Day 2

Correct Answer: A. Ask the patient to remain still and avoid talking during the procedure.

Rationale: Movement and talking can interfere with the accuracy of the ECG recording.
Shaving is not always necessary—clipping excessive hair may suffice. Limb electrodes can be placed on the wrists and ankles, not just the upper arms and thighs. The patient should breathe normally during the test.

Correct Answer: B. Place a pillow between the patient’s legs before turning.
Rationale:
Placing a pillow between the patient’s legs helps maintain proper body alignment and reduces pressure on bony prominences, preventing discomfort and injury. Option A is incorrect because pulling a patient by their arms can cause injury. Option C is incorrect because holding their breath is unnecessary and could cause distress. Option D is incorrect because positioning directly on the hip increases pressure ulcer risk; instead, the patient should be positioned at a 30-degree lateral tilt to reduce pressure.

Correct Answers: A, C, and D
Rationale:
A. Assess vital signs – Hypotension and tachycardia may indicate active bleeding and hypovolemic shock, requiring immediate intervention.
C. Check hemoglobin and hematocrit levels – Monitoring Hgb/Hct helps assess the severity of blood loss and need for transfusion.
D. Administer IV proton pump inhibitors (PPIs) – PPIs help reduce gastric acid secretion, preventing further bleeding from stress ulcers or gastritis.

Incorrect Answers:
B. Increase NGT suction to continuous high suction – High suction can cause gastric mucosal damage, worsening bleeding. Low intermittent suction is preferred.
E. Position the patient flat in bed – This can impair gastric drainage and increase aspiration risk. The patient should be positioned with the head of the bed elevated to at least 30 degrees.

Correct Answer: B. Keep the head of the bed elevated to 30 degrees and avoid excessive neck flexion.
Rationale: Elevating the head of the bed to 30 degrees helps promote venous drainage, reduces intracranial pressure (ICP), and prevents complications such as brain swelling. Avoiding excessive neck flexion ensures proper blood flow.

Placing the patient on the operative side (option A) is not appropriate due to the risk of pressure on the surgical site.

While coughing and deep breathing (option C) can prevent pneumonia, excessive coughing may increase ICP.

Pressure dressings (option D) are not appropriate for craniectomy patients, as swelling should be managed with positioning and monitoring.

Correct Answer: A. Reinsert the tracheostomy tube using the obturator and a new sterile tracheostomy tube.
Rationale:

-A trained nurse can reinsert a tracheostomy tube after accidental decannulation (removal), but only under specific circumstances and with the proper equipment and procedures. If not trained, call the emergency response team to attempt reinsertion of the tracheostomy tube. Note, if the stoma is less than 7 days old, special care should be taken to avoid creating a false passage during reinsertion.

NOTE: In general, nurses are not typically permitted to reinsert a tracheostomy tube after accidental removal without the presence and guidance of a medical professional, such as a doctor or a respiratory therapist. Reinsertion should be attempted only when a trained clinician is present and the stoma is more than seven days old.
However, if a situation arises where a nurse is the only one available and the patient’s airway is at risk:
The nurse should:
-Call for help immediately and prepare for reintubation.
-Maintain the patient’s airway and ventilation as best as possible using a bag-valve-mask device or other available equipment.
-Apply oxygen if needed.

Secure the airway as best as possible until a trained professional can assist.
Accidental dislodgement of a tracheostomy tube is an emergency, especially in a pediatric patient, as the airway can quickly close. The priority action is to reinsert the tracheostomy tube using a new sterile tube with an obturator to maintain airway patency. If reinsertion is not possible, emergency interventions such as bag-mask ventilation or intubation may be needed.

Option B is incorrect because covering the stoma can block the airway.
Option C is incorrect because assessing the respiratory status is important, but immediate reinsertion of the tube is the priority.
Option D is incorrect because while a suction catheter may help maintain patency temporarily, it does not replace the tracheostomy tube.

Correct Answer: C. Discontinue the IV and restart it at a different site.
Rationale: The signs of swelling, coolness, and resistance when flushing suggest IV infiltration or occlusion. The priority is to discontinue the IV to prevent further complications, such as tissue damage or medication extravasation.

Option A may help in managing minor infiltration but does not address the need to restart the IV.

Option B is incorrect because forcing a flush can worsen infiltration or cause damage.

Option D is unsafe, as continuing to use a compromised IV site can lead to further complications.

Correct Answer: C. Notify the healthcare provider immediately.
Rationale: Coffee-ground NGT output suggests upper gastrointestinal bleeding, likely due to gastric irritation, stress ulcers, or surgical complications. This finding requires immediate notification of the healthcare provider to assess the need for interventions such as medication administration, endoscopic evaluation, or changes in treatment.

Flushing the NGT (option A) does not address the underlying cause.

Monitoring alone (option B) may delay necessary treatment.

Lowering the suction setting (option D) is not the priority when active bleeding is suspected.

Correct Answer: D. Use seizure precautions and monitor for changes in neurological status.
Rationale: After a craniectomy, the patient is at risk for seizures and neurological changes due to brain swelling and altered cerebral perfusion. Seizure precautions, close monitoring, and maintaining head elevation (typically 30-45 degrees) are essential.

Option A is incorrect because keeping the head flat may increase ICP.

Option B is incorrect because excessive coughing can increase ICP.

Option C is incorrect because positioning depends on the surgeon’s recommendation, and placing pressure on the operative side can be harmful.

