1.1 Cardiac Failure
The nurse
​1.2 Acute myocardial infarction
1. A nurse caring for a client in one room is told by
another nurse that a second client has developed
severe pulmonary edema. On entering the 2nd
client’s room, the nurse would expect the client to
be:
A. Slightly anxious
B. Mildly anxious
C. Moderately anxious
D. Extremely anxious
2. A client with pulmonary edema has been on
diuretic therapy. The client has an order for
additional furosemide (Lasix) in the amount of 40
mg IV push. Knowing that the client also will be
started on digoxin (Lanoxin), a nurse checks the
client’s most recent:
A. Digoxin level
B. Sodium level
C. Potassium level
D. Creatinine level
3. A client who had cardiac surgery 24 hours ago
has a urine output averaging 19 ml/hr for 2 hours.
The client received a single bolus of 500 ml of IV
fluid. Urine output for the subsequent hour was 25
ml. Daily laboratory results indicate the blood urea
nitrogen is 45 mg/dL and the serum creatinine is
2.2 mg/dL. A nurse interprets the client is at risk for:
A. Hypovolemia
B. UTI
C. Glomerulonephritis
D. Acute renal failure
4. A nurse is preparing to ambulate a client on the
3rd day after cardiac surgery. The nurse would plan
to do which of the following to enable the client to
best tolerate the ambulation?
A. Encourage the client to cough and deep
breathe.
B. Premedicate the client with an analgesic.
C. Provide the client with a walker.
D. Remove telemetry equipment because it weighs
down the hospital gown.
5. A client’s electrocardiogram strip shows atrial
and ventricular rates of 80 complexes per minute.
The PR interval is 0.14 second, and the QRS
complex measures 0.08 second.
interprets this rhythm is:
A. Normal sinus rhythm
B. Sinus bradycardia
C. Sinus tachycardia
D. Sinus dysrhythmia
6. A client has frequent bursts of ventricular
tachycardia on the cardiac monitor. A nurse is most
concerned with this dysrhythmia because:
A. It is uncomfortable for the client, giving a sense
of impending doom.
B. It produces a high cardiac output that quickly
leads to cerebral and myocardial ischemia.
C. It is almost impossible to convert to a normal
sinus rhythm.
D. It can develop into ventricular fibrillation at any
time.
7. A home care nurse is making a routine visit to a
client receiving digoxin (Lanoxin) in the treatment of
heart failure. The nurse would particularly assess
the client for:
A. Thrombocytopenia and weight gain
B. Anorexia, nausea, and visual disturbances
C. Diarrhea and hypotension
D. Fatigue and muscle twitching
8. A client with angina complains that the angina
pain is prolonged and severe and occurs at the
same time each day, most often in the morning, On
further assessment a nurse notes that the pain
occurs in the absence of precipitating factors. This
type of anginal pain is best described as:
A. Stable angina
B. Unstable angina
C. Variant angina
D. Nonanginal pain
9. The physician orders continuous intravenous
nitroglycerin infusion for the client with MI. Essential
nursing actions include which of the following?
A. Obtaining an infusion pump for the medication.
B. Monitoring BP q4h.
C. Monitoring urine output hourly.
D. Obtaining serum potassium levels daily.
10. Aspirin is administered to the client E. Acute pain related to inability to meet the
experiencing an MI because of its: oxygen demands.
A. Antipyretic action
B. Antithrombotic action 15. Which of the following would be a priority
C. Antiplatelet action nursing diagnosis for the client with heart failure
D. Analgesic action and pulmonary edema?
A. Risk for infection related to stasis of alveolar
11. Which of the following is an expected outcome secretions.
for a client on the second day of hospitalization B. Impaired skin integrity related to pressure.
after an MI? C. Activity intolerance related to pump failure.
A. Has severe chest pain. D. Constipation related to immobility.
B. Can identify risk factors for MI.
C. Agrees to participate in a cardiac rehabilitation 16. Captopril may be administered to a client with
walking program. HF because it acts as a:
D. Can perform personal self-care activities without A. Vasopressor
pain. B. Volume expander
C. Vasodilator
12. Which of the following reflects the principle on D. Potassium-sparing diuretic
which a client’s diet will most likely be based during
the acute phase of MI? 17. Furosemide is administered intravenously to a
client with HF. How soon after administration should
A. Liquids as ordered the nurse begin to see evidence of the drug’s
B. Small, easily digested meals desired effect?
C. Three regular meals per day A. 5 to 10 minutes
D. NPO B. 30 to 60 minutes
Incorrect C. 2 to 4 hours
D. 6 to 8 hours
13. An older, sedentary adult may not respond to
emotional or physical stress as well as a younger 18. Which of the following foods should the nurse
individual because of: teach a client with heart failure to avoid or limit
A. Left ventricular atrophy when following a 2-gram sodium diet?
B. Irregular heartbeats A. Apples
C. Peripheral vascular occlusion B. Tomato juice
D. Pacemaker placement C. Whole wheat bread
D. Beef tenderloin
14. Question1 point(s)
Which of the following nursing diagnoses would be 19. The nurse finds the apical pulse below the 5th
appropriate for a client with heart failure? Select all intercostal space. The nurse suspects:
that apply. A. Left atrial enlargement
A. Ineffective tissue perfusion related to decreased B. Left ventricular enlargement
peripheral blood flow secondary to decreased C. Right atrial enlargement
cardiac output. D. Right ventricular enlargement
B. Activity intolerance related to increased cardiac
output. 20. Which of the following arteries primarily feeds
C. Decreased cardiac output related to structural the anterior wall of the heart?
and functional changes. A. Circumflex artery
D. Impaired gas exchange related to decreased B. Internal mammary artery
sympathetic nervous system activity. C. Left anterior descending artery
D. Right coronary artery
 A. Dilated aorta.
21. The most important factor in regulating the B. Normally functioning heart.
caliber of blood vessels, which determines C. Decreased myocardial contractility.
resistance to flow, is: D. Failure of the ventricle to eject all of the blood
A. Hormonal secretion during systole.
B. Independent arterial wall activity.
C. The influence of circulating chemicals 3. Which of the following classes of drugs is most
D. The sympathetic nervous system widely used in the treatment of cardiomyopathy?
A. Antihypertensives
22. With peripheral arterial insufficiency, leg pain B. Beta-adrenergic blockers
during rest can be reduced by: C. Calcium channel blockers
A. Elevating the limb above heart level. D. Nitrates
B. Lowering the limb so it is dependent.
C. Massaging the limb after application of cold 4. If medical treatments fail, which of the following
compresses. invasive procedures is necessary for treating
D. Placing the limb in a plane horizontal to the cardiomyopathy?
body. A. Cardiac catheterization
B. Coronary artery bypass graft (CABG)
23. Buerger’s disease is characterized by all of the C. Heart transplantation
following except: D. Intra-aortic balloon pump (IABP)
A. Arterial thrombosis formation and occlusion.
B. Lipid deposits in the arteries. 5. Which of the following conditions is associated
C. Redness or cyanosis in the limb when it is with a predictable level of pain that occurs as a
dependent. result of physical or emotional stress?
D. Venous inflammation and occlusion. A. Anxiety
B. Stable angina
24. A significant cause of venous thrombosis is: C. Unstable angina
A. Altered blood coagulation D. Variant angina
B. Stasis of blood
C. Vessel wall injury 6. Which of the following types of angina is most
D. All of the above closely related with an impending MI?
Incorrect A. Angina decubitus
25. When caring for a patient who has started B. Chronic stable angina
anticoagulant therapy with warfarin (Coumadin), the C. Nocturnal angina
nurse knows not to expect therapeutic benefits for: D. Unstable angina
A. At least 12 hours
B. The first 24 hours 7. Which of the following conditions is the
C. 2-3 days predominant cause of angina?
D. 1 week A. Increased preload
B. Decreased afterload
1. In which of the following types of cardiomyopathy C. Coronary artery spasm
does cardiac output remain normal? D. Inadequate oxygen supply to the myocardium.
A. Dilated
B. Hypertrophic 8. Which of the following tests is used most often to
C. Obliterative diagnose angina?
D. Restrictive A. Chest x-ray
B. Echocardiogram
2. Which of the following cardiac conditions does a C. Cardiac catheterization
fourth heart sound (S4) indicate? D. 12-lead electrocardiogram (ECG)
 15. Which of the following actions is the appropriate
9. Which of the following results is the primary initial response to a client coughing up pink, frothy
treatment goal for angina? sputum?
A. Call for help.
A. Reversal of ischemia. B. Call the physician.
B. Reversal of infarction. C. Start an I.V. line.
C. Reduction of stress and anxiety. D. Suction the client.
D. Reduction of associated risk factors.
16. Which of the following terms describes the force
10. Which of the following interventions should be against which the ventricle must expel blood?
the first priority when treating a client experiencing A. Afterload
chest pain while walking? B. Cardiac output
A. Sit the client down. C. Overload
B. Get the client back to bed. D. Preload
C. Obtain an ECG.
D. Administer sublingual nitroglycerin. 17. Acute pulmonary edema caused by heart failure
is usually a result of damage to which of the
11. Myocardial oxygen consumption increases as following areas of the heart?
which of the following parameters increase? A. Left atrium
A. Preload, afterload, and cerebral blood flow. B. Right atrium
B. Preload, afterload, and renal blood flow. C. Left ventricle
C. Preload, afterload, contractility, and heart rate. D. Right ventricle
D. Preload, afterload, cerebral blood flow, and
heart rate. 18. An 18-year-old client who recently had an URI
is admitted with suspected rheumatic fever. Which
12. Which of the following positions would best aid assessment findings confirm this diagnosis?
breathing for a client with acute pulmonary edema? A. Erythema marginatum, subcutaneous nodules,
A. Lying flat in bed. and fever
B. Left side-lying. B. Tachycardia, finger clubbing, and a load S3
C. In high Fowler’s position. C. Dyspnea, cough, and palpitations
D. In semi-Fowler’s position. D. Dyspnea, fatigue, and syncope

