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Nursing School original latest material

90 questions · Original · Latest version

Question 1

A 78-year-old client admitted with pneumonia is weak and becomes lightheaded when standing. Blood pressure changes from 132/76 mm Hg supine to 106/62 mm Hg standing. Which nursing intervention is most appropriate to reduce the client's risk for falling?

  1. A. Encourage the client to walk independently to regain strength.
  2. B. Assist the client to sit at the bedside before standing and remain with the client during transfers.
  3. C. Keep all four side rails raised whenever the client is in bed.
  4. D. Limit oral fluids to reduce trips to the bathroom.

ANS: Answer: B

The blood pressure decrease and lightheadedness indicate orthostatic hypotension. Gradual position changes and direct assistance during transfers reduce the risk of falling. Independent ambulation is unsafe while the client is symptomatic. Raising all four side rails can function as a restraint and may increase injury risk if the client climbs over them. Fluid restriction without an indication can worsen volume depletion and orthostatic hypotension.

Question 2

A client being evaluated for heart failure reports increasing shortness of breath. Which assessment finding most directly supports pulmonary fluid accumulation?

  1. A. Bilateral inspiratory crackles at the lung bases
  2. B. Hyperactive bowel sounds in all quadrants
  3. C. Unilateral calf tenderness
  4. D. Dry oral mucous membranes

ANS: Answer: A

Bilateral basal crackles can occur when fluid accumulates in the pulmonary interstitium and alveoli, as in left-sided heart failure. Hyperactive bowel sounds do not indicate pulmonary congestion. Unilateral calf tenderness suggests a possible deep vein thrombosis and requires further evaluation, but it is not direct evidence of pulmonary fluid accumulation. Dry mucous membranes more commonly suggest dehydration rather than fluid overload.

Question 3

A client develops a rapid heart rate after losing blood from a traumatic injury. The nurse explains that this response helps maintain cardiac output. Which relationship correctly explains this compensatory mechanism?

  1. A. Cardiac output equals heart rate multiplied by stroke volume.
  2. B. Cardiac output equals blood pressure divided by heart rate.
  3. C. Cardiac output equals respiratory rate multiplied by tidal volume.
  4. D. Cardiac output equals stroke volume divided by heart rate.

ANS: Answer: A

Cardiac output is the volume of blood pumped each minute and equals heart rate multiplied by stroke volume. Blood loss reduces venous return and can decrease stroke volume; an increased heart rate initially helps compensate. Blood pressure divided by heart rate does not define cardiac output. Respiratory rate multiplied by tidal volume describes minute ventilation. Dividing stroke volume by heart rate is not a valid calculation of cardiac output.

Question 4

A hospitalized client develops frequent watery stools after antibiotic therapy, and testing confirms Clostridioides difficile infection. Which actions should the nurse include in the care plan? Select all that apply.

  1. A. Use a gown and gloves when entering the client's room.
  2. B. Use soap and water for handwashing after providing care.
  3. C. Use a facility-approved sporicidal product to disinfect contaminated surfaces.
  4. D. Require an N95 respirator for every routine room entry.
  5. E. Use alcohol-based hand sanitizer as the sole method of hand hygiene after stool exposure.

Question 5

A client with small-cell lung cancer develops confusion. Laboratory results show sodium 119 mEq/L, low serum osmolality, and inappropriately concentrated urine. The provider suspects syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which mechanism best explains these findings?

  1. A. Excess antidiuretic hormone increases renal water reabsorption, diluting serum sodium.
  2. B. Insufficient antidiuretic hormone causes excessive loss of dilute urine.
  3. C. Excess aldosterone causes large urinary sodium losses.
  4. D. Reduced insulin secretion shifts sodium from the blood into cells.

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