (D) confirms proper placement and rules out complications like pneumothorax.

Correct Answer: B. Abnormal pupillary reflexes and altered level of consciousness

Rationale:
The midbrain plays a crucial role in regulating visual and auditory reflexes, consciousness, and motor control. Damage to the midbrain can impair the function of the oculomotor nerve (cranial nerve III), leading to abnormal pupillary responses. It is also part of the brainstem’s reticular activating system (RAS), which is responsible for maintaining consciousness.

A (Impaired balance and coordination) is more related to cerebellar dysfunction.
C (Loss of fine motor control in the hands) is associated with damage to the motor cortex or pyramidal tract.
D (Expressive aphasia and difficulty forming words) is linked to damage in Broca’s area, located in the frontal lobe.

Correct Answer: A. Difficulty with balance and coordination

Rationale:
The cerebellum is responsible for coordinating voluntary movements, maintaining posture, and ensuring balance. Damage to the cerebellum can lead to ataxia (lack of coordination), dysmetria (impaired ability to judge distances), and an unsteady gait.

Sensory loss (B) is more indicative of peripheral nerve or spinal cord issues.

Expressive aphasia (C) is associated with damage to Broca’s area in the frontal lobe.

Absence of deep tendon reflexes (D) is more commonly linked to peripheral neuropathy or lower motor neuron dysfunction.

Correct Answer: C. The heart muscle relaxes, allowing the ventricles to fill with blood.

Rationale:
Diastole is the phase of the cardiac cycle during which the heart relaxes, allowing the ventricles to fill with blood from the atria. This occurs after the semilunar valves (aortic and pulmonary) close, creating the second heart sound (“dub”). During this phase, the atrioventricular (AV) valves (tricuspid and mitral) remain open to permit ventricular filling.

Correct Answer: B. The ventricles contract, ejecting blood into the pulmonary and systemic circulation.

Rationale:
Systole refers to the phase of the cardiac cycle in which the ventricles contract, leading to the ejection of blood into the aorta and pulmonary artery. This occurs after the closure of the atrioventricular (AV) valves (tricuspid and mitral), which produces the first heart sound (“lub”). Diastole, on the other hand, is when the heart relaxes and fills with blood.

Correct Answer: B. Irregular respiratory patterns

Rationale:
The pons, located in the brainstem, plays a crucial role in regulating respiration by transmitting signals between the brain and the respiratory centers. Damage to the pons can result in irregular respiratory patterns, such as apneustic or ataxic breathing.

While the pons is involved in motor control and coordination, primary balance issues (A) are more associated with the cerebellum. Fine motor skill loss (C) is typically linked to damage in the motor cortex. Difficulty understanding language (D) is related to damage in Wernicke’s area, located in the temporal lobe.

Correct Answer: B) Respiratory rate of 10 breaths per minute

Rationale:
Propofol is a potent sedative-hypnotic that can cause respiratory depression. A respiratory rate of 10 breaths per minute is concerning and may indicate the need to adjust the infusion rate or provide ventilatory support.

Hypotension (A) is a known side effect but not immediately life-threatening at this level. Green urine (C) is a harmless side effect of propofol metabolism. Unresponsiveness to verbal stimuli (D) is expected in a sedated patient, depending on the sedation goal.

Correct Answer: C. “Levetiracetam binds to synaptic vesicle proteins, reducing neurotransmitter release and preventing seizures.”

Rationale: Levetiracetam’s primary mechanism of action involves binding to the synaptic vesicle protein SV2A, which helps regulate neurotransmitter release, thereby stabilizing neuronal activity and preventing seizures. Unlike other antiepileptic drugs, it does not work by enhancing GABA activity or blocking sodium channels.

Correct Answer: D. “Since I have been seizure-free for a month, I can stop taking the medication.”
Rationale: Levetiracetam should never be stopped abruptly, as it may increase the risk of seizures. Clients should always consult their healthcare provider before making any changes to their medication regimen.

Correct Answer: A) Splenic rupture
Rationale:
Blunt abdominal trauma, such as from a punch, can cause internal organ injury. The spleen is particularly vulnerable, and signs of rupture include abdominal pain, guarding, and bruising (Cullen’s sign, which can indicate intra-abdominal bleeding).

Peritonitis (B) can develop secondary to organ rupture but is not the primary concern. Liver failure (C) is more commonly associated with chronic disease rather than acute trauma. Pancreatitis (D) may occur due to blunt trauma but is less likely than splenic injury in this scenario.

Correct Answer: B) It maintains hemodynamic stability with minimal cardiovascular effects.
Rationale:
Etomidate is commonly used for rapid sequence intubation because it provides sedation with minimal cardiovascular depression, making it a preferred choice for patients who are hemodynamically unstable. However, it does not provide analgesia (A), has a short duration of action (C), and actually decreases intracranial pressure rather than increasing it (D).

Correct Answer: B. Insert the oral airway after the seizure has ended.

Rationale: An oral airway should only be inserted after the seizure has ended, when the patient is no longer clenching their teeth. Attempting to insert it during the seizure (Options A and C) could cause injury to the patient or the nurse. Option D is incorrect because an oral airway may be used after the seizure to maintain an open airway if needed.

Correct Answer: C) Discontinue the suspected causative medication

Rationale:
Stevens-Johnson Syndrome is a severe hypersensitivity reaction, often triggered by medications. The priority intervention is to immediately discontinue the offending drug to prevent further progression of the condition. Supportive care, including fluid management, pain control, and wound care, is essential, but stopping the causative agent is the first critical step.

Correct Answer: C. “Snoring is always harmless and does not require medical attention.”
Rationale:
While snoring can be benign, it may also indicate underlying conditions like obstructive sleep apnea (OSA), which can have serious health consequences if left untreated. Patients should be aware of risk factors and symptoms that warrant medical evaluation.