would you like free audiobooks click the link in the description question one a 72-year-old patient with congestive heart failure is showing signs of fluid overload which assessment finding would most likely indicate the need for immediate intervention by the nurse a weight gain of 1 kilogram in the past 24 hours B crackles heard halfway up both long feet s c edema noted around the ankles and feet D blood pressure of 150 over 90 mm of mercury answer B crackles H halfway up both long Fields rationale crackles H halfway up both lung Fields indicate fluid accumulation in the lungs suggesting pulmonary edema a serious complication of fluid overload that requires immediate intervention to prevent respiratory distress while the other options are significant findings in a patient with fluid overload they do not indicate an immediate need for intervention as much as the presence of crackles does which suggests impaired gas exchange question two a nurse is planning care for a patient with a diagnosis of type 1 diabetes melodus who is scheduled for a fasting blood glucose test which action is most appropriate for the nurse to include in the plan of care a instruct the patient to consume a carbohydrate Rich meal the night before the test B administer the usual dose of insulin as prescribed C withhold all diabetes medications on the morning of the test D ensure the patient consumes only clear liquids for 8 hours before the test answer C withhold all diabetes medications on the morning of the test rationale withholding all diabetes medications on the morning of the test is the most appropriate action to obtain accurate fasting blood glucose levels administering insulin or other diabetes medications could artificially lower the patient blood glucose level leading to inaccurate test results the patient should fast not consume clear liquids or specific meals to ensure the test reflects the patient true fasting glucose level question three a nurse is caring for a patient who has just undergone a total hip replacement which of the following actions should the nurse prioritize during the immediate post-operative period a encourage the patient to ambulate with assistance B maintain the patient in a low Fowler's position C assess for signs of deep vein thrombosis DVT D apply a cold compress to the surgical site answer C assess for signs of deep vein thrombosis DVT rationale in the immediate postoperative period after a total hip replacement assessing for signs of DVT is a priority because of the high risk of blood clots due to immobility and the surgical procedure signs of DVT include pain swelling and redness in the affected limb early detection and treatment are crucial to prevent potentially life-threatening complications such as pulmonary embolism question four a patient presents to the emergency department with chest pain diaphoresis nausea and shortness of breath the ECG indicates ST segment elevation what is the most appropriate nursing action a prepare the patient for immediate coronary artery bypass graft cabbage surgery B administer sublingual nitroglycerin and aspirin C initiate cardiopulmonary resuscitation CPR D provide oxygen therapy and prepare for thrombolytic therapy answer D provide oxygen therapy and prepare for thrombolytic therapy rationale the presentation and ECG findings are indicative of an ST segment elevation myocardial infarction stemi a type of heart attack that requires immediate intervention to restore blood flow to the heart providing oxygen therapy and preparing for thrombotic therapy to dissolve the clot are the most appropriate initial actions while sublingual nitroglycerin and aspirin are important they are part of the overall management plan and the immediate goal is to restore profusion question five a nurse is caring for a patient with acute pancreatitis which dietary instruction should the nurse provide to help manage the patient's condition a increase intake of high fat foods to provide energy B consume small frequent meals rich in proteins and carbohydrates C avoid alcohol and foods that are high in sugar D follow a strict vegetarian diet to reduce pancreatic stimulation answer C avoid alcohol and foods that are high in sugar rationale alcohol avoidance is crucial in managing and preventing further episodes of acute pancreatitis as alcohol can trigger or exacerbate the condition foods high in sugar can also exacerbate pancreatitis by stimulating the pancreas to secrete insulin the focus should be on a balanced diet that avoids known triggers like alcohol and high sugar Foods question six when planning care for a patient with a history of pulmonary emis M PE which intervention should the nurse prioritize to prevent recurrence a encourage deep breathing exercises every 2 hours B maintain the patient on strict bed rest for 72 hours C administer anti-coagulant therapy as prescribed D apply sequential compression devices scds to both legs answer C administer anti-coagulant therapy as prescribed rationale anti-coagulant therapy is the Cornerstone of preventing recurrence of pulmonary embolism PE these medications help prevent the formation of new clots and the growth of existing clots addressing the underlying issue that leads to PE while scds deep breathing exercises and Mobility are important for overall patient care and can help prevent complications anti-coagulant therapy directly targets the prevention of clot formation question seven a nurse is preparing to administer blood transfusions for a patient with severe anemia which of the following actions is most critical to ensuring the safety of the patient during the transfusion a premedicate the patient with an antihistamine to prevent allergic reactions B confirm the patient's identity and blood group compatibility with the blood Unit C Infuse the blood product rapidly to quickly alleviate symptoms of anemia D keep the patient in a semi-recumbent position throughout the transfusion answer B confirm the patient's identity and blood group compatibility with the blood unit rationale confirming the patient identity and ensuring blood group