Answers | Latest Version | 2025/2026 |
Correct & Verified
A patient with chronic heart failure reports weight gain of 4 pounds in 2 days. What should the
nurse suspect?
✔✔Fluid retention.
A patient with chest trauma has absent breath sounds on one side. What is the likely condition?
✔✔Pneumothorax.
A patient with cirrhosis has yellowing of the skin and sclera. What is this called?
✔✔Jaundice.
A patient with a tracheostomy accidentally dislodges the tube. What should the nurse do first?
✔✔Insert a new tracheostomy tube immediately.
A patient with multiple sclerosis reports blurred vision and muscle weakness. What type of
disease is this?
1
,✔✔Autoimmune demyelinating disease.
A patient with diabetic ketoacidosis has fruity breath odor. What causes this smell?
✔✔Acetone production.
A patient receiving chemotherapy has a WBC count of 2,000/mm³. What is the priority action?
✔✔Implement neutropenic precautions.
A patient with asthma is using an albuterol inhaler more than every 4 hours. What does this
indicate?
✔✔Poorly controlled asthma.
A patient after thyroidectomy develops tingling around the mouth and fingertips. What is the
likely cause?
✔✔Hypocalcemia.
A patient with end-stage renal disease has itching and grayish skin color. What causes this
symptom?
2
,✔✔Uremic toxins in the skin.
A patient with liver failure has confusion and tremors. What condition should the nurse suspect?
✔✔Hepatic encephalopathy.
A patient after hip replacement is instructed not to bend the hip more than 90 degrees. What is
this to prevent?
✔✔Hip dislocation.
A patient with acute pancreatitis reports severe abdominal pain radiating to the back. Which
position can help relieve the pain?
✔✔Sitting and leaning forward.
A patient with a chest tube has continuous bubbling in the water seal chamber. What does this
indicate?
✔✔Air leak.
A patient with a recent myocardial infarction develops crushing chest pain unrelieved by
nitroglycerin. What complication should the nurse suspect?
3
, ✔✔Reinfarction.
A patient with a suspected stroke arrives with slurred speech and facial droop. What is the
priority action?
✔✔Initiate rapid stroke protocol and call for CT scan.
A patient on IV heparin develops sudden severe abdominal pain and hypotension. What
complication should be suspected?
✔✔Internal bleeding.
A patient with COPD has a barrel-shaped chest. What causes this appearance?
✔✔Chronic air trapping.
A patient with a spinal cord injury at T4 is at risk for autonomic dysreflexia. What is a common
trigger?
✔✔Bladder distention.
A patient with acute glomerulonephritis has dark, cola-colored urine. What causes this change?
4