CORRECT ANSWERS 2025/2026
Fluid in the lungs sounds like - correct answers -crackles
Ausculation of the heart placement - correct answers -APEToMan
aortic
pulmonic
erb's point
tricuspic
mitral
Physiologic and system changes during the dying process - correct answers -all
body systems slow down
Which patient is of highest priority
a. tracheal edema after extubation
b. emphysema, O2 88% and tachypneic
c. heart failure, +4 pitting edema and irregular HR
d. meningitis, temp 40 and pain 7/10 - correct answers -a. tracheal edema after
extubation
,Indications of over-hydration - correct answers -crackles in the lungs
edema
bounding pulses
hypertension
intake > output
tachycardia
increased body weight
How to prevent DVTs - correct answers -apply SCDs
encourage ambulation
elevate legs in bed
apply compression stockings
encourage the patient to change positions in bed
ensure the patient has a DVT prophylaxis med ordered
Progression of pressure injuries - correct answers -stage 1: "non-blanching"
stage 2: surface
stage 3: penetrating surface
deep tissue injury
How to prevent pneumonia - correct answers -incentive spirometry
make sure the pt is awake enough before giving anything PO
encouraging coughing and deep breathing (CDB)
,encourage ambulation
keep pain under control
Things to check when infusing blood - correct answers -verify IV is 20g or larger
transfuse with NS only
use blood tubing
verify blood with 2nd person
remain with the patient for the first 15 minutes
describe s/s the patient should report
start the infusion within 30 minutes of receiving the blood
complete the infusion within 4 hours
You are admitting a patient who flew in from Madagascar yesterday and is
complaining of leg pain and shortness of breath. What do you do first? - correct
answers -assess ABCs
In order to maintain restraints - correct answers -active order: type, time applied,
reason
assess at least q2h: circulation, ongoing need for restraint, patient's need for
food/hydration and toileting
Ways to break sterile technique - correct answers -a sterile item goes over the 1
inch border
a non-sterile item touches inside the 1 inch border
you turn your back on the sterile field
, those present don't wear masks
something wet goes through the sterile field
you touch a non-sterile item with sterile gloves
Your patient voices discouragement regarding all the different kinds of pills they
are being discharged with. What would be the best response? - correct answers
-"what are you most concerned about with your medications?"
Things to do/monitor with a pt receiving enteral feedings - correct answers -
monitor: electrolytes, I&Os, abdominal cramping, diarrhea
do: keep HOB elevated, flush with H2O prior to and after meds, oral care
Your pt's O2 is 95% on RA, she has had a 5 lb weight gain over the last week,
hasn't urinated in 2 days, and has +4 pitting edema. which would be your priority
nursing diagnosis?
a. impaired gas exchange related to ineffective breathing
b. fluid volume, deficient related to excess fluid loss
c. electrolyte imbalance related to decreased oral intake
d. fluid volume, excess related to limited fluid output - correct answers -d. fluid
volume, excess related to limited fluid output
When to clamp a chest tube - correct answers -checking for air leak
prior to removal
changing the chamber
when there's an order for it