NCLEX- RN Practice Exam 18

Questions

1. Nurse Olivia is conducting a follow-up assessment on a patient who has had a cast applied to his left lower extremity. During her assessment, she inquires about the patient’s comfort and adherence to care instructions. Which of the following statements from the patient would be of greatest concern to Olivia?

A) “I can’t seem to get rid of the itch inside my cast on my left leg.”
B) “My arthritis is acting up when I put weight on my crutches.”
C) “I must admit, I haven’t kept my extremity elevated as the doctor instructed.”
D) “Lately, I’ve been feeling pain in my left calf.”

2. Nurse James is caring for a 93-year-old female who has recently been admitted to the Alzheimer’s unit. The patient, with a history of Alzheimer’s Disease, shows increased confusion and unstable gait. She’s adamantly refusing to use a wheelchair (w/c). What is the most appropriate course of action for Nurse James to take?

A) Suggest that family members bring photos to personalize her room.
B) Advise that the patient should stay in her room at all times.
C) Propose a consultation with a speech therapist to the attending physician.
D) Encourage the patient to walk, using the wheelchair as a supportive device for safety.

3. Nurse Martin is working in an outpatient orthopedic clinic. During an assessment of a patient’s history, the patient reveals, “I tore 3 of my 4 rotator cuff muscles in the past.” Nurse Martin knows that the rotator cuff consists of specific muscles. Which of the following muscles cannot be considered as possibly being torn?

A) The Infraspinatus muscle
B) Teres major muscle
C) Muscle of Supraspinatus
D) Minor muscle of Teres

4. Nurse Williams is covering a pediatric unit and caring for a 15-year-old male patient. The patient’s mother shares her observation, stating, “I think my son is showing a sexual interest in girls.” What is the most appropriate course of action for Nurse Williams in responding to the mother?

A) “I’ll be sure to discuss this with the doctor.”
B) “Has this interest been noticeable for some time now?”
C) “What makes you believe he’s showing this interest?”
D) “It’s not uncommon for teenagers to begin showing signs of sexual interest in the opposite gender.”

5. Nurse Taylor, a high school nurse, observes a 14-year-old female student rubbing her scalp excessively while in the gym. What is the most appropriate course of action for Nurse Taylor to take?

A) Reach out to the female student’s parents to share the observations.
B) Contact the student’s primary care physician directly.
C) Examine the hairline and scalp for possible signs of lice or other irritation.
D) Send a request for a private evaluation of the girl’s scalp to her parents.

6. Nurse Harris is caring for a patient who has recently been diagnosed with both fibromyalgia and chronic obstructive pulmonary disease (COPD). She’s planning the patient’s care and determining which tasks to delegate. Which of the following tasks should Nurse Harris delegate to a nursing assistant?

A) Assisting the patient in ambulating for the first time after diagnosis.
B) Assessing and recording the patient’s breath sounds.
C) Providing education to the patient on techniques for monitoring fatigue.
D) Safely transferring the patient to the shower for hygiene care.

7. Nurse Patel has been instructed to place an IV line in a patient who has active tuberculosis (TB) and HIV. What safety equipment should Nurse Patel wear to ensure proper protection during this procedure?

A) Goggles, face mask, gloves, and a protective gown.
B) Two pairs of gloves, a protective gown, and a face mask.
C) Sterile gloves, a face mask, and safety goggles.
D) Surgical cap, gloves, face mask, and proper protective footwear.

8. A patient recovering from a stroke has been diagnosed with dysphagia. Which dietary modification is MOST appropriate to prevent aspiration?

A. Offering the patient thickened liquids and pureed foods.
B. Encouraging the patient to consume more raw vegetables and fruits for fiber.
C. Recommending a high protein diet with lean meats and legumes.
D. Increasing fluid intake with thin liquids like water and juice.

9. Nurse Anderson has just begun her 7 PM shift on the surgical unit. She’s reviewing the patient list and determining who needs immediate attention. Which of the following patients should Nurse Anderson check on first?

A) A 21-year-old male who underwent a lower extremity below-knee amputation (BKA) following a motor vehicle accident (MVA) yesterday, and is experiencing phantom pain.
B) A 75-year-old female scheduled for an esophagogastroduodenoscopy (EGD) in 10 hours.
C) A 34-year-old male who is reporting low back pain after back surgery and has experienced urinary incontinence in the last hour.
D) A 27-year-old female who received 1.5 units of red blood cells (RBCs) via transfusion the previous day.

10. Nurse Simmons is caring for a 64-year-old Alzheimer’s patient who has exhibited excessive cognitive decline resulting in harmful behaviors. The physician has ordered restraints to be placed on the patient for safety. What is the appropriate procedure that Nurse Simmons should follow?

A) Discuss with both the patient and family the need for restraints, ensuring understanding and consent.
B) Inform the physician immediately that the restraints have been properly placed.
C) Elevate the head of the bed at a 45-degree angle to enhance comfort.
D) Attach the restraints securely to the bed rails on all four extremities.

11. Nurse Wilson is caring for a 22-year-old patient in a mental health lock-down unit under suicide watch. The patient, who had previously been very withdrawn, suddenly appears happy about being discharged soon. What is probably happening in this situation?

A) The patient’s mood is genuinely improving, reflecting recovery.
B) The patient is excited about the possibility of reuniting with family and friends.
C) The patient’s suicide plan has likely progressed, and the happiness masks underlying intentions.
D) The patient’s plans for the future have become more clear, resulting in optimism.