Correct Answer: A. Secure the knife in place and stabilize it with bulky dressings

Rationale: In penetrating chest trauma, the object (knife) should never be removed because it may be tamponading (blocking) a major vessel and preventing excessive bleeding. The priority is to stabilize the object with bulky dressings and prevent movement until surgical intervention.
Incorrect Answers:
❌ B. Immediately remove the knife to prevent further injury → Wrong! Removing the knife can cause uncontrolled bleeding and worsened damage. Only a surgeon should remove it in a controlled setting.
❌ C. Apply direct pressure to the wound to control bleeding → Wrong! Applying pressure around (not directly on) the object is appropriate, but the primary action is stabilization.
❌ D. Turn the patient to the side to prevent aspiration → Wrong! This position is not appropriate for chest trauma, as it may worsen injury or impair breathing.

Correct Answer: D. Administer continuous nebulized Albuterol and IV corticosteroids
Rationale: Status asthmaticus is a life-threatening asthma exacerbation that does not respond to initial bronchodilator therapy. The priority treatment is continuous beta-agonist therapy (Albuterol), IV corticosteroids to reduce inflammation, and oxygen support.
Incorrect Answers:
❌ A. Administer a scheduled dose of an inhaled corticosteroid → Inhaled corticosteroids are for long-term control, not emergency treatment.
❌ B. Obtain a sputum culture to rule out infection → Infection is a possible trigger, but treatment should not be delayed in a respiratory emergency.
❌ C. Prepare for intubation and mechanical ventilation → This may be needed if the patient deteriorates, but the first priority is aggressive bronchodilator and anti-inflammatory therapy.

NCLEX Tips:
Red flags for impending respiratory failure:
-Silent chest (no wheezing = no air movement!)
-Severe accessory muscle use
-Inability to speak in full sentences
-Decreasing oxygen saturation despite treatment
First-line treatment:
-Oxygen, continuous albuterol, IV corticosteroids, and possibly magnesium sulfate
If no improvement → Prepare for intubation!

Correct Answer: B. Wheezing that suddenly stops with a silent chest
Rationale: A sudden absence of wheezing in a patient with severe respiratory distress may indicate impending respiratory failure due to severe airway obstruction (Status asthmaticus). This is a medical emergency requiring immediate airway management.

Incorrect Answers:
❌ A. Wheezing heard throughout inspiration and expiration → Suggests severe airway narrowing, but wheezing is still present, meaning air is moving. Requires monitoring but is not an immediate crisis.
❌ C. Wheezing that improves after bronchodilator administration → This is a positive response and indicates effective treatment, not an emergency.
❌ D. Wheezing localized to one lung field → This may suggest a foreign body, pneumonia, or partial obstruction, but it does not require immediate intervention unless severe respiratory distress is present.

NCLEX Tips:
Wheezing = Airway constriction (common in asthma, COPD, anaphylaxis).
“Silent chest” = Critical airway obstruction! Requires rapid intervention (oxygen, bronchodilators, possible intubation).
Unilateral wheezing → Think of foreign body aspiration or localized lung disease.

Correct Answer: B. Gastroesophageal reflux disease (GERD)
Rationale: GERD is one of the most common causes of a chronic cough, especially in patients with a history of reflux. Acid irritation can cause microaspiration or vagal nerve stimulation, leading to a persistent, dry cough.
Incorrect Answers:
❌ A. Asthma or airway hyperreactivity → Asthma can cause chronic cough, wheezing, and shortness of breath, but GERD is more likely given the patient’s history.
❌ C. Lung cancer → Chronic cough is a symptom of lung cancer, but this patient lacks risk factors (e.g., smoking, weight loss, hemoptysis).
❌ D. Pneumonia → Pneumonia typically causes acute cough with fever, chills, and productive sputum, not a chronic, persistent cough.

NCLEX Tips:
GERD-related cough is worse at night or after eating; lifestyle changes (avoiding spicy foods, elevating the head of the bed) can help.
Common causes of chronic cough (>8 weeks): GERD, asthma, postnasal drip, and ACE inhibitors.
Red flags for cough: Hemoptysis, weight loss, night sweats (consider TB or cancer).

Correct Answer: B. Increasing acetylcholine and phospholipid synthesis to support brain cell repair
Rationale: Citicoline is a nootropic drug that supports membrane repair and neurotransmitter synthesis (especially acetylcholine and phosphatidylcholine), helping with cognitive recovery after stroke or brain injury.
Incorrect Answers:
❌ A. Enhancing dopamine release to improve motor function → Incorrect; this applies to dopaminergic drugs (e.g., levodopa in Parkinson’s disease).
❌ C. Blocking glutamate receptors to prevent excitotoxicity → Incorrect; citicoline may reduce excitotoxicity indirectly, but it does not act as a glutamate receptor blocker.
❌ D. Inhibiting platelet aggregation to prevent further clot formation → Incorrect; antiplatelet drugs (e.g., aspirin, clopidogrel) are used for stroke prevention, not citicoline.

NCLEX Tips:
-Citicoline is used to enhance recovery after stroke and traumatic brain injury.
-It may improve memory, attention, and cognitive function in dementia or brain injuries.
-Monitor for mild side effects like headache, insomnia, or GI discomfort.

Correct Answer: B. “Cerebrolysin provides neurotrophic support and may help protect nerve cells.”
Rationale: Cerebrolysin is a neuropeptide derived from pig brain proteins. It has neuroprotective and neurotrophic effects, promoting nerve cell repair and survival. It is used in conditions like vascular dementia, Alzheimer’s disease, and stroke recovery.