13. Which of the following blood gas abnormalities 19. A client admitted with angina complains of
is initially most suggestive of pulmonary edema? severe chest pain and suddenly becomes
unresponsive. After establishing unresponsiveness,
A. Anoxia which of the following actions should the nurse take
B. Hypercapnia first?
C. Hyperoxygenation A. Activate the resuscitation team.
D. Hypocapnia B. Open the client’s airway.
C. Check for breathing.
14. Which of the following is a compensatory D. Check for signs of circulation.
response to decreased cardiac output?
A. Decreased BP. 20. A 55-year-old client is admitted with an acute
B. Alteration in LOC. inferior-wall myocardial infarction. During the
C. Decreased BP and diuresis. admission interview, he says he stopped taking his
D. Increased BP and fluid retention. metoprolol (Lopressor) 5 days ago because he was
feeling better. Which of the following nursing
diagnoses takes priority for this client?
A. Anxiety
B. Ineffective tissue perfusion; cardiopulmonary
C. Acute pain
D. Ineffective therapeutic regimen management
21. A client comes into the E.R. with acute
shortness of breath and a cough that produces
pink, frothy sputum. Admission assessment reveals
crackles and wheezes, a BP of 85/46, a HR of 122
BPM, and a respiratory rate of 38 breaths/minute.
The client’s medical history included DM, HTN, and
heart failure. Which of the following disorders
should the nurse suspect?
A. Pulmonary edema
B. Pneumothorax
C. Cardiac tamponade
D. Pulmonary embolism
22. The nurse coming on duty receives the report
from the nurse going off duty. Which of the following
clients should the on-duty nurse assess first?
A. The 58-year-old client who was admitted 2 days
ago with heart failure, BP of 126/76, and a
respiratory rate of 21 breaths a minute.
B. The 88-year-old client with end-stage right-sided
heart failure, BP of 78/50, and a DNR order.
C. The 62-year-old client who was admitted one
day ago with thrombophlebitis and receiving IV
heparin.
D. A 76-year-old client who was admitted 1 hour
ago with new-onset atrial fibrillation and is receiving
IV diltiazem (Cardizem).
23. When developing a teaching plan for a client
with endocarditis, which of the following points is
most essential for the nurse to include?
A. “Report fever, anorexia, and night sweats to the
physician.”
B. “Take prophylactic antibiotics after dental work
and invasive procedures.”
C. “Include potassium rich foods in your diet.”
D. “Monitor your pulse regularly.”
24. A nurse is conducting a health history with a
client with a primary diagnosis of heart failure.
Which of the following disorders reported by the
client is unlikely to play a role in exacerbating the
heart failure?
A. Recent URI
B. Nutritional anemia
C. Peptic ulcer disease
D. A-Fib
25. A nurse is preparing for the admission of a
client with heart failure who is being sent directly to
the hospital from the physician’s office. The nurse
would plan on having which of the following
medications readily available for use?
A. diltiazem (Cardizem)
B. digoxin (Lanoxin)
C. propranolol (Inderal)
D. metoprolol (Lopressor)
1. Mike, a 43-year old construction worker, has a
history of hypertension. He smokes two packs of
cigarettes a day, is nervous about the possibility of
being unemployed, and has difficulty coping with
stress. His current concern is calf pain during
minimal exercise that decreased with rest. The
nurse assesses Mike’s symptoms as being
associated with peripheral arterial occlusive
disease. The nursing diagnosis is probably:
A. Alteration in tissue perfusion related to
compromised circulation.
B. Dysfunctional use of extremities related to
muscle spasms.
C. Impaired mobility related to stress associated
with pain.
D. Impairment in muscle use is associated with
pain on exertion.
2. A 24-year old man seeks medical attention for
complaints of claudication in the arch of the foot. A
nurse also notes superficial thrombophlebitis of the
lower leg. The nurse would next assess the client
for:
A. Familial tendency toward peripheral vascular
disease.
B. Smoking history.
C. Recent exposures to allergens.
D. History of insect bites.
3. Intravenous heparin therapy is ordered for a
client. While implementing this order, a nurse
ensures that which of the following medications is
available in the nursing unit?
A. Vitamin K
B. Aminocaproic acid
C. Potassium chloride
D. Protamine sulfate
4. A client who has been receiving heparin therapy
also is started on warfarin sodium (coumadin). The
client asks the nurse why both medications are
being administered. In formulating a response, the
nurse incorporates the understanding that warfarin
sodium:
A. Stimulates the breakdown of specific clotting
factors by the liver, and it takes 2-3 days for this to
exhibit an anticoagulant effect.
B. Inhibits synthesis of specific clotting factors in
the liver, and it takes 3 to 4 days for this medication
to exert an anticoagulation effect.
C. Stimulates production of the body’s own
thrombolytic substances, but it takes 2-4 days for it
to begin.
D. Has the same mechanism action of heparin,
and the crossover time is needed for the serum
level of warfarin sodium to be therapeutic.
5. A nurse has the order to begin administering
warfarin sodium (Coumadin) to a client. While
implementing this order, the nurse ensures that
which of the following medications is available on
the nursing unit as the antidote for Coumadin?
A. Vitamin K
B. Aminocaproic acid
C. Potassium chloride
D. Protamine sulfate
6. A nurse is assessing the neurovascular status of
a client who returned to the surgical nursing unit 4
hours ago after undergoing an aortoiliac bypass
graft. The affected leg is warm, and the nurse notes
redness and edema. The pedal pulse is palpable
and unchanged from admission. The nurse
interprets that the neurovascular status is:
A. Normal because of the increased blood flow
through the leg.
B. Slightly deteriorating and should be monitored
for another hour.
C. Moderately impaired, and the surgeon should
be called.
D. Adequate from the arterial approach, but
venous complications are arising.
7. A client is admitted with a venous stasis leg
ulcer. A nurse assesses the ulcer, expecting to note
that the ulcer:
A. Has a pale colored base.
B. Is deep, with even edges.
C. Has little granulation tissue.
D. Has brown pigmentation around it.
8. In preparation for the discharge of a client with
arterial insufficiency and Raynaud’s disease, client
teaching instructions should include:
A. Walking several times each day as an exercise
program.
B. Keeping the heat up so that the environment is
warm.
C. Wearing a TED hose during the day.
D. Using hydrotherapy for increasing oxygenation.
9. A client comes to the outpatient clinic and tells
the nurse that he has had leg pains that begin
when he walks but cease when he stops walking.
Which of the following conditions would the nurse
assess for?
A. An acute obstruction in the vessels of the legs.
B. Peripheral vascular problems in both legs.
C. Diabetes
D. Calcium deficiency
10. Which of the following characteristics is typical
of the pain associated with DVT?
A. Dull ache
B. No pain
C. Sudden onset
D. Tingling
11. Cancer can cause changes in what component
of Virchow’s triad?
A. Blood coagulability
B. Vessel walls
C. Blood flow
D. Blood viscosity
12. Varicose veins can cause changes in what
component of Virchow’s triad?
A. Blood coagulability
B. Vessel walls
C. Blood flow
D. Blood viscosity
 D. Chest pain
13. Which technique is considered the gold
standard for diagnosing DVT? 18. The nurse expects that a client with mitral
A. Ultrasound imaging stenosis would demonstrate symptoms associated
B. Venography with congestion in the:
C. MRI A. Aorta
D. Doppler flow study B. Right atrium
C. Superior vena cava
14. A nurse is assessing a client with an abdominal D. Pulmonary circulation
aortic aneurysm. Which of the following
assessment findings by the nurse is probably 19. Because a client has mitral stenosis and is a
unrelated to an aneurysm? prospective valve recipient, the nurse
A. Pulsatile abdominal mass. preoperatively assesses the client’s past
B. Hyperactive bowel sounds in that area. compliance with medical regimens. Lack of
C. Systolic bruit over the area of the mass. compliance with which of the following regimens
D. Subjective sensation of “heart beating” in the would pose the greatest health hazard to this
abdomen. client?
A. Medication therapy
15. A nurse is caring for a client who had a B. Diet modification
percutaneous insertion of an inferior vena cava C. Activity restrictions
filter and was on heparin therapy before surgery. D. Dental care
The nurse would inspect the surgical site most
closely for signs of: 20. Good dental care is an important measure in
A. Thrombosis and infection reducing the risk of endocarditis. A teaching plan to
B. Bleeding and infection promote good dental care in a client with mitral
C. Bleeding and wound dehiscence. stenosis should include a demonstration of the
D. Wound dehiscence and evisceration. proper use of:
A. A manual toothbrush
16. A 68-year-old woman is scheduled to undergo B. An electric toothbrush
mitral valve replacement for severe mitral stenosis C. An irrigation device
and mitral regurgitation. Although the diagnosis D. Dental floss
was made during childhood, she did not have any
symptoms until 4 years ago. Recently, she noticed 21. A client has been admitted to the hospital with a
increased symptoms, despite daily doses of digoxin diagnosis of suspected bacterial endocarditis. The
and furosemide. During the initial interview with the complication the nurse will constantly observe for
nice lady, the nurse would most likely learn that the is:
client’s childhood health history included: A. Presence of heart murmur
B. Systemic emboli
A. Chicken pox C. Fever
B. Poliomyelitis D. Congestive heart failure
C. Rheumatic fever
D. Meningitis 22. Cholesterol, frequently discussed in relation to
atherosclerosis, is a substance that:
17. Which of the following signs and symptoms
would most likely be found in a client with mitral A. May be controlled by eliminating food sources.
regurgitation? B. Is found in many foods, both plant and animal
A. Exertional dyspnea sources.
B. Confusion C. All persons would be better off without because
C. Elevated creatine phosphokinase concentration it causes the disease process.
 D. Circulates in the blood, the level of which
usually decreases when unsaturated fats are
substituted for saturated fats.
23. When teaching a client with a cardiac problem,
who is on a high-unsaturated fatty-acid diet, the
nurse should stress the importance of increasing
the intake of:
A. Enriched whole milk
B. Red meats, such as beef
C. Vegetables and whole grains
D. Liver and other glandular organ meats
24. A 2-gram sodium diet is prescribed for a client
with severe hypertension. The client does not like
the diet, and the nurse hears the client’s request
that the spouse “Bring in some good home-cooked
food.” It would be most effective for the nurse to
plan to:
A. Call in the dietician for client teaching.
B. Wait for the client’s family and discuss the diet
with the client and family.
C. Tell the client that the use of salt is forbidden,
because it will raise BP.
D. Catch the family members before they go into
the client’s room and tell them about the diet.
25. What criteria should the nurse use to determine
normal sinus rhythm for a client on a cardiac
monitor? Select all that apply.
A. The RR intervals are relatively consistent.
B. One P wave precedes each QRS complex.
C. Four to eight complexes occur in a 6-second
strip.
D. The ST segment is higher than the PR interval.
E. The QRS complex ranges from 0.12 to 0.2
seconds.
1. Which of the following patients are MOST at risk
for developing heart failure? Select-all-that-apply:
A. A 69 year old male with a history of alcohol
abuse and is recovering from a myocardial
infarction.
B. A 55 year old female with a health history of
asthma and hypoparathyroidism.
C. A 30 year old male with a history of endocarditis
and has severe mitral stenosis.
D. A 45 year old female with lung cancer stage 2.
E. A 58 year old female with uncontrolled
hypertension and is being treated for influenza.
2. A patient is being discharged home after
hospitalization of left ventricular systolic
dysfunction. As the nurse providing discharge
teaching to the patient, which statement is NOT a
correct statement about this condition?
A. "Signs and symptoms of this type of heart failure
can include: dyspnea, persistent cough, difficulty
breathing while lying down, and weight gain."
B. "It is important to monitor your daily weights, fluid
and salt intake."
C. "Left-sided heart failure can lead to right-sided
heart failure, if left untreated."
D. "This type of heart failure can build up pressure
in the hepatic veins and cause them to become
congested with fluid which leads to peripheral
edema."
3. Which of the following are NOT typical signs and
symptoms of right-sided heart failure?
Select-all-that-apply:
A. Jugular venous distention
B. Persistent cough
C. Weight gain
D. Crackles
E. Nocturia
F. Orthopnea
4. A patient is diagnosed with left-sided systolic
dysfunction heart failure. Which of the following are
expected findings with this condition?
A. Echocardiogram shows an ejection fraction of
38%.
B. Heart catheterization shows an ejection fraction
of 65%.
C. Patient has frequent episodes of nocturnal
paroxysmal dyspnea.
D. Options A and C are both expected findings with
left-sided systolic dysfunction heart failure.
5. True or False: Patients with left-sided diastolic
dysfunction heart failure usually have a normal
ejection fraction.
True
False
6. A patient has a history of heart failure. Which of
the following statements by the patient indicates the
patient may be experiencing heart failure
exacerbation?
A. “I’ve noticed that I’ve gain 6 lbs in one week.”
B. “While I sleep I have to prop myself up with a
pillow so I can breathe.”
C. “I haven’t noticed any swelling in my feet or
hands lately.”
D. Options B and C are correct.
E. Options A and B are correct.
F. Options A, B, and C are all correct.
7. Patients with heart failure can experience
episodes of exacerbation. All of the patients below
have a history of heart failure. Which of the
following patients are at MOST risk for heart failure
exacerbation?
A. A 55 year old female who limits sodium and fluid
intake regularly.
B. A 73 year old male who reports not taking
Amiodarone for one month and is experiencing
atrial fibrillation.
C. A 67 year old female who is being discharged
home from heart valve replacement surgery.
D. A 78 year old male who has a health history of
eczema and cystic fibrosis.
8. A 74 year old female presents to the ER with
complaints of dyspnea, persistent cough, and
unable to sleep at night due to difficulty breathing.
On assessment, you note crackles throughout the
lung fields, respiratory rate of 25, and an oxygen
saturation of 90% on room air. Which of the
following lab results confirm your suspicions of
heart failure?
A. K+ 5.6
B. BNP 820
C. BUN 9
D. Troponin <0.02
9. Which of the following tests/procedures are NOT
used to diagnose heart failure?
A. Echocardiogram
B. Brain natriuretic peptide blood test
C. Nuclear stress test
D. Holter monitoring
10. What type of heart failure does this statement
describe? The ventricle is unable to properly fill with
blood because it is too stiff. Therefore, blood backs
up into the lungs causing the patient to experience
shortness of breath.
A. Left ventricular systolic dysfunction
B. Left ventricular ride-sided dysfunction
C. Right ventricular diastolic dysfunction
D. Left ventricular diastolic dysfunction
11. A patient with left-sided heart failure is having
difficulty breathing. Which of the following is the
most appropriate nursing intervention?
A. Encourage the patient to cough and deep
breathe.
B. Place the patient in Semi-Fowler's position.
C. Assist the patient into High Fowler's position.
D. Perform chest percussion therapy.
12. You're providing diet discharge teaching to a
patient with a history of heart failure. Which of the
following statements made by the patient
represents they understood the diet teaching?
A. "I will limit my sodium intake to 5-6 grams a day."
B. "I will be sure to incorporate canned vegetables
and fish into my diet."
C. "I'm glad I can still eat sandwiches because I
love bologna and cheese sandwiches."
D. "I will limit my consumption of frozen meals."
13. Select all the correct statements about
educating the patient with heart failure:
A. It is important patients with heart failure notify
their physician if they gain more than 6 pounds in a
day or 10 pounds in a week.
B. Patients with heart failure should receive an
annual influenza vaccine and be up-to-date with the
pneumonia vaccine.
C. Heart failure patients should limit sodium intake
to 2-3 grams per day.
D. Heart failure is exacerbated by illness, too much
fluid or sodium intake, and arrhythmias.
E. Patients with heart failure should limit exercise
because of the risks.
14. A patient taking Digoxin is experiencing severe
bradycardia, nausea, and vomiting. A lab draw
shows that their Digoxin level is 4 ng/mL. What
medication do you anticipate the physician to order 19. Select all the correct statements about the
for this patient? pharmacodynamics of Beta-blockers for the
A. Narcan treatment of heart failure:
B. Aminophylline A. These drugs produce a negative inotropic effect
C. Digibind on the heart by increasing myocardial contraction.
D. No medication because this is a normal Digoxin B. A side effect of these drugs include bradycardia.
level. C. These drugs are most commonly prescribed for
patients with heart failure who have COPD.
15. Which of the following is a late sign of heart D. Beta-blockers are prescribed with ACE or ARBs
failure? to treat heart failure.
A. Shortness of breath
B. Orthopnea 20. You are assisting a patient up from the bed to
C. Edema the bathroom. The patient has swelling in the feet
D. Frothy-blood tinged sputum and legs. The patient is receiving treatment for
heart failure and is taking Hydralazine and Isordil.
16. These drugs are used as first-line treatment of Which of the following is a nursing priority for this
heart failure. They work by allowing more blood to patient while assisting them to the bathroom?
flow to the heart which decreases the work load of A. Measure and record the urine voided.
the heart and allows the kidneys to secrete sodium. B. Assist the patient up slowing and gradually.
However, some patients can develop a nagging C. Place the call light in the patient's reach while in
cough with these types of drugs. This description the bathroom.
describes? D. Provide privacy for the patient.
A. Beta-blockers
B. Vasodilators 21. A patient is taking Digoxin. Prior to
C. Angiotensin II receptor blockers administration you check the patient's apical pulse
D. Angiotensin-converting-enzyme inhibitors and find it to be 61 bpm. Morning lab values are the
following: K+ 3.3 and Digoxin level of 5 ng/mL.
17. A patient with heart failure is taking Losartan Which of the following is the correct nursing action?
and Spironolactone. The patient is having EKG A. Hold this dose and administer the second dose
changes that presents with tall peaked T-waves at 1800.
and flat p-waves. Which of the following lab results B. Administer the dose as ordered.
confirms these findings? C. Hold the dose and notify the physician of the
A. Na+ 135 digoxin level.
B. BNP 560 D. Hold this dose until the patient’s potassium level
C. K+ 8.0 is normal.
D. K+ 1.5
22. Which of the following is a common side effect
18. During your morning assessment of a patient of Spironolactone?
with heart failure, the patient complains of sudden A. Renal failure
vision changes that include seeing yellowish-green B. Hyperkalemia
halos around the lights. Which of the following C. Hypokalemia
medications do you suspect is causing this issue? D. Dry cough
A. Lisinopril
B. Losartan 23. The physician’s order says to administered
C. Lasix Lasix 40 mg IV twice a day. The patient has the
D. Digoxin following morning labs: Na+ 148, BNP 900, K+ 2.0,
and BUN 10. Which of the following is a nursing
priority?
A. Administer the Lasix as ordered
B. Notify the physician of the BNP level
C. Assess the patient for edema
D. Hold the dose and notify the physician about the
potassium level
1.3 Acute pulmonary failure
To evaluate the effectiveness of prescribed
therapies for a patient with ventilatory failure, which
diagnostic test will be most useful to the nurse?
a. Chest x-rays
b. Pulse oximetry
c. Arterial blood gas (ABG) analysis
d. Pulmonary artery pressure monitoring
While caring for a patient who has been admitted
with a pulmonary embolism, the nurse notes a
change in the patient's oxygen saturation (SpO2)
from 94% to 88%. The nurse will
a. increase the oxygen flow rate.
b. suction the patient's oropharynx.
c. assist the patient to cough and deep breathe.
d. help the patient to sit in a more upright position.
A patient with respiratory failure has a respiratory
rate of 8 and an SpO2 of 89%. The patient is
increasingly lethargic. The nurse will anticipate
assisting with
a. administration of 100% oxygen by
non-rebreather mask.
b. endotracheal intubation and positive pressure
ventilation.
c. insertion of a mini-tracheostomy with frequent
suctioning.
d. initiation of bilevel positive pressure ventilation
(BiPAP).
The pulse oximetry for a patient with right lower
lobe pneumonia indicates an oxygen saturation of
90%. The patient has rhonchi, a weak cough effort,
and complains of fatigue. Which action is best for
the nurse to take?
a. Position the patient on the right side.
b. Place a humidifier in the patient's room.
c. Assist the patient with staged coughing.
d. Schedule a 2-hour rest period for the patient.
When the nurse is caring for an obese patient with
left lower lobe pneumonia, gas exchange will be
best when the patient is positioned
a. on the left side.
b. on the right side.
c. in the tripod position.
d. in the high-Fowler's position.
When admitting a patient in possible respiratory
failure with a high PaCO2, which assessment
information will be of most concern to the nurse?
a. The patient is somnolent.
b. The patient's SpO2 is 90%.
c. The patient complains of weakness.
d. The patient's blood pressure is 162/94.
A patient with acute respiratory distress syndrome
(ARDS) and acute renal failure has the following
medications prescribed. Which medication should
the nurse discuss with the health care provider
before administration?
a. ranitidine (Zantac) 50 mg IV
b. gentamicin (Garamycin) 60 mg IV
c. sucralfate (Carafate) 1 g per nasogastric tube
d. methylprednisolone (Solu-Medrol) 40 mg IV
A patient develops increasing dyspnea and
hypoxemia 2 days after having cardiac surgery. To
determine whether the patient has acute respiratory
distress syndrome (ARDS) or pulmonary edema
caused by left ventricular failure, the nurse will
anticipate assisting with
a. inserting a pulmonary artery catheter.
b. obtaining a ventilation-perfusion scan.
c. drawing blood for arterial blood gases.
d. positioning the patient for a chest radiograph.
Which assessment finding by the nurse when
caring for a patient with ARDS who is being treated
with mechanical ventilation and high levels of
positive end-expiratory pressure (PEEP) indicates
that the PEEP may need to be decreased?
a. The patient has subcutaneous emphysema.
b. The patient has a sinus bradycardia with a rate
of 52.
c. The patient's PaO2 is 50 mm Hg and the SaO2 is
88%.
d. The patient has bronchial breath sounds in both
the lung fields.
Which statement by the nurse when explaining the
purpose of positive end-expiratory pressure (PEEP)
to the family members of a patient with ARDS is
correct?
a. "PEEP will prevent fibrosis of the lung from
occurring."
b. "PEEP will push more air into the lungs during
inhalation."
c. "PEEP allows the ventilator to deliver 100%
oxygen to the lungs."
d. "PEEP prevents the lung air sacs from collapsing
during exhalation."
When prone positioning is used in the care of a
patient with acute respiratory distress syndrome
(ARDS), which information obtained by the nurse
indicates that the positioning is effective?
a. The patient's PaO2 is 90 mm Hg, and the SaO2
is 92%.
b. Endotracheal suctioning results in minimal
mucous return.
c. Sputum and blood cultures show no growth after
24 hours.
d. The skin on the patient's back is intact and
without redness.
The nurse obtains the vital signs for a patient
admitted 2 days ago with gram-negative sepsis:
temperature 101.2° F, blood pressure 90/56 mm
Hg, pulse 92, respirations 34. Which action should
the nurse take next?
a. Administer the scheduled IV antibiotic.
b. Give the PRN acetaminophen (Tylenol) 650 mg.
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the patient's
vital signs.
To decrease the risk for ventilator-associated
pneumonia, which action will the nurse include in
the plan of care for a patient who requires
intubation and mechanical ventilation?
a. Avoid use of positive end-expiratory pressure
(PEEP).
b. Suction every 2 hours.
c. Elevate head of bed to 30 to 45 degrees.
d. Give enteral feedings at no more than 10 mL/hr.
A patient has a nursing diagnosis of ineffective
airway clearance related to thick, secretions. Which
action will be best for the nurse to include in the
plan of care?
a. Encourage use of the incentive spirometer.
b. Offer the patient fluids at frequent intervals.
c. Teach the patient the importance of coughing.
d. Increase oxygen level to keep O2 saturation
>95%.
A patient with acute respiratory distress syndrome
(ARDS) who is intubated and receiving mechanical
ventilation develops a pneumothorax. Which action
will the nurse anticipate taking?
a. Lower the positive end-expiratory pressure
(PEEP).
b. Increase the fraction of inspired oxygen (FIO2).
c. Suction more frequently.
d. Increase the tidal volume.
After receiving change-of-shift report, which patient
will the nurse assess first?
a. A patient with cystic fibrosis who has thick,
green-colored sputum
b. A patient with pneumonia who has coarse
crackles in both lung bases
c. A patient with emphysema who has an oxygen
saturation of 91% to 92%
d. A patient with septicemia who has intercostal
and suprasternal retractions
A patient with chronic obstructive pulmonary
disease (COPD) arrives in the emergency
department complaining of shortness of breath and
dyspnea. Which assessment finding by the nurse is
most important to report to the health care
provider?
a. The patient has bibasilar lung crackles.
b. The patient is sitting in the tripod position.
c. The patient's respiratory rate has decreased from
30 to 10 breaths/min.
d. The patient's pulse oximetry indicates an O2
saturation of 91%.
When assessing a patient with chronic lung
disease, the nurse finds a sudden onset of agitation
and confusion. Which action should the nurse take
first?
a. Check pupil reaction to light.
b. Notify the health care provider.
c. Attempt to calm and reassure the patient.
d. Assess oxygenation using pulse oximetry.
The nurse is caring for a 22-year-old patient who
came to the emergency department with acute
respiratory distress. Which information about the
patient requires the most rapid action by the nurse?
a. Respiratory rate is 32 breaths/min.
b. Pattern of breathing is shallow.
c. The patient's PaO2 is 45 mm Hg.
d. The patient's PaCO2 is 34 mm Hg.
The nurse is caring for a patient who was
hospitalized 2 days earlier with aspiration
pneumonia. Which assessment information is most
important to communicate to the health care
provider?
a. Cough that is productive of blood-tinged sputum
b. Scattered crackles throughout the posterior lung
bases
c. Temperature of 101.5° F (38.6° C) after 2 days of
IV antibiotic therapy
d. Oxygen saturation (SpO2) has dropped to 90%
with administration of 100% O2 by non-rebreather
mask.
Which of these nursing actions included in the care
of a mechanically ventilated patient with acute
respiratory distress syndrome (ARDS) can the RN
delegate to an experienced LPN/LVN working in the
intensive care unit?
a. Assess breath sounds
b. Insert a retention catheter
c. Place patient in the prone position
d. Monitor pulmonary artery pressures
A patient with ARDS who is receiving mechanical
ventilation using synchronized intermittent
mandatory ventilation (SIMV) has settings of
fraction of inspired oxygen (FIO2) 80%, tidal
volume 500, rate 18, and positive end-expiratory
pressure (PEEP) 5 cm. Which assessment finding
is most important for the nurse to report to the
health care provider?
a. Oxygen saturation 99%
b. Patient respiratory rate 22 breaths/min
c. Crackles audible at lung bases
d. Apical pulse rate 104 beats/min
1.4 Acute Renal Failure
1. ______________ is solely filtered from the
bloodstream via the glomerulus and is NOT
reabsorbed back into the bloodstream but is
excreted through the urine.
A. Urea
B. Creatinine
C. Potassium
D. Magnesium
2. A patient with acute renal injury has a GFR
(glomerular filtration rate) of 40 mL/min. Which
signs and symptoms below may this patient present
with? Select all that apply:
A. Hypervolemia
B. Hypokalemia
C. Increased BUN level
D. Decreased Creatinine level
3. You're assessing morning lab values on a female
patient who is recovering from a myocardial
infraction. Which lab value below requires you to
notify the physician?
A. Potassium level 4.2 mEq/L
B. Creatinine clearance 35 mL/min
C. BUN 20 mg/dL
D. Blood pH 7.40
4. A 55-year-old male patient is admitted with a
massive GI bleed. The patient is at risk for what
type of acute kidney injury?
A. Post-renal
B. Intra-renal
C. Pre-renal
D. Intrinsic renal
5. Select all the patients below that are at risk for
acute intra-renal injury?
A. A 45 year old male with a renal calculus.
B. A 65 year old male with benign prostatic
hyperplasia.
C. A 25 year old female receiving chemotherapy.
D. A 36 year old female with renal artery stenosis.
E. A 6 year old male with acute glomerulonephritis.
F. An 87 year old male who is taking an
aminoglycoside medication for an infection.
6. A patient with acute kidney injury has the
following labs: GFR 92 mL/min, BUN 17 mg/dL,
potassium 4.9 mEq/L, and creatinine 1 mg/dL. The
patient's 24 hour urinary output is 1.75 Liters.
Based on these findings, what stage of AKI is this 11. While educating a group of nursing students
patient in? about the stages of acute kidney injury, a student
A. Initiation asks how long the oliguric stage lasts. You explain
B. Diuresis to the student this stage can last?
C. Oliguric A. 1-2 weeks
D. Recovery B. 1-3 days
C. Few hours to 2 weeks
7. A 36-year-old male patient is diagnosed with D. 12 months
acute kidney injury. The patient is voiding 4 L/day of
urine. What complication can arise based on the 12. A patient with AKI has a urinary output of 350
stage of AKI this patient is in? Select all that apply: mL/day. In addition, morning labs showed an
A. Water intoxication increased BUN and creatinine level along with
B. Hypotension potassium level of 6 mEq/L. What type of diet
C. Low urine specific gravity ordered by the physician is most appropriate for
D. Hypokalemia this patient?
E. Normal GFR A. Low-sodium, high-protein, and low-potassium
B. High-protein, low-potassium, and low-sodium
8. True or False: All patients with acute renal injury C. Low-protein, low-potassium, and low-sodium
will progress through the oliguric stage of AKI but D. High-protein and high-potassium
not all patients will progress through the diuresis
stage.
True 1. While administering peritoneal dialysis to Mr.
False Thompson in the dialysis unit, Nurse Emily notes
that the return fluid is draining more slowly than
9. Which patient below with acute kidney injury is in usual. What is Nurse Emily's most appropriate
the oliguric stage of AKI: immediate course of action to address the slow
A. A 56 year old male who has metabolic acidosis, drainage of return fluid during Mr. Thompson's
decreased GFR, increased BUN/Creatinine, peritoneal dialysis?
hyperkalemia, edema, and urinary output 350 A. Elevate the drainage bag higher than Mr.
mL/day. Thompson's abdomen.
B. A 45 year old female with metabolic alkalosis, B. Inspect the outflow tubing for any kinks or
hypokalemia, normal GFR, increased obstructions.
BUN/creatinine, edema, and urinary output 600 C. Request Mr. Thompson to perform a cough.
mL/day. D. Adjust Mr. Thompson's bed to a reverse
C. A 39 year old male with metabolic acidosis, Trendelenburg position.
hyperkalemia, improving GFR, resolving edema,
and urinary output 4 L/day. 2. Nurse Emily is responsible for a patient who
D. A 78 year old female with respiratory acidosis, recently had an arteriovenous fistula placed for
increased GFR, decreased BUN/creatinine, hemodialysis. She knows it's crucial to regularly
hypokalemia, and urinary output 550 mL/day. assess for patency. What is the best method for
Emily to check the patency of this arteriovenous
10. You're developing a nursing care plan for a fistula?
patient in the diuresis stage of AKI. What nursing A. Evaluate capillary refill time in the nail beds of
diagnosis would you include in the care plan? the same arm.
A. Excess fluid volume B. Aspirate blood from the fistula using a needle
B. Risk for electrolyte imbalance and syringe.
C. Urinary retention C. Compress the fistula and observe the rate of
D. Acute pain refilling upon release.
D. Palpate along the entire length of the fistula for
the presence of a thrill.
3. Nurse Sarah is caring for a paraplegic patient
who has been diagnosed with renal calculi. Sarah
is trying to understand the contributing factors that
led to the formation of these calculi. Which factor is
likely to have contributed to the development of
renal calculi in this patient?
A. Enhanced loss of calcium from the skeletal
system.
B. Lowered dietary calcium intake.
C. Reduced renal function.
D. Elevated fluid consumption.
4. Nurse Olivia is caring for a 32-year-old patient
and is reviewing the patient's medical chart. Based
on the symptoms exhibited, what would lead Nurse
Olivia to suspect the patient may have acute
glomerulonephritis?
A. Symptoms of painful urination, frequent
urination, and a sense of urgency.
B. Elevated blood pressure, reduced urine output,
and complaints of fatigue.
C. Complaints of back pain accompanied by
nausea and vomiting.
D. Symptoms of fever, chills, and pain in the right
upper quadrant radiating to the back.
5. Nurse Olivia is caring for a patient who has
recently undergone a kidney transplant. She
understands the importance of immunosuppressive
therapy to prevent rejection of the new organ. For
how long is immunosuppression generally
continued following a kidney transplantation?
A. Only for one week post-transplant.
B. For the initial 24 hours following the transplant.
C. Until there are no further signs of kidney
rejection.
D. Indefinitely, for the duration of the patient's life.
6. Nurse Ethan is reviewing the medical history of
Mrs. Clark, who reports that she leaks urine
whenever she coughs, sneezes, or lifts heavy
items. Based on this description, what type of
urinary incontinence is Mrs. Clark likely
experiencing?
A. Urge Incontinence.
B. Reflex Incontinence.
C. Overflow Incontinence.
D. Stress Incontinence.
7. Nurse James is crafting a care plan focused on
the nursing diagnosis of "risk for infection" for his
patient who has recently undergone a kidney
transplant. What would be an appropriate goal to
set for this patient?
A. Return to regular employment within a period of
2 to 3 weeks post-surgery.
B. Maintain a normal body temperature and have
cultures that show no infection.
C. Resume usual fluid consumption within a 48 to
72-hour timeframe.
D. Work toward ceasing the use of cyclosporine
(Neoral) as expediently as safe.
8. Nurse Amanda is responsible for caring for Mr.
Johnson, who has just undergone a prostatectomy.
What complication requires immediate and priority
assessment in Mr. Johnson's post-operative care?
A. The onset of deep vein thrombosis symptoms.
B. Early indications of pneumonia.
C. Signs of hemorrhaging or excessive bleeding.
D. Symptoms of urine retention.
9. Nurse Ethan is reviewing the medical histories of
two different patients: one with renal failure and
another with prerenal failure. Ethan aims to
differentiate the two conditions based on treatment
responsiveness. Which statement accurately
distinguishes prerenal failure from renal failure?
A. In prerenal failure, diuretics like furosemide
(Lasix) are less effective in eliciting a response.
B. In prerenal failure, blood urea nitrogen (BUN)
levels can be lowered through hemodialysis.
C. In prerenal failure, vasoactive agents such as
dopamine (Intropin) elevate blood pressure levels.
D. In prerenal failure, administering an intravenous
infusion of isotonic saline enhances urine
production.
10. Nurse Olivia is monitoring a postoperative
patient who has been back from surgery for six
hours. The patient has an indwelling urinary
catheter, which was empty upon return but now
shows only 120ml of urine. Olivia confirms that the
drainage system is not obstructed. What is Olivia's
priority intervention in this situation?
A. Position the patient for shock management and
alert the surgical team.
B. Assess the patient's circulatory status and vital
signs.
C. Administer a 500ml bolus of isotonic saline
solution.
D. Irrigate the urinary catheter with sterile saline or
water
11. Nurse Brian is reviewing the medical history of
several patients admitted to the general medical
floor. Based on their profiles, which patient is at the
greatest risk for developing a urinary tract infection
(UTI)?
A. A 28-year-old individual diagnosed with angina.
B. A 20-year-old woman diagnosed with asthma.
C. A 50-year-old postmenopausal woman.
D. A 35-year-old woman who has a fractured wrist.
12. Nurse Olivia is caring for a patient who has
diabetes mellitus and has recently started
hemodialysis due to renal failure. What would be
the most appropriate dietary recommendation for
this patient on the days between dialysis
treatments?
A. A low-protein diet with no restrictions on water
intake.
B. No dietary restrictions whatsoever.
C. A diet devoid of protein, along with the use of a
salt substitute.
D. A low-protein diet with a physician-prescribed
amount of water intake.
13. Nurse Anthony is caring for a patient diagnosed
with acute renal failure. He notes that the patient is
also experiencing elevated blood pressure levels.
Anthony wants to identify the most prevalent cause
of hypertension in the context of acute renal failure.
What is the most common cause of hypertension in
cases of acute renal failure?
A. Excessive fluid volume in the body.
B. Fluid accumulation in the lungs.
C. Low levels of red blood cells.
D. Insufficient fluid volume in the body.
14. Nurse Olivia is conducting an educational
session on the early signs of kidney disease for a
group of nursing students. She poses a question:
What is the most frequently observed early sign of
kidney disease?
A. Blood in the urine.
B. Proteinuria.
C. Elevated blood pressure.
D. Excessive thirst and hunger
15. Nurse Jane is closely monitoring a patient who
has been diagnosed with nephritic syndrome. Jane
is eager to identify any positive indicators that
would suggest her patient is on the path to
recovery. What change would signify that the
patient with nephritic syndrome is recovering?
A. Decreased levels of serum albumin.
B. Complete absence of protein in the urine.
C. Elevated levels of lipids in the blood serum.
D. An increase in overall body weight.
16. Nurse Laura is assessing a patient suspected
of progressing through the stages of acute renal
failure. What sign would indicate to her that the
patient is in the second phase of acute renal
failure?
A. Stabilization of kidney function.
B. Urine production is less than 400 ml per day.
C. A daily urine output that doubles, reaching 4 to 5
liters per day.
D. A daily urine output of less than 100 ml.
17. Nurse Sarah is conducting a follow-up visit in
the outpatient clinic for a patient who recently
received a kidney transplant. The patient reports
discovering a lump in her breast. What should
Nurse Sarah consider regarding transplant
recipients?
A. More prone to tumor formation directly due to the
kidney transplant.
B. At a lower likelihood for developing cancer, thus
the lump is probably non-malignant.
C. Overwhelmed with anxiety post the life-altering
kidney transplant experience.
D. At a heightened risk for cancer development
because of immunosuppressive therapy with
cyclosporine (Neoral).
18. Nurse Anthony is on his rounds when he
checks on Mrs. Smith, who has recently been
diagnosed with acute pyelonephritis. Based on her
diagnosis, which symptoms would Nurse Anthony
expect to observe in Mrs. Smith?
A. A burning sensation during urination.
B. Jaundice and pain in the flank area.
C. Increased frequency of urination and urination at
night.
D. Tenderness at the costovertebral angle along
with chills.
19. Nurse Karen is caring for a patient who has just
been wheeled back from the operating theater
following a repair of an abdominal aortic aneurysm.
She's vigilant for signs of potential complications,
particularly acute renal failure. What symptom
should alert Nurse Karen to the possibility of acute
renal failure in this postoperative patient?
A. Frequent bowel movements.
B. Nausea and vomiting.
C. Complete absence of urine.
D. Oliguria
20. Nurse Anna is evaluating a patient who may be
suffering from a urinary tract infection (UTI). To
further confirm the diagnosis, Anna pays close
attention to the patient's subjective symptoms.
Which statement from the patient would most likely
indicate the presence of a UTI?
A. "I can go for long stretches without feeling the
need to urinate."
B. "I've been urinating quite frequently."
C. "I experience a burning sensation during
urination."
D. "There's a sweet odor coming from my urine."
21. Nurse David is overseeing the hemodialysis
treatment of a patient when he notices that she
starts to become agitated. She complains of a
headache and mentions feeling nauseous. David
needs to identify the likely complication that could
be manifesting. What complication should Nurse
David suspect based on the patient's symptoms
during hemodialysis?
A. Disequilibrium syndrome.
B. Bacterial or viral infection.
C. Entrapment of air in the bloodstream.
D. Acute hemolysis.
22. Nurse Emily is providing education to a
22-year-old patient with diabetic nephropathy. The
patient expresses the belief that since they are
young and have two kidneys, sticking to their
insulin schedule will prevent kidney damage. What
is the best response that Nurse Emily should give?
A. "Your statement would hold true if diabetes could
solely be managed through insulin."
B. "You should consult with your physician;
statistics suggest your viewpoint may be too
optimistic."
C. "Despite following your insulin schedule, the risk
of kidney damage remains a concern."
D. "As long as your kidneys continue to produce
urine, you have minimal concern."
23. Nurse Emma is caring for a 60-year-old patient
diagnosed with pyelonephritis and suspected
