MS Drills

NGN QUESTIONS
1. While crafting a care plan for a patient with Cushing's disease, which abnormal laboratory values would the nurse
anticipate? Please choose the appropriate options:
1. Elevated serum calcium levels
2. Elevated salivary cortisol levels
3. Elevated urinary cortisol levels
4. Reduced serum glucose levels
5. Reduced sodium levels
6. Elevated serum cortisol levels
2. In order to maintain oral hygiene for a patient in the process of recuperating from a transsphenoidal
hypophysectomy, what guidance should the nurse provide?
1. Gargle the mouth with saline solution.
2. Engage in regular toothbrushing sessions.
3. Utilize an electric toothbrush to cleanse the teeth.
4. Thoroughly use dental floss on the teeth.
3. Upon admission of a patient with syndrome of inappropriate diuretic hormone, what signs would the nurse likely
identify? Please choose the appropriate options:
1. Heightened thirst
2. Tachycardia
3. Excessive urination
4. Hostility
5. Muscular weakness
4. After achieving stability in Addison's disease, the nurse educates the client on managing stress. What guidance
should the nurse provide to the client?
1. Address and eradicate the sources of stress in daily life.
2. Utilize relaxation methods like engaging with music.
3. Consider antianxiety medication as a temporary measure during times of heightened stress.
4. Exercise caution when discussing and revisiting stressful experiences.
5. After conducting a comprehensive assessment, a nurse determines that the endeavors of a patient with type 2
diabetes mellitus (DM) to manage their blood glucose levels have yielded remarkably positive outcomes during the
preceding 3-month period. Which observation substantiates the nurse's deduction?
1. Hemoglobin A1c level at 5%
2. Absence of diabetic ketoacidosis (DKA) cases
3. Lack of ketones detected in the urine
4. Adverse results in the oral glucose tolerance test (OGTT)
6. A male aged 74, who has a medical history of type II diabetes, arrived at the emergency department due to an
alteration in his mental state.
NURSES’ NOTES
At 1200, a 74-year-old man with a medical background of type II diabetes was taken to the emergency department
by his spouse due to alterations in his mental condition compared to his usual state. The patient's wife reports that
he started his morning routine at 0600. Around 1100, he suddenly lost awareness of his surroundings, experienced
excessive sweating, and had difficulty speaking clearly. Breath sounds are normal, but there is a noticeable fruity
citrus smell on his breath, and he is breathing deeply and rapidly. The cardiac monitor indicates sinus tachycardia.
He is conscious and attentive, with equal and responsive pupils that react to light.
Vital Signs
Time 1200
Temp 99.5° F (37.5 °C)
P 119
RR 32 34
B/P 97/66 98/68 mmHg
Pulse oximeter 89% on RA
MEDICATIONS
Empagliflozin 10 mg PO daily
Sitagliptin / metformin 50-1000 mg PO daily
Valsartan 160 mg PO daily
Which four observations carry the greatest significance?

1. Breath sounds
2. Medical record of type II diabetes*
3. Respiratory condition*
4. Blood circulation*
5. Pupil reactions
6. Body temperature
7. Cognitive/mental status
8. Prescribed medications
7. The nurse initiates an IV and examines the laboratory results.
NURSES’ NOTES
At 1200, a 74-year-old man with a medical background of type II diabetes was taken to the emergency department
by his spouse due to alterations in his mental condition compared to his usual state. The patient's wife reports that
he started his morning routine at 0600. Around 1100, he suddenly lost awareness of his surroundings, experienced
excessive sweating, and had difficulty speaking clearly. Breath sounds are normal, but there is a noticeable fruity
citrus smell on his breath, and he is breathing deeply and rapidly. The cardiac monitor indicates sinus tachycardia.
He is conscious and attentive, with equal and responsive pupils that react to light.
At 12:15, the client discharged 30mL of urine with a dark amber color, which was subsequently sent for urinalysis.
In addition to this, a comprehensive metabolic panel, complete blood count (CBC), and arterial blood gas (ABG)
were ordered. An intravenous infusion of normal saline was initiated. The capillary glucose level measured 440.
Vital Signs
Time 12:00 12:15
Temp 99.5° F (37.5 °C) 99.5° F (37.5 °C)
P 119 115
RR 32 34 30
B/P 97/66 98/68 mmHg 98/70
Pulse oximeter 89% on RA 89% on RA
LAB REPORT
Lab Results Reference Range
ABG pH 7.20 7.35-7.45
ABG PC02 45 35-45
ABG HC03 33 22-26
Creatine (Serum) 1.8 0.5-1.5
Glucose random 436 70- 140
Other (urine) Positive ketones Negative
Potassium(serum) 3.4 3.5 to 5 mEq/L
Indicate whether each discovery aligns with ketoacidosis or hyperglycemic hyperosmolar syndrome. Each observation
could correspond with multiple conditions. Each column should contain at least one accurate choice.
Laboratory Report Ketoacidosis Hyperglycemic

hyperosmolar
syndrome
pH
Blood glucose
Serum Creatinine
Urine
8. Complete the sentence from the list of drop-down options.

The primary issue demanding the nurse's attention is ___________________________
1. Correcting pH
2. Restoring fluid volume*
3. Reducing glucose levels
9. Upon diagnosing the client with ketoacidosis, the nurse initiates the care planning process.
Click to designate the appropriateness of each nursing intervention as indicated, contraindicated, or non-essential.
Nursing Intervention Indicated Contraindicated Non-essential

Collect glycosylated hemoglobin A1C levels
Administer subcutaneous insulin glargine
Place an indwelling Foley catheter
Provide IV potassium infusion
Supervise EKG monitoring
Educate the client about pursed-lipped breathing
10. The nurse reviews and examines the prescribed orders.

• Admission to the Intensive Care Unit (ICU) with a ketoacidosis diagnosis is necessary.
• Administer a 1000ml intravenous bolus of 0.9% normal saline over a 30-minute period.
• Initiate an infusion of NSS with 20mEq of potassium chloride (KCL) per 100 mL at a rate of 125 mL/h.
• Commence a regular insulin infusion at a rate of 0.1 Units/kg/h following the fluid bolus.
• Perform hourly fingerstick blood glucose checks and adjust the insulin infusion as per the ICU protocol.
• Collect electrolyte samples every 2 hours.
• Maintain continuous cardiac monitoring.
Which actions should the nurse carry out during the execution of the treatment plan? Choose all that are applicable.
1. Initiate insulin infusion at a rate of 0.9 Units/hr following the bolus.
2. Be prepared to pause insulin administration if potassium levels decrease significantly*
3. Suggest intravenous fluids containing dextrose as glucose levels begin to normalize*
4. Permit the client to consume food once their condition becomes stable*
5. Watch for indications of potential fluid overload*
11. A client undergoing thrombolytic therapy through a continuous alteplase infusion experiences sudden intense
anxiety and reports itching. The nurse observes stridor, generalized urticaria, and hypotension. Which interventions
should the nurse anticipate? Select all that apply.
1. Halt the infusion.
2. Elevate the head of the bed.
3. Administer protamine sulfate.
4. Administer diphenhydramine.
5. Summon the Rapid Response Team (RRT).
12. A fellow employee brings a coworker to the emergency department exhibiting symptoms of headache, weakness,
and mild confusion. The healthcare provider diagnoses carbon monoxide poisoning. What is the initial action the nurse
should take?
1. Initiate gastric lavage.
2. Sustain body temperature.
3. Administer 100% oxygen through a mask.
4. Secure a psychiatric referral.
13. The nurse is providing discharge instructions for a client who underwent surgical removal of a fish hook embedded
in the eye. Although the fish hook has been successfully removed, the client currently experiences no vision in that
eye. The surgeon has explained that a corneal transplant may potentially restore some vision, but the procedure can
only take place after 6 to 8 weeks, provided there is no infection. What information should be included in the
discharge teaching plan?
1. Emphasize the importance of rest to alleviate strain on the eye and facilitate healing post-surgery.
2. Instruct the client to meticulously wash hands to maintain cleanliness in the area and minimize the risk of infection.
3. Encourage the client to express their emotions and feelings regarding the loss of vision.
4. Recommend maintaining a healthy diet to support the healing process and prevent constipation.
14. The nurse attending to a refugee evaluates which healthcare requirement takes precedence for this client:
1. Accessibility to housing
2. Accessibility to clean water
3. Accessibility to transportation
4. Accessibility to mental health care services
15. The nurse manager is reviewing the facility's tornado protocol with the staff. Which instructions should be part of
the discussion? Select all that apply.
1. Keep doors to client rooms open.
2. Shift beds away from windows.
3. Close window shades and curtains.
4. Cover clients who are confined to bed with blankets.
5. Guide ambulatory clients from the hallways back into their rooms.
16. A child receives a diagnosis of early hypovolemic shock after undergoing surgical intervention for a ruptured
appendix. Which nursing assessment findings validate this diagnosis?
1. Tachycardia, capillary refill exceeding 2 seconds, cold extremities, and weak distal pulses
2. Bradycardia, hypotension, mottled color, and weak distal pulses
3. Irritability and anxiousness, capillary refill exceeding 2 seconds, and absent distal pulses
4. Lethargy, cold extremities, reduced urine output, and absent distal pulses
17. A suspected anthrax outbreak transmitted through skin exposure prompts a client's admission to the emergency
department due to lesions on the hands. The healthcare provider prescribes antibiotics and releases the client. What
instructions should the nurse provide to the client? Select all that apply.
1. Complete the full course of prescribed antibiotics over 60 days.
2. Refrain from contact with other family members throughout the treatment duration.
3. Wear a mask continuously for 60 days.
4. Anticipate the resolution of skin lesions within 1 to 2 weeks.
5. Practice frequent handwashing.
18. A nurse is overseeing a group of clients in a medical unit at a rural hospital. Which client would the nurse be least
likely to monitor for the potential complication of a brain abscess?
1. Client with endocarditis
2. Client with idiopathic epilepsy
3. Client who has had a liver transplant
4. Client with meningitis
19. The nurse is attending to a client after the removal of a central line catheter when the client unexpectedly
experiences dyspnea and reports substernal chest pain. The client exhibits noticeable confusion and fear. Given these
symptoms, the nurse should consider which complication of central line use?
1. Myocardial infarction
2. Air embolus
3. Intrathoracic bleeding
4. Vagal response
20. The nurse educator is teaching the nurses in the ICU about the different shock and their clinical manifestations.
Put a tick on each manifestation corresponding to the type of shock.
Clinical Manifestation Hypovolemic Anaphylactic Septic Neurogenic

Shock Shock Shock Shock
1. Restless & Anxious
2. Cool, pale
3. Hypotension
4. Tachycardia
5. Tachypnea
6. Initially Increased Urine Output
7. Bradycardia
ANSWER:
Clinical Manifestation Hypovolemic Anaphylactic Septic Neurogenic

Shock Shock Shock Shock
1. Restless & Anxious / / /
2. Cool, pale Skin / / /
3. Hypotension / / / /
4. Tachycardia / / /
5. Tachypnea / / / /
6. Initially Increased Urine Output /
7. Bradycardia /
21. The nurse educates the parents of a 4-year-old who has been diagnosed with iron deficiency anemia regarding
possible side effects associated with the use of an iron supplement. The nurse gauges the need for further instruction
when the parents mention a side effect of the iron supplement as being related to which of the following factors:
1. Staining of teeth
2. Presence of black stools
3. Experience of a metallic taste
4. Darkening of urine
22. How should a nurse manage the wound suction device used for blood recovery following a left total knee
replacement to facilitate blood reinfusion within the first 6 hours post-surgery?
1. Dispose of the initial 500 mL in the suction container and await a full container before initiating reinfusion.
2. Once the designated amount is reached in the container, retrieve the blood and prepare it for intravenous reinfusion
for the client.
3. Segregate the blood from the drainage and reinfuse it back into the wound via the drainage system.
4. Extract the blood from the drainage system and send it to the blood bank for preparation for infusion.
23. What should be the nurse's initial priority intervention for an 8-year-old diagnosed with a vaso-occlusive sickle cell
crisis who presents with a severe headache?
1. Administer 6 L of oxygen via nasal cannula.
2. Evaluate and assess the client's neurological status.
3. Administer a narcotic analgesic through intravenous push (IVP).
4. Increase the client's intravenous (IV) rate.
24. The nurse recognizes the need for further instruction for a client undergoing leukemia induction therapy when the
client utters which of the following statements?
1. "I will schedule my activities with intervals for rest."
2. "I'm eager to return home to my cat!"
3. "I'll opt for a warm saline gargle instead of brushing my teeth."
4. "I need to report a temperature of 100°F (37.7°C)."
25. The nurse is formulating a discharge plan for a client undergoing chemotherapy for lymphoma. The plan should
incorporate the following:
1. Use a mask when venturing outside the home.
2. Rest as necessary.
3. Steer clear of individuals with colds or the flu.
4. Do not reduce protein intake in your diet.
5. Notify the healthcare provider (HCP) promptly if a fever arises.
26. A client who has received 50 mL of a unit of whole blood expresses low back pain. The nurse's initial response to
this symptom should be:
1. Reposition the client.
2. Assess the pain further.
3. Administer an analgesic.
4. Stop the blood transfusion.
27. Which of the following assessment findings should be a cause for concern in a child with sickle cell anemia?
1. He actively participates in baseball with the school team.
2. He consumes several carbonated drinks per day.
3. He requires eight to ten hours of sleep each night.
4. He occasionally uses ibuprofen to manage minor pain.
28. A patient is admitted from the emergency department after a fall down a flight of stairs at home. The patient's
vital signs are stable, and the medical history indicates a gastric stapling procedure performed 2 years ago. The
patient humorously mentions recent clumsiness and tripping. To gather more information, the nurse should inquire
about which of the following aspects? Please choose all applicable options.
1. "Are you experiencing any numbness in your extremities?"
2. "How much vitamin B12 are you currently receiving?"
3. "Are you experiencing feelings of depression?"
4. "Do you feel secure and safe in your home environment?"
5. "Are you ensuring an adequate intake of iron in your diet?"
29. The nurse is providing care for a 65-year-old patient undergoing a yearly physical exam. She stands at 60 inches
tall and weighs 81 kilograms. Her fasting blood sugar measures 134, and her total cholesterol is 175 mg/dL. Her
family history includes an aunt who passed away due to breast cancer at age 55. Her parents are alive and in good
health. She doesn't smoke and occasionally drinks a couple of glasses of red wine on the Jewish Sabbath. Her
mammograms show dense breast tissue. She's married and has never been pregnant.
VITAL SIGNS
Temperature: 98.2°F (36.8˚C)
Pulse: 101 beats per minute
Respirations: 16 breaths per minute
Blood Pressure (BP): 145/92 mmHg
Oxygen Saturation: 97%
Highlight or emphasize 5 information that raises the patient’s likelihood of developing breast cancer (Use the above
situation.
30. A patient with sickle cell disease is admitted with vaso-occlusive crisis and complains of severe abdominal and
flank pain. Which analgesic medication would be most appropriate for the nurse to administer immediately in the
patient's treatment protocol?
1. Oral administration of Ibuprofen 800 mg
2. Intravenous injection of Morphine sulfate 4 mg
3. Liquid form of Hydrocodone 5 mg orally
4. Transdermal patch application of Fentanyl 25 mcg/hr
31. CASE STUDY QUESTION 1

