15 free questions from the CinnaRN physiological adaptation bank (1,062 in the app). Tap an answer to check it. The rationale opens right away.
A nurse is performing discharge teaching for a client recovering from Guillain-Barre syndrome. Which statement about recovery is accurate for the nurse to share?
Answer: A. Recovery generally occurs gradually over weeks to months
Recovery from Guillain-Barre syndrome usually occurs in the reverse order of symptom onset (descending recovery) over weeks to months, and most clients recover, though some have residual weakness. Recovery is generally gradual, not immediate. It is not a relapsing-remitting disease like MS, and most clients do not remain permanently paralyzed.
A client with lung cancer develops facial and neck swelling, distended neck veins, and dyspnea. The nurse suspects superior vena cava syndrome. What is the priority nursing action?
Answer: B. Raise the head of the bed to ease breathing and promote venous drainage
Superior vena cava syndrome is caused by tumor compression of the superior vena cava, impairing venous return and threatening the airway. Raising the head of the bed promotes venous drainage and eases breathing while emergent treatment (radiation, stenting) is arranged. Lying flat or applying tight items would worsen obstruction.
A client is brought to the emergency department with sudden onset of right-sided weakness and slurred speech that began 1 hour ago. Which action should the nurse take FIRST?
Answer: A. Establish the exact time the symptoms began (last known well time)
For a suspected acute stroke, establishing the exact time of symptom onset (last known well) is the priority because it determines eligibility for thrombolytic therapy. A noncontrast CT then rules out hemorrhage, but the time-of-onset history must be obtained immediately and drives the entire treatment pathway. Glucose and vital signs are also obtained quickly, but time of onset is the gating factor for tPA.
A client with metabolic acidosis from diabetic ketoacidosis is being treated. Which arterial blood gas finding does the nurse expect before treatment?
Answer: B. pH 7.28, bicarbonate 16 mEq/L
Metabolic acidosis is defined by a low pH (below 7.35) and a low bicarbonate (below 22 mEq/L). In DKA the client hyperventilates (Kussmaul respirations) to blow off CO2 as respiratory compensation, lowering PaCO2. The hallmark uncompensated picture is low pH with low bicarbonate.
A client recovering from extensive burns reports epigastric pain and has coffee-ground nasogastric drainage. The nurse recognizes this as a sign of which burn complication?
Answer: A. Curling ulcer (gastric stress ulcer)
A Curling ulcer is an acute gastric or duodenal stress ulcer that occurs after severe burns, caused by reduced gastrointestinal blood flow and increased acid production. Epigastric pain, occult or frank blood in gastric secretions (coffee-ground drainage), and melena are signs. Prophylactic proton pump inhibitors or H2 blockers and early enteral feeding help prevent it.
A laboring client at 5 cm dilation suddenly reports a gush of fluid. The nurse notes a fetal heart rate deceleration to 90 bpm that does not recover quickly. What is the priority nursing action?
Answer: B. Reposition the client to a knee-chest position to relieve cord pressure
A variable deceleration with sudden onset after membrane rupture suggests cord compression, possibly cord prolapse. The priority is to relieve pressure on the cord by repositioning the client (knee-chest or Trendelenburg) and, if a cord is palpated, lifting the presenting part off the cord. Increasing IV fluids and oxygen follow, but immediate repositioning to relieve compression comes first.
A nonimmunized child develops a confluent, blotchy maculopapular rash that begins at the hairline and face and spreads downward, along with cough, coryza, and conjunctivitis. Which infection is most likely?
Answer: B. Measles (rubeola)
Measles (rubeola) classically presents with the three Cs: cough, coryza, and conjunctivitis, followed by a maculopapular rash that begins on the face and hairline and spreads downward to the trunk and extremities.
A nurse is assessing a client who reports an unusual smell and a feeling of deja vu just before a seizure. The nurse documents this as which phenomenon?
Answer: A. An aura
An aura is a sensory warning that some clients experience before a seizure, such as an unusual smell, taste, visual change, or a feeling of deja vu. The postictal phase is the period of confusion and fatigue after a seizure. The tonic phase is muscle rigidity during the seizure, and the clonic phase is the rhythmic jerking.
A client is 24 hours postoperative following bowel surgery and has absent bowel sounds, abdominal distention, and no passage of flatus. The nurse recognizes these findings as consistent with which complication?
Answer: A. Paralytic ileus
Paralytic ileus is a temporary cessation of intestinal peristalsis common after abdominal surgery and anesthesia. Signs include absent bowel sounds, distention, lack of flatus or stool, and nausea. Management includes nothing by mouth, possible nasogastric decompression, and gradual return of motility.
A newborn has a heart rate of 120 and is warm and pink but begins showing grunting, nasal flaring, and intercostal retractions at 1 hour of age. What does the nurse recognize these findings indicate?
Answer: B. Respiratory distress requiring further assessment
Grunting, nasal flaring, and retractions are the cardinal signs of respiratory distress in a newborn. They reflect increased work of breathing and the infant's attