QUESTIONS WITH VERIFIED ANSWERS AND i,- i,- i,- i,- i,-
RATIONALE | LATEST 2025/2026 UPDATE. i,- i,- i,- i,-
The nurse is caring for a client with a fractured right elbow. Which
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assessment finding has the highest priority and requires
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immediate intervention? i,-
A. Ecchymosis over the right elbow area
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B. Deep unrelenting pain in the right arm
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C. An edematous right elbow
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D. The presence of crepitus in the right elbow
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Answer: B i,-
Rationale:Compartment syndrome is a condition involving i,- i,- i,- i,- i,- i,-
increased pressure and constriction of the nerves and vessels
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within an anatomic compartment, causing pain uncontrolled by
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opioids and neurovascular compromise. Option A is an expected
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finding. Option C related to compartment syndrome cannot be
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seen, and any visible edema is an expected finding related to the
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injury. Option D is an expected finding.
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,The nurse notes that a client who is scheduled for surgery the
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next morning has an elevated blood urea nitrogen (BUN) level.
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Which condition is most likely to have contributed to this finding?
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A. Myocardial infarction 2 months ago
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B. Anorexia and vomiting for the past 2 days
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C.Recently diagnosed type 2 diabetes mellitus i,- i,- i,- i,- i,-
D. Skeletal traction for a right hip fracture
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Rationale:The blood urea nitrogen (BUN) level indicates the i,- i,- i,- i,- i,- i,- i,- i,-
effectiveness of the kidneys in filtering waste from the blood. i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
Dehydration, which could be caused by vomiting, would cause an i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
increased BUN level. Option A would affect serum enzyme levels,
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not the BUN level. Option C would primarily affect the blood
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glucose level; renal failure that could increase the BUN level
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would be unlikely in a client newly diagnosed with type 2
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diabetes. Effects of option D might affect the complete blood
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count (CBC) but would not directly increase the BUN level.
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Which instruction is best for the nurse to provide to a client with
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emphysema and chronic fatigue? i,- i,- i,-
A."Pace your activities and schedule rest periods."
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B."Increase the amount of oxygen you use at night."i,- i,- i,- i,- i,- i,- i,- i,-
C."Obtain medical evaluation for antibiotic therapy."
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,D."Reduce your intake of fluids containing caffeine."
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Answer: A i,-
Rationale:Manifestations of emphysema include an increase in AP i,- i,- i,- i,- i,- i,- i,- i,-
diameter (referred to as a barrel chest), nail bed clubbing, and
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fatigue. The nurse can provide instructions to promote energy
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management, such as pacing activities and scheduling rest i,- i,- i,- i,- i,- i,- i,- i,-
periods. Option B may result in a decreased drive to breathe. The
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client is not exhibiting any symptoms of infection, so option C is
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not necessary. Option D is less beneficial than option A.
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Which nursing action would be appropriate for a client who is
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newly diagnosed with Cushing syndrome?
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A.Monitor blood glucose levels daily. i,- i,- i,- i,-
B.Increase intake of fluids high in potassium.
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C.Encourage adequate rest between activities. i,- i,- i,- i,-
D.Offer the client a sodium-enriched menu.
i,- i,- i,- i,- i,- i,-i,- i,- Correct Answer: A i,- i,-
Rationale: Cushing syndrome results from a hypersecretion of
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glucocorticoids in the adrenal cortex. Clients with Cushing i,- i,- i,- i,- i,- i,- i,- i,-
syndrome often develop diabetes mellitus. Monitoring of serum
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glucose levels assesses for increased blood glucose levels so that
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treatment can begin early. A common finding in Cushing
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syndrome is generalized edema. Although potassium is needed, it
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, is generally obtained from food intake, not by offering potassium-
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enhanced fluids. Fatigue is usually not an overwhelming factor in
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Cushing syndrome, so an emphasis on the need for rest is not
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indicated. A low-calorie, low-carbohydrate, low-sodium diet is not
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recommended.
During the change of shift report, the charge nurse reviews the
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infusions being received by clients on the oncology unit. The
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client receiving which infusion should be assessed first?
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A.Continuous IV infusion of magnesium i,- i,- i,- i,-
B.One-time infusion of albumin i,- i,- i,-
C.Continuous epidural infusion of morphine i,- i,- i,- i,-
D.Intermittent infusion of IV vancomycin i,- i,- i,- i,- i,-i,- i,- Correct Answer: C i,- i,-
Rationale: All four of these clients have the potential to have
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significant complications. The client with the morphine epidural
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infusion is at highest risk for respiratory depression and should
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be assessed first. Option A can cause hypotension. The client
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receiving option B is at lowest risk for serious complications.
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Although option D can cause nephrotoxicity and phlebitis, these
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problems are not as immediately life threatening as option C.
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A client who received a nephrotoxic drug is admitted with acute
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renal failure and asks the nurse if dialysis will always be needed.
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