7:00 The nurse intends to visit a patient who was released from the hospital a week ago. The nurse will go through
the discharge summary in the medical records and the Nurses' Notes from the earlier home visit conducted the day
after the hospital discharge.
Health History
1 Week Prior: Three months ago, this 32-year-old individual experienced a T6 spinal cord injury due to a motor
vehicle accident resulting in lower body paralysis. The incident involved a collision with a truck, causing the client's
car to overturn three times and land in a roadside ditch. The client was trapped in the car, with severe damage to
the lower body from the car's impact. A three-month hospitalization followed, with emergency care initially provided
and subsequent monitoring for complications. Rehabilitation, including physical and occupational therapy, was
administered, and home care services were established for discharge.
The client is married, and their spouse manages the care of their two children, aged 7 and 10. Prior to the injury,
the client worked as a forklift driver at an industrial manufacturing company.
There's no prior medical history, no medication intake, no smoking, and occasional alcohol consumption at social
events.
NURSES’ NOTES
One day after being discharged: The client is alert and oriented, sitting up in a wheelchair. They mention using a
transfer board with the assistance of their spouse to move from bed to the wheelchair. The client notes spending
the entire day in the wheelchair, expressing a fair appetite and regular fluid intake. They complain of fatigue,
occasionally falling asleep in the wheelchair during the day. Nighttime sweating is reported, with cessation upon
repositioning, but difficulty returning to sleep. The client mentions experiencing muscle spasms in the lower body
and denies any headaches. They self-catheterize every 6 hours, and their last bowel movement occurred on the day
of hospital discharge. Vital signs are as follows:
Temperature = 98.6°F (37.0°C)
Heart Rate = 86 BPM
Respiratory Rate = 18 bpm
Blood Pressure = 120/78 mm Hg
Highlight the findings in the assessment that are of immediate concern.
Vital Signs:
Heart Rate = 60 BPM
Blood Pressure = 150/90 mm Hg.
The client is alert and oriented. They mention having a poor appetite for the past few days and experiencing
nausea. The client complains of ongoing tiredness, night sweats, and worsening muscle spasms in the lower
body. There was one instance of incontinence during the night. The client reports feeling like they might be
coming down with the flu due to symptoms such as nausea, nasal congestion, and intense headaches. They note
that their last bowel movement occurred four days ago.
32. QUESTION NUMBER 2

The nurse examines the assessment findings that require immediate attention to form an interpretation regarding the
client's condition. Complete the sentence by selecting an option from the provided list.
The nurse determines that the client assessment findings would most likely be the result of ____________________.
1. Anxiety
2. Noxious stimuli
3. Further spinal cord
damage
4. Urinary Incontinence
caused by the__________________________.
1. Infection
2. Paralysis
3. Constipation
4. Worsening muscle spasms
33. QUESTION 3
After conducting a focused assessment on the client, the nurse identifies potential risk conditions. Which three
conditions pose the highest risk for the client's development?
1. ☐ Malnutrition
2. ☐ Spinal shock
3. ☐ Hyperthermia
4. ☐ Neurogenic shock
5. ☐ Autonomic dysreflexia
6. ☐ Skin breakdown
7. ☐ Infection
34. QUESTION 4
Given the highest-risk conditions, the nurse promptly formulates a care plan for the client along with potential
interventions. Click to indicate whether each potential intervention for the client’s care is indicated or not indicated.
Possible Intervention Indicated Not

Indicated
1. Help the client return to bed and position supine
2. Regularly monitor blood pressure.
3. Examine for bladder distention.
4. Assess for bowel impaction.
5. Get in touch with the physician.
6. Apply cold packs on the back of the client’s neck and in the axilla areas.
7. Administer sublingual nifedipine.
35. QUESTION 5
The nurse promptly evaluates the care plan and takes steps to address the complication the client is facing.
Which actions would the nurse perform immediately? Select all that apply:
☐ 1. Catheterize the client.
☐ 2. Loosen the client’s clothing.
☐ 3. Remove impacted stool digitally.
☐ 4. Assist the client into bed in an upright position.
☐ 5. Send a urine specimen to the lab for culture and sensitivity.
☐ 6. Educate the client on measures to prevent autonomic dysreflexia.
☐ 7. Contact EMS to transport the client to the hospital.
36. The nurse, having implemented the interventions, evaluated the client and recorded the following in the Nurses'
Notes.
Vital Signs:
Heart Rate = 77 BPM
Blood Pressure = 134/80 mm Hg.
NURSES’ NOTES
The client was assisted to bed and is sitting upright.
Bladder distended, with 400 mL urine output obtained through catheterization.
Urine collected for culture and sensitivity pending physician’s order.
Moderate stool removed digitally.
Client teaching initiated about measures to prevent autonomic dysreflexia.
Reports a mild headache and nasal stuffiness.
The nurse educates the client on preventive measures for avoiding episodes of autonomic dysreflexia. Which
statement from the client shows understanding or signifies the need for additional instruction? Mark an X in either the
Understood or Requires Further Teaching column.
Client Statement Understood Requires Further
Teaching
1. "I should adhere to the bowel regimen daily."
2. "A low-fiber diet can alleviate abdominal discomfort and muscle spasms."
3. "I must monitor my bladder for distension and prevent it from becoming too
full."
4. "If I experience any of these symptoms, I'll immediately call 911 for hospital
transport."
5. "My spouse should assist me in checking my skin for any signs of redness or
skin breakdown."
6. "It's advisable to return to bed during the day and limit wheelchair use to 2
to 3 hours daily."
37. Caring for a client diagnosed with amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease), the nurse should
prioritize:
1. Evaluating the client's respiratory condition
2. Offering an alternative method of communication
3. Directing the client and their family to community support groups
4. Establishing a regimen of active range-of-motion exercises
38. The charge nurse is assigning clients on a neuro-medical floor. The most experienced nurse should be assigned to:
1. The elderly client currently undergoing a stroke in evolution.
2. The client diagnosed with a transient ischemic attack 48 hours ago.
3. The client diagnosed with Guillain-Barré syndrome expressing leg pain.
4. The client with Alzheimer’s disease who is wandering in the halls.
39. When evaluating a client with multiple sclerosis for potential complications of the disease, the nurse should
examine the client for which symptoms? Please select all that apply.
1. Dehydration
2. Falls
3. Seizures
4. Skin breakdown
5. Fatigue
40. A client is admitted with suspected Guillain-Barre syndrome. The nurse anticipates that the cerebrospinal fluid
(CSF) analysis would reveal which of the following to confirm the diagnosis?
1. CSF protein of 10mg/dL and WBC 2 cells/mm3
41. A client experiencing myocardial infarction and developing cardiogenic shock requires careful assessment for
which condition?
1. Pulsus paradoxus
2. Ventricular dysrhythmias
3. Increasing diastolic blood pressure
4. Decreasing central venous pressure
42. A client brought to the emergency department with atrial fibrillation, displaying a heart rate of 160 bpm, requires
the nurse to prioritize which prescription first?
1. Administer a heparin bolus.
2. Administer a beta-blocker.
3. Administer oxygen through a nasal cannula.
4. Prepare the client for an immediate cardioversion.
43. A client is brought to the emergency department with atrial fibrillation and is uncertain about the duration of the
rapid pulse and irregular heart rate. What goals of care should the nurse prioritize at this time? Choose all that apply.
1. Convert the heart rate to sinus rhythm.
2. Decrease cardiac output and workload.
3. Limit activity to being out of bed.
4. Maintain a ventricular response below 100 bpm.
5. Prevent an embolic stroke.
44. A healthcare provider (HCP) prescribes a second medication to enhance blood pressure control for a client with
poorly managed blood pressure on a single antihypertensive drug. If the HCP orders the following medication
combinations, which combination should the nurse question?
1. Atenolol (Tenormin) and metoprolol (Lopressor)
2. Metolazone (Zaroxolyn) and valsartan (Diovan)
3. Captopril (Capoten) and furosemide (Lasix)
4. Bumetanide (Bumex) and diltiazem (Cardizem)
45. A patient presents to the emergency room with substernal chest pain radiating to the left jaw. Which ECG finding
indicates a potential acute myocardial infarction?
1. Elevated or peaked P wave
2. Alterations in ST segment
3. Minimal QRS wave
4. Prominent U wave
46. Which patient should the telemetry nurse prioritize for assessment first after receiving the morning shift report?
1. The patient diagnosed with deep vein thrombosis exhibiting an edematous right calf.
2. The patient diagnosed with mitral valve stenosis experiencing heart palpitations.
3. The patient diagnosed with arterial occlusive disease presenting with intermittent claudication.
4. The patient diagnosed with congestive heart failure demonstrating pink frothy sputum.
47-50 CLOZE
The nurse is performing the morning assessment on a patient who has breast cancer. The patient states her gown
feels tight and uncomfortable at the neckline. She also reports feeling uneasy and having a restless night with
difficulty breathing and a dry cough.
Vital signs:
Temperature: 98.6°F (37°C)
Pulse: 110 beats/minute
Respirations: 30 breaths/minute
Oxygen Saturation: 92% on room air
Assessment Findings:
The patient is alert and oriented. Facial and periorbital edema and
jugular vein distention are noted and are more pronounced in the supine
position.
Instructions: Complete the sentences by choosing the most probable option for the omitted information that
corresponds with the same numbered list of options provided.
The nurse has concerns about a potential oncology emergency and evaluates the patient for additional signs and
symptoms of ____________1____________. The primary nursing assessment is __________2_____________.
_________3____________would be a threatening sign for this oncology emergency. The initial nursing action is to
__________4____________.
Blank 1 Blank 2 Blank 3 Blank 4
1.Third space syndrome 1. Progression of edema 1. Electrocardiogram 1. Establish IV access
in the extremities changes
2. Superior vena cava 2. Auscultation of breath 2. Hypotension 2. Alert the rapid
syndrome sounds response team
3. Tumor lysis syndrome 3. Patency of airway 3. Stridor 3. Place patient in a
Fowler's position
4. Cardiac tamponade 4. Auscultation of heart 4. Chest pain 4. Obtain order for an IV
sounds diuretic
5. Cardiac artery rupture 5. Assess for headache 5. Intense back pain 5. Oxygenate using a
bag-valve-mask
CASE STUDY 51-56