12. Nurse Johnson is caring for a patient who has delivered an 8.2 lb. baby boy 3 days ago via C-section. The patient reports persistent white patches on her breast that aren’t going away. Which of the following medications may be necessary for this condition?

A) Amoxicillin (Amoxil)
B) Nystatin
C) Atropine
D) Lortab

13. Nurse Mitchell is working at an outpatient clinic and has a list of phone calls to return. She must prioritize the calls based on urgency. Which of the following calls should have the highest priority for medical intervention?

A) A middle-aged patient says, “My knee is still aching after my total knee replacement (TKR).”
B) A patient who received an upper extremity cast yesterday says, “I can’t feel my fingers in my right hand today.”
C) A young female says, “I think I might have sprained my ankle about two weeks ago.”
D) A home health patient says, “I am noticing a breakdown on my heels.”

14. In the emergency department, Nurse Jackson is assigned to a 13-year-old girl who is complaining of lower right abdominal discomfort. Exhibiting signs of distress and pain, the young patient looks to Nurse Jackson, who must act quickly. What is the FIRST appropriate measure that Nurse Jackson should take for this patient?

A. Position the patient in the right side-lying position for pressure relief.
B. Utilize non-pharmacological pain reduction techniques, such as deep breathing or distraction.
C. Immediately insert a Central Line.
D. Administer Lortab to the patient for pain relief without a physician’s order.

15. Nurse Anderson is monitoring a 64-year-old male patient diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Over the last few days, the patient exhibits an increase in total body weight of 10 lbs. Aware of the potential implications of this finding, Nurse Anderson must decide on the next course of action. What should the nurse do?

A. Check the patient’s vitals every 2 hours.
B. Review the intake and output on the patient’s flow sheet.
C. Contact the patient’s physician immediately.
D. Encourage the patient to ambulate to reduce lower extremity edema.

16. A 32-year-old male patient is under Nurse Williams’ care, presenting a complaint of dizziness. With an order for Morphine via IV on hand, Nurse Williams recognizes the need for a thorough assessment before proceeding. What should be the nurse’s FIRST course of action?

A. Review the results of the patient’s chest x-ray examination.
B. Retake and carefully assess the vitals, focusing on blood pressure.
C. Conduct a detailed neurological screening on the patient.
D. Promptly request the physician on-call to come and assess the patient.

17. Nurse Thompson is caring for a patient diagnosed with Tuberculosis (TB). The medical team is discussing the conditions under which the patient can be taken off restrictions. As the conversation unfolds, Nurse Thompson considers which of the following parameters must be met for the patient to be taken off restrictions:

A. Sustaining a non-productive cough for a duration of 72 hours.
B. Completing a mandatory isolation period of 30 days.
C. Maintaining a normal body temperature consistently for 48 hours.
D. Receiving negative culture results from laboratory testing.

18. Nurse Miller is working with a patient diagnosed with Chronic Obstructive Pulmonary Disease (COPD), preparing to teach them pulmonary exercises to enhance lung function. Understanding the particular needs and limitations of a COPD patient, Nurse Miller considers which of the following approaches to take:

A. Advocate for engaging in repetitive heavy lifting exercises to augment muscular strength.
B. Restrict exercises based on the occurrence of respiratory acidosis symptoms.
C. Plan for intermittent breaks every 10-20 minutes during the exercises.
D. Instruct the patient in the practice of pursed-lip breathing techniques as part of their routine.

19. A patient, concerned about exposure to Tuberculosis (TB), approaches Nurse Davis with a query. “I’m worried about TB exposure, Nurse. What’s the best way to identify it? Which procedure or test is the most definitive for TB?” Nurse Davis considers the most accurate response:

A. Culturing sputum specifically for gram-negative bacteria.
B. Conducting a detailed examination of the patient’s breath sounds.
C. Performing the Mantoux test, also known as a Tuberculin Skin Test (TST).
D. Utilizing a chest x-ray to visualize lung abnormalities.

20. While working in the surgical unit, Nurse Harris observes a patient displaying shortness of breath (SOB), calf pain, and warmth over the posterior calf. Recognizing that these signs could be indicative of a specific medical condition, Nurse Harris reflects on what these symptoms may signal. Which of the following medical conditions might the patient be experiencing?

A. The patient may be in the late phases of Congestive Heart Failure (CHF).
B. The patient may be experiencing anxiety following the surgical procedure.
C. The patient may have developed a Deep Vein Thrombosis (DVT).
D. The patient may be exhibiting signs of an underlying dermatitis condition.

Answers and Rationales

1. Correct answer:

D) “Lately, I’ve been feeling pain in my left calf.” Pain in the calf area, especially after a cast has been applied, could be indicative of a serious underlying condition such as a deep vein thrombosis (DVT). DVT is a blood clot that forms in a vein deep in the body, often in the legs. This condition can lead to serious complications if the clot breaks loose and travels to the lungs, causing a pulmonary embolism.

In the context of a cast, reduced mobility and blood flow can contribute to the formation of a clot. The pain in the calf might be the only symptom of this potentially life-threatening condition, and immediate medical evaluation and intervention might be required.

Imagine a river flowing smoothly. If a dam (clot) suddenly forms, the water (blood) can’t flow properly, leading to potential flooding (swelling and pain) and other downstream problems.

Incorrect answer options:

A) “I can’t seem to get rid of the itch inside my cast on my left leg.” While itching can be uncomfortable, it is a common complaint with casts and is usually not indicative of a serious underlying problem. It can often be managed with over-the-counter remedies or gentle techniques to alleviate the itch.

B) “My arthritis is acting up when I put weight on my crutches.” This statement reflects a chronic condition (arthritis) that may be exacerbated by the use of crutches but is not directly related to the cast or the injury. It may require attention but is not as urgent as the pain in the calf.

C) “I must admit, I haven’t kept my extremity elevated as the doctor instructed.” While failure to elevate the extremity may lead to increased swelling and discomfort, it is not as immediately concerning as the potential for a DVT. Education and reinforcement of care instructions would be appropriate here.

2. Correct answer:

D) Encourage the patient to walk, using the wheelchair as a supportive device for safety. Patients with Alzheimer’s Disease often experience confusion and changes in mobility, including an unstable gait. It’s essential to maintain their independence and dignity while ensuring safety. Encouraging the patient to walk, with the wheelchair as a supportive device, aligns with this approach.

Promoting Independence and Safety: By encouraging the patient to walk and using the wheelchair as a supportive device, Nurse James is promoting both independence and safety. This approach respects the patient’s autonomy and desire to walk while providing a safety net. It’s a balanced strategy that recognizes the patient’s needs and preferences without compromising her well-being.

Therapeutic Communication and Trust Building: This approach also involves therapeutic communication. By engaging the patient in her care and offering a compromise that respects her wishes, Nurse James can build trust. This trust is vital in caring for patients with Alzheimer’s, as they may have difficulty understanding their surroundings and the people around them.

Think of the wheelchair as training wheels on a bicycle. For a child learning to ride, the training wheels provide support and safety without taking away the experience of riding the bike. Similarly, the wheelchair offers support and safety to the patient without taking away her ability to walk and maintain some level of independence.

Incorrect answer options:

A) Suggest that family members bring photos to personalize her room. While personalizing the room can be a comforting strategy for patients with Alzheimer’s, it doesn’t directly address the immediate concern of the patient’s unstable gait and refusal to use a wheelchair. It’s a valuable approach but not the most appropriate response to the specific situation presented.

B) Advise that the patient should stay in her room at all times. This option is overly restrictive and doesn’t respect the patient’s autonomy or need for social interaction and physical activity. It may lead to further confusion, agitation, and decline in physical condition. It’s a response that doesn’t consider the complexity of caring for a patient with Alzheimer’s.

C) Propose a consultation with a speech therapist to the attending physician. While speech therapy may be beneficial for some patients with Alzheimer’s, particularly those with communication difficulties, it doesn’t address the immediate issue of the patient’s unstable gait and refusal to use a wheelchair. It’s an unrelated intervention that doesn’t meet the specific needs of the situation.

3. Correct answer:

B) Teres major muscle. The rotator cuff is a group of four muscles that stabilize the shoulder joint. These muscles include the Infraspinatus, Supraspinatus, Teres Minor, and Subscapularis muscles. The Teres Major muscle is not part of the rotator cuff, so it cannot be considered as possibly being torn in the context of the patient’s statement.

The rotator cuff muscles work together to stabilize the head of the humerus within the shallow socket of the shoulder blade.

Think of the rotator cuff as a group of friends holding hands in a circle, each one contributing to keeping a ball (the head of the humerus) in the center of the circle (the shoulder socket). If one or more of these friends lets go, the ball can move out of place, leading to instability and injury.

Incorrect answer options:

A) The Infraspinatus muscle. This is one of the four muscles that make up the rotator cuff. It helps with the rotation and stabilization of the shoulder joint.

C) Muscle of Supraspinatus. This is also one of the four muscles in the rotator cuff. It helps initiate the lifting of the arm.

D) Minor muscle of Teres. This refers to the Teres Minor muscle, another one of the four muscles in the rotator cuff. It assists with the rotation of the arm.

4. Correct answer:

D) “It’s not uncommon for teenagers to begin showing signs of sexual interest in the opposite gender.” This response acknowledges the mother’s observation without making it a medical issue or probing for unnecessary details. It normalizes the behavior, which is a typical developmental milestone for a teenager.

In adolescence, individuals often begin to explore their sexuality and develop sexual interests. This is a normal part of human development and is often guided by hormonal changes that occur during puberty. Nurse Williams’ response in this option provides reassurance to the mother that her son’s behavior is typical for his age. It’s akin to noticing that a flower is beginning to bloom in the springtime; it’s a natural process that occurs at a certain stage of development.

This response maintains the patient’s privacy and dignity by not delving into personal details or making it a topic for medical intervention. It’s like noticing a teenager starting to grow facial hair or develop a deeper voice; these are normal signs of maturation that don’t require medical intervention or detailed investigation.

Lastly, this response fosters open communication between the nurse and the family without crossing professional boundaries. It’s a gentle way of addressing a potentially sensitive topic without making it a problem or prying into private family matters. Think of it as a teacher acknowledging a student’s growth in a subject without probing into how they study at home; it’s an observation of a normal process without unnecessary intrusion.

Incorrect answer options:

A) “I’ll be sure to discuss this with the doctor.” This response may unnecessarily medicalize a normal developmental behavior. It could cause the mother to worry that there is something wrong with her son’s interest in girls. It’s like telling a parent you’ll talk to the principal because their child is making friends at school; it turns a normal behavior into a potential problem.

B) “Has this interest been noticeable for some time now?” This response may be seen as prying into personal family matters. While it might be intended to gather more information, it could make the mother uncomfortable by asking for details that are not relevant to the patient’s medical care. It’s akin to asking a parent detailed questions about their child’s social life when they mention their child has made a new friend; it’s unnecessary and can feel intrusive.

C) “What makes you believe he’s showing this interest?” This response might be interpreted as challenging the mother’s observation or asking her to justify her statement. It could create a barrier in the nurse-family relationship by seeming to question the mother’s understanding of her son. It’s like asking a parent to prove that their child likes a particular subject in school; it’s confrontational and doesn’t foster trust.

5. Correct answer:

C) Examine the hairline and scalp for possible signs of lice or other irritation. This response is the most appropriate initial action for Nurse Taylor to take, as it directly addresses the observed behavior without involving others unnecessarily.

The observation of a student rubbing her scalp excessively could indicate a variety of underlying issues, such as lice, dandruff, or other scalp irritations. By examining the hairline and scalp, Nurse Taylor can assess the situation and determine the appropriate next steps.

Think of this like noticing a plant with wilting leaves; before taking any action, you would examine the soil, water level, and sunlight exposure to understand what might be causing the problem.

If Nurse Taylor finds signs of lice or other issues, she can then communicate with the student’s parents and provide guidance on treatment. This approach respects the student’s privacy and autonomy, while also addressing the potential issue promptly and professionally.

It’s akin to a teacher noticing a student struggling with a particular subject and offering extra help or resources before contacting the parents; it’s a direct and thoughtful response to an observed need.

Incorrect answer options:

A) Reach out to the female student’s parents to share the observations. This response might be premature without first assessing the situation. It could cause unnecessary concern for the parents without knowing the underlying cause of the behavior. It’s like calling a parent to report that their child is struggling with math before even talking to the child or assessing their work; it may create worry without reason.

B) Contact the student’s primary care physician directly. This response would be inappropriate as it breaches confidentiality and oversteps professional boundaries. Medical information should only be shared with the consent of the student or their guardians, and this action would not respect that principle. It’s akin to a teacher calling a child’s private tutor without permission to discuss their progress; it’s an overreach that disregards privacy.

D) Send a request for a private evaluation of the girl’s scalp to her parents. This response might also be premature and could create unnecessary concern or confusion for the parents. Without first assessing the situation, sending a request for a private evaluation might seem excessive. It’s like sending a letter home recommending tutoring for a student before assessing their needs or offering assistance; it may be an overreaction to a situation that could be addressed more simply.

6. Correct answer:

D) Safely transferring the patient to the shower for hygiene care. This task is within the scope of practice for a nursing assistant and doesn’t require the specialized knowledge or judgment that a registered nurse would provide.

Transferring a patient to the shower for hygiene care is a routine task that doesn’t require specialized assessment or intervention related to the patient’s specific diagnoses.

Think of this like a chef in a gourmet kitchen delegating the washing of vegetables to a kitchen assistant; it’s a necessary task but doesn’t require the chef’s specialized culinary skills.

In this context, the nursing assistant would be responsible for ensuring the patient’s safety during the transfer, taking into account any mobility limitations or other individual needs. The nursing assistant would follow established protocols and communicate with the nurse as needed.

Furthermore, by delegating this task, Nurse Harris can focus her time and expertise on the more complex aspects of the patient’s care, such as assessment, education, and coordination of care.

Incorrect answer options:

A) Assisting the patient in ambulating for the first time after diagnosis. This task requires the specialized assessment and judgment of a registered nurse, especially given the patient’s recent diagnosis with fibromyalgia and COPD.

B) Assessing and recording the patient’s breath sounds. This task requires specialized knowledge and skill to accurately assess and interpret the patient’s breath sounds, especially in the context of COPD.

C) Providing education to the patient on techniques for monitoring fatigue. This task requires an understanding of the patient’s specific conditions and the ability to tailor education to the patient’s needs.

7. Correct answer:

A) Goggles, face mask, gloves, and a protective gown. This combination of safety equipment provides comprehensive protection for Nurse Patel during the procedure of placing an IV line in a patient with active tuberculosis (TB) and HIV.

Tuberculosis is an airborne disease, and HIV is transmitted through blood and body fluids. Therefore, the safety equipment must protect against both respiratory droplets and potential exposure to blood. Wearing goggles and a face mask will protect the eyes, nose, and mouth from droplets that may contain TB bacteria. Gloves will protect against potential exposure to blood that may contain HIV, and a protective gown will shield the nurse’s clothing and skin from possible contamination.

Think of this like a firefighter wearing a full set of protective gear, including a helmet, face shield, gloves, and fire-resistant clothing. Each piece of equipment serves a specific purpose in protecting against different hazards, and together they provide comprehensive protection.

The use of proper safety equipment not only protects the healthcare provider but also helps prevent the spread of infections within the healthcare setting. It’s essential to follow established protocols for infection control, including the use of appropriate personal protective equipment (PPE). This ensures the safety of both the healthcare provider and other patients.

Furthermore, the selection of appropriate PPE reflects an understanding of the specific risks associated with the patient’s diagnoses and the procedure being performed. It’s a demonstration of professional responsibility and commitment to patient safety. Just as a construction worker would select specific safety equipment based on the task at hand and the potential hazards, healthcare providers must choose the appropriate PPE based on a careful assessment of the situation.

Incorrect answer options:

B) Two pairs of gloves, a protective gown, and a face mask. While this option includes important protective elements, it lacks goggles, which are necessary to protect the eyes from potential exposure to TB droplets. It’s like wearing a raincoat and boots without an umbrella; you’re still exposed to the rain.

C) Sterile gloves, a face mask, and safety goggles. This option lacks a protective gown, leaving the nurse’s clothing and skin potentially exposed to contamination. It’s akin to wearing a helmet and knee pads for rollerblading but neglecting to wear elbow pads; there’s still a vulnerable area left unprotected.

D) Surgical cap, gloves, face mask, and proper protective footwear. This option does not include a protective gown or goggles, leaving the nurse’s eyes and clothing unprotected. It’s like wearing a seatbelt and helmet in a car but neglecting to use the airbags; essential safety features are missing.

8. Correct answer:

A. Offering the patient thickened liquids and pureed foods. Patients with dysphagia, or difficulty swallowing, are at a high risk of aspiration, which can lead to pneumonia and other serious complications. Offering thickened liquids and pureed foods can help prevent aspiration by making it easier for the patient to swallow safely. Thickened liquids move more slowly, allowing the patient more time to control the swallow, and pureed foods eliminate the need to chew, reducing the risk of choking.

Imagine trying to walk on a slippery, icy path (thin liquids) versus a stable, gravel path (thickened liquids). The icy path offers no control, leading to slips and falls (aspiration), while the gravel path provides stability and control, preventing falls. Similarly, thickened liquids and pureed foods provide a “stable path” for swallowing, reducing the risk of food or liquid “slipping” into the lungs.

The act of swallowing involves multiple muscles and nerves working together to move food from the mouth to the stomach. Dysphagia can interrupt this process, causing food or liquid to enter the trachea instead of the esophagus, leading to aspiration. Thickened liquids and pureed foods are easier to control during swallowing, reducing the risk of aspiration.

Incorrect answer options:

B. Encouraging the patient to consume more raw vegetables and fruits for fiber. While a diet rich in fruits and vegetables is generally healthy, it is not appropriate for individuals with dysphagia. Raw vegetables and fruits can be difficult to chew and swallow, increasing the risk of aspiration.

C. Recommending a high protein diet with lean meats and legumes. A high-protein diet with lean meats and legumes may be nutritionally beneficial, but it is not suitable for patients with dysphagia. Meats and legumes can be tough to chew and swallow, posing a choking hazard.

D. Increasing fluid intake with thin liquids like water and juice. Increasing fluid intake with thin liquids like water and juice is contraindicated for patients with dysphagia. Thin liquids can quickly lead to aspiration as they are difficult for the patient to control while swallowing.

9. Correct answer:

C) A 34-year-old male who is reporting low back pain after back surgery and has experienced urinary incontinence in the last hour. This patient’s situation requires immediate attention due to the potential underlying issues related to the back surgery and the new symptom of urinary incontinence.

Urinary incontinence following back surgery could be indicative of a serious complication, such as nerve damage or other underlying issues related to the surgical site. Immediate assessment and intervention may be required to prevent further complications.

Think of this like noticing a leak in the ceiling near electrical wiring; immediate attention is required to prevent potential damage and danger.

The patient’s report of low back pain, coupled with the incontinence, adds to the urgency of the situation. Pain management is a critical aspect of postoperative care, and uncontrolled pain can lead to complications such as increased stress response, delayed healing, and decreased patient satisfaction. Addressing the pain promptly can enhance the patient’s comfort and overall recovery.

Furthermore, the combination of these symptoms requires a comprehensive assessment to determine the underlying cause and appropriate interventions. Nurse Anderson’s prompt attention to this patient can facilitate timely diagnosis and treatment, potentially preventing further complications and enhancing the patient’s recovery. It’s akin to a mechanic hearing an unusual noise in a car engine and immediately investigating to find the source before it leads to more significant problems.

Incorrect answer options:

A) A 21-year-old male who underwent a lower extremity below-knee amputation (BKA) following a motor vehicle accident (MVA) yesterday, and is experiencing phantom pain. While phantom pain is distressing, it is a common phenomenon following amputation and does not present an immediate threat to the patient’s health. It’s like hearing a creaking noise in a house; it may be annoying but doesn’t necessarily indicate an urgent problem.

B) A 75-year-old female scheduled for an esophagogastroduodenoscopy (EGD) in 10 hours. This patient is scheduled for a procedure but is not experiencing any acute symptoms or issues that require immediate attention. It’s akin to knowing you have an appointment later in the day; it’s on the schedule but doesn’t require immediate action.

D) A 27-year-old female who received 1.5 units of red blood cells (RBCs) via transfusion the previous day. Without any indication of complications or acute symptoms related to the transfusion, this patient’s situation does not require immediate attention. It’s like watering a plant the previous day; as long as the plant looks healthy, there’s no need for immediate concern.

10. Correct answer:

A) Discuss with both the patient and family the need for restraints, ensuring understanding and consent. The use of restraints in healthcare, especially with patients who have cognitive impairments like Alzheimer’s disease, is a complex and sensitive issue. It requires careful consideration, communication, and adherence to ethical principles and legal guidelines.

First and foremost, the decision to use restraints must be based on a thorough assessment of the patient’s condition and behavior, and the determination that restraints are necessary to ensure the safety of the patient or others.

Think of this like installing a safety gate at the top of a staircase in a home with a toddler; it’s a measure taken to prevent harm, but it must be done with understanding and care.

Next, it’s essential to communicate with both the patient (to the extent possible) and the family about the need for restraints, the goals of the intervention, and the measures that will be taken to ensure the patient’s comfort and dignity. This conversation should include an opportunity for questions and concerns to be addressed.

It’s akin to discussing a treatment plan with a patient and their family, ensuring that they understand the reasons for the treatment and what to expect.

Finally, the use of restraints must be in accordance with legal and regulatory guidelines, including obtaining proper consent and documenting the intervention appropriately. Regular monitoring and reassessment are also required to ensure that the restraints are used only as long as necessary and that the patient’s physical and emotional well-being is maintained. It’s like following a specific set of instructions when assembling a piece of furniture; each step must be followed carefully to achieve the desired result safely and effectively.

Incorrect answer options:

B) Inform the physician immediately that the restraints have been properly placed. While communication with the physician is important, this option does not address the essential steps of assessment, communication with the patient and family, and adherence to ethical and legal guidelines.

C) Elevate the head of the bed at a 45-degree angle to enhance comfort. While patient comfort is important, this option does not address the fundamental issues related to the decision to use restraints and the process of obtaining consent and ensuring understanding.

D) Attach the restraints securely to the bed rails on all four extremities. This option focuses on the physical act of applying restraints but does not address the complex ethical, legal, and communication aspects of this intervention.

11. Correct answer:

C) The patient’s suicide plan has likely progressed, and the happiness masks underlying intentions. In the context of a mental health lock-down unit, especially under suicide watch, a sudden and unexplained change in mood can be a significant warning sign.

A sudden shift from being very withdrawn to appearing happy, especially in the context of an impending discharge, may indicate that the patient has made a decision about a suicide plan. This decision can bring a sense of relief or resolution, leading to a temporary improvement in mood.

Think of this like a person who has been struggling with a difficult decision and suddenly appears relieved and content after making a choice; the underlying reasons for that choice may not be apparent to others.

It’s essential for Nurse Wilson to recognize this change in behavior as a potential red flag and to respond with a thorough assessment and appropriate interventions. This may include communicating with the mental health team, reassessing the patient’s risk for suicide, and implementing additional safety measures as needed.

The situation underscores the complexity of mental health care and the importance of careful observation, understanding of mental health disorders, and collaboration with the mental health team. Just as a sudden change in a patient’s physical condition requires immediate attention and assessment, so too does a sudden change in a patient’s mental or emotional state.

Incorrect answer options:

A) The patient’s mood is genuinely improving, reflecting recovery. While this is a possibility, it would be unwise to assume that a sudden change in mood reflects genuine improvement without a thorough assessment, especially in the context of suicide watch.

B) The patient is excited about the possibility of reuniting with family and friends. While this may be a contributing factor, it does not fully explain the sudden change in behavior, and it would be risky to overlook the potential underlying intentions related to suicide.

D) The patient’s plans for the future have become more clear, resulting in optimism. Again, while this may be a contributing factor, it does not fully explain the sudden change in behavior, and it would be risky to overlook the potential underlying intentions related to suicide.

12. Correct answer:

B) Nystatin. The persistent white patches on the patient’s breast that aren’t going away are likely indicative of a yeast infection, commonly known as thrush. This can occur in breastfeeding mothers and may cause discomfort and difficulty with breastfeeding.

Nystatin is an antifungal medication commonly used to treat yeast infections, including thrush. It can be applied topically to the affected area to eliminate the yeast infection.

Think of this like using a specific weed killer to target a particular type of weed in a garden; Nystatin is specifically designed to target the yeast that causes thrush.

In the context of breastfeeding, it’s essential to address thrush promptly, as it can interfere with the mother’s ability to breastfeed comfortably and effectively. Treatment with Nystatin can help to resolve the infection, alleviate symptoms, and support continued breastfeeding.

Furthermore, the healthcare provider may also assess the baby for signs of thrush, as the infection can be passed between mother and baby during breastfeeding. Coordinated care and treatment can help to resolve the infection and support the health and well-being of both mother and baby.

Incorrect answer options:

A) Amoxicillin (Amoxil). This is an antibiotic used to treat bacterial infections, not fungal infections like thrush. It would be like using a broad-spectrum weed killer that doesn’t target the specific weed you’re trying to eliminate.

C) Atropine. This medication is used to treat certain types of heart conditions, poisonings, and to reduce saliva production during surgery. It is not relevant to the treatment of thrush.

D) Lortab. This is a combination of acetaminophen and hydrocodone and is used to treat moderate to severe pain. While it might help with pain associated with breastfeeding due to thrush, it does not treat the underlying fungal infection.

13. Correct answer:

B) A patient who received an upper extremity cast yesterday says, “I can’t feel my fingers in my right hand today.” This situation requires immediate medical intervention, as it may indicate a serious complication such as compartment syndrome or nerve compression.

Compartment syndrome is a medical emergency where pressure within a muscle compartment builds up to dangerous levels, potentially leading to nerve and muscle damage. The loss of feeling in the fingers could be a sign that the cast is too tight, restricting blood flow and compressing nerves.

Think of this like a garden hose that’s been kinked; the water can’t flow, and the hose may become damaged if the kink isn’t promptly corrected.

Immediate assessment and intervention are required to prevent permanent damage. This may include loosening or removing the cast, assessing the affected extremity, and implementing appropriate medical treatment.

Incorrect answer options:

A) A middle-aged patient says, “My knee is still aching after my total knee replacement (TKR).” While postoperative pain is a concern and should be addressed, it is not as urgent as the potential compartment syndrome or nerve compression in the correct option. Pain following a TKR is expected, and the patient likely needs reassessment and possibly pain management adjustment. It’s akin to hearing a squeaky door; it needs attention, but it’s not an emergency.

C) A young female says, “I think I might have sprained my ankle about two weeks ago.” This situation, while requiring attention, is not urgent. A sprain that occurred two weeks ago without immediate complications is likely not a medical emergency. It’s like noticing a small crack in a window; it needs to be fixed, but it’s not an immediate threat.

D) A home health patient says, “I am noticing a breakdown on my heels.” Skin breakdown is a serious concern, especially in home health patients who may have limited mobility. However, compared to the potential compartment syndrome in the correct option, this situation is less urgent. It’s like noticing a leak in the roof; it needs to be addressed promptly, but it’s not as immediate a concern as a fire in the house.

14. Correct answer:

B) Utilize non-pharmacological pain reduction techniques, such as deep breathing or distraction. In the emergency department, when a patient presents with lower right abdominal discomfort, it’s essential to consider potential causes, such as appendicitis. While further assessment and diagnostic tests are needed, immediate care should focus on alleviating the patient’s distress and pain.

Non-pharmacological pain reduction techniques, such as deep breathing or distraction, can be effective in providing immediate comfort without interfering with the diagnostic process. These techniques can be implemented quickly and without a physician’s order, making them an appropriate first step in care.

Think of this approach like using a fan to cool down a room on a hot day while waiting for the air conditioning to be fixed. It’s not a permanent solution, but it provides immediate relief without causing any potential harm or interfering with the repair process.

Incorrect answer options:

A) Position the patient in the right side-lying position for pressure relief. While positioning can be an important part of pain management, the right side-lying position might actually increase pain in a patient with appendicitis. It’s like putting pressure on a bruise; it might make the situation worse.

C) Immediately insert a Central Line. This intervention is highly invasive and would not be the first step in managing a patient with lower right abdominal discomfort. It would be like using a sledgehammer to hang a picture; it’s an excessive measure for the situation at hand.

D) Administer Lortab to the patient for pain relief without a physician’s order. Administering medication without a physician’s order is not appropriate, and it could interfere with the diagnostic process. It’s like painting over a stain on a wall without first identifying and addressing the source of the stain; it might cover up the problem temporarily but doesn’t address the underlying issue.

15. Correct answer:

B) Review the intake and output on the patient’s flow sheet. A sudden increase in body weight, especially in a patient with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF), could be indicative of fluid retention. This can be a sign of worsening heart failure, and it’s essential to assess the situation carefully.

Reviewing the intake and output on the patient’s flow sheet will provide valuable information about the patient’s fluid balance. This data can help determine whether the weight gain is related to fluid retention or other factors.

Think of this like checking the water level in a fish tank that’s overflowing. Before taking any drastic measures, you would first want to see if there’s a balance between the water being added and the water being drained. If more water is coming in than going out, it could explain the overflow.

Incorrect answer options:

A) Check the patient’s vitals every 2 hours. While monitoring vital signs is essential in patient care, especially for those with COPD and CHF, it may not directly address the underlying cause of the sudden weight gain. It’s like checking the temperature in a room without investigating why it’s suddenly too hot or too cold.

C) Contact the patient’s physician immediately. While communication with the physician is crucial, especially if the weight gain is determined to be due to fluid retention, the nurse should first gather relevant data (such as intake and output) to provide a clear picture of the situation. It’s like calling a plumber before checking if the faucet is simply left open.

D) Encourage the patient to ambulate to reduce lower extremity edema. While ambulation can be beneficial for reducing edema, it may not be the appropriate immediate response without first assessing the underlying cause of the weight gain. It’s like trying to fix a leaky roof by cleaning the gutters; it might help, but you need to find the source of the leak first.

16. Correct answer:

B) Retake and carefully assess the vitals, focusing on blood pressure. Dizziness is a common complaint and can be associated with various underlying causes, including changes in blood pressure. In the context of an order for Morphine via IV, it’s essential to recognize that Morphine can cause a drop in blood pressure, potentially exacerbating the patient’s dizziness.

The nurse’s first course of action should be to retake and carefully assess the patient’s vital signs, with a particular focus on blood pressure. This will provide immediate information about the patient’s cardiovascular status and may help identify the underlying cause of the dizziness.

Understanding the patient’s baseline blood pressure and current readings will also inform the decision to administer Morphine, as a significant drop in blood pressure could lead to further complications. It’s like checking the oil level in a car before adding more; you need to know the current status to make an informed decision about what to do next.

Furthermore, a thorough assessment of the patient’s vital signs, including heart rate, respiratory rate, and oxygen saturation, will provide a comprehensive picture of the patient’s overall condition. This information is essential for guiding further care and ensuring that interventions, such as the administration of Morphine, are appropriate and safe.

Think of the process of assessing blood pressure like checking the foundation of a house when you notice a crack in the wall. Before you patch the crack or make any other changes, you need to understand the underlying structure and stability. If the foundation is unstable, simply patching the crack won’t address the root problem, and further issues may arise.

Incorrect answer options:

A) Review the results of the patient’s chest x-ray examination. While diagnostic tests may be relevant, they are not the immediate priority when a patient presents with dizziness, especially in the context of a potential medication administration.

C) Conduct a detailed neurological screening on the patient. While neurological assessment may be part of the overall evaluation, it’s not the first step in this scenario. Understanding the patient’s cardiovascular status through vital signs assessment is more immediately relevant.

D) Promptly request the physician on-call to come and assess the patient. While collaboration with the physician is essential, the nurse should first gather relevant data, such as vital signs, to inform the physician and guide further care.

17. Correct answer:

D) Receiving negative culture results from laboratory testing. Tuberculosis (TB) is a contagious bacterial infection that primarily affects the lungs. The decision to take a patient off restrictions or isolation is typically based on specific clinical and laboratory criteria.

Negative culture results from laboratory testing indicate that the TB bacteria are no longer present in the patient’s sputum. This is a critical parameter in determining that the patient is no longer infectious and can be taken off restrictions. It’s like receiving a clear water test result after treating a contaminated well; the negative result indicates that the problem has been resolved, and the water is safe to use again.

The process of obtaining negative culture results involves collecting sputum samples over several days and testing them in the laboratory. This can take time, as TB bacteria grow slowly, but it provides definitive evidence that the patient is no longer contagious.

Think of the process of obtaining negative culture results like testing a batch of cookies for doneness by inserting a toothpick. If the toothpick comes out clean, it’s a clear indication that the cookies are done. Similarly, negative culture results provide clear evidence that the TB infection has been successfully treated, and the patient is no longer contagious.

Incorrect answer options:

A) Sustaining a non-productive cough for a duration of 72 hours. While a non-productive cough might indicate improvement, it’s not a definitive sign that the patient is no longer contagious.

B) Completing a mandatory isolation period of 30 days. Isolation periods for TB are not typically defined by a specific number of days but rather by clinical and laboratory criteria, including negative culture results.

C) Maintaining a normal body temperature consistently for 48 hours. While a normal body temperature might indicate improvement, it’s not a definitive sign that the patient is no longer contagious.

18. Correct answer:

D) Instruct the patient in the practice of pursed-lip breathing techniques as part of their routine. Pursed-lip breathing is a specific technique that helps people with Chronic Obstructive Pulmonary Disease (COPD) to breathe more effectively. It involves inhaling through the nose and exhaling slowly through pursed lips, like blowing out a candle. This technique helps to keep the airways open longer, allowing more air to flow in and out of the lungs.

Pursed-lip breathing can reduce shortness of breath, improve oxygenation, and enhance the overall quality of life for individuals with COPD. It’s a simple yet powerful tool that can be incorporated into daily routines and exercise programs.

Think of pursed-lip breathing like using a slow, controlled release valve on a pressurized container. By controlling the flow of air, you can ensure that the pressure is maintained at an optimal level, allowing the contents to be used more efficiently. Similarly, pursed-lip breathing helps to control the flow of air in and out of the lungs, optimizing lung function.

Incorrect answer options:

A) Advocate for engaging in repetitive heavy lifting exercises to augment muscular strength. While strength training can be part of a comprehensive exercise program for COPD patients, heavy lifting might be too strenuous and could exacerbate symptoms.

B) Restrict exercises based on the occurrence of respiratory acidosis symptoms. While monitoring for symptoms is essential, restricting exercises solely based on respiratory acidosis symptoms might not provide a comprehensive approach to exercise planning for COPD patients.

C) Plan for intermittent breaks every 10-20 minutes during the exercises. While breaks are essential, the timing should be individualized based on the patient’s tolerance and needs rather than a fixed interval.

19. Correct answer:

C) Performing the Mantoux test, also known as a Tuberculin Skin Test (TST). The Mantoux test is a standard method used to detect latent Tuberculosis (TB) infection. It involves injecting a small amount of tuberculin purified protein derivative (PPD) into the inner surface of the forearm. The test is read 48 to 72 hours later by measuring the size of the induration (swelling) at the injection site.

The TST is a valuable tool for identifying individuals who have been infected with the TB bacteria, even if they do not have active symptoms. It’s commonly used in screening programs, especially for those at higher risk of TB exposure.

Think of the TST like a metal detector at the airport. It’s a screening tool that helps identify potential threats (in this case, TB infection) but doesn’t provide detailed information about the nature of the threat. If the metal detector goes off, further investigation (such as a sputum culture) may be needed to identify the specific cause.

It’s important to note that the TST is used to identify latent TB infection, not active TB disease. If the TST is positive, further tests such as a sputum culture or chest x-ray may be needed to confirm or rule out active TB disease.

Incorrect answer options:

A) Culturing sputum specifically for gram-negative bacteria. While sputum culture is the gold standard for diagnosing active TB disease, it’s not typically used for screening or identifying latent TB infection.

B) Conducting a detailed examination of the patient’s breath sounds. Abnormal breath sounds may indicate a lung problem but are not specific to TB.

D) Utilizing a chest x-ray to visualize lung abnormalities. A chest x-ray may show signs consistent with TB but is not used as a definitive test for latent TB infection.

20. Correct answer:

C. The patient may have developed a Deep Vein Thrombosis (DVT). Deep Vein Thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the legs. The symptoms described, such as shortness of breath (SOB), calf pain, and warmth over the posterior calf, are classic signs of DVT. The shortness of breath may be indicative of a pulmonary embolism (PE), a complication of DVT where the clot travels to the lungs. Immediate medical intervention is necessary to diagnose and treat DVT to prevent serious complications.

Imagine a river flowing smoothly. If a dam is suddenly built (like a blood clot in DVT), the water flow is obstructed, causing problems upstream. In the body, a clot in a deep vein can obstruct blood flow, causing pain, warmth, and potentially leading to life-threatening complications if not treated promptly.

Incorrect answer options:

A. The patient may be in the late phases of Congestive Heart Failure (CHF). While CHF can cause shortness of breath, the specific symptoms of calf pain and warmth over the posterior calf are not typical of CHF. CHF would more likely present with symptoms like edema, fatigue, and difficulty breathing while lying down.

B. The patient may be experiencing anxiety following the surgical procedure. Anxiety can cause shortness of breath, but it would not typically cause localized calf pain and warmth. These symptoms are more specific to a physical condition like DVT rather than a psychological response.

D. The patient may be exhibiting signs of an underlying dermatitis condition. Dermatitis might cause warmth and discomfort in a localized area, but it would not typically cause shortness of breath or the specific calf pain described. Dermatitis is more associated with skin inflammation, redness, and itching, not the symptoms described in the scenario.