Board Vitals Remediation Questions With Complete
Solutions
A 28-year-old male client is undergoing tests to confirm the
diagnosis of Hodgkin's lymphoma. The client and his wife are
worried that he may have cancer. The wife states, "dont you
think that it is unlikely for someone like my husband to have
cancer?" The nurse's response is based on the info that
Hodgkin's lymphoma is:
a) more likely to affect women than men
b) often diagnosed during adolescence and young adulthood
c) usually occurs frequently among populations as Asian
heritage
d) typically a disease of the elderly rather than younger adults
Correct Answers correct answer: B
Rationale: Hodgkin's lymphoma occurs most often between the
ages 15 to 35 and between 50 to 60 years of age
A charge nurse in a pediatric unit is providing a room
assignment for a child who is postoperative following an
appendectomy. The charge nurse should place the postoperative
child with which of the following clients?
a) a child who is experiencing sickle cell crisis
b) a child who has pertussis
c) a child who has a head injury
d) a child who has a new diagnosis of type 1 DM Correct
Answers correct answer: D
Rationale: the child who has DM requires monitoring and
teaching, and the child who is postoperative following
,appendectomy requires frequent assessments and interventions.
Furthermore, both of these children are in stable condition and
are noninfectious. Therefore, the RN should assign these two
clients to the same room
A charge nurse is admitting a client who has bipolar disorder
and is experiencing a manic episode. Which of the following
client room assignments should the nurse make?
a) a semi-private room across from the dayroom
b) a private room across from the linen room
c) a private room across from the exercise room
d) a semi-private room across from the nurses' station Correct
Answers correct answer: B
Rationale: The nurse should work to maintain a safe
environment for the client and minimize distractions and other
environmental stimuli. Assigning the client to a private room in
a quiet area of the unit decreases stimuli for the client, thus
reducing client anxiety. The area around the linen room should
be low-traffic area, which will help decrease the client's anxiety
and manic activities.
A charge nurse on the med-surg unit is implementing a new
initiative intended to identify clients at high risk for decubitus
ulcer formation in order to intervene with additional preventive
measures. Which of the following clients is at greatest risk of
developing a decubitus ulcer?
a) an 84-year-old client with dementia who is 1 day postop hip
replacement with a jackson-pratt drain
,b) a 40-year-old client with paraplegia after a spinal cord injury
and a hct of 43% who is being treated with norepinephrine
infusion for hypotension
c) an 80-year-old client with incontinence who is 2 days postop
radical prostatectomy with an albumin of 2.0 dg/dL
d) a 30-year-old client with sepsis and hypotension postop repair
of a femur fracture sustained in a MVC and a MAP of 52 mmHg
with PaO2 64 mmHg despite mechanical ventilation, who is
receiving a norepinephrine infusion Correct Answers correct
answer: D
Rationale: pressure ulcers develop when the capillaries that
supply the skin and subcutaneous tissues are compressed and
impede perfusion, leading to tissue necrosis. Contributory
factors are listed in the table below. This client has 5
contributory factors: postoperative surgical procedure, hypoxia,
hypotension, norepinephrine infusion, and infection
A client complains of feeling "lightheaded" after radiofrequency
catheter ablation. His cardiac monitor reveals dissociation of P
waves and QRS complexes. Which of the following is the most
appropriate first nursing intervention?
a) call the rapid response team for cardioversion
b) notify the healthcare provider and prepare to administer
atropine
c) notify the cardiologist and prepare for transcutaneous or
transvenous pacing
d) document the rhythm and assessment in the client's chart and
monitor for further changes Correct Answers correct answer: C
, Rationale: whatever the cause, the nurse should recognize a
complete heart block. The rhythm shown is third-degree heart
block, which is complete dissociation of atrial and ventricular
arrhythmia caused by failure of the conduction system. This can
occur after radiofrequency ablation, which is ablation of
electrical pathways that case tachyarrhythmia. Third-degree
heart block can result in pre-syncope (lightheadedness),
dizziness, fainting, confusion, hypotension, bradycardia, or heart
failure. The ECG will demonstrate a regular rate and rhythm, but
the P waves and Q waves have no relationship to one another.
Third-degree heart block requires temporary or permanent
pacing and is a life-threatening condition.
A client presents for an initial prenatal assessment, reporting that
her last menstrual period began on Jan 1 and ended on Jan 5.
She notes she has unprotected intercourse on Jan 15 and some
spotting on Jan 22. According to Naegele's rule, which of the
following is the estimate date of delivery?
a) Oct 8
b) Oct 12
C) Oct 22
d) Oct 30 Correct Answers correct answer: A
Rationale: To arrive at the estimated date of delivery, Naegele's
rule uses the first day of the date of the last normal menstrual
period minus 3 months plus 7 days. Therefore, this client's
estimated date of delivery is (Jan 1) - 3 months plus 7 days, or
Oct 8. Other methods to determine the estimated date of delivery
include measurement of the uterine height (McDonald's
measurement); auscultation of fetal heart rate by doppler; are
ultrasound, specifically around the 16-18th week of pregnancy.