compatibility with the blood unit are critical steps in preventing transfusion reactions which can be life-threatening proper identification and compatibility checks directly prevent incompatibility reactions the most serious type of transfusion reaction while premedication and patient positioning are important considerations ensuring compatibility is the primary safety measure question eight a patient with chronic obstructive pulmonary disease COPD is on long-term oxygen therapy the nurse observes that the patient's oxygen saturation levels drop significantly during meals what is the most appropriate intervention a increase the oxygen flow rate during meals B suggest the patient to stop oxygen therapy during meals C encourage the patient to eat smaller more frequent meals D instruct the patient to hold their breath while eating answer C encourage the patient to eat smaller more frequent meals rationale patients with COPD often experience difficulty breathing during meals leading to decreased oxygen saturation encouraging smaller more frequent meals can help reduce the energy expenditure and breathing difficulty associated with eating larger meals thereby preventing significant drops in oxygen saturation increasing the oxygen flow rate might be considered but it's important to assess the patient's overall oxygen needs and toolerance to avoid oxygen toxicity question nine a nurse is caring for a patient who is receiving intervenous antibiotics for a bacterial infection the patient complains of pain along the vein used for the IV infusion upon assessment the nurse notes redness warmth and swelling at the site what is the most appropriate Next Step a apply a warm compress to the site and continue monitoring B discontinue the IV line and prepare to start a new IV line in another extremity C increase the rate of IV infusion to flush the vein D administer an analgesic to relieve the pain and continue to observe answer B discontinue the IV line and prepare to start a new IV line in another extremity rationale the patient symptoms suggest fitis an inflam of the vein that can occur with IV Therapy the appropriate action is to discontinue the IV line to prevent further irritation and possible infection and then start a new IV line in another extremity to continue the antibiotic therapy warm compresses and analgesics may be used as supportive measures but the primary action is to remove the source of irritation question 10 a patient diagnosed with acute renal failure ARF is experiencing fluid overload as evidenced by peripheral edema and Pulmonary crackles which of the following dietary modifications should the nurse recommend a increased dietary protein intake B restrict fluid intake to 1.5 L per day C limit sodium and potassium intake D consume a high carbohydrate diet answer C limit sodium and potassium intake rationale in acute renal failure ARF the kidney's ability to regulate fluid and electrolyte balance is compromised limiting sodium intake helps to manage fluid retention and hypertension while restricting potassium intake is important to prevent hyperkalemia a potentially life-threatening condition fluid restriction is also a common recommendation but the specific amount should be individualized based on the patient's condition and daily weight measure measurements protein and carbohydrate intake need to be carefully balanced based on the patient overall nutritional status and renal function question 11 a nurse is caring for a patient who has been admitted with severe depression the patient refuses to participate in any form of therapy or activities which of the following approaches is most appropriate for the nurse to take first a inform the patient of the consequences of not participating in therapy B arrange for a psychiatric consultation to consider medication adjustments C use therapeutic communication to explore the patient feelings about therapy D encourage participation by offering rewards for attendance at therapy sessions answer C use therapeutic communication to explore the patient feelings about therapy rationale using therapeutic communication to explore the patient feelings and perceptions about therapy is an essential first step it helps in understanding the patient reluctance and addresses any misconceptions or fears this approach respects the patient autonomy while providing support and information potentially leading to more engagement in therapy while the other options may be considered based on the patient response and clinical judgment establishing a rapport and understanding the patient pers perspective is foundational question 12 a patient with Advanced lung cancer is experiencing severe dpia at rest which of the following interventions should the nurse prioritize to alleviate the patient discomfort a administer a high dose of systemic steroids B provide supplemental oxygen through a nasal canula C initiate a referral for surgical intervention D encourage the use of Pur lip breathing techniques answer B provide supplemental oxygen through a nasal canula rationale providing supplemental oxygen is a primary intervention to alleviate dpia in patients with Advanced lung cancer it helps increase the oxygen level in the blood thereby reducing the sensation of breathlessness P lip breathing can be a helpful adjunct to ease dmia but it may not be sufficient for severe cases at rest systemic steroids and surgical interventions might be considered in specific contexts but are not immediate interventions for acute dpia relief question 13 a nurse is planning care for a patient with bipolar disorder who is experiencing a manic episode which of the following interventions is most appropriate to include in the plan of care a encourage the patient to engage in group therapy sessions twice a day B provide a quiet room with minimal stimulation c Schedule physical activities late in the evening to promote fatigue before bedtime D allow the patient to make decisions about all aspects of their care to promote Independence answer B provide a quiet room with minimal stimulation rationale patients experiencing a manic