51. A female patient, aged 57, who was involved in a serious motor vehicle collision, has been admitted to the
intensive care unit due to rib fractures.
3:00 PM
The patient's condition is characterized by lethargy but is responsive when aroused. She is experiencing chest pain
during inhalation and is struggling to breathe. The chest pain intensifies to a level of 5 out of 10 during inhalation.
There are no breath sounds detectable on the front and back of the lower left chest wall. Chest movement is
uneven, with less expansion on the left side. The patient exhibits cyanosis of the lips and fingertips. There is
bruising on the front of the chest from the seat belt. An intravenous (IV) line has been initiated, delivering a
solution of 0.9% normal saline at a rate of 100 ml per hour in the left arm. Additionally, the patient has been placed
on 4 liters of oxygen per nasal cannula.
3:30 PM
The client is experiencing worsening breathlessness, struggling with breathing, exhibiting an elevated heart rate,
and a decreasing blood pressure. Heart sounds are muffled, and the client is in a stuporous state. Additionally,
tracheal deviation has been observed.
VITAL SIGNS 3:00 PM

Temperature 98.4˚F (36.8˚C)
Pulse rate 98 per minute
Respiratory rate 28 breaths per minute
Blood pressure 138/90
Pulse oximeter reading 89%
Pain level 5 out of 10
Which of the following assessment findings necessitate immediate attention? Please check all that apply:
1. Heart rate of 98 beats/min
2. Respiratory rate of 28/min
3. Pulse oximeter reading of 89%
4. Blood Pressure of 138/90
5. Pain level of 5/10 with inspiration
6. Temperature of 98.4˚F
7. Absence of breath sounds
8. Bruising on the anterior chest
9. Cyanosis of lips and fingertips
3:00 PM The patient's condition is characterized by lethargy but is responsive when aroused. She is experiencing
chest pain during inhalation and is struggling to breathe. The chest pain intensifies to a level of 5 out of 10 during
inhalation. There are no breath sounds detectable on the front and back of the lower left chest wall. Chest
movement is uneven, with less expansion on the left side. The patient exhibits cyanosis of the lips and fingertips.
There is bruising on the front of the chest from the seat belt. An intravenous (IV) line has been initiated, delivering
a solution of 0.9% normal saline at a rate of 100 ml per hour in the left arm. Additionally, the patient has been
placed on 4 liters of oxygen per nasal cannula.
At 3:30 PM, the client is experiencing worsening breathlessness, struggling with breathing, exhibiting an elevated
heart rate, and a decreasing blood pressure. Heart sounds are muffled, and the client is in a stuporous state.
Additionally, tracheal deviation has been observed.
VITAL SIGNS 3:00 PM 3:30 PM
Temperature 98.4˚F (36.8˚C) 98.0˚F (36.6 ˚C)
Pulse rate 98 per minute 112 per minute
Respiratory rate 28 breaths per minute 36 breaths per minute
Blood pressure 138/90 98/60
Pulse oximeter reading 89% 80% 4L NC
Pain level 5 out of 10 10/10
Lab Results Reference range

ABG pH 7.25 7.35-7.45
ABG P02 50 mm Hg 75-100 mm Hg
ABG PC02 80 mm Hg 35-45 mmHg
ABG SaP02 84 % 95-100%
ABG HC03 27 mEq/L 22-26 mEq/L
The nurse examines the blood gas report and conducts a follow-up assessment of the client.
For each observation, please click to specify whether it aligns with pulmonary contusion, cardiac tamponade, or
tension pneumothorax. It's possible for each observation to be associated with more than one condition. Ensure that
each column contains at least one observation.
Cardiac Tamponade Tension Pneumothorax Pulmonary Contusion

1. Absent breath sounds
2. Paradoxical chest movement
3. Blood gas
4. Hypotension
5. History of chest trauma
6. Muffled heart sounds
7. Chest pain
8. Crooked trachea
3:00 PM The patient's condition is characterized by lethargy but is responsive when aroused. She is experiencing
chest pain during inhalation and is struggling to breathe. The chest pain intensifies to a level of 5 out of 10 during
inhalation. There are no breath sounds detectable on the front and back of the lower left chest wall. Chest
movement is uneven, with less expansion on the left side. The patient exhibits cyanosis of the lips and fingertips.
There is bruising on the front of the chest from the seat belt. An intravenous (IV) line has been initiated, delivering
a solution of 0.9% normal saline at a rate of 100 ml per hour in the left arm. Additionally, the patient has been
placed on 4 liters of oxygen per nasal cannula.
At 3:30 PM, the client is experiencing worsening breathlessness, struggling with breathing, exhibiting an elevated
heart rate, and a decreasing blood pressure. Heart sounds are muffled, and the client is in a stuporous state.
Additionally, tracheal deviation has been observed.
VITAL SIGNS 3:00 PM 3:30 PM

Temperature 98.4˚F (36.8˚C) 98.0˚F (36.6 ˚C)
Pulse rate 98 per minute 112 per minute
Respiratory rate 28 breaths per minute 36 breaths per minute
Blood pressure 138/90 98/60
Pulse oximeter reading 89% 80% 4L NC
Pain level 5 out of 10 10/10

ABG pH 7.25 7.35-7.45
ABG SaP02 84 % 95-100%
Complete the sentence by selecting an option from the list provided.
The client is most likely experiencing _______________ 1. cardiac tamponade

2. pulmonary contusion
3. tension pneumothorax
as primarily indicated by ________________________ 1. the laboratory report
2. respiratory assessment
3. cardiovascular assessment
54. Which of the following actions should the nurse expect to be ordered? Please select all that apply:
1. Assist with thoracentesis
2. Administer pain medication
3. Insert a Foley catheter
4. Obtain a stat chest X-ray
5. Set up a chest drainage system
6. Transfuse a unit of blood
3:00 PM
3:30 PM
3:45 PM
A chest X-ray was performed. The patient received a dose of morphine. The healthcare provider utilized a 14-gauge
spinal needle to withdraw air from the chest cavity and placed a 28F chest tube in the lower left chest wall. The
chest tube was connected to a wall suction set at 20 cm H2O and a water seal drainage system. Fluctuations were
observed in the water seal chamber. Approximately 20 ml of lightly colored red fluid was collected in the drainage
chamber. Crackling lung sounds (rales) were detected in the right lung fields, while breath sounds on the left were
notably reduced.
VITAL SIGNS 3:00 PM 3:30 PM 3:45 PM

