NCLEX-RN Nursing — All Questions

A nurse is obtaining a throat swab for culture from an adolescent with a sore throat and fever. Which technique should the nurse use?

• a.Rub the swab over the lips, gums, and the front surface of the tongue
• b.Ask the client to swallow, then swab the uvula with light, brief pressure
• c.Rub the swab along the inner cheeks and beneath the tongue for 5 seconds
• d.Rub the swab across both tonsillar areas and the back of the throat✓

Group A streptococcus colonizes the tonsillar pillars and posterior oropharynx, so the swab is rubbed over both tonsillar areas and the back of the throat while avoiding the tongue, teeth, and gums. Sampling the cheeks, gums, or tongue collects normal oral flora and produces a falsely negative culture.

A nurse is obtaining a swab culture from a chronic sacral wound that has purulent drainage on the surface and a rim of dry eschar at one edge. Which action should the nurse take?

• a.Swab the dry eschar at the wound edge, then irrigate with sterile normal saline
• b.Apply an antiseptic to the wound bed, then swab the center of the cleansed area
• c.Irrigate with sterile normal saline, then rotate the swab on viable wound tissue✓
• d.Swab the purulent drainage first, since organisms are most concentrated there

In the Levine technique the wound is first irrigated with normal saline to remove drainage and debris, then the swab is pressed and rotated over about 1 cm of clean, viable tissue so it samples the organisms actually invading the wound. Swabbing exudate or eschar returns surface colonizers rather than the pathogen, and antiseptic kills organisms before they can be cultured.

A client receiving broad-spectrum antibiotics passes a formed, brown stool. The nursing assistant asks whether to send the specimen for Clostridioides difficile testing. Which response by the nurse is correct?

• a.A formed stool is sent because the test detects carriers before diarrhea develops
• b.Only unformed stool from a client who has diarrhea is sent for C. difficile testing✓
• c.A formed stool is sent each day until three specimens have been reported negative
• d.Any stool from a client on broad-spectrum antibiotics goes for C. difficile testing

CDC directs laboratories to test only unformed stool, because a person who is colonized with C. difficile but has no diarrhea will test positive without having infection, and treating that result exposes the client to antibiotics they do not need. For the same reason, testing is not repeated to prove cure after treatment, since the test can stay positive for six weeks or longer.

A nurse has just inserted a small-bore nasogastric feeding tube for a client who is to begin enteral feeding. The nurse aspirates a small amount of cloudy tan fluid that tests at a pH of 5.0. Which action should the nurse take next?

• a.Inject 30 mL of air and listen over the stomach for a rush of air before feeding
• b.Start the feeding, because an aspirate pH of 5.0 confirms placement in the stomach
• c.Keep the tube clamped and unused until a radiograph confirms its full course✓
• d.Advance the tube another 5 centimeters and retest the aspirate pH before feeding

AACN states that placement of a blindly inserted feeding tube must be confirmed with a radiograph visualizing the entire course of the tube before it is first used for feeding or medication; aspirate pH and appearance are supportive bedside checks, not initial confirmation. Auscultating an insufflated air bolus is still taught in many nursing texts, but it cannot distinguish a tube in the stomach from one in the lung or esophagus and AACN directs nurses not to use it.

A client is being discharged after a total hip replacement done through a posterior approach, and the surgeon has prescribed hip precautions for the next six weeks. Which statement by the client indicates that the teaching about protecting the new joint was effective?

• a.I will keep a pillow between my thighs when I turn in bed.✓
• b.I will settle into the low, soft armchair to watch television.
• c.I will bend forward at the waist to pull my own socks on.
• d.I will cross my ankles when I put my feet up to rest.

Keeping a pillow between the thighs holds the operated leg from crossing midline, because adduction combined with flexion past 90 degrees and internal rotation is the position that levers a posterior-approach prosthesis out of its socket. Bending forward at the waist to reach the feet is the most tempting wrong choice since it feels routine, yet it carries the hip far past 90 degrees of flexion, which is exactly why a sock aid and a reacher are supplied at discharge. Discharge instructions also direct the client to sit in a firm chair with the hips higher than the knees and to keep the legs and ankles uncrossed when sitting, standing, or lying down.

A nurse cannot flush a client's percutaneous endoscopic gastrostomy tube and finds it occluded. Which action should the nurse take first?

• a.Push saline firmly through the tube with a 3 mL syringe for greater pressure
• b.Gently push and pull warm water through the tube with a 60 mL syringe✓
• c.Gently push and pull cranberry juice through the tube with a 60 mL syringe
• d.Gently push and pull carbonated cola through the tube with a 30 mL syringe

Warm water instilled with a gentle push-pull motion is the first-line method for an occluded feeding tube. Cranberry juice and cola are widely repeated bedside remedies, but their acidity precipitates the protein in enteral formula and can harden the clog, and a small-barrel syringe generates high pressure that may rupture the tube.

A provider orders knee-high antiembolism stockings for a 78-year-old client. On assessment the nurse finds absent dorsalis pedis pulses, shiny hairless shins, and a documented history of peripheral arterial disease. Which action should the nurse take?

• a.Apply the stockings and assess the feet for warmth every hour
• b.Hold the stockings and discuss the arterial findings with the provider✓
• c.Apply the stockings at night only, while the client is lying flat in bed
• d.Apply a larger size so the stockings sit more loosely on the lower leg

Peripheral arterial disease is a listed contraindication to graduated compression stockings, because external compression on a limb that already has reduced arterial inflow can drive tissue ischemia and skin necrosis. Frequent circulation checks are appealing but do not make a contraindicated device safe, and sizing up simply removes the graduated pressure the stocking exists to deliver.

A client has worn knee-high antiembolism stockings for two days after abdominal surgery. Which finding requires the nurse to remove the stockings and contact the provider?

• a.Faint indentation lines on the calf just after the stockings come off
• b.A report that the stockings feel snug when they are first pulled on
• c.Dry, flaking skin on both heels seen during the morning bath
• d.New numbness of the toes, with cool and dusky skin on that foot✓

New numbness with cool, dusky toes signals that the stocking is compromising arterial perfusion and nerve function distally, so it is removed and the finding is reported. Transient indentation marks, a snug sensation on application, and dry heel skin are expected or minor findings managed with skin care and a recheck of sizing, not with escalation.

A client with a complete spinal cord injury at T4 suddenly reports a pounding headache. The blood pressure is 186/104 mm Hg from a baseline of 104/62 mm Hg, the heart rate is 50, the face and neck are flushed and sweaty, and both legs are cool and pale. Which action should the nurse take first?

• a.Lay the client flat and raise both legs on two pillows
• b.Notify the provider and recheck the pressure in 15 minutes
• c.Sit the client upright and lower both legs below the heart✓
• d.Give the prescribed acetaminophen for the client's headache

These findings are autonomic dysreflexia, an exaggerated sympathetic response to a stimulus below the level of injury that occurs with lesions at or above T6; sitting the client upright with the legs down is the first step because it pools blood in the legs and lowers the pressure within seconds, while the nurse looks for the trigger, most often a distended bladder or a blocked catheter. Lying the client flat with the legs raised drives the pressure higher, and waiting on a provider call or an analgesic leaves a hypertensive emergency that can cause seizure or stroke untreated.

A client with cirrhosis and tense ascites is scheduled for a bedside abdominal paracentesis. Which action should the nurse take immediately before the procedure?

• a.Position the client on the left side with the knees drawn up to the chest
• b.Have the client drink 500 mL of water just before the needle is inserted
• c.Position the client prone with a pillow placed under the abdomen
• d.Have the client empty the bladder just before the needle is inserted✓

The paracentesis needle enters the lower abdomen, and a distended bladder rises into that field, so having the client void immediately beforehand is the specific precaution that prevents bladder perforation. Drinking fluid does the opposite by filling the bladder; the prone and knee-to-chest positions belong to other procedures and do not expose the puncture site.

A client has a chest tube connected to a closed drainage system after a lobectomy. Midway through the shift the nurse observes continuous bubbling in the water seal chamber that was not present earlier. How should the nurse interpret this finding?

• a.The client's lung has fully re-expanded and the tube can now be removed.
• b.Air is leaking into the system between the client and the unit.✓
• c.A clot is obstructing the tubing and blocking fluid from draining.
• d.The prescribed suction level is too low for the size of the pneumothorax.

Continuous bubbling in the water seal chamber signals an air leak, and the nurse traces the tubing from the chest wall toward the drainage unit to locate it. Full lung re-expansion produces the opposite picture, because bubbling and tidaling stop when the pleural space is no longer venting air.

A client's chest tube is accidentally pulled out of the chest wall while the client is being repositioned in bed. What should the nurse do immediately?

• a.Place the end of the dislodged tube into a bottle of sterile water.
• b.Cover the site with a sterile occlusive dressing taped on three sides.✓
• c.Reinsert the tube into the same opening and secure it with wide silk tape.
• d.Seal the site with a sterile occlusive dressing taped on all four sides.

Taping a sterile occlusive dressing on three sides lets trapped air escape through the untaped edge, which prevents a tension pneumothorax; sealing all four sides traps air in the pleural space and can cause the very emergency the dressing is meant to prevent. Submerging the tube end in sterile water is the maneuver for a broken drainage unit, not for a tube that has come out of the client.

A preceptor observes a newly hired nurse caring for a client with a chest tube after thoracic surgery. Which action by the new nurse requires the preceptor to intervene?

• a.Squeezing the tubing hand over hand to move a clot along.✓
• b.Coiling excess tubing flat on the bed with no dependent loops.
• c.Keeping the unit upright and below the level of the client's chest.
• d.Marking the drainage level on the chamber with the date and time.

Stripping or milking chest tube tubing generates extremely high negative intraluminal pressure that can injure lung tissue, so it is not part of routine care. Marking drainage, keeping the unit upright below chest level so gravity drains the pleural space, and avoiding dependent loops are all correct chest tube management.

The nurse is suctioning a client's tracheostomy using an open suction catheter. Which action indicates the nurse needs further instruction on the procedure?

• a.Limiting each suction pass to 15 seconds or less of applied suction.
• b.Allowing the client to recover between passes and using no more than two.
• c.Applying suction while advancing the catheter into the tracheostomy tube.✓
• d.Preoxygenating the client with 100% oxygen for 30 seconds before the pass.

Suction is applied only as the catheter is withdrawn; applying it during insertion removes oxygen from the airway for the whole pass and abrades the tracheal mucosa. Preoxygenation with 100% oxygen, passes of 15 seconds or less, and limiting the number of passes with recovery time between them are all correct technique.

A tracheostomy tube placed surgically two days ago becomes dislodged when the client pulls at the ties. The client is dyspneic and the oxygen saturation is falling. What should the nurse do?

• a.Call for emergency help and ventilate by mask over the face and nose.✓
• b.Reinsert the same tube with the obturator and auscultate the chest.
• c.Place the client in Trendelenburg and wait for the surgeon to arrive.
• d.Pass a suction catheter through the stoma and apply continuous suction.

A tracheostomy tract is not considered mature until roughly five to seven days after surgery, and blind reinsertion into an immature tract can create a false passage in the soft tissue of the neck, causing subcutaneous emphysema and loss of the airway. The nurse oxygenates from above with a bag-valve mask over the mouth and nose while emergency airway support is summoned; reinsertion with an obturator is appropriate only once the stoma is well formed.

The high-pressure alarm sounds on the ventilator of an intubated client who is coughing and has coarse crackles over the large airways. Which action should the nurse take first?

• a.Silence the alarm and increase the set tidal volume by 100 mL.
• b.Reconnect the ventilator circuit at the endotracheal tube adapter.
• c.Deflate the endotracheal tube cuff until the alarm stops.
• d.Suction the endotracheal tube to clear the secretions.✓

A high peak pressure alarm means resistance to airflow has risen, and secretions in a coughing client with coarse breath sounds are a cause the nurse can correct directly by suctioning. The cause of a ventilator alarm is identified before the alarm is silenced, and adjusting the tidal volume or cuff does not remove the obstruction.

An intubated client on a ventilator suddenly desaturates to 84%, and the nurse cannot identify the cause of the alarm after a rapid bedside check. Which action should the nurse take?

• a.Disconnect the ventilator and ventilate by hand with a bag-valve device.✓
• b.Raise the FiO2 setting on the ventilator and recheck in five minutes.
• c.Silence the alarm and observe the client for another three minutes.
• d.Reposition the pulse oximeter probe and repeat the reading in two minutes.

When a ventilated client deteriorates and the cause is not immediately apparent, the client is taken off the machine and ventilated manually with 100% oxygen while displacement, obstruction, pneumothorax and equipment failure are worked through. Adjusting settings or watching the monitor leaves the client dependent on a device that may itself be the source of the failure.

Which intervention should the nurse include in the plan of care for a mechanically ventilated client to reduce the risk of ventilator-associated pneumonia?

• a.Keep the head of the bed elevated 30 to 45 degrees unless it is contraindicated.✓
• b.Position the client flat with the head of the bed lowered to 0 degrees.
• c.Replace the ventilator circuit tubing at the start of every eight-hour shift.
• d.Instill sterile saline into the endotracheal tube before every suction pass.

Elevating the head of the bed to 30 to 45 degrees reduces aspiration of gastric and oropharyngeal secretions, which is the main route by which ventilated clients acquire pneumonia. Lying flat increases that aspiration risk rather than reducing it, and routine circuit changes and saline instillation are not recommended preventive measures.

A nurse cares for a client whose tracheostomy was placed four days ago. During the shift the client's secretions become thick and crusted and are increasingly difficult to clear. Which action should the nurse take?

• a.Restrict the client's oral fluids so that fewer tracheal secretions form
• b.Deliver humidified gas by tracheostomy collar and encourage oral fluids✓
• c.Suction the tracheostomy each hour overnight whether or not it is needed
• d.Loosen the tracheostomy ties so the tube can move freely within the stoma

A tracheostomy bypasses the nose, which normally warms and moistens inspired air, so humidified gas at the tracheostomy collar together with adequate fluid intake is what keeps secretions thin and prevents mucous plugging. Restricting fluids works in the opposite direction and thickens secretions further, and suctioning is done when secretions are present rather than on a fixed hourly schedule.

The nurse observes that the reservoir bag on a client's non-rebreather mask collapses completely each time the client inhales. Which action should the nurse take?

• a.Lower the flow rate so the bag can refill between breaths.
• b.Document the finding as the expected response to inhalation.
• c.Increase the oxygen flow rate until the bag stays partly inflated.✓
• d.Remove the one-way valve between the bag and the mask.

The reservoir bag on a non-rebreather must not fully deflate; a bag that empties on inspiration means the flow is below the client's inspiratory demand, so the nurse raises the flow, generally to 10 to 15 L/min, until the bag remains partly inflated. Lowering the flow or removing a valve would let the client rebreathe exhaled carbon dioxide.

A provider prescribes postural drainage with chest percussion for several clients on a medical unit. For which client should the nurse question the prescription?

• a.A client with cystic fibrosis and thick, tenacious sputum in both lungs.
• b.A client with bronchiectasis who expectorates thick sputum each morning.
• c.A client with COPD and retained secretions in the lower lobes.
• d.A client with multiple rib fractures after a motor vehicle crash.✓

Percussion delivered over a chest wall with recent rib fractures can displace fracture fragments and worsen the injury, so the nurse questions that prescription before carrying it out. Cystic fibrosis, bronchiectasis and retained lower-lobe secretions are exactly the mucus-clearance problems chest physiotherapy is intended to treat.

On the sixth postoperative day after abdominal surgery, a client coughs forcefully and a loop of bowel protrudes through the incision. What should the nurse do first?

• a.Cover the incision with a dry sterile dressing and reposition the client.
• b.Irrigate the exposed bowel with povidone-iodine and cover it with dry gauze.
• c.Cover the bowel with sterile gauze moistened with sterile normal saline.✓
• d.Gently replace the bowel into the abdomen and apply a snug binder.

Evisceration is a surgical emergency, and the nurse keeps the exposed viscera covered with saline-moistened sterile gauze to prevent drying and fluid loss until the surgeon returns the bowel to the abdomen in the operating room. Pushing the bowel back in at the bedside risks perforation and peritoneal contamination, and a dry dressing lets the tissue desiccate.

Six hours after surgery the nurse finds a client's Jackson-Pratt bulb fully expanded and containing 15 mL of serosanguineous drainage. Which action should the nurse take?

• a.Empty and measure the drainage, then compress the bulb and replug it.✓
• b.Notify the surgeon that the drainage system has stopped working properly.
• c.Connect the bulb to low continuous wall suction to restore the vacuum.
• d.Irrigate the drain with 10 mL of sterile normal saline to clear it.

A Jackson-Pratt drain generates its own vacuum from the bulb being squeezed flat and stoppered, so an expanded bulb has simply lost that vacuum; the nurse empties and measures the output, recompresses the bulb, and reseals the port. This is a nursing action rather than a reason to call the surgeon, and the closed bulb system is not attached to wall suction.

A client has a stage 3 pressure injury that soaks through its dressing between scheduled changes. Which dressing should the nurse anticipate applying?

• a.A hydrocolloid dressing left in place for up to five days.
• b.A calcium alginate dressing covered with a secondary pad.✓
• c.A dry woven gauze dressing taped over the wound daily.
• d.A transparent film dressing changed every seven days.

Alginate dressings are highly absorptive and are chosen for wounds producing heavy exudate, drawing fluid away while keeping the wound bed moist. A transparent film has essentially no absorptive capacity, so exudate would pool beneath it and macerate the surrounding skin.

The nurse reviews the record of a client scheduled to begin negative pressure wound therapy. Which finding should the nurse report to the provider before the therapy is started?

• a.The wound was sharply debrided at the bedside yesterday.
• b.The wound bed is covered by adherent black eschar.✓
• c.The wound base has healthy red granulation tissue throughout.
• d.The client ambulates in the hallway three times a day.

Necrotic tissue and eschar must be debrided before negative pressure wound therapy is applied, because the therapy cannot draw granulation tissue up through devitalized tissue and infection can be driven deeper. A wound that has already been debrided and shows red granulation tissue is an appropriate candidate for the therapy.

The nurse assesses a client on the first day after creation of a colostomy. Which finding should the nurse report to the surgeon immediately?

• a.The stoma is beefy red and bleeds slightly when cleansed.
• b.The stoma is dusky purple and dry rather than moist.✓
• c.The pouch contains a small amount of loose brown output.
• d.The peristomal skin is slightly pink under the adhesive edge.

A viable stoma is moist and pink to beefy red; a dusky, purple or black stoma that is dry indicates compromised blood supply and needs immediate surgical evaluation. Slight bleeding when the stoma is cleansed is expected because stomal tissue is highly vascular.

Which statement by a client who is learning to care for a new colostomy indicates that the teaching was effective?

• a.I will empty the pouch when it is about one-third full of stool.✓
• b.I will change the whole pouching system every single morning.
• c.I will cut the barrier opening one inch wider than my stoma.
• d.I will wait until the pouch is completely full to empty it.

Emptying at about one-third full keeps the weight of the effluent from peeling the skin barrier away from the skin and causing leaks. The barrier opening should clear the stoma by only about one-sixteenth to one-eighth of an inch, and the pouching system is generally changed every five to seven days rather than daily.

On the first day after upper abdominal surgery a client has an oxygen saturation of 92%, diminished breath sounds at both lung bases, and reports incisional pain rated 7 out of 10. Which action should the nurse take first?

• a.Give the prescribed analgesic so the client can deep breathe and cough.✓
• b.Collect a sputum specimen and send it for culture and sensitivity.
• c.Lay the client flat and apply oxygen by non-rebreather mask.
• d.Limit oral fluids so that pulmonary secretions do not increase.

Basilar atelectasis after upper abdominal surgery comes from shallow, splinted breathing, and unrelieved incisional pain is what stops the client from taking the deep breaths and coughs that re-expand alveoli, so treating the pain is what makes the pulmonary hygiene possible. Lying the client flat reduces lung expansion further and worsens the underlying problem.

A conscious adult client in the dining room suddenly clutches the throat and is unable to speak or cough. Following current American Heart Association guidance, what should the nurse do?

• a.Encourage forceful coughing and observe until the client becomes unresponsive.
• b.Deliver five back blows, then five abdominal thrusts, and repeat the cycles.✓
• c.Begin chest compressions at once and continue until help reaches the client.
• d.Deliver abdominal thrusts only, repeating them until the object comes out.

The 2025 American Heart Association guidelines direct rescuers to alternate five back blows with five abdominal thrusts for a responsive choking adult until the object is expelled or the person becomes unresponsive; abdominal thrusts alone reflect the older guidance. A client who cannot speak or cough has a complete obstruction, so coughing cannot be encouraged and waiting costs the client oxygen.

While the nurse is changing the injection cap on a client's central venous catheter, the client becomes acutely dyspneic, hypotensive, and confused. After clamping the catheter, what should the nurse do next?

• a.Sit the client upright and have the client bear down forcefully.
• b.Place the client flat in bed and elevate both legs above the level of the heart.
• c.Turn the client onto the right side with the head of the bed elevated.
• d.Turn the client onto the left side with the head of the bed lowered.✓

These findings suggest venous air embolism; the left lateral decubitus position with the head down traps air at the apex of the right ventricle so it cannot obstruct the pulmonary outflow tract, and 100% oxygen is given at the same time. Turning to the right with the head raised does the opposite and helps air move on into the pulmonary circulation.

A client with end-stage kidney disease has a serum potassium of 7.2 mEq/L. The cardiac monitor shows tall peaked T waves and a QRS complex that has widened over the last hour. The provider writes four prescriptions. Which one should the nurse administer first?

• a.Nebulized albuterol by mouthpiece
• b.Intravenous calcium gluconate 10%✓
• c.Intravenous regular insulin with dextrose
• d.Oral sodium polystyrene sulfonate

Calcium does not lower the serum potassium at all; it raises the threshold potential and stabilizes the myocardium, which is what the widening QRS demands right now, so it goes first whenever hyperkalemia has produced ECG changes. Insulin with dextrose genuinely does lower potassium by shifting it into cells, but it works over roughly 15 to 30 minutes and leaves the heart unprotected in the meantime.

A client on long-term furosemide is admitted with a serum potassium of 2.4 mEq/L. After two doses of oral potassium chloride the repeat potassium is 2.5 mEq/L. The nurse notes the serum magnesium is 1.1 mg/dL. Which action should the nurse anticipate?

• a.Switching to an enteric-coated potassium tablet
• b.Replacing magnesium before more potassium✓
• c.Holding potassium until the morning laboratory draw
• d.Doubling the next dose of oral potassium chloride

A serum magnesium of 1.1 mg/dL is below the normal 1.7 to 2.2 mg/dL, and low magnesium drives renal potassium wasting, so potassium replacement stays ineffective until the magnesium is corrected. Giving a larger potassium dose treats the number rather than the reason the number will not rise, and risks overshooting once magnesium is restored and the kidney stops dumping potassium.

A client who was cooled with targeted temperature management after cardiac arrest is now being rewarmed at a controlled rate. Which finding requires the nurse's immediate action?

• a.Blood pressure falls to 76/40 mm Hg✓
• b.Heart rate rises from 52 to 78 beats/min
• c.Urine output of 50 mL in the past hour
• d.Oxygen saturation reads 96% on 4 L/min

Rewarming produces peripheral vasodilation and redistribution of blood volume, so hypotension is the expected complication, and a pressure of 76/40 mm Hg falls below the normal adult range and must be treated at once to protect tissue oxygen delivery. A heart rate moving from 52 to 78 beats/min is the anticipated resolution of hypothermic bradycardia and sits inside the normal 60 to 100 range, while the urine output and oxygen saturation are adequate.

A severely malnourished client with a body mass index of 14 is started on enteral tube feedings. Two days later the nurse reviews new laboratory results. Which value requires the most immediate follow-up?

• a.Serum phosphorus 1.2 mg/dL✓
• b.Serum magnesium 1.9 mg/dL
• c.Serum calcium 9.1 mg/dL
• d.Serum sodium 137 mEq/L

Reintroducing nutrition raises insulin, which drives phosphate into cells, and a phosphorus of 1.2 mg/dL against a normal adult range of 2.8 to 4.5 mg/dL is low enough to cause respiratory muscle failure and arrhythmias. The magnesium, calcium, and sodium values given all sit inside their normal ranges and call for continued monitoring rather than intervention.

A client in the intensive care unit has a blood pressure of 88/50 mm Hg. The nurse calculates the mean arterial pressure (MAP). Rounded to the nearest whole number, what is the client's MAP?

• a.69 mm Hg
• b.38 mm Hg
• c.63 mm Hg✓
• d.75 mm Hg

MAP equals the diastolic pressure plus one third of the pulse pressure: 88 minus 50 is a pulse pressure of 38, one third of 38 is 12.7, and 50 plus 12.7 is 62.7, which rounds to 63 mm Hg. Simply averaging the systolic and diastolic pressures yields 69 mm Hg, adding two thirds of the pulse pressure yields 75 mm Hg, and 38 mm Hg is the pulse pressure itself.

A client being treated for gram-negative sepsis develops oozing from two peripheral intravenous sites and petechiae across the trunk. Laboratory results show a platelet count of 38,000/mcL, a fibrinogen of 90 mg/dL, and a markedly elevated D-dimer. Which complication should the nurse suspect?

• a.Immune thrombocytopenic purpura relapse
• b.Vitamin K deficiency coagulopathy
• c.Disseminated intravascular coagulation✓
• d.Heparin-induced thrombocytopenia type II

Widespread microvascular clotting consumes platelets and fibrinogen while the clots that form are broken down, which is why the platelet count of 38,000/mcL and the fibrinogen of 90 mg/dL are both far below their normal ranges at the same moment the D-dimer is high; sepsis is the single most common trigger. Heparin-induced thrombocytopenia also drops the platelet count, but it causes clotting with a preserved fibrinogen rather than the diffuse oozing seen here.

A nurse responds to a telemetry client who is unresponsive, apneic, and without a palpable carotid pulse. Asystole is confirmed in two leads. Which action should the nurse take?

• a.Give amiodarone 300 mg by IV push
• b.Deliver a synchronized shock at 50 J
• c.Start high-quality chest compressions✓
• d.Deliver an unsynchronized shock at 200 J

Asystole is a nonshockable rhythm, so a shock has no organized electrical activity to terminate; the treatment is uninterrupted high-quality CPR with epinephrine every 3 to 5 minutes while reversible causes are sought. Defibrillation is reserved for ventricular fibrillation and pulseless ventricular tachycardia, and shocking asystole only pulls the rescuer's hands off the chest.

A client on telemetry converts to atrial fibrillation with a ventricular rate of 168 beats per minute. The client is diaphoretic, reports crushing chest pressure, and has a blood pressure of 76/44 mm Hg with a palpable pulse. For which intervention should the nurse prepare the client?

• a.Vagal maneuvers with bearing down
• b.Synchronized cardioversion✓
• c.Unsynchronized defibrillation
• d.Adenosine 6 mg by IV push

The client has a pulse but is hemodynamically unstable, and every unstable tachycardia with a pulse is treated with synchronized cardioversion, which times the shock to the R wave and avoids delivering it on the T wave. Defibrillation is unsynchronized and belongs to pulseless rhythms; used here it risks the R-on-T phenomenon and ventricular fibrillation.

A client on telemetry has a heart rate of 38 beats per minute and a blood pressure of 82/48 mm Hg, reports dizziness, and has cool, clammy skin. Which prescription should the nurse expect the provider to order first?

• a.Adenosine 6 mg IV push
• b.Metoprolol 5 mg by IV push
• c.Transcutaneous pacing at 70
• d.Atropine 1 mg by IV push✓

Atropine 1 mg intravenously is the first-line intervention for symptomatic bradycardia, and transcutaneous pacing is a reasonable second-line measure when atropine does not raise the rate or is unavailable. Metoprolol would slow an already dangerous rate further, and adenosine is used to interrupt fast supraventricular rhythms, not a rate of 38.

A monitor technician calls to report that a telemetry client's rhythm has gone to a flat line. The nurse enters the room and finds the client sitting upright, brushing her teeth, and talking normally. Which action should the nurse take?

• a.Charge the defibrillator to 200 J
• b.Activate the rapid response team
• c.Check the electrodes and lead wires✓
• d.Begin chest compressions immediately

A client who is awake, talking, and moving has a perfusing rhythm, so a flat tracing represents a disconnected or dried-out electrode rather than asystole, and the nurse corrects the equipment problem she can see. Starting compressions or shocking a conscious client causes real injury and does nothing about the loose lead that produced the tracing.

A client has a temporary transvenous pacemaker set at a rate of 70. The nurse sees regular pacing spikes at 70 on the monitor, but most of the spikes are not followed by a QRS complex, and the palpated radial pulse is 44. How should the nurse interpret this finding?

• a.The pacemaker is failing to capture✓
• b.The pacemaker is failing to sense
• c.The pacemaker is oversensing signals
• d.The pacemaker is failing to output

Failure to capture means the impulse is delivered but does not depolarize the myocardium, which is exactly a spike with no QRS after it and a pulse slower than the programmed rate. An output failure would show no pacing spikes at all on the tracing, and failure to sense would show spikes landing on top of the client's own intrinsic beats.

A client is being discharged after implantation of a permanent pacemaker. Which statement by the client indicates that the discharge teaching was effective?

• a.I will stop counting my own pulse now that the device sets the rate.
• b.I will tell any provider about my pacemaker before an MRI.✓
• c.I will give up using the microwave oven in my kitchen from now on.
• d.I will carry my mobile phone in the shirt pocket over the device.

Magnetic resonance imaging can alter the programmed settings and heat the lead tips, so scanning is done only when the device is MRI-conditional and a specific protocol is followed, which makes disclosing the pacemaker beforehand the safest habit. A household microwave oven is not a hazard, the phone is kept on the opposite side of the chest, and the client still checks the pulse and reports a rate below the set rate.

A nurse raises the head of a client's bed and then notices that the arterial line transducer is taped to the IV pole about 10 cm above the client's phlebostatic axis. The displayed arterial pressure has dropped since the position change. Which action should the nurse take?

• a.Notify the provider of the falling arterial pressure
• b.Relevel the transducer to the phlebostatic axis and rezero it✓
• c.Obtain a cuff pressure and chart it in place of the line
• d.Flush the arterial line and repeat the square wave test

A transducer sitting above the phlebostatic axis has a shorter fluid column pressing on it and therefore reports pressures that are falsely low, so releveling to the phlebostatic axis and rezeroing is what restores an accurate number. Escalating a reading produced by transducer position, or substituting a cuff, responds to an artifact instead of correcting it.

A nurse admits a client who has an arteriovenous fistula in the left forearm and receives hemodialysis three times a week. Which direction should the nurse give the unlicensed assistive personnel (UAP) assigned to this client?

• a.Keep the left arm elevated on two pillows.
• b.Apply a warm compress to the fistula.
• c.Take blood pressures in the right arm only.✓
• d.Report any bruit heard over the fistula.

