Answer Key
Question 1 See full question 13s
A client displays signs associated with a possible ruptured aortic aneurysm. What is
the priority nursing intervention?
You Selected:
Prepare the client for surgical intervention
Correct response:
Prepare the client for surgical intervention
Explanation:
When the vessel ruptures, prompt surgery is required for it’s repair.
Antihypertensive medications and beta-adrenergic blockers can help control
hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used
to detect an aneurysm.
Remediation:
Aneurysm (thoracic aortic)
Question 2 See full question 45s
After undergoing a cardiac catheterization, a client has a large puddle of blood
under his buttocks. What is the nurse’s priority action?
You Selected:
Assess the groin site
Correct response:
Assess the groin site
Explanation:
,Assessment of the groin site is the priority. This establishes the source of the blood,
and determines how much blood has been lost. The goal is to stop the bleeding.
The nurse would call for help if needed after the assessment of the situation. After
determining the extent of the bleeding, vital sign assessment is important. The
nurse should never move the client, in case a clot has formed. Moving can disturb
the clot and cause re-bleeding.
Remediation:
Cardiac catheterization
Question 3 See full question 33s
The nurse is ambulating a client. The client experiences chest pain after ambulating
50 feet. What is the nurse’s priority intervention?
You Selected:
Sit the client down
Correct response:
Sit the client down
Explanation:
The priority is to decrease oxygen consumption by sitting this client down. When
the client’s condition is stabilized, he can be returned to bed. An ECG can be
obtained after the client is sitting down, and the ordered sublingual nitroglycerin
could be administered.
Remediation:
Ambulation, progressive
Question 4 See full question 1m 24s
The nurse is assigned to care for four clients. Which client should the nurse assess
first?
You Selected:
, A client admitted one hour ago with new-onset atrial fibrillation who is
receiving IV diltiazem
Correct response:
A client admitted one hour ago with new-onset atrial fibrillation who is
receiving IV diltiazem
Explanation:
The client with atrial fibrillation has the greatest potential to become unstable, and
is on IV medication that requires close monitoring. After assessing this client, the
nurse should assess the client with thrombophlebitis who is receiving a heparin
infusion, and then the client admitted two days ago with heart failure. The client
with end-stage right-sided heart failure, who is identified as a hospice client is of
lowest priority.
Remediation:
Prioritizing care
Question 5 See full question 39s
A client has received an infusion of antibiotics and is now experiencing an
anaphylactic reaction. What is the most important intervention by the nurse?
You Selected:
Maintain a patent airway
Correct response:
Maintain a patent airway
Explanation:
The first priority is to maintain a patent airway. The client will then require an
epinephrine injection. If hypotension develops, a saline bolus may be given. The
client’s vital signs should be monitored, but not as the first action.
Remediation:
Anaphylaxis emergency patient care, ambulatory care
, Question 6 See full question 35s
What is the priority nursing measure for a client with von Willebrand’s disease who
is having epistaxis?
You Selected:
Avoid pressure to the nose
Correct response:
Apply pressure to the nose
Explanation:
Applying pressure to the nose may stop the bleeding because most bleeds occur in
the anterior part of the nasal septum. Mouth breathing should be encouraged until
the bleeding is under control. The child should be instructed to sit up and lean
forward to avoid aspiration of blood. Packing with tissue or cotton may be used to
help stop bleeding if applying pressure is unsuccessful, but care must be taken
while removing packing to avoid dislodging the clot. Pressure should be maintained
for at least 10 minutes to allow clotting to occur.
Remediation:
von Willebrand disease
von Willebrand disease, pediatric
Question 7 See full question 12m 9s
A child with hemophilia is hospitalized with bleeding into the knee. Which action
should the nurse take first?
You Selected:
Elevate the affected part
Correct response:
Elevate the affected part
Explanation:
Question 1 See full question 13s
A client displays signs associated with a possible ruptured aortic aneurysm. What is
the priority nursing intervention?
You Selected:
Prepare the client for surgical intervention
Correct response:
Prepare the client for surgical intervention
Explanation:
When the vessel ruptures, prompt surgery is required for it’s repair.
Antihypertensive medications and beta-adrenergic blockers can help control
hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used
to detect an aneurysm.
Remediation:
Aneurysm (thoracic aortic)
Question 2 See full question 45s
After undergoing a cardiac catheterization, a client has a large puddle of blood
under his buttocks. What is the nurse’s priority action?
You Selected:
Assess the groin site
Correct response:
Assess the groin site
Explanation:
,Assessment of the groin site is the priority. This establishes the source of the blood,
and determines how much blood has been lost. The goal is to stop the bleeding.
The nurse would call for help if needed after the assessment of the situation. After
determining the extent of the bleeding, vital sign assessment is important. The
nurse should never move the client, in case a clot has formed. Moving can disturb
the clot and cause re-bleeding.
Remediation:
Cardiac catheterization
Question 3 See full question 33s
The nurse is ambulating a client. The client experiences chest pain after ambulating
50 feet. What is the nurse’s priority intervention?
You Selected:
Sit the client down
Correct response:
Sit the client down
Explanation:
The priority is to decrease oxygen consumption by sitting this client down. When
the client’s condition is stabilized, he can be returned to bed. An ECG can be
obtained after the client is sitting down, and the ordered sublingual nitroglycerin
could be administered.
Remediation:
Ambulation, progressive
Question 4 See full question 1m 24s
The nurse is assigned to care for four clients. Which client should the nurse assess
first?
You Selected:
, A client admitted one hour ago with new-onset atrial fibrillation who is
receiving IV diltiazem
Correct response:
A client admitted one hour ago with new-onset atrial fibrillation who is
receiving IV diltiazem
Explanation:
The client with atrial fibrillation has the greatest potential to become unstable, and
is on IV medication that requires close monitoring. After assessing this client, the
nurse should assess the client with thrombophlebitis who is receiving a heparin
infusion, and then the client admitted two days ago with heart failure. The client
with end-stage right-sided heart failure, who is identified as a hospice client is of
lowest priority.
Remediation:
Prioritizing care
Question 5 See full question 39s
A client has received an infusion of antibiotics and is now experiencing an
anaphylactic reaction. What is the most important intervention by the nurse?
You Selected:
Maintain a patent airway
Correct response:
Maintain a patent airway
Explanation:
The first priority is to maintain a patent airway. The client will then require an
epinephrine injection. If hypotension develops, a saline bolus may be given. The
client’s vital signs should be monitored, but not as the first action.
Remediation:
Anaphylaxis emergency patient care, ambulatory care
, Question 6 See full question 35s
What is the priority nursing measure for a client with von Willebrand’s disease who
is having epistaxis?
You Selected:
Avoid pressure to the nose
Correct response:
Apply pressure to the nose
Explanation:
Applying pressure to the nose may stop the bleeding because most bleeds occur in
the anterior part of the nasal septum. Mouth breathing should be encouraged until
the bleeding is under control. The child should be instructed to sit up and lean
forward to avoid aspiration of blood. Packing with tissue or cotton may be used to
help stop bleeding if applying pressure is unsuccessful, but care must be taken
while removing packing to avoid dislodging the clot. Pressure should be maintained
for at least 10 minutes to allow clotting to occur.
Remediation:
von Willebrand disease
von Willebrand disease, pediatric
Question 7 See full question 12m 9s
A child with hemophilia is hospitalized with bleeding into the knee. Which action
should the nurse take first?
You Selected:
Elevate the affected part
Correct response:
Elevate the affected part
Explanation:
