Question 1
The nurse is caring for a client who is 2 days postoperative craniotomy with bone flap
removal. The nurse notes clear wound drainage saturating the dressing over the incision.
Which action by the nurse is most appropriate at this time?
1. Cleanse the incision site with saline and apply a new, sterile dressing
2. Mark the edges of the drainage on the dressing and continue to monitor
3. Notify the health care provider of the color and amount of drainage 4. Turn the client onto
the nonoperative side using the log-rolling technique
CORRECT ANSWER
CORRECT ANSWER: 3
A craniotomy involves incision into the cranium and is indicated for elevated intracranial
pressure or removal of tumors, blood, or abscesses. Postoperative clients are at risk for
developing a cerebrospinal fluid (CSF) leak from an intraoperative dural injury, which
increases the risk for meningitis.
Excessive drainage from a craniotomy incision (eg, saturated dressing, >50 mL per shift into
the drain) or from the nose or ear suggests a possible CF leak requiring immediate
notification of the health care provider (HCP) (Option 3 is correct). Interventions focus on
decreasing strain on the dural tear to encourage closure and include bedrest, lumbar drain
placement, and surgical intervention.
(Option 1 is wrong) The incision should not be re-dressed until the HCP can evaluate the
wound and drainage.
1
@THE STUDY VAULT
, (Option 2 is wrong) The nurse should mark the drainage edges at least once per shift for
comparison. However, a saturated dressing may indicate a CSF leak.
(Option 4 is wrong) Repositioning may be indicated but is not the most appropriate action
at this time. Specific client positioning postoperative craniotomy is prescribed by the HCP.
The head of the bed is usually elevated approximately 30 degrees to facilitate venous
drainage and prevent increased intracranial pressure. If flat positioning is prescribed, the
nurse should log-roll the client to alternate between the back and the nonoperative side.
Question 2
An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided
cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been
placed on a dysphagia diet. Which actions require intervention by the nurse? Select all
that apply.
1. The UAP adds milk to mashed potatoes to make them thinner.
2. The UAP encourages the client to occasionally turn the head to the left.
3. The UAP helps the client sit in an upright position.
4. The UAP places food on the strong side of the client's mouth.
5. The UAP puts a straw in a fruit smoothie to prevent spilling.
CORRECT ANSWER
CORRECT ANSWER: 1, 5
Adding milk to mashed potatoes will alter the consistency; if the consistency is too thin,
the client will be at increased risk of aspiration.
Using a straw for drinking liquids might cause increased swallowing difficulty and choking.
Controlling liquid intake through a straw is more difficult than drinking straight from a cup
or glass.
2
@THE STUDY VAULT
,Question 3
A client comes to the emergency department for the second time with shortness of breath
and substernal pressure that radiates to the jaw. The nurse understands that angina
pectoris may be precipitated by which of these factors? Select all that apply.
1. Amphetamine use
2. Cigarette smoking
3. Cold exposure
4. Deep sleep
5. Sexual intercourse
CORRECT ANSWER
CORRECT ANSWER: 1, 2, 3, 5
Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased
blood flow to the heart muscle). Any factor that increases oxygen demand or decreases
oxygen supply to cardiac muscle may cause angina, including the following:
• Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole
(time of maximum blood flow to the myocardium)
• Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and
increases cardiac workload
• Temperature extremes: Usually cold exposure and hypothermia
(vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling)
• Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide;
nicotine causes vasoconstriction and catecholamine release
• Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction
3
@THE STUDY VAULT
, • Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood
flow to myocardium
(Option 4 is wrong) Deep sleep doesn't increase oxygen demand.
Question 4
A client is admitted to the emergency department after a fall with dizziness and light-
headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the rhythm
in the image. The nurse recognizes it as which rhythm? Go to the image link below for
more information.
Image: https://imgur.com/qPQ6jW3
1. Complete heart block
2. 1st-degree heart block
3. Sinus bradycardia
4. Sinus rhythm
CORRECT ANSWER
CORRECT ANSWER: 3
Go to this image for more help about this question: https://imgur.com/j4xFw2a
Sinus bradycardia (SB) has the same conduction pathway as sinus rhythm, but the
sinoatrial node fires at a rate of <60/min. SB is classified as symptomatic if, in addition to a
heart rate <60/min, the client experiences such symptoms as dizziness, syncope, chest
pain, and hypotension.
