NCLEX-RN diagnostic test
52 original questions from all eight NCLEX-RN test plan categories, weighted like the test plan.
- NGN items get partial credit the way NCSBN describes.
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- With full access, the report also scores every topic and gives each weak topic a lesson and a practice set.
- Unfolding case studies are in the full practice test. For exam study only, not medical advice.
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NCLEX-RN quick diagnostic
- 52 questions
- Management of Care · Safety and Infection Control · Health Promotion · Psychosocial Integrity · Basic Care and Comfort · Pharmacology · Reduction of Risk · Physiological Adaptation
- 104 min in exam mode
- Practice mode, no timer
A short set from this test. We don't have free questions on that topic here yet, so this set mixes topics. Sets on a single topic are included with full access, so this set mixes topics. Take the full test instead
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Questions are original practice items written to the published exam content, not real exam questions.
An RN on a medical-surgical unit works with one assistive personnel (AP). For each task, indicate whether the RN can give it to the AP or must keep it.
Can give to the AP RN keeps the task Measure and record urine output for a stable client Teach a client newly prescribed insulin how to self-inject Take vital signs on a client whose blood pressure has dropped since the last check Help a stable client walk to the bathroom Complete the admission assessment of a client who just arrived Remind a client to use the incentive spirometer the RN taught them to use this morning Select one option in each row.
Correct answer: Measure and record urine output for a stable client: Can give to the AP; Teach a client newly prescribed insulin how to self-inject: RN keeps the task; Take vital signs on a client whose blood pressure has dropped since the last check: RN keeps the task; Help a stable client walk to the bathroom: Can give to the AP; Complete the admission assessment of a client who just arrived: RN keeps the task; Remind a client to use the incentive spirometer the RN taught them to use this morning: Can give to the AP
Assistive personnel can do routine tasks for stable clients that need no clinical judgment: intake and output, ambulation help, and reinforcing teaching the nurse already gave. Assessment, new client teaching, and any care for an unstable client stay with the RN, because they require nursing judgment and the right circumstance (a stable client) is missing.
- Measure and record urine output for a stable client Can give to the AP: measuring intake and output is routine data collection that needs no clinical judgment.
- Teach a client newly prescribed insulin how to self-inject RN keeps: new client teaching requires nursing knowledge; AP may only reinforce teaching already given.
- Take vital signs on a client whose blood pressure has dropped since the last check RN keeps: a falling blood pressure means the client may be unstable, so the right circumstance for delegation is missing.
- Help a stable client walk to the bathroom Can give to the AP: help with ambulation and toileting for a stable client is an AP activity of daily living task.
- Complete the admission assessment of a client who just arrived RN keeps: admission assessments require clinical judgment and cannot go to an AP or LPN/VN.
- Remind a client to use the incentive spirometer the RN taught them to use this morning Can give to the AP: reminding a client to use a device the RN already taught them to use reinforces existing teaching; it is not new teaching.
Learn this topic: Delegation and assignment: what the RN can hand off, and to whom 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 3.3 Assignment · Open RN Nursing Management and Professional Concepts 2e, 3.4 Delegation ·
Two clients on a medical unit both have a temperature of 100.8°F (38.2°C) and a cough. Client A was admitted 2 days ago with community-acquired pneumonia and is receiving IV antibiotics; the temperature and cough are unchanged since admission. Client B was admitted yesterday for observation after a fall at home and has a history of osteoarthritis. The nurse's first action should be to because, for that client, the findings are .
Choose the best option from each list to complete the sentence.
Correct answer: assess Client B; unexpected for the client's condition
When two clients have the same findings, ask whether each finding is expected or unexpected for that client's condition. Fever and cough are expected with pneumonia, are unchanged, and are already addressed by the antibiotic plan, but they are unexpected in a client admitted after a fall and may signal a new problem, so that client is assessed first. Unexpected findings often need immediate nursing action.
- Assess Client B first: the same findings are new and unexplained in a client admitted after a fall. Client A's fever and cough fit the known pneumonia and are unchanged; rechecking temperatures delays the needed assessment, and requesting orders before assessing skips the assessment step.
- The findings are unexpected for Client B's condition; they are not expected with a fall or osteoarthritis, they are new rather than chronic, and they are actual rather than potential.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing · MedlinePlus: Community-acquired pneumonia in adults ·
A nurse is teaching a newly admitted client about advance directives. For each statement the client makes, indicate whether it is accurate or inaccurate.
Accurate Inaccurate "My health care agent will also handle my bank accounts." "My living will says which treatments I do or don't want." "I need to hire a lawyer to make this legal." "I can change my advance directive whenever I want." "A DNR order means no one will treat my pain." "My provider writes the DNR order in my chart." Select one option in each row.
Correct answer: "My health care agent will also handle my bank accounts.": Inaccurate; "My living will says which treatments I do or don't want.": Accurate; "I need to hire a lawyer to make this legal.": Inaccurate; "I can change my advance directive whenever I want.": Accurate; "A DNR order means no one will treat my pain.": Inaccurate; "My provider writes the DNR order in my chart.": Accurate
A living will states the treatments a client wants or refuses if they become unable to decide, and a health care power of attorney names an agent for health care decisions only. Advance directives do not require an attorney and can be changed at any time. A DNR is a provider's medical order about CPR only; it does not stop other treatment such as pain medicine.
- "My health care agent will also handle my bank accounts." Inaccurate: a health care power of attorney covers health care decisions, not finances; a financial power of attorney is a separate document.
- "My living will says which treatments I do or don't want." Accurate: a living will records the treatments the client wants or refuses if incapacitated.
- "I need to hire a lawyer to make this legal." Inaccurate: advance directives do not require an attorney; social workers or chaplains often help complete them.
- "I can change my advance directive whenever I want." Accurate: a client can change advance directive decisions at any time and should share the new documents.
- "A DNR order means no one will treat my pain." Inaccurate: a DNR order is specific to CPR and does not cover pain medicine, other medicines or nutrition.
- "My provider writes the DNR order in my chart." Accurate: a DNR is a medical order written by the health care provider after discussion with the client or proxy.
Learn this topic: Informed consent and advance directives: the nurse's role 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 5.6 Other Legal Issues · MedlinePlus: Advance care directives · MedlinePlus: Do-not-resuscitate order ·
The provider has just explained a colonoscopy to an 81-year-old client, and the nurse is about to witness the consent form. Click to highlight the findings that should lead the nurse to question the client's decision-making capacity and contact the provider.
1430: Client is wearing reading glasses and holding the consent form. When asked if they have questions, client says, , and . Client correctly states . Client points to the corner and says . Client's son . Per the assistive personnel, client this morning, which is new since admission.
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: "Whatever you want, just do it"; asks nothing about the procedure; "the bugs are back on the wall"; could not feed or dress themself
Formal capacity decisions belong to providers, but the nurse should raise concerns when cues appear. Blanket acceptance of care, no questions about the treatment, hallucinations, and a new inability to perform activities of daily living all suggest the client may not be able to give informed consent right now, so the nurse holds the signing and contacts the provider.
- "Whatever you want, just do it" Highlight: blanket acceptance of whatever is offered is a cue to question decision-making capacity.
- asks nothing about the procedure Highlight: an absence of questions about the treatment being offered is a capacity cue.
- full name and date of birth Do not highlight: correctly stating name and date of birth is an expected, reassuring finding.
- "the bugs are back on the wall" Highlight: describing things that are not there suggests hallucinations, a cue to question capacity.
- is sitting at the bedside Do not highlight: a family member at the bedside is not a sign of impaired capacity and does not change who consents.
- could not feed or dress themself Highlight: a new inability to perform activities of daily living is a cue that decision-making capacity may have changed.
Learn this topic: Informed consent and advance directives: the nurse's role 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 5.6 Other Legal Issues ·
The adult daughter of a client calls the medical unit and asks why her mother was moved to the telemetry unit overnight. The client is alert and oriented and has not told the nurse whether she wants health information shared with her family. Which response by the nurse is best?
Correct answer: C
When an alert client is available to decide, HIPAA lets the nurse share health information with a family member only after the client agrees or, given the chance, does not object, and Open RN advises checking first whether the client has granted permission (agency policy may require it in writing). Until then the nurse does not release, hint at, or summarize the information. The nurse can ask the client and then follow her wishes.
- A Incorrect: a date of birth confirms who the caller knows, not that the client agreed to share her information.
- B Incorrect: even a brief summary of her condition discloses health information the client has not agreed to share.
- C Correct: the alert client decides whether her daughter receives her health information, so the nurse asks the client first.
- D Incorrect: the provider is under the same rule; transferring the call does not replace the client's permission.
Source: Open RN Nursing Fundamentals 2e, 1.6 Legal Considerations and Ethics · 45 CFR 164.510 Uses and disclosures requiring an opportunity for the individual to agree or to object (Cornell LII) ·
A client's family files a malpractice lawsuit against a nurse. Which elements must be proven for the claim to succeed? Select all that apply.
Select all that apply.
Correct answer: A, B, C, D
Malpractice is negligence by a licensed professional, and it is an unintentional tort, so intent to harm is not part of the claim. The plaintiff must prove four elements: duty, breach of the standard of care, causation and harm with damages. Civil cases are decided by a preponderance of the evidence, not the criminal standard of beyond a reasonable doubt.
- A Correct: duty exists once the nurse accepts responsibility for the client, such as after a handoff report.
- B Correct: breach means the nurse did not act as a reasonably prudent nurse would in the same situation.
- C Correct: causation links the nurse's breach to the client's injury.
- D Correct: harm means the injury caused damages, such as added medical costs or lost function.
- E Incorrect: malpractice is an unintentional tort; intent belongs to torts such as battery.
