1 :

The male client is 56 years old and recently underwent a laparotomy for a bowel resection due to colon cancer. He has a history of hypertension and type 2 diabetes, well-managed with medication. The surgery was uneventful, and the client was transferred to the recovery unit in stable condition. No known allergies. His pain is being managed with morphine.

0900: 

Client is alert and oriented to person, place, and time. The client reports incisional pain rated 9 on a scale of 0 to 10 and is grimacing. Morphine 10 mg subcutaneously administered as prescribed.

1000: 

Client is difficult to arouse. The client’s face appears flushed, and his breathing is shallow. His eyes are closed, and he is not responding to verbal stimuli. Morphine administration was noted 60 minutes ago.

Pupils are 3 mm, equal, and reactive to light.

Skin is warm and dry with no signs of infection at the surgical site.

Abdomen is soft, with moderate tenderness over the surgical site.

The client is restless and grimacing, and his respirations are shallow and slow.

Temperature: 37.5°C (99.5°F)

Pulse: 61/min

Respiratory Rate: 10/min

Blood Pressure: 99/46 mm Hg

Pulse Oximetry: 88% on room air (normal range: 95%-100%)

None provided.

Continue with morphine as prescribed.

Monitor vital signs every 30 minutes for the next 2 hours.

Alert the primary healthcare provider if respiratory rate drops below 12/min or if oxygen saturation falls below 90%.

Morphine 10 mg subcutaneously every 3 hours as needed for pain.

The client received a dose of morphine at 0900.

Select the documentation in the client's medical record that requires further action by the nurse. Select all that apply

Answer Options

Hint : ⚠️Which findings suggest the medication caused suppressed breathing?

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

2 :

Day 1, 1100:

Client admitted from the emergency department with a new diagnosis of pneumonia, confirmed by chest x-ray and laboratory results. Client reports dyspnea and exhibits shortness of breath at rest. Client is hypoxic, confirmed by oxygen saturation of 89%. Placed on oxygen at 2 L/min via nasal cannula. Congested cough with green sputum noted. Sputum specimen obtained and sent to the laboratory for further analysis. Crackles heard on auscultation, breath sounds diminished bilaterally. IV initiated in the left forearm with a 22-gauge angiocath for intermittent antibiotic therapy and further treatment. Client remains hypoxic. Less dyspnea noted at rest, but extreme shortness of breath noted on exertion.

Day 2, 1500:

Client is stable with ongoing IV antibiotic treatment. Oxygen saturation remains at 92% on 2 L/min nasal cannula. No signs of infection at the IV site. Client's cough remains productive with green sputum. Continue monitoring respiratory status and adjust oxygen as necessary.

Chronic Obstructive Pulmonary Disease (COPD)

Hypertension

Type 2 Diabetes Mellitus

History of smoking (40 pack-years)

Chest x-ray: Bilateral infiltrates suggestive of pneumonia.

Sputum culture: Positive for Streptococcus pneumoniae.

Oxygen saturation: 89% on room air, 92% on 2 L/min oxygen via nasal cannula.

Temperature: 101.2°F (38.4°C)

Pulse: 102 beats per minute

Respiratory Rate: 22 breaths per minute

Blood Pressure: 130/85 mmHg

Oxygen Saturation: 89% on room air, 92% on 2 L/min nasal cannula

On physical examination, the client appears mildly distressed, with labored breathing and use of accessory muscles. The client is alert and oriented but appears fatigued. Breath sounds are diminished bilaterally with crackles noted on auscultation. There is no cyanosis, but the client is visibly short of breath, especially on exertion. The chest is clear to percussion, but there is a productive cough with green sputum. No signs of swelling or infection at the IV site. Heart sounds are regular, and there are no murmurs or additional heart sounds noted.

IV antibiotics (ceftriaxone 1g daily)

Oxygen therapy at 2 L/min via nasal cannula

Chest x-ray and blood cultures for pneumonia confirmation

Sputum culture for microbiological analysis

Maintain IV access for further antibiotic therapy

The client is a 68-year-old male with a history of smoking for 40 years and mild chronic obstructive pulmonary disease (COPD). He presents with a new diagnosis of pneumonia, confirmed by chest x-ray and laboratory results. He reports increasing shortness of breath over the past 48 hours, along with a productive cough with greenish sputum. He has a history of hypertension and diabetes type 2, which are both managed with medications. The client denies any recent travel or exposure to sick contacts. The primary health care provider initiated a chest x-ray and blood cultures to confirm the diagnosis of pneumonia. The client is also receiving IV antibiotics and supplemental oxygen.

Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)

Answer Options

Hint : 🏠What instructions ensure the infection is treated and the home remains safe?

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

3 :

Hint : 🚓When the safety of a child is in question, alerting authorities is non-negotiable.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

4 :

Hint : 🥗Think creamy, not crunchy, when looking for high-potassium snacks.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

5 :

Hint : 🛌Elevation and alignment matter most after neck surgery.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

6 :

Hint : 🥪Preservatives may offer shelf life—but cost gut health.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

7 :

Hint : 🐾Look for red flags that started before adulthood.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

8 :

Hint : 🧷If it goes straight to the bloodstream, it needs an RN’s eyes.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

9 :

Hint : 💢When treatment hurts more than the injury, prep for pain first.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

10 :

Hint : 🛴Gross means go—think big body movements.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

11 :

Hint : ✂️In an emergency, only one tool can open the airway.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

12 :

Hint : 📞Don’t guess with the heart—always ask first when in doubt.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

13 :

Hint : 🧲Treat lead by locking it up and flushing it out.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

14 :

Hint : 🚫Keep the elbows from helping curious hands reach the face.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

15 :

Hint : 🧪If it blunts heart rate, it may blunt your warning signs too.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

16 :

Hint : 🕯️A soft glow often does more than a strong pill.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

17 :

Hint : 🤦‍♂️When toxins build up, the skin speaks up.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

18 :

Hint : 🩸When a blood thinner dose raises eyebrows, pause before poking.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

19 :

Hint : 🥗Simple and salt-free is the recipe for balance.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

20 :

Hint : 🌃When legs drain overnight, the bladder gets busy.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

21 :

Hint : 📍Think of the smallest site that shows the biggest signal.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

22 :

Hint : 🔍When precision is everything, the right tool matters most.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

23 :

Hint : 💊Fear fades when comfort is part of the plan.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

24 :

Hint : 🎯When a rash looks like a target, it points to the diagnosis.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

25 :

Hint : 🌱Not all grains are guilty—some are safe and gluten-free.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

26 :

Hint : 🌡️When the temperature spikes on an antipsychotic, act fast.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

27 :

Hint : 💁‍♂️This med gives your gums extra attention—whether you want it or not.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

28 :

Hint : 🧬A heparin-related drug needs a heparin-specific antidote.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

29 :

Hint : 📅When the mind drifts, gently bring it back to the present.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

30 :

Hint : ⚠️Avoid anything that thins blood in a bleeding disorder.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

31 :

Hint : 🧂Kitchen ingredients can calm down skin when used wisely.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

32 :

Hint : 🚽When plumbing is misrouted, function is altered.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

33 :

Hint : 📚If it’s prescribed in hospitals, it can’t be Schedule I.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

34 :

Hint : 💡Fast relief of chest pain often hints at a less severe cause.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

35 :

Hint : 🚽Without hydration, roughage doesn't move.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

36 :

Hint : 🌊Too much salt can flood the balance system.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

37 :

Hint : 👀Look at the face—it reflects fluid danger.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

38 :

Hint : 🧩Teaching clients how to reach out helps them replace harmful coping habits.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

39 :

Hint : 🧴Always clean the slate before applying another dose of topical medication.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

40 :

Hint : 🤦‍♂️When someone wakes disoriented, start with simple facts to ground them.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

41 :

Hint : 🌙The brain usually needs time to rest after a major electrical storm.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

42 :

Hint : 🥄Some vegetables can pack hidden trouble for stone formers.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

43 :

Hint : 🚷Some hip conditions demand complete off-loading to heal.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

44 :

Hint : 👶When the bowel stalls, the belly swells.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

45 :

Hint : 🥤A tangy partner helps iron work better.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

46 :

Hint : 🍽️Even in high-risk pregnancies, too few calories can harm more than help.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

47 :

Hint : 🧭When mental maps fade, poor choices rise.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

48 :

Hint : 🎯To hear the heart clearly, aim for the spine side.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

49 :

Hint : 🛑Easing the brain off alcohol needs a calming touch.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

50 :

Hint : ⏰Short-acting insulin needs a meal to meet it halfway.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

51 :

Hint : 🧴When babies can’t speak, their behaviors become their language.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

52 :

Hint : 🦷Some meds can leave a mark that smiles can’t hide.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

53 :

Hint : 🧪Autoimmune flare-ups often strike the kidneys hardest.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

54 :

Hint : 🥓Fast food habits can slow your colon's future.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

55 :

Hint : 🧴Comfort tools should never tug at healing stitches.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

56 :

Hint : 📦Sometimes it's the form—not the drug—that matters most.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

