Question

A nurse is assisting with the care of a client.

Answer 1

Correct Answers

Blank 1 Correct Option: first administer oxygen at 2 L/min via nasal cannula
Blank 2 Correct Option: administer sublingual nitroglycerin

Rationale :

💊Administering aspirin is a priority intervention for a client with suspected acute coronary syndrome, as it helps inhibit platelet aggregation and reduce further clot formation.

❤️After aspirin, the nurse should give sublingual nitroglycerin to help relieve chest pain by vasodilation, improving coronary blood flow.

🧪The client’s troponin is currently normal, but the clinical presentation (chest pain, radiation, risk factors) strongly suggests a possible myocardial infarction, warranting urgent treatment.

✍️Other actions such as ambulation, meals, or general assessments are inappropriate priorities in acute chest pain management.

📌Core Message

Suspected cardiac ischemia requires prompt aspirin administration followed by nitroglycerin to reduce clot formation and relieve chest pain.

Answer 2

Correct Answers

Blank 1 Correct Option: compartment syndrome
Blank 2 Correct Option: edema of toes

Rationale :

🦵Compartment syndrome is a serious complication of fractures and casting that results from increased pressure within a muscle compartment, impairing circulation and nerve function.

💥Edema of the toes, especially when increasing, is an early indicator of circulatory compromise, and must be closely monitored for signs of worsening.

🩸The presence of brisk capillary refill and intact pulses is reassuring for now, but moderate edema and continued pain raise suspicion for early compartment syndrome.

📈Other conditions like pneumonia or DVT are less likely based on current data, and findings like decreased heart rate or absent bowel sounds do not align with the localized musculoskeletal concern.

📌Core Message

Compartment syndrome is a complication of fractures and casts, signaled by increasing pain and limb edema that can compromise circulation.

Answer 3

Correct Answers:

Sodium and potassium levels monitored

Rationale :

🧪Addison’s disease leads to electrolyte imbalances, especially hyponatremia and hyperkalemia.

⚠️Vomiting worsens these imbalances, making serum monitoring essential.

💉IV glucocorticoids can also affect electrolyte and glucose levels, but sodium/potassium shifts are most dangerous.

📈This helps guide adjustments in fluid and steroid therapy.

📌Core Message

In Addison’s disease with vomiting, monitor sodium and potassium levels closely to prevent electrolyte crises.

Answer 4

Correct Answers:

Check the calcium level

Rationale :

🧬Tingling and numbness are signs of hypocalcemia, which can occur if the parathyroid glands were damaged or removed.

🩺Low calcium after thyroid surgery is common and urgent, as it can lead to tetany or laryngospasm.

🚨Checking calcium confirms the diagnosis and guides rapid intervention.

💉Other actions are important but not the immediate priority here.

📌Core Message

Tingling after thyroidectomy is an early sign of hypocalcemia, so the nurse should check calcium levels immediately.

Answer 5

Correct Answers:

Decreased cardiac output r/t bradycardia

Rationale :

💁‍♂️Bradycardia in hypothyroidism can reduce cardiac output, compromising oxygen delivery to tissues.

⚠️This presents the most immediate threat to life, making it a priority diagnosis.

📉Other issues like mobility and cognition are secondary to the hemodynamic compromise.

🧬Managing the cardiac function is essential before addressing other concerns.

📌Core Message

In hypothyroidism with bradycardia, the primary concern is decreased cardiac output, which must be addressed first.

Answer 6

Correct Answers:

"That feeling of warmth is normal when the dye is injected."

Rationale :

🔥The sensation of warmth is a common and expected response during contrast dye injection.

💉This effect occurs as the dye passes through the vasculature, especially in large vessels.

🧠Reassuring the client reduces anxiety and avoids unnecessary alarm about normal procedural effects.

📋There is no evidence of allergic reaction unless accompanied by rash, difficulty breathing, or hypotension.

📌Core Message

During an arteriogram, feeling warmth from contrast dye is a normal effect and should be calmly explained.

Answer 7

Correct Answers:

The nurse wears gloves to take the client’s vital signs.

Rationale :

🧤Wearing gloves for vital signs is unnecessary unless there is an expectation of contact with body fluids.

🧼Standard precautions require hand hygiene, but not gloves for routine, non-invasive procedures.

🧪Excessive use of gloves can create barriers to proper technique and waste resources.

📋The other actions represent proper infection control practices.

📌Core Message

Gloves are not needed when taking routine vital signs unless there's a risk of body fluid exposure.