- F Incorrect: beyond a reasonable doubt is the criminal standard; civil malpractice uses a preponderance of the evidence.
Learn this topic: What are a nurse's legal duties, and how does charting protect clients? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 5.2 Understanding the Legal System · Open RN Nursing Fundamentals 2e, 1.6 Legal Considerations and Ethics ·
A provider prescribes a medication dose that is 10 times the maximum dose listed in the drug reference. When the nurse calls, the provider says, "It's correct. Just give it." What should the nurse do next?
Correct answer: C
Safety first: a nurse who carries out an order that the nurse knew or should have known could harm a client can be disciplined, so "the provider ordered it" is not a defense. Changing the dose on one's own is practicing beyond the nurse's scope. The nurse holds the dose, follows the chain of command until the concern is resolved, and documents exactly who was notified and when.
- A Incorrect: executing an order the nurse knows could harm the client is grounds for discipline.
- B Incorrect: changing a prescribed dose without an order is practicing beyond the nurse's scope.
- C Correct: the nurse holds the dose and pursues the concern through the chain of command to resolution.
- D Incorrect: handing the unsafe dose to a coworker still exposes the client to harm and avoids the nurse's duty.
Learn this topic: What are a nurse's legal duties, and how does charting protect clients? 5-minute lesson
Source: Open RN Nursing Pharmacology 2e, 2.3 Legal Foundations and National Guidelines for Safe Medication Administration · Open RN Nursing Management and Professional Concepts 2e, 5.2 Understanding the Legal System · Open RN Nursing Management and Professional Concepts 2e, 5.4 Frequent Allegations and SBON Investigations · Open RN Nursing Management and Professional Concepts 2e, 5.5 Protecting Your Nursing License ·
A nurse is giving bedside shift report for a client in a semiprivate room. The roommate has two visitors in the room. For each action, indicate whether it is good practice or should be avoided.
Good practice Avoid Introducing the oncoming nurse and inviting the client to take part Looking at the IV site and the incision together with the oncoming nurse Asking the client what she wants to happen during the next shift Stating the client's new cancer diagnosis aloud while the roommate's visitors are present Using medical shorthand so the report goes faster Scanning the room for safety hazards, such as clutter on the floor Select one option in each row.
Correct answer: Introducing the oncoming nurse and inviting the client to take part: Good practice; Looking at the IV site and the incision together with the oncoming nurse: Good practice; Asking the client what she wants to happen during the next shift: Good practice; Stating the client's new cancer diagnosis aloud while the roommate's visitors are present: Avoid; Using medical shorthand so the report goes faster: Avoid; Scanning the room for safety hazards, such as clutter on the floor: Good practice
Bedside shift report involves the client and family: introduce the oncoming nurse, invite them to take part, give the report in words they understand, look at lines, wounds and drains together, sweep the room for safety hazards, and ask what the client wants to happen during the next shift. HIPAA still applies, so sensitive information is not said aloud where visitors can overhear.
- Introducing the oncoming nurse and inviting the client to take part Good practice: the report starts by introducing staff and inviting the client and family to take part.
- Looking at the IV site and the incision together with the oncoming nurse Good practice: both nurses visually inspect IV sites, incisions and drains during the report.
- Asking the client what she wants to happen during the next shift Good practice: the report asks for the client's own goal for the next shift.
- Stating the client's new cancer diagnosis aloud while the roommate's visitors are present Avoid: HIPAA rules must be kept in mind when visitors are present or the room is shared.
- Using medical shorthand so the report goes faster Avoid: the report should use words that the client and family can understand.
- Scanning the room for safety hazards, such as clutter on the floor Good practice: a visual sweep of the room for physical safety concerns is part of the report.
Learn this topic: How do nurses hand off care safely between shifts, units and home? 5-minute lesson
Source: AHRQ, Bedside Shift Report Checklist (Guide to Patient and Family Engagement) · AHRQ, Strategy 3: Nurse Bedside Shift Report · Open RN Nursing Fundamentals 2e, 2.4 Communicating With Health Care Team Members ·
At discharge, a nurse compares the client's home medication list with the discharge orders. The client took furosemide daily at home, but furosemide is not mentioned anywhere in the discharge orders. The nurse should , because .
Choose the best option from each list to complete the sentence.
Correct answer: clarify the discrepancy with the provider first; medication errors often happen at transitions of care
Medication reconciliation compares the best possible medication history with current orders, resolves every difference and communicates the changes to the client and the next providers. Discrepancies are common at transitions such as discharge, so a home drug that is neither continued nor stopped in the orders is clarified with the provider before the client leaves. The discharge instructions should list every medicine, with new, changed and stopped drugs marked.
- The unexplained difference is clarified with the provider before discharge; telling the client to take everything or stop everything guesses at the provider's intent, and leaving it to the community pharmacist sends an unresolved discrepancy home.
- Medication errors often happen during transitions of care, which is why reconciliation is done at each one; the other reasons are false generalizations.
Learn this topic: How do nurses hand off care safely between shifts, units and home? 5-minute lesson
Source: Open RN Nursing Pharmacology 2e, 2.5 Preventing Medication Errors · MedlinePlus, Leaving the hospital - your discharge plan ·
A nursing home resident is colonized with methicillin-resistant Staphylococcus aureus (MRSA) and has an indwelling urinary catheter. The resident has no diarrhea and no draining wounds, and is on enhanced barrier precautions. When should staff wear a gown and gloves? Select all that apply.
Select all that apply.
Correct answer: A, C, E
Enhanced barrier precautions target gown and glove use to high-contact care: dressing, bathing, transferring, hygiene, changing linens or briefs, toileting help, device care and wound care. Low-contact tasks need only standard precautions. Residents on enhanced barrier precautions are not confined to their rooms and may join group activities.
- A Correct: changing linens is listed as a high-contact care activity.
- B Delivering a tray is not high-contact care, so standard precautions are enough.
- C Correct: care of an indwelling device such as a urinary catheter is high-contact care.
- D Talking with the resident involves no high-contact care and needs no gown or gloves.
- E Correct: bathing or showering is a high-contact care activity.
- F Residents on enhanced barrier precautions may attend group activities, and walking alongside is not high-contact care.
Learn this topic: Which isolation precautions does each infection need? 5-minute lesson
Source: CDC: Implementing Enhanced Barrier Precautions in Nursing Homes ·
Complete the statements about restraint safety. An order to restrain a 30-year-old client for violent behavior is valid for up to before it must be renewed. The client must be seen face to face by a physician, other licensed practitioner or specially trained registered nurse within of starting the restraint. Raising all four side rails so a client who wants to get up cannot leave the bed is considered .
Choose the best option from each list to complete the sentence.
Correct answer: 4 hours; 1 hour; a restraint
For violent or self-destructive behavior, each restraint order lasts up to 4 hours for adults, 2 hours for ages 9 to 17 and 1 hour for children under 9, renewable up to 24 hours in total, and the client must be seen face to face within 1 hour. Whether side rails are a restraint depends on purpose: used to keep a client from leaving the bed, they restrict freedom of movement and are a restraint.
- 4 hours is the adult limit; 2 hours applies to ages 9 to 17, 1 hour to children under 9, and 24 hours is the total renewal cap, not a single order.
- The face-to-face evaluation must happen within 1 hour of starting a restraint for violent or self-destructive behavior.
- Side rails used to prevent a client from voluntarily leaving the bed meet the definition of a restraint; rails raised to help with repositioning do not.
Learn this topic: How do nurses prevent falls and use restraints safely? 5-minute lesson
Source: 42 CFR 482.13 Condition of participation: Patient's rights (restraint or seclusion) · Open RN Nursing Fundamentals 2e, 5.7 Restraints ·
A nurse enters a client's room and finds a small fire burning in the wastebasket next to the bed. The nurse's first action is to . Next, the nurse . When using the fire extinguisher, the nurse aims the nozzle at .
Choose the best option from each list to complete the sentence.
Correct answer: move the client away from the fire; activates the fire alarm; the base of the fire
Fire response follows RACE: rescue anyone in immediate danger, activate the alarm, confine the fire by closing doors and windows, then extinguish a small fire or evacuate. Extinguishers follow PASS: pull the pin, aim low at the base of the fire, squeeze the handle and sweep side to side, because the base is where the fire is smothered.
- Rescue comes first in RACE: the client next to the fire is in immediate danger; alarm, confine and extinguish follow.
- Activating the alarm is the second RACE step so others can start safety measures; calling family and documenting can wait.
- Aim at the base of the fire; spraying the top of the flames or the smoke does not smother the fire.
Learn this topic: How do nurses triage victims in a disaster? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 5.9 Environmental Safety ·
At 1400, a nurse discovers that a client's 1000 dose of an IV antibiotic was not given. The nurse notifies the provider and gives the dose as prescribed. Complete the statements. The incident report is completed by . The incident report . In the client's medical record, the nurse documents .
Choose the best option from each list to complete the sentence.
Correct answer: the staff member involved in the event; is not part of the medical record; the event, provider notification and care given
An incident (variance) report is completed by the staff member involved whenever an error, injury, fall or near miss occurs. It is a quality and safety tool for finding system problems, not a disciplinary record, and it is not part of the medical record. The chart describes the event itself, provider notification and the care given, but it does not mention the incident report.
- The staff member involved in the occurrence completes the report, because that person knows what happened and what was done in response.
- Incident reports are kept out of the medical record and are used to improve systems, not to punish staff.
- The medical record documents the event, provider notification and interventions, but never refers to the incident report itself.
Source: Open RN Nursing Fundamentals 2e, 2.5 Documentation · Open RN Nursing Fundamentals 2e, 5.2 Basic Safety Concepts ·
Fifteen minutes after a medication pass, a nurse realizes that a client received amlodipine 10 mg by mouth instead of the prescribed 5 mg. Which action should the nurse take first?