septicemia. The patient has had recurrent UTIs, is
sleep-deprived, and has lost weight due to frequent
urination, including at night. The patient's lab
results indicate sodium levels of 154 mEq/L,
osmolarity at 340 mOsm/L, glucose at 127 mg/dl,
and potassium at 3.9 mEq/L. What is the priority
nursing diagnosis for this patient?
A. Altered Nutrition: Less Than Body Requirements
related to the catabolic effects of insulin deficiency.
B. Altered Nutrition: Less Than Body Requirements
related to a hypermetabolic state.
C. Fluid Volume Deficit related to osmotic diuresis
triggered by hyponatremia.
D. Fluid Volume Deficit related to the inability to
conserve water.
24. Nurse Emily is attending to Lisa, a 30-year-old
woman who is undergoing hemodialysis treatment.
Lisa has an internal arteriovenous fistula in her arm
for vascular access. Emily wants to take measures
to minimize the risk of complications associated
with the arteriovenous fistula. What action should
Emily take to prevent complications related to this
vascular access device?
A. Establish intravenous lines proximal to the
location of the arteriovenous fistula.
B. Refrain from measuring blood pressure on the
arm containing the arteriovenous fistula.
C. Feel for pulses distal to the arteriovenous fistula
site.
D. Notify the healthcare provider if a bruit or thrill is
detected over the arteriovenous fistula.
25. Nurse Lauren is caring for a patient, Mr. Patel,
who has been admitted with acute renal calculi and
is experiencing significant pain. What type of
medication is generally indicated for the
management of pain related to acute renal calculi?
A. Narcotic analgesics.
B. Salicylates
C. Nonsteroidal anti-inflammatory drugs (NSAIDs).
D. Muscle relaxants.
26. Nurse Melissa is caring for a patient with renal
failure and has orders to administer Polystyrene
sulfonate (Kayexalate). She understands that this
medication has a specific role in managing the
complications associated with renal failure. What is
the primary purpose of using Polystyrene sulfonate
(Kayexalate) in patients with renal failure?
A. To lower elevated serum phosphate
concentrations.
B. To rectify acid-base imbalances.
C. To swap potassium ions for sodium ions.
D. To counteract constipation resulting from sorbitol
usage.
27. Nurse Jennifer is preparing discharge
instructions for a patient who was diagnosed with
sepsis stemming from a urinary tract infection
(UTI). What key point should Nurse Jennifer include
in her patient's discharge teaching plan?
A. Abstain from engaging in sexual activity.
B. Consume 8 to 10 eight-ounce glasses of water
each day.
C. Refrain from using tampons.
D. Take cool baths to manage symptoms.
28. Nurse Laura is caring for Mr. Harris, who has
been recently diagnosed with acute
glomerulonephritis. Based on the diagnosis, what
clinical manifestations would Nurse Laura expect to
see in Mr. Harris?
A. Increased thirst and frequent urination.
B. Reduced urine output and generalized swelling.
C. Chills and pain in the area between the ribs and
hip.
D. Painful urination and low blood pressure.
29. Nurse Zachary is preparing medication
education for a patient diagnosed with a urinary
tract infection (UTI) and prescribed
phenazopyridine (Pyridium). What important
information should Nurse Zachary include in the
patient's medication teaching?
A. "You must complete this antibiotic course for a
total of 7 days."
B. "Administer this medication between your meals
and at bedtime."
C. "Avoid this drug if you have a penicillin allergy."
D. "Expect your urine to possibly change to a bright
orange color."
30. Nurse Emily is closely monitoring the cardiac
status of a patient with end-stage renal disease.
The cardiac monitor starts showing frequent PVCs
(Premature Ventricular Contractions). What is the
priority nursing intervention for this situation?
A. Contact the healthcare provider immediately.
B. Administer intravenous lidocaine (Xylocaine) to
the patient.
C. Review the most recent laboratory results for the
patient's potassium level.
D. Ready the equipment for potential defibrillation
of the patient.
31. Nurse John is formulating a care plan for a
patient who is in end-stage renal disease. Among
the various aspects of patient care that need to be
addressed, what would be the priority nursing
diagnosis for this patient?
A. Reduced tolerance for physical activity.
B. Excess fluid volume.
C. Nutritional imbalance: insufficient dietary intake.
D. Elevated risk for physical harm.
32. Nurse Alex is discussing dietary modifications
with a patient who has both diabetes and a
longstanding history of multiple renal stones. Now
facing chronic renal failure, which nutritional
component needs to be notably decreased in this
patient's meal plan?
A. Carbohydrate intake
B. Dietary fats
C. Protein sources
D. Ascorbic acid (Vitamin C)
33. Nurse William is speaking to a men's health
group about the importance of screening for
prostate cancer. One of the attendees asks him
what is the most indicative diagnostic test for
detecting prostate cancer. What should Nurse
William reply?
A. The use of magnetic resonance imaging (MRI).
B. Excretory urography as a diagnostic measure.
C. Testing for prostate-specific antigen (PSA)
levels.
D. An in-depth digital rectal examination.
34. Nurse William is setting up for the urinary
catheterization of a patient who has recently
suffered from a traumatic injury. As he gets ready,
William notices that there's blood present at the
opening of the urethra (urethral meatus). What
should be William's priority action in this situation?
A. Postpone the catheterization and alert the
physician.
B. Analyze the discharge for hidden blood prior to
inserting the catheter.
C. Thoroughly rinse and clean the urethral opening
before proceeding with catheterization.
D. Generously apply lubrication to the catheter
before insertion.
35. Nurse Anthony is taking care of a patient who
has been diagnosed with end-stage renal disease.
What should be the priority nursing diagnosis for
this patient?
A. Intolerance to Physical Activity.
B. Excess Fluid Volume.
C. Deficit in Patient Knowledge.
D. Experience of Pain.
36. While attending to Mrs. Jones, who is currently
in the oliguric phase of renal failure, Nurse
Rebecca wonders what level of 24-hour urine
output she should expect to be below for this
patient.
A. Not exceeding 1000 milliliters.
B. Less than 400 milliliters.
C. Under 800 milliliters.
D. Below 200 milliliters.
37. Nurse Sarah is reviewing the care plan for Mr.
Anderson, a patient with chronic renal failure who is
complaining about persistent itching or pruritus.
What instruction should Nurse Sarah include in Mr.
Anderson's teaching plan to manage this
symptom?
A. Take baths frequently to keep the skin clean.
B. Utilize alcohol-based emollients for skin
moisture.
C. Vigorously rub the affected skin areas with a
towel.
D. Maintain short, clean fingernails.
38. David, a dialysis nurse, is preparing a
54-year-old patient for hemodialysis. The patient
has a functioning arteriovenous (AV) fistula in
place. What should David prioritize to ensure the
patency of the AV fistula before initiating
hemodialysis?
A. Elevate the extremity with the AV fistula above
heart level.
B. Apply a warm compress to the AV fistula site.
C. Auscultate the AV fistula for bruit and palpate for
thrill.
D. Administer a bolus of saline through the AV
fistula.
39. Nurse Maya is working on a rehabilitation plan
for a patient who has a neurogenic bladder. Which
action should be considered the most critical when
undertaking bladder training for this patient?
A. Suggest the continued use of an indwelling
urinary catheter.
B. Promote the practice of Kegel exercises.
C. Establish designated times for bladder emptying.
D. Advocate for increased fluid intake.
40. Nurse Sarah is caring for a patient with
end-stage renal disease (ESRD) who has an
arteriovenous fistula in the left arm for
hemodialysis. What intervention should be included
in the patient's plan of care?
A. Keep the left arm completely dry.
B. Elevate the left arm on an arm board for a
minimum of 30 minutes.
C. Maintain the head of the bed at a 45-degree
elevation.
D. Apply consistent pressure to the needle insertion
site upon ceasing hemodialysis.
41. Nurse Laura is preparing a teaching care plan
for a patient diagnosed with cystitis, who is being
treated with phenazopyridine (Pyridium). Laura
wants to include essential guidance for the safe
and effective use of this medication. What
instruction should Nurse Laura include in the care
plan for this patient?
A. Stop the course of prescribed antibiotics once
the painful urination is alleviated.
B. Contact the physician if your urine becomes
orange-red in color.
C. Administer phenazopyridine immediately prior to
urinating to alleviate discomfort.
D. Cease taking phenazopyridine as soon as
symptoms of painful urination subside
42. Nurse David is developing a care plan for Ms.
Garcia, who has been diagnosed with renal calculi.
What intervention should Nurse David include in
the care plan to best manage Ms. Garcia's
condition?
A. Encourage a diet high in purines.
B. Limit fluid intake to reduce urine output.
C. Instruct the patient to strain all urine.
D. Advise the patient to maintain complete bed rest.
43. An 18-year-old college student is admitted to
the hospital presenting with dark urine, fever, and
flank pain. After diagnostic tests, the student is
diagnosed with acute glomerulonephritis. What
health history factor is most likely to be present in
this student's case?
A. Previous renal trauma.
B. Family history of acute glomerulonephritis.
C. History of renal calculi (kidney stones).
D. A recent episode of a sore throat.
44. You're caring for a patient who recently
underwent a kidney transplant. You become
concerned about the possibility of kidney transplant
rejection. Which symptoms would arouse your
suspicion?
A. Discomfort at the surgical site, overall malaise,
and low blood pressure.
B. Discomfort at the surgical site, overall feeling of
weakness, and signs of depression.
C. Reduced urine production accompanied by low
blood pressure.
D. Elevated body temperature, an increase in
weight, and reduced urine production.
45. During a session of hemodialysis, Nurse Alex
notices that her patient, Mrs. Wilson, starts to
complain about experiencing muscle cramps. What
should Nurse Alex do immediately to effectively
relieve Mrs. Wilson's muscle cramps?
A. Administer a 5% dextrose solution intravenously.
B. Accelerate the rate of the ongoing hemodialysis
treatment.
C. Infuse a normal saline solution intravenously.
D. Urge Mrs. Wilson to perform active
range-of-motion exercises.
46. Nurse Megan is attending a continuing
education seminar on preventing urinary tract
infections (UTIs) in hospitalized patients. The
speaker asks the audience which factor is primarily
responsible for the majority of UTIs in hospitalized
settings. What is the most likely answer?
A. The use of invasive procedures.
B. Inadequate fluid intake.
C. Immunosuppressed state of the patient.
D. Insufficient perineal hygiene.
47. Nurse Jake is monitoring a patient who has just
completed their first session of hemodialysis.
Shortly afterward, the patient starts to experience a
headache, elevated blood pressure, restlessness,
mental confusion, nausea, and vomiting. What
condition is most likely indicated by these
symptoms?
A. Disequilibrium Syndrome
B. Respiratory Distress
C. Hypervolemia
D. Peritonitis
48. Nurse Isabella is working with a patient who
may need to transition to continuous peritoneal
dialysis. Before making any recommendations, she
needs to evaluate whether the patient meets
certain criteria to be eligible for this treatment
option. What is a required criterion for a patient to
be considered for continuous peritoneal dialysis?
A. Previous attempts at hemodialysis must have
been unsuccessful.
B. The patient must have severe pulmonary
edema.
C. The patient's vascular access point needs to be
fully healed.
D. The patient needs to have stable hemodynamic
parameters.
49. Nurse Emily is assessing a patient who
presents with intense pain on the right side of his
lower back, nausea, vomiting, and restlessness.
The patient also appears somewhat pale and is
sweating. His vital signs are: BP 140/90 mmHg,
Pulse 118 beats/min., Respirations 33 breaths/min.,
and Temperature 98.0°F. Based on the subjective
data, which symptom most strongly suggests the
diagnosis of renal calculi (kidney stones)?
A. Vomiting that resembles coffee grounds in color.
B. Pain that extends toward the right upper
abdominal area.
C. Urine that is dark in color and produced in low
amounts.
D. A history of experiencing mild symptoms of the
flu the previous week.
50. Nurse Emily is caring for a patient who recently
underwent surgery to create an arteriovenous
fistula for hemodialysis. What key information
should Nurse Emily keep in mind when providing
care for this patient?
A. Auscultating the fistula with a stethoscope is not
advised.
B. The patient should not experience pain during
the initiation of dialysis.
C. Measuring blood pressure on the arm with the
arteriovenous fistula can lead to clot formation.
D. The patient generally feels at their best
immediately following dialysis treatment.
How do you determine that a patient's oliguria is
associated with acute renal failure (ARF)?
A. Specific gravity of urine at 3 different times is
1.010.
B. The serum creatinine level is normal.
C. The blood urea nitrogen (BUN) level is normal or
below.
D. Hypokalemia is identified.
When caring for a patient during the oliguric phase
of acute kidney injury, what would be an
appropriate nursing intervention?
A. Weigh patient three times weekly
B. Increase dietary sodium and potassium
C. Provide a low-protein, high-carbohydrate diet
D. Restrict fluids according to the previous day's
fluid loss
Which assessment finding is commonly found in
the oliguric phase of acute kidney injury (AKI)?
A. Hypovolemia
B. Hyperkalemia
C. Hypernatremia
D. Thrombocytopenia
Which patient has the greatest risk for prerenal
AKI?
A. The patient is hypovolemic because of
hemorrhage.
B. The patient relates a history of chronic urinary
tract obstruction.
C. The patient has vascular changes related to
coagulopathies.
D. The patient is receiving antibiotics such as
gentamicin.
The patient admitted to the intensive care unit after
a motor vehicle accident has been diagnosed with
AKI. Which finding indicates the onset of oliguria
resulting from AKI?
A. Urine output less than 1000 mL for the past 24
hours
B. Urine output less than 800 mL for the past 24
hours
C. Urine output less than 600 mL for the past 24
hours
D. Urine output less than 400 mL for the past 24
hours
The patient in the oliguric phase of AKI excreted
300 mL of urine in addition to 100 mL of other
losses during the past 24 hours. With appropriate
calculations, you determine that for the next 24
hours the patient's fluid allocation is
A. 600 mL.
B. 800 mL.
C. 1000 mL.
D. 1200 mL.
Your plan for care of a patient with AKI includes
which goal of dietary management?
A. Provide sufficient calories while preventing
nitrogen excess.
B. Deliver adequate calories while restricting fat
and protein intake.
C. Replace protein intake with enough fat intake to
sustain metabolism.
D. Restrict fluids, increase potassium intake, and
regulate sodium intake.
For the patient with AKI, which laboratory result
would cause you the greatest concern?
A. Potassium level of 5.9 mEq/L
B. BUN level of 25 mg/dL
C. Sodium level of 144 mEq/L
D. pH of 7.5
Important nursing interventions for the patient with
AKI are (select all that apply)
A. careful monitoring of intake and output.
B. daily patient weights.
C. meticulous aseptic technique.
D. increase intake of vitamin A and D.
E. frequent mouth care.
What characterizes AKI (select all that apply)?
A. Primary cause of death is infection.
B. It usually affects older people.
C. The disease course is potentially reversible.
D. The most common cause is diabetic
nephropathy.
E. Cardiovascular disease is the most common
cause of death.
During the oliguric phase of AKI, you monitor the
patient for (select all that apply)
A. hypertension.
B. electrocardiographic (ECG) changes.
C. hypernatremia.
D. pulmonary edema.
E. urine with high specific gravity.
If a patient is in the diuretic phase of AKI, you must
monitor for which serum electrolyte imbalances?
A. Hyperkalemia and hyponatremia
B. Hyperkalemia and hypernatremia
C. Hypokalemia and hyponatremia
D. Hypokalemia and hypernatremia
You are preparing to administer a dose of PhosLo
to a patient with chronic kidney disease (CKD). This
medication should have a beneficial effect on which
laboratory value?
A. Sodium
B. Potassium
C. Magnesium
D. Phosphorus
A patient is admitted to the hospital with CKD. You
understand that this condition is characterized by
A. Progressive irreversible destruction of the
kidneys
B. A rapid decrease in urinary output with an
elevated BUN level
C. Increasing creatinine clearance with a decrease
in urinary output
D. Prostration, somnolence, and confusion with
coma and imminent death
Nurses need to educate patients at risk for CKD.
Which individuals are considered to be at increased
risk (select all that apply)?
A. Older African Americans
B. Individuals older than 60 years
C. Those with a history of pancreatitis
D. Those with a history of hypertension
E. Those with a history of type 2 diabetes
Patients with CKD have an increased incidence of
cardiovascular disease related to (select all that
apply)
A. hypertension.
B. vascular calcifications.
C. a genetic predisposition.
D. hyperinsulinemia causing dyslipidemia.
E. increased high-density lipoproteins levels.
Measures indicated in the conservative therapy of
CKD include
A. decreased fluid intake, carbohydrate intake, and
protein intake.
B. increased fluid intake; decreased carbohydrate
intake and protein intake.
C. decreased fluid intake and protein intake;
increased carbohydrate intake.
D. decreased fluid intake and carbohydrate intake;
increased protein intake.
The advantage of continuous replacement therapy
over hemodialysis is its ability to
A. remove fluid without the use of a dialysate.
B. remove fluid in less than 24 hours.
C. allow the patient to receive the therapy at the
work site.
D. be administered through a peripheral line.
You are caring for a patient receiving continuous
replacement therapy and notice that the filtrate is
blood tinged. What is your priority action?
A. Place the patient in Trendelenburg position.
B. Initiate a peripheral intravenous line.
C. Suspend treatment immediately.
D. Administer vitamin K (Aquamephyton) per order.
A patient with a history of end-stage renal disease
(ESRD) resulting from diabetes mellitus has
presented to the outpatient dialysis unit for his
scheduled hemodialysis. Which assessment should
you prioritize before, during, and after his
treatment?
A. Level of consciousness
B. Blood pressure and fluid balance
C. Temperature, heart rate, and blood pressure
D. Assessment for signs and symptoms of infection
Which statement regarding continuous ambulatory
peritoneal dialysis (CAPD) is of highest priority
when teaching a patient new to this procedure?
A. "It is essential that you maintain aseptic
technique to prevent peritonitis."
B. "You will be allowed a more liberal protein diet
after you complete CAPD."
C. "It is important for you to maintain a daily written
record of blood pressure and weight."
D. "You must continue regular medical and nursing
follow-up visits while performing CAPD."
How should you assess the patency of a newly
placed arteriovenous graft for dialysis?
A. Irrigate the graft daily with low-dose heparin.
B. Monitor for any increase in blood pressure in the
affected arm.
C. Listen with a stethoscope over the graft for
presence of a bruit.
D. Frequently monitor the pulses and
neurovascular status distal to the graft.
What are the main advantages of peritoneal
dialysis compared to hemodialysis?
A. No medications are required because of the
enhanced efficiency of the peritoneal membrane in
removing toxins.
B. The diet is less restricted and dialysis can be
performed at home.
C. The dialysate is biocompatible and causes no
long-term consequences.
D. High glucose concentrations of the dialysate
cause a reduction in appetite, promoting weight
loss.
A patient is recovering in the intensive care unit
(ICU) after receiving a kidney transplant
approximately 24 hours earlier. What is an
expected assessment finding for this patient during
the early stage of recovery?
A. Hypokalemia
B. Hyponatremia
C. Large urine output
D. Leukocytosis with cloudy urine output
An ESRD patient receiving hemodialysis is
considering asking a relative to donate a kidney for
transplantation. In assisting the patient to make a
decision about treatment, what do you tell the
patient?
A. Successful transplantation usually provides
better quality of life than that offered by dialysis.
B. If rejection of the transplanted kidney occurs, no
further treatment for the renal failure is available.
C. The immunosuppressive therapy that is required
after transplantation causes fatal malignancies in
many patients.
D. Hemodialysis replaces the normal functions of
the kidneys, and patients do not have to live with
the continual fear of rejection.
A kidney transplant recipient complains of fever,
chills, and dysuria over the past 2 days. What is the
first action that you should take?
A. Assess temperature and initiate a workup to rule
out infection.
B. Provide warm covers for the patient and give 1
gram of acetaminophen orally.
C. Reassure the patient and let him know this is
common after transplantation.
D. Notify the nephrologist that the patient has
developed symptoms of acute rejection.
Which descriptions characterize AKI? Select all that
apply
a. primary cause of death is infection
b. it almost always affects older people
c. disease course is potentially reversible
d. most common cause is diabetic nephropathy
e. cardiovascular disease is most common cause of
death
During the oliguric phase of AKI, the nurse monitors
the patient for Select all that apply
a. hypotension
b. ECG changes
c. hypernatremia
d. pulmonary edema
e. urine with high specific gravity
If a patient is in the diuretic phase of AKI, the nurse
must monitor for which serum electrolyte
imbalances?
a. hyperkalemia and hyponatremia
b. hyperkalemia and hypernatremia
c. hypokalemia and hyponatremia
d. hypokalemia and hypernatremia
The nurse is caring for a 68-yr-old man who had
coronary artery bypass surgery 3 weeks ago.
During the oliguric phase of acute kidney disease,
which action would be appropriate to include in the
plan of care?
a. Provide foods high in potassium.
b. Restrict fluids based on urine output.
c. Monitor output from peritoneal dialysis.
d. Offer high-protein snacks between meals.
When caring for a patient during the oliguric phase
of acute kidney injury (AKI), which nursing action is
appropriate?
a. Weigh patient three times weekly.
b. Increase dietary sodium and potassium.
c. Provide a low-protein, high-carbohydrate diet.
d. Restrict fluids according to previous daily loss
Which patient diagnosis or treatment is most
consistent with prerenal acute kidney injury (AKI)?
a. IV tobramycin
b. Incompatible blood transfusion
c. Poststreptococcal glomerulonephritis
d. Dissecting abdominal aortic aneurysm
The patient has rapidly progressing glomerular
inflammation. Weight has increased and urine
output is steadily declining. What is the priority
nursing intervention?
a. Monitor the patient's cardiac status.
b. Teach the patient about hand washing.
c. Obtain a serum specimen for electrolytes.
d. Increase direct observation of the patient.
Which assessment findings would alert the nurse
that the patient has entered the diuretic phase of
acute kidney injury (AKI)? Select all that apply
a. Dehydration
b. Hypokalemia
c. Hypernatremia
d. BUN increases
e. Urine output increases
An unlicensed assistive personnel (UAP) reports to
the RN that a patient with acute kidney failure had a
urine output of 350 mL over the past 24 hours after
receiving furosemide 40 mg IV push. The UAP asks
the nurse how this can happen. What is the nurse's
best response?
a. "During the oliguric phase of acute kidney failure,
patients often do not respond well to either fluid
challenges or diuretics."
b. "There must be some sort of error. Someone
must have failed to record the urine output."
c. "A patient with acute kidney failure retains
sodium and water, which counteracts the action of
the furosemide."
d. "The gradual accumulation of nitrogenous waste
products results in the retention of water and
sodium."
The RN supervising a senior nursing student is
discussing methods for preventing acute kidney
injury (AKI). Which points would the RN be sure to
include in this discussion? Select all that apply
a. Encourage patients to avoid dehydration by
drinking adequate fluids.
b. Instruct patients to drink extra fluids during
periods of strenuous exercise.
c. Immediately report a urine output of less than 2
mL/kg/hr.
d. Record intake and output and weigh patients
daily.
e. Monitor laboratory values that reflect kidney
function.
For which patient is the nurse most concerned
about the risk for developing kidney disease?
a. A 25-year-old patient who developed a urinary
tract infection (UTI) during pregnancy
b. A 55-year-old patient with a history of kidney
stones
c. A 63-year-old patient with type 2 diabetes
d. A 79-year-old patient with stress urinary
incontinence
A patient with acute kidney injury (AKI) has an
arterial blood pH of 7.30. The nurse will assess the
patient for
a. vasodilation.
b. poor skin turgor.
c. bounding pulses.
d. rapid respirations.
A patient with severe heart failure develops
elevated blood urea nitrogen (BUN) and creatinine
levels. The nurse will plan care to meet the goal of
a. replacing fluid volume.
b. preventing hypertension.
c. maintaining cardiac output.
d. diluting nephrotoxic substances.
A patient who has acute glomerulonephritis is
hospitalized with acute kidney injury (AKI) and
hyperkalemia. Which information will the nurse
obtain to evaluate the effectiveness of the
prescribed calcium gluconate IV?
a. Urine output
b. Calcium level
c. Cardiac rhythm
d. Neurologic status
Which information will be most useful to the nurse
in evaluating improvement in kidney function for a
patient who is hospitalized with acute kidney injury
(AKI)?
a. Blood urea nitrogen (BUN) level
b. Urine output
c. Creatinine level
d. Calculated glomerular filtration rate (GFR)
In a patient with acute kidney injury (AKI) who
requires hemodialysis, a temporary vascular
access is obtained by placing a catheter in the left
femoral vein. Which intervention will be included in
the plan of care?
a. Place the patient on bed rest.
b. Start continuous pulse oximetry.
c. Discontinue the retention catheter.
d. Restrict the patients oral protein intake.
Which information about a patient who was
admitted 10 days previously with acute kidney
injury (AKI) caused by dehydration will be most
important for the nurse to report to the health care
provider?
a. The blood urea nitrogen (BUN) level is 67 mg/dL.
b. The creatinine level is 3.0 mg/dL.
c. Urine output over an 8-hour period is 2500 mL.
d. The glomerular filtration rate is <30
mL/min/1.73m2.
After noting lengthening QRS intervals in a patient
with acute kidney injury (AKI), which action should
the nurse take first?
a. Document the QRS interval.
b. Notify the patients health care provider.
c. Look at the patients current blood urea nitrogen
(BUN) and creatinine levels.
d. Check the chart for the most recent blood
potassium level.
When caring for a dehydrated patient with acute
kidney injury who is oliguric, anemic, and
hyperkalemic, which of the following prescribed
actions should the nurse take first?
a. Insert a urinary retention catheter.
b. Place the patient on a cardiac monitor.
c. Administer epoetin alfa (Epogen, Procrit).
d. Give sodium polystyrene sulfonate (Kayexalate).
What are intrarenal causes of AKI? Select all that
apply
a. anaphylaxis
b. renal stones
c. nephrotoxic drugs
d. acute glomerulonephritis
e. tubular obstruction by myoglobin
An 83 year old female patient was found lying on
the bathroom floor. She said she fell 2 days ago
and has not been able to take her heart medicine or
eat or drink anything since then. What conditions
could be causing prerenal AKI in this patient?
Select all that apply
a. anaphylaxis
b. renal calculi
c. hypovolemia
d. nephrotoxic drugs
e. decreased cardiac output
ATN is the most common cause of intrarenal AKI.
Which patient is most likely to develop ATN?
a. patient with DM
b. patient with hypertensive crisis
c. patient who tried to overdose on acetaminophen
d. patient with major surgery who required a blood
transfusion
What indicates to the nurse that a patient with
oliguria has prerenal oliguria?
a. urine testing reveals a low specific gravity
b. causative factor is malignant hypertension
c. urine testing reveals a high sodium concentration
d. reversal of oliguria occurs with fluid replacement
Metabolic acidosis occurs in the oliguric phase of
AKI as a result of impairment of
a. excretion of sodium
b. excretion of bicarbonate
c. conservation of potassium
d. excretion of hydrogen ions
What indicates to the nurse that a patient with AKI
is in the recovery phase?
a. a return to normal weight
b. a urine output of 3,700 mL/day
c. decreasing sodium and potassium levels
d. decreasing BUN and creatinine levels
While caring for the patient in the oliguric phase of
AKI, the nurse monitors the patient for associated
collaborative problems. When should the nurse
notify the HCP?
a. urine output is 300 ml/day
b. edema occurs in the feet, legs, and sacral area
c. cardiac monitor reveals a depressed T wave and
elevated ST segment
d. the patient experiences increasing muscle
weakness and abdominal cramping
In caring for the patient with AKI, of what should the
nurse be aware?
a. the most common cause of death is irreversible
metabolic acidosis
b. during the oliguric phase, daily fluid intake is
limited to 1,000 ml plus the prior day's measured
fluid loss
c. dietary sodium and potassium during the oliguric
phase of AKI are managed according to the
patient's urinary output
d. one of the most important nursing measures in
managing fluid balance in the patient with AKI is
taking accurate daily weights
A 68 year old man with a history of HF resulting
from HTN has AKI as a result of the effects of
nephrotoxic diuretics. Currently his serum
potassium is 6.2 with cardiac changes, BUN is 108,
serum creatinine 4.1, and serum HCO3 13. He is
somnolent and disoriented. Which treatment should
the nurse expect to be used for him?
a. loop diuretics
b. renal replacement therapy
c. insulin and sodium bicarbonate
d. sodium polystyrene sulfonate (kayexalate)
A patient with AKI has a serum potassium level of
6.7 and the following ABG results: pH: 7.28,
PaCO2: 30, PaO2: 86, HCO3: 18. The nurse
recognizes that treatment of the acid-base problem
with sodium bicarbonate would cause a decrease in
which value?
a. pH
b. potassium level
c. bicarbonate level
d. carbon dioxide level
A patient with AKI is a candidate for continuous
renal replacement therapy (CRRT). What is the
most common indication for use of CRRT?
a. pericarditis
b. hyperkalemia
c. fluid overload
d. hypernatremia
A nurse is planning care for a client who has
prerenal AKI following abdominal aortic aneurysm
repair. Urinary output is 60 ml in the past 2 hours,
and BP is 92/58. The nurse should expect which of
the following interventions?
a. prepare the client for a CT scan with contrast dye
b. plan to administer nitroprusside
c. prepare to administer a fluid challenge
d. plan to position the client in Trendelenburg
A nurse is assessing a client who has prerenal AKI.
Which of the following findings should the nurse
expect? Select all that apply
a. reduced BUN
b. elevated cardiac enzymes
c. reduced urine output
d. elevated blood creatinine
e. elevated blood calcium
A client has been admitted with acute renal failure.
What should the nurse do? Select all that apply
a. elevate the HOB 30-45 degrees
b. take vital signs
c. establish an IV site
d. call the admitting healthcare provider for
prescriptions
e. contact the hemodialysis unit
Which initial manifestation of acute renal failure is
most common?
a. dysuria
b. anuria
c. hematuria
d. oliguria
The client who is in acute renal failure has an
elevated BUN. What is the likely cause of this
finding?
a. fluid retention
b. hemolysis of RBCs
c. below-normal metabolic rate
d. reduced renal blood flow
A client with acute renal failure has an increase in
the serum potassium level. The nurse should
monitor the client for
a. cardiac arrest
b. pulmonary edema
c. circulatory collapse
d. hemorrhage
A high-carbohydrate, low-protein diet is prescribed
for the client with acute renal failure. The intended
outcome of this diet is to
a. act as a diuretic
b. reduce demands on the liver
c. help maintain urine acidity
d. prevent the development of ketosis
The client with acute renal failure asks the nurse for
a snack. Because the client's potassium level is
elevated, which snack is most appropriate?
a. a gelatin dessert
b. yogurt
c. an orange
d. peanuts
In the oliguric phase of acute renal failure, the
nurse should assess the client for
a. pulmonary edema
b. metabolic alkalosis
c. hypotension
d. hypokalemia
The client in acute renal failure has an external
cannula inserted in the forearm for hemodialysis.
Which nursing measure is appropriate for the care
of this client?
a. use the unaffected arm for blood pressure
measurements
b. draw blood from the cannula for routine
laboratory work
c. percuss the cannula for bruits each shift
d. inject heparin into the cannula each shift
During dialysis, the client has disequilibrium
syndrome. The nurse should first
a. administer oxygen per nasal cannula
b. slow the rate of dialysis
c. reassure the client that the symptoms are normal
d. place the client in Trendelenburg's position
Which abnormal blood value would not be
improved by dialysis treatment?
a. elevated serum creatinine level
b. hyperkalemia
c. decreased hemoglobin concentration
d. hypernatremia
The client with acute renal failure is recovering and
asks the nurse, "will my kidneys ever function
normally again?" The nurse's response is based on
the knowledge that the client's renal status will most
likely
a. continue to improve over a period of weeks
b. result in the need for permanent hemodialysis
c. improve only if the client receives a renal
transplant
d. result in end-stage renal failure
A client with AKI has a serum potassium level of
7.0. The nurse should plan which actions as a
priority? Select all that apply
a. place the client on a cardiac monitor
b. notify the HCP
c. put the client on NPO status except for ice chips
d. review the client's medications to determine if
any contain or retain potassium
e. allow an extra 500 ml of IV fluid intake to dilute
the electrolyte concentration
Which assessment finding is commonly found in
the oliguric phase of acute kidney injury (AKI)?
a. Hypovolemia
b. Hyperkalemia
c. Hypernatremia
d. Thrombocytopenia
Which patient has the greatest risk for prerenal
AKI?
a. The patient who is hypovolemic because of
hemorrhage.
b. The patient who relates a history of chronic
urinary tract obstruction.
c. The patient with vascular changes related to
coagulopathies.
d. The patient receiving antibiotics such as
gentamicin.
Important nursing interventions for the patient with
AKI are Select all that apply
a. careful monitoring of intake and output.
b. daily patient weights.
c. meticulous aseptic technique.
d. increase intake of vitamin A and D.
e. frequent mouth care.
You expect a patient in the oliguric phase of renal
failure to have a 24 hour urine output less than:
1) 200ml
2) 400ml
3) 800ml
4) 1000ml
The most common early sign of kidney disease is:
1. Sodium retention
2. Elevated BUN level
3. Development of metabolic acidosis
4. Inability to dilute or concentrate urine
Which sign indicated the second phase of acute
renal failure?
1. Daily doubling of urine output (4 to 5 L/day)
2. Urine output less than 400 ml/day
3. Urine output less than 100 ml/day
4. Stabilization of renal function
A patient who received a kidney transplant returns
for a follow-up visit to the outpatient clinic and
reports a lump in her breast. Transplant recipients
are:
1) At increased risk for cancer due to
immunosuppression caused by cyclosporine
(Neoral)
2) Consumed with fear after the life-threatening
experience of having a transplant
3) At increased risk for tumors because of the
kidney transplant
4) At decreased risk for cancer, so the lump is most
likely benign
You're developing a care plan with the nursing
diagnosis risk for infection for your patient that
received a kidney transplant. A goal for this patient
is to:
1) Remain afebrile and have negative cultures
2) Resume normal fluid intake within 2 to 3 days
3) Resume the patient's normal job within 2 to 3
weeks
4) Try to discontinue cyclosporine (Neoral) as
quickly as possible
You suspect kidney transplant rejection when the
patient shows which symptoms?
1) Pain in the incision, general malaise, and
hypotension
2) Pain in the incision, general malaise, and
depression
3) Fever, weight gain, and diminished urine output
4) Diminished urine output and hypotension
Which cause of hypertension is the most common
in acute renal failure?
1) Pulmonary edema
2) Hypervolemia
3) Hypovolemia
4) Anemia
Which statement correctly distinguishes renal
failure from prerenal failure?
1) With prerenal failure, vasoactive substances
such as dopamine (Intropin) increase blood
pressure
2) With prerenal failure, there is less response to
such diuretics as furosemide (Lasix)
3) With prerenal failure, an IV isotonic saline
infusion increases urine output
4) With prerenal failure, hemodialysis reduces the
BUN level
The home care nurse is making follow-up visits to a
client following renal transplant. The nurse
assesses the client for which signs of acute graft
rejection?
a) hypotension, graft tenderness, and anemia
b) hypertension, oliguria, thirst, and hypothermia
c) fever, hypertension, graft tenderness, and
malaise
d) fever, vomiting, hypotension, and copious
amounts of dilute urine
The client with acute renal failure has a serum
potassium of 6.0 mEq/L. The nurse would plan
which of the following as a priority action?
a) check the sodium level
b) place the client on a cardiac monitor
c) encourage increased vegetables in the diet
d) allow an extra 500 ml of fluid intake to dilute the
electrolyte concentration
A adult client has had laboratory work done as part
of a routine physical examination. The nurse
interprets that the client may have a mild degree of
renal insufficiency if which of the following serum
creatinine levels is noted?
a) 0.2 mg/dlL
b) 0.5 mg/dL
c) 1.9 mg/dL
d) 3.5 mg/dL
The client in end-stage of renal failure had
undergone kidney transplant. Which of the following
assessment findings indicate kidney transplant
rejection?
a) increased urinary output, BUN = 15 mg/dL
b) HCT = 50%, Hgb = 17 g/dl
c) decreased urinary output, sudden weight gain
d) decreased urinary output, sudden weight loss
Which of the following anti-hypertensive
medications is contraindicated for clients with renal
insufficiency?
a) beta-adrenergic blockers
b) calcium-channel blockers
c) direct-acting vasodilators
d) angiotensin-converting enzyme inhibitors
In the oliguric phase of renal failure, what is the
most appropriate nursing diagnosis?
a) fluid volume deficit
b) activity intolerance
c) ineffective breathing pattern
d) fluid volume excess
A patient with acute renal failure (ARF) has an
arterial blood pH of 7.30. The nurse will assess the
patient for
a. tachycardia.
b. rapid respirations.
c. poor skin turgor.
d. vasodilation.
A patient with severe heart failure develops
elevated BUN and creatinine levels. The nurse
plans care for the patient based on the knowledge
that collaborative care of the patient will be directed
toward the goal of
a. preventing hypertension.
b. replacing fluid volume.
c. diluting nephrotoxic substances.
d. maintaining cardiac output.
A patient admitted with sepsis has had several
episodes of severe hypotension. Laboratory results
indicate a BUN 50 mg/dl (10.7 mmol/L), serum
creatinine 2.0 mg/dl (177 µmol/L), urine sodium 70
mEq/L (70 mmol/L), urine specific gravity 1.010,
and cellular casts and debris in the urine. The
nurse knows these findings are consistent with
a. chronic renal insufficiency.
b. prerenal failure.
c. postrenal failure.
d. acute tubular necrosis.
A patient in the oliguric phase of acute renal failure
has a 24-hour fluid output of 150 ml emesis and
250 ml urine. The nurse plans a fluid replacement
for the following day of ___ ml.
a. 400
b. 800
c. 1000
d. 1400
The health care provider orders IV glucose and
insulin to be given to a patient in ARF whose serum
potassium level is 6.3 mEq/L. To best evaluate the
effectiveness of the medications, the nurse will
a. monitor the patient's electrocardiograph (ECG).
b. check the blood glucose level.
c. obtain serum potassium levels.
d. assess BUN and creatinine levels.
A patient in ARF has a gradual increase in urinary
output to 3400 ml a day with a BUN of 92 mg/dl (33
mmol/L) and a serum creatinine of 4.2 mg (371
μmol/L). The nurse should plan to
a. use a urine dipstick to monitor for proteinuria.
b. auscultate the lungs to assess for pulmonary
edema.
c. take the blood pressure to check for hypotension.
d. draw blood to monitor for hyperkalemia.
After noting increasing QRS intervals in a patient
with ARF, which action should the nurse take first?
a. Notify the patient's health care provider.
b. Check the chart for the most recent blood
potassium level.
c. Look at the patient's current BUN and creatinine
levels.
d. Document the QRS interval.
A patient with renal insufficiency is scheduled for an
intravenous pyelogram (IVP). Which of the
following orders for the patient will the nurse
question?
a. Ibuprofen (Advil) 400 mg PO PRN for pain
b. Dulcolax suppository 4 hours before IVP
procedure
c. Normal saline 500 ml IV before procedure
d. NPO for 6 hours before IVP procedure
Before administering sodium polystyrene sulfonate
(Kayexalate) to a patient with hyperkalemia, the
nurse should assess
a. the BUN and creatinine.
b. the blood glucose level.
c. the patient's bowel sounds.
d. the level of consciousness (LOC).
In the immediate postoperative period, the nurse
caring for a patient who is a recipient of a kidney
transplant would expect that fluid therapy would
involve administration of IV fluids
a. to be determined hourly, based on every milliliter
of urine output.
b. at a minimum rate of 100 ml/hr to perfuse the
kidney.
c. titrated to keep blood pressure within a normal
range.
d. at a rate to keep urine clear and without blood
clots.
To monitor for corticosteroid-related complications
after a kidney transplant, the nurse teaches the
patient to report
a. pain at the donor kidney site.
b. dizziness with position change.
c. pain in the hips, knees, and other joints.
d. changes in the character of the urine.

Two hours after a kidney transplant, the nurse
obtains the following pieces of data when
assessing the patient. Which information is most
important to communicate to the health care
provider?
a. The BUN and creatinine levels are elevated.
b. The urine output is 900 to 1100 ml/hr.
c. The patient's central venous pressure (CVP) is
decreased.
d. The patient has level 8 (on a 10-point scale)
incision pain when coughing.
Which data obtained when assessing a patient who
had a kidney transplant 8 years ago and who is
receiving the immunosuppressants tacrolimus
(Prograf), cyclosporine (Sandimmune), and
prednisone (Deltasone) will be of most concern to
the nurse?
a. The blood glucose is 144 mg/dl.
b. The patient has a round, moonlike face.
c. There is a nontender lump in the axilla.
d. The patient's blood pressure is 150/92.
A client has just received a renal transplant and has
started cyclosporine therapy to prevent graft
rejection. Which of the following conditions is a
major complication of this drug therapy?
1) Depression
2) Hemorrhage
3) Infection
4) Peptic ulcer disease
A client received a kidney transplant 2 months ago.
He's admitted to the hospital with the diagnosis of
acute rejection. Which of the following assessment
findings would be expected?
1) Hypotension
2) Normal body temperature
3) Decreased WBC count
4) Elevated BUN and creatinine levels
The client is to undergo kidney transplantation with
a living donor. Which of the following preoperative
assessments is important?
1) Urine output
2) Signs of graft rejection
3) Signs and symptoms of rejection
4) Client's support system and understanding of
lifestyle changes.
Which of the following symptoms indicate acute
rejection of a transplanted kidney?
1) Edema, nausea
2) Fever, anorexia
3) Weight gain, pain at graft site
4) Increased WBC count, pain with voiding
Adverse reactions of prednisone therapy include
which of the following conditions?
1) Acne and bleeding gums
2) Sodium retention and constipation
3) Mood swings and increased temperature
4) Increased blood glucose levels and decreased
wound healing.
The nurse is caring for a client following a kidney
transplant. The client develops oliguria. Which of
the following would the nurse anticipate to be
prescribed as the treatment of oliguria?
1) Encourage fluid intake
2) Administration of diuretics
3) Irrigation of foley catheter
4) Restricting fluids
A hospitalized patient is in the oliguric phase of
acute renal failure. The nurse should implement
which of the following?
Select all that apply.
A. Keep strict intake and output records.
B. Closely monitor potassium levels.
C. Administer dopamine to increase renal
perfusion.
D. Limit fluid intake.
E. Administer laxatives to prevent fluid overload.
A patient has developed acute renal failure (ARF)
with a 24-hour urine output of 350 mL. The nurse
should assess the patient for:
Pruritus
Polyphagia
Cardiac arrhythmias
Tetany
For a male client in the oliguric phase of acute renal
failure (ARF), which nursing intervention is most
important?
A. Encouraging coughing and deep breathing
B. Promoting carbohydrate intake
C. Limiting fluid intake
D. Providing pain-relief measures
The nurse is reviewing laboratory results on a client
with acute renal failure. Which one of the following
should be reported IMMEDIATELY?
a. Blood urea nitrogen 50 mg/dl
b. Hemoglobin of 10.3 mg/dl
c. Venous blood pH 7.30
d. Serum potassium 6 mEq/L
A client with acute renal failure moves into the
diuretic phase after 1 week of therapy. During this
phase, the client must be assessed for signs of
developing:
a. Renal failure
b. Hypovolemia
c. Hyperkalemia
d. Metabolic acidosis
A male client develops acute renal failure (ARF)
after receiving I.V. therapy with a nephrotoxic
antibiotic. Because the client's 24-hour urine output
totals 240 ml, nurse Andy suspects that the client is
at risk for:
a. cardiac arrhythmia.
b. paresthesia.
c. dehydration.
d. pruritus.
A hospitalized patient is in the oliguric phase of
acute renal failure. The nurse should implement
which of the following interventions?
A. Administer laxatives to prevent fluid overload
B. Limit fluid intake
C. Closely monitor hemoglobin level
D. Administer dopamine to increase renal perfusion
1.5 Stroke
1. A patient is admitted with uncontrolled atrial
fibrillation. The patient’s medication history includes
vitamin D supplements and calcium. What type of
stroke is this patient at MOST risk for?
A. Ischemic thrombosis
B. Ischemic embolism
C. Hemorrhagic
D. Ischemic stenosis
2. Which patient below is at most risk for a
hemorrhagic stroke?
A. A 65 year old male patient with carotid stenosis.
B. A 89 year old female with atherosclerosis.
C. A 88 year old male with uncontrolled
hypertension and a history of brain aneurysm repair
2 years ago.
D. A 55 year old female with atrial flutter.
3. You're educating a patient about transient
ischemic attacks (TIAs). Select all the options that
are incorrect about this condition:
A. TIAs are caused by a temporary decrease in
blood flow to the brain.
B. TIAs produce signs and symptoms that can last
for several weeks to months.
C. A TIAs is a warning sign that an impending
stroke may occur.
D. TIAs don't require medical treatment.
4. A patient who suffered a stroke one month ago is
experiencing hearing problems along with issues
learning and showing emotion. On the MRI what
lobe in the brain do you expect to be affected?
A. Frontal lobe
B. Occipital lobe
C. Parietal lobe
D. Temporal
5. A patient's MRI imaging shows damage to the
cerebellum a week after the patient suffered a
stroke. What assessment findings would correlate
with this MRI finding?
A. Vision problems
B. Balance impairment
C. Language difficulty
D. Impaired short-term memory
6. A patient is demonstrating signs and symptoms
of stroke. The patient reports loss of vision. What
area of the brain do you suspect is affected based
on this finding?
A. Brain stem
B. Hippocampus
C. Parietal lobe
D. Occipital lobe
7. A patient has right side brain damage from a B. Don't repeat questions.
stroke. Select all the signs and symptoms that C. Ask questions that require a simple response.
occur with this type of stroke: D. Use a communication board.
A. Right side hemiplegia E. Discourage the patient from using words.
B. Confusion on date, time, and place
C. Aphasia 12. While conversing with a patient who had a
D. Unilateral neglect stroke six months ago, you note their speech is
E. Aware of limitations hard to understand and slurred. This is known as:
F. Impulsive A. Dysarthria
G. Short attention span B. Apraxia
H. Agraphia C. Alexia
D. Dysphagia
8. You're educating a group of nursing students
about left side brain damage. Select all the signs 13. You're reading the physician’s history and
and symptoms noted with this type of stroke: physical assessment report. You note the physician
A. Aphasia wrote that the patient has apraxia. What
B. Denial about limitations assessment finding in your morning assessment
C. Impaired math skills correlates with this condition?
D. Issues with seeing on the right side A. The patient is unable to read.
E. Disoriented B. The patient has limited vision in half of the visual
F. Depression and anger field.
G. Impulsive C. The patient is unable to wink or move his arm to
H. Agraphia scratch his skin.
D. The patient doesn't recognize a pencil or
television.
9. During discharge teaching for a patient who
experienced a mild stroke, you are providing details 14. You need to obtain informed consent from a
on how to eliminate risk factors for experiencing patient for a procedure. The patient experienced a
another stroke. Which risk factors below for stroke stroke three months ago. The patient is unable to
are modifiable? sign the consent form because he can't write. This
A. Smoking is known as what:
B. Family history A. Agraphia
C. Advanced age B. Alexia
D. Obesity C. Hemianopia
E. Sedentary lifestyle D. Apraxia

