PCA Nematodes Exam Newest With Complete And
Correct Detailed Answers| Brand New Version
1. A patient with severe sepsis and acute respiratory distress syndrome (ARDS) is receiving
volume-controlled ventilation with a tidal volume of 6 mL/kg ideal body weight, PEEP of 10 cm
H2O, and FiO2 of 0.8. Plateau pressure is 28 cm H2O, and PaO2 is 55 mm Hg. Which intervention
should be prioritized to improve oxygenation while minimizing ventilator-induced lung injury?
A. Increase tidal volume to 8 mL/kg ideal body weight.
B. Switch to pressure-controlled ventilation with a driving pressure of 15 cm H2O.
C. Increase PEEP to 15 cm H2O and perform a recruitment maneuver.
D. Increase FiO2 to 1.0 and continue current settings.
Answer: C
Rationale: With low PaO2 despite high FiO2, the priority is to improve oxygenation by recruiting lung
units. Increasing PEEP (with or without a recruitment maneuver) can improve alveolar recruitment and
oxygenation. Option A would increase tidal volume above lung-protective limits, risking volutrauma.
Option C does not specifically address recruitment. Option D reduces FiO2 prematurely and prone
positioning is not the first step.
2. A client with a history of chronic obstructive pulmonary disease (COPD) is receiving
supplemental oxygen at 2 L/min via nasal cannula. Arterial blood gas (ABG) results show pH 7.32,
PaCO2 58 mm Hg, PaO2 74 mm Hg, and HCO3- 26 mEq/L. Which intervention should the nurse
anticipate?
A. Administer intravenous sodium bicarbonate.
B. Prepare for endotracheal intubation and mechanical ventilation.
C. Increase the oxygen flow rate to 4 L/min.
D. Prepare for noninvasive positive pressure ventilation (NIPPV).
Answer: D
Rationale: The ABG shows acute respiratory acidosis (low pH, high PaCO2, normal HCO3-) in a client
with COPD. NIPPV (e.g., BiPAP) is indicated to improve ventilation and correct hypercapnia.
Increasing oxygen may suppress hypoxic drive, and sodium bicarbonate is not first-line. Decreasing
oxygen could worsen hypoxia.
3. A nurse is caring for a client in the advanced stage of amyotrophic lateral sclerosis (ALS).
Which referral should the nurse prioritize?
A. Occupational therapist
B. Physical therapist
C. Speech-language pathologist
D. Respiratory therapist
Page 1
,Answer: A
Rationale: In advanced ALS, maintaining functional independence and quality of life is paramount. The
occupational therapist specializes in adaptive strategies and assistive devices to optimize daily living
activities, making this referral the priority over other therapies that address specific impairments.
4. A patient with bipolar disorder has a lithium level of 0.8 mEq/L. The patient reports mild
nausea, fine hand tremor, and polyuria. Which of the following is the most appropriate nursing
action?
A. Withhold the next dose and obtain a stat serum lithium level to confirm toxicity.
B. Administer the next dose as scheduled; these are expected side effects at therapeutic levels.
C. Administer the next dose with a large amount of fluid to dilute the lithium and reduce side effects.
D. Hold the next dose and notify the prescriber because the lithium level is above the therapeutic range.
Answer: B
Rationale: The lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L). Mild nausea,
fine tremor, and polyuria are common side effects at therapeutic levels, not toxicity. Option A is
incorrect as toxicity typically occurs above 1.5 mEq/L. Option C is premature without evidence of
supratherapeutic levels. Option D may help with nausea but is not the primary action.
5. A nurse is caring for a client with chronic pancreatitis. Which dietary recommendation should
the nurse provide?
A. Warm toast with margarine
B. High-fiber cereal with skim milk
C. Fried chicken with white rice
D. Fresh fruit salad with yogurt
Answer: A
Rationale: Chronic pancreatitis impairs fat digestion, so a low-fat, easily digestible food like warm toast
with margarine is appropriate. High-fiber or high-fat options can exacerbate symptoms, and acidic
fruits may cause discomfort.
6. A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a client.
Which of the following statements should the nurse include in the teaching?
A. You can adjust the amount of pain medication you receive by pushing on the keypad.
B. The PCA pump is set to deliver a maximum dose per hour, so you cannot receive too much medication.
C. The PCA pump will deliver a continuous infusion of pain medication regardless of your input.
D. You should ask a family member to press the button for you if you are unable to do so.
Answer: A
Rationale: The correct answer indicates that the patient can self-administer additional doses by pressing
the keypad, which is the fundamental principle of PCA. The first distractor is incorrect because PCA
typically allows patient-controlled boluses on demand, not a continuous infusion without patient input.
The second distractor is wrong because only the patient should press the button to ensure safety and
prevent overdose. The third distractor is partially true but misleading; while PCA pumps have lockout
intervals and dose limits, the statement implies no risk of excessive medication, which is inaccurate as
improper use can still lead to adverse effects.