Temperature 98.4˚F (36.8˚C) 98.0˚F (36.6 ˚C) 98.0˚F (36.6 ˚C)
Pulse rate 98 per minute 112 per minute 80 per minute
Respiratory rate 28 breaths per minute 36 breaths per minute 23 breaths per minute
Blood pressure 138/90 98/60 127/97
Pulse oximeter reading 89% 80% 4L NC 95% 4L NC
Pain level 5/10 10/10 5/10

ABG pH 7.25 7.35-7.45
ABG SaP02 84 % 95-100%
DIAGNOSTIC TEST
Chest X-ray: "X-ray of the chest reveals a fracture of the 6th and 7th ribs on the left side and a
significant tension pneumothorax."
The patient has been diagnosed with a pneumothorax, and the healthcare provider has inserted a chest tube.
Click to indicate whether each nursing action is indicated or not."
Nursing Actions Indicated Not indicated

1. Administer IV morphine sulfate as required.
2. Position the drainage system at heart level.
3. Assist with ambulation in the hallway.
4. Monitor changes in the water seal chamber.
5. Schedule a follow-up chest X-ray for the morning.
6. Record chest tube drainage during each shift.
7. Change the chest dressing at every shift."
3:00 PM
3:30 PM
3:45 PM
A chest X-ray was performed. The patient received a dose of morphine. The healthcare provider utilized a 14-gauge
spinal needle to withdraw air from the chest cavity and placed a 28F chest tube in the lower left chest wall. The
chest tube was connected to a wall suction set at 20 cm H2O and a water seal drainage system. Fluctuations were
observed in the water seal chamber. Approximately 20 ml of lightly colored red fluid was collected in the drainage
chamber. Crackling lung sounds (rales) were detected in the right lung fields, while breath sounds on the left were
notably reduced.
4:00 PM
The patient is currently in a supine position in bed. The chest tube is draining a minimal quantity of pale red fluid
into the collection chamber. There is symmetrical movement of the chest observed, and the lips and fingertips
exhibit a healthy pink color.
VITAL SIGNS 3:00 PM 3:30 PM 3:45 PM 4:00 PM

Temperature 98.4˚F (36.8˚C) 98.0˚F (36.6 ˚C) 98.0˚F (36.6 ˚C) 98.0˚F (36.6 ˚C)
Pulse rate 98 per minute 112 per minute 80 per minute 74 per minute
Respiratory rate 28 breaths/minute 36 breaths/minute 23 breaths/minute 20 breaths/minute
Blood pressure 138/90 98/60 127/97 124/74
Pulse oximeter reading 89% 80% 4L NC 95% 4L NC 98% 4L NC
Pain level 5/10 10/10 5/10 5/10
Laboratories Results Reference range

ABG pH 7.25 7.35-7.45
ABG SaP02 84 % 95-100%
DIAGNOSTIC TEST
Chest X-ray: "X-ray of the chest reveals a fracture of the 6th and 7th ribs on the left side and a
significant tension pneumothorax."
The nurse conducts a follow-up assessment of the patient's condition and then proceeds to:
Finish the sentence by making a selection from the list of choices provided.
The nurse evaluates the client's condition, finding it to be __________________________.
1. Improving
2. Deteriorating
3. Unchanged
The next steps for the nurse should include ____________________________.