10. Your patient who had a stroke has issues with 15. You're assessing your patient's pupil size and
understanding speech. What type of aphasia is this vision after a stroke. The patient says they can only
patient experiencing and what area of the brain is see half of the objects in the room. You document
affected? this finding as:
A. Expressive; Wernicke's area A. Hemianopia
B. Receptive, Broca's area B. Opticopsia
C. Expressive; hippocampus C. Alexia
D. Receptive; Wernicke's area D. Dysoptic

11. Your patient has expressive aphasia. Select all 16. A patient who has hemianopia is at risk for
the ways to effectively communicate with this injury. What can you educate the patient to perform
patient? regularly to prevent injury?
A. Fill in the words for the patient they can't say. A. Wearing anti-embolism stockings daily
B. Consume soft foods and tuck in chin while
swallowing
C. Scanning the room from side to side frequently
D. Muscle training
17. You receive a patient who is suspected of
experiencing a stroke from EMS. You conduct a
stroke assessment with the NIH Stroke Scale. The
patient scores a 40. According to the scale, the
result is:
A. No stroke symptoms
B. Severe stroke symptoms
C. Mild stroke symptoms
D. Moderate stroke symptoms
18. In order for tissue plasminogen activator (tPA)
to be most effective in the treatment of stroke, it
must be administered?
A. 6 hours after the onset of stroke symptoms
B. 3 hours before the onset of stroke symptoms
C. 3 hours after the onset of stroke symptoms
D. 12 hours before the onset of stroke symptoms
19. Which patients are NOT a candidate for tissue
plasminogen activator (tPA) for the treatment of
stroke?
A. A patient with a CT scan that is negative.
B. A patient whose blood pressure is 200/110.
C. A patient who is showing signs and symptoms of
ischemic stroke.
D. A patient who received Heparin 24 hours ago.
20. You're assisting a patient who has right side
hemiparesis and dysphagia with eating. It is very
important to:
A. Keep the head of bed less than 30'.
B. Check for pouching of food in the right cheek.
C. Prevent aspiration by thinning the liquids.
D. Have the patient extend the neck upward away
from the chest while eating.
21. A patient has experienced right side brain
damage. You note the patient is experiencing
neglect syndrome. What nursing intervention will
you include in the patient's plan of care?
A. Remind the patient to use and touch both sides
of the body daily.
B. Offer the patient a soft mechanical diet with
honey thick liquids.
C. Ask direct questions that require one word
responses.
D. Offer the bedpan and bedside commode every 2
hours.
The nurse is caring for a patient with a history of
transient ischemic attacks (TIAs) and moderate
carotid stenosis who has undergone a carotid
endarterectomy. Which of the following
postoperative findings would cause the nurse the
most concern?
a) Blood pressure (BP): 128/86 mm Hg
b) Neck pain: 3/10 (0 to 10 pain scale)
c) Mild neck edema
d) Difficulty swallowing
An emergency department nurse is interviewing a
client with signs of an ischemic stroke that began 2
hours ago. The client reports that she had a
cholecystectomy 6 weeks ago and is taking digoxin,
coumadin, and labetelol. This client is not eligible
for thrombolytic therapy for which of the following
reasons?
a) She is not within the treatment time window.
b) She had surgery 6 weeks ago.
c) She is taking digoxin.
d) She is taking coumadin.
Which disturbance results in loss of half of the
visual field?
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia
A client with a cerebrovascular accident (CVA) is
having difficulty with eating food on the plate.
Which is the best nursing action to be taken?
a) Reposition the tray and plate.
b) Perform a vision field assessment.
c) Know this is a normal finding for CVA.
d) Assist the client with feeding.
A client is hospitalized when they present to the
Emergency Department with right-sided weakness.
Within 6 hours of being admitted, the neurologic
deficits had resolved and the client was back to
their presymptomatic state. The nurse caring for the
client knows that the probable cause of the
neurologic deficit was what?
a) Cerebral aneurysm
b) Transient ischemic attack
c) Left-sided stroke
d) Right-sided stroke
Which of the following terms refer to the failure to
recognize familiar objects perceived by the senses?
a) Agnosia
b) Perseveration
c) Apraxia
d) Agraphia
During a class on stroke, a junior nursing student
asks what the clinical manifestations of stroke are.
What would be the instructor's best answer?
a) "Clinical manifestations of a stroke depend on
the area of the cortex, the affected hemisphere, the
degree of blockage, and the availability of collateral
circulation."
b) "Clinical manifestations of a stroke generally
include aphasia, one-sided flaccidity, and trouble
swallowing."
c) "Clinical manifestations of a stroke depend on
how quickly the clot can be dissolved."
d) "Clinical manifestations of a stroke are highly
variable, depending on the cardiovascular health of
the client."
When communicating with a client who has sensory
(receptive) aphasia, the nurse should:
a) speak loudly and articulate clearly.
b) allow time for the client to respond.
c) give the client a writing pad.
d) use short, simple sentences.
The nurse is providing information about strokes to
a community group. Which of the following would
the nurse identify as the primary initial symptoms of
an ischemic stroke?
a) Footdrop and external hip rotation
b) Vomiting and seizures
c) Severe headache and early change in level of
consciousness
d) Weakness on one side of the body and difficulty
with speech
Which of the following insults or abnormalities can
cause an ischemic stroke?
a) Arteriovenous malformation
b) Intracerebral aneurysm rupture
c) Cocaine use
d) Trauma
A nurse is working with a student nurse who is
caring for a client with an acute bleeding cerebral
aneurysm. Which action by the student nurse
requires further intervention?
a) Maintaining the client in a quiet environment
b) Keeping the client in one position to decrease
bleeding
c) Positioning the client to prevent airway
obstruction
d) Administering I.V. fluid as ordered and
monitoring the client for signs of fluid volume
excess
The nurse is caring for a patient with aphasia.
Which of the following strategies will the nurse use
to facilitate communication with the patient?
a) Speaking in complete sentences
b) Speaking loudly
c) Avoiding the use of hand gestures
d) Establishing eye contact
While providing information to a community group,
the nurse tells them the primary initial symptoms of
a hemorrhagic stroke are:
a) Footdrop and external hip rotation
b) Severe headache and early change in level of
consciousness
c) Weakness on one side of the body and difficulty
with speech
d) Confusion or change in mental status
A client is admitted with weakness, expressive
aphasia, and right hemianopia. The brain MRI
reveals an infarct. The nurse understands these
symptoms to be suggestive of which of the
following findings?
a) Left-sided cerebrovascular accident (CVA)
b) Right-sided cerebrovascular accident (CVA)
c) Transient ischemic attack (TIA)
d) Completed Stroke
A nurse is caring for a client who has returned to
his room after a carotid endarterectomy. Which
action should the nurse take first?
a) Take the client's blood pressure.
b) Ask the client if he has a headache.
c) Ask the client if he has trouble breathing.
d) Place antiembolism stockings on the client.
The nurse is caring for a patient with dysphagia.
Which of the following interventions would be
contraindicated while caring for this patient?
a) Allowing ample time to eat
b) Assisting the patient with meals
c) Testing the gag reflex prior to offering food or
fluids
d) Placing food on the affected side of mouth
A 64-year-old client reports symptoms consistent
with a transient ischemic attack (TIA) to the
physician in the emergency department. After
completing ordered diagnostic tests, the physician
indicates to the client what caused the symptoms
that brought him to the hospital. What is the origin
of the client's symptoms?
a) Hypertension
b) Cardiac disease
c) Diabetes insipidus
d) Impaired cerebral circulation
A client is admitted to the intensive care unit (ICU)
with a diagnosis of cerebrovascular accident (CVA).
Which assessment by the nurse provides the most
significant finding in differentiating between
ischemic and hemorrhagic strokes?
a) Oropharyngeal suctioning as needed.
b) Kepprais ordered for treatment of focal seizures.
c) A unit of fresh frozen plasma is infusing.
d) Neurological checks are ordered every 2 hours.
The nurse is caring for a patient with aphasia.
Which of the following strategies will the nurse use
to facilitate communication with the patient?
a) Avoiding the use of hand gestures
b) Establishing eye contact
c) Speaking in complete sentences
d) Speaking loudly
The provider diagnoses the patient as having had
an ischemic stroke. The etiology of an ischemic
stroke would include which of the following?
a) Cerebral aneurysm
b) Cardiogenic emboli
c) Intracerebral hemorrhage
d) Arteriovenous malformation
A patient is in the acute phase of an ischemic
stroke. How long does the nurse know that this
phase may last?
a) Up to 1 week
b) Up to 24 hours
c) 1 to 3 days
d) Up to 2 weeks
Which of the following terms refer to the inability to
perform previously learned purposeful motor acts
on a voluntary basis?
a) Agraphia
b) Perseveration
c) Agnosia
d) Apraxia
A nurse is working with a student nurse who is
caring for a client with an acute bleeding cerebral
aneurysm. Which action by the student nurse
requires further intervention?
a) Maintaining the client in a quiet environment
b) Positioning the client to prevent airway
obstruction
c) Keeping the client in one position to decrease
bleeding
d) Administering I.V. fluid as ordered and
monitoring the client for signs of fluid volume
excess
A client has experienced an ischemic stroke that
has damaged the lower motor neurons of the brain.
Which of the following deficits would the nurse
expect during assessment?
a) Limited attention span and forgetfulness
b) Visual agnosia
c) Auditory agnosia
d) Lack of deep tendon reflexes
A nurse knows that, for a patient with an ischemic
stroke, tPA is contraindicated if the blood pressure
reading is:
a) 170 mm Hg/105 mm Hg
b) 185 mm Hg/110 mm Hg
c) 190 mm Hg/120 mm Hg
d) 175 mm Hg/100 mm Hg
A patient who has suffered a stroke begins having
complications regarding spasticity in the lower
extremity. What ordered medication does the nurse
administer to help alleviate this problem?
a) Pregabalin (Lyrica)
b) Diphenhydramine (Benadryl)
c) Heparin
d) Lioresal (Baclofen)
A patient diagnosed with a stroke is ordered to
receive warfarin (Coumadin). Later, the nurse
learns that the warfarin is contraindicated and the
order is canceled. The nurse knows that the best
alternative medication to give is which of the
following?
a) Ticlodipine (Ticlid)
b) Dipyridamole (Persantine)
c) Clopidogrel (Plavix)
d) Aspirin
Which of the following is the most common side
effect of tissue plasminogen activator (tPA)?
a) Increased intracranial pressure (ICP)
b) Hypertension
c) Headache
d) Bleeding
Which of the following antiseizure medication has
been found to be effective for post-stroke pain?
a) Carbamazepine (Tegretol)
b) Lamotrigine (Lamictal)
c) Topiramate (Topamax)
d) Phenytoin (Dilantin)
The nurse practitioner advises a patient who is at
high risk for a stroke to be vigilant in his medication
regime, to maintain a healthy weight, and to adopt
a reasonable exercise program. This advice is
based on research data that shows the most
important risk factor for stroke is:
a) Dyslipidemia
b) Obesity
c) Hypertension
d) Smoking
While providing information to a community group,
the nurse tells them the primary initial symptoms of
a hemorrhagic stroke are:
a) Footdrop and external hip rotation
b) Severe headache and early change in level of
consciousness
c) Confusion or change in mental status
d) Weakness on one side of the body and difficulty
with speech
A client is admitted with weakness, expressive
aphasia, and right hemianopia. The brain MRI
reveals an infarct. The nurse understands these
symptoms to be suggestive of which of the
following findings?
a) Left-sided cerebrovascular accident (CVA)
b) Completed Stroke
c) Transient ischemic attack (TIA)
d) Right-sided cerebrovascular accident (CVA)
A physician orders several drugs for a client with
hemorrhagic stroke. Which drug order should the
nurse question?
a) Phenytoin (Dilantin)
b) Methyldopa (Aldomet)
c) Heparin sodium
d) Dexamethasone (Decadron)
A patient presents to the emergency room with
complaints of having an "exploding headache" for
the last 2 hours. The patient is immediately seen by
a triage nurse who suspects the patient is
experiencing a stroke. Which of the following is a
possible cause based on the characteristic
symptom?
a) Cerebral aneurysm
b) Cardiogenic emboli
c) Large artery thrombosis
d) Small artery thrombosis
Which of the following is accurate regarding a
hemorrhagic stroke?
a) It is caused by a large-artery thrombosis.
b) One of the main presenting symptoms is
numbness or weakness of the face.
c) Main presenting symptom is an "exploding
headache."
d) Functional recovery usually plateaus at 6
months.
A 73-year-old client is visiting the neurologist. The
client reports light-headedness, speech
disturbance, and left-sided weakness that have
lasted for several hours. In the examination, an
abnormal sound is auscultated in an artery leading
to the brain. What is the term for the auscultated
discovery?
a) Atherosclerotic plaque
b) TIA
c) Diplopia
d) Bruit
Which of the following statements reflect nursing
management of the patient with expressive
aphasia?
a) Frequently reorient the patient to time, place,
and situation
b) Speak clearly to the patient in simple sentences,
use gestures or pictures when able
c) Speak slowly and clearly to assist the patient in
forming the sounds
d) Encourage the patient to repeat sounds of the
alphabet
Which of the following is the initial diagnostic test
for a stroke?
a) Noncontrast CT scan
b) Transcranial Doppler studies
c) ECG
d) Carotid Doppler
A patient has been diagnosed as having global
aphasia. The nurse recognizes that the patient will
be unable to do which of the following actions?
a) Form words that are understandable
b) Speak at all
c) Form words that are understandable or
comprehend the spoken word
d) Comprehend the spoken word
A patient is admitted via ambulance to the
emergency room of a stroke center at 1:30 p.m.
with symptoms that the patient said began at 1:00
p.m. Within 1 hour, an ischemic stroke had been
confirmed and the doctor ordered tPA. The nurse
knows to give this drug no later than what time?
a) 5:30 p.m.
b) 3:00 p.m.
c) 4:00 p.m.
d) 2:30 p.m.
The nurse is providing diet-related advice to a male
patient following a cerebrovascular accident (CVA).
The patient wants to minimize the volume of food
and yet meet all nutritional elements. Which of the
following suggestions should the nurse give to the
patient about controlling the volume of food intake?
a) Provide a high-fat diet.
b) Include dry or crisp foods and chewy meats.
c) Always serve hot or tepid foods.
d) Provide thickened commercial beverages and
fortified cooked cereals.
A client is receiving an I.V. infusion of mannitol
(Osmitrol) after undergoing intracranial surgery to
remove a brain tumor. To determine whether this
drug is producing its therapeutic effect, the nurse
should consider which finding most significant?
a) Elevated blood pressure
b) Decreased level of consciousness (LOC)
c) Increased urine output
d) Decreased heart rate
Which of the following is a contraindication for the
administration of tissue plasminogen activator
(t-PA)?
a) Systolic blood pressure less than or equal to 185
mm Hg
b) Ischemic stroke
c) Intracranial hemorrhage
d) Age 18 years of age or older
1. A patient has had an ischemic stroke and has
been admitted to the medical unit. What action
should the nurse perform to best prevent joint
deformities?
A) Place the patient in the prone position for 30
minutes/day.
B) Assist the patient in acutely flexing the thigh to
promote movement.
C) Place a pillow in the axilla when there is limited
external rotation.
D) Place patient's hand in pronation.

A patient diagnosed with transient ischemic attacks
(TIAs) is scheduled for a carotid endarterectomy.
The nurse explains that this procedure will be done
for what purpose?
A) To decrease cerebral edema
B) To prevent seizure activity that is common
following a TIA
C) To remove atherosclerotic plaques blocking
cerebral flow
D) To determine the cause of the TIA
The nurse is discharging home a patient who
suffered a stroke. He has a flaccid right arm and leg
and is experiencing problems with urinary
incontinence. The nurse makes a referral to a home
health nurse because of an awareness of what
common patient response to a change in body
image?
A) Denial
B) Fear
C) Depression
D) Disassociation
When caring for a patient who had a hemorrhagic
stroke, close monitoring of vital signs and
neurologic changes is imperative. What is the
earliest sign of deterioration in a patient with a
hemorrhagic stroke of which the nurse should be
aware?
A) Generalized pain
B) Alteration in level of consciousness (LOC)
C) Tonic-clonic seizures
D) Shortness of breath
The nurse is performing stroke risk screenings at a
hospital open house. The nurse has identified four
patients who might be at risk for a stroke. Which
patient is likely at the highest risk for a hemorrhagic
stroke?
A) White female, age 60, with history of excessive
alcohol intake
B) White male, age 60, with history of uncontrolled
hypertension
C) Black male, age 60, with history of diabetes
D) Black male, age 50, with history of smoking
A patient who just suffered a suspected ischemic
stroke is brought to the ED by ambulance. On what
should the nurse's primary assessment focus?
A) Cardiac and respiratory status
B) Seizure activity
C) Pain
D) Fluid and electrolyte balance
A patient with a cerebral aneurysm exhibits signs
and symptoms of an increase in intracranial
pressure (ICP). What nursing intervention would be
most appropriate for this patient?
A) Range-of-motion exercises to prevent
contractures
B) Encouraging independence with ADLs to
promote recovery
C) Early initiation of physical therapy
D) Absolute bed rest in a quiet, nonstimulating
environment
A patient recovering from a stroke has severe
shoulder pain from subluxation of the shoulder and
is being cared for on the unit. To prevent further
injury and pain, the nurse caring for this patient is
aware of what principle of care?
A) The patient should be fitted with a cast because
use of a sling should be avoided due to adduction
of the affected shoulder.
B) Elevation of the arm and hand can lead to
further complications associated with edema.
C) Passively exercising the affected extremity is
avoided in order to minimize pain.
D) The patient should be taught to interlace fingers,
place palms together, and slowly bring scapulae
forward to avoid excessive force to shoulder.
The patient has been diagnosed with aphasia after
suffering a stroke. What can the nurse do to best
make the patient's atmosphere more conducive to
communication?
A) Provide a board of commonly used needs and
phrases.
B) Have the patient speak to loved ones on the
phone daily.
C) Help the patient complete his or her sentences.
D) Speak in a loud and deliberate voice to the
patient.
The nurse is assessing a patient with a suspected
stroke. What assessment finding is most
suggestive of a stroke?
A) Facial droop
B) Dysrhythmias
C) Periorbital edema
D) Projectile vomiting
The nurse is caring for a patient diagnosed with an
ischemic stroke and knows that effective
positioning of the patient is important. Which of the
following should be integrated into the patient's
plan of care?
A) The patient's hip joint should be maintained in a
flexed position.
B) The patient should be in a supine position unless
ambulating.
C) The patient should be placed in a prone position
for 15 to 30 minutes several times a day.
D) The patient should be placed in a Trendelenberg
position two to three times daily to promote cerebral
perfusion.
A patient has been admitted to the ICU after being
recently diagnosed with an aneurysm and the
patient's admission orders include specific
aneurysm precautions. What nursing action will the
nurse incorporate into the patient's plan of care?
A) Elevate the head of the bed to 45 degrees.
B) Maintain the patient on complete bed rest.
C) Administer enemas when the patient is
constipated.
D) Avoid use of thigh-high elastic compression
stockings.
A nurse is caring for a patient diagnosed with a
hemorrhagic stroke. When creating this patient's
plan of care, what goal should be prioritized?
A) Prevent complications of immobility.
B) Maintain and improve cerebral tissue perfusion.
C) Relieve anxiety and pain.
D) Relieve sensory deprivation.
The nurse is preparing health education for a
patient who is being discharged after hospitalization
for a hemorrhagic stroke. What content should the
nurse include in this education?
A) Mild, intermittent seizures can be expected.
B) Take ibuprofen for complaints of a serious
headache.
C) Take antihypertensive medication as ordered.
D) Drowsiness is normal for the first week after
discharge.
A patient diagnosed with a cerebral aneurysm
reports a severe headache to the nurse. What
action is a priority for the nurse?
A) Sit with the patient for a few minutes.
B) Administer an analgesic.
C) Inform the nurse-manager.
D) Call the physician immediately.
A patient is brought by ambulance to the ED after
suffering what the family thinks is a stroke. The
nurse caring for this patient is aware that an
absolute contraindication for thrombolytic therapy is
what?
A) Evidence of hemorrhagic stroke
B) Blood pressure of 180/110 mm Hg
C) Evidence of stroke evolution
D) Previous thrombolytic therapy within the past 12
months
When caring for a patient who has had a stroke, a
priority is reduction of ICP. What patient position is
most consistent with this goal?
A) Head turned slightly to the right side
B) Elevation of the head of the bed
C) Position changes every 15 minutes while awake
D) Extension of the neck
A patient who suffered an ischemic stroke now has
disturbed sensory perception. What principle
should guide the nurse's care of this patient?
A) The patient should be approached on the side
where visual perception is intact.
B) Attention to the affected side should be
minimized in order to decrease anxiety.
C) The patient should avoid turning in the direction
of the defective visual field to minimize shoulder
subluxation.
D) The patient should be approached on the
opposite side of where the visual perception is
intact to promote recovery.
What should be included in the patient's care plan
when establishing an exercise program for a patient
affected by a stroke?
A) Schedule passive range of motion every other
day.
B) Keep activity limited, as the patient may be over
stimulated.
C) Have the patient perform active range-of-motion
(ROM) exercises once a day.
D) Exercise the affected extremities passively four
or five times a day.
A female patient is diagnosed with a right-sided
stroke. The patient is now experiencing
hemianopsia. How might the nurse help the patient
manage her potential sensory and perceptional
difficulties?
A) Keep the lighting in the patient's room low.
B) Place the patient's clock on the affected side.
C) Approach the patient on the side where vision is
impaired.
D) Place the patient's extremities where she can
see them.
The public health nurse is planning a health
promotion campaign that reflects current
epidemiologic trends. The nurse should know that
hemorrhagic stroke currently accounts for what
percentage of total strokes in the United States?
A) 43%
B) 33%
C) 23%
D) 13%
A patient who has experienced an ischemic stroke
has been admitted to the medical unit. The patient's
family in adamant that she remain on bed rest to
hasten her recovery and to conserve energy. What
principle of care should inform the nurse's response
to the family?
A) The patient should mobilize as soon as she is
physically able.
B) To prevent contractures and muscle atrophy, bed
rest should not exceed 4 weeks.
C) The patient should remain on bed rest until she
expresses a desire to mobilize.
D) Lack of mobility will greatly increase the patient's
risk of stroke recurrence.
A patient has recently begun mobilizing during the
recovery from an ischemic stroke. To protect the
patient's safety during mobilization, the nurse
should perform what action?
A) Support the patient's full body weight with a
waist belt during ambulation.
B) Have a colleague follow the patient closely with
a wheelchair.
C) Avoid mobilizing the patient in the early morning
or late evening.
D) Ensure that the patient's family members do not
participate in mobilization.
A patient diagnosed with a hemorrhagic stroke has
been admitted to the neurologic ICU. The nurse
knows that teaching for the patient and family
needs to begin as soon as the patient is settled on
the unit and will continue until the patient is
discharged. What will family education need to
include?
A) How to differentiate between hemorrhagic and
ischemic stroke
B) Risk factors for ischemic stroke
C) How to correctly modify the home environment
D) Techniques for adjusting the patient's medication
dosages at home
After a subarachnoid hemorrhage, the patient's
laboratory results indicate a serum sodium level of
less than 126 mEq/L. What is the nurse's most
appropriate action?
A) Administer a bolus of normal saline as ordered.
B) Prepare the patient for thrombolytic therapy as
ordered.
C) Facilitate testing for hypothalamic dysfunction.
D) Prepare to administer 3% NaCl by IV as
ordered.
A community health nurse is giving an educational
presentation about stroke and heart disease at the
local senior citizens center. What nonmodifiable risk
factor for stroke should the nurse cite?
A) Female gender
B) Asian American race
C) Advanced age
D) Smoking
A family member brings the patient to the clinic for
a follow-up visit after a stroke. The family member
asks the nurse what he can do to decrease his
chance of having another stroke. What would be
the nurse's best answer?
A) "Have your heart checked regularly."
B) "Stop smoking as soon as possible."
C) "Get medication to bring down your sodium
levels."
D) "Eat a nutritious diet."
The nurse is reviewing the medication
administration record of a female patient who
possesses numerous risk factors for stroke. Which
of the woman's medications carries the greatest
potential for reducing her risk of stroke?
A) Naproxen 250 PO b.i.d.
B) Calcium carbonate 1,000 mg PO b.i.d.
C) Aspirin 81 mg PO o.d.
D) Lorazepam 1 mg SL b.i.d. PRN
A nurse in the ICU is providing care for a patient
who has been admitted with a hemorrhagic stroke.
The nurse is performing frequent neurologic
assessments and observes that the patient is
becoming progressively more drowsy over the
course of the day. What is the nurse's best
response to this assessment finding?
A) Report this finding to the physician as an
indication of decreased metabolism.
B) Provide more stimulation to the patient and
monitor the patient closely.
C) Recognize this as the expected clinical course of
a hemorrhagic stroke.
D) Report this to the physician as a possible sign of
clinical deterioration.
Following diagnostic testing, a patient has been
admitted to the ICU and placed on cerebral
aneurysm precautions. What nursing action should
be included in patient's plan of care?
A) Supervise the patient's activities of daily living
closely.
B) Initiate early ambulation to prevent complications
of immobility.
C) Provide a high-calorie, low-protein diet.
D) Perform all of the patient's hygiene and feeding.
A preceptor is discussing stroke with a new nurse
on the unit. The preceptor would tell the new nurse
which cardiac dysrhythmia is associated with
cardiogenic embolic strokes?
A) Ventricular tachycardia
B) Atrial fibrillation
C) Supraventricular tachycardia
D) Bundle branch block
The pathophysiology of an ischemic stroke involves
the ischemic cascade, which includes the following
steps:
1. Change in pH
2. Blood flow decreases
3. A switch to anaerobic respiration
4. Membrane pumps fail
5. Cells cease to function
6. Lactic acid is generated
Put these steps in order in which they occur.
A) 635241
B) 352416
C) 236145
D) 162534
As a member of the stroke team, the nurse knows
that thrombolytic therapy carries the potential for
benefit and for harm. The nurse should be
cognizant of what contraindications for thrombolytic
therapy? Select all that apply.
A) INR above 1.0
B) Recent intracranial pathology
C) Sudden symptom onset
D) Current anticoagulation therapy
E) Symptom onset greater than 3 hours prior to
admission
After a major ischemic stroke, a possible
complication is cerebral edema. Nursing care
during the immediate recovery period from an
ischemic stroke should include which of the
following?
A) Positioning to avoid hypoxia
B) Maximizing PaCO2
C) Administering hypertonic IV solution
D) Initiating early mobilization
The nurse is caring for a patient recovering from an
ischemic stroke. What intervention best addresses
a potential complication after an ischemic stroke?
A) Providing frequent small meals rather than three
larger meals
B) Teaching the patient to perform deep breathing
and coughing exercises
C) Keeping a urinary catheter in situ for the full
duration of recovery
D) Limiting intake of insoluble fiber
During a patient's recovery from stroke, the nurse
should be aware of predictors of stroke outcome in
order to help patients and families set realistic
goals. What are the predictors of stroke outcome?
Select all that apply.
A) National Institutes of Health Stroke Scale
(NIHSS) score
B) Race
C) LOC at time of admission
D) Gender
E) Age
A nursing student is writing a care plan for a newly
admitted patient who has been diagnosed with a
stroke. What major nursing diagnosis should most
likely be included in the patient's plan of care?
A) Adult failure to thrive
B) Post-trauma syndrome
C) Hyperthermia
D) Disturbed sensory perception
When preparing to discharge a patient home, the
nurse has met with the family and warned them that
the patient may exhibit unexpected emotional
responses. The nurse should teach the family that
these responses are typically a result of what
cause?
A) Frustration around changes in function and
communication
B) Unmet physiologic needs
C) Changes in brain activity during sleep and
wakefulness
D) Temporary changes in metabolism
A rehabilitation nurse caring for a patient who has
had a stroke is approached by the patient's family
and asked why the patient has to do so much for
herself when she is obviously struggling. What
would be the nurse's best answer?
A) "We are trying to help her be as useful as she
possibly can."
B) "The focus on care in a rehabilitation facility is to
help the patient to resume as much self-care as
possible."
C) "We aren't here to care for her the way the
hospital staff did; we are here to help her get better
so she can go home."
D) "Rehabilitation means helping patients do
exactly what they did before their stroke."
A patient with a new diagnosis of ischemic stroke is
deemed to be a candidate for treatment with tissue
plasminogen activator (t-PA) and has been
admitted to the ICU. In addition to closely
monitoring the patient's cardiac and neurologic
status, the nurse monitors the patient for signs of
what complication?
A) Acute pain
B) Septicemia
C) Bleeding
D) Seizures
1. A nurse is communicating with a client who has
aphasia after having a stroke. Which action should
the nurse take?
a. Use one long sentence to say everything that
needs to be said.
b. Keep the television on while she speaks.
c. Talk in a louder than normal voice.
d. Face the client and establish eye contact.
2. A client who has experienced an initial transient
ischemic attack (TIA) states: "I'm glad it wasn't
anything serious." Which is the best nursing
response to this statement?
a. "I sense that you are happy it was not a stroke".
b. "People who experience a TIA will develop a
stroke".
c. "TIA symptoms are short-lived and resolve within
24 hours".
d. "TIA is a warning sign. Let's talk about lowering
your risks."
3. When caring for a patient who had a
hemorrhagic stroke, close monitoring of vital signs
and neurologic changes is imperative. What is the
earliest sign of deterioration in a patient with a
hemorrhagic stroke of which the nurse should be
aware?
a. Generalized pain
b. Alteration in level of consciousness (LOC)
c. Tonic-clonic seizures
d. Shortness of breath
4. When caring for a patient who has had a stroke,
a priority is reduction of ICP. What patient position
is most consistent with this goal?
a. Head turned slightly to the right side
b. Elevation of the head of the bed
c. Position changes every 15 minutes while awake
d. Extension of the neck
5. A patient diagnosed with an ischemic stroke
should be treated within the first 3 hours of
symptom onset with which of the following?
a. Clopidogrel
b. Extended release dipyridamole
c. Tissue plasminogen activator (tPA)
d. Atorvastatin
6. A nurse is assisting with a community screening
for people at high risk for stroke. To which of the
following clients would the nurse pay most
attention?
a. A 60-year-old African-American man
b. A 40-year-old Caucasian woman
c. A 62-year-old Caucasian woman
d. A 28-year-old pregnant African-American woman
7. The nurse is reviewing the medication
administration record of a female patient who
possesses numerous risk factors for stroke. Which
of the woman's medications carries the greatest
potential for reducing her risk of stroke?
a. Naproxen 250 PO b.i.d.
b. Calcium carbonate 1,000 mg PO b.i.d.
c. Aspirin 81 mg PO o.d.
d. Lorazepam 1 mg SL b.i.d. PRN
8. A nurse in the ICU is providing care for a patient
who has been admitted with a hemorrhagic stroke.
The nurse is performing frequent neurologic
assessments and observes that the patient is
becoming progressively more drowsy over the
course of the day. What is the nurse's best
response to this assessment finding?
a. Report this finding to the physician as an
indication of decreased metabolism.
b. Provide more stimulation to the patient and
monitor the patient closely.
c. Recognize this as the expected clinical course of
a hemorrhagic stroke.
d. Report this to the physician as a possible sign of
clinical deterioration.
9. An emergency department nurse is interviewing
a client with signs of an ischemic stroke that began
2 hours ago. The client reports that she had a
cholecystectomy 6 weeks ago and is taking digoxin,
coumadin, and labetelol. This client is not eligible
for thrombolytic therapy for which of the following
reasons?
a. She is taking coumadin.
b. She is not within the treatment time window.
c. She is taking digoxin.
d. She had surgery 6 weeks ago
10. From which direction should a nurse approach
a client who is blind in the right eye?
a. From directly in front of the client
b. From the right side of the client
c. From the left side of the client
d. From directly behind the client
11. Which of the following is a contraindication for
the administration of tissue plasminogen activator
(t-PA)?
a. Intracranial hemorrhage
b. Ischemic stroke
c. Age 18 years of age or older
d. Systolic blood pressure less than or equal to 185
mm Hg
12. A client with a history of atrial fibrillation has
experienced a TIA. In an effort to reduce the risk of
cerebrovascular accident (CVA), the nurse
anticipates the medical treatment to include which
of the following?
a. Cholesterol-lowering drugs
b. Anticoagulant therapy
c. Monthly prothrombin levels
d. Carotid endarterectomy
13. A patient is exhibiting classic signs of a
hemorrhagic stroke. What complaint from the
patient would be an indicator of this type of
stroke13%
a. Numbness of an arm or leg
b. Double vision
c. Severe headache
d. Dizziness and tinnitus
14. A 154-pound woman has been prescribed tPA
(0.9 mg/kg) for an ischemic stroke. The nurse
knows to give how many mg initially?
a. 6.3 mg
b. 7.5 mg
c. 8.3 mg
d. 10 mg
15. What clinical manifestations does the nurse
recognize when a patient has had a right
hemispheric stroke?
a. Left visual field deficit
b. Aphasia
c. Slow, cautious behavior
d. Altered intellectual ability
16. A physician orders several drugs for a client
with hemorrhagic stroke. Which drug order should
the nurse question?
a. Heparin sodium
b. Dexamethasone (Decadron)
c. Methyldopa (Aldomet)
d. Phenytoin (Dilantin)
17. The nurse is caring for a patient diagnosed with
a hemorrhagic stroke. The nurse recognizes that
which of the following interventions is most
important?
a. Elevating the head of the bed at 30 degrees
b. Monitoring for seizure activity
c. Administering a stool softener
d. Maintaining a patent airway
18. The nurse is performing stroke risk screenings
at a hospital open house. The nurse has identified
four patients who might be at risk for a stroke.
Which patient is likely at the highest risk for a
hemorrhagic stroke?
a. White female, age 60, with history of excessive
alcohol intake
b. White male, age 60, with history of uncontrolled
hypertension
c. Black male, age 60, with history of diabetes
d. Black male, age 50, with history of smoking
19. A patient who has suffered a stroke begins
having complications regarding spasticity in the
lower extremity. What ordered medication does the
nurse administer to help alleviate this problem?
a. Diphenhydramine (Benadryl)
b. Lioresal (Baclofen)
c. Heparin
d. Pregabalin (Lyrica)
In promoting health maintenance for prevention of
strokes, the nurse understands that the highest risk
for the most common type of stroke is present in
which people?
a. blacks
b. women who smoke
c. persons with hypertension and diabetes
d. those who are obese with high dietary fat intake
a thrombus that develops in a cerebral artery does
not always cause a loss of neurologic function
because
a. the body can dissolve atherosclerotic plaques as
they form
b. some tissues of the brain do not require constant
blood supply to prevent damage
c. circulation via the circle of willis may provide
blood supply to the affected area of the brain
d. neurologic deficits occur only when major
arteries are occluded by thrombus formation
around atherosclerotic plaque
a patient comes to the ED with numbest of the face
and an inability to speak. while the patient awaits
examination, the symptoms disappear and the
patient requests discharge. why should the nurse
emphasize that it is important for the patient to be
treated before leaving
a. the patient has probably experience an
asymptotic lacunar stroke
b. the symptoms are likely to return and progress to
worsening neurologic deficit in the next 24 hours
c. neurologic deficits that are transient occur most
often as a result of small hemorrhages that clot off
d. the patient has probably had a transient ischemic
attack (TIA) which is a sign of progressive
cerebrovascular disease
which statement describe characteristics of a stroke
caused by an intracerebral hemorrhage> (select all
that apply)?
a. carries poor prognosis
b. caused by rupture of a vessel
c. strong association with hypertension The incidence of ischemic stroke in patients with
d. commonly occurs during or after sleep TIAs and other risk factors is reduced with
e. creates a mass that compresses the brain administration of
a. nimodipine (Nimotop)
which type of stroke is associated with endocardial b. furosemide (Lasix)
disorders, has a rapid onset and is likely to occur c. warfarin (Coumadin)
during activity? d. daily low dose aspirin
a. embolic
b. thrombotic
c. intracerebral hemorrhage
d. subarachnoid hemorrhage what is the priority intervention in the ED for the
patient with a stroke?
what primarily determines the neurological a. IV fluid replacement
functions that are affected by a stroke? b. giving osmotic diuretics to reduce cerebral
a. the amount of tissue area involved edema
b. the rapidity of the onset of symptoms c. starting hypothermia to decrease the oxygen
c. the brain area perfused by the affected artery needs of the brain
d. the presence or absence of collateral circulation d.maintaining respiratory function with a patent
airway and oxygen administration
the patient has a lack of comprehension of both
verbal and written language. which type of A diagnosis of a ruptured cerebral aneurysm has
communication difficulty does this patient. have? been made in a patient with manifestations of a
a. dysarthria stroke. The nurse anticipates that treatment options
b. fluent dysphasia that would be evaluated for the patient include
c. receptive aphasia a. hyperventilation therapy
d. expressive aphasia b. surgical clipping of the aneurysm
c. administration of hyperosmotic agents
A patient is admitted to the hospital with a left d. administration of thrombolytic therapy
hemiplegia. To determine the size and location and
to ascertain whether a stroke is ischemic or During the acute phase of a stroke, the nurse
hemorrhagic, the nurse anticipates that the health assesses the patient's vital signs and neurologic
care provider will request a status every 4 hours. A cardiovascular sign that the
a. lumbar puncture nurse would see as the body attempts to increase
b. cerebral angiography cerebral blood flow is
c. MRI a. hypertension
d. CT scan with contrast b. fluid overload
c. cardiac dysrhythmias
A carotid endarterectomy is being considered as a d. S3 and S4 heart sounds
treatment for a patient who has had several TIAs.
The nurse explains to the patient that this surgery During the secondary assessment of a patient with
a. involves intracranial surgery to join a superficial a stroke, what should be included (select all that
extracranial artery to an intracranial artery apply)?
b. is used to restore blood to the brain following an a. gaze
obstruction of a cerebral artery b. sensation
c. is used to open a stenosis in a carotid artery with c. facial palsy
a balloon and stent to restore cerebral circulation d. proprioception
d. involves removing an atherosclerotic plaque in e. current medications
the carotid artery to prevent an impending stroke f. distal motor function

what is a nursing intervention that is indicated for
the patient with hemiplegia?
a. the use of a footboard to prevent plantar flexion
b. immobilization of the affected arm against the
chest with a sling
c. positioning the patient in bed with each joint
lower than the joint proximal to it
d. having the patient perform passive rang of
motion (ROM) of the affected limb with the
unaffected limb
a newly admitted patient diagnosed with a right
sided brain stroke has homonymous hemianopsia.
early in the case of the patient what should the
nurse do ?
a. place objects on the right side within the patients
field of vision
b. approach the patient from the left side to assess
the patients ability to compensate
c. place objects on the left side to assess the
patients ability to compensate
d. patch the affected eye to encourage patient to
turn the head to scan the environments
four days following a stroke, a patient is to start oral
fluids and feedings. before feeding the patient, what
should the nurse do first?
a. check the patient's gag reflex
b. order a soft diet for the paitnet
c. raise the head of the bed to a sitting position
d. assess the patients ability to swallow tiny
amounts of crushed ice
what is an appropriate food for a patient with a
stroke who has mild dysphagia?
a. fruit juices
b. pureed meats
c. scrambled eggs
d. fortified milkshakes
a patients wife asks the nurse why her husband did
not receive the clot-busting medication (tissue
plasminogen activators [tPA]) she has been riding
about. her husband is diagnosed with a
hemorrhagic stroke. what is the best response by
the nurse to the patients wife?
a. " he didn't arrive within the time frame for that
therapy"
b. " not everyone is eligible for this drug. has he
had surgery lately?"
c. "you should discuss the treatment of your
husband with his doctors"
d. "the medication you are talking about dissolves
clots and could cause more bleeding in your
husbands brain"
the rehab nurse assesses the patient, caregiver
and family before planning the rehab program for
this patient. what must be included in this
assessment (select all that apply)?
a. cognitive status of the family
b. patient resources and support
c. physical status of all body systems
d. rehab potential of patient
e. body strength remaining after the stroke
f. patient and caregiver expectation of the rehab
what is an appropriate nursing intervention to
promote communication during rehab of the patient
with aphasia?
a. allow time for the individual to complete their
thoughts
b. use gestures, pic utters, and music to stimulate
patients responses
c. structure statements so that the patient does not
have to respond verbally
d. use flashcards with simple words and pictures to
promote recall of language
A patient with right hemisphere stroke has
unilateral neglect . During the patient's
rehabilitation, it is important for the nurse to
a. avoid positioning the patient on the affected side
b. place all objects for care on the patient's
unaffected side
c. teach the patient to care consciously for the
affected side
d. protect the affected side from injury with pillows
and supports
A patient with a stroke has a right sided hemiplegia.
The nurse prepares family members to help control
behavior changes seen with this type of stroke by
teaching them to
a. ignore undesirable behaviors manifested by the
patient
b. provide directions to the patient verbally in small
steps
c. distract the patient from inappropriate emotional
responses
d. supervise all activities before allowing the patient
to pursue them independently
the nurse can best assist the patient and family in
coping with the long-term effects of a stroke by
doing what?
a. informing family members that the patient will
need assistance with almost all ADLs
b. explain that the patents prestroke behavior will
return as improvement progresses
c. encouraging the patient and family members to
seek assistance from family therapy or stroke
support groups
d. helping the patient and family understand the
significance of residual stroke damage to promote
problem solving and planning
which intervention can the nurse delegate to the
licenses practical nurse when caring for a patient
following an acute stroke
a. assess the patients neurological status
b. assess the patients gag reface before beginning
feeding
c. administer ordered antihypertensives and platelet
inhibitors
d. teach the patients caregivers strategies to
minimize unilateral neglect
1.6 Increased ICP
1. Select the main structures below that play a role
with altering intracranial pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura mater
2. The Monro-Kellie hypothesis explains the
compensatory relationship among the structures in
the skull that play a role with intracranial pressure.
Which of the following are NOT compensatory
mechanisms performed by the body to decrease
intracranial pressure naturally? Select all that apply:
A. Shifting cerebrospinal fluid to other areas of the
brain and spinal cord
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid production
D. Leaking proteins into the brain barrier
3. A patient is being treated for increased
intracranial pressure. Which activities below should
the patient avoid performing?
A. Coughing
B. Sneezing
C. Talking
D. Valsalva maneuver
E. Vomiting
F. Keeping the head of the bed between 30- 35
degrees
4. A patient is experiencing hyperventilation and
has a PaCO2 level of 52. The patient has an ICP of
20 mmHg. As the nurse you know that the PaCO2
level will?
A. cause vasoconstriction and decrease the ICP
B. promote diuresis and decrease the ICP
C. cause vasodilation and increase the ICP
D. cause vasodilation and decrease the ICP
5. You're providing education to a group of nursing
students about ICP. You explain that when cerebral
perfusion pressure falls too low the brain is not
properly perfused and brain tissue dies. A student
asks, "What is a normal cerebral perfusion pressure
level?" Your response is:
A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg
6. Which patient below is at MOST risk for
increased intracranial pressure?
A. A patient who is experiencing severe
hypotension.
B. A patient who is admitted with a traumatic brain
injury.
C. A patient who recently experienced a myocardial
infarction.
D. A patient post-op from eye surgery.
7. A patient with increased ICP has the following
vital signs: blood pressure 99/60, HR 65,
Temperature 101.6 'F, respirations 14, oxygen B. Tachycardia
saturation of 95%. ICP reading is 21 mmHg. Based C. Decrease in pulse pressure
on these findings you would? D. Cheyne-stokes
A. Administered PRN dose of a vasopressor E. Hemiplegia
B. Administer 2 L of oxygen F. Decerebrate posturing
C. Remove extra blankets and give the patient a
cool bath 14. You're maintaining an external ventricular drain.
D. Perform suctioning The ICP readings should be?
A. 5 to 15 mmHg
8. A patient has a ventriculostomy. Which finding B. 20 to 35 mmHg
would you immediately report to the doctor? C. 60 to 100 mmHg
A. Temperature 98.4 'F D. 5 to 25 mmHg
B. CPP 70 mmHg
C. ICP 24 mmHg 15. Which patient below with ICP is experiencing
D. PaCO2 35 Cushing's Triad? A patient with the following:
A. BP 150/112, HR 110, RR 8
9. External ventricular drains monitor ICP and are B. BP 90/60, HR 80, RR 22
inserted where? C. BP 200/60, HR 50, RR 8
A. Subarachnoid space D. BP 80/40, HR 49, RR 12
B. Lateral Ventricle
C. Epidural space 16. The patient has a blood pressure of 130/88 and
D. Right Ventricle ICP reading of 12. What is the patient's cerebral
perfusion pressure, and how do you interpret this
10. Which of the following is contraindicated in a as the nurse?
patient with increased ICP? A. 90 mmHg, normal
A. Lumbar puncture B. 62 mmHg, abnormal
B. Midline position of the head C. 36 mmHg, abnormal
C. Hyperosmotic diuretics D. 56 mmHg, normal
D. Barbiturates medications
17. According to question 16, the patient's blood
11. You're collecting vital signs on a patient with pressure is 130/88. What is the patient's mean
ICP. The patient has a Glascoma Scale rating of 4. arterial pressure (MAP)?
How will you assess the patient's temperature? A. 42
A. Rectal B. 74
B. Oral C. 102
C. Axillary D. 88

12. A patient who experienced a cerebral 18. During the assessment of a patient with
hemorrhage is at risk for developing increased ICP. increased ICP, you note that the patient's arms are
Which sign and symptom below is the EARLIEST extended straight out and toes pointed downward.
indicator the patient is having this complication? You will document this as:
A. Bradycardia A. Decorticate posturing
B. Decerebrate posturing B. Decerebrate posturing
C. Restlessness C. Flaccid posturing
D. Unequal pupil size

