Question 1: A nurse obtains a health history from a patient who has a 35-pack-year
smoking history. The patient reports hoarseness, tightness in the throat, and
di iculty swallowing. Which question is important for the nurse to ask?
A. "How much alcohol do you drink in an average week?"
B. "Have you had a recent upper respiratory infection?"
C. "Do you have a family history of throat cancer?"
D. "Have you experienced any recent weight loss?"
CORRECT ANSWER: A. "How much alcohol do you drink in an average week?"
Rationale: The patient's symptoms (hoarseness, throat tightness, dysphagia) in the
context of a heavy smoking history suggest possible laryngeal or esophageal pathology.
Alcohol consumption is a significant risk factor for these conditions, and quantifying it
is essential for a complete assessment. While weight loss and family history are
relevant, alcohol use combined with smoking creates a synergistic risk for head and
neck cancers .
Question 2: Which action should the nurse take first when a patient develops
epistaxis?
A. Apply squeezing pressure to the nostrils for 10 minutes
B. Apply ice to the bridge of the nose
C. Tilt the patient's head backward
D. Insert nasal packing
CORRECT ANSWER: A. Apply squeezing pressure to the nostrils for 10 minutes
Rationale: The initial management of epistaxis is to apply firm, continuous pressure to
the nostrils for 10-15 minutes, with the patient leaning forward to prevent blood from
flowing down the throat. This direct pressure promotes clot formation and stops
bleeding in most cases. Tilting the head backward is contraindicated because it allows
blood to drain into the pharynx, which can cause nausea and obscure the amount of
bleeding .
Question 3: Which patient in the ear, nose, and throat (ENT) clinic should the nurse
assess first?
A. A patient who reports having a sore throat and a mu led voice
B. A patient with seasonal allergies and sneezing
C. A patient with a history of chronic sinusitis
D. A patient with a foreign body in the ear canal
,CORRECT ANSWER: A. A patient who reports having a sore throat and a mu led
voice
Rationale: A mu led voice (often described as "hot potato" voice) along with sore throat
is a hallmark sign of a peritonsillar abscess, which can progress to airway obstruction.
This patient requires priority assessment to evaluate airway patency. Seasonal allergies
and chronic sinusitis are non-urgent. A foreign body in the ear canal is uncomfortable
but not immediately life-threatening .
Question 4: The emergency department nurse notes tachycardia and absent breath
sounds over the right thorax of a patient who has just arrived after an automobile
accident. For which intervention will the nurse prepare the patient?
A. Chest tube connection to suction
B. Needle decompression
C. Oxygen therapy
D. Intubation
CORRECT ANSWER: A. Chest tube connection to suction
Rationale: Tachycardia and absent breath sounds over one hemithorax in a trauma
patient suggest a tension pneumothorax, a life-threatening condition that requires
immediate chest tube insertion to suction to reexpand the lung and restore
hemodynamic stability. Needle decompression may be performed as an emergency
temporizing measure, but chest tube insertion is the definitive treatment .
Question 5: The nurse is caring for a patient who is orally intubated and receiving
mechanical ventilation. To decrease the risk for ventilator-associated pneumonia,
which action will the nurse include in the plan of care?
A. Elevate head of bed to 30-45 degrees
B. Suction the patient every hour
C. Change the ventilator circuit daily
D. Administer prophylactic antibiotics
CORRECT ANSWER: A. Elevate head of bed to 30-45 degrees
Rationale: Elevating the head of the bed to 30-45 degrees is a key evidence-based
intervention to prevent ventilator-associated pneumonia (VAP). This position reduces
the risk of aspiration of gastric contents. Routine circuit changes are not recommended,
and prophylactic antibiotics are not indicated .
,Question 6: A nurse is assessing a client with suspected left-sided heart failure.
Which finding is the nurse most likely to encounter?
A. Jugular vein distention
B. Hepatomegaly
C. Bibasilar crackles
D. Peripheral edema
CORRECT ANSWER: C. Bibasilar crackles
Rationale: Left-sided heart failure occurs when the left ventricle cannot e ectively
pump blood out to the body, causing blood to back up into the pulmonary circulation.
This results in pulmonary congestion, leading to crackles (rales) in the lung bases. JVD,
hepatomegaly, and peripheral edema are classic signs of right-sided heart failure .
Question 7: A client with an acute myocardial infarction (MI) receives thrombolytic
therapy. Which assessment finding would indicate to the nurse that the therapy is
e ective?
A. Decreased creatine kinase-MB levels
B. Increase in troponin I
C. Resolution of chest pain
D. Presence of reperfusion dysrhythmias
CORRECT ANSWER: D. Presence of reperfusion dysrhythmias
Rationale: Reperfusion dysrhythmias (e.g., accelerated idioventricular rhythm, PVCs)
are a clinical sign that blood flow is being restored to the ischemic myocardium. While
resolution of chest pain is a positive sign, it is subjective. The presence of reperfusion
dysrhythmias is an objective indicator of successful thrombolysis .