Page 2
,7. A nurse is assessing a newborn with a blood glucose level of 30 mg/dL. Which of the following
clinical manifestations should the nurse expect?
A. Bradycardia
B. Hyperthermia
C. Jitteriness
D. Abdominal distention
Answer: D
Rationale: Abdominal distention is a common sign of hypoglycemia in newborns due to decreased
gastrointestinal motility. Jitteriness and bradycardia are also associated with hypoglycemia, but
abdominal distention is a more specific finding in this context. Hyperthermia is not typically linked to
low blood glucose levels.
8. A nurse is providing teaching to a client with multiple sclerosis. Which of the following
statements should the nurse include?
A. Perform Kegel exercises only when experiencing urinary urgency.
B. Use a heating pad on the lower abdomen to promote bladder emptying.
C. Limit fluid intake to reduce urinary frequency.
D. Establish a voiding schedule by urinating once every 4 hours.
Answer: D
Rationale: A voiding schedule helps manage neurogenic bladder, a common issue in multiple sclerosis, by
preventing urinary retention and incontinence. Limiting fluids can lead to dehydration and worsen
bladder problems. Heat may exacerbate MS symptoms, and Kegel exercises should be performed
regularly, not just during urgency.
9. A newly licensed nurse is uncertain whether a specific task falls within their scope of practice.
Which resource should the nurse consult to determine this?
A. Experienced nurse colleague
B. Hospital policy and procedure manual
C. Written prescription from the provider
D. State board of nursing website
Answer: C
Rationale: The written prescription from the provider directly specifies the task ordered, and the nurse
must verify that performing it is within their scope of practice as defined by law and facility policy.
Consulting the prescription ensures the task is authorized by the provider, which is the primary
determinant of whether the nurse can proceed.
10. A client with a diagnosis of deep vein thrombosis (DVT) is receiving a continuous heparin
infusion. The nurse reviews the laboratory results: aPTT 120 seconds (therapeutic range 60-80
seconds). Which action should the nurse take?
A. Administer protamine sulfate as an antidote.
B. Decrease the heparin infusion rate per protocol.
C. Increase the heparin infusion rate per protocol.
Page 3
, D. Continue the current infusion rate and recheck aPTT in 6 hours.
Answer: B
Rationale: An aPTT of 120 seconds is above the therapeutic range, indicating excessive anticoagulation
and increased bleeding risk. The nurse should decrease the heparin infusion rate per protocol.
Protamine sulfate is the antidote for severe bleeding, not for a mildly elevated aPTT without signs of
bleeding.
11. A nurse is caring for a client receiving a unit of packed red blood cells. Thirty minutes after the
transfusion begins, the client develops chills, fever, and low back pain. What is the nurse's priority
action?
A. Slow the transfusion rate and notify the healthcare provider
B. Increase the IV flow rate of normal saline
C. Stop the transfusion immediately
D. Administer an antipyretic as prescribed
Answer: C
Rationale: These signs indicate a hemolytic transfusion reaction, which is a medical emergency. The
priority is to stop the transfusion immediately to prevent further infusion of incompatible blood. Option
A may be done after stopping, but not first. Option B is incorrect because slowing does not prevent the
reaction. Option D is important but not the first action.
12. A client with a history of gastroesophageal reflux disease (GERD) is prescribed omeprazole.
When should the nurse instruct the client to take this medication?
A. On an empty stomach, 30-60 minutes before breakfast.
B. With meals to reduce gastrointestinal irritation.
C. At bedtime to suppress nighttime acid production.
D. Immediately after eating to neutralize stomach acid.
Answer: A
Rationale: Omeprazole, a proton pump inhibitor, is most effective when taken on an empty stomach 30-60
minutes before the first meal of the day because it inhibits the proton pump that is activated by food.
Taking with meals reduces efficacy; bedtime dosing is not optimal; as-needed use is not recommended
for healing esophagitis.
13. A patient with chronic kidney disease (CKD) stage 4 is admitted with hyperkalemia (K+ 6.8
mEq/L) and ECG changes. The provider prescribes intravenous calcium gluconate, regular insulin
plus dextrose 50%, and albuterol nebulization. Which mechanism explains the synergistic effect of
these interventions in reducing serum potassium?
A. Calcium gluconate directly binds potassium in the blood, insulin shifts potassium into cells by increasing
glucose uptake, and albuterol increases renal potassium excretion.
B. Calcium gluconate stabilizes cardiac membranes, insulin promotes cellular uptake via Na-K-ATPase, and
albuterol activates beta-2 receptors to enhance Na-K-ATPase activity.
C. Calcium gluconate buffers extracellular potassium, insulin enhances potassium excretion in the urine, and
albuterol inhibits potassium release from muscle cells.
