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1) QUESTION 1
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A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour
after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart
rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding
to the surgeon, which action should the nurse implement first?
A. Measure and document the client’s urinary output.
B. Request the client’s reserved unit of packed red blood cells.
C. Prepare the placement of a central venous catheter.
D. Increase the infusion rate of Lactated Ringer’s solution.
Correct Answer: D. Increase the infusion rate of Lactated Ringer’s solution.
Explanation (Long, Expert-Verified):
• Since the client has lost a significant amount of blood (300 mL in one hour indicates acute blood
loss), the immediate concern is preventing hypovolemic shock progression.
• Tachycardia at 155 beats/minute and hypotension at 78/48 mmHg demonstrate shocky
hemodynamics.
• Increasing the IV fluid rate gives an immediate intravascular volume boost while awaiting further
orders (e.g., blood transfusion).
• It is critical to maintain blood pressure and perfusion to vital organs.
• Other actions, like measuring urine output and obtaining or requesting packed RBCs, are important
but do not supersede rapidly restoring intravascular volume.
NGN/Case-Study Adaptation:
• A short unfolding scenario could present real-time vital signs, outputs, and lab changes. Then the
test-taker must drag-and-drop or prioritize which action is most critical.
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2) QUESTION 2
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An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department before his transfer to the
,ICU. The nurse notes that the suction control chamber is bubbling at the −10 cm H2O mark, with
fluctuation in the water seal; and over the past hour 75 mL of bright red blood was measured in the
collection chamber. Which intervention should the nurse implement?
A. Add sterile water to the suction control chamber.
B. Give blood from the collection chamber as auto-transfusion.
C. Manipulate blood in tubing to drain into chamber.
D. Increase wall suction to eliminate fluctuation in water seal.
Correct Answer: A. Add sterile water to the suction control chamber.
Explanation:
• The nurse must ensure that the water level in the suction control chamber is maintained properly
(−10 cm H2O) to provide adequate negative pressure.
• Bubbling in the suction control chamber is normal, but if levels are dropping or any portion has
evaporated, the nurse should add sterile water to maintain suction level.
• Fluctuation in the water seal (tidaling) is expected with a pneumothorax and normal breathing cycle.
• Increasing wall suction so that the water seal no longer fluctuates could cause excessive negative
pressure, leading to lung tissue injury.
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3) QUESTION 3
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A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg,
heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client presents with
shortness of breath, bilateral +2 pedal edema, and an oxygen saturation on room air of 89%. Which
action should the nurse take first?
A. Elevate the foot of the bed.
B. Restrict the client’s fluid.
C. Begin supplemental oxygen.
D. Prepare the client for hemodialysis.
Correct Answer: C. Begin supplemental oxygen.
Explanation:
• The client’s respiratory rate is 36/min, oxygen saturation is 89% on room air, and they have
dyspnea—indicating significant respiratory distress.
,• The immediate nursing action is to improve oxygenation. Administering supplemental oxygen
stabilizes oxygen saturation and prevents further hypoxia.
• Although fluid restriction and possible dialysis may be indicated, the priority is to address acute
hypoxemia first, following the ABC (Airway, Breathing, Circulation) protocol.
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4) QUESTION 4 (Select all that apply)
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A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation. Based
on the client’s admitting diagnosis, which findings require immediate action by the nurse? (Select all
that apply)
A. Headache and tremors
B. Irregular heart rate
C. Skin hyperpigmentation
D. Postural hypotension
E. Pallor and diaphoresis
Correct Answers: A, B, E.
Explanation:
• Addison’s crisis can lead to severe hypoglycemia and electrolyte imbalances, manifesting as
headache, tremors (neuroglycopenic symptoms), and cardiac arrhythmias (irregular heart rate) from
hyperkalemia.
• Pallor and diaphoresis often accompany acute hypothermia or shock states, also consistent with
Addisonian crisis.