1. Checking for air leaks
2. Obtaining a stat blood gas
3. Monitoring breath sounds
57. The nurse is overseeing a nursing student providing care for a patient with shortness of breath who has expressed
an interest in smoking cessation. Which questions would the nurse recommend the student ask to assess nicotine
dependence?
Instructions: Review the case study below and encircle the numbers that best answer the question.
1. When do you smoke shortly after waking up in the morning?
2. Do other members of your family smoke?
3. Do you smoke when you are ill?
4. Do you wake up in the middle of your sleep to smoke?
5. Do you smoke indoors or only outside?
6. Do you have a difficult time not smoking in places where it is not allowed?
7. Have you tried e-cigarettes?
8. Has anyone in your family developed lung cancer?
9. Have you ever attempted to quit smoking?
58. The supervising nurse is overseeing an RN located in the medical-surgical unit to the emergency department. The
lead nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which instructions would the
supervising nurse clearly provide to the RN? Select all that apply.
1. Position the patient supine and turned on their side.
2. Apply direct lateral pressure to the nose for 5 minutes.
3. Maintain standard body substance precautions.
4. Apply ice or cold compresses to the nose.
5. Instruct the patient not to blow the nose for several hours.
6. Teach the patient to avoid vigorous nose blowing.
59. The nurse is providing nutritional guidance to the parents of a preschooler who has had a tonsillectomy and
adenoidectomy. Which dietary selection made by the parents would demonstrate effective teaching?
1. Meatloaf and raw carrots
2. Pork and noodle casserole
3. Cream of chicken soup and orange sherbet
4. Hotdog and potato chips
60. An 11-year-old has been admitted for the management of an asthma attack. What sign suggests that urgent
action is required?
1. Scant, abundant mucus discharge
2. Cough that produces mucus
3. Intercostal retractions
4. A breathing rate of 20 breaths per minute
51. The nurse is caring for an 83-year-old female admitted to medical unit with a urinary tract infection.
Nurse's Documentation:
0930: Admission notes for the patient received from the emergency room indicate dehydration, along with new-
onset incontinence and mild confusion. The patient, who has recently lost their spouse and is now residing with
their daughter and son-in-law, has been experiencing decreased oral fluid intake over the past week. The daughter
reports foul-smelling, pink-tinged urine, incontinence, and a low-grade fever in the patient. There have been no
reports of pain or burning, but the patient has displayed restlessness and mild confusion. Upon admission to the
medical unit, the patient was alert and oriented only to person, displaying pleasant and cooperative behavior. Vital
signs include a temperature of 101.8°F (38.7°C), heart rate of 96, respiratory rate of 18, and blood pressure of
105/52. Pulse oximetry reading on room air is 97%. The patient's skin is dry with poor turgor, and neck veins
appear flat. Frequent use of a bedpan has resulted in small volumes of concentrated, pinkish, foul-smelling urine.
The patient denies experiencing pain or burning. Urine and blood cultures have been obtained, with pending results.
The daughter has reported a Sulfa allergy.
1000: The patient received the first dose of IV ciprofloxacin and an IV normal saline bolus. Additionally,
acetaminophen 650 mg was administered orally to address the fever.
1400: The patient's vital signs indicate a temperature of 100.2°F (37.8°C), heart rate of 85, respiratory rate of 16,
and blood pressure of 134/64. Pulse oximetry reading on room air is 97%. The patient is receiving IV normal saline
at a rate of 50 cc/hr through a left peripheral line. The patient remains calm and is encouraged to maintain
adequate fluid intake. The patient has continued to use the bedpan, resulting in slightly more dilute, yellow, and
cloudy urine, with an output of 450 mL since the fluid bolus.
1800: An incident occurred where Unlicensed Assistive Personnel (UAP) called for assistance in the patient's room.
The patient suddenly became restless, disoriented, and exhibited fluctuating levels of consciousness. The patient
pushed their tray away and tampered with the IV line, expressing a strong desire to leave their bed. Reorienting the
patient to their name, location, and situation proved to be challenging. Vital signs include a temperature of 99.8°F
(37.6°C), heart rate of 80, respiratory rate of 20, and blood pressure of 138/69. Pulse oximetry reading on room air
is 97%.
Drag 1 condition and 1 finding to fill in the blanks of the following sentence.
At 1800, it is highly probable that the patient is exhibiting signs indicative of___________________________
1.Hypovolemic shock
2. Respiratory distress syndrome
3. Delirium
4. Chronic renal failure
5. End-stage Alzheimer’s
as evidenced by ______________________________
1. Heart rate decrease
2. Decrease in serum creatinine
3. Urinary color/character
4. Disorientation
5. Respiratory status
52. A client seeks clarification from a nurse regarding the healthcare provider's instructions for an upcoming
cystectomy with an ileal conduit for urinary diversion. In explaining this procedure, the nurse should mention that:
1. No stoma is required in this surgery, and the normal anatomical urinary flow remains intact.
2. A permanent external urinary collecting device will be necessary.
3. Urinary continence can be achieved through muscle control and Kegel exercises.
4. Bladder retraining will be taught during the recovery process.
53. Which interventions should a nurse include when caring for a female client experiencing new-onset urge urinary
incontinence? Please select all that apply:
1. Take the client to the bathroom every 4 hours.
2. Administer diuretics at supper time so the bladder is empty at night.
3. Turn on the water or flush the toilet to assist the client to void.
4. Space fluids at regular intervals during the day and limit fluids after the dinner hour.
5. Instruct the client on insertion of vaginal weights to be worn throughout the day.
54. An adolescent male who has a history of spinal cord injury has reported experiencing periodic episodes of urine
leakage. When developing the client's care plan, a nurse should document the nursing diagnosis as follows:
1. Functional Urinary Incontinence
2. Reflex Urinary Incontinence
3. Stress Urinary Incontinence
4. Urge Urinary Incontinence
55. An 84-year-old patient was transferred to an acute care unit from an assisted-living facility due to a low-grade
fever and sudden confusion. The patient's daughter informed the admitting nurse that her mother had a stroke two
years ago, resulting in left-sided weakness and urinary incontinence. The patient had been residing in the assisted
living facility for the past five months. The patient has a longstanding history of well-controlled type 2 diabetes.
However, the daughter had not been able to visit her mother at the facility until today due to the COVID-19 pandemic.
During her visit, the daughter noticed that her mother was lethargic, disoriented, and unable to walk with her walker.
Point-of-care testing in the emergency department indicated the presence of multiple bacteria in the patient's urine
and a fasting blood sugar level of 331 mg/dL (18.4 mmol/L). The patient's blood pressure is currently 96/48 mm Hg.
After reviewing the patient's assessment findings, the nurse concludes that the patient most likely has which of the
following condition. Select all that apply.
1. Urosepsis
2. Delirium
3. Dehydration
4. COVID-19
5. DKA
6. Transient ischemic attack
7. Hyperglycemic hyperosmolar syndrome
56. After administering oxycodone (OxyContin) to an 86-year-old client recovering from hip surgery, the nurse should
monitor the client for which potential side effects?
1. Elevated blood glucose levels
2. Respiratory alkalosis
3. Urinary retention
4. Decreased appetite
57. A nurse is examining the hospital admission orders for a patient diagnosed with acute prostatitis. Before
implementing these orders, which one should the nurse potentially raise concerns about?
1. Initiate intravenous administration of trimethoprim/sulfamethoxazole (Bactrim) at a dosage of 1 gram every 6
hours.
2. Administer ibuprofen (Motrin) orally at 600 mg every 6 hours as needed (prn).
3. Maintain bedrest for the patient with bathroom privileges.
4. Place a Foley urinary drainage catheter.
58. A nurse is providing education to the parent of a male infant client diagnosed with phimosis. Which key concept
should the nurse emphasize during the teaching session?
1. Periodically, the constriction may impede the urine flow, leading to a dribbling stream.
2. As the infant grows and starts toilet training, achieving a straight urine stream may become challenging.
3. It is essential to gently retract the foreskin from the tip of the penis regularly to prevent urinary retention.
4. Keep an eye out for any testicular enlargement, as fluid accumulation may occur.
59. When caring for a client with a history of benign prostatic hypertrophy (BPH), what actions should the nurse take?
Please select all appropriate options:
1. Ensure the client has privacy and ample time for voiding.
2. Continuously monitor the client's fluid intake and urine output.
3. Catheterize the client to assess postvoid residual urine.
4. Inquire with the client about any signs of urinary retention.
5. Perform a urine test to check for the presence of hematuria.
60. patient who underwent a transurethral resection of the prostate is experiencing urinary dribbling after the removal
of their Foley catheter on the second day postoperatively. The nurse has observed that the patient had a 200 mL urine
output in the past 8 hours with a 1,000-mL intake. What should be the nurse's initial action?
1. Apply a condom catheter.
2. Check for bladder distention.
3. Collect a urine sample for culture.
4. Educate the client on Kegel exercises.
71. The nurse is preparing to educate a patient with a new diagnosis of osteoporosis about strategies for preventing
falls. Which teaching points should the nurse ensure to include? Select all that are applicable.
1. Utilize a hip protector when engaging in activities that may lead to falls.
2. Remove throw rugs and other obstacles at home.
3. Incorporate exercise to help strengthen your muscles.
4. Expect occasional bumps and bruises when moving around.
5. Rest when you are feeling fatigued.
6. Avoid consuming three or more alcoholic drinks per day.
72. In the orthopedic unit, the nurse is prioritizing assessments. Which client should the nurse evaluate first?
1.The client, who underwent open reduction and external fixation (ORIF) of the right hip two weeks ago, and is
experiencing pain while walking.
2. The client, who had a left total knee replacement (TKR) surgery ten days ago but is declining to use the continuous
passive motion (CPM) machine.
3. The client, who had an L3–L4 laminectomy surgery a week ago, and is reporting numbness and tingling in the feet.
4. The client admitted to the rehabilitation unit from the orthopedic surgical unit following a motor vehicle accident
(MVA).
73. A client who has been prescribed alendronate (Fosamax) for osteoporosis should receive which instruction?
1. After taking the medication, remain in bed and avoid activity for a minimum of 30 minutes.
2. Following medication administration, refrain from sudden or fast movements.
3. Take the medication with water exclusively.
4. Ensure at least a one-hour gap between taking this medicine and any other medications.
74. For a child with spastic cerebral palsy starting botulinum toxin type A injections, which treatment goals should the
healthcare team establish related to botulinum toxin? Please select all that apply.
1. Enhanced nutritional well-being
2. Alleviated discomfort caused by spasticity
3. Enhanced motor function
4. Boosted self-confidence and self-esteem
5. Minimized the burden on caregivers
6. Mitigated speech impediments
75. The nurse delegates the task of measuring vital signs to an experienced assistant personnel (AP). The patient has
been diagnosed with osteomyelitis. Which vital sign value should the nurse instruct the AP to report immediately for
this patient?
1. Temperature of 101°F (38.3°C)
2. Blood pressure of 136/80 mm Hg
3. Heart rate of 96 beats per minute
4. Respiratory rate of 24 breaths per minute
76. The nurse observes the assistant personnel (AP) carrying out these actions for a patient with carpal tunnel
syndrome (CTS). Which action should prompt the nurse to intervene immediately?
1. Organizing the patient's meal tray and slicing their meat.
2. Supplying warm water and aiding the patient with their bathing routine.
3. Adjusting the patient's splint into a hyperextension posture.
4. Cautioning the patient against lifting excessively heavy items.
77. The emergency department nurse receives a call about a patient with a traumatic finger amputation. What
instructions will the nurse provide to the patient's spouse? Please select all that apply.
1. Wrap the completely severed finger in dry sterile gauze or a clean cloth.
2. Place the finger in a watertight, sealed plastic bag.
3. Position the bag directly on ice.
4. Elevate the affected extremity above the patient's heart.
5. Examine the amputation site and apply direct pressure with layers of dry gauze.
6. After performing these steps, call 911 and check the patient for breathing.
78. The home health nurse is attending to a client experiencing a flare-up of rheumatoid arthritis. To minimize the
risk of knee joint deformities, the nurse should:
1. Advise the client to walk without flexing the knees.
2. Promote movement within the confines of discomfort.
3. Guide the client to sit primarily in a reclining chair.
4. Recommend the client to stay in bed only while the joints are painful.
79. During a physical examination of a one-month-old infant, a nurse observes blue sclerae in the infant's eyes. The
nurse suspects that the infant may have:
1. Juvenile arthritis.
2. Tay-Sachs disease.
3. Muscular dystrophy (MD).
4. Osteogenesis imperfecta.
80. Which information should the nurse incorporate into the educational session while preparing a client for
arthrocentesis? Please select all that apply.
1. "A local anesthetic agent may be injected into the joint site for your comfort."
2. "A syringe and needle will be used to withdraw fluid from your joint."
3. "The procedure, although not painful, will provide immediate relief."
4. "We will encourage you to maintain joint mobility after the procedure to enhance blood circulation."
5. "You will be required to wear a compression bandage for several days following the procedure."
81. A 25-year-old patient who is using hydroxychloroquine to manage rheumatoid arthritis mentions experiencing
visual impairment in their left eye. What does this observation suggest?
1. The formation of a cataract.
2. Potential retinal degeneration.
3. An aspect of the disease progression.
4. A coincidental event.
82. The nurse is getting a patient ready for cataract surgery and is mindful of the following:
1. Mydriatics will be employed to enlarge the pupil.
2. Miotics will be utilized to reduce the size of the pupil.
3. A laser will be employed to refine and reshape the lens.
4. Silicone oil injections will be administered to secure the positioning of the retina.
83. The nurse at the pediatric outpatient clinic is conducting an admission assessment for a 6-year-old accompanied
by their parent. The child has complained of right ear discomfort lasting for the past three days. The nurse records the
subsequent assessment findings.
Describes right ear pain persisting for three days, characterized as continuous and aching without spreading to
other areas. Denies experiencing dry mucous membranes, eye discharge, nasal drainage, or throat discomfort.
Examination of the oropharynx reveals it to be pink, moist, with no signs of redness, swelling, or exudate.
Reports no exposure to sick individuals and has been consistently attending school for full days. Additionally,
mentions swimming daily over the past week. Denies any neck stiffness, neck swelling, or enlarged lymph nodes.
No complaints of cough, wheezing, or breathing difficulties, and lung sounds are clear upon assessment.
Upon palpation and manipulation of the right auricle, tenderness is observed, and there is redness in the ear canal;
however, there is no discharge. Conversely, the left auricle is non-tender. Immunizations are current, and there are
no known allergies.
VITAL SIGNS
Weight: 55 pounds, placing them in the 59th percentile.
Height: 49.25 inches, in the 55th percentile.
BMI: 15.94, indicating the 58th percentile.
Temperature: 97.9°F (36.6°C) recorded using a temporal thermometer.
Heart Rate: 98 beats per minute.
Respiratory Rate: 18 breaths per minute.
Blood Pressure: 108/70 mm Hg.
Finish the sentence by selecting words from the options provided below and placing them in the blanks.
The nurse concludes that the child is dealing with otitis externa based on assessment findings which encompass
_______________________________, ___________________________, and ___________________________.
1. Absence of any sick contacts 1. No complaints of neck stiffness 1. No cough reported

