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:

  • Respiratory rate 10/min
  • Pulse oximetry 88% on room air
  • Morphine 10 mg administered subcutaneously

Rationale :

💁‍♂️A respiratory rate of 10/min indicates respiratory depression, which is a critical side effect of morphine.

📉A pulse oximetry reading of 88% signals hypoxemia, requiring immediate intervention per the provider’s instructions.

💉The fact that morphine 10 mg was recently administered further links these findings to a possible opioid overdose or sensitivity.

📋These findings all align with the provider’s alert threshold and require immediate action and notification.

📌core message

A low RR, low oxygen saturation, and recent morphine administration together indicate opioid-induced respiratory depression, requiring urgent intervention.

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:

  • Take antibiotics for 10 days.
  • Ensure the oxygen delivery system is at least 8 feet from any heat source.

Rationale :

💊Completing the full 10-day course of antibiotics is essential to fully eradicate the infection and prevent antibiotic resistance.

🔥Keeping the oxygen delivery system at least 8 feet from heat sources is critical to prevent fire hazards, as oxygen supports combustion.

🚫Steroids and oxygen flow rate changes require provider supervision and are not part of standard discharge teaching unless prescribed.

📝These two choices reflect key priorities in infection control and home safety education for a client being discharged with pneumonia and home oxygen.

📌core message

Discharge teaching for pneumonia must emphasize completing antibiotics and safe oxygen equipment use to prevent complications.

3 :

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

Correct Answers:

  • Inform the law enforcement for a possible child abuse

Rationale :

🚨The presence of genital bruising in a child is a strong indicator of possible sexual abuse, requiring immediate reporting to law enforcement or child protective services.

📞In most jurisdictions, nurses are mandated reporters and must take prompt action to protect the child from further harm.

📝While documentation is important, it should occur after initiating the required report, since the child's safety takes precedence.

⚖️Failure to report suspected abuse may result in legal consequences and puts the child at risk of continued maltreatment.

📌Core Message

In suspected child abuse, the nurse’s first priority is to report the incident to authorities to ensure the child’s immediate safety and initiate legal protection.

4 :

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

Correct Answers:

  • Avocado

Rationale :

🥑Avocados are exceptionally rich in potassium, making them the best choice for clients on potassium-wasting diuretics like hydrochlorothiazide.

💊Hydrochlorothiazide increases renal potassium excretion, so replenishing potassium is essential to prevent hypokalemia.

🍊While oranges have some potassium, avocados contain significantly more per serving.

📋Symptoms of hypokalemia include muscle weakness, cramps, and cardiac arrhythmias, so diet plays a preventive role.

📌Core Message

Avocados are a potassium-rich food ideal for clients on thiazide diuretics to prevent hypokalemia.

5 :

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

Correct Answers:

  • Maintain the client in a semi-Fowler’s position with the head and neck supported by pillows

Rationale :

🛏️Semi-Fowler’s position reduces swelling and supports respiratory function post-thyroidectomy.

🦴Neck support is essential to avoid strain on the incision site and reduce the risk of hemorrhage or airway obstruction.

💨Supine positioning may increase neck tension and airway compromise, especially with postoperative edema.

📋Coughing is important, but neck flexion or strain must be avoided immediately after thyroid surgery.

📌Core Message

After thyroidectomy, keep the client in semi-Fowler’s with neck support to prevent airway compromise and bleeding.

6 :

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

Correct Answers:

  • Luncheon meats

Rationale :

🥩Luncheon meats are high in nitrates and nitrites, which are known carcinogens associated with gastric cancer risk.

🔥Preserved, smoked, or processed foods can damage the gastric mucosa, especially with long-term consumption.

🥤While carbonated drinks and sugars affect digestion, they are not linked directly to gastric cancer.

📋Patient teaching should include diet modification to reduce processed meat intake and promote gastric health.

📌Core Message

Frequent intake of processed meats like luncheon meats increases the risk of gastric cancer due to carcinogenic preservatives.

7 :

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

Correct Answers:

  • A history of cruelty to animals

Rationale :

🧠Cruelty to animals, fire setting, and lack of empathy are classic signs of antisocial personality disorder, often noted in early childhood.

📚These behaviors fall under conduct disorder, which may precede a diagnosis of antisocial behavior in adulthood.

🧊Clients typically show no remorse and have normal or above-average intelligence, making those options incorrect.

📋Social and occupational instability is common, not consistent employment.

📌Core Message

Cruelty to animals is an early sign linked to antisocial personality disorder, indicating a pattern of aggression and disregard for others.

8 :

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

Correct Answers:

  • With a venous access device

Rationale :

💉Clients with central or venous access devices require advanced assessment and intervention skills, which fall under RN scope of practice.

🧪These devices can have complications such as infection, occlusion, or embolism, needing immediate clinical judgment.

🛌An LVN can care for stable clients post-op or in psych units under supervision, but not manage invasive vascular access independently.

📋Delegation decisions must align with state practice acts and facility policy.

📌Core Message

LVNs cannot assume primary care for clients with venous access devices due to the complexity and risk involved.

9 :

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

Correct Answers:

  • Administering pain medication

Rationale :

🔥Sulfamylon (mafenide acetate) can cause significant burning pain upon application, especially on deep wounds.

💉Pre-medicating for pain ensures client comfort and cooperation during dressing changes.

📊CBC and urine output are important, but not the immediate need before painful topical treatment.

📋Uncontrolled pain increases physiologic stress, which can interfere with healing.

📌Core Message

Pain control must come before dressing application with Sulfamylon due to its irritating effects on burn tissue.

10 :

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

Correct Answers:

  • She can pull a toy behind her

Rationale :

🚶‍♀️Pulling a toy demonstrates gross motor coordination, which is typical of toddlers aged 12–24 months.

🧸Gross motor skills involve large muscle groups, used for walking, running, and dragging objects.

🧱Stacking blocks and drawing lines are fine motor skills, while broad-jumping occurs later in preschool years.

📋Developmental milestones help identify neuromuscular progression and potential delays.

📌Core Message

Pulling a toy is a typical gross motor milestone in toddlers, reflecting age-appropriate large muscle development.

Total Questions: 10

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