4
@THE STUDY VAULT
The nurse is caring for a client who is 2 days postoperative craniotomy with bone flap
removal. The nurse notes clear wound drainage saturating the dressing over the incision.
Which action by the nurse is most appropriate at this time?
1. Cleanse the incision site with saline and apply a new, sterile dressing
2. Mark the edges of the drainage on the dressing and continue to monitor
3. Notify the health care provider of the color and amount of drainage 4. Turn the client onto
the nonoperative side using the log-rolling technique
CORRECT ANSWER
CORRECT ANSWER: 3
A craniotomy involves incision into the cranium and is indicated for elevated intracranial
pressure or removal of tumors, blood, or abscesses. Postoperative clients are at risk for
developing a cerebrospinal fluid (CSF) leak from an intraoperative dural injury, which
increases the risk for meningitis.
Excessive drainage from a craniotomy incision (eg, saturated dressing, >50 mL per shift into
the drain) or from the nose or ear suggests a possible CF leak requiring immediate
notification of the health care provider (HCP) (Option 3 is correct). Interventions focus on
decreasing strain on the dural tear to encourage closure and include bedrest, lumbar drain
placement, and surgical intervention.
(Option 1 is wrong) The incision should not be re-dressed until the HCP can evaluate the
wound and drainage.
1
@THE STUDY VAULT
, (Option 2 is wrong) The nurse should mark the drainage edges at least once per shift for
comparison. However, a saturated dressing may indicate a CSF leak.
(Option 4 is wrong) Repositioning may be indicated but is not the most appropriate action
at this time. Specific client positioning postoperative craniotomy is prescribed by the HCP.
The head of the bed is usually elevated approximately 30 degrees to facilitate venous
drainage and prevent increased intracranial pressure. If flat positioning is prescribed, the
nurse should log-roll the client to alternate between the back and the nonoperative side.
Question 2
An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided
cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been
placed on a dysphagia diet. Which actions require intervention by the nurse? Select all
that apply.
1. The UAP adds milk to mashed potatoes to make them thinner.
2. The UAP encourages the client to occasionally turn the head to the left.
3. The UAP helps the client sit in an upright position.
4. The UAP places food on the strong side of the client's mouth.
5. The UAP puts a straw in a fruit smoothie to prevent spilling.
CORRECT ANSWER
CORRECT ANSWER: 1, 5
Adding milk to mashed potatoes will alter the consistency; if the consistency is too thin,
the client will be at increased risk of aspiration.
Using a straw for drinking liquids might cause increased swallowing difficulty and choking.
Controlling liquid intake through a straw is more difficult than drinking straight from a cup
or glass.
2
@THE STUDY VAULT
,Question 3
A client comes to the emergency department for the second time with shortness of breath
and substernal pressure that radiates to the jaw. The nurse understands that angina
pectoris may be precipitated by which of these factors? Select all that apply.
1. Amphetamine use
2. Cigarette smoking
3. Cold exposure
4. Deep sleep
5. Sexual intercourse
CORRECT ANSWER
CORRECT ANSWER: 1, 2, 3, 5
Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased
blood flow to the heart muscle). Any factor that increases oxygen demand or decreases
oxygen supply to cardiac muscle may cause angina, including the following:
• Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole
(time of maximum blood flow to the myocardium)
• Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and
increases cardiac workload
• Temperature extremes: Usually cold exposure and hypothermia
(vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling)
• Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide;
nicotine causes vasoconstriction and catecholamine release
• Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction
3
@THE STUDY VAULT
, • Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood
flow to myocardium
(Option 4 is wrong) Deep sleep doesn't increase oxygen demand.
Question 4
A client is admitted to the emergency department after a fall with dizziness and light-
headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the rhythm
in the image. The nurse recognizes it as which rhythm? Go to the image link below for
more information.
Image: https://imgur.com/qPQ6jW3
1. Complete heart block
2. 1st-degree heart block
3. Sinus bradycardia
4. Sinus rhythm
CORRECT ANSWER
CORRECT ANSWER: 3
Go to this image for more help about this question: https://imgur.com/j4xFw2a
Sinus bradycardia (SB) has the same conduction pathway as sinus rhythm, but the
sinoatrial node fires at a rate of <60/min. SB is classified as symptomatic if, in addition to a
heart rate <60/min, the client experiences such symptoms as dizziness, syncope, chest
pain, and hypotension.
4
@THE STUDY VAULT