Incorrect Answers:
❌ A. “This medication enhances dopamine production to improve cognitive function.” → Incorrect; dopaminergic drugs (e.g., levodopa) are used in Parkinson’s disease, not vascular dementia.
❌ C. “This drug prevents the breakdown of acetylcholine to slow cognitive decline.” → Incorrect; this describes acetylcholinesterase inhibitors like donepezil, used for Alzheimer’s disease.
❌ D. “Cerebrolysin is an anticoagulant that prevents further ischemic brain injury.” → Incorrect; anticoagulants (e.g., warfarin) are used for stroke prevention, but Cerebrolysin does not have anticoagulant properties.

NCLEX Tips:
– Cerebrolysin is given via IV or IM and is commonly used in Europe and Asia (not FDA-approved in the U.S.).
– Monitor for allergic reactions (e.g., dizziness, headache, agitation).
– It may be used in stroke rehabilitation to improve cognitive and motor recovery.

Correct Answers:
✅ B. Assess for rhythmic jerking movements of the limbs → Generalized tonic-clonic seizures involve stiffening (tonic) followed by jerking (clonic) movements.
✅ C. Check for eye deviation or repetitive eye blinking → Seizures often involve involuntary eye movements, which can help differentiate them from other conditions.
✅ D. Measure oxygen saturation and assess for cyanosis → Seizures can cause hypoxia due to impaired breathing during prolonged episodes.

Incorrect Answers:
❌ A. Attempt to wake the patient by calling their name and applying a sternal rub → Patients in an active seizure will not respond to stimuli, but a postictal patient may gradually regain consciousness.
❌ E. Ask the patient to squeeze your hand to assess responsiveness → A patient having a seizure will likely not follow commands. However, this can help assess postictal recovery.

NCLEX Tip:
Seizures vs. Pseudoseizures: If a patient is unresponsive but maintains purposeful movements or follows commands, it may not be a true seizure.
Assess postictal state: After a seizure, the patient may be confused, drowsy, or unresponsive for several minutes.

Correct Answers:
✅ A. Place the patient in contact isolation precautions → C. difficile is highly contagious and requires contact precautions (gown & gloves).
✅ B. Wash hands with soap and water → Alcohol-based sanitizers do not kill C. difficile spores.
✅ D. Prepare to administer oral vancomycin or fidaxomicin → These are the first-line treatments for C. difficile infection.

Incorrect Answers:
❌ C. Administer loperamide (Imodium) → This is contraindicated because it can worsen C. difficile infection by trapping toxins in the gut.
❌ E. Encourage probiotic-rich yogurt → While probiotics may help prevent C. difficile, they are not a treatment for an active infection.

Correct answers:
✅ C. Turn the client to the side. (Prevents aspiration and maintains airway patency.)
✅ D. Loosen restrictive clothing around the client’s neck. (Promotes breathing and circulation.)
✅ E. Note the time and duration of the seizure. (Important for documentation and assessing seizure activity.)
Incorrect:
❌ A. Restrain the client’s arms and legs. (Can cause injury; instead, protect the client from harm.)
❌ B. Place a padded tongue blade in the client’s mouth. (Never insert anything in the client’s mouth during a seizure; it can cause choking or injury.)

Correct Answer: A. Administer lorazepam (Ativan) IV
Rationale:
Status epilepticus is a life-threatening condition characterized by prolonged or recurrent seizures without recovery of consciousness between episodes. The priority intervention is to stop the seizure as quickly as possible to prevent neurological damage, hypoxia, and other complications.

Benzodiazepines (e.g., lorazepam or diazepam) are first-line medications for immediate seizure control.

B (EEG) is useful for diagnosis but is not the priority in an emergency.
C (Intubation) may be required if airway compromise occurs but is not the first action.
D (Serum electrolytes) may be relevant in identifying underlying causes but does not stop the seizure.

Correct Answer: C) “I will be awake and able to talk during the entire procedure.”
Rationale:
A TEE involves inserting an ultrasound probe into the esophagus to obtain detailed images of the heart. Conscious sedation is typically used to help the patient relax and minimize discomfort, meaning the patient will not be fully awake or able to talk throughout the procedure. The nurse should clarify this with the patient.
Option A is correct: Fasting for at least 6 hours before the test helps prevent aspiration.
Option B is correct: A sore throat is a common side effect due to the probe insertion.
Option D is correct: Sedation is used, so the patient should not drive afterward.

Correct Answer: C) “I should avoid eating or drinking for 8 hours before the test.”

Rationale:
A 2D echocardiogram is a non-invasive ultrasound test that evaluates the structure and function of the heart. Unlike a transesophageal echocardiogram (TEE), a standard 2D Echo does not require fasting because the probe is placed on the chest, not inserted into the esophagus. The patient only needs to lie still while the technician moves the probe over the chest (transthoracic echocardiogram). Therefore, option C is incorrect and indicates the need for further teaching.

Correct Answer: C) The patient complains of abdominal cramping and diarrhea.
Rationale:
Bethanechol chloride is a cholinergic agonist used to stimulate bladder contraction in cases of urinary retention. However, it can cause excessive parasympathetic stimulation, leading to side effects such as diarrhea, abdominal cramping, bradycardia, and hypotension. If the patient experiences excessive gastrointestinal symptoms, it may indicate overstimulation of the muscarinic receptors, requiring the nurse to hold the medication and notify the provider.

Correct Answer: C) “HbA1c reflects my average blood sugar over the past two to three months.”
Rationale:

-HbA1c measures the percentage of glycated hemoglobin in the blood, providing an estimate of blood glucose control over the past 2-3 months.

-It does not reflect immediate blood sugar levels (eliminating option A).

-It is not a daily test (eliminating option B).

-For most individuals with diabetes, a target HbA1c is below 7% (eliminating option D).

Correct Answers: A, B, and C

Rationale:

A. Rinsing the mouth with water helps remove oral contaminants and ensures a better sputum sample.

B. Morning samples are preferred because sputum accumulates overnight and is more concentrated.

C. A deep cough is necessary to obtain a true sputum sample from the lungs rather than saliva, which can contaminate the results.

D. Antibiotics should ideally be started after the sample is collected to avoid altering the bacterial culture results.

E. Sputum samples should be sent to the lab immediately rather than refrigerated, as delays can affect bacterial growth.

Correct Answers: A, B, and D

Rationale:
Correct
A. Keeping the head of the bed elevated (30-45 degrees) reduces the risk of aspiration by preventing reflux.
B. Checking gastric residual volume regularly helps monitor gastric emptying and prevent overfeeding, reducing aspiration risk.
D. Confirming tube placement ensures that the tube is in the correct position before administering feedings, preventing aspiration into the lungs.

Incorrect
C. Supine positioning increases aspiration risk and should be avoided.
E. Increasing the feeding rate without assessing tolerance may increase aspiration risk.

Correct Answer: A
Rationale:

Acute angle-closure glaucoma is a medical emergency caused by a sudden rise in intraocular pressure.

Immediate treatment includes administering IV acetazolamide (Diamox) to reduce intraocular pressure and prevent permanent vision loss.

The client may also need topical beta-blockers and emergency ophthalmologic intervention, such as laser peripheral iridotomy.

Correct Answer: B
Rationale:

Clients should not double up on missed doses of glaucoma medications, as this can increase the risk of side effects. Instead, they should take the next dose as scheduled and consult their provider if they have concerns.

Correct Answer: C) Implement strict isolation precautions for infected patients.
Rationale:
Infection control is a top priority during a pandemic. Isolating infected patients helps prevent the spread of the disease to others.

Education (B) is important but not the immediate priority.

Prophylactic treatment (A) may not be appropriate for all infections.

Stockpiling PPE (D) is useful but does not directly control the current spread.

Correct Answer: B. Encourage the patient to write or use picture boards
Rationale:
Expressive aphasia (Broca’s aphasia) affects a person’s ability to produce spoken or written language, though comprehension remains intact.

Using alternative communication methods, such as writing, gestures, or picture boards, helps the patient express their needs.

Speaking loudly does not improve comprehension, limiting communication is counterproductive, and open-ended questions may increase frustration.

Correct Answer: C. “I will ask my doctor for antibiotics to help clear the infection.”
Rationale:
Acute bronchitis is most often caused by a viral infection, meaning antibiotics are usually not necessary. Instead, treatment focuses on symptom management, including hydration, rest, humidified air, and avoiding respiratory irritants.

Antibiotics are only prescribed if a bacterial infection is confirmed.

Correct Answer: B. Blood pressure of 82/45 mmHg and altered mental status
Rationale:
Hypotension and altered mental status indicate septic shock, which requires immediate intervention, including fluid resuscitation and vasopressor support.

While fever, tachycardia, elevated WBC count, and increased respiratory rate are concerning signs of sepsis, hypotension signals progression to life-threatening organ dysfunction.

Correct Answer: C. Implement bleeding precautions and use a soft-bristled toothbrush

Rationale:
A platelet count below 50,000/mm³ increases the risk of bleeding. The nurse should implement bleeding precautions, including using a soft-bristled toothbrush, avoiding IM injections, and preventing injury.

Firm-bristled toothbrushes and IM injections can cause bleeding, and contact sports pose a high risk of trauma, making options A, B, and D incorrect.

Correct Answer:
B. Consume more leafy green vegetables, red meat, and legumes

Rationale:
Anemia, particularly iron-deficiency anemia, can be improved with iron-rich foods such as red meat, leafy greens, and legumes. These foods help increase hemoglobin levels by providing the necessary iron for red blood cell production.

Vitamin C enhances iron absorption, whereas calcium can inhibit it, making option A incorrect.

Correct Answer:
C. Impending respiratory failure requiring urgent intervention

Rationale:
Diminished breath sounds with no audible wheezing can indicate severe airway obstruction and impending respiratory failure.

The absence of wheezing suggests that little to no air is moving through the airways, which is a life-threatening sign.

Immediate intervention, including oxygen therapy, bronchodilators, and possibly mechanical ventilation, is necessary.

Correct Answer: D. “I should avoid all physical activity to prevent worsening my condition.”

Rationale: Avoiding all physical activity can lead to muscle weakness and decreased spinal flexibility, which may worsen symptoms of thoracic spondylosis (degenerative changes in the thoracic spine).

Exercise, good posture, and pain management strategies such as heat or cold therapy (A, B, and C) can help maintain mobility and reduce discomfort.

Patients should engage in low-impact activities to strengthen muscles and support spinal health.

Correct Answer: C. Respiratory rate of 32 breaths per minute with use of accessory muscles

Rationale:

-A respiratory rate >30 breaths per minute with accessory muscle use suggests respiratory distress and possible impending respiratory failure, requiring immediate intervention such as oxygen therapy, ventilatory support, or escalation of care.

-Crackles and productive cough (A) are expected findings in pneumonia.

-Fever and increased sputum production (B) indicate infection but are not immediately life-threatening.

-Oxygen saturation of 94% with mild dyspnea (D) is stable and does not require urgent intervention.

Correct Answer: C. Severe groin pain with nausea and a firm, non-reducible mass

Rationale:

-Severe pain, nausea, and a firm, non-reducible mass suggest incarceration or strangulation of the hernia, which can lead to intestinal obstruction and tissue necrosis. This is a surgical emergency requiring immediate intervention.

-A soft, reducible bulge (A) is a common finding in a non-complicated hernia.

-Mild discomfort that worsens with activity (B) is typical of a reducible hernia.

-A painless hernia present for years (D) may be monitored but does not require urgent intervention unless symptoms develop.

Correct Answer: C. “The pain suddenly went away, but now my scrotum feels cold and numb.”

Rationale:

-A sudden loss of pain with scrotal coldness or numbness may indicate testicular torsion, a surgical emergency that requires immediate intervention to prevent permanent testicular damage.

-Gradual scrotal pain (A), swelling and warmth (B), and painful urination with discharge (D) are common symptoms of epididymitis, an infection or inflammation of the epididymis, which can be treated with antibiotics and supportive care. However, testicular torsion must be ruled out in cases of sudden symptom changes.

Correct Answer: D. “If I don’t feel any lumps or changes, I only need to check every six months.”

Rationale:

-Testicular self-examinations (TSE) should be done monthly, not every six months, to detect any early signs of testicular cancer, which is most common in young men.

-Performing TSE after a warm shower (A) helps relax the scrotum, making it easier to detect abnormalities.

-A small, firm lump (B) should always be reported, as it could indicate cancer.

-It is normal for one testicle to be slightly larger or hang lower than the other (C), and this does not indicate a problem.

Correct Answer: B. “This procedure is typically done under local or regional anesthesia.”

Rationale:

-A lipoma is a benign fatty tumor that is often removed through a minor surgical procedure under local or regional anesthesia.

-A urinary catheter (A) is not necessary for this type of surgery.

-Walking restrictions for a week (C) are not needed, though the patient should avoid strenuous activities for a short period.

-Lipomas are benign and rarely become cancerous (D), so removal is usually done for comfort or cosmetic reasons.

Correct Answer: D. Inability to urinate with suprapubic pain and distention

Rationale:

-Acute urinary retention is a medical emergency that requires immediate catheterization to prevent bladder damage and postrenal acute kidney injury. This is indicated by suprapubic pain, bladder distention, and the inability to urinate.

-Difficulty starting a urine stream (A) and increased urinary frequency (B) are common BPH symptoms but do not require urgent intervention.

-A post-void residual of 500 mL (C) suggests significant urinary retention but is not immediately life-threatening.

Correct Answer: B. Serum potassium level of 6.5 mEq/L

Rationale:

-Hyperkalemia (serum potassium >5.0 mEq/L) is a life-threatening complication of acute kidney injury because it can cause fatal cardiac arrhythmias. A potassium level of 6.5 mEq/L requires immediate intervention, such as administering calcium gluconate, insulin with glucose, or sodium polystyrene sulfonate (Kayexalate).

-Urine output of 25 mL/hour (A) is low but not immediately life-threatening.

-Elevated BUN (C) indicates impaired kidney function but does not require urgent intervention.

-Mild peripheral edema (D) is expected in kidney dysfunction but does not require emergency treatment.

Correct Answer: C. Positive Turner’s sign (bruising on the flanks)

Rationale:

-Turner’s sign (flank bruising) indicates retroperitoneal bleeding, a serious complication of acute pancreatitis that may suggest hemorrhagic pancreatitis. This requires immediate intervention.

-Severe epigastric pain (A) and elevated serum lipase levels (B) are expected in acute pancreatitis but do not require urgent intervention.

-Nausea and vomiting (D) are common symptoms but are not immediately life-threatening.

Correct Answer: C. Vomiting bright red blood

Rationale:

-Hematemesis (vomiting blood) may indicate ruptured esophageal varices, a life-threatening complication of liver cirrhosis and portal hypertension. This requires immediate medical intervention to prevent severe blood loss and shock.

-Jaundice and pruritus (A) are common in liver disease but are not emergencies.

-Ascites with shifting dullness (B) indicates fluid accumulation and should be monitored, but it does not require immediate intervention unless respiratory distress occurs.

-Spider angiomas (D) are a sign of liver dysfunction but are not an urgent concern.

Correct Answer: A. “Drink several glasses of water and do not urinate before the test.”

Rationale:

-In early and mid-pregnancy, a full bladder is needed for a sonogram (ultrasound) to help lift the uterus and improve visualization of the fetus.

-Fasting (B) is not required for a routine obstetric ultrasound.

-Contrast dye (C) is not used in standard sonography.

-Lying on the left side (D) is helpful for circulation in late pregnancy but is not required for the ultrasound itself.

Correct Answer: D. The urine output is 10 mL over the past two hours

Rationale:

-Urine output less than 30 mL per hour may indicate decreased kidney perfusion, urinary obstruction, or catheter malfunction, requiring immediate assessment and intervention.

-Cloudy urine with sediment (B) may suggest a urinary tract infection (UTI) but is not an emergency.

-Proper securing of the catheter to the thigh (A) and positioning the drainage bag below the bladder (C) help prevent trauma and backflow but do not require urgent intervention.

Correct Answer: C. Complaints of sudden, severe back or abdominal pain

Rationale:

-A sudden onset of severe back or abdominal pain may indicate an impending or ruptured AAA, which is a life-threatening emergency requiring immediate medical intervention.

-A pulsating mass in the periumbilical area (A) and a bruit over the abdominal aorta (D) are common findings in an AAA but do not necessarily indicate rupture.

-Blood pressure of 140/80 mmHg (B) should be monitored but is not an immediate danger unless it becomes significantly elevated, increasing the risk of rupture.