2. Experiencing ear pain but without 2. Up-to-date on immunizations 2. No swollen lymph nodes
a fever 3. Engaging in daily swimming for 3. Tenderness observed when
3. Regularly attending full school the past week manipulating the right auricle
days 4. No signs of nasal drainage or 4. Clear lung sounds detected
4. The left auricle doesn't show throat pain during bilateral auscultation
tenderness upon manipulation
84. Which of the following statements about Betoptic (betaxolol) ophthalmic suspension, prescribed for a patient with
open-angle glaucoma, is accurate?
1. Betoptic ophthalmic suspension typically does not result in systemic side effects.
2. Betoptic can be safely used by individuals with a prior history of congestive heart failure.
3. Betoptic has the potential to reduce the effectiveness of insulin.
4. Betoptic may lead to feelings of dizziness or vertigo.
85. Which post-cataract surgery symptom should be promptly reported to the healthcare provider?
1. A scratchy feeling in the operated eye.
2. Diminished perception of depth with the eye patch in place.
3. Reduced vision 6 to 8 hours after patch removal.
4. Pain that does not respond to prescribed medication.
86. A 65-year-old patient of African American descent presents with a sudden, severe eye pain along with a visual
disturbance characterized by the appearance of colored halos around lights and blurred vision in the right eye. The
healthcare provider has determined that the patient is experiencing an episode of angle-closure glaucoma. What
actions should the nurse expect to carry out in response to this urgent medical condition?
Instructions: Please review the case study provided below and identify each intervention that the nurse should
anticipate performing for this patient. Select all that apply.
1. Prepare the patient for photodynamic therapy.
2. Administer a mydriatic medication, such as phenylephrine.
3. Administer a miotic medication, such as pilocarpine.
4. Administer a cycloplegic medication, such as tropicamide.
5. Administer an oral hyperosmotic medication, such as isosorbide.
6. Apply a cool compress to the patient's forehead.
7. Provide a darkened, quiet, and private environment for the patient.
8. Explain to the patient that reduced visual acuity in low light conditions is an anticipated side effect of the
medications.
9. Prepare educational materials regarding laser peripheral iridotomy or surgical iridectomy as required for long-term
management.
10. Get the patient ready for cataract extraction.
87. As per the evidence-based recommendations of the American Optometric Association, which changeable risk
factor should be emphasized the most when educating patients to lower the risk of age-related macular degeneration?
1. Initiate efforts to quit smoking.
2. Incorporate vitamin D and E supplements into your diet.
3. Include dark green, leafy vegetables in your meals.
4. Utilize protective eyewear when required.
88. A patient presents with a hordeolum (sty) on the upper eyelid of the right eye. What initial action should the nurse
advise?
1. Begin applying warm compresses four times daily.
2. Gently conduct hygienic cleansing of the eyelid.
3. Secure a prescription for antibiotic eye drops.
4. Get in touch with the ophthalmologist.
89. While on a camping trip, the nurse encounters a situation where a man has been struck in the eye by a piece of
debris while chopping wood. On examination, it's evident that there is a wood splinter protruding from his eye. What
should be the nurse's initial action?
1. Instruct the man to recline in the back seat of a vehicle and transport him to the emergency department.
2. Gently remove the wood fragment and apply a sterile dressing over the eye.
3. Delicately position a plastic cup on the orbital rim and secure it with tape.
4. Rinse the affected eye thoroughly with a large quantity of clean tepid water and then assess visual acuity.
90. A client who experiences severe visual impairment struggles with visual discrimination. Which actions should a
nurse suggest to enhance the client's visual experience in their home environment? Select all that apply.
1. Incorporate contrasting colors into the environment while avoiding the use of green and blue.
2. Create lists for the client using a black marker on a white background.
3. Maintain the same color for light switches as the wall but add a Velcro® tab to indicate the specific off/on switch.
4. Apply a bright, contrasting color to paint doorknobs on the doors.
5. Coordinate the color of dishes with the color of tablecloths or placemats.
CASE STUDY
91. The emergency department nurse is attending to a 43-year-old patient who is experiencing nausea and vomiting.
Click to identify the two observations that need urgent attention.
NURSES’ NOTES
04:45 The patient has been admitted to the emergency department due to experiencing epigastric pain, along with
symptoms of nausea and vomiting. The client describes the pain as a 6 out of 10 in intensity, noting that it began
approximately 2 hours after eating the previous night. Additionally, the client mentions vomiting three times before
seeking emergency care.
The patient also communicates a recent increase in the frequency of epigastric pain, intermittent chest pain, and a
chronic cough that has persisted for several months. The pain has been disruptive to the client's sleep. The patient
explicitly denies having diarrhea, current chest pain, or shortness of breath.
Vital signs indicate a body temperature of 37.1°C (98.9°F), a pulse rate of 90, a respiratory rate of 18, blood
pressure reading of 130/86, and a pulse oximeter reading of 97% on room air.
92. For each observation, select the corresponding condition (gastroesophageal reflux disease, peptic ulcer, or
cholecystitis) that best aligns with the finding. It's possible for a single observation to be indicative of multiple
conditions. Ensure that each column contains at least one chosen response option.
Assessment/Finding Gastroesophageal Peptic Ulcer Cholecystitis