13. Select all the signs and symptoms that occur 19. While positioning a patient in bed with
with increased ICP: increased ICP, it important to avoid?
A. Decorticate posturing A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips
20. During the eye assessment of a patient with
increased ICP, you need to assess the
oculocephalic reflex. If the patient has brain stem
damage what response will you find?
A. The eyes will roll down as the head is moved
side to side.
B. The eyes will move in the opposite direction as
the head is moved side to side.
C. The eyes will roll back as the head is moved
side to side.
D. The eyes will be in a fixed mid-line position as
the head is moved side to side.
21. A patient is receiving Mannitol for increased
ICP. Which statement is INCORRECT about this
medication?
A. Mannitol will remove water from the brain and
place it in the blood to be removed from the body.
B. Mannitol will cause water and electrolyte
reabsorption in the renal tubules.
C. When a patient receives Mannitol the nurse
must monitor the patient for both fluid volume
overload and depletion.
D. Mannitol is not for patients who are experiencing
anuria.
22. What assessment finding requires immediate
intervention if found while a patient is receiving
Mannitol?
A. An ICP of 10 mmHg
B. Crackles throughout lung fields
C. BP 110/72
D. Patient complains of dry mouth and thirst
1.7 Diabetic Ketoacidosis
Which of the following is not a sign or symptom of
Diabetic Ketoacidosis?*
A. Positive Ketones in the urine
B. Oliguria
C. Polydipsia
D. Abdominal Pain
A patient is admitted with Diabetic Ketoacidosis.
The physician orders intravenous fluids of 0.9%
Normal Saline and 10 units of intravenous regular
insulin IV bolus and then to start an insulin drip per
protocol. The patient's labs are the following: pH
7.25, Glucose 455, potassium 2.5. Which of the
following is the most appropriate nursing
intervention to perform next?*
A. Start the IV fluids and administer the insulin
bolus and drip as ordered
B. Hold the insulin and notify the doctor of the
potassium level of 2.5
C. Hold IV fluids and administer insulin as ordered
D. Recheck the glucose level
Which patient is MOST likely to develop Diabetic
Ketoacidosis?*
A. A 25 year old female newly diagnosed with
Cushing's Disease taking glucocorticoids.
B. A 36 year old male with diabetes mellitus who
has been unable to eat the past 2 days due to a
gastrointestinal illness and has been unable to take
insulin.
C. A 35 year old female newly diagnosed with Type
2 diabetes.
D. None of the options are correct.
Which of the following statements are INCORRECT
about Diabetic Ketoacidoisis?*
A. Extreme Hyperglycemia that presents with blood
glucose >600 mg/dL
B. Ketones are present in the urine
C. Metabolic acidosis is present with Kussmaul
breathing
D. Potassium levels should be at least 3.3 or higher
during treatment of DKA with insulin therapy
You are providing care to a patient experiencing
diabetic ketoacidosis. The patient is on an insulin
drip and their current glucose level is 300. In
addition to this, the patient also has 5% Dextrose
0.45% NS infusing in the right antecubital vein.
Which of the following patient signs/symptoms
causes concern?*
A. Patient complains of thirst.
B. Patient has a potassium level of 2.3
C. Patient's skin and mucous membranes are dry.
D. Patient is nauseous.
What type of insulin do you expect the doctor to
order for treatment of DKA?*
A. IV Novolog
B. IV Levemir
C. IV NPH
D. IV Regular Insulin
A patient diagnosed with diabetes mellitus is being
discharged home and you are teaching them about
preventing DKA. What statement by the patient
demonstrates they understood your teaching about
this condition?*
A. "I should not be alarmed if ketones are present
in my urine because this is expected during illness."
B. "It is normal for my blood sugar to be 250-350
mg/dL while I'm sick."
C. "I will hold off taking my insulin while I'm sick."
D. "It is important I check my blood glucose every
3-4 hours when I'm sick and consume liquids."
The nurse assisting in the admission of a client with
diabetic ketoacidosis will anticipate the physician
ordering which of the following types of intravenous
solution if the client cannot take any fluids orally? "
a. 0.45% normal saline solution
b. Lactated Ringer's solution
c. 0.9 normal saline solution
d. 5% dextrose in water (D5W
A. 0.45% normal saline solution
Which of the following statements are INCORRECT
about Diabetic Ketoacidosis?
A. Extreme Hyperglycemia that presents with blood
glucose >600 mg/dL
B. Ketones are present in the urine
C. Metabolic acidosis is present with Kussmaul
breathing
D. Potassium levels should be at least 3.3 or higher
during treatment of DKA with insulin therapy
1.8 Extensive Burns
When assessing a patient who spilled hot oil on the
right leg and foot, the nurse notes that the skin is
dry, pale, hard skin. The patient states that the burn
is not painful. What term would the nurse use to
document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction
On admission to the burn unit, a patient with an
approximate 25% total body surface area (TBSA)
burn has the following initial laboratory results: Hct
58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9
mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L
(135 mmol/L). Which action will the nurse anticipate
taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
A patient is admitted to the burn unit with burns to
the head, face, and hands. Initially, wheezes are
heard, but an hour later, the lung sounds are
decreased and no wheezes are audible. What is
the best action for the nurse to take?
a. Encourage the patient to cough and auscultate
the lungs again.
b. Notify the health care provider and prepare for
endotracheal intubation.
c. Document the results and continue to monitor the
patient's respiratory rate.
d. Reposition the patient in high-Fowler's position
and reassess breath sounds.
A patient with severe burns has crystalloid fluid
replacement ordered using the Parkland formula.
The initial volume of fluid to be administered in the
first 24 hours is 30,000 mL. The initial rate of
administration is 1875 mL/hr. After the first 8 hours,
what rate should the nurse infuse the IV fluids?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250 mL/hour
During the emergent phase of burn care, which
assessment will be most useful in determining
whether the patient is receiving adequate fluid
infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output.
A patient has just been admitted with a 40% total
body surface area (TBSA) burn injury. To maintain
adequate nutrition, the nurse should plan to take
which action?
a. Insert a feeding tube and initiate enteral
feedings.
b. Infuse total parenteral nutrition via a central
catheter.
c. Encourage an oral intake of at least 5000 kcal
per day.
d. Administer multiple vitamins and minerals in the
IV solution.
While the patient's full-thickness burn wounds to
the face are exposed, what is the best nursing
action to prevent cross contamination?
a. Use sterile gloves when removing old dressings.
b. Wear gowns, caps, masks, and gloves during all
care of the patient.
c. Administer IV antibiotics to prevent bacterial
colonization of wounds.
d. Turn the room temperature up to at least 70° F
(20° C) during dressing changes.
A nurse is caring for a patient who has burns of the
ears, head, neck, and right arm and hand. The
nurse should place the patient in which position?
a. Place the right arm and hand flexed in a position
of comfort.
b. Elevate the right arm and hand on pillows and
extend the fingers.
c. Assist the patient to a supine position with a
small pillow under the head.
d. Position the patient in a side-lying position with
rolled towel under the neck.
A patient with circumferential burns of both legs
develops a decrease in dorsalis pedis pulse
strength and numbness in the toes. Which action
should the nurse take?
a. Notify the health care provider.
b. Monitor the pulses every 2 hours.
c. Elevate both legs above heart level with pillows.
d. Encourage the patient to flex and extend the toes
on both feet.
Esomeprazole (Nexium) is prescribed for a patient
who incurred extensive burn injuries 5 days ago.
Which nursing assessment would best evaluate the
effectiveness of the medication?
a. Bowel sounds
b. Stool frequency
c. Abdominal distention
d. Stools for occult blood
The nurse is reviewing the medication
administration record (MAR) on a patient with
partial-thickness burns. Which medication is best
for the nurse to administer before scheduled wound
debridement?
a. Ketorolac (Toradol)
b. Lorazepam (Ativan)
c. Gabapentin (Neurontin)
d. Hydromorphone (Dilaudid)
A young adult patient who is in the rehabilitation
phase after having deep partial-thickness face and
neck burns has a nursing diagnosis of disturbed
body image. Which statement by the patient
indicates that the problem is resolving?
a. "I'm glad the scars are only temporary."
b. "I will avoid using a pillow, so my neck will be
OK."
c. "I bet my boyfriend won't even want to look at me
anymore."
d. "Do you think dark beige makeup foundation
would cover this scar on my cheek?"
The nurse caring for a patient admitted with burns
over 30% of the body surface assesses that urine
output has dramatically increased. Which action by
the nurse would best ensure adequate kidney
function?
a. Continue to monitor the urine output.
b. Monitor for increased white blood cells (WBCs).
c. Assess that blisters and edema have subsided.
d. Prepare the patient for discharge from the burn
unit.
A patient with burns covering 40% total body
surface area (TBSA) is in the acute phase of burn
treatment. Which snack would be best for the nurse
to offer to this patient?
a. Bananas
b. Orange gelatin
c. Vanilla milkshake
d. Whole grain bagel
A patient has just arrived in the emergency
department after an electrical burn from exposure
to a high-voltage current. What is the priority
nursing assessment?
a. Oral temperature
b. Peripheral pulses
c. Extremity movement
d. Pupil reaction to light
An employee spills industrial acids on both arms
and legs at work. What is the priority action that the
occupational health nurse at the facility should
take?
a. Remove nonadherent clothing and watch.
b. Apply an alkaline solution to the affected area.
c. Place cool compresses on the area of exposure.
d. Cover the affected area with dry, sterile
dressings.
A patient who has burns on the arms, legs, and
chest from a house fire has become agitated and
restless 8 hours after being admitted to the
hospital. Which action should the nurse take first?
a. Stay at the bedside and reassure the patient.
b. Administer the ordered morphine sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check the oxygen
saturation.
A patient arrives in the emergency department with
facial and chest burns caused by a house fire.
Which action should the nurse take first?
a. Auscultate the patient's lung sounds.
b. Determine the extent and depth of the burns.
c. Infuse the ordered lactated Ringer's solution.
d. Administer the ordered hydromorphone
(Dilaudid).
A patient with extensive electrical burn injuries is
admitted to the emergency department. Which
prescribed intervention should the nurse implement
first?
a. Assess oral temperature.
b. Check a potassium level.
c. Place on cardiac monitor.
d. Assess for pain at contact points.
Eight hours after a thermal burn covering 50% of a
patient's total body surface area (TBSA) the nurse
assesses the patient. Which information would be a
priority to communicate to the health care provider?
a. Blood pressure is 95/48 per arterial line.
b. Serous exudate is leaking from the burns.
c. Cardiac monitor shows a pulse rate of 108.
d. Urine output is 20 mL per hour for the past 2
hours.
Which patient should the nurse assess first?
a. A patient with smoke inhalation who has
wheezes and altered mental status
b. A patient with full-thickness leg burns who has a
dressing change scheduled
c. A patient with abdominal burns who is
complaining of level 8 (0 to 10 scale) pain
d. A patient with 40% total body surface area
(TBSA) burns who is receiving IV fluids at 500
mL/hour
Which patient is most appropriate for the burn unit
charge nurse to assign to a registered nurse (RN)
who has floated from the hospital medical unit?
a. A 34-year-old patient who has a weight loss of
15% from admission and requires enteral feedings.
b. A 67-year-old patient who has blebs under an
autograft on the thigh and has an order for bleb
aspiration
c. A 46-year-old patient who has just come back to
the unit after having a cultured epithelial autograft
to the chest
d. A 65-year-old patient who has twice-daily burn
debridements and dressing changes to
partial-thickness facial burns
A patient who was found unconscious in a burning
house is brought to the emergency department by
ambulance. The nurse notes that the patient's skin
color is bright red. Which action should the nurse
take first?
a. Insert two large-bore IV lines.
b. Check the patient's orientation.
c. Assess for singed nasal hair and dark oral
mucous membranes.
d. Place the patient on 100% oxygen using a
non-rebreather mask.
The nurse is reviewing laboratory results on a
patient who had a large burn 48 hours ago. Which
result requires priority action by the nurse?
a. Hematocrit 53%
b. Serum sodium 147 mEq/L
c. Serum potassium 6.1 mEq/L
d. Blood urea nitrogen 37 mg/dL A patient is brought to the emergency department
from the site of a chemical fire, where he suffered a
The charge nurse observes the following actions burn that involves the epidermis, dermis, and the
being taken by a new nurse on the burn unit. Which muscle and bone of the right arm. On inspection,
action by the new nurse would require an the skin appears charred. Based on these
intervention by the charge nurse? assessment findings, what is the depth of the burn
a. The new nurse uses clean latex gloves when on the patient's arm?
applying antibacterial cream to a burn wound. A) Superficial partial-thickness
b. The new nurse obtains burn cultures when the B) Deep partial-thickness
patient has a temperature of 95.2° F (35.1° C). C) Full partial-thickness
c. The new nurse administers PRN fentanyl D) Full-thickness
(Sublimaze) IV to a patient 5 minutes before a
dressing change. The current phase of a patient's treatment for a
d. The new nurse calls the health care provider for burn injury prioritizes wound care, nutritional
a possible insulin order when a nondiabetic support, and prevention of complications such as
patient's serum glucose is elevated. infection. Based on these care priorities, the patient
is in what phase of burn care?
Which nursing action is a priority for a patient who A) Emergent
has suffered a burn injury while working on an B) Immediate resuscitative
electrical power line? C) Acute
a. Obtain the blood pressure. D) Rehabilitation
b. Stabilize the cervical spine.
c. Assess for the contact points. A patient in the emergent/resuscitative phase of a
d. Check alertness and orientation. burn injury has had blood work and arterial blood
gases drawn. Upon analysis of the patient's
Which action will the nurse include in the plan of laboratory studies, the nurse will expect the results
care for a patient in the rehabilitation phase after a to indicate what?
burn injury to the right arm and chest? A) Hyperkalemia, hyponatremia, elevated
a. Keep the right arm in a position of comfort. hematocrit, and metabolic acidosis
b. Avoid the use of sustained-release narcotics. B) Hypokalemia, hypernatremia, decreased
c. Teach about the purpose of tetanus hematocrit, and metabolic acidosis
immunization. C) Hyperkalemia, hypernatremia, decreased
d. Apply water-based cream to burned areas hematocrit, and metabolic alkalosis
frequently. D) Hypokalemia, hyponatremia, elevated
hematocrit, and metabolic alkalosis
A young adult patient who is in the rehabilitation
phase 6 months after a severe face and neck burn A patient has experienced an electrical burn and
tells the nurse, "I'm sorry that I'm still alive. My life has developed thick eschar over the burn site.
will never be normal again." Which response by the Which of the following topical antibacterial agents
nurse is best? will the nurse expect the physician to order for the
a. "Most people recover after a burn and feel wound?
satisfied with their lives." A) Silver sulfadiazine 1% (Silvadene) water-soluble
b. "It's true that your life may be different. What cream
concerns you the most?" B) Mafenide acetate 10% (Sulfamylon)
c. "It is really too early to know how much your life hydrophilic-based cream
will be changed by the burn." C) Silver nitrate 0.5% aqueous solution
d. "Why do you feel that way? You will be able to D) Acticoat
adapt as your recovery progresses."
An occupational health nurse is called to the floor of
a factory where a worker has sustained a flash burn
to the right arm. The nurse arrives and the flames
have been extinguished. The next step is to ìcool
the burn.î How should the nurse cool the burn?
A) Apply ice to the site of the burn for 5 to 10
minutes.
B) Wrap the patient's affected extremity in ice until
help arrives.
C) Apply an oil-based substance or butter to the
burned area until help arrives.
D) Wrap cool towels around the affected extremity
intermittently.
An emergency department nurse has just admitted
a patient with a burn. What characteristic of the
burn will primarily determine whether the patient
experiences a systemic response to this injury?
A) The length of time since the burn
B) The location of burned skin surfaces
C) The source of the burn
D) The total body surface area (TBSA) affected by
the burn
A nurse on a burn unit is caring for a patient in the
acute phase of burn care. While performing an
assessment during this phase of burn care, the
nurse recognizes that airway obstruction related to
upper airway edema may occur up to how long
after the burn injury?
A) 2 days
B) 3 days
C) 5 days
D) 1 week
A patient has sustained a severe burn injury and is
thought to have an impaired intestinal mucosal
barrier. Since this patient is considered at an
increased risk for infection, what intervention will
best assist in avoiding increased intestinal
permeability and prevent early endotoxin
translocation?
A) Early enteral feeding
B) Administration of prophylactic antibiotics
C) Bowel cleansing procedures
D) Administration of stool softeners
A patient has been admitted to a burn intensive
care unit with extensive full-thickness burns over
25% of the body. After ensuring cardiopulmonary
stability, what would be the nurse's immediate,
priority concern when planning this patient's care?
A) Fluid status
B) Risk of infection
C) Nutritional status
D) Psychosocial coping
The nurse is preparing the patient for mechanical
dÈbridement and informs the patient that this will
involve which of the following procedures?
A) A spontaneous separation of dead tissue from
the viable tissue
B) Removal of eschar until the point of pain and
bleeding occurs
C) Shaving of burned skin layers until bleeding,
viable tissue is revealed
D) Early closure of the wound
A patient with a partial-thickness burn injury had
Biobrane applied 2 weeks ago. The nurse notices
that the Biobrane is separating from the burn
wound. What is the nurse's most appropriate
intervention?
A) Reinforce the Biobrane dressing with another
piece of Biobrane.
B) Remove the Biobrane dressing and apply a new
dressing.
C) Trim away the separated Biobrane.
D) Notify the physician for further
emergency-related orders.
An emergency department nurse learns from the
paramedics that they are transporting a patient who
has suffered injury from a scald from a hot kettle.
What variables will the nurse consider when
determining the depth of burn?
A) The causative agent
B) The patient's preinjury health status
C) The patient's prognosis for recovery
D) The circumstances of the accident
A nurse is caring for a patient who has sustained a
deep partial-thickness burn injury. In prioritizing the
nursing diagnoses for the plan of care, the nurse
will give the highest priority to what nursing
diagnosis?
A) Activity Intolerance
B) Anxiety
C) Ineffective Coping
D) Acute Pain
A triage nurse in the emergency department (ED)
receives a phone call from a frantic father who saw
his 4-year-old child tip a pot of boiling water onto
her chest. The father has called an ambulance.
What would the nurse in the ED receiving the call
instruct the father to do?
A) Cover the burn with ice and secure with a towel.
B) Apply butter to the area that is burned.
C) Immerse the child in a cool bath.
D) Avoid touching the burned area under any
circumstances.
A nurse is teaching a patient with a
partial-thickness wound how to wear his elastic
pressure garment. How would the nurse instruct the
patient to wear this garment?
A) 4 to 6 hours a day for 6 months
B) During waking hours for 2 to 3 months after the
injury
C) Continuously
D) At night while sleeping for a year after the injury
A patient is brought to the ED by paramedics, who
report that the patient has partial-thickness burns
on the chest and legs. The patient has also
suffered smoke inhalation. What is the priority in
the care of a patient who has been burned and
suffered smoke inhalation?
A) Pain
B) Fluid balance
C) Anxiety and fear
D) Airway management
A patient arrives in the emergency department after
being burned in a house fire. The patient's burns
cover the face and the left forearm. What extent of
burns does the patient most likely have?
A) 13%
B) 25%
C) 9%
D) 18%
A nurse is caring for a patient in the
emergent/resuscitative phase of burn injury. During
this phase, the nurse should monitor for evidence
of what alteration in laboratory values?
A) Sodium deficit
B) Decreased prothrombin time (PT)
C) Potassium deficit
D) Decreased hematocrit
A nurse is developing a care plan for a patient with
a partial-thickness burn, and determines that an
appropriate goal is to maintain position of joints in
alignment. What is the best rationale for this
intervention?
A) To prevent neuropathies
B) To prevent wound breakdown
C) To prevent contractures
D) To prevent heterotopic ossification
A patient's burns have required a homograft.
During the nurse's most recent assessment, the
nurse observes that the graft is newly covered with
purulent exudate. What is the nurse's most
appropriate response?
A) Perform mechanical dÈbridement to remove the
exudate and prevent further infection.
B) Inform the primary care provider promptly
because the graft may need to be removed.
C) Perform range of motion exercises to increase
perfusion to the graft site and facilitate healing.
D) Document this finding as an expected phase of
graft healing.
A nurse who is taking care of a patient with burns is
asked by a family member why the patient is losing
so much weight. The patient is currently in the
intermediate phase of recovery. What would be the
nurse's most appropriate response to the family
member?
A) ìHe's on a calorie-restricted diet in order to divert
energy to wound healing.î
B) ìHis body has consumed his fat deposits for fuel
because his calorie intake is lower than normal.î
C) ìHe actually hasn't lost weight. Instead, there's
been a change in the distribution of his body fat.î
D) ìHe lost many fluids while he was being treated
in the emergency phase of burn care.î
A nurse has reported for a shift at a busy burns and
plastics unit in a large university hospital. Which
patient is most likely to have life-threatening
complications?
A) A 4-year-old scald victim burned over 24% of the
body
B) A 27-year-old male burned over 36% of his body
in a car accident
C) A 39-year-old female patient burned over 18% of
her body
D) A 60-year-old male burned over 16% of his body
in a brush fire
A patient is brought to the emergency department
with a burn injury. The nurse knows that the first
systemic event after a major burn injury is what?
A) Hemodynamic instability
B) Gastrointestinal hypermotility
C) Respiratory arrest
D) Hypokalemia
A patient with severe burns is admitted to the
intensive care unit to stabilize and begin fluid
resuscitation before transport to the burn center.
The nurse should monitor the patient closely for
what signs of the onset of burn shock?
A) Confusion
B) High fever
C) Decreased blood pressure
D) Sudden agitation
An emergency department nurse has just received
a patient with burn injuries brought in by
ambulance. The paramedics have started a
large-bore IV and covered the burn in cool towels.
The burn is estimated as covering 24% of the
patient's body. How should the nurse best address
the pathophysiologic changes resulting from major
burns during the initial burn-shock period?
A) Administer IV fluids
B) Administer broad-spectrum antibiotics
C) Administer IV potassium chloride
D) Administer packed red blood cells
A patient's burns are estimated at 36% of total body
surface area; fluid resuscitation has been ordered
in the emergency department. After establishing
intravenous access, the nurse should anticipate the
administration of what fluid?
A) 0.45% NaCl with 20 mEq/L KCl
B) 0.45% NaCl with 40 mEq/L KCl
C) Normal saline
D) Lactated Ringer's
A patient is admitted to the burn unit after being
transported from a facility 1000 miles away. The
patient has burns to the groin area and
circumferential burns to both upper thighs. When
assessing the patient's legs distal to the wound
site, the nurse should be cognizant of the risk of
what complication?
A) Ischemia
B) Referred pain
C) Cellulitis
D) Venous thromboembolism (VTE)
A patient experienced a 33% TBSA burn 72 hours
ago. The nurse observes that the patient's hourly
urine output has been steadily increasing over the
past 24 hours. How should the nurse best respond
to this finding?
A) Obtain an order to reduce the rate of the
patient's IV fluid infusion.
B) Report the patient's early signs of acute kidney
injury (AKI).
C) Recognize that the patient is experiencing an
expected onset of diuresis.
D) Administer sodium chloride as ordered to
compensate for this fluid loss.
A public health nurse has reviewed local data about
the incidence and prevalence of burn injuries in the
community. These data are likely to support what
health promotion effort?
A) Education about home safety
B) Education about safe storage of chemicals
C) Education about workplace health threats
D) Education about safe driving
A nurse is performing a home visit to a patient who
is recovering following a long course of inpatient
treatment for burn injuries. When performing this
home visit, the nurse should do which of the
following?
A) Assess the patient for signs of electrolyte
imbalances.
B) Administer fluids as ordered.
C) Assess the risk for injury recurrence.
D) Assess the patient's psychosocial state.
A patient has experienced burns to his upper thighs
and knees. Following the application of new wound
dressings, the nurse should perform what nursing
action?
A) Instruct the patient to keep the wound site in a
dependent position.
B) Administer PRN analgesia as ordered.
C) Assess the patient's peripheral pulses distal to
the dressing.
D) Assist with passive range of motion exercises to
ìsetî the new dressing.
A nurse is caring for a patient with burns who is in
the later stages of the acute phase of recovery. The
plan of nursing care should include which of the
following nursing actions?
A) Maintenance of bed rest to aid healing
B) Choosing appropriate splints and functional
devices
C) Administration of beta adrenergic blockers
D) Prevention of venous thromboembolism
A patient is in the acute phase of a burn injury. One
of the nursing diagnoses in the plan of care is
Ineffective Coping Related to Trauma of Burn
Injury. What interventions appropriately address
this diagnosis? Select all that apply.
A) Promote truthful communication.
B) Avoid asking the patient to make decisions.
C) Teach the patient coping strategies.
D) Administer benzodiazepines as ordered.
E) Provide positive reinforcement.
A patient who was burned in a workplace accident
has completed the acute phase of treatment and
the plan of care has been altered to prioritize
rehabilitation. What nursing action should be
prioritized during this phase of treatment?
A) Monitoring fluid and electrolyte imbalances
B) Providing education to the patient and family
C) Treating infection
D) Promoting thermoregulation
A burn patient is transitioning from the acute phase
of the injury to the rehabilitation phase. The patient
tells the nurse, ìI can't wait to have surgery to
reconstruct my face so I look normal again.î What
would be the nurse's best response?
A) ìThat's something that you and your doctor will
likely talk about after your scars mature.î
B) ìThat is something for you to talk to your doctor
about because it's not a nursing responsibility.î
C) ìI know this is really important to you, but you
have to realize that no one can make you look like
you used to.î
D) ìUnfortunately, it's likely that you will have most
of these scars for the rest of your life.î
A patient who is in the acute phase of recovery
from a burn injury has yet to experience adequate
pain control. What pain management strategy is
most likely to meet this patient's needs?
A) A patient-controlled analgesia (PCA) system
B) Oral opioids supplemented by NSAIDs
C) Distraction and relaxation techniques
supplemented by NSAIDs
D) A combination of benzodiazepines and topical
anesthetics
The nurse caring for a patient who is recovering
from full-thickness burns is aware of the patient's
risk for contracture and hypertrophic scarring. How
can the nurse best mitigate this risk?
A) Apply skin emollients as ordered after
granulation has occurred.
B) Keep injured areas immobilized whenever
possible to promote healing.
C) Administer oral or IV corticosteroids as ordered.
D) Encourage physical activity and range of motion
exercises.
While performing a patient's ordered wound care
for the treatment of a burn, the patient has made a
series of sarcastic remarks to the nurse and
criticized her technique. How should the nurse best
interpret this patient's behavior?
A) The patient may be experiencing an adverse
drug reaction that is affecting his cognition and
behavior.
B) The patient may be experiencing neurologic or
psychiatric complications of his injuries.
C) The patient may be experiencing inconsistencies
in the care that he is being provided.
D) The patient may be experiencing anger about
his circumstances that he is deflecting toward the
nurse.
A home care nurse is performing a visit to a
patient's home to perform wound care following the
patient's hospital treatment for severe burns. While
interacting with the patient, the nurse should
assess for evidence of what complication?
A) Psychosis
B) Post-traumatic stress disorder
C) Delirium
D) Vascular dementia
A nurse who provides care on a burn unit is
preparing to apply a patient's ordered topical
antibiotic ointment. What action should the nurse
perform when administering this medication?
A) Apply the new ointment without disturbing the
existing layer of ointment.
B) Apply the ointment using a sterile tongue
depressor.
C) Apply a layer of ointment approximately 1/16
inch thick.
D) Gently irrigate the wound bed after applying the
antibiotic ointment.
A client's burn is infected and mafenide
(Sulfamylon) is prescribed. The nurse's knowledge
about this medication would indicate that which
organism is involved?
a. pseudomonas aeruginosa
b. tubercle bacillus
c. Methicillin resistant staphylococcus aureus
(MRSA)
d. Candida albicans
The nurse should expect to apply which type of
ordered antiseptic to a client with a burn wound,
once the area has been cleansed with sterile
saline?
a. copper containing
b. silver containing
c. biguanide
d. acetic acid
The patient sustained a full-thickness burn
encompassing the entire right arm. What is the best
indicator an escharotomy achieved its desired
effect?
A. Patient rates the pain at less than 4.
B. Blood pressure remains above 120/80 mm Hg.
C. Right fingers blanch with a 2-second refill.
D. Patient maintains full range of motion for the
right arm.
Multiple patients arrive in the emergency
department from a house fire. Which patient is a
priority?
A. Patient with erythremic, dry burns over the arms
and a history of taking prednisone
B. Patient with moist blisters over the chest and
who reports pain as 10
C. Patient with dry, black skin on one hand and a
history of diabetes mellitus
D. Patient with multiple reddened skin areas on the
chest and with high-pitched respiratory sounds
A client with burn injury asks the nurse what the
term full thickness means. The nurse should
respond that burns classified as full thickness
involve tissue destruction down to which level?
a. epidermis
b. dermis
c. subcutaneous tissue
d. internal organs
A child has just been admitted to the pediatric burn
unit. Currently, the child is being evaluated for
burns to his chest and upper legs. He complains of
thirst and asks for a drink. What is the most
appropriate nursing action?
a. give a small glass of clear liquid
b. give a small glass of a full liquid
c. keep the child NPO
d. order a pediatric meal tray with extra liquids
A child was admitted to the ED with a thermal burn
to the right arm and leg. Which assessment by the
nurse requires immediate action?
a. coughing and wheezing
b. bright red skin with small blister on the burn sites
c. thirst
d. singed hair
The condition of a client with extensive third degree
burns begins to deteriorate. The nurse is aware that
which type of shock may occur as a result of
inadequate circulating blood volume that occurs
with a burn injury?
a. cardiogenic
b. distributive
c. hypovolemic
d. septic