57 :

Hint : 🥄Too much red meat feeds iron overload.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

58 :

Hint : 🛌Face-down flat can help stand up straighter later.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

59 :

Hint : 🥬Keep it light on fat to keep the pancreas calm.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

60 :

Hint : 🧤Better to bundle than to burn.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

61 :

Hint : 🚭Voice box cancer often starts with bad habits.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

62 :

Hint : 🔌When nerves go numb, think B12.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

63 :

Hint : 🔍Clients who struggle to shift topics may show signs of perseveration.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

64 :

Hint : 🛠️Morning adaptations that minimize joint stress improve comfort and functionality.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

65 :

Hint : ⚖️Expected infant growth milestones are based on consistent patterns like doubling of birth weight at 6 months.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

66 :

Hint : 🍽️Watch out for hidden gluten in processed or thickened foods.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

67 :

Hint : 💦Improved kidney function and diuresis often follow successful cardiac support.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

68 :

Hint : 🧸Choose toys that encourage active movement and large muscle coordination.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

69 :

Hint : 🩺Always assess bowel patterns when clients are on aluminum-based antacids.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

70 :

Hint : 🔎Look for central abdominal pulsations during focused assessments.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

71 :

Hint : 🚨Sudden low blood pressure in a critically ill client should prompt suspicion of adrenal insufficiency.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

72 :

Hint : 🧃Post-TURP urine should progressively clear, not become brighter or clot-laden.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

73 :

Hint : 🧠Look for joint symptoms that migrate and involve redness, warmth, and swelling to identify rheumatic fever.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

74 :

Hint : 🌫️Cool mist therapy targets airway swelling and thickened secretions in respiratory infections.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

75 :

Hint : 🤦‍♂️Symptoms of metabolic slowing often point toward thyroid hormone deficiency.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

76 :

Hint : 📅Transmission can occur before the rash appears and stops only after crusting of all lesions.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

77 :

Hint : 🌟False beliefs of being someone famous or powerful reflect grandiosity, not spiritual insight.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

78 :

Hint : 🥄Always ensure swallowing ability is intact before offering oral fluids post-procedure.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

79 :

Hint : 🛡️Nighttime shielding helps avoid unintentional eye contact during sleep.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

80 :

Hint : 🗣️Muffled voice, drooling, and stridor in a febrile child point toward airway inflammation.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

81 :

Hint : 🧃Frequent feedings help remove bilirubin through stool and urine during therapy.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

82 :

Hint : 🔎Observation after meals helps detect and prevent compensatory behaviors.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

83 :

Hint : 🚴‍♂️Tasks like schoolwork, chores, and team activities foster development of industry.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

84 :

Hint : 🤲Shaky hands or tremors may occur shortly after taking fast-acting respiratory medications.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

85 :

Hint : 🧦Blue hands and feet are a common non-serious reason for a slightly reduced Apgar score.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

86 :

Hint : 👶Bulging of soft skull spots may indicate increased brain pressure in infants.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

87 :

Hint : 🧻A soft abdomen means the tube is relieving pressure from gas or fluid buildup.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

88 :

Hint : 🟥Watch for changes in skin color such as redness that may signal dropping glucose levels.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

89 :

Hint : 🔍Sudden changes in vision are early indicators of nervous system inflammation in MS.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

90 :

Hint : 🧬Diseases involving high uric acid levels can lead to kidney stone development.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

91 :

Hint : 🕐Frequent, light meals are easier to tolerate in clients with poor absorption and low energy.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

92 :

Hint : 🌡️Steroids increase acid production—acid reducers can prevent GI complications.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

93 :

Hint : 👶Choose bland, iron-rich, mashed or pureed solids when starting weaning.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

94 :

Hint : 🔽Use the thickest thigh muscle for newborn injections to avoid nerve injury.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

95 :

Hint : 💦More fluids reduce bladder toxicity from chemotherapy drugs like cyclophosphamide.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

96 :

Hint : 🌙Benzodiazepines are the drug of choice for calming CNS activity during withdrawal.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

97 :

Hint : 🕔Intermediate insulins like NPH peak about 6–8 hours after injection.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

98 :

Hint : 🧍‍♀️Positioning and limited activity help protect the eye before or after surgical repair.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

99 :

Hint : 🦿Early joint movement improves flexibility and preserves function after knee replacement.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

100 :

Hint : 🚦Young children often link right or wrong with punishment or reward.

Correct Answers:

  • No Correct Answers Available !

Rationale :

Rationale to be Available Soon

Total Questions: 100

Choose Different Exam !