• Skin hyperpigmentation is a more chronic sign of Addison’s disease rather than an acute crisis red-
flag.
• Postural hypotension is common but less emergent than arrhythmia or neuroglycopenic
presentation in a crisis context.
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5) QUESTION 5
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An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is
the best indicator of hydration that the nurse should report to the healthcare provider?
, A. Urine specific gravity is 1.040
B. Systolic blood pressure decreases 10 points when standing.
C. The client denies being thirsty.
D. Skin tenting occurs when the client’s forearm is pinched.
Correct Answer: D. Skin tenting occurs when the client’s forearm is pinched.
Explanation:
• Skin tenting is a classic sign of decreased skin turgor, which strongly suggests persistent dehydration
or significant volume deficit.
• While urine specific gravity of 1.040 is high, it is not as direct an observable sign compared to visible
skin tenting.
• A 10-point drop in systolic BP on standing is mild orthostatic change, but skin tenting is a direct
measure of inadequate hydration.
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6) QUESTION 6
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After an in-service about electronic health record (EHR) security and safeguarding client information,
the nurse observes a colleague going home with printed copies of client information in a uniform
pocket. Which action should the nurse take?
A. File a detailed incident report with the specific hiring facility.
B. Warn the colleague that their actions are unprofessional.
C. Comment anonymously about the action on a staff discussion board.
D. Communicate the colleague’s actions to the unit charge nurse.
Correct Answer: A. File a detailed incident report with the specific hiring facility.
Explanation:
• HIPAA and facility privacy policies require immediate and formal documentation of any breach or
suspected breach.
• Filing an incident report initiates an official process that can correct the problem and reinforce the
confidentiality aspect.
• Providing direct feedback is also an option, but the priority is to document properly to protect
clients and address the violation.
──────────────────────────────────────────
──────────────
──────────────
1) QUESTION 1
──────────────────────────────────────────
──────────────
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour
after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart
rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding
to the surgeon, which action should the nurse implement first?
A. Measure and document the client’s urinary output.
B. Request the client’s reserved unit of packed red blood cells.
C. Prepare the placement of a central venous catheter.
D. Increase the infusion rate of Lactated Ringer’s solution.
Correct Answer: D. Increase the infusion rate of Lactated Ringer’s solution.
Explanation (Long, Expert-Verified):
• Since the client has lost a significant amount of blood (300 mL in one hour indicates acute blood
loss), the immediate concern is preventing hypovolemic shock progression.
• Tachycardia at 155 beats/minute and hypotension at 78/48 mmHg demonstrate shocky
hemodynamics.
• Increasing the IV fluid rate gives an immediate intravascular volume boost while awaiting further
orders (e.g., blood transfusion).
• It is critical to maintain blood pressure and perfusion to vital organs.
• Other actions, like measuring urine output and obtaining or requesting packed RBCs, are important
but do not supersede rapidly restoring intravascular volume.
NGN/Case-Study Adaptation:
• A short unfolding scenario could present real-time vital signs, outputs, and lab changes. Then the
test-taker must drag-and-drop or prioritize which action is most critical.
──────────────────────────────────────────
──────────────
2) QUESTION 2
──────────────────────────────────────────
──────────────
An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the emergency department before his transfer to the
,ICU. The nurse notes that the suction control chamber is bubbling at the −10 cm H2O mark, with
fluctuation in the water seal; and over the past hour 75 mL of bright red blood was measured in the
collection chamber. Which intervention should the nurse implement?
A. Add sterile water to the suction control chamber.
B. Give blood from the collection chamber as auto-transfusion.
C. Manipulate blood in tubing to drain into chamber.
D. Increase wall suction to eliminate fluctuation in water seal.
Correct Answer: A. Add sterile water to the suction control chamber.
Explanation:
• The nurse must ensure that the water level in the suction control chamber is maintained properly
(−10 cm H2O) to provide adequate negative pressure.
• Bubbling in the suction control chamber is normal, but if levels are dropping or any portion has
evaporated, the nurse should add sterile water to maintain suction level.
