1. Which of the following lab results is most concerning in a critically ill
patient with a history of heart failure?
A. Potassium level of 3.5 mEq/L
B. Blood glucose level of 120 mg/dL
C. Serum sodium level of 140 mEq/L
D. Blood urea nitrogen (BUN) level of 45 mg/dL
Answer: d) Blood urea nitrogen (BUN) level of 45 mg/dL
Rationale: An elevated BUN level could indicate renal impairment or
dehydration, both of which are concerning in heart failure patients, as
these conditions can worsen fluid status and cardiac function.
2. What is the most common cause of a fever within the first 48 hours
after major surgery?
A. Wound infection
,B. Atelectasis
C. Deep vein thrombosis (DVT)
D. Sepsis
Answer: b) Atelectasis
Rationale: Atelectasis is a common cause of fever in the early
postoperative period due to the lungs' decreased ability to expand and
clear secretions.
3. A patient who is post-operative day 1 following a major surgery
develops confusion and agitation. What should the nurse suspect as the
most likely cause?
A. Postoperative pain
B. Delirium
C. Acute blood loss
D. Hypoxia
Answer: b) Delirium
,Rationale: Postoperative delirium is common, especially in older adults,
and is characterized by confusion and agitation. It can be triggered by
anesthesia, medications, pain, or infection.
4. Which of the following is the most important factor to assess in a
patient with suspected ischemic stroke?
A. Blood pressure
B. Oxygen saturation
C. Blood glucose level
D. Time of symptom onset
Answer: d) Time of symptom onset
Rationale: Time of symptom onset is crucial for determining eligibility
for thrombolytic therapy. The earlier the treatment, the better the
chances of reversing ischemia.
5. A nurse is caring for a patient with a chest tube. What is the priority
nursing intervention?
, A. Ensure the drainage system is below the level of the chest
B. Irrigate the chest tube regularly to prevent occlusion
C. Encourage the patient to cough forcefully every hour
D. Change the chest tube dressing every 8 hours
Answer: a) Ensure the drainage system is below the level of the chest
Rationale: The chest tube drainage system must be kept below the level
of the chest to prevent the re-entry of fluid or air into the pleural space,
which can compromise the patient's respiratory status.
6. A nurse is caring for a patient with a newly placed central venous
catheter (CVC). What is the most important nursing action?
A. Ensure the CVC is flushed with saline after use
B. Change the dressing every 48 hours
C. Observe the site for signs of infection or clotting
D. Position the patient in a supine position only
Answer: c) Observe the site for signs of infection or clotting
patient with a history of heart failure?
A. Potassium level of 3.5 mEq/L
B. Blood glucose level of 120 mg/dL
C. Serum sodium level of 140 mEq/L
D. Blood urea nitrogen (BUN) level of 45 mg/dL
Answer: d) Blood urea nitrogen (BUN) level of 45 mg/dL
Rationale: An elevated BUN level could indicate renal impairment or
dehydration, both of which are concerning in heart failure patients, as
these conditions can worsen fluid status and cardiac function.
2. What is the most common cause of a fever within the first 48 hours
after major surgery?
A. Wound infection
,B. Atelectasis
C. Deep vein thrombosis (DVT)
D. Sepsis
Answer: b) Atelectasis
Rationale: Atelectasis is a common cause of fever in the early
postoperative period due to the lungs' decreased ability to expand and
clear secretions.
3. A patient who is post-operative day 1 following a major surgery
develops confusion and agitation. What should the nurse suspect as the
most likely cause?
A. Postoperative pain
B. Delirium
C. Acute blood loss
D. Hypoxia
Answer: b) Delirium
,Rationale: Postoperative delirium is common, especially in older adults,
and is characterized by confusion and agitation. It can be triggered by
anesthesia, medications, pain, or infection.
4. Which of the following is the most important factor to assess in a
patient with suspected ischemic stroke?
A. Blood pressure
B. Oxygen saturation
C. Blood glucose level
D. Time of symptom onset
Answer: d) Time of symptom onset
Rationale: Time of symptom onset is crucial for determining eligibility
for thrombolytic therapy. The earlier the treatment, the better the
chances of reversing ischemia.
5. A nurse is caring for a patient with a chest tube. What is the priority
nursing intervention?
, A. Ensure the drainage system is below the level of the chest
B. Irrigate the chest tube regularly to prevent occlusion
C. Encourage the patient to cough forcefully every hour
D. Change the chest tube dressing every 8 hours
Answer: a) Ensure the drainage system is below the level of the chest
Rationale: The chest tube drainage system must be kept below the level
of the chest to prevent the re-entry of fluid or air into the pleural space,
which can compromise the patient's respiratory status.
6. A nurse is caring for a patient with a newly placed central venous
catheter (CVC). What is the most important nursing action?
A. Ensure the CVC is flushed with saline after use
B. Change the dressing every 48 hours
C. Observe the site for signs of infection or clotting
D. Position the patient in a supine position only
Answer: c) Observe the site for signs of infection or clotting