Correct Answer: B. Sharp right upper quadrant pain that radiates to the shoulder

Rationale:

-Cholelithiasis (gallstones) often presents with biliary colic, which is characterized by right upper quadrant (RUQ) pain that may radiate to the right shoulder or back, especially after consuming fatty foods.

-Left lower quadrant pain relieved by defecation (A) is more characteristic of irritable bowel syndrome (IBS).

-Epigastric pain worsened by an empty stomach (C) is typical of peptic ulcer disease.

-Cramping abdominal pain with bloody diarrhea (D) suggests inflammatory bowel disease (e.g., ulcerative colitis or Crohn’s disease).

Correct Answer: B. “Avoid eating or drinking anything for at least 6 to 8 hours before the ultrasound.”

Rationale:

-A whole abdomen ultrasound requires the patient to be NPO (nothing by mouth) for 6 to 8 hours to reduce bowel gas and improve visualization of abdominal organs, including the liver, gallbladder, pancreas, and intestines.

-Drinking excessive water before the test (A) is usually required for a pelvic ultrasound, not a whole abdomen ultrasound.

-Laxatives (C) are not routinely needed unless the provider orders bowel preparation.

-Eating a high-fat meal (D) before the test can cause gallbladder contraction, making visualization difficult.

Correct Answer: B. Infuse potassium chloride at a rate no faster than 10 mEq/hour

Rationale:

-IV potassium chloride must be administered slowly to prevent cardiac arrhythmias and vein irritation.

-The maximum infusion rate for peripheral IV administration is 10 mEq/hour and up to 40 mEq/hour via a central line with continuous cardiac monitoring.

-IV push potassium (A) is fatal and should never be done.

-Mixing with dextrose (C) can stimulate insulin release and worsen hypokalemia. The Trendelenburg position (D) is not necessary and does not aid potassium administration.

Correct Answer: C. The patient has a moderate brain injury and requires close monitoring

Rationale:

-The Glasgow Coma Scale (GCS) is used to assess a patient’s level of consciousness based on eye, verbal, and motor responses.

-A score of 9-12 indicates a moderate brain injury and requires frequent neurological assessments.

-A GCS of 8 or lower (A) indicates a severe brain injury and often requires intubation.

-A score of 13-15 (B) indicates a mild brain injury.

-A score below 8 (D) suggests severe impairment with a lack of purposeful movement.

Correct Answer: B. The patient has a weak or delayed cough reflex

Rationale:

-A weak or absent cough reflex suggests impaired airway protection, increasing the risk of aspiration.

-In a dysphagia test, patients are often asked to swallow water or food while the nurse observes for coughing, choking, or voice changes. Swallowing without coughing (A) and a clear voice after swallowing (D) indicate a normal response.

-Feeling thirsty (C) is not a sign of dysphagia. If aspiration risk is suspected, a speech-language pathologist evaluation and further testing, such as a videofluoroscopic swallow study, may be needed.

Correct Answer: B. Urine output of 20 mL over the past hour.

Rationale:

-Norepinephrine is a vasopressor that increases blood pressure by vasoconstriction. A urine output of less than 30 mL/hour may indicate decreased renal perfusion, which can lead to acute kidney injury. This requires immediate intervention, such as adjusting the infusion rate or assessing for fluid resuscitation needs.

-A blood pressure increase (A) is an expected effect.

-A heart rate of 90 bpm (C) is within normal range.

-A capillary refill time of less than 2 seconds (D) suggests adequate perfusion.

Correct Answer: A. Serum potassium level of 2.8 mEq/L

Rationale:

-Furosemide is a loop diuretic that can cause significant potassium loss, leading to hypokalemia. A potassium level of 2.8 mEq/L is critically low and requires immediate intervention to prevent complications such as arrhythmias.

-A blood pressure of 130/80 mmHg (B) is within normal limits.

-Increased urine output (C) is an expected effect.

-Mild ringing in the ears (D) may occur but is more concerning if it becomes severe, as furosemide can cause ototoxicity, especially with high doses or rapid IV administration.

Correct Answer: A. Administer desmopressin as prescribed

Rationale:

-Diabetes insipidus is characterized by excessive urine output due to a deficiency of antidiuretic hormone (ADH). Desmopressin (DDAVP) is a synthetic ADH that helps reduce urine output.

-Restricting fluids (B) could lead to dehydration.

-A high-sodium diet (C) could worsen dehydration, and loop diuretics (D) would increase urine output rather than reduce it.

Correct Answer: B. Obtain a midstream clean-catch urine sample in a sterile container.

Rationale:

-A midstream clean-catch urine sample is the preferred method for urine C&S to reduce contamination.

-The first voided urine in the morning (A) may be useful for other tests but is not specifically required for C&S.

-Urine should never be collected from a catheter drainage bag (C) due to contamination risk; instead, it should be obtained from the catheter’s sampling port.

-Storing urine at room temperature (D) can lead to bacterial overgrowth, potentially affecting results.

Correct Answer: A. Muscle weakness and flattened T waves.

Rationale:

-Hypokalemia (low potassium) commonly causes muscle weakness, fatigue, and ECG changes such as flattened or inverted T waves. Other symptoms may include constipation and decreased deep tendon reflexes.

-Options B and C describe symptoms of hyperkalemia, while bradycardia (D) can occur but is more typical in severe hyperkalemia.

Correct Answer:
C. Peaked T waves on ECG

Rationale:
-Hyperkalemia can cause life-threatening cardiac dysrhythmias. Peaked T waves are an early ECG sign of severe hyperkalemia and indicate a risk for ventricular fibrillation or cardiac arrest. This requires immediate intervention, such as administration of calcium gluconate, insulin with dextrose, sodium bicarbonate, or dialysis, depending on severity.