Question 8: The nurse is caring for a client 4 hours after a cardiac catheterization
via the right femoral artery. What is the priority nursing assessment?
A. Breath sounds in the chest
B. Capillary refill of the right toes
C. Auscultation of heart sounds
D. Intake and output since the procedure
CORRECT ANSWER: B. Capillary refill of the right toes
Rationale: Following a femoral artery catheterization, the priority is to assess circulation
to the a ected extremity (distal to the insertion site). This includes checking pedal
, pulses, capillary refill, color, and sensation to detect arterial occlusion, hematoma, or
thrombus formation .
Question 9: A client with chronic stable angina is prescribed nitroglycerin
(Nitrostat) sublingual tablets. Which instruction should the nurse include in the
discharge teaching?
A. "Swallow the tablet with a full glass of water for faster absorption."
B. "Take one tablet every 15 minutes until the chest pain subsides."
C. "Keep the tablets in a clear plastic pill box so you can see if they are still good."
D. "If pain is not relieved after one tablet, call 911, and take up to two more tablets while
waiting."
CORRECT ANSWER: D. "If pain is not relieved after one tablet, call 911, and take up
to two more tablets while waiting."
Rationale: The correct protocol for angina is to stop activity and take one tablet. If pain
is unrelieved after 5 minutes, call emergency services, and take a second tablet. If
unrelieved after another 5 minutes, a third tablet is taken. Nitroglycerin should be
stored in a dark, airtight container, not plastic, and administered sublingually, not
swallowed .
Question 10: A client with infective endocarditis develops sudden onset hemiplegia
and slurred speech. The nurse should suspect which complication?
A. Mycotic aneurysm
B. Pulmonary embolism
C. Embolic stroke
D. Hypoglycemic event
CORRECT ANSWER: C. Embolic stroke
Rationale: Vegetations (clumps of platelets, fibrin, and microorganisms) from infective
endocarditis can dislodge and travel to the cerebral circulation, causing a stroke. This is
a common and serious complication of endocarditis .
Question 11: A nurse is caring for a client with a history of cardiac and vascular
disease. Which fats should the nurse allow in the client's diet for his condition?
A. Saturated fats
B. Hydrogenated fats
smoking history. The patient reports hoarseness, tightness in the throat, and
di iculty swallowing. Which question is important for the nurse to ask?
A. "How much alcohol do you drink in an average week?"
B. "Have you had a recent upper respiratory infection?"
C. "Do you have a family history of throat cancer?"
D. "Have you experienced any recent weight loss?"
CORRECT ANSWER: A. "How much alcohol do you drink in an average week?"
Rationale: The patient's symptoms (hoarseness, throat tightness, dysphagia) in the
context of a heavy smoking history suggest possible laryngeal or esophageal pathology.
Alcohol consumption is a significant risk factor for these conditions, and quantifying it
is essential for a complete assessment. While weight loss and family history are
relevant, alcohol use combined with smoking creates a synergistic risk for head and
neck cancers .
Question 2: Which action should the nurse take first when a patient develops
epistaxis?
A. Apply squeezing pressure to the nostrils for 10 minutes
B. Apply ice to the bridge of the nose
C. Tilt the patient's head backward
D. Insert nasal packing
CORRECT ANSWER: A. Apply squeezing pressure to the nostrils for 10 minutes
Rationale: The initial management of epistaxis is to apply firm, continuous pressure to
the nostrils for 10-15 minutes, with the patient leaning forward to prevent blood from
flowing down the throat. This direct pressure promotes clot formation and stops
bleeding in most cases. Tilting the head backward is contraindicated because it allows
blood to drain into the pharynx, which can cause nausea and obscure the amount of
bleeding .
Question 3: Which patient in the ear, nose, and throat (ENT) clinic should the nurse
assess first?
A. A patient who reports having a sore throat and a mu led voice
B. A patient with seasonal allergies and sneezing
C. A patient with a history of chronic sinusitis
D. A patient with a foreign body in the ear canal
,CORRECT ANSWER: A. A patient who reports having a sore throat and a mu led
voice
Rationale: A mu led voice (often described as "hot potato" voice) along with sore throat
is a hallmark sign of a peritonsillar abscess, which can progress to airway obstruction.
This patient requires priority assessment to evaluate airway patency. Seasonal allergies
and chronic sinusitis are non-urgent. A foreign body in the ear canal is uncomfortable
but not immediately life-threatening .
Question 4: The emergency department nurse notes tachycardia and absent breath
sounds over the right thorax of a patient who has just arrived after an automobile
accident. For which intervention will the nurse prepare the patient?
A. Chest tube connection to suction
B. Needle decompression
C. Oxygen therapy
D. Intubation
CORRECT ANSWER: A. Chest tube connection to suction
Rationale: Tachycardia and absent breath sounds over one hemithorax in a trauma
patient suggest a tension pneumothorax, a life-threatening condition that requires
immediate chest tube insertion to suction to reexpand the lung and restore
hemodynamic stability. Needle decompression may be performed as an emergency
temporizing measure, but chest tube insertion is the definitive treatment .
Question 5: The nurse is caring for a patient who is orally intubated and receiving
mechanical ventilation. To decrease the risk for ventilator-associated pneumonia,
which action will the nurse include in the plan of care?
A. Elevate head of bed to 30-45 degrees
B. Suction the patient every hour
C. Change the ventilator circuit daily
D. Administer prophylactic antibiotics
CORRECT ANSWER: A. Elevate head of bed to 30-45 degrees
Rationale: Elevating the head of the bed to 30-45 degrees is a key evidence-based
intervention to prevent ventilator-associated pneumonia (VAP). This position reduces
the risk of aspiration of gastric contents. Routine circuit changes are not recommended,
and prophylactic antibiotics are not indicated .
,Question 6: A nurse is assessing a client with suspected left-sided heart failure.
Which finding is the nurse most likely to encounter?
A. Jugular vein distention
B. Hepatomegaly
C. Bibasilar crackles
D. Peripheral edema
CORRECT ANSWER: C. Bibasilar crackles
Rationale: Left-sided heart failure occurs when the left ventricle cannot e ectively
pump blood out to the body, causing blood to back up into the pulmonary circulation.
This results in pulmonary congestion, leading to crackles (rales) in the lung bases. JVD,
hepatomegaly, and peripheral edema are classic signs of right-sided heart failure .
Question 7: A client with an acute myocardial infarction (MI) receives thrombolytic
therapy. Which assessment finding would indicate to the nurse that the therapy is
e ective?
A. Decreased creatine kinase-MB levels
B. Increase in troponin I
C. Resolution of chest pain
D. Presence of reperfusion dysrhythmias
CORRECT ANSWER: D. Presence of reperfusion dysrhythmias
Rationale: Reperfusion dysrhythmias (e.g., accelerated idioventricular rhythm, PVCs)
are a clinical sign that blood flow is being restored to the ischemic myocardium. While
resolution of chest pain is a positive sign, it is subjective. The presence of reperfusion
dysrhythmias is an objective indicator of successful thrombolysis .
Question 8: The nurse is caring for a client 4 hours after a cardiac catheterization
via the right femoral artery. What is the priority nursing assessment?
A. Breath sounds in the chest
B. Capillary refill of the right toes
C. Auscultation of heart sounds
D. Intake and output since the procedure
CORRECT ANSWER: B. Capillary refill of the right toes
Rationale: Following a femoral artery catheterization, the priority is to assess circulation
to the a ected extremity (distal to the insertion site). This includes checking pedal
, pulses, capillary refill, color, and sensation to detect arterial occlusion, hematoma, or
thrombus formation .
Question 9: A client with chronic stable angina is prescribed nitroglycerin
(Nitrostat) sublingual tablets. Which instruction should the nurse include in the
discharge teaching?
A. "Swallow the tablet with a full glass of water for faster absorption."
B. "Take one tablet every 15 minutes until the chest pain subsides."
C. "Keep the tablets in a clear plastic pill box so you can see if they are still good."
D. "If pain is not relieved after one tablet, call 911, and take up to two more tablets while
waiting."
CORRECT ANSWER: D. "If pain is not relieved after one tablet, call 911, and take up
to two more tablets while waiting."
Rationale: The correct protocol for angina is to stop activity and take one tablet. If pain
is unrelieved after 5 minutes, call emergency services, and take a second tablet. If
unrelieved after another 5 minutes, a third tablet is taken. Nitroglycerin should be
stored in a dark, airtight container, not plastic, and administered sublingually, not
swallowed .
Question 10: A client with infective endocarditis develops sudden onset hemiplegia
and slurred speech. The nurse should suspect which complication?
A. Mycotic aneurysm
B. Pulmonary embolism
C. Embolic stroke
D. Hypoglycemic event
CORRECT ANSWER: C. Embolic stroke
Rationale: Vegetations (clumps of platelets, fibrin, and microorganisms) from infective
endocarditis can dislodge and travel to the cerebral circulation, causing a stroke. This is
a common and serious complication of endocarditis .
Question 11: A nurse is caring for a client with a history of cardiac and vascular
disease. Which fats should the nurse allow in the client's diet for his condition?
A. Saturated fats
B. Hydrogenated fats
