Question set A: eight items across three systems

1. A nurse is caring for four patients on the first postoperative day after craniotomy. Which change requires immediate assessment?

1. A patient who rates a headache 4 out of 10, relieved by repositioning.
2. A patient who vomited once two hours ago and is now comfortable.
3. A patient who opened his eyes spontaneously last hour and now opens them only when his name is called loudly.
4. A patient whose blood pressure has risen from 130/74 to 138/78 mm Hg.

2. Select all actions the nurse takes during an active generalized tonic-clonic seizure.

1. Turn the patient to a side-lying position.
2. Insert a padded tongue blade between the teeth.
3. Note the time the seizure began.
4. Loosen clothing around the neck.
5. Hold the extremities still to prevent injury.
6. Keep suction and oxygen available at the bedside.

3. A patient with a complete spinal cord injury at the fifth thoracic level suddenly reports a severe pounding headache. What is the first nursing action?

1. Palpate the bladder for distention.
2. Raise the head of the bed to a full upright position and lower the legs.
3. Notify the provider.
4. Obtain a blood pressure reading.

4. A patient reports two days of vomiting with almost no oral intake. Urine output is scant and dark. Serum creatinine is 1.2 mg/dL; his documented baseline is 0.6 mg/dL → BOOK 07 · P9. How should the nurse classify this?

1. Prerenal acute kidney injury.
2. Intrarenal acute kidney injury.
3. Postrenal acute kidney injury.
4. No kidney injury, since the creatinine is inside the population reference range.

5. A patient is on continuous ambulatory peritoneal dialysis. Select all findings the nurse reports.

EXCH FILL DWELL DRAIN EFFLUENT 1 2000 mL 4 hr 2150 mL clear, pale yellow 2 2000 mL 4 hr 2100 mL clear, pale yellow 3 2000 mL 4 hr 1800 mL clear, pale yellow 4 2000 mL 4 hr 1750 mL cloudy

1. The cloudy effluent on exchange 4.
2. Drain volume below the instilled volume on two consecutive exchanges, with new abdominal fullness.
3. Clear, pale yellow effluent on exchanges 1 through 3.
4. Temperature 101.4 degrees Fahrenheit with abdominal tenderness.
5. Outflow that slows when the patient sits forward and resumes when he is repositioned.

6. A 78-year-old with type 2 diabetes has had three days of worsening lethargy during a gastrointestinal illness with poor fluid intake. She is now obtunded. Respirations are 20 and unlabored with no unusual breath odor. Mucous membranes are dry and skin turgor is poor. No laboratory results are available yet. Which condition is most consistent with this presentation?

1. Diabetic ketoacidosis.
2. Hyperosmolar hyperglycemic state.
3. Severe hypoglycemia.
4. Syndrome of inappropriate antidiuretic hormone.

7. A patient with small cell lung cancer has a falling serum sodium, scant concentrated urine, and a 4-pound weight gain in two days with no dependent edema. What is the priority nursing intervention?

1. Restrict fluid intake and institute seizure precautions.
2. Encourage free water to correct the concentrated urine.
3. Administer a rapid isotonic fluid bolus.
4. Record daily weights and continue to monitor.

8. A patient who takes prednisone daily for rheumatoid arthritis is admitted with pneumonia. His blood pressure falls to 78/44 mm Hg and does not improve after a fluid bolus. What is the most likely cause?

1. Adrenal crisis.
2. Hypovolemia from fever and insensible loss.
3. Anaphylaxis to the antibiotic.
4. Neurogenic shock.

SELF-SCORE STRIP. 1 N · 2 N · 3 N · 4 R · 5 R · 6 E · 7 E · 8 E. Tally your misses by letter.

Margin noteif two answers are actions, the earlier one usually wins. Priority framework selection is → BOOK 03 · P5.

Takeawaya candidate who misses three items in one system has a system problem, not a question problem.