Nursing Practice Exam - Key Points

Question 1: Congestive Heart Failure and Fluid Overload

• Finding Indicating Immediate Intervention: Crackles halfway up lung fields
  • Rationale: Indicates pulmonary edema, a serious complication requiring immediate intervention.

Question 2: Type 1 Diabetes and Fasting Blood Glucose Test

• Appropriate Action: Withhold all diabetes medications on the morning of the test
  • Rationale: Ensures accurate fasting blood glucose levels without artificial lowering from medications.

Question 3: Post-Operative Care for Total Hip Replacement

• Priority Action: Assess for signs of Deep Vein Thrombosis (DVT)
  • Rationale: High risk for blood clots; early detection is crucial to prevent serious complications like pulmonary embolism.

Question 4: ST-Elevation Myocardial Infarction

• Most Appropriate Nursing Action: Provide oxygen therapy and prepare for thrombolytic therapy
  • Rationale: Immediate intervention to restore blood flow is critical in STEMI cases.

Question 5: Acute Pancreatitis Dietary Instructions

• Dietary Instruction: Avoid alcohol and foods that are high in sugar
  • Rationale: Alcohol and high sugar foods can trigger or exacerbate pancreatitis.

Question 6: Pulmonary Embolism Prevention

• Priority Intervention: Administer anticoagulant therapy as prescribed
  • Rationale: Prevents new clot formation and growth of existing clots.

Question 7: Blood Transfusion Safety

• Critical Action: Confirm patient's identity and blood group compatibility with the blood unit
  • Rationale: Prevents life-threatening transfusion reactions.

Question 8: COPD and Oxygen Saturation During Meals

• Intervention: Encourage the patient to eat smaller, more frequent meals
  • Rationale: Reduces energy expenditure and breathing difficulty during meals.

Question 9: IV Therapy and Pain Along the Vein

• Next Step: Discontinue the IV line and start a new IV in another extremity
  • Rationale: Prevents further vein irritation and possible infection.

Question 10: Acute Renal Failure and Dietary Modifications

• Recommendation: Limit sodium and potassium intake
  • Rationale: Manages fluid retention and prevents hyperkalemia.

Question 11: Severe Depression and Refusal of Therapy

• First Approached: Use therapeutic communication to explore the patient's feelings
  • Rationale: Helps understand the patient's reluctance and addresses misconceptions.

Question 12: Advanced Lung Cancer and Dyspnea

• Prioritized Intervention: Provide supplemental oxygen through a nasal cannula
  • Rationale: Reduces breathlessness by increasing blood oxygen levels.

Question 13: Bipolar Disorder and Manic Episode

• Intervention: Provide a quiet room with minimal stimulation
  • Rationale: Reduces over-stimulation that can exacerbate symptoms.

Question 14: Post-Abdominal Surgery and Calf Pain

• Best First Action: Elevate the affected leg and notify the healthcare provider immediately
  • Rationale: Symptoms suggest DVT, requiring urgent medical attention.

Question 15: End-Stage Renal Disease and High Phosphorus

• Dietary Advice: Avoid Cola drinks and processed foods
  • Rationale: These are high in phosphorus and should be avoided to manage hyperphosphatemia.

Question 16: Blood Transfusion Reaction

• Immediate Action: Stop the transfusion, maintain the IV with saline, and notify the healthcare provider
  • Rationale: Prevents further exposure to the triggering blood product.

Question 17: Heart Failure and Concerned Finding

• Most Concerning Finding: Jugular venous distension
  • Rationale: Indicates worsening heart failure and fluid overload.

Question 18: Liver Failure and Critical Lab Result

• Prioritized Lab Result: Prolonged Prothrombin Time (PT)
  • Rationale: Indicates coagulation issues and an increased risk of bleeding.

Question 19: Myocardial Infarction Lifestyle Modification

• Most Important Modification: Quitting smoking and avoiding secondhand smoke
  • Rationale: Major risk factor for coronary artery disease; quitting reduces risk of recurrent heart events.

Question 20: Post-Colectomy Incentive Spirometer Use

• Best Approach: Offer pain medication before using the spirometer
  • Rationale: Reduces discomfort, increasing compliance in essential activities.

Question 21: Sepsis and Indicative Lab Finding

• Most Indicative: High procalcitonin levels
  • Rationale: Biomarker highly indicative of bacterial infection leading to sepsis.

Question 22: Schizophrenia and Auditory Hallucinations

• Intervention: Teach grounding techniques
  • Rationale: Helps redirect focus and manage hallucinations.

Question 23: Advanced Dementia and Aggressive Behavior

• Effective Intervention: Create a calm, familiar environment and routine
  • Rationale: Reduces confusion and anxiety, minimizing aggressive behavior.

Question 24: Chronic Kidney Disease and Dialysis Evaluation

• Monitored Lab Value: Glomerular Filtration Rate (GFR)
  • Rationale: Key indicator for determining the need for dialysis.

Question 25: Pain Management for Patient with Opioid Addiction

• Best Approach: Develop a plan that includes both pharmacologic and non-pharmacologic strategies
  • Rationale: Allows effective pain management while addressing concerns about opioid use.