• Fluctuation in the water seal (tidaling) is expected with a pneumothorax and normal breathing cycle.
• Increasing wall suction so that the water seal no longer fluctuates could cause excessive negative
pressure, leading to lung tissue injury.
──────────────────────────────────────────
──────────────
3) QUESTION 3
──────────────────────────────────────────
──────────────
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg,
heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client presents with
shortness of breath, bilateral +2 pedal edema, and an oxygen saturation on room air of 89%. Which
action should the nurse take first?
A. Elevate the foot of the bed.
B. Restrict the client’s fluid.
C. Begin supplemental oxygen.
D. Prepare the client for hemodialysis.
Correct Answer: C. Begin supplemental oxygen.
Explanation:
• The client’s respiratory rate is 36/min, oxygen saturation is 89% on room air, and they have
dyspnea—indicating significant respiratory distress.
,• The immediate nursing action is to improve oxygenation. Administering supplemental oxygen
stabilizes oxygen saturation and prevents further hypoxia.
• Although fluid restriction and possible dialysis may be indicated, the priority is to address acute
hypoxemia first, following the ABC (Airway, Breathing, Circulation) protocol.
──────────────────────────────────────────
──────────────
4) QUESTION 4 (Select all that apply)
──────────────────────────────────────────
──────────────
A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation. Based
on the client’s admitting diagnosis, which findings require immediate action by the nurse? (Select all
that apply)
A. Headache and tremors
B. Irregular heart rate
C. Skin hyperpigmentation
D. Postural hypotension
E. Pallor and diaphoresis
Correct Answers: A, B, E.
Explanation:
• Addison’s crisis can lead to severe hypoglycemia and electrolyte imbalances, manifesting as
headache, tremors (neuroglycopenic symptoms), and cardiac arrhythmias (irregular heart rate) from
hyperkalemia.
• Pallor and diaphoresis often accompany acute hypothermia or shock states, also consistent with
Addisonian crisis.
• Skin hyperpigmentation is a more chronic sign of Addison’s disease rather than an acute crisis red-
flag.
• Postural hypotension is common but less emergent than arrhythmia or neuroglycopenic
presentation in a crisis context.
──────────────────────────────────────────
──────────────
5) QUESTION 5
──────────────────────────────────────────
──────────────
An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is
the best indicator of hydration that the nurse should report to the healthcare provider?
, A. Urine specific gravity is 1.040
B. Systolic blood pressure decreases 10 points when standing.
C. The client denies being thirsty.
D. Skin tenting occurs when the client’s forearm is pinched.
Correct Answer: D. Skin tenting occurs when the client’s forearm is pinched.
Explanation:
• Skin tenting is a classic sign of decreased skin turgor, which strongly suggests persistent dehydration
or significant volume deficit.
• While urine specific gravity of 1.040 is high, it is not as direct an observable sign compared to visible
skin tenting.
• A 10-point drop in systolic BP on standing is mild orthostatic change, but skin tenting is a direct
measure of inadequate hydration.
──────────────────────────────────────────
──────────────
6) QUESTION 6
──────────────────────────────────────────
──────────────
After an in-service about electronic health record (EHR) security and safeguarding client information,
the nurse observes a colleague going home with printed copies of client information in a uniform
pocket. Which action should the nurse take?
A. File a detailed incident report with the specific hiring facility.
B. Warn the colleague that their actions are unprofessional.
C. Comment anonymously about the action on a staff discussion board.
D. Communicate the colleague’s actions to the unit charge nurse.
Correct Answer: A. File a detailed incident report with the specific hiring facility.
Explanation:
• HIPAA and facility privacy policies require immediate and formal documentation of any breach or
suspected breach.
• Filing an incident report initiates an official process that can correct the problem and reinforce the
confidentiality aspect.
• Providing direct feedback is also an option, but the priority is to document properly to protect
clients and address the violation.
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