Correct answer: D
Client safety comes first: when a medication error occurs, the nurse's first response is to assess and monitor the client for effects of the medication. Next, the nurse notifies the nurse manager and the provider, who may order treatment or extra monitoring. The incident report comes after that, and it is never mentioned in the medical record.
- A The incident report is completed, but only after the client is assessed and the right people are notified.
- B The nurse manager and provider are notified, but assessing the client comes first.
- C Incident reports are not part of the medical record and are not mentioned in it.
- D Correct: the first response to a medication error is to monitor the client's condition.
Learn this topic: How do nurses prevent medication errors? 5-minute lesson
Source: Open RN Nursing Skills 2e, 15.2 Basic Concepts of Administering Medications · Open RN Nursing Fundamentals 2e, 2.5 Documentation ·
A nurse educator observes nurses during a medication pass. Which actions help prevent medication errors? Select all that apply.
Select all that apply.
Correct answer: A, C, E
Safe medication practice combines two identifiers, the rights checked three times, immediate documentation and clarification of unclear orders. The room number is never an identifier because clients change rooms. Nurses give only medications they checked themselves, and a barcode alert is a signal to stop and investigate, not to work around it.
- A Correct: at least two identifiers are confirmed against the wristband and the MAR before giving a medication.
- B Incorrect: a room number is never used as an identifier, because clients change rooms.
- C Correct: documenting immediately after giving a dose prevents another nurse from repeating it.
- D Incorrect: a nurse never gives a medication that the nurse did not personally check.
- E Correct: an order with an error-prone abbreviation is clarified with the provider and rewritten.
- F Incorrect: overriding an alert is a workaround; the nurse stops and investigates.
Learn this topic: How do nurses prevent medication errors? 5-minute lesson
Source: Open RN Nursing Skills 2e, 15.2 Basic Concepts of Administering Medications · Open RN Nursing Pharmacology 2e, 2.5 Preventing Medication Errors · Open RN Nursing Management and Professional Concepts 2e, 5.5 Protecting Your Nursing License ·
After reporting a needlestick, a nurse asks about the follow-up the employer must provide under the OSHA Bloodborne Pathogens Standard. Which statements are accurate? Select all that apply.
Select all that apply.
Correct answer: A, D, E
OSHA requires employers to make a confidential post-exposure evaluation and follow-up available immediately, at no cost to the employee. It documents the route and circumstances of the exposure and tests the source individual's blood for HBV and HIV as soon as feasible after consent. The hepatitis B vaccine is offered within 10 working days of starting a job with exposure risk, not only after an exposure.
- A Correct: all evaluations and follow-up, including prophylaxis, are at no cost to the employee.
- B Incorrect: the employer provides the evaluation at no cost, with no condition about missed work.
- C Incorrect: findings stay confidential; they are not shared with coworkers.
- D Correct: the post-exposure medical evaluation is confidential.
- E Correct: the source individual's blood is tested as soon as feasible after consent is obtained.
- F Incorrect: the vaccine is offered within 10 working days of initial assignment to jobs with exposure risk.
Learn this topic: How do nurses handle sharps, hazardous drugs, radiation and chemicals safely? 5-minute lesson
Source: OSHA 29 CFR 1910.1030, Bloodborne Pathogens · CDC NIOSH: Bloodborne Infectious Disease Risk Factors ·
The nurse assesses a 9-month-old infant at a well-child visit. Which finding requires follow-up?
Correct answer: D
CDC milestones are skills most children (75% or more) can do by a given age, so a missed milestone needs follow-up and screening. By 9 months most infants sit without support, babble sounds like "mamamama," and are shy or fearful with strangers. Walking alone is listed at 18 months and saying "mama" or "dada" as a name at 1 year, so their absence at 9 months is not yet a concern.
- A Expected: shyness, clinginess or fear around strangers is a 9-month milestone.
- B Expected: walking without holding on is an 18-month milestone.
- C Expected: at 9 months infants babble; calling a parent "mama" or "dada" is a 1-year milestone.
- D Correct: sitting without support is a 9-month movement milestone, so its absence needs follow-up.
Learn this topic: Growth and development milestones from birth to adolescence 6-minute lesson
Source: CDC Milestones by 9 Months · CDC Milestones by 18 Months · CDC Learn the Signs. Act Early: Milestones ·
During an annual wellness visit, the nurse assesses a 78-year-old client. For each finding, indicate whether it is an expected age-related change or requires follow-up.
Expected age-related change Requires follow-up Holds the menu at arm's length to read it Reports a sudden shower of new floaters in the right eye Has trouble following conversation in a noisy restaurant Respiratory rate 26/min at rest, with visible effort to breathe Pulse takes longer than before to slow down after climbing stairs Thin skin that bruises more easily than it did years ago Select one option in each row.
Correct answer: Holds the menu at arm's length to read it: Expected age-related change; Reports a sudden shower of new floaters in the right eye: Requires follow-up; Has trouble following conversation in a noisy restaurant: Expected age-related change; Respiratory rate 26/min at rest, with visible effort to breathe: Requires follow-up; Pulse takes longer than before to slow down after climbing stairs: Expected age-related change; Thin skin that bruises more easily than it did years ago: Expected age-related change
Many changes are expected with aging: trouble focusing on near objects (presbyopia), loss of high-frequency hearing with trouble hearing over background noise (presbycusis), a slower heart-rate recovery after exercise and thinner skin with fragile vessels that bruise easily. A sudden increase in floaters can signal retinal detachment, and breathing rate usually does not change with age, so a fast, labored rate at rest needs follow-up. Separate expected aging from new or sudden changes.
- Holds the menu at arm's length to read it Expected: presbyopia, difficulty focusing on close-up objects, is the most common vision change with aging.
- Reports a sudden shower of new floaters in the right eye Requires follow-up: floaters that appear suddenly or rapidly increase can indicate a retinal detachment.
- Has trouble following conversation in a noisy restaurant Expected: presbycusis often makes conversation hard to follow when there is background noise.
- Respiratory rate 26/min at rest, with visible effort to breathe Requires follow-up: breathing rate usually does not change with age, and 26/min with effort is above the adult range of 12–20/min.
- Pulse takes longer than before to slow down after climbing stairs Expected: with aging, the pulse takes longer to rise and to slow back down after exercise.
- Thin skin that bruises more easily than it did years ago Expected: the outer skin thins and dermal blood vessels become more fragile, so older adults bruise more easily.
Source: MedlinePlus Medical Encyclopedia: Aging changes in the senses · MedlinePlus Medical Encyclopedia: Aging changes in vital signs · MedlinePlus Medical Encyclopedia: Aging changes in skin · Open RN Nursing Skills 2e, 10.3 Respiratory Assessment ·
On the first day after a vaginal birth, the nurse expects lochia . To check the fundus, the nurse places one hand on the fundus and uses the other hand to . A peripad saturated within is a heavy amount that the nurse reports promptly.
Choose the best option from each list to complete the sentence.
Correct answer: rubra, red; support the lower uterus above the pubic bone; 1 hour
Lochia rubra (red) is expected for the first 1 to 3 days, followed by pinkish-brown lochia serosa and then yellow-white lochia alba. During a fundal check, one hand supports the lower uterus near the symphysis pubis while the other locates the fundus. Saturating a peripad within 1 hour, or clots larger than a golf ball, is a heavy amount that suggests postpartum hemorrhage.
- Rubra: lochia rubra, bright to dark red, is expected during the first 1 to 3 days after birth.
- Support the lower uterus: the second hand supports the uterus near the symphysis pubis during the fundal check.
- 1 hour: a peripad saturated in 1 hour or clots larger than a golf ball are reported as suspected postpartum hemorrhage.
Learn this topic: Labor and postpartum care: the stages, the fetal heart rate and the checks after birth 6-minute lesson
Source: Open RN Nursing Health Promotion, 11.2 Postpartum Physiological Adaptations · Open RN Nursing Health Promotion, 11.5 Applying the Nursing Process and the Clinical Judgment Model to Postpartum Care ·
The nurse reviews the CDC adult immunization schedule with a group of adult clients. Which teaching points are correct? Select all that apply.
Select all that apply.
Correct answer: B, C, E
The CDC adult schedule gives influenza vaccine once a year, a Td or Tdap booster every 10 years, 1 dose of Tdap during each pregnancy (preferably early in weeks 27 to 36) and 2 doses of recombinant zoster vaccine 2 to 6 months apart for adults 50 and older. MMR and varicella are live vaccines that are contraindicated during pregnancy; a nonimmune client receives them after the birth, before discharge.
- A Incorrect: MMR is contraindicated during pregnancy; it is given after birth, before discharge.
- B Correct: after the primary series and a Tdap dose, Td or Tdap is given every 10 years.
- C Correct: adults receive 1 dose of an age-appropriate influenza vaccine every year.
- D Incorrect: 1 dose of Tdap is recommended during each pregnancy.
- E Correct: adults 50 and older receive a 2-dose series of recombinant zoster vaccine 2 to 6 months apart.
- F Incorrect: varicella vaccine is contraindicated during pregnancy.
Learn this topic: Immunizations and adult screening: what to give, when to hold it and who to screen 6-minute lesson
Source: CDC: Adult Immunization Schedule Notes · CDC: Adult Immunization Schedule by Age ·
The nurse plans care for several clients. For each intervention, indicate the level of prevention it represents.
Primary Secondary Tertiary Giving a healthy adult the yearly influenza vaccine Offering hepatitis C screening to a 40-year-old with no symptoms Teaching a client with heart failure to limit sodium to avoid readmission Teaching a teen soccer team to apply sunscreen before practice Measuring blood pressure in a 30-year-old at a routine visit Showing a client with long-standing COPD how to pace daily activities Select one option in each row.