-While muscle weakness, nausea, and tingling are also symptoms of hyperkalemia, they are not as immediately life-threatening as cardiac effects.

Correct Answer:
B. Assess the patient’s airway, breathing, and circulation (ABCs)

Rationale:
-In an acute stroke, ensuring a patent airway and adequate breathing and circulation is the priority.

-Stroke patients are at risk for airway obstruction due to decreased level of consciousness or difficulty swallowing (dysphagia).

-Once ABCs are stabilized, the nurse can proceed with neurological assessments, obtaining a history, and administering thrombolytic therapy if the patient is eligible.

Correct Answer: C. “The X-ray will expose me to a large amount of radiation, which is very dangerous.”

Rationale:
-Option C is incorrect because chest X-rays use a very low dose of radiation and are generally safe. While unnecessary exposure should be avoided, the benefits outweigh the risks when medically indicated.
-Option A is correct because metal objects can interfere with imaging.
-Option B is correct because holding breath reduces motion blur and improves image quality.
-Option D is correct because pregnant patients should inform providers to consider shielding or alternative imaging (e.g., ultrasound).

NCLEX Tip:
Educate patients that chest X-rays are quick, painless, and use minimal radiation. Always check for pregnancy before performing radiologic exams.

Correct Answer: A. Check the patient’s vital signs and verify blood product compatibility with another nurse.

Rationale:

-Option A is correct because verifying patient identity, blood type, and compatibility with another nurse is critical to prevent life-threatening reactions. Baseline vital signs are also essential to detect early transfusion reactions.
-Option B is incorrect because acute reactions (e.g., hemolytic, febrile, or allergic) are more urgent than delayed reactions.
-Option C is incorrect because only normal saline (0.9% NaCl) should be used to prime IV lines for blood transfusions. Lactated Ringer’s or dextrose solutions can cause hemolysis.
-Option D is incorrect because blood should be started slowly (≤2 mL/min for the first 15 minutes) to monitor for adverse reactions.

NCLEX Tip:
Always verify blood products with another nurse, use normal saline, and monitor for reactions (e.g., fever, chills, hypotension, dyspnea).

Correct Answer: A. “Since I have no family history of breast cancer, I don’t need a mammogram.”

Rationale:

-All women over 40–50 years old (depending on guidelines) should get regular screening mammograms, regardless of family history. Most breast cancer cases occur in women without a family history.
-Option B is correct; mammograms can detect tumors before they are palpable.
-Option C is correct; deodorants, lotions, and powders can interfere with imaging.
-Option D is correct; breast cancer risk increases with age, making screening more crucial.

NCLEX Tip:
-Patients should be educated on early detection and screening guidelines. The USPSTF recommends biennial mammograms starting at age 50, while other organizations (like the ACS) suggest starting at 40.

Correct Answer: B. Heat intolerance, tachycardia, and weight loss

Rationale:
-A low TSH level (below the normal range of approximately 0.4–4.2 µIU/mL) suggests possible hyperthyroidism, in which excessive thyroid hormone production suppresses TSH secretion.

-Hyperthyroidism presents with increased metabolism, leading to tachycardia, weight loss, heat intolerance, and anxiety.

-Option A & D describe hypothyroidism, which is associated with a high TSH.
-Option C includes symptoms of adrenal insufficiency rather than thyroid dysfunction.

NCLEX Tip: Always correlate lab values with clinical presentation. TSH alone isn’t diagnostic—check Free T3 and Free T4 for a complete thyroid assessment!

Correct Answer: C. Perform an abdominal assessment, including auscultation and palpation

Rationale:

-The nurse should first assess the patient to determine the presence of bowel sounds, distention, or signs of impaction before implementing interventions.

-Encouraging ambulation (option A) and administering a stool softener (option B) may be appropriate but should follow a thorough assessment.

-Notifying the provider (option D) may be necessary if impaction or obstruction is suspected, but assessment is the priority action.

Correct Answer: C. Assess for air leakage and ensure the mask is properly fitted

Rationale:

-A poorly fitted BiPAP mask can cause air leaks, leading to inadequate ventilation and patient discomfort.

-Before making any adjustments to the settings or discontinuing BiPAP, the nurse should check for a secure fit. If anxiety persists after ensuring proper fit, further interventions may be needed.

-Removing the BiPAP (option D) without provider approval can worsen respiratory distress.

-Increasing pressure settings (option B) without assessment can cause discomfort or barotrauma.

-Encouraging continued use (option A) is appropriate, but addressing the cause of distress takes priority.

Correct Answer:
B. Check the medical record for a sliding scale insulin order and administer the appropriate dose.

Rationale:
-A blood glucose level of 250 mg/dL is above the normal range and requires intervention to prevent hyperglycemia complications. Many diabetic patients have sliding scale insulin orders for elevated blood glucose levels. The nurse should first check for a prescribed insulin regimen and administer the appropriate dose if ordered.
-A.) Long-acting insulin is important for basal glucose control but does not provide immediate correction for hyperglycemia.
-C.) Hydration is helpful, but it is not the primary intervention.
-D.) While persistent hyperglycemia should be reported, an isolated blood glucose reading of 250 mg/dL does not require immediate provider notification unless accompanied by symptoms of ketoacidosis or another emergency.

Correct Answer: A. Administer IV furosemide as prescribed

Rationale:

-An elevated pro-BNP (>450 pg/mL in patients over 50) indicates heart failure, as BNP is released in response to ventricular stretching due to fluid overload. Diuretics like furosemide help reduce fluid retention, relieve pulmonary congestion, and improve symptoms.

B is incorrect because increasing fluid intake can worsen fluid overload in heart failure.

C is incorrect because placing the patient in a supine position can exacerbate pulmonary congestion and worsen breathing difficulty. Elevating the head of the bed is preferred.

D is incorrect because fluid overload is a concern, and IV fluid boluses are contraindicated in decompensated heart failure unless there is clear evidence of hypovolemia.

NCLEX TIPS:

BNP (B-type Natriuretic Peptide)
Normal Range: Less than 100 pg/mL

Clinical Indications:

BNP levels >100 pg/mL may suggest heart failure, especially if consistent with clinical symptoms such as dyspnea, edema, or fatigue.

-Higher levels typically correlate with worse heart failure severity.

NT-proBNP (N-terminal pro b-type Natriuretic Peptide)
Normal Ranges:

Age < 75 years: Less than 125 pg/mL

Age ≥ 75 years: Less than 450 pg/mL

Clinical Indications:

NT-proBNP levels >900 pg/mL (in patients under 50, some guidelines use >450 pg/mL) may indicate acute or decompensated heart failure.

Like BNP, values increase with worsening heart function and can be influenced by age, renal function, and obesity.

Correct Answer: B. Obtain a 12-lead electrocardiogram (ECG)

Rationale:
-An elevated troponin level suggests myocardial injury, possibly an acute coronary syndrome (ACS) or myocardial infarction (MI). The priority action is to obtain a 12-lead ECG to assess for ischemic changes or ST-elevation. This helps guide immediate treatment decisions.

-A (Nitroglycerin): While nitroglycerin can relieve chest pain, assessing cardiac electrical activity first is essential.

-C (Notify provider): The provider should be informed, but obtaining an ECG provides critical information for immediate decision-making.

-D (Ambulation): Ambulating a patient with possible MI is inappropriate and could worsen their condition.

Troponin I (cTnI) – Normal Range
Normal Range:
Less than 0.04 ng/mL (or <40 pg/mL, depending on the unit used)

Clinical Interpretation:
0.04–0.39 ng/mL: May be considered borderline — further monitoring and clinical correlation are needed.

≥0.40 ng/mL: Often considered elevated and may indicate myocardial injury, such as a heart attack (myocardial infarction), especially when there’s a rising or falling pattern.

Note: Normal values can vary slightly depending on the lab and the specific assay used. Always interpret in the context of symptoms, ECG findings, and other clinical data.

Correct Answer: C. Vitamin K

Rationale:

-Vitamin K is required for the liver to synthesize clotting factors II, VII, IX, and X. A deficiency can lead to impaired coagulation and prolonged bleeding.

-The other vitamins listed do not play a direct role in clotting factor production.

Correct Answer: C. Assess eye opening, verbal response, and motor response.

Rationale:
-The GCS is used to evaluate a patient’s level of consciousness and neurological status, especially after a head injury or stroke. It includes three components: eye opening (E), verbal response (V), and motor response (M). Each component has a numerical score, and the total score helps determine the severity of the patient’s condition.

Correct Answer:
B. “I should not eat or drink anything for 8 hours before the test.”
Rationale:
-A 2D echocardiogram is a non-invasive procedure that uses ultrasound to visualize the heart. Unlike a transesophageal echocardiogram (TEE), a standard 2D echo does not require fasting. The other options are accurate statements about the test.

Correct Answer: C. Keep the patient NPO and monitor for signs of increased intracranial pressure

Rationale:
-The patient’s symptoms suggest a possible stroke, but since the onset was 9 hours ago, she is outside the 4.5-hour window for thrombolytic therapy.
-The nurse’s priority is to maintain safety by keeping the patient NPO (due to risk of aspiration) and monitoring for signs of increased ICP.
-Neurological assessment and notifying the provider are important, but managing airway and ICP takes precedence.

Correct Answer: C. 4.7 mL

Calculation:

1. Convert weight from pounds to kilograms:
22 lb ÷ 2.2 = 10 kg

2. Calculate dose in mg:
15 mg × 10 kg = 150 mg

3. Use the concentration to find volume:
(150 mg ÷ 160 mg) × 5 mL = 4.69 mL ≈ 4.7 mL

Correct Answer:
B. Vitamin K (phytonadione)

Rationale:
-Vitamin K is the antidote for warfarin toxicity, as it helps the liver produce clotting factors and reverses the anticoagulant effects.
-Protamine sulfate is the antidote for heparin, not warfarin.
-Activated charcoal may be used in acute overdose situations if ingestion is recent but is not the antidote.
-Atropine is used for bradycardia, not for anticoagulant overdose.

Correct Answer:
B. The patient’s heart rate increases to 70 bpm.

Rationale:
-Atropine is an anticholinergic used to treat symptomatic bradycardia by increasing the heart rate.
-An increase in heart rate toward a normal range indicates the medication is working.
-Chest pain or a new arrhythmia may be adverse effects.
-Increased drowsiness would not indicate improvement; the patient should be more alert as perfusion improves.

Correct Answer:
D. Ensure the patient is in a safe environment and implement suicide precautions

Rationale:
-Patient safety is the highest priority, especially in the context of a potential suicide attempt.
-While involving psychiatric services (Option A) is important, it comes after immediate safety measures are established.
-IV access and assessment are secondary to ensuring the patient cannot harm himself further.
-Let me know if you’d like to build this into a case study or add lab interpretation.