Answer 8

Correct Answers:

Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep

Rationale :

🔦Pinworms are best detected when they emerge at night around the anus to lay eggs.

🧫The worms are visible with a flashlight, usually 2–3 hours after sleep onset.

📉Stool and hair samples are ineffective in detecting pinworms.

👪Parents can directly visualize or use tape for sample collection as advised.

📌Core Message

Pinworms are detected by inspecting the perianal area at night, typically 2–3 hours after sleep.

Answer 9

Correct Answers:

The entire family should be treated.

Rationale :

👨‍👩‍👧Pinworm infections spread easily among household contacts, even if asymptomatic.

💊Treating the entire family prevents reinfection and cross-contamination.

🧪Treatment usually involves oral antihelminthics, not IV antibiotics.

📅It is not prolonged—typically a short course with a second dose after 2 weeks.

📌Core Message

In cases of enterobiasis, it's important to treat the entire household to prevent reinfection.

Answer 10

Correct Answers:

The client who returned from placement of iridium seeds for prostate cancer

Rationale :

☢️Iridium seeds for prostate cancer are a form of sealed internal radiation and pose minimal risk to caregivers.

👶Pregnant nurses must avoid clients with unsealed or high-dose radiation, such as radium or soluble isotopes.

🧬The radiation is localized and contained, with no significant exposure risk to others.

📋Soluble therapy (like radioactive iodine) is contraindicated for pregnant caregivers.

📌Core Message

Pregnant nurses can safely care for clients with sealed radiation implants like iridium seeds.

1 :
A nurse is assisting with the care of a client.

Correct Answers

2 :
A nurse is assisting with the care of an adolescent.

Correct Answers

3 :
A client with Addison’s disease is vomiting and on IV steroids. What should the nurse prioritize in care?

4 :
A client one day post-total thyroidectomy reports tingling in the face and fingers. What should the nurse do next?

5 :
A 32-year-old mother presents with bradycardia, 30-lb weight gain, and cold intolerance. She is diagnosed with hypothyroidism. What is the priority nursing diagnosis?

6 :
A client undergoing an arteriogram reports feeling very hot during the procedure. What is the best response by the nurse?

7 :
Which action observed among healthcare workers indicates the need for further instruction?

8 :
To assess for pinworms in a 5-year-old child, how should the nurse instruct the mother to collect the specimen?

9 :
When educating a mother about treating enterobiasis (pinworms), what instruction should the nurse provide?

10 :
A pregnant nurse is receiving client assignments. Which client is safe for her to care for?

1 : A nurse is assisting with the care of a client.

Correct Answers

2 : A nurse is assisting with the care of an adolescent.

Correct Answers

3 : A client with Addison’s disease is vomiting and on IV steroids. What should the nurse prioritize in care?

4 : A client one day post-total thyroidectomy reports tingling in the face and fingers. What should the nurse do next?

5 : A 32-year-old mother presents with bradycardia, 30-lb weight gain, and cold intolerance. She is diagnosed with hypothyroidism. What is the priority nursing diagnosis?

6 : A client undergoing an arteriogram reports feeling very hot during the procedure. What is the best response by the nurse?

7 : Which action observed among healthcare workers indicates the need for further instruction?

8 : To assess for pinworms in a 5-year-old child, how should the nurse instruct the mother to collect the specimen?

9 : When educating a mother about treating enterobiasis (pinworms), what instruction should the nurse provide?

10 : A pregnant nurse is receiving client assignments. Which client is safe for her to care for?

1 :
A nurse is assisting with the care of a client.

2 :
A nurse is assisting with the care of an adolescent.

3 :
A client with Addison’s disease is vomiting and on IV steroids. What should the nurse prioritize in care?

4 :
A client one day post-total thyroidectomy reports tingling in the face and fingers. What should the nurse do next?

5 :
A 32-year-old mother presents with bradycardia, 30-lb weight gain, and cold intolerance. She is diagnosed with hypothyroidism. What is the priority nursing diagnosis?

6 :
A client undergoing an arteriogram reports feeling very hot during the procedure. What is the best response by the nurse?

7 :
Which action observed among healthcare workers indicates the need for further instruction?

8 :
To assess for pinworms in a 5-year-old child, how should the nurse instruct the mother to collect the specimen?

9 :
When educating a mother about treating enterobiasis (pinworms), what instruction should the nurse provide?

10 :
A pregnant nurse is receiving client assignments. Which client is safe for her to care for?