What is the best method for preventing
hypovolemic shock in a client admitted with severe
burns?
a. administering dopamine
b. applying medical antishock trousers
c. infusing i.v. fluids
d. infusing fresh frozen plasma
A client is admitted to a burn intensive care unit
with extensive full thickness burns. What should be
the nurse's initial concern?
a. fluid status
b. risk for infection
c. body image
d. level of pain
A nurse is caring for a client with a new donor site
that was harvested to treat a burn. The nurse
should position the client to:
a. allow ventilation of the site
b. make the site dependent
c. avoid pressure on the site
d. keep the site fully covered
Knowing the most common causes of household
fires, which of the following prevention strategies
would the nurse focus on when teaching about fire
safety?
a. set how water temp at 140 F
b. use only hardwired smoke detectors
c. encourage regular home fire exit drills
d. never permit older adults to cook unattended.
The injury that is least likely to result in a full
thickness burn is:
a. sunburn
b. scald injury
c. chemical burn
d. electrical injury
When assessing a pt with a partial thickness burn,
the nurse would expect to find (select all that apply)
a. blisters
b. exposed fascia
c. exposed muscles
d. intact nerve endings
e. red, shiny, wet appearance
A patient is admitted to the burn center with burns
over his head, neck, chest, back, and left arm and
hand after an explosion and fire in his garage. On
admission to the unit, you auscultate wheezes
throughout the lung fields. On reassessment, you
notice that the wheezes are gone and the breath
sounds are greatly diminished. Which of the
following actions is the most appropriate next step?
a. place the pt in high fowler's position
b. encourage the pt to cough and auscultate the
lungs again
c. document the results and continue to monitor the
pt's progress
d. anticipate the need for endotracheal intubation
and notify the physician
Fluid and electrolyte shifts that occur during the
early emergent phase include
a. adherence of albumin to vascular walls
b. movement of potassium into the vascular space
c. sequestering of sodium and water in the
interstitial fluid.
d. hemolysis of red blood cells from large volumes
of rapidly administered fluid.
To maintain a positive nitrogen balance in a major
burn, the patient must
a. increase normal caloric intake by about 3 times
b. eat a high-protein, low-fat, high-carbohydrate
diet.
c. eat at least 1500 calories per day in small,
frequent meals.
d. eat rice and whole wheat for the chemical effect
on nitrogen balance
A patient has 25% TBSA burned from a car fire. His
wounds have been debrided and covered with a
silver-impregnated dressing. Your priority
intervention for wound care is to:
a. reapply a new dressing without disturbing the
wound bed
b. observe the wound for signs of infection during
dressing changes
c. apply cool compresses for pain relief in between
dressing changes
d. wash the wound aggressively with soap and
water three times each day.
Pain management for the burn patient is most
effective when
a. opoids are administered on a set schedule
around the clock
b. the patient has as much control over the
management of the pain as possible.
c. there is flexibility to administer opioids withing a
dosage and frequency range
d. painful dressing changes are delayed until the
pt's pain is totally relieved.
A therapeutic measure used to prevent
hypertrophic scarring during the rehabilitative
phase of burn recovery is:
a. applying pressure garments.
b. repositioning the pt every 2 hours
c. performing active ROM at least every 4 hours
d. massaging the new tissue with water based
moisturizers
A patient has been treated for second- and
third-degree burns over 30% of his body and is now
ready for discharge. You provide discharge
instructions related to wound care. Which
statement indicates that the patient understands
the instructions?
a. I can expect occasional periods of low grade
fever and can take Tylenol every 4 hours
b. I must wear my jobst elastic garment all day and
can only remove it when I'm going to bed.
c. I will need to take sponge baths at home to avoid
exposing the wounds to unsterile bath water.
d. If any healed areas break open, I should cover
them with a sterile dressing and then immediately
report it."
A nurse is caring for a patient with second- and
third-degree burns to 50% of the body. The nurse
prepares fluid resuscitation based on knowledge of
the Parkland (Baxter) formula that includes which of
the following recommendations?
A. The total 24-hour fluid requirement should be
administered in the first 8 hours.
B. One half of the total 24-hour fluid requirement
should be administered in the first 8 hours.
C. One third of the total 24-hour fluid requirement
should be administered in the first 4 hours.
D. One half of the total 24-hour fluid requirement
should be administered in the first 4 hours.
The nurse is caring for a patient with superficial
partial-thickness burns of the face sustained within
the last 12 hours. Upon assessment, the nurse
would expect to find which of the following
symptoms?
A. Blisters
B. Reddening of the skin
C. Destruction of all skin layers
D. Damage to sebaceous glands
The nurse is planning care for a patient with partial-
and full-thickness skin destruction related to burn
injury of the lower extremities. Which of the
following interventions would the nurse expect to
include in this patient's care (select all that apply)?
A.Escharotomy
B.Administration of diuretics
C.IV and oral pain medications
D.Daily cleansing and debridement
E.Application of topical antimicrobial agent
The nurse is caring for a patient with partial- and
full-thickness burns to 65% of the body. When
planning nutritional interventions for this patient, the
nurse should implement which of the following
dietary choices?
A. Full liquids only
B. Whatever the patient requests
C. High-protein and low-sodium foods
D. High-calorie and high-protein foods
A patient is admitted to the emergency department
with first- and second-degree burns after being
involved in a house fire. Which of the following
assessment findings would alert you to the
presence of an inhalation injury (select all that
apply)?
A.Singed nasal hair
B.Generalized pallor
C.Painful swallowing
D.Burns on the upper extremities
E.History of being involved in a large fire
When caring for a patient with an electrical burn
injury, the nurse should question a health care
provider's order for
A. Mannitol 75 gm IV.
B. Urine for myoglobulin.
C. Lactated Ringer's at 25 ml/hr.
D. Sodium bicarbonate 24 mEq every 4 hours.
A patient is admitted with first- and second-degree
burns covering the face, neck, entire right upper
extremity, and the right anterior trunk area. Using
the rule of nines, the nurse would calculate the
extent of these burns as being
A. 9%.
B. 18%.
C. 22.5%.
D. 36%.
1. A 65 year old male patient has experienced
full-thickness electrical burns on the legs and arms.
As the nurse you know this patient is at risk for the
following: Select all that apply:
A. Acute kidney injury
B. Dysrhythmia
C. Iceberg effect
D. Hypernatremia
E. Bone fractures
F. Fluid volume overload
2. True or False: A patient who experiences an
alkali chemical burn is easier to treat because the
skin will neutralize the chemical rather than with an
acidic chemical burn.
3. As the nurse providing care to a patient who
experienced a full-thickness electrical burn you
know to monitor the patient’s urine for:
A. Hemoglobin and myoglobin
B. Free iron and white blood cells
C. Protein and red blood cells
D. Potassium and Urea
4. Select the patient below who is at MOST risk for
complications following a burn:
A. A 42 year old male with partial-thickness burns
on the front of the right and left arms and legs.
B. A 25 year old female with partial-thickness burns
on the front of the head and neck and front and
back of the torso.
C. A 36 year old male with full-thickness burns on
the front of the left arm.
D. A 10 year old with superficial burns on the right
leg.
5. The _____________ layer of the skin helps
regulate our body temperature.
A. Epidermis
B. Dermis
C. Hypodermis
D. Fascia
6. You receive a patient who has experienced a
burn on the right leg. You note the burn contains
small blisters and is extremely pinkish red and
shiny/moist. The patient reports severe pain. You
document this burn as:
A. 1st Degree (superficial)
B. 2nd Degree (partial-thickness)
C. 3rd Degree (full-thickness)
D. 4th Degree (deep full-thickness)
7. Based on the depth of the burn in figure 1
(picture is above), you would expect to find:
A. report of sensation to only pressure
B. blanching
C. anesthetization to feeling
D. extreme pain
8. A 58 year old female patient has superficial
partial-thickness burns to the anterior head and
neck, front and back of the left arm, front of the
right arm, posterior trunk, front and back of the right
leg, and back of the left leg. Using the Rule of
Nines, calculate the total body surface area
percentage that is burned?
A. 63%
B. 81%
C. 72%
D. 54%
9. A 30 year old female patient has deep partial
thickness burns on the front and back of the right
and left leg, front of right arm, and anterior trunk.
The patient weighs 63 kg. Use the Parkland Burn
Formula: What is the flow rate during the FIRST 8
hours (mL/hr) based on the total you calculated?
A. 921 mL/hr
B. 938 mL/hr
C. 158 mL/hr
D. 789 mL/hr
10. A patient has a burn on the back of the torso
that is extremely red and painful but no blisters are
present. When you pressed on the skin it blanches.
You document this as a:
A. 1st degree (superficial) burn
B. 2nd degree (partial-thickness) burn
C. 3rd degree (full-thickness) burn
D. 4th degree (deep full-thickness) burn
11. A patient has experienced full-thickness burns
to the face and neck. As the nurse it is priority to:
A. Prevent hypothermia
B. Assess the blood pressure
C. Assess the airway
D. Prevent infection
12. A patient is in the acute phase of burn
management. The patient experienced
full-thickness burns to the perineum and sacral
area of the body. In the patient’s plan of care, which
nursing diagnosis is priority at this time?
A. Impaired skin integrity
B. Risk for fluid volume overload
C. Risk for infection
D. Ineffective coping
13. The nurse notes a patient has full-thickness
circumferential burns on the right leg. The nurse
would: select all that apply
A. Place cold compressions on the burn and
elevate the right leg below the heart level
B. Assess the distal pulses in the right extremity
C. Elevate the right leg above the heart level
D. Place gauze securely around the leg to prevent
infection
14. A patient arrives to the ER with full-thickness
burns on the front and back of the torso and neck.
The patient has no spinal injuries but is disoriented
and coughing up black sooty sputum. Vital signs
are: oxygen saturation 63%, heart rate 145, blood
pressure 80/56, and respiratory rate 39. As the
nurse you will:
A. Place the patient in High Fowler’s positon.
B. Prep the patient for escharotomy.
C. Prep the patient for fasciotomy.
D. Prep the patient for intubation.
E. Place a pillow under the patient’s neck.
F. Obtain IV access at two sites.
G. Restrict fluids.
15. A patient arrives to the ER due to experiencing
burns while in an enclosed warehouse. Which
assessment findings below demonstrate the patient
may have experienced an inhalation injury?
A. Carbonaceous sputum
B. Hair singeing on the head and nose
C. Lhermitte’s Sign
D. Bright red lips
E. Hoarse voice
F. Tachycardia
16. You’re providing education to a group of local
firefighters about carbon monoxide poisoning.
Which statement is correct about the
pathophysiology regarding this condition?
A. “Patients are most likely to present with cyanosis
around the lips and face.”
B. “In this condition, carbon monoxide binds to the
hemoglobin of the red blood cell leading to a
decrease in the ability of the hemoglobin to carry
oxygen to the body.”
C. “Carbon monoxide poisoning leads to a
hyperoxygenated state, which causes
hypercapnia.”
D. “Carbon monoxide binds to the hemoglobin of
the red blood cell and prevents the transport of
carbon dioxide out of the blood, which leads to
poisoning.”
17. A patient experienced a full-thickness burn 72
hours ago. The patient’s vital signs are within
normal limits and urinary output is 50 mL/hr. This is
known as what phase of burn management?
A. Emergent
B. Acute
C. Rehabilitative
18. What are some patient priorities during the
emergent phase of burn management?
A. Fluid volume
B. Respiratory status
C. Psychosocial
D. Wound closure
E. Nutrition
19. During the emergent phase of burn
management, you would expect the following lab
values:
A. Low sodium, low potassium, high glucose, low
hematocrit
B. High sodium, low potassium, low glucose, high
hematocrit
C. High sodium, high potassium, high glucose, low
hematocrit
D. Low sodium, high potassium, high glucose, high
hematocrit
20. A patient is receiving IV Lactated Ringers 950
mL/hr post 18 hours after a receiving a severe
burn. The patient urinary output is 20 mL/hr. As the
nurse your next nursing action is to:
A. Increase the IV fluids
B. Continue to monitor the patient
C. Decrease the IV fluids
D. Notify the physician of this finding
21. A patient who is being treated for partial
thickness burns on 60% of the body is now in the
acute phase of burn management. The nurse
assesses the patient for a possible Curling’s Ulcer.
What signs and symptoms can present with this
condition?
A. Swelling and pain on the area distal to the burn
B. Burning, gnawing sensation pain in the stomach
and vomiting
C. Dark red or gray sores on the soles of the feet
D. Difficulty swallowing and gagging
22. During the acute phase of burn management,
what is the best diet for a patient who has
experienced severe burns?
A. High fiber, low calories, and low protein
B. High calorie, high protein and carbohydrate
C. High potassium, high carbohydrate, and low
protein
D. Low sodium, high protein, and restrict fluids to 1
liter per day
23. You’re assisting the nursing assistant with
repositioning a patient with full-thickness burns on
the neck. Which action by the nursing assistant
requires you to intervene?
A. The nursing assistant elevates the head of the
bed above 30 degrees.
B. The nursing assistant places a pillow under the
patient’s head.
C. The nursing assistant places rolled towels under
the patient’s shoulders.
D. The nursing assistant covers the patient with
sterile linens.
24. A patient has full-thickness burns on the front
and back of both arm and hands. It is nursing
priority to:
A. Elevate and extend the extremities
B. Elevate and flex the extremities
C. Keep extremities below heart level and extended
D. Keep extremities level with the heart level and
flexed
25. A patient has an emergency escharotomy
performed on the right leg. The patient has
full-thickness circumferential burns on the leg.
Which finding below demonstrates the procedure
was successful?
A. The patient can move the extremity.
B. The right foot’s capillary refill is less than 2
seconds.
C. The patient reports a new sensation of extreme
pain.
D. The patient has a positive babinski reflex.
26. Your patient with severe burns is due to have a
dressing change. You will pre-medicate the patient
prior to the dressing change. The patient has
standing orders for all the medications below.
Which medication is best for this patient?
A. IM morphine
B. PO morphine
C. IV morphine
D. Subq morphine
27. After receiving report on a patient receiving
treatment for severe burns, you perform your
head-to-toe assessment. On arrival to the patient’s
room you note the room temperature to be 75’F.
You will:
A. Decrease the temperature by 5-10 degrees to
prevent hyperthermia.
B. Leave the temperature setting.
C. Increase the temperature to a minimum of 85’F.
28. You are about to provide care to a patient with
severe burns. You will don:
A. gloves
B. goggles
C. gown
D. N-95 mask
E. surgical mask
F. shoe covers
G. hair cover
29. While collecting a medical history on a patient
who experienced a severe burn, which statement
by the patient’s family member requires nursing
intervention?
A. “He takes medication for glaucoma”.
B. “I think it has been 10 years or more since he
had a tetanus shot.”
C. “He was told he had COPD last year.”
D. “He smokes 2 packs of cigarettes a day.”
30. A patient is presenting with bright red lips,
headache, and nausea. The physician suspects
carbon monoxide poisoning. As the nurse, you
know the patient needs:
A. Oxygen nasal cannula 5-6 Liters
B. 100% oxygen via non-rebreather mask
C. Continuous Bipap
D. Venturi mask 6 L oxygen
1. A 23-year-old male client who has had a
full-thickness burn is being discharged from the
hospital. Which information is most important for
the nurse to provide prior to discharge?
A. How to maintain home smoke detectors
B. Joining a community reintegration program
C. Learning to perform dressing changes
D. Options available for scar removal
2. A client who is admitted after a thermal burn
injury has the following vital signs: blood pressure,
70/40; heart rate, 140 beats/min; respiratory rate,
25/min. He is pale in color and it is difficult to find
pedal pulses. Which action will the nurse take first?
A. Start intravenous fluids.
B. Check the pulses using a Doppler device.
C. Obtain a complete blood count (CBC).
D. Obtain an electrocardiogram (ECG).
3. A 40-year-old male client who was burned was
admitted under your care. Assessment reveals he
has crackles, respiratory rate of 40/min, and is
coughing up blood-tinged sputum. What action will
the nurse take first?
A. Administer digoxin
B. Perform chest physiotherapy
C. Monitor urine output
D. Place the client in an upright position
4. How will the nurse position a client with a burn
wound to the posterior neck to prevent
contractures?
A. Have the client turn the head from side to side.
B. Keep the client in a supine position without the
use of pillows.
C. Keep the client in a semi-Fowler's position with
her or his arms elevated.
D. Place a towel roll under the client's neck or
shoulder.
5. On assessment, the nurse notes that the client
has burns inside the mouth and is wheezing.
Several hours later, the wheezing is no longer
heard. What is the nurse’s next action?
A. Documenting the findings
B. Loosening any dressings on the chest
C. Raising the head of the bed
D. Preparing for intubation
6. Ten hours after the client with 50% burns is
admitted, her blood glucose level is 142 mg/dL.
What is the nurse’s best action?
A. Documents the finding
B. Obtains a family history of diabetes
C. Repeats the glucose measurement
D. Stop IV fluids containing dextrose
7. A 32-year-old client, who is on an anticoagulant
medication due to a history of deep vein
thrombosis, arrives at the emergency department
after accidentally spilling a pot of boiling water
mixed with hot oil on their right arm while
attempting to deep-fry food at home. The client is in
significant pain and reports that the burn occurred
approximately 30 minutes ago. Upon assessment,
the nurse observes a large burned area on the
client’s right arm with a mix of pink and mottled red
areas, blisters, and signs of active bleeding from
the blistered areas. The burned area is very painful
to touch and the client is visibly anxious.
Based on the assessment findings and the client’s
medical history, how will the nurse categorize this
burn injury?
A. Full-thickness
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full-thickness deep
8. The client has burns on both legs. These areas
appear white and leather-like. No blisters or
bleeding are present, and there is just a “small
amount of pain.” How will the nurse categorize this
injury?
A. Full-thickness
B. Partial-thickness superficial
C. Partial-thickness deep
D. Superficial
9. The client has experienced an electrical injury of
the lower extremities. Which are the priority
assessment data to obtain from this client?
A. Current range of motion in all extremities
B. Heart rate and rhythm
C. Respiratory rate and pulse oximetry reading
D. Orientation to time, place, and person
10. A 35-year-old male client was admitted due to
severe burns around his right hip. Which position is
most important to use to maintain the maximum
function of this joint?
A. Hip maintained in 30-degree flexion
B. Hip at zero flexion with leg flat
C. Knee flexed at 30-degree angle
D. Leg abducted with a foam wedge
11. The client who is burned is drooling and having
difficulty swallowing. Which action will the nurse
take first?
A. Assesses level of consciousness and pupillary
reactions
B. Ascertains the time food or liquid was last
consumed
C. Auscultates breath sounds over the trachea and
mainstem bronchi
D. Measures abdominal girth and auscultates
bowel sounds
Incorrect
12. A 22-year-old female client with a full-thickness
burn is being discharged to home after a month in
the hospital. Her wounds are minimally opened and
she will be receiving home care. Which nursing
diagnosis has the highest priority?
A. Acute Pain
B. Deficient Diversional Activity
C. Impaired Adjustment
D. Imbalanced Nutrition: Less than Body
Requirements
13. The client with a new burn injury asks the nurse
why he is receiving intravenous cimetidine
(Tagamet). What is the nurse’s best response?
A. "Tagamet will stimulate intestinal movement."
B. "Tagamet can help prevent hypovolemic shock."
C. "This will help prevent stomach ulcers."
D. "This drug will help prevent kidney damage."
Incorrect
14. A 12-year-old male with facial burns asks the
nurse if he will ever look the same. Which response
is best for the nurse to provide?
A. "With reconstructive surgery, you can look the
same."
B. "We can remove the scars with the use of a
pressure dressing."
C. "You will not look exactly the same."
D. "You shouldn't start worrying about your
appearance right now."
15. The client with open burn wounds begins to
have diarrhea. The client is found to have a
below-normal temperature, with a white blood cell
count of 4000/mm3. Which is the nurse’s best
action?
A. Continuing to monitor the client
B. Increasing the temperature in the room
C. Increasing the rate of the intravenous fluids
D. Preparing to do a workup for sepsis
16. The family of a client who has been burned
asks at what point the client will no longer be at
greater risk for infection. What is the nurse’s best
response?
A. "As soon as he finishes his antibiotic
prescription."
B. "As soon as his albumin level returns to
normal."
C. "When fluid remobilization has started."
D. "When the burn wounds are closed."
17. The nurse is conducting a home safety class. It
is most important for the nurse to include which
information in the teaching plan?
A. Have chimneys swept every 2 years.
B. Keep a smoke detector in each bedroom.
C. Use space heaters instead of gas heaters.
D. Use carbon monoxide detectors only in the
garage.
Incorrect
18. The nurse provides wound care for a client 48
hours after a burn injury. To achieve the desired
outcome of the procedure, which nursing action will
be carried out first?
A. Applies silver sulfadiazine (Silvadene) ointment
B. Covers the area with an elastic wrap
C. Places a synthetic dressing over the area
D. Removes loose nonviable tissue
19. The nurse should teach the community that a
minor burn injury could be caused by what common
occurrence?
A. Chimney sweeping every year
B. Cooking with a microwave oven
C. Use of sunscreen agents
D. Use of space heaters
20. The nurse uses topical gentamicin sulfate
(Garamycin) on a client’s burn injury. Which
laboratory value will the nurse monitor?
A. Creatinine
B. Red blood cells
C. Sodium
D. Magnesium level
1.9 Poisoning and Antidotes
1.10 SARS
1.11 ARDS
1.) You’re providing care to a patient who is being
treated for aspiration pneumonia. The patient is on
a 100% non-rebreather mask. Which finding below
is a HALLMARK sign and symptom that the patient
is developing acute respiratory distress syndrome
(ARDS)?
A. The patient is experiencing bradypnea.
B. The patient is tired and confused.
C. The patient’s PaO2 remains at 45 mmHg.
D. The patient’s blood pressure is 180/96.
2. You’re teaching a class on critical care concepts
to a group of new nurses. You’re discussing the
topic of acute respiratory distress syndrome
(ARDS). At the beginning of the lecture, you assess
the new nurses understanding about this condition.
Which statement by a new nurse demonstrates he
understands the condition?
A. “This condition develops because the exocrine
glands start to work incorrectly leading to thick,
copious mucous to collect in the alveoli sacs.”
B. “ARDS is a pulmonary disease that gradually
causes chronic obstruction of airflow from the
lungs.”
C. “Acute respiratory distress syndrome occurs due
to the collapsing of a lung because air has
accumulated in the pleural space.”
D. “This condition develops because alveolar
capillary membrane permeability has changed
leading to fluid collecting in the alveoli sacs.”
3. During the exudative phase of acute respiratory
distress syndrome (ARDS), the patient’s lung cells
that produce surfactant have become damaged. As
the nurse you know this will lead to?
A. bronchoconstriction
B. atelectasis
C. upper airway blockage
D. pulmonary edema
4. A patient has been hospitalized in the ICU for a
near drowning event. The patient’s respiratory
function has been deteriorating over the last 24
hours. The physician suspects acute respiratory
distress syndrome. A STAT chest x-ray is ordered.
What finding on the chest x-ray is indicative of
ARDS?
A. infiltrates only on the upper lobes
B. enlargement of the heart with bilateral lower lobe
infiltrates
C. white-out infiltrates bilaterally
D. normal chest x-ray
5. You’re providing care to a patient who was just
transferred to your unit for the treatment of ARDS.
The patient is in the exudative phase. The patient is
ordered arterial blood gases. The results are back.
Which results are expected during this early phase
of acute respiratory distress syndrome that
correlates with this diagnosis?
A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23
B. PaO2 85, pH 7.42, PaCO2 37, HCO3 26
C. PaO2 50, pH 7.20, PaCO2 48, HCO3 29
D. PaO2 55, pH 7.26, PaCO2 58, HCO3 19
6. Which patient below is at MOST risk for
developing ARDS and has the worst prognosis?
A. A 52-year-old male patient with a pneumothorax.
B. A 48-year-old male being treated for diabetic
ketoacidosis.
C. A 69-year-old female with sepsis caused by a
gram-negative bacterial infection.
D. A 30-year-old female with cystic fibrosis.
7. As the nurse you know that acute respiratory
distress syndrome (ARDS) can be caused by direct
or indirect lung injury. Select below all the
INDIRECT causes of ARDS:
A. Drowning
B. Aspiration
C. Sepsis
D. Blood transfusion
E. Pneumonia
F. Pancreatitis
8. A patient is on mechanical ventilation with PEEP
(positive end-expiratory pressure). Which finding
below indicates the patient is developing a
complication related to their therapy and requires
immediate treatment?
A. HCO3 26 mmHg
B. Blood pressure 70/45
C. PaO2 80 mmHg
D. PaCO2 38 mmHg
9. You are caring for a patient with acute respiratory
distress syndrome. As the nurse you know that
prone positioning can be beneficial for some
patients with this condition. Which findings below
indicate this type of positioning was beneficial for
your patient with ARDS?
A. Improvement in lung sounds
B. Development of a V/Q mismatch
C. PaO2 increased from 59 mmHg to 82 mmHg
D. PEEP needs to be titrated to 15 mmHg of water
10. A patient is experiencing respiratory failure due
to pulmonary edema. The physician suspects
ARDS but wants to rule out a cardiac cause. A
pulmonary artery wedge pressure is obtained. As
the nurse you know that what measurement
reading obtained indicates that this type of
respiratory failure is NOT cardiac related?
A. >25 mmHg
B. <10 mmHg
C. >50 mmHg
D. <18 mmHg
11. You’re precepting a nursing student who is
assisting you care for a patient on mechanical
ventilation with PEEP for treatment of ARDS. The
student asks you why the PEEP setting is at 10
mmHg. Your response is:
A. “This pressure setting assists the patient with
breathing in and out and helps improve air flow.”
B. “This pressure setting will help prevent a
decrease in cardiac output and hyperinflation of the
lungs.”
C. “This pressure setting helps prevent fluid from
filling the alveoli sacs.”
D. “This pressure setting helps open the alveoli
sacs that are collapsed during exhalation.”
The nurse is caring for a client with suspected
acute respiratory distress syndrome​(ARDS). Which
symptom of ARDS should the nurse anticipate will
appear within 24 to 48 hours after the initial​insult?
(Select all that​apply.)
Shortness of breath
Rapid breathing
Fluid imbalance
Chest​x-ray clear of infiltrates
Arterial blood gases varying from normal limits
A client is diagnosed with acute respiratory distress
syndrome​ (ARDS). The​ client's spouse asks the
nurse what caused ARDS. Which etiology of
indirect injury to the lungs should the nurse include
in the​response? (Select all that​apply.)
Smoke inhalation
Systemic sepsis
Fat embolism
Multiple blood transfusions
Pancreatitis
The nurse is caring for a client who had an episode
of​ near-drowning 5 days ago. This​ morning, the
nurse noted rhonchi in the lower lung lobes on
auscultation. Which action by the nurse is best​?
Documenting the findings as normal
Preparing for intubation
Notifying the healthcare provider
Monitoring vital signs and oxygen saturation every
2 hours
A client is brought into the emergency department
after aspirating on pureed foods at the​ long-term
care facility. The nurse knows that which
physiologic change can trigger acute respiratory
distress​syndrome?
Release of chemical mediators
Increased surfactant production
Destruction of extracellular platelets
Intracellular edema
The nurse is caring for a client with respiratory
acidosis secondary to​ end-stage acute respiratory
distress syndrome​(ARDS). Which result should the
nurse anticipate on the arterial blood​gas?
High PaO2 and low PaCO2
Low PaO2 and low PaCO2
Low PaO2 and high PaCO2
High PaO2 and high PaCO2
A pediatric client is not responding to treatment for
acute respiratory distress syndrome​ (ARDS) and
requires intubation. The mother is anxious that the
procedure will hurt. Which is the best response by
the​nurse?
"​ We will administer medication to help him sleep
through the intubation and as needed while he is on
the​ventilator."
​"Don't worry; intubation and using a ventilator​
doesn't hurt at​all."
​"He may feel a little​nervous, but he will get used to
the ventilator soon​enough."
​"He will actually feel better and may even like the
ventilator because he will be able to breathe more​
comfortably."
A pregnant woman presents with worsening
dyspnea and tachypnea since being diagnosed with
pneumonia last week. The client is currently at 28
weeks of gestation and asks the nurse if she will
need to deliver early. Which is the best reply by the​
nurse?
"​ Yes, we will need to delivery your baby as soon as​
possible."
​"It's hard to know right​now."
​"There's no need to deliver your baby early. The
baby is safer in your​womb."
​"We'll monitor the baby very closely and plan for
delivery if needed for the​baby's safety."
A pregnant woman has been diagnosed with acute
respiratory distress syndrome​ (ARDS) and
prescribed corticosteroids. The woman asks the
nurse if it is safe to take this medication. Which is
the best reply by the​nurse?
​"Corticosteroids are safe to take during pregnancy
in some​cases, and you need the​medicine."
​"Let's call the doctor and pharmacist to double
check the safety profile of these​drugs."
​"That is an​error; you​shouldn't take corticosteroids
during​pregnancy."
​"If the doctor prescribed the​ medication, I'm sure
that​it's fine to take​it."
The nurse is preparing a program about acute
respiratory distress syndrome​ (ARDS) in the older
adult and plans to explain why this population is at
greater risk for the disease. Which topic should be
included in the​discussion? (Select all that​apply.)
Poor muscle strength
Lower functional residual capacity
Loss of elastic tissue
Increased chest diameter
Higher sedation requirements
The nurse is caring for an older adult client who
may need to be intubated. The family asks about
the potential risks. Which is the best reply by the​
nurse?
"​ There are no risks to​intubation."
​"The doctor feels that intubation is the best option
for your family​member."
​"Older adults may be more likely to experience
injury to the airway during​intubation."
​"Intubation and mechanical ventilation are not​
long-term solutions. They just allow the lungs to​
rest."
The nurse is caring for an adult who is diagnosed
with acute respiratory distress syndrome​ (ARDS)
after a​ near-drowning episode last week. Which
type of medication should the nurse anticipate the
provider ordering to help open​alveoli?
Inhaled nitric oxide
Surfactant therapy
Nonsteroidal​anti-inflammatory drugs​(NSAIDs)
Corticosteroids
The nurse is caring for a client with acute
respiratory distress syndrome​ (ARDS) who needs
an artificial airway to assist in maintaining an open
airway. Which airway will the nurse plan to
reposition every 8 hours while providing​care?
Endotracheal
Nasopharyngeal
Oropharyngeal
Tracheostomy
A client who is diagnosed with acute respiratory
distress syndrome​ (ARDS) requires mechanical
ventilation. Which ventilator mode should the nurse
expect to implement to promote pressure
throughout the respiratory​cycle?
Sensitivity
Positive​end-expiratory pressure​(PEEP)
Flow rate
Tidal volume​(TV)
The nurse is caring for a client who has been using
mechanical ventilation for several months after an
episode of sepsis and acute respiratory distress
syndrome​ (ARDS). Which ventilator setting should
the nurse anticipate the healthcare provider
ordering for​weaning?
Synchronized intermittent mandatory ventilation​
(SIMV)
Positive​end-expiratory pressure​(PEEP)
​Assist-control mode ventilation​(ACMV)
Bilevel ventilation​(BIPAP)
During assessment of a client with acute respiratory
distress syndrome​ (ARDS), the nurse notes an
oxygen saturation of​78% and a respiratory rate of
28​ breaths/min. The nurse notifies the healthcare
provider and should prepare for intubation using
which type of​airway?
Tracheostomy
Endotracheal tube
Oropharyngeal airway
Nasopharyngeal airway
The nurse is assessing an older adult client with
acute respiratory distress syndrome​(ARDS). Which
assessment finding indicates an early sign of
hypoxemia for this​client? (Select all that​apply.)
Agitation
Tachypnea
Confusion
Anxiety
Dyspnea
The nurse is providing care to a client with acute
respiratory distress syndrome​ (ARDS). Which
independent intervention should the nurse prepare
to perform for this​client? (Select all that​apply.)
Maintain the head of the bed at 30 degrees.
Recommend a prone position to facilitate
oxygenation.
Prescribe analgesia for pain.
Order a Foley catheter to monitor urine output.
Auscultate heart and lung sounds.
The nurse is planning care for a client with acute
respiratory distress syndrome​ (ARDS). Which
independent nursing intervention should the nurse
include in the care of this​ client? (Select all that​
apply.)
Maintain the head of the bed at less than 30
degrees.
Obtain a sputum culture.
Prescribe surfactant therapy.
Position the client in a prone position for 60 minutes
five times a day.
Suction the airway as needed.

The nurse is developing a plan of care for an older

adult client who presents with hypoxemia and
agitation. What nursing diagnosis is the priority for
this​client?
​Confusion, Risk for Acute
​Coping, Ineffective
Anxiety
​Pain, Acute

The nurse is caring for a client who is in the

process of weaning off of mechanical ventilation.
Which assessment finding should the nurse report
to the healthcare​provider? (Select all that​apply.)
Abdominal breathing
Oxygen saturation level of​98%
Respiratory rate of 18​beats/min
Pallor
Agitation

2.1 CPR/Basic Life Support

2.2 First Aid Training