**THE NURSING ACUITY ACCELERATOR: 110 CLINICAL
DECISIONS**
Question 1: A nurse is assessing a client with Cushing's syndrome. Which finding is consistent with this
disorder?
A) Hypotension
B) Weight loss
C) Purple striae on the abdomen
D) Hypoglycemia
💫RATIONALE✔️✔️: Purple striae (stretch marks) result from thinning skin and protein wasting due to
chronic cortisol excess.
💫ANSWER✔️✔️: C) Purple striae on the abdomen
---
Question 2: A client with a history of venous thromboembolism is prescribed warfarin. The nurse
teaches the client to avoid which over-the-counter supplement due to increased bleeding risk?
A) Vitamin C
B) Ginger
C) Calcium
D) Magnesium
💫RATIONALE✔️✔️: Ginger has antiplatelet effects and can potentiate warfarin, increasing INR and
bleeding risk.
💫ANSWER✔️✔️: B) Ginger
---
Question 3: A nurse is caring for a patient with a new tracheostomy. Which finding indicates a need for
immediate suctioning?
A) Oxygen saturation of 91% on room air
,B) Coarse crackles heard over the trachea
C) Patient coughing up white sputum
D) Respiratory rate of 18 breaths/min
💫RATIONALE✔️✔️: Coarse crackles (rhonchi) over the trachea indicate secretions in the airway that the
patient cannot clear.
💫ANSWER✔️✔️: B) Coarse crackles heard over the trachea
---
Question 4: A client with bipolar disorder is taking lithium. Which sign of lithium toxicity is most severe
and requires immediate intervention?
A) Fine hand tremor
B) Nausea and diarrhea
C) Ataxia and confusion
D) Polyuria and polydipsia
💫RATIONALE✔️✔️: Ataxia, confusion, and seizures indicate severe neurotoxicity; level is likely >2.5
mEq/L and requires hemodialysis.
💫ANSWER✔️✔️: C) Ataxia and confusion
---
Question 5: A nurse is assessing a newborn for hypoglycemia. Which finding is most consistent?
A) Ruddy skin color
B) Jitteriness and poor feeding
C) Excessive crying
D) Hyperreflexia
💫RATIONALE✔️✔️: Jitteriness, lethargy, poor feeding, and hypothermia are classic signs of neonatal
hypoglycemia.
💫ANSWER✔️✔️: B) Jitteriness and poor feeding
, ---
Question 6: A client with heart failure is receiving furosemide and digoxin. The nurse notes a new onset
of nausea, vomiting, and yellow halos around lights. What should the nurse do first?
A) Administer an antiemetic
B) Check the digoxin level
C) Hold the next dose of furosemide
D) Notify the provider of possible digoxin toxicity
💫RATIONALE✔️✔️: Yellow-green halos (xanthopsia) and GI symptoms are classic signs of digoxin toxicity;
check level and hold digoxin.
💫ANSWER✔️✔️: B) Check the digoxin level
---
Question 7: A patient is admitted with a small bowel obstruction. The nurse notes a nasogastric tube is
draining 1500 mL of green fluid in 8 hours. Which electrolyte imbalance is the priority concern?
A) Hypernatremia
B) Hypokalemia
C) Hypercalcemia
D) Hypomagnesemia
💫RATIONALE✔️✔️: Large losses of gastric fluid cause hypokalemia and metabolic alkalosis, risking cardiac
dysrhythmias.
💫ANSWER✔️✔️: B) Hypokalemia
---
Question 8: A nurse is teaching a client with a new colostomy about pouch care. Which statement
indicates understanding?
A) "I will change the pouch every day to prevent infection."
B) "I will cut the wafer opening 1/8 inch larger than my stoma."
DECISIONS**
Question 1: A nurse is assessing a client with Cushing's syndrome. Which finding is consistent with this
disorder?
A) Hypotension
B) Weight loss
C) Purple striae on the abdomen
D) Hypoglycemia
💫RATIONALE✔️✔️: Purple striae (stretch marks) result from thinning skin and protein wasting due to
chronic cortisol excess.
💫ANSWER✔️✔️: C) Purple striae on the abdomen
---
Question 2: A client with a history of venous thromboembolism is prescribed warfarin. The nurse
teaches the client to avoid which over-the-counter supplement due to increased bleeding risk?
A) Vitamin C
B) Ginger
C) Calcium
D) Magnesium
💫RATIONALE✔️✔️: Ginger has antiplatelet effects and can potentiate warfarin, increasing INR and
bleeding risk.
💫ANSWER✔️✔️: B) Ginger
---
Question 3: A nurse is caring for a patient with a new tracheostomy. Which finding indicates a need for
immediate suctioning?
A) Oxygen saturation of 91% on room air
,B) Coarse crackles heard over the trachea
C) Patient coughing up white sputum
D) Respiratory rate of 18 breaths/min
💫RATIONALE✔️✔️: Coarse crackles (rhonchi) over the trachea indicate secretions in the airway that the
patient cannot clear.
💫ANSWER✔️✔️: B) Coarse crackles heard over the trachea
---
Question 4: A client with bipolar disorder is taking lithium. Which sign of lithium toxicity is most severe
and requires immediate intervention?
A) Fine hand tremor
B) Nausea and diarrhea
C) Ataxia and confusion
D) Polyuria and polydipsia
💫RATIONALE✔️✔️: Ataxia, confusion, and seizures indicate severe neurotoxicity; level is likely >2.5
mEq/L and requires hemodialysis.
💫ANSWER✔️✔️: C) Ataxia and confusion
---
Question 5: A nurse is assessing a newborn for hypoglycemia. Which finding is most consistent?
A) Ruddy skin color
B) Jitteriness and poor feeding
C) Excessive crying
D) Hyperreflexia
💫RATIONALE✔️✔️: Jitteriness, lethargy, poor feeding, and hypothermia are classic signs of neonatal
hypoglycemia.
💫ANSWER✔️✔️: B) Jitteriness and poor feeding
, ---
Question 6: A client with heart failure is receiving furosemide and digoxin. The nurse notes a new onset
of nausea, vomiting, and yellow halos around lights. What should the nurse do first?
A) Administer an antiemetic
B) Check the digoxin level
C) Hold the next dose of furosemide
D) Notify the provider of possible digoxin toxicity
💫RATIONALE✔️✔️: Yellow-green halos (xanthopsia) and GI symptoms are classic signs of digoxin toxicity;
check level and hold digoxin.
💫ANSWER✔️✔️: B) Check the digoxin level
---
Question 7: A patient is admitted with a small bowel obstruction. The nurse notes a nasogastric tube is
draining 1500 mL of green fluid in 8 hours. Which electrolyte imbalance is the priority concern?
A) Hypernatremia
B) Hypokalemia
C) Hypercalcemia
D) Hypomagnesemia
💫RATIONALE✔️✔️: Large losses of gastric fluid cause hypokalemia and metabolic alkalosis, risking cardiac
dysrhythmias.
💫ANSWER✔️✔️: B) Hypokalemia
---
Question 8: A nurse is teaching a client with a new colostomy about pouch care. Which statement
indicates understanding?
A) "I will change the pouch every day to prevent infection."
B) "I will cut the wafer opening 1/8 inch larger than my stoma."