episode often benefit from environments that reduce stimulation as excess sensory input can exacerbate their symptoms providing a quiet room with minimal stimulation helps to reduce agitation and hyperactivity promoting a sense of calm and potentially aiding in the stabilization of mood while engaging in therapy and physical activities is important the timing and nature of these activities should be carefully considered to avoid over stimulation allowing the patient to make decisions about their care is important but this should be balanced with the need for safety and structure during a manic episode question 14 a patient postabdominal surgery reports a sudden sharp pain in the calf accompanied by swelling and redness what is the nurse's best first action a apply a warm compress to the affected area B measure the circumference of Both calves for comparison C advise the patient to ambulate to improve blood flow D Elevate the affected leg and notify the health care provider immediately answer D Elevate the affected leg and notify the health care provider immediately rationale the symptoms described are suggestive of a deep vein thrombosis DVT a serious complication that requires immediate medical attention elevating the affected leg can help reduce swelling and improve Venus return while awaiting further evaluation and treatment measuring the circumference of Both calves is a useful diagnostic step but should not delay notification of the healthc care provider applying warm compresses and Advising the patient to ambulate could potentially dislodge the clot leading to a pulmonary embolism and therefore should be avoided until DVT is ruled out question 15 a nurse is caring for a patient with endstage renal disease ESRD on hemodialysis the patient has a high phosphorus level which dietary advice is most appropriate a increase intake of dairy products B consume more whole grains C avoid Cola drinks and processed foods D include more citrus fruits in the diet answer C avoid Cola drinks and processed foods rationale patients with the SRD often have difficulty excreting phosphorus leading to hyperphosphatemia Cola drinks and processed foods are high in phosphorus and should be avoided to help manage phosphorus levels dairy products and whole grains are also high in phosphorus and should be limited citrus fruits do not significantly affect phosphorus levels but do not specifically address hyperphosphatemia management question 16 a nurse is administering a blood transfusion to a patient and observes that the patient is developing ticaria itching and respiratory distress what is the nurse's immediate action a slow the rate of the transfusion and monitor the patient closely B stop the transfusion maintain the four with saline and notify the healthc care provider C administer an antihistamine to the patient and continue the transfusion at the same rate d increase the rate of transfusion to complete it quickly and reduce exposure time question 16 answer B stop the transfusion maintain the four with saline and notify the healthc care provider rationale the symptoms described are indicative of a transfusion reaction which can be potentially life-threatening the immediate action is to stop the transfusion to prevent further exposure to the triggering blood product maintain the four line with saline to ensure Venus access and notify the healthc care provider for further assessment and management slowing the rate or continuing the transfusion could exacerbate the patient's reaction and while antihistamines might be administered they do not address the underlying cause of the reaction question 17 a nurse is assessing a patient who reports increased shortness of breath and fatigue the patient has a history of heart failure which assessment finding would most concern the nurse a peripheral edema B blood pressure of 130 over 85 mm of mercury C jugular Venus distension D heart rate of 88 beats per minute answer C jugular Venus distension rationale jugular Venus distension jbd is a significant finding in patients with heart failure as it indic Ates worsening heart failure and fluid overload suggesting right-sided heart failure while peripheral edema elevated blood pressure and an increased heart rate are important findings in heart failure jvd directly indicates increased Central Venus pressure and is often a more specific sign of acute decompensation that requires immediate intervention question 18 a patient with a history of chronic alcohol use is admitted with signs of liver failure which labor atory result would the nurse prioritize for immediate intervention a elevated aspartate aminot transferase a b low serum albumin C prolonged Prothrombin time PT D increased alkaline phosphatase Alp answer C prolonged Prothrombin time PT rationale a prolonged PT indicates a CO coagulation disorder which is a critical issue in patients with liver failure as the liver is responsible for producing clotting factors this finding suggests a significant risk for bleeding which requires prompt intervention and monitoring while elevated a low serum albumin and increased Alp are indicative of liver dysfunction and damage a prolonged PT directly impacts the patient immediate safety by increasing the risk of bleeding question 19 a nurse is planning discharge teaching for a patient who had a myocardial infarction what should the nurse emphasize as the most important lifestyle modification a engaging in regular moderate intensity exercise B following a strict vegetarian diet C eliminating all forms of stress D quitting smoking and avoiding secondhand smoke answer D quitting smoking and avoiding secondhand smoke rationale quitting smoking is the most critical lifestyle modification for patients recovering from a myocardial infarction smoking is a major risk factor for coronary artery disease and subsequent myocardial infections eliminating smoking can significantly reduce the risk of recurrent heart events and improve overall cardiovascular health while exercise diet and Stress Management are important components of a heart healthy lifestyle quitting smoking has the most immediate impact on reducing future cardiac risk question 20 a nurse is caring for a patient who is post-operative day one following a colectomy the patient is reluctant to use the incentive spirometer what is the best approach for the nurse to encourage use of the device a explain that using the incentive spirometer will prevent post-operative complication s b tell the patient that use of the spirometer is mandatory and not optional C offer pain medication before using the spirometer to reduce discomfort D wait until the patient feels more comfortable and willing to try the spirometer answer C offer pain medication before using the spirometer to reduce discomfort rationale patients postabdominal surgery often experience pain which can make deep breathing exercises such as using an incentive spirometer uncomfortable offering pain medication before using the spirometer can help reduce discomfort making the patient more likely to participate in this important activity explaining the benefits of the spirometer is also important but addressing pain effectively is key to compliance and prevention of postoperative complications like pneumonia question 21 a nurse is reviewing laboratory results for a patient with suspected sepsis which finding would the nurse identify as most indicative of this condition a elevated white blood cell count B decreased hemoglobin levels C increased blood uan nitrogen bu D high procalcitonin levels answer D high procalcitonin levels rationale high procalcitonin levels are particularly indicative of sepsis as procalcitonin is a biomarker that increases significantly in response to a bacterial infection leading to systemic inflammation while an elevated white blood cell count decreased hemoglobin and increased bu can be associated with various conditions including sepsis the elevation of procalcitonin levels is more specifically associated with bacterial infections and has been used to Aid in the diagnosis of sepsis question 22 a nurse is developing a care plan for a patient with schizophrenia who experiences auditory hallucinations which intervention is most appropriate to include a keep the patient in a brightly lit room at all times B encourage the patient to interact socially in large groups C teach the patient to use grounding techniques when hallucinations occur d isolate the patient from others to reduce the risk of agitation answer C teach the patient to use grounding techniques when hallucinations occur rationale teaching the patient to use grounding techniques such as mindfulness exercises or focusing on physical Sensations can help them manage auditory hallucinations by redirecting their focus to the present moment and away from the hallucinations this strategy empowers the patient to gain control over their symptoms keeping the patient in a well-lit room or encouraging social interaction may not directly address the issue of hallucinations and isolating the patient could exacerbate feelings of loneliness or paranoia question 23 for a patient with Advanced dementia exhibiting aggressive behavior which nursing intervention is most effective in managing these behaviors a implementing strict behavioral modification techniques techniques B administering antis psychotic medication as the first line of treatment C using restraints to prevent harm to the patient or others D creating a calm familiar environment and routine for the patient answer D creating a calm familiar environment and routine for the patient rationale creating a calm familiar environment and maintaining a consistent routine can significantly reduce agitation and aggression in patients with Advanced dementia this approach minimizes confusion and anxiety which are common triggers for aggressive behavior while anticho medications and behavioral techniques may be used as part of a comprehensive care plan they are not the first line of intervention due to potential side effects and the importance of addressing the underlying causes of agitation restraints should be used only as a last resort and under strict guidelines as they can increase agitation and pose ethical concerns question 24 a patient with chronic kidney disease CKD is undergoing evaluation for potential dialysis which laboratory value with the nurse monitor closely to determine the need for initiating dialysis a serum calcium level B hemoglobin level C serum potassium level D glomerular filtration rate GFR answer D glomerular filtration rate GFR rationale the glomerular filtration rate GFR is a key indicator of kidney function and is used to Stage chronic kidney disease and determine the need for dialysis a significantly reduced GFR indicates that the kidneys are no longer able to effectively filter waste products from the blood necessitating dialysis to perform dysfunction while abnormalities in serum calcium hemoglobin and potassium levels can occur in CKD and impact patient management the GFR is the most direct measure of kidney function and the need for dialysis a nurse is caring for a patient who reports significant pain following orthopedic surgery the patient has a history of opioid addiction and is concerned about the use of opioid medications for pain management what is the best approach for managing ing this patient pain a avoid the use of all pain medications to prevent relapse B use non-steroidal anti-inflammatory drugs nids exclusively for pain management C develop a pain management plan that includes both pharmacologic and non-pharmacologic strategies answer C develop a pain management plan that includes both pharmacologic and non-pharmacologic Strat strategies rationale developing a Comprehensive Pain Management plan that includes both pharmacologic such as nids and if necessary carefully monitored use of opioids and non-pharmacologic strategies such as ice elevation physical therapy and relaxation techniques is the best approach this allows for Effective pain management while addressing the patients concerns about opioid use and the risk of relapse visit nurs study.net for more nursing practice exams care plans and study guides