Page 4
Correct Detailed Answers| Brand New Version
1. A patient with severe sepsis and acute respiratory distress syndrome (ARDS) is receiving
volume-controlled ventilation with a tidal volume of 6 mL/kg ideal body weight, PEEP of 10 cm
H2O, and FiO2 of 0.8. Plateau pressure is 28 cm H2O, and PaO2 is 55 mm Hg. Which intervention
should be prioritized to improve oxygenation while minimizing ventilator-induced lung injury?
A. Increase tidal volume to 8 mL/kg ideal body weight.
B. Switch to pressure-controlled ventilation with a driving pressure of 15 cm H2O.
C. Increase PEEP to 15 cm H2O and perform a recruitment maneuver.
D. Increase FiO2 to 1.0 and continue current settings.
Answer: C
Rationale: With low PaO2 despite high FiO2, the priority is to improve oxygenation by recruiting lung
units. Increasing PEEP (with or without a recruitment maneuver) can improve alveolar recruitment and
oxygenation. Option A would increase tidal volume above lung-protective limits, risking volutrauma.
Option C does not specifically address recruitment. Option D reduces FiO2 prematurely and prone
positioning is not the first step.
2. A client with a history of chronic obstructive pulmonary disease (COPD) is receiving
supplemental oxygen at 2 L/min via nasal cannula. Arterial blood gas (ABG) results show pH 7.32,
PaCO2 58 mm Hg, PaO2 74 mm Hg, and HCO3- 26 mEq/L. Which intervention should the nurse
anticipate?
A. Administer intravenous sodium bicarbonate.
B. Prepare for endotracheal intubation and mechanical ventilation.
C. Increase the oxygen flow rate to 4 L/min.
D. Prepare for noninvasive positive pressure ventilation (NIPPV).
Answer: D
Rationale: The ABG shows acute respiratory acidosis (low pH, high PaCO2, normal HCO3-) in a client
with COPD. NIPPV (e.g., BiPAP) is indicated to improve ventilation and correct hypercapnia.
Increasing oxygen may suppress hypoxic drive, and sodium bicarbonate is not first-line. Decreasing
oxygen could worsen hypoxia.
3. A nurse is caring for a client in the advanced stage of amyotrophic lateral sclerosis (ALS).
Which referral should the nurse prioritize?
A. Occupational therapist
B. Physical therapist
C. Speech-language pathologist
D. Respiratory therapist
Page 1
,Answer: A
Rationale: In advanced ALS, maintaining functional independence and quality of life is paramount. The
occupational therapist specializes in adaptive strategies and assistive devices to optimize daily living
activities, making this referral the priority over other therapies that address specific impairments.
4. A patient with bipolar disorder has a lithium level of 0.8 mEq/L. The patient reports mild
nausea, fine hand tremor, and polyuria. Which of the following is the most appropriate nursing
action?
A. Withhold the next dose and obtain a stat serum lithium level to confirm toxicity.
B. Administer the next dose as scheduled; these are expected side effects at therapeutic levels.
C. Administer the next dose with a large amount of fluid to dilute the lithium and reduce side effects.
D. Hold the next dose and notify the prescriber because the lithium level is above the therapeutic range.
Answer: B
Rationale: The lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L). Mild nausea,
fine tremor, and polyuria are common side effects at therapeutic levels, not toxicity. Option A is
incorrect as toxicity typically occurs above 1.5 mEq/L. Option C is premature without evidence of
supratherapeutic levels. Option D may help with nausea but is not the primary action.
5. A nurse is caring for a client with chronic pancreatitis. Which dietary recommendation should
the nurse provide?
A. Warm toast with margarine
B. High-fiber cereal with skim milk
C. Fried chicken with white rice
D. Fresh fruit salad with yogurt
Answer: A
Rationale: Chronic pancreatitis impairs fat digestion, so a low-fat, easily digestible food like warm toast
with margarine is appropriate. High-fiber or high-fat options can exacerbate symptoms, and acidic
fruits may cause discomfort.
6. A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a client.
Which of the following statements should the nurse include in the teaching?
A. You can adjust the amount of pain medication you receive by pushing on the keypad.
B. The PCA pump is set to deliver a maximum dose per hour, so you cannot receive too much medication.
C. The PCA pump will deliver a continuous infusion of pain medication regardless of your input.
D. You should ask a family member to press the button for you if you are unable to do so.
Answer: A
Rationale: The correct answer indicates that the patient can self-administer additional doses by pressing
the keypad, which is the fundamental principle of PCA. The first distractor is incorrect because PCA
typically allows patient-controlled boluses on demand, not a continuous infusion without patient input.
The second distractor is wrong because only the patient should press the button to ensure safety and
prevent overdose. The third distractor is partially true but misleading; while PCA pumps have lockout
intervals and dose limits, the statement implies no risk of excessive medication, which is inaccurate as
improper use can still lead to adverse effects.