The access arm is kept free of blood pressure cuffs, venipuncture, and intravenous lines because compression and puncture threaten the fistula, so pressures are taken in the opposite arm. A bruit over the fistula is the expected sound of flowing blood; its absence, not its presence, is the finding that must be reported.

Before a scheduled hemodialysis session, a nurse assesses a client's arteriovenous fistula and can no longer palpate a thrill or auscultate a bruit over the site. The client states the arm feels the same as always. Which action should the nurse take?

• a.Chart the finding and continue care
• b.Notify the provider immediately✓
• c.Apply warm soaks to the arm
• d.Recheck the site in four hours

The thrill felt and the bruit heard over a fistula are the evidence that blood is moving through it, so losing both suggests the access has thrombosed and needs urgent evaluation if it is to be salvaged and dialysis is to proceed. A normal-feeling arm is reassuring about perfusion but says nothing about the access, so waiting to reassess or applying heat only spends the time the fistula does not have.

A client who performs continuous ambulatory peritoneal dialysis at home telephones the clinic. Which report requires the most immediate follow-up?

• a.The exit site dressing was changed twice.
• b.The drained fluid is pale straw colored.
• c.The drained fluid has become cloudy.✓
• d.The last outflow took ten minutes longer.

Cloudy effluent is the hallmark of peritoneal dialysis peritonitis, present in nearly every case, and it must be evaluated with a cell count and culture of the drained fluid before the infection worsens. Pale straw-colored effluent is the normal appearance, and a drain that ran slightly long is common and not urgent on its own.

A client with a blood urea nitrogen of 180 mg/dL is receiving a first hemodialysis treatment. Ninety minutes into the session the client develops a headache, nausea, and restlessness and cannot state where he is. The blood pressure is unchanged from baseline. Which complication should the nurse suspect?

• a.Hemolysis of the circulating blood
• b.An intradialytic hypotension episode
• c.Air embolism from the blood circuit
• d.Dialysis disequilibrium syndrome✓

Rapid clearance of urea leaves the brain relatively hyperosmolar compared with the blood, water shifts into brain cells, and the client develops headache, nausea, restlessness, and confusion; a very high starting blood urea nitrogen during a first session is the classic setup. Intradialytic hypotension can also cause nausea and light-headedness, but it is defined by a marked fall in blood pressure, and this client's pressure has not changed.

Forty minutes into a general anesthetic with sevoflurane and succinylcholine, the nurse notes that the end-tidal carbon dioxide has climbed steadily, the heart rate is 148 beats per minute, and the jaw is rigid. The core temperature is 37.4 C (99.3 F). Which action should the team take first?

• a.Treat the tachycardia with IV esmolol
• b.Begin surface cooling with ice packs
• c.Stop the sevoflurane and succinylcholine✓
• d.Recheck the core temperature in 15 minutes

A steadily rising end-tidal carbon dioxide with tachycardia and masseter rigidity is malignant hyperthermia, and because temperature elevation is a late sign the team does not wait for a fever; the triggering volatile agent and succinylcholine are discontinued at once while dantrolene 2.5 mg/kg is drawn up. Cooling and rate control address downstream effects while the trigger keeps driving the hypermetabolic crisis.

A nurse is caring for a client with a severe traumatic brain injury and an intraventricular intracranial pressure monitor in place. Which nursing action best supports control of the client's intracranial pressure?

• a.Keep the head of the bed at 30 degrees, head midline.✓
• b.Place the client in Trendelenburg two hours each shift.
• c.Position the client flat in bed with the neck rotated.
• d.Lower the head of the bed for one hour after each turn.

Elevating the head of the bed to about 30 degrees while keeping the head and neck in neutral midline alignment lets blood drain freely out of the skull through the jugular veins, which lowers cerebral blood volume and intracranial pressure. Flat and head-down positions raise venous pressure inside the head, and rotating or flexing the neck kinks the jugular outflow the position is meant to protect.

A newborn at 40 hours of life is placed under overhead phototherapy for hyperbilirubinemia. Which action by the nurse is correct?

• a.Apply an oil-based lotion to the exposed skin surfaces.
• b.Apply eye shields and leave the newborn in only a diaper.✓
• c.Withhold feedings until the phototherapy ends.
• d.Swaddle the newborn in a light blanket under the lights.

Phototherapy only works on skin the light reaches, so the newborn is undressed to a diaper to maximize the treated surface area, and the eyes are shielded because the light can damage the retina. Swaddling covers the very skin the therapy depends on, and feedings are continued and encouraged because phototherapy increases fluid loss and bilirubin leaves the body in urine and stool.