Correct answer: Giving a healthy adult the yearly influenza vaccine: Primary; Offering hepatitis C screening to a 40-year-old with no symptoms: Secondary; Teaching a client with heart failure to limit sodium to avoid readmission: Tertiary; Teaching a teen soccer team to apply sunscreen before practice: Primary; Measuring blood pressure in a 30-year-old at a routine visit: Secondary; Showing a client with long-standing COPD how to pace daily activities: Tertiary
Primary prevention stops illness before it starts, through immunizations and healthy behaviors. Secondary prevention finds disease early through screening, often before symptoms appear. Tertiary prevention reduces the severity and effects of a disease the client already has, such as by teaching self-management of a chronic condition.
- Giving a healthy adult the yearly influenza vaccine Primary: immunizations prevent disease before it occurs.
- Offering hepatitis C screening to a 40-year-old with no symptoms Secondary: screening adults aged 18 to 79 for hepatitis C detects infection early, before symptoms.
- Teaching a client with heart failure to limit sodium to avoid readmission Tertiary: teaching self-management of existing heart failure reduces the severity of established disease.
- Teaching a teen soccer team to apply sunscreen before practice Primary: sunscreen use is a healthy behavior that prevents skin damage before disease develops.
- Measuring blood pressure in a 30-year-old at a routine visit Secondary: blood pressure screening of adults 18 and older finds hypertension early.
- Showing a client with long-standing COPD how to pace daily activities Tertiary: helping a client manage an existing chronic disease maintains function and quality of life.
Learn this topic: Immunizations and adult screening: what to give, when to hold it and who to screen 6-minute lesson
Source: Open RN Nursing Health Promotion, 2.2 Health, Wellness, and Disease Prevention · Open RN Nursing Health Promotion, 2.4 Secondary Prevention · Open RN Nursing Health Promotion, 2.5 Tertiary Prevention · USPSTF: A and B Recommendations ·
A client admitted with major depressive disorder tells the nurse, "I have it all worked out. I've been saving up my pills for when the time is right." Which action will the nurse take first?
Correct answer: C
A client who describes a specific plan and has gathered the means is at high risk, so safety comes first. The nurse does not leave the client alone, gets help so the provider is notified, and then removes the saved medication and follows agency observation policy. Documentation is required but comes after the client is safe.
- A Documentation is needed, but it does not protect the client and is not the first action.
- B A group session does not address the immediate risk of a client with a plan and the means.
- C Correct: a client making suicidal statements with a plan must not be left alone, and the provider must be notified.
- D This is false reassurance; it blocks communication and ignores the immediate danger.
Learn this topic: How nurses assess suicide risk and respond to a client in crisis 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 7.5 Applying the Nursing Process to Depressive Disorders · Open RN Nursing: Mental Health and Community Concepts 2e, 1.6 Establishing Safety ·
A client with a long history of heavy alcohol use is being treated for alcohol withdrawal. The nurse notes new confusion, an unsteady gait and jerky, involuntary eye movements. Which prescription does the nurse expect the provider to give?
Correct answer: C
Confusion, ataxia and nystagmus in a client with alcohol use disorder point to Wernicke encephalopathy, an acute, life-threatening condition caused by thiamine (vitamin B1) deficiency. Thiamine replacement treats it; untreated, it can progress to Korsakoff syndrome, a chronic memory disorder. The other drugs are used for opioid overdose or opioid withdrawal.
- A Naloxone reverses opioids; it does not treat thiamine deficiency.
- B Clonidine relieves autonomic symptoms of opioid withdrawal, not Wernicke encephalopathy.
- C Correct: thiamine treats and prevents Wernicke encephalopathy, which presents with confusion, ataxia and nystagmus.
- D Buprenorphine treats opioid withdrawal and opioid use disorder, not thiamine deficiency.
Learn this topic: Alcohol withdrawal: what happens when, and how the nurse keeps the client safe 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 14.3 Withdrawal Management/Detoxification · MedlinePlus: Wernicke-Korsakoff syndrome · MedlinePlus Drug Information: Naloxone injection ·
A client with schizophrenia who has a history of auditory hallucinations is sitting alone in the dayroom, whispering and glancing toward an empty corner. The client looks frightened. Which statement by the nurse is best?
Correct answer: C
Assess first: when a client shows signs of hallucinating, the nurse finds out what the client is experiencing and then asks about the content, including whether the client hears commands to harm self or others. The nurse states what they observe and asks an open question rather than referring to the voices as if they were real. False reassurance, arguing that the voices are not real or giving medication before assessing does not address the client's fear or safety.
- A False reassurance dismisses the client's fear and skips assessment of what the client is experiencing, including possible commands to harm self or others.
- B Trying to convince the client the voices are not real is not helpful; the nurse offers their own perception and empathy instead.
- C Correct: the nurse names an observed behavior and asks an open question, which starts the assessment of the hallucination without implying the voices are real.
- D Giving medication before assessing the content and the client's response skips assessment, including the check for command hallucinations.
A nurse in a prenatal clinic is screening a client for intimate partner violence. The client's partner came to the visit. Which actions by the nurse are appropriate? Select all that apply.
Select all that apply.
Correct answer: A, B, E
Routine screening for intimate partner violence happens in private, so others are asked to leave; a partner who refuses is a warning sign. The nurse assures confidentiality within the limits of mandatory reporting, asks a few open-ended questions using words like "hurt" or "afraid" rather than "victim" or "abused," never asks why the client has not left and never discusses concerns with the partner. If abuse is disclosed, the priority is a personal safety plan and resources.
- A Correct: privacy makes disclosure safer; the interview and exam happen without the partner present.
- B Correct: asking about being hurt or afraid mirrors everyday words and feels less threatening.
- C Labels such as "victim" or "abuse" can feel shaming and make disclosure less likely.
- D Asking why the client hasn't left implies blame; leaving is often the most dangerous time.
- E Correct: the nurse assures confidentiality but is honest that mandatory reporting may apply.
- F Sharing concerns with the partner could put the client in danger.
Learn this topic: How nurses recognize abuse and neglect and what they must do next 5-minute lesson
Source: Open RN Nursing: Mental Health and Community Concepts 2e, 15.5 Intimate Partner Violence · Open RN Nursing: Mental Health and Community Concepts 2e, 15.7 Applying the Nursing Process to Clients Experiencing Trauma, Abuse, or Violence ·
A nurse is assessing clients whose spouses died 4 months ago. For each finding, indicate whether it is more consistent with normal grief or with major depression.
Normal grief Major depression Sadness comes in waves that are mixed with fond memories of the spouse Feels worthless and full of self-loathing Self-esteem is intact; says, "I was a good husband to her" Low mood all day, every day, with no ability to expect any pleasure Describes a hollow, empty feeling and longs to see the spouse again Select one option in each row.
Correct answer: Sadness comes in waves that are mixed with fond memories of the spouse: Normal grief; Feels worthless and full of self-loathing: Major depression; Self-esteem is intact; says, "I was a good husband to her": Normal grief; Low mood all day, every day, with no ability to expect any pleasure: Major depression; Describes a hollow, empty feeling and longs to see the spouse again: Normal grief
Grief and depression overlap, but they differ in pattern. In grief, painful feelings come in waves, ease over time, mix with positive memories and center on emptiness and longing, and self-esteem is usually preserved. In major depression, mood is constantly low, pleasure cannot be expected and worthlessness or self-loathing is common; depression can develop after a loss and needs referral.
- Sadness comes in waves that are mixed with fond memories of the spouse Waves of sadness mixed with positive memories are typical of the normal grieving process.
- Feels worthless and full of self-loathing Worthlessness and self-loathing point to major depression; self-esteem is usually kept in grief.
- Self-esteem is intact; says, "I was a good husband to her" Preserved self-esteem fits normal grief.
- Low mood all day, every day, with no ability to expect any pleasure A constant low mood with inability to expect pleasure is characteristic of major depression.
- Describes a hollow, empty feeling and longs to see the spouse again Emptiness and yearning for the deceased are core features of grief.
Learn this topic: How nurses tell normal grief from complicated grief and support the family 5-minute lesson
Source: National Cancer Institute: Grief, Bereavement, and Coping With Loss (PDQ) – Health Professional Version · Open RN Nursing Fundamentals 2e, 17.2 Basic Concepts (grief, loss, end of life) ·
A client has been on bed rest for 4 days after abdominal surgery. The provider now prescribes ambulation. Which action should the nurse take first?
Correct answer: B
After days in bed, blood pools in the legs and the client is at risk for orthostatic hypotension: a systolic drop of 20 mm Hg or more, or a diastolic drop of 10 mm Hg or more, within 3 minutes of sitting or standing. Safety comes first, so every transfer or walk begins with dangling at the edge of the bed and checking for dizziness before standing.
- A Standing before a sitting check skips the step that detects dizziness and orthostatic hypotension while the client is still safe on the bed.
- B Correct: dangling for a few minutes lets the nurse check for dizziness or orthostatic hypotension before the client bears weight.
- C Walking comes later; a gait belt does not replace checking how the client tolerates sitting up first.
- D Walking alone after 4 days of bed rest is unsafe until the client's tolerance and need for help are assessed.
Learn this topic: How bed rest harms the body, and how turning and positioning prevent it 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 13.2 Mobility Basic Concepts · Open RN Nursing Fundamentals 2e, 13.3 Mobility: Applying the Nursing Process ·
The nurse is reviewing care for a client with an indwelling urinary catheter. For each action, indicate whether it is indicated or not indicated to prevent catheter-associated urinary tract infection (CAUTI).