Solutions
A 28-year-old male client is undergoing tests to confirm the
diagnosis of Hodgkin's lymphoma. The client and his wife are
worried that he may have cancer. The wife states, "dont you
think that it is unlikely for someone like my husband to have
cancer?" The nurse's response is based on the info that
Hodgkin's lymphoma is:
a) more likely to affect women than men
b) often diagnosed during adolescence and young adulthood
c) usually occurs frequently among populations as Asian
heritage
d) typically a disease of the elderly rather than younger adults
Correct Answers correct answer: B
Rationale: Hodgkin's lymphoma occurs most often between the
ages 15 to 35 and between 50 to 60 years of age
A charge nurse in a pediatric unit is providing a room
assignment for a child who is postoperative following an
appendectomy. The charge nurse should place the postoperative
child with which of the following clients?
a) a child who is experiencing sickle cell crisis
b) a child who has pertussis
c) a child who has a head injury
d) a child who has a new diagnosis of type 1 DM Correct
Answers correct answer: D
Rationale: the child who has DM requires monitoring and
teaching, and the child who is postoperative following
,appendectomy requires frequent assessments and interventions.
Furthermore, both of these children are in stable condition and
are noninfectious. Therefore, the RN should assign these two
clients to the same room
A charge nurse is admitting a client who has bipolar disorder
and is experiencing a manic episode. Which of the following
client room assignments should the nurse make?
a) a semi-private room across from the dayroom
b) a private room across from the linen room
c) a private room across from the exercise room
d) a semi-private room across from the nurses' station Correct
Answers correct answer: B
Rationale: The nurse should work to maintain a safe
environment for the client and minimize distractions and other
environmental stimuli. Assigning the client to a private room in
a quiet area of the unit decreases stimuli for the client, thus
reducing client anxiety. The area around the linen room should
be low-traffic area, which will help decrease the client's anxiety
and manic activities.
A charge nurse on the med-surg unit is implementing a new
initiative intended to identify clients at high risk for decubitus
ulcer formation in order to intervene with additional preventive
measures. Which of the following clients is at greatest risk of
developing a decubitus ulcer?
a) an 84-year-old client with dementia who is 1 day postop hip
replacement with a jackson-pratt drain
,b) a 40-year-old client with paraplegia after a spinal cord injury
and a hct of 43% who is being treated with norepinephrine
infusion for hypotension
c) an 80-year-old client with incontinence who is 2 days postop
radical prostatectomy with an albumin of 2.0 dg/dL
d) a 30-year-old client with sepsis and hypotension postop repair
of a femur fracture sustained in a MVC and a MAP of 52 mmHg
with PaO2 64 mmHg despite mechanical ventilation, who is
receiving a norepinephrine infusion Correct Answers correct
answer: D
Rationale: pressure ulcers develop when the capillaries that
supply the skin and subcutaneous tissues are compressed and
impede perfusion, leading to tissue necrosis. Contributory
factors are listed in the table below. This client has 5
contributory factors: postoperative surgical procedure, hypoxia,
hypotension, norepinephrine infusion, and infection
A client complains of feeling "lightheaded" after radiofrequency
catheter ablation. His cardiac monitor reveals dissociation of P
waves and QRS complexes. Which of the following is the most
appropriate first nursing intervention?
a) call the rapid response team for cardioversion
b) notify the healthcare provider and prepare to administer
atropine
c) notify the cardiologist and prepare for transcutaneous or
transvenous pacing
d) document the rhythm and assessment in the client's chart and
monitor for further changes Correct Answers correct answer: C
, Rationale: whatever the cause, the nurse should recognize a
complete heart block. The rhythm shown is third-degree heart
block, which is complete dissociation of atrial and ventricular
arrhythmia caused by failure of the conduction system. This can
occur after radiofrequency ablation, which is ablation of
electrical pathways that case tachyarrhythmia. Third-degree
heart block can result in pre-syncope (lightheadedness),
dizziness, fainting, confusion, hypotension, bradycardia, or heart
failure. The ECG will demonstrate a regular rate and rhythm, but
the P waves and Q waves have no relationship to one another.
Third-degree heart block requires temporary or permanent
pacing and is a life-threatening condition.
A client presents for an initial prenatal assessment, reporting that
her last menstrual period began on Jan 1 and ended on Jan 5.
She notes she has unprotected intercourse on Jan 15 and some
spotting on Jan 22. According to Naegele's rule, which of the
following is the estimate date of delivery?
a) Oct 8
b) Oct 12
C) Oct 22
d) Oct 30 Correct Answers correct answer: A
Rationale: To arrive at the estimated date of delivery, Naegele's
rule uses the first day of the date of the last normal menstrual
period minus 3 months plus 7 days. Therefore, this client's
estimated date of delivery is (Jan 1) - 3 months plus 7 days, or
Oct 8. Other methods to determine the estimated date of delivery
include measurement of the uterine height (McDonald's
measurement); auscultation of fetal heart rate by doppler; are
ultrasound, specifically around the 16-18th week of pregnancy.