reflux disease
Intermittent chest pain
Cough
Vomiting
Epigastric pain
93. Complete the sentence from the list of options.
NURSES’ NOTES
At 04:45, the patient has been admitted to the emergency department due to experiencing epigastric pain, along
with symptoms of nausea and vomiting. The client describes the pain as a 6 out of 10 in intensity, noting that it
began approximately 2 hours after eating the previous night. Additionally, the client mentions vomiting three times
before seeking emergency care.
The nurse should identify that the client is most likely undergoing _____________________________
1. Gastroesophageal reflux disease
2. Cholecystitis
3. Peptic ulcer
94. With the diagnosis of gastroesophageal reflux, the nurse should incorporate the following interventions into the
care plan. Select all that apply.
NURSES’ NOTES
At 0445, the patient has been admitted to the emergency department due to experiencing epigastric pain, along
Progress Notes
Working diagnosis probable gastroesophageal reflux
1. Collect a stool culture.

2. Request a complete blood count (CBC).
3. Monitor the lab report for levels of sodium and potassium.
4. Administer antiemetics as prescribed.
5. Arrange for an abdominal CT scan.
6. Educate the client about maintaining their health.
7. Dispense analgesics as directed.
95.
NURSES’ NOTES
At 0415, an intravenous line was established, and the patient received a 0.9% sodium chloride infusion at a rate of
100 mL per hour. The patient was also administered intravenous medications, including 2 mg/mL of Morphine and 4
mg/2 mL of Ondansetron. Laboratory tests were performed.
PROGRESS NOTES
ORDERS
1. Initiate an infusion of 0.9% Sodium chloride at a rate of 100ml per hour.
2. Provide an immediate intravenous dose of 2 mg morphine.
3. Administer 4 mg of ondansetron intravenously without delay.
4. Perform a comprehensive blood panel to assess sodium and potassium levels.
5. Offer the client education regarding adjustments to their lifestyle.
6. Arrange a future appointment with a gastroenterologist for follow-up.
LABORATORIES Lab Results Reference range

Potassium(serum) 3.1 mEq/L 3.5 to 5 mEq/L
Sodium (serum) 134 mEq/L 135 to 145 mEq/L
The nurse has received instructions regarding the teaching plan. Please select all the modifications that the nurse
should include:
1. Encourage avoiding large meals
2. Recommend avoiding eating late at night
3. Suggest taking aspirin for intermittent pain
4. Advise adopting a low-fat diet
5. Recommend limiting the intake of caffeinated beverages
6. Do not recommend drinking carbonated beverages for nausea
7. Mention sleeping on your right side
8. Emphasize the importance of maintaining a healthy weight
96. The nurse provides the client with education on lifestyle management.
NURSES’ NOTES
At 0415, an intravenous line was established, and the patient received a 0.9% sodium chloride infusion at a rate of
100 mL per hour. The patient was also administered intravenous medications, including 2 mg/mL of Morphine and 4
mg/2 mL of Ondansetron. Laboratory tests were performed.
PROGRESS NOTES
ORDERS
1. Initiate an infusion of 0.9% Sodium chloride at a rate of 100ml per hour.
2. Provide an immediate intravenous dose of 2 mg morphine.
3. Administer 4 mg of ondansetron intravenously without delay.
4. Perform a comprehensive blood panel to assess sodium and potassium levels.
5. Offer the client education regarding adjustments to their lifestyle.
6. Arrange a future appointment with a gastroenterologist for follow-up.
LABORATORIES Lab Results Reference range

Potassium(serum) 3.1 mEq/L 3.5 to 5 mEq/L
Sodium (serum) 134 mEq/L 135 to 145 mEq/L
The nurse can ascertain that the dietary instruction was effective if the patient opts for which item from the following
list?
1. Chocolate
2. Coffee
3. Nonfat milk
4. Mint tea
97. For a patient with short bowel syndrome, the nurse would inquire about the prescription of which of the following
enteral formulas?
1. High sodium content
2. High fat content
3. High protein content
4. Modified carbohydrate content
98. The head nurse needs to assess the conditions and situations of patients in order to identify suitable roommates.
Considering their present conditions and statuses, which pair of patients could potentially share a room?
Patients are listed in the left-hand column. In the right-hand column, put an X to indicate which two patients could be
roomed together.
Patients in the unit who can be paired together for comfort include:
1. A 35-year-old woman experiencing copious and 1

uncontrollable nausea and vomiting.
2. A 43-year-old woman who underwent a
cholecystectomy 2 days ago.
3. A 53-year-old woman with pain related to alcohol-
associated pancreatitis.
4. A 70-year-old woman with stool culture results
indicating Clostridium difficile. 2.
5. A 55-year-old woman with symptoms following
exposure to norovirus.
6. A 62-year-old woman with colon cancer undergoing
chemotherapy and radiation.
7. A 59-year-old woman with a suspected methicillin-
resistant Staphylococcus aureus infection in a wound.
99. A patient is admitted with a preliminary diagnosis of hepatitis. The nurse identifies which statement from the
patient as being consistent with the diagnosis?
1. "I have been having trouble sleeping due to experiencing significant heartburn at night, which wakes me up."
2. "Whenever I consume dairy products, I suffer from diarrhea for a few days."
3. "Recently, I've noticed breathlessness during my walk from the bus stop to work."
4. "Even though I'm a smoker, I've found myself unable to tolerate the taste of cigarettes lately."
100. To aid a client in managing and alleviating the sensation of nausea, which nonpharmacological intervention
should a nurse suggest?
1. Consuming ginger root tea
2. Rapidly changing body positions during movement
3. Reducing the intake of food
4. Playing loud rock music

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NGN QUESTIONS

Which four observations carry the greatest significance?

7. The nurse initiates an IV and examines the laboratory results.

Laboratory Report Ketoacidosis Hyperglycemic

8. Complete the sentence from the list of drop-down options.

Nursing Intervention Indicated Contraindicated Non-essential

10. The nurse reviews and examines the prescribed orders.

Clinical Manifestation Hypovolemic Anaphylactic Septic Neurogenic

Clinical Manifestation Hypovolemic Anaphylactic Septic Neurogenic

31. CASE STUDY QUESTION 1

Highlight the findings in the assessment that are of immediate concern.

32. QUESTION NUMBER 2

Possible Intervention Indicated Not

CASE STUDY 51-56

VITAL SIGNS 3:00 PM

Lab Results Reference range

Cardiac Tamponade Tension Pneumothorax Pulmonary Contusion

VITAL SIGNS 3:00 PM 3:30 PM

Lab Results Reference range

The client is most likely experiencing _______________ 1. cardiac tamponade

VITAL SIGNS 3:00 PM 3:30 PM 3:45 PM

Lab Results Reference range

Nursing Actions Indicated Not indicated

VITAL SIGNS 3:00 PM 3:30 PM 3:45 PM 4:00 PM

Laboratories Results Reference range

The nurse evaluates the client's condition, finding it to be __________________________.

The next steps for the nurse should include ____________________________.

1. Absence of any sick contacts 1. No complaints of neck stiffness 1. No cough reported

Assessment/Finding Gastroesophageal Peptic Ulcer Cholecystitis

93. Complete the sentence from the list of options.

1. Collect a stool culture.

Working diagnosis probable gastroesophageal reflux

LABORATORIES Lab Results Reference range

Working diagnosis probable gastroesophageal reflux

LABORATORIES Lab Results Reference range

1. A 35-year-old woman experiencing copious and 1

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