and Answers (2026) | Latest Exam Practice
Questions | Fully Verified Answers | A+
• When caring for a client on a vent, which finding provides the greatest indication that
the client has an open airway? -✓✓Bilateral breath sounds can be auscultated
• The nurse performs a prescribed a neurological check at the beginning of the shift on
a client who was admitted with a subarachnoid brain attack (Stroke). The client's GCS is
9. What information is most important for the nurse to determine? -✓✓The client's
previous GCS score
• An adult female with a history of type 1 diabetes has been vomiting for the past 48
hours and is admitted to the ICU with DKA. Which assessment finding warrants
immediate intervention by the nurse? -✓✓Excessive thirst
• A client admitted to the ICU after a colon resection with the formation of the loop
colostomy. The nurse determines that the clients abdominal dressing is clean and dry.
Vital signs are: HR: 130, temperature: 100, BP: 88/65, and urine output of 10 mL/hr.
What interventions should the nurse implement? -✓✓Give a 500 mL IV fluid bolus
challenge
• A client is admitted with syncopal episodes related to a third degree heart block. After
the placement of a transcutaneous pacemaker, the nurse observes several episodes
the pacemaker failure to sense. What action should the nurse take? -✓✓Increase the
sensitivity
• A client is receiving CPR. After systole is confirmed in two leads and sending the
transcutaneous pacemaker, which IV medication should be administered? -
✓✓Epinephrine (adrenaline)
• A client has a chest tube connected to a closed water seal drainage system with
suction. What equipment should the nurse always have available at the clients bedside?
-✓✓Occlusive dressing
• Bretylium 1 mg/min via infusion is prescribed for a client and ventricular tachycardia.
The available solution is 500 mL D5W contains bretylium 1 gram. The nurse should
program the infusion time to deliver how many mL/hr? -✓✓30
• The client is receiving an infusion of nitroglycerin 100 mg and 500 mL D5W at 6 mL/hr.
How many mcg/min of nitroglycerin is infusing? -✓✓20
, • A client arrives in the ER complaining of pain. What description of pain should prompt
the nurse to suspect it originated in the myocardium? -✓✓Produces chest heaviness
with left arm pain
• Four days ago a chest tube was inserted into the second intercostal space of a client
who has a pneumothorax. Today the nurse notes that there is no fluctuation in the
water-seal chamber of the Pleuravac. Which intervention would be most appropriate for
the nurse to implement? -✓✓Assess the clients breath sounds of the affected lung
• In developing a care plan for a client that has a chest tube due to a hemothorax, the
nurse should recognize which intervention is essential? -✓✓Encourage the client to
breathe deeply and cough at frequent intervals
• A postoperative client is admitted the ICU with an inflated pressure infuser containing
solution of heparin 2 units/mL attached to an intraarterial cannula. Which finding
indicated that the heparin infusion has achieved its therapeutic use? -✓✓Intra-arterial
cannula remain patent
• The nurse suspects that a client with a central venous catheter in the left subclavian
vein is experiencing an embolism. What signs and symptoms are most indicative of this
condition? -✓✓Anxiety, confusion, lightheadedness, and loss consciousness
• A female client has been in systole for 20 minutes. She is intubated, and epinephrine
(adrenaline) 1 mg and atropine sulfate 1 mg IV were administered, with no change in
rhythm. What intervention should the nurse implement? -✓✓Bring members of the
family to a private area to discuss the desire to continue life saving efforts
• The nurse is evaluating a clients central venous pressure reading that are trending
upwards. What nursing diagnosis is supported but the pathophysiological mechanism
most likely causing this increase? -✓✓Impaired cardiac output
• The high pressure alarm on a mechanical vent is alarming. What intervention should
the nurse implement immediately? -✓✓Auscultate bilaterally for breath sounds and
confirm endotracheal suctioning
• A client with a history of vasovagal attacks resulting in brady-dysrhythmias. Which
instruction is the most important in the teaching plan? -✓✓Use stool softeners regularly
• The ECG pattern of a client indicates that the cardiac rhythm has changed from first
degree to third degree AV block. What intervention should the nurse implement? -
✓✓Assess the clients BP
• The nurse caring for a client who hemorrhaged postoperatively and is in the early
stage of shock. Which cardiopulmonary symptoms are most indicative of progression