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1. Question Category: Management of Care
Scenario:
A nurse is managing care for multiple clients in an outpatient clinic. Which client should the
nurse prioritize in responding to first?
A. A patient with hepatitis A reporting itching in the arms and legs.
B. A patient with a right leg cast stating, "I feel something strange in my right leg."
C. A patient with spinal osteomyelitis reporting nausea and difficulty eating.
D. A patient with rheumatoid arthritis stating, "I am having trouble sleeping."
Answer & Rationale:
Correct Answer: B. A patient with a right leg cast stating, "I feel something strange in
my right leg."
This may indicate a neurovascular issue, which requires immediate assessment.
2. Question Category: Management of Care
Scenario:
A nurse is prioritizing care for postoperative clients. Which patient should the nurse assess first?
A. A 35-year-old patient with a gunshot wound and dark drainage at the dressing site.
B. A 43-year-old post-mastectomy patient with 23 ml of fluid in the Jackson-Pratt drain.
C. A 59-year-old patient with a history of a collapsed lung and no drainage in the chest tube.
D. A 54-year-old post-knee replacement with moderate swelling at the surgical site.
E. A 47-year-old post-laparoscopic cholecystectomy patient with mild incision pain.
F. A 62-year-old post-abdominal-perineal resection patient reporting chills.
Answer & Rationale:
Correct Answer: F. A 62-year-old post-abdominal-perineal resection patient reporting
chills.
Chills may indicate infection, requiring immediate evaluation for peritonitis.
, 3. Question Category: Physiological Adaptation
Scenario:
A nurse is monitoring a 46-year-old patient post-thyroidectomy for Grave’s disease. Which
observation should most concern the nurse?
A. Blood pressure of 138/82 mmHg, respiration rate of 16, and temperature of 37.2°C.
B. The patient supports their neck when turning their head to the right.
C. The patient expresses difficulty swallowing but can manage liquids.
D. The patient appears drowsy and has a sore throat.
E. The patient exhibits involuntary flexion of the wrist when blood pressure is measured.
F. The patient has a hoarse voice.
Answer & Rationale:
Correct Answer: E. The patient exhibits involuntary flexion of the wrist when blood
pressure is measured.
This indicates Trousseau's sign, a sign of hypocalcemia, which is a critical post-thyroidectomy
complication.
4. Question Category: Physiological Adaptation
Scenario:
A 38-year-old patient presents with severe right lower quadrant pain, nausea, and a low-grade
fever. The nurse considers pain relief strategies. What should the nurse prioritize?
A. Encourage frequent position changes in bed.
B. Administer Demerol 50 mg IM q 4 hours and as needed.
C. Apply warmth to the abdomen with a heating pad.
D. Use pillows to position the patient comfortably.
E. Administer an antiemetic as prescribed.
Answer & Rationale:
Correct Answer: D. Use pillows to position the patient comfortably.
Positioning with pillows is a non-pharmacological method of pain relief that provides comfort
while avoiding further aggravation.
5. Question Category: Physiological Adaptation
Scenario: