Answers Latest Version Graded A+
What is the nurse’s priority action when a post-op patient suddenly develops chest pain and
shortness of breath?
✔✔ Assess for signs of pulmonary embolism (e.g., tachycardia, hypoxia) and notify the provider
immediately.
How should the nurse position a patient with acute pancreatitis to reduce pain?
✔✔ Place the patient in a side-lying or fetal position to relieve pressure on the abdomen.
What is the most critical complication to monitor for in a patient with a new tracheostomy?
✔✔ Airway obstruction from mucus plugs or dislodgement of the tracheostomy tube.
Why is it important to check capillary blood glucose before administering insulin to a diabetic
patient with nausea and vomiting?
✔✔ To prevent hypoglycemia if the patient is not eating adequately.
What immediate action should the nurse take if a patient’s IV site is swollen, pale, and painful?
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,✔✔ Stop the IV infusion and assess for infiltration or extravasation.
How does the nurse assess for Chvostek’s sign in a patient with suspected hypocalcemia?
✔✔ Tap the facial nerve near the ear and observe for twitching of the mouth or nose.
What is the most likely cause of sudden confusion in an elderly patient post-hip replacement?
✔✔ Urinary tract infection or electrolyte imbalance.
Why should a patient with heart failure avoid over-the-counter NSAIDs?
✔✔ NSAIDs can cause fluid retention and worsen heart failure symptoms.
What is the nurse’s first action if a patient with a nasogastric tube begins vomiting bright red
blood?
✔✔ Keep the patient NPO, maintain suction, and notify the provider immediately.
How should the nurse document a stage 3 pressure ulcer correctly?
✔✔ "Full-thickness tissue loss with visible subcutaneous fat; no bone, tendon, or muscle
exposed."
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,What is the priority teaching point for a patient newly diagnosed with COPD?
✔✔ "Purse-lipped breathing can help reduce shortness of breath during activity."
Why is it unsafe to administer morphine to a patient with acute abdominal pain before diagnosis?
✔✔ It can mask symptoms and delay diagnosis of conditions like appendicitis.
What is the most concerning finding in a patient with cirrhosis who develops confusion?
✔✔ Elevated ammonia levels leading to hepatic encephalopathy.
How does the nurse assess for pitting edema in a patient with heart failure?
✔✔ Press firmly on the skin over the tibia for 5 seconds and measure the depth of indentation.
What is the best way to prevent catheter-associated UTIs in a hospitalized patient?
✔✔ Maintain a closed drainage system and ensure the catheter is secured properly.
Why should a patient with thrombocytopenia avoid rectal suppositories?
✔✔ Risk of trauma to rectal mucosa leading to bleeding.
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, What is the nurse’s priority intervention for a patient exhibiting signs of alcohol withdrawal?
✔✔ Implement seizure precautions and administer ordered benzodiazepines.
How should the nurse position a patient with increased intracranial pressure (ICP)?
✔✔ Elevate the head of the bed 30 degrees and keep the neck midline.
What is the most accurate way to measure fluid intake and output for a patient with renal failure?
✔✔ Use a graduated container for urine and document all oral/IV intake in mL.
Why is it critical to monitor potassium levels in a patient receiving digoxin?
✔✔ Hypokalemia increases the risk of digoxin toxicity.
What is the first sign of compartment syndrome the nurse should assess for in a patient with a leg
fracture?
✔✔ Pain out of proportion to injury that worsens with passive stretching.
How does the nurse verify placement of a nasogastric tube before feeding?
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