Page 2
,7. A nurse is assessing a newborn with a blood glucose level of 30 mg/dL. Which of the following
clinical manifestations should the nurse expect?
A. Bradycardia
B. Hyperthermia
C. Jitteriness
D. Abdominal distention
Answer: D
Rationale: Abdominal distention is a common sign of hypoglycemia in newborns due to decreased
gastrointestinal motility. Jitteriness and bradycardia are also associated with hypoglycemia, but
abdominal distention is a more specific finding in this context. Hyperthermia is not typically linked to
low blood glucose levels.
8. A nurse is providing teaching to a client with multiple sclerosis. Which of the following
statements should the nurse include?
A. Perform Kegel exercises only when experiencing urinary urgency.
B. Use a heating pad on the lower abdomen to promote bladder emptying.
C. Limit fluid intake to reduce urinary frequency.
D. Establish a voiding schedule by urinating once every 4 hours.
Answer: D
Rationale: A voiding schedule helps manage neurogenic bladder, a common issue in multiple sclerosis, by
preventing urinary retention and incontinence. Limiting fluids can lead to dehydration and worsen
bladder problems. Heat may exacerbate MS symptoms, and Kegel exercises should be performed
regularly, not just during urgency.
9. A newly licensed nurse is uncertain whether a specific task falls within their scope of practice.
Which resource should the nurse consult to determine this?
A. Experienced nurse colleague
B. Hospital policy and procedure manual
C. Written prescription from the provider
D. State board of nursing website
Answer: C
Rationale: The written prescription from the provider directly specifies the task ordered, and the nurse
must verify that performing it is within their scope of practice as defined by law and facility policy.
Consulting the prescription ensures the task is authorized by the provider, which is the primary
determinant of whether the nurse can proceed.
10. A client with a diagnosis of deep vein thrombosis (DVT) is receiving a continuous heparin
infusion. The nurse reviews the laboratory results: aPTT 120 seconds (therapeutic range 60-80
seconds). Which action should the nurse take?
A. Administer protamine sulfate as an antidote.
B. Decrease the heparin infusion rate per protocol.
C. Increase the heparin infusion rate per protocol.
Page 3
, D. Continue the current infusion rate and recheck aPTT in 6 hours.
Answer: B
Rationale: An aPTT of 120 seconds is above the therapeutic range, indicating excessive anticoagulation
and increased bleeding risk. The nurse should decrease the heparin infusion rate per protocol.
Protamine sulfate is the antidote for severe bleeding, not for a mildly elevated aPTT without signs of
bleeding.
11. A nurse is caring for a client receiving a unit of packed red blood cells. Thirty minutes after the
transfusion begins, the client develops chills, fever, and low back pain. What is the nurse's priority
action?
A. Slow the transfusion rate and notify the healthcare provider
B. Increase the IV flow rate of normal saline
C. Stop the transfusion immediately
D. Administer an antipyretic as prescribed
Answer: C
Rationale: These signs indicate a hemolytic transfusion reaction, which is a medical emergency. The
priority is to stop the transfusion immediately to prevent further infusion of incompatible blood. Option
A may be done after stopping, but not first. Option B is incorrect because slowing does not prevent the
reaction. Option D is important but not the first action.
12. A client with a history of gastroesophageal reflux disease (GERD) is prescribed omeprazole.
When should the nurse instruct the client to take this medication?
A. On an empty stomach, 30-60 minutes before breakfast.
B. With meals to reduce gastrointestinal irritation.
C. At bedtime to suppress nighttime acid production.
D. Immediately after eating to neutralize stomach acid.
Answer: A
Rationale: Omeprazole, a proton pump inhibitor, is most effective when taken on an empty stomach 30-60
minutes before the first meal of the day because it inhibits the proton pump that is activated by food.
Taking with meals reduces efficacy; bedtime dosing is not optimal; as-needed use is not recommended
for healing esophagitis.
13. A patient with chronic kidney disease (CKD) stage 4 is admitted with hyperkalemia (K+ 6.8
mEq/L) and ECG changes. The provider prescribes intravenous calcium gluconate, regular insulin
plus dextrose 50%, and albuterol nebulization. Which mechanism explains the synergistic effect of
these interventions in reducing serum potassium?
A. Calcium gluconate directly binds potassium in the blood, insulin shifts potassium into cells by increasing
glucose uptake, and albuterol increases renal potassium excretion.
B. Calcium gluconate stabilizes cardiac membranes, insulin promotes cellular uptake via Na-K-ATPase, and
albuterol activates beta-2 receptors to enhance Na-K-ATPase activity.
C. Calcium gluconate buffers extracellular potassium, insulin enhances potassium excretion in the urine, and
albuterol inhibits potassium release from muscle cells.
Page 4