Indicated Not indicated Keep the drainage bag below the level of the bladder and off the floor Clean the area around the urethra with antiseptic solution each shift Empty the bag into a separate clean container used only for this client Irrigate the catheter every day to keep it open Replace the catheter every 7 days on a set schedule Secure the catheter to the thigh to prevent movement Select one option in each row.
Correct answer: Keep the drainage bag below the level of the bladder and off the floor: Indicated; Clean the area around the urethra with antiseptic solution each shift: Not indicated; Empty the bag into a separate clean container used only for this client: Indicated; Irrigate the catheter every day to keep it open: Not indicated; Replace the catheter every 7 days on a set schedule: Not indicated; Secure the catheter to the thigh to prevent movement: Indicated
CAUTI prevention depends on a closed system, free urine flow, a low bag, clean emptying and a secured catheter. CDC does not recommend antiseptic periurethral cleaning, routine irrigation, or changing catheters at fixed intervals; routine hygiene during bathing and changes for clinical reasons are used instead.
- Keep the drainage bag below the level of the bladder and off the floor Indicated: a bag below the bladder keeps urine flowing away from the bladder; the floor contaminates it.
- Clean the area around the urethra with antiseptic solution each shift Not indicated: antiseptics are not used on the periurethral area while the catheter is in; routine hygiene is enough.
- Empty the bag into a separate clean container used only for this client Indicated: a separate clean container for each client prevents cross-contamination when emptying.
- Irrigate the catheter every day to keep it open Not indicated: routine irrigation is not recommended unless obstruction is expected.
- Replace the catheter every 7 days on a set schedule Not indicated: catheters are changed for clinical reasons, not at fixed intervals.
- Secure the catheter to the thigh to prevent movement Indicated: securing the catheter prevents movement and urethral traction.
Learn this topic: How to care for an indwelling urinary catheter and prevent CAUTI 5-minute lesson
Source: CDC: CAUTI Guideline, Summary of Recommendations · Open RN Nursing Skills 2e, 21.4 Inserting and Managing Indwelling Urinary Catheters ·
A client with osteoarthritis of the left knee is learning to walk with a single-tip cane. Which statement by the client shows correct understanding of the teaching?
Correct answer: B
A cane is held in the hand opposite the weak or painful leg, and the cane and the weak leg move forward together so the cane takes some of the load off that leg. The handle should be at wrist level with the elbow slightly bent. On a step or curb, the stronger leg leads going up; going down, the cane is set on the lower level first and the weaker leg follows.
- A The cane goes in the hand opposite the weak leg, so this client should hold it in the right hand.
- B Correct: the cane and the weaker leg advance together, then the stronger leg steps past the cane.
- C Going up a step or curb, the stronger (right) leg leads and the cane and weaker leg follow.
- D The handle belongs at wrist level so the elbow is slightly bent; elbow height is too tall.
Source: MedlinePlus: Using a cane · Open RN Nursing Assistant, 8.5 Assisting With Ambulation ·
A client admitted with a stroke passed a swallow screen yesterday and is eating lunch. The nurse reviews the lunch note. Click to highlight the findings that suggest a swallowing problem.
1215: Client is for lunch. after each spoonful of soup. after sips of the thickened juice. Tray . Voice sounds after swallowing. and has eaten 20% of the meal in 30 minutes. Temperature . Client is .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: Coughs; Clears throat repeatedly; wet and gurgly; Chews very slowly
Coughing or choking during or after eating, throat clearing after drinking, a wet or gurgly voice and slow chewing are signs of dysphagia, even in a client who passed an earlier screen. When they appear, the nurse stops the meal and notifies the provider so the speech-language pathologist can assess. A normal temperature does not rule out aspiration, which can be silent.
- sitting upright in a chair Sitting upright in a chair is the correct position for eating.
- Coughs Highlight: coughing during or after eating is a sign of a swallowing problem.
- Clears throat repeatedly Highlight: throat clearing after drinking is a symptom of dysphagia.
- matches the diet card A tray that matches the diet card is correct practice.
- wet and gurgly Highlight: a wet or gurgly voice during or after eating is a sign of dysphagia.
- Chews very slowly Highlight: slow chewing or eating is a symptom of a swallowing problem.
- 98.6°F (37.0°C) A normal temperature does not rule out aspiration, but it is not itself a sign of a swallowing problem.
- alert and follows commands Being alert and following commands is a reassuring finding.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: MedlinePlus: Swallowing problems · ASHA Practice Portal: Adult Dysphagia · Open RN Nursing Fundamentals 2e, 14.3 Nutrition: Applying the Nursing Process ·
The nurse needs to assess pain in a client with advanced dementia who can no longer communicate verbally. Which tool is most appropriate?
Correct answer: A
The Pain Assessment in Advanced Dementia (PAINAD) scale scores breathing, negative vocalization, facial expression, body language and consolability from 0 to 2 each, for a total of 0 to 10. It is designed for noncommunicative clients with advanced dementia. Self-report tools such as the 0–10 numeric scale and the FACES scale need the client to choose a rating.
- A Correct: PAINAD is a valid, reliable tool for noncommunicative clients with advanced dementia.
- B The numeric scale depends on the client's self-report, which this client cannot give.
- C With the FACES scale, the client chooses the face; the nurse does not pick one based on appearance.
- D The COMFORT Behavioral Scale is validated for children receiving mechanical ventilation.
Learn this topic: How nurses assess pain and relieve it with comfort measures beyond medication 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 11.3 Pain Assessment Methods · Open RN Nursing Fundamentals 2e, 11.5 Comfort: Applying the Nursing Process ·
A client is prescribed 1,000 mL of 0.9% sodium chloride IV over 8 hours. If an infusion pump is used, the nurse programs it at . If the pump fails and the nurse runs the fluid by gravity using tubing with a drop factor of 15 gtt/mL, the nurse regulates the drip at .
Choose the best option from each list to complete the sentence.
Correct answer: 125 mL/hr; 31 gtt/min
A pump is set in mL/hr: 1,000 mL / 8 hr = 125 mL/hr. A gravity drip is set in gtt/min: 125 mL/hr x 15 gtt/mL / 60 min = 31.25, rounded to 31 gtt/min because drops are counted as whole numbers. Always check which unit the device needs before you calculate.
- 1,000 mL divided by 8 hours is 125 mL/hr; 83 mL/hr would be a 12-hour rate, 8 mL/hr confuses the number of hours with the rate, and 62.5 mL/hr would take 16 hours.
- 125 mL/hr x 15 gtt/mL / 60 min = 31.25, so 31 gtt/min; 125 gtt/min assumes 60 gtt/mL microdrip tubing, 8 gtt/min divides 125 by 15, and 1,875 gtt/min forgets to divide by 60 minutes.
Learn this topic: How to calculate oral, liquid, weight-based and IV doses 5-minute lesson
Source: Open RN Nursing Skills 2e, 5.15 IV Infusion by Pump · Open RN Nursing Skills 2e, 5.14 IV Infusion by Gravity · Open RN Nursing Skills 2e, 5.5 Rounding ·
The nurse reviews laboratory results for five clients receiving anticoagulants. For each result, indicate whether it is expected for the client's therapy or requires follow-up.
Expected Requires follow-up Continuous IV heparin: aPTT 62 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Warfarin for atrial fibrillation: INR 4.8 (normal 0.8–1.1; prescribed target 2.0–3.0) Continuous IV heparin, day 6: platelets 96,000/mm³ (normal 150,000–400,000/mm³; baseline 220,000/mm³) Warfarin for atrial fibrillation: INR 2.6 (normal 0.8–1.1; prescribed target 2.0–3.0) Continuous IV heparin: aPTT 30 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Select one option in each row.
Correct answer: Continuous IV heparin: aPTT 62 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds): Expected; Warfarin for atrial fibrillation: INR 4.8 (normal 0.8–1.1; prescribed target 2.0–3.0): Requires follow-up; Continuous IV heparin, day 6: platelets 96,000/mm³ (normal 150,000–400,000/mm³; baseline 220,000/mm³): Requires follow-up; Warfarin for atrial fibrillation: INR 2.6 (normal 0.8–1.1; prescribed target 2.0–3.0): Expected; Continuous IV heparin: aPTT 30 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds): Requires follow-up
On IV heparin the aPTT is meant to be prolonged, roughly 1.5 to 2 times normal, inside the target set by the facility protocol in the order. On warfarin the INR is meant to sit inside the prescribed target, usually 2.0 to 3.0. Results above the target raise bleeding risk, results below it mean the drug is not protecting the client, and a platelet drop of 30% or more on heparin suggests heparin-induced thrombocytopenia.
- Continuous IV heparin: aPTT 62 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Expected: an aPTT of 62 seconds is prolonged on purpose and falls inside the protocol target of 46–70 seconds.
- Warfarin for atrial fibrillation: INR 4.8 (normal 0.8–1.1; prescribed target 2.0–3.0) Requires follow-up: an INR of 4.8 is well above the 2.0–3.0 target and puts the client at high risk for bleeding.
- Continuous IV heparin, day 6: platelets 96,000/mm³ (normal 150,000–400,000/mm³; baseline 220,000/mm³) Requires follow-up: platelets fell by more than half from baseline (a drop of 30% or more suggests heparin-induced thrombocytopenia) and are below 100,000/mm³, the level at which the heparin label calls for stopping heparin and evaluating for HIT.
- Warfarin for atrial fibrillation: INR 2.6 (normal 0.8–1.1; prescribed target 2.0–3.0) Expected: an INR of 2.6 is inside the prescribed 2.0–3.0 target for warfarin therapy.
- Continuous IV heparin: aPTT 30 seconds (normal 25–35 seconds; facility protocol target 46–70 seconds) Requires follow-up: an aPTT of 30 seconds is in the normal range, so the heparin is below the protocol target and the dose needs adjustment per protocol.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · MedlinePlus: Partial thromboplastin time (PTT) · MedlinePlus: Prothrombin time (PT) · MedlinePlus: Platelet count ·
The nurse is preparing insulin and heparin for several clients. Which actions reflect safe practice for these high-alert medications? Select all that apply.
Select all that apply.
Correct answer: A, C, F
ISMP lists all insulin and the anticoagulants as high-alert medications, so their use is built around redundant checks. Before subcutaneous insulin the nurse reviews the current glucose and tells the client the product, dose and purpose. Heparin comes in many strengths, so the label is checked against the order every time.
- A Correct: ISMP guidance has the nurse assess the most current blood glucose before subcutaneous insulin.
- B Incorrect: an insulin pen is never used for more than one client, even with a new needle, because of bloodborne pathogen exposure.
- C Correct: fatal heparin errors have come from choosing the wrong strength, so the product is checked against the order.
- D Incorrect: U-500 insulin is measured only with a U-500 syringe to avoid a dosing error.
- E Incorrect: a verbally reported glucose is never the only source of information for an insulin dose.
- F Correct: telling the client the product name, dose and intended action is part of ISMP's safe insulin practice and gives the client a chance to catch an error.
Learn this topic: How to give insulin, heparin and warfarin safely 5-minute lesson
Source: Open RN Nursing Pharmacology, 9.4 Antidiabetics · Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers · DailyMed: Heparin Sodium in Dextrose Injection label · ISMP List of High-Alert Medications in Acute Care Settings (2024) ·
A client with symptomatic anemia is prescribed 1 unit of packed red blood cells. Consent is signed and the crossmatch is complete. Before the nurse calls for the unit, the client's temperature is 101.0°F (38.3°C); it was 98.6°F (37.0°C) four hours ago. What is the best action by the nurse?
Correct answer: D
A pre-transfusion temperature above 100.4°F (37.8°C) is reported to the provider before the blood is picked up. A new fever would hide the main early sign of a transfusion reaction, and once a unit leaves the blood bank it must be started within about 30 minutes and can't be returned. Clarifying first is the safe choice when data change before a high-risk procedure.
- A Starting with a new fever means a reaction fever couldn't be told apart from the baseline fever, and the provider hasn't been told about the change.
- B Blood is never stored in a unit refrigerator; it must start within about 30 minutes of leaving the blood bank.
- C Acetaminophen has not been prescribed, and treating the fever without telling the provider skips the needed clarification.
- D Correct: a febrile client is reported to the provider before the unit is obtained, because blood can't go back to the bank once it is picked up.
Learn this topic: How nurses give blood safely and spot transfusion reactions 5-minute lesson
Source: Open RN Nursing Advanced Skills, 3.3 Applying the Nursing Process · Open RN Nursing Advanced Skills, 3.4 Checklist: Administer Blood Products ·
A client returns from abdominal surgery with patient-controlled analgesia (PCA) delivering IV morphine. Which actions by the nurse are appropriate? Select all that apply.
Select all that apply.
Correct answer: B, C, D
A PCA is safe because a client who is too sedated cannot press the button, so no one else, not even the nurse, presses it. A second RN verifies the programming when the PCA starts, and the nurse monitors respiratory rate, SpO2, sedation level and mental status, because sedation usually comes before respiratory depression. Uncontrolled pain is reported to the provider rather than handled by changing the pump limits.
- A "PCA by proxy" defeats the safety design and can cause oversedation and respiratory depression.
- B Correct: the client must be alert enough to press the button, which is the built-in safeguard against overdose.
- C Correct: agency policy has another RN verify the order and pump programming when a PCA is started.
- D Correct: clients on PCA opioids are watched closely for oversedation and respiratory depression.
- E A bowel program is started with the first opioid dose and continued, because opioids slow peristalsis.
- F The lockout and hourly limits are prescribed safety settings; ongoing pain is reported to the provider, not fixed by changing the limits.
Source: Open RN Nursing Advanced Skills, 1.7 Specialized Infusions · Open RN Nursing Fundamentals 2e, 11.4 Pain Management ·
A client has received total parenteral nutrition (TPN) through a peripherally inserted central catheter (PICC) for 4 days. For each finding, indicate whether it is expected (acceptable for safe TPN care) or requires follow-up.
Expected Requires follow-up Capillary blood glucose 118 mg/dL (random; usually 125 mg/dL or lower) Temperature 101.4°F (38.6°C) with chills Transparent dressing dated 2 days ago, clean, dry and intact Current TPN bag hung 30 hours ago and still infusing Capillary blood glucose 262 mg/dL Upper arm circumference unchanged from baseline Select one option in each row.
Correct answer: Capillary blood glucose 118 mg/dL (random; usually 125 mg/dL or lower): Expected; Temperature 101.4°F (38.6°C) with chills: Requires follow-up; Transparent dressing dated 2 days ago, clean, dry and intact: Expected; Current TPN bag hung 30 hours ago and still infusing: Requires follow-up; Capillary blood glucose 262 mg/dL: Requires follow-up; Upper arm circumference unchanged from baseline: Expected
TPN care centers on three risks: hyperglycemia from the dextrose, infection because the nutrients support microbial growth, and problems with the line itself. A normal glucose, a current intact dressing and an unchanged arm circumference are reassuring. Fever with chills, a glucose well above the usual range and a bag that has hung longer than 24 hours all need action.
- Capillary blood glucose 118 mg/dL (random; usually 125 mg/dL or lower) Expected: a random glucose of 125 mg/dL or lower is in the usual range.
- Temperature 101.4°F (38.6°C) with chills Requires follow-up: fever and chills can be early signs of infection in a client receiving TPN.
- Transparent dressing dated 2 days ago, clean, dry and intact Expected: transparent dressings are changed at least every 7 days and when damp, loose or soiled.
- Current TPN bag hung 30 hours ago and still infusing Requires follow-up: the label says to complete the infusion within 24 hours, so a bag still running after 30 hours is past that limit.
- Capillary blood glucose 262 mg/dL Requires follow-up: dextrose given faster than it can be used causes hyperglycemia, which is monitored and treated.
- Upper arm circumference unchanged from baseline Expected: an increase of 3 cm or more would suggest thrombosis; no change is reassuring.
Learn this topic: How nurses care for central lines and keep TPN safe 5-minute lesson
Source: DailyMed: Clinimix E (amino acids with electrolytes in dextrose with calcium) injection label · Open RN Nursing Advanced Skills, 4.3 Applying the Nursing Process (central venous access devices) · MedlinePlus: Blood sugar test ·
A subclavian central venous catheter is placed at the bedside without fluoroscopy. Before the catheter is used, the nurse makes sure that . Two hours later, the client reports sharp chest pain that worsens with each breath and shortness of breath; SpO2 is 88%. All lumens are capped and clamped, and no line has been opened. The nurse suspects and should .
Choose the best option from each list to complete the sentence.
Correct answer: a chest X-ray confirms the tip position; a pneumothorax; stay, call for help and give oxygen
When fluoroscopy is not used during insertion, a chest X-ray confirms the catheter tip position and also checks for a pneumothorax, which can happen if the needle punctures the lung. Sharp, stabbing chest pain that worsens on inspiration with dyspnea after a neck or chest insertion points to pneumothorax rather than air embolism, especially with a closed system. The nurse stays with the client, calls for help and the rapid response team, and gives high-flow oxygen.
- A post-procedure chest X-ray confirms tip placement when fluoroscopy was not used; a dated dressing and a normal glucose do not show where the tip is.
- Sharp chest pain that worsens with breathing after a subclavian insertion fits pneumothorax; air embolism needs air entry through an open line, and CLABSI causes fever, not sudden pleuritic pain.
- For pneumothorax, the nurse stays, calls for help and gives high-flow oxygen; the left-side, head-down position is for air embolism, and flushing does not treat a collapsed lung.
Learn this topic: How nurses care for central lines and keep TPN safe 5-minute lesson
Source: Open RN Nursing Advanced Skills, 4.2 Basic Concepts (central venous access devices) · Open RN Nursing Advanced Skills, 4.3 Applying the Nursing Process (central venous access devices) ·
A client who had spinal anesthesia for knee surgery will give enoxaparin injections at home. Which statements by the client show correct understanding? Select all that apply.
Select all that apply.
Correct answer: B, D, E
Enoxaparin goes into a pinched fold of abdominal skin, using the whole needle and holding the fold during the injection, and sites alternate between the left and right sides. The air bubble in the prefilled syringe stays in to avoid losing drug, and the site is not rubbed, which limits bruising. After spinal anesthesia, numbness, tingling or leg weakness is reported immediately because it can signal a spinal hematoma, and NSAIDs are avoided because they add to bleeding risk.
- A The label says not to expel the air bubble from the prefilled syringe, to avoid losing drug.
- B Correct: the whole needle goes into a skin fold on the abdomen that is held throughout the injection.
- C Rubbing the site after the injection increases bruising and is avoided.
- D Correct: injections alternate between the left and right sides of the abdomen.
- E Correct: numbness, tingling or leg weakness after spinal anesthesia can signal a spinal or epidural hematoma and is reported at once.
- F NSAIDs such as ibuprofen increase bleeding risk with enoxaparin and are avoided unless the provider approves.
Learn this topic: How nurses keep clients on anticoagulants from bleeding 5-minute lesson
Source: DailyMed: Enoxaparin Sodium Injection label · MedlinePlus: Enoxaparin Injection · Open RN Nursing Pharmacology, 6.12 Blood Coagulation Modifiers ·
The nurse is assessing several clients on a surgical unit. For each finding, indicate the postoperative complication it most likely suggests.
Atelectasis Deep vein thrombosis Paralytic ileus Wound dehiscence Diminished breath sounds at the lung bases and SpO2 lower than baseline Swelling, warmth, redness and pain in the right calf only Distended abdomen with no bowel sounds heard Incision edges pulling apart with a sudden increase in drainage Shallow, rapid breathing in a client who avoids the incentive spirometer Nausea and vomiting with a firm, bloated abdomen Select one option in each row.
Correct answer: Diminished breath sounds at the lung bases and SpO2 lower than baseline: Atelectasis; Swelling, warmth, redness and pain in the right calf only: Deep vein thrombosis; Distended abdomen with no bowel sounds heard: Paralytic ileus; Incision edges pulling apart with a sudden increase in drainage: Wound dehiscence; Shallow, rapid breathing in a client who avoids the incentive spirometer: Atelectasis; Nausea and vomiting with a firm, bloated abdomen: Paralytic ileus
Each complication has a signature: atelectasis shows decreased breath sounds, low SpO2, dyspnea and tachypnea; DVT shows one-sided leg swelling, pain, warmth and redness; paralytic ileus shows abdominal distension, absent bowel sounds, nausea and vomiting; dehiscence shows wound edges separating with increased drainage. Matching the finding to the body system narrows the hypothesis quickly.
- Diminished breath sounds at the lung bases and SpO2 lower than baseline Atelectasis: collapsed alveoli reduce breath sounds and oxygen saturation.
- Swelling, warmth, redness and pain in the right calf only Deep vein thrombosis: one-sided calf swelling, warmth, redness and pain are classic DVT findings.
- Distended abdomen with no bowel sounds heard Paralytic ileus: a distended abdomen with absent bowel sounds means the bowel is not moving.
- Incision edges pulling apart with a sudden increase in drainage Wound dehiscence: separation of the incision edges with more drainage defines dehiscence.
- Shallow, rapid breathing in a client who avoids the incentive spirometer Atelectasis: shallow breathing and not using the incentive spirometer let alveoli collapse; tachypnea is a sign.
- Nausea and vomiting with a firm, bloated abdomen Paralytic ileus: nausea and vomiting with abdominal distension fit a bowel that has stopped moving.
Learn this topic: Which postoperative complications should a nurse watch for? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 27.3 Hospitalized Postoperative Patient · OpenStax Fundamentals of Nursing, 31.4 Postoperative Phase ·
The nurse reviews vital-sign trends for four adult clients on a medical unit. Which trend should the nurse follow up on immediately?
Correct answer: B
A change in respiratory rate is an early sign that a client is deteriorating, and new restlessness can reflect low oxygen or high carbon dioxide. A rate of 26/min is above the adult range of 12–20/min, so this client needs a full assessment and prompt reporting. The other trends stay within normal limits or have an obvious harmless cause.
- A Both temperatures are within the normal oral range, so this small rise is not urgent.
- B Correct: a rising respiratory rate above 20/min with new restlessness is an early warning of deterioration.
- C A small rise in blood pressure that stays near normal does not need immediate action.
- D A modest rise in heart rate right after activity is expected and stays within 60–100/min.
Learn this topic: How do vital-sign trends warn you that a client is getting worse? 5-minute lesson
Source: Open RN Nursing Skills 2e, 10.3 Respiratory Assessment · Open RN Nursing Skills 2e, 1.3 Vital Signs ·
A client is preparing for a colonoscopy next week. The nurse teaches the client to have on the day before the test. The client takes an iron supplement and is told to stop it a few days before the test, as instructed, because iron can . When the client asks about stopping daily aspirin, the nurse explains that the client should .
Choose the best option from each list to complete the sentence.
Correct answer: clear liquids only; turn the stool dark black and hide the bowel lining; follow the provider's instructions and not stop it on their own
The bowel must be completely clean so problems are not missed, so the client takes clear liquids only the day before and completes the bowel prep. Iron makes the stool dark black, which makes it harder to see the inside of the bowel. Aspirin and other blood thinners are often continued; the client follows the provider's instructions and does not stop them without talking to the provider, especially with a heart problem.
- Clear liquids only (o2) the day before helps empty and clean the bowel.
- Iron turns the stool dark black (o3), which makes it harder for the doctor to see inside the bowel.
- Aspirin is stopped only if the provider says so (o1); many times it is continued, and ibuprofen is another drug the client may be told to stop.
Learn this topic: How do you keep a client safe before and after a diagnostic procedure? 5-minute lesson
Source: MedlinePlus: Colonoscopy ·
A client had a chest tube placed for a hemothorax 3 hours ago. For each of the last 2 hours, 250 mL of bright red drainage has collected in the drainage unit. What should the nurse do?
Correct answer: C
A sudden increase in bright red drainage of more than 200 mL per hour may mean a vascular injury that needs surgical repair. The nurse obtains vital signs, assesses the client's heart and lung status and reports the amount and color of the drainage to the provider. Clamping, stripping and lifting the unit above the chest are all unsafe.
- A Routine clamping is not recommended because it risks a tension pneumothorax.
- B Stripping creates high pressure in the tube that can cause a life-threatening pneumothorax.
- C Correct: more than 200 mL/hour of bright red drainage is assessed and reported at once.
- D The unit stays below the chest so drainage does not flow back into the chest.
Learn this topic: How do you manage a chest tube and know when something is wrong? 5-minute lesson
Source: Open RN Nursing Advanced Skills, 6.4 Troubleshooting Problems and Complications · Open RN Nursing Advanced Skills, 6.3 Nursing Responsibilities for Clients With Chest Tube Drainage Systems ·
A client with heart failure takes digoxin and furosemide. Today's results are potassium 3.1 mEq/L (3.5–5.1 mEq/L) and digoxin 1.2 ng/mL (0.8–2.0 ng/mL). Why does the nurse report the potassium result promptly?
Correct answer: B
Safety first: hypokalemia increases the effect of digoxin and can lead to digoxin toxicity, even when the digoxin level itself is in range. A potassium below 3.5 mEq/L in a client on digoxin should be reported to the provider right away.
- A The risk with low potassium is a stronger digoxin effect and toxicity, not a false lab value.
- B Correct: hypokalemia increases digoxin's effect and the risk of toxicity, so it must be reported.
- C The digoxin level of 1.2 ng/mL is inside the 0.8–2.0 ng/mL range, so nothing suggests the dose is too low.
- D Diuretics that waste potassium can lower it, but a low potassium is not safe for a client taking digoxin.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: Open RN Nursing Pharmacology, 6.7 Cardiac Glycosides · Open RN Nursing Fundamentals 2e, 15.4 Electrolytes ·
The nurse reviews four abnormal results. For each result, indicate what it mainly tells the nurse about.
Kidney function Liver cell injury Breathing (CO₂ removal) Bleeding risk Creatinine 2.1 mg/dL (0.7–1.3 mg/dL for males) ALT 112 U/L (4–36 U/L) PaCO₂ 54 mm Hg (35–45 mm Hg) Platelets 48,000/mcL (150,000–400,000/mcL) Select one option in each row.
Correct answer: Creatinine 2.1 mg/dL (0.7–1.3 mg/dL for males): Kidney function; ALT 112 U/L (4–36 U/L): Liver cell injury; PaCO₂ 54 mm Hg (35–45 mm Hg): Breathing (CO₂ removal); Platelets 48,000/mcL (150,000–400,000/mcL): Bleeding risk
Link each lab to the organ or process it reflects. The kidneys remove creatinine, ALT leaks from injured liver cells, the lungs control PaCO₂ through breathing rate and depth, and a low platelet count raises the risk of bleeding.
- Creatinine 2.1 mg/dL (0.7–1.3 mg/dL for males) Kidney function: creatinine is removed by the kidneys, so a high level suggests the kidneys are not working well.
- ALT 112 U/L (4–36 U/L) Liver cell injury: ALT is an enzyme found mostly in the liver and is released into the blood when liver cells are injured.
- PaCO₂ 54 mm Hg (35–45 mm Hg) Breathing: the lungs regulate CO₂ by changing the rate and depth of breathing, so a high PaCO₂ means CO₂ is not being removed.
- Platelets 48,000/mcL (150,000–400,000/mcL) Bleeding risk: below 50,000/mcL, bleeding can happen even with everyday activities.
Learn this topic: Which lab values should make a nurse act right away? 5-minute lesson
Source: MedlinePlus: Creatinine blood test · MedlinePlus: Alanine transaminase (ALT) blood test · Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · MedlinePlus: Platelet count ·
A client with diabetic ketoacidosis has received 1 L of 0.9% sodium chloride. Current results: glucose 486 mg/dL (fasting 70–99 mg/dL), arterial pH 7.18 (7.35–7.45), potassium 3.1 mEq/L (3.5–5.1 mEq/L). A continuous IV insulin infusion is prescribed. Which action should the nurse take first?
Correct answer: B
Insulin and correction of acidosis drive potassium into the cells, so serum potassium falls during DKA treatment. When potassium is already below 3.5 mEq/L, insulin is delayed and potassium is replaced first (per protocol or after notifying the provider) to prevent dangerous dysrhythmias and muscle weakness. Safety of the heart comes before lowering glucose.
- A Starting insulin now would push the already low potassium even lower and risk life-threatening dysrhythmias.
- B Correct: current guidance delays insulin and replaces potassium first when potassium is below 3.5 mEq/L.
- C Bicarbonate is not routine in DKA and is considered only when pH is below 7.0; it would also lower potassium.
- D Dextrose is added only after glucose falls below about 250 mg/dL; at 486 mg/dL it is not indicated.
Learn this topic: Diabetic ketoacidosis vs hyperosmolar hyperglycemic state 5-minute lesson
Source: Umpierrez GE et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care 2024 (PMC) · Open RN Nursing Fundamentals 2e, 15.4 Electrolytes · Open RN Health Alterations, 7.5 Diabetes Mellitus ·
A client lying in bed begins a generalized tonic-clonic seizure. The nurse removes the extra pillows, raises the side rails and should . If the seizure continues for more than , the nurse calls for emergency assistance because the client is in status epilepticus. When the jerking stops, the nurse places the client .
Choose the best option from each list to complete the sentence.
Correct answer: note the time the seizure started; 5 minutes; on one side
During a seizure the nurse protects the client from injury and observes: nothing goes in the mouth, the client is not restrained, and the start and end times are recorded. A seizure lasting more than 5 minutes is status epilepticus, an emergency that needs immediate help. Afterward, the client is kept on one side to prevent aspiration.
- Recording the start time is a key nursing action; objects in the mouth can break teeth or injure the tongue, restraining the client causes injury, and moving a convulsing client into a chair is unsafe.
- Status epilepticus is a seizure lasting more than 5 minutes (or repeated seizures without recovery between them); waiting 15 or 30 minutes delays emergency care, and 1 minute is shorter than a typical tonic-clonic seizure, which lasts about 2 to 5 minutes.
- Keeping the client on one side is the recommended position to prevent aspiration; lying on the back, sitting upright and lying face down are not the recommended position after a seizure.
Source: Open RN Health Alterations, 9.7 Seizures and Epilepsy ·
A client on a medical unit was seen by the assistive personnel at 0545 talking normally and asking for water. At 0720 the nurse finds the client with a drooping mouth on the left side and slurred speech. The client cannot say when the symptoms started. Which time should the nurse report to the stroke team as the onset of symptoms?
Correct answer: B
Stroke onset is counted from the time the client was last known well, meaning last seen without symptoms. Here that is 0545, when the client was talking normally. The time symptoms were discovered (0720) is later than the true onset, and using it could make the client look eligible for time-sensitive treatment when they are not.
- A 0720 is when the symptoms were found, not the last time the client was known to be well.
- B Correct: 0545 is the last time the client was seen acting normally, so it is the time last known well.
- C The time of the stroke response call does not tell the team when the brain lost its blood flow.
- D The time of the previous evening's assessment is not the most recent time the client was known to be well.
Learn this topic: How do you recognize an acute stroke and what does the nurse do first? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 15.2 Ischemic Stroke · CDC, Signs and Symptoms of Stroke ·
A client with an ischemic stroke is 1 hour into an IV alteplase infusion. Before treatment the client had right arm weakness. For each finding, indicate whether it requires the nurse's immediate action or can be addressed with continued routine monitoring.
Immediate action Routine monitoring New severe headache and vomiting Blood pressure 168/94 mm Hg Swelling of the tongue and lips Right arm weakness unchanged from before the infusion Client, alert before the infusion, now opens eyes only to a loud voice Select one option in each row.
Correct answer: New severe headache and vomiting: Immediate action; Blood pressure 168/94 mm Hg: Routine monitoring; Swelling of the tongue and lips: Immediate action; Right arm weakness unchanged from before the infusion: Routine monitoring; Client, alert before the infusion, now opens eyes only to a loud voice: Immediate action
The major risk of a thrombolytic is bleeding, especially into the brain. A new severe headache with vomiting or a falling level of consciousness can mean hemorrhagic transformation, and lip or tongue swelling is angioedema; the label says to stop the infusion for serious bleeding or angioedema, so these need immediate action. A blood pressure within the 180/105 mm Hg limit and weakness unchanged from before treatment are monitored routinely.
- New severe headache and vomiting Immediate action: a sudden severe headache with vomiting may be bleeding in the brain.
- Blood pressure 168/94 mm Hg Routine monitoring: 168/94 mm Hg is within the limit of 180/105 mm Hg or lower used for clients receiving a thrombolytic.
- Swelling of the tongue and lips Immediate action: swelling of the tongue and lips during alteplase is angioedema, a reason to stop the infusion.
- Right arm weakness unchanged from before the infusion Routine monitoring: weakness that is unchanged from before treatment is not a new deficit.
- Client, alert before the infusion, now opens eyes only to a loud voice Immediate action: a falling level of consciousness is a new neurologic decline that may signal bleeding.
Learn this topic: How do you recognize an acute stroke and what does the nurse do first? 5-minute lesson
Source: OpenStax Medical-Surgical Nursing, 15.2 Ischemic Stroke · DailyMed, Alteplase for injection prescribing information · Open RN Health Alterations, 9.9 Cerebrovascular Accident ·
A client who has had severe diarrhea for 3 days has these arterial blood gas results: pH 7.29 (7.35–7.45), PaCO2 30 mm Hg (35–45 mm Hg), HCO3 16 mEq/L (22–26 mEq/L). How should the nurse interpret these results?
Correct answer: C
Start with the pH: 7.29 is acidosis. HCO3 is low and moves in the same direction as the pH, so the cause is metabolic (Metabolic Equal); severe diarrhea removes bicarbonate. PaCO2 is also low because the lungs are blowing off CO2 to compensate, but the pH is still abnormal, so the compensation is partial.
- A Respiratory acidosis would need a PaCO2 above 45 mm Hg; here PaCO2 is low.
- B Uncompensated would mean PaCO2 is still normal; here it is already below 35 mm Hg.
- C Correct: pH and HCO3 are both low (metabolic acidosis), and the low PaCO2 shows the lungs are compensating while the pH is still abnormal.
- D Full compensation would bring the pH back into the 7.35–7.45 range.
Learn this topic: How do you read an arterial blood gas step by step? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · OpenStax Medical-Surgical Nursing, 10.4 Acid-Base Imbalance ·
A client with a fractured femur is in severe pain, breathing 30 times per minute and reports numb, tingling fingers. ABG results: pH 7.50 (7.35–7.45), PaCO2 29 mm Hg (35–45 mm Hg), HCO3 24 mEq/L (22–26 mEq/L). The nurse interprets the results as that is . In addition to giving the prescribed analgesic, the nurse should .
Choose the best option from each list to complete the sentence.
Correct answer: respiratory alkalosis; uncompensated; coach slow abdominal breathing with a longer exhale
A high pH with a low PaCO2 (moving opposite to the pH) is respiratory alkalosis, caused here by pain-driven hyperventilation. HCO3 is still normal, so the kidneys have not begun to compensate. Treatment targets the cause: relieve the pain, reassure the client and coach slow abdominal breathing; rebreathing into a paper bag is no longer recommended because it can cause hypoxemia.
- PaCO2 is low and moves opposite to the high pH, so the cause is respiratory alkalosis; metabolic alkalosis would need a high HCO3, and acidosis would need a low pH.
- HCO3 is still in the normal range, so the imbalance is uncompensated; partial compensation would show a low HCO3, and full compensation would bring the pH back to normal.
- Slow abdominal breathing with a longer exhale reduces CO2 loss; a paper bag can cause hypoxemia, deep breathing to blow off CO2 worsens alkalosis, and bicarbonate would add base.
Learn this topic: How do you read an arterial blood gas step by step? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · OpenStax Medical-Surgical Nursing, 10.4 Acid-Base Imbalance · MedlinePlus, Respiratory alkalosis ·
For each client, indicate the acid–base imbalance the nurse should anticipate.
Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis A client who received several doses of an opioid has a respiratory rate of 7/min A client in shock has a serum lactate of 5.1 mmol/L (less than 2 mmol/L) A sedated client on a mechanical ventilator has a set rate that is too high for the client A client taking a high-dose loop diuretic has a potassium of 2.9 mEq/L (3.5–5.1 mEq/L) Select one option in each row.
Correct answer: A client who received several doses of an opioid has a respiratory rate of 7/min: Respiratory acidosis; A client in shock has a serum lactate of 5.1 mmol/L (less than 2 mmol/L): Metabolic acidosis; A sedated client on a mechanical ventilator has a set rate that is too high for the client: Respiratory alkalosis; A client taking a high-dose loop diuretic has a potassium of 2.9 mEq/L (3.5–5.1 mEq/L): Metabolic alkalosis
Match the imbalance to the cause. Too little breathing retains CO2 (respiratory acidosis); too much breathing removes CO2 (respiratory alkalosis). Acid build-up such as lactic acid from poor perfusion causes metabolic acidosis, while loss of hydrogen ions through the urine with diuretics or a shift of hydrogen into cells in hypokalemia causes metabolic alkalosis.
- A client who received several doses of an opioid has a respiratory rate of 7/min Respiratory acidosis: opioid oversedation slows breathing, so CO2 builds up.
- A client in shock has a serum lactate of 5.1 mmol/L (less than 2 mmol/L) Metabolic acidosis: poor tissue oxygenation in shock produces lactic acid.
- A sedated client on a mechanical ventilator has a set rate that is too high for the client Respiratory alkalosis: a ventilator rate that is too high removes too much CO2.
- A client taking a high-dose loop diuretic has a potassium of 2.9 mEq/L (3.5–5.1 mEq/L) Metabolic alkalosis: diuretics cause loss of hydrogen ions in the urine, and hypokalemia shifts hydrogen ions into cells.
Learn this topic: How do you read an arterial blood gas step by step? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 15.5 Acid-Base Balance · OpenStax Medical-Surgical Nursing, 10.4 Acid-Base Imbalance · OpenStax Medical-Surgical Nursing, 23.2 Hypovolemic Shock · Open RN Nursing Fundamentals 2e, 15.4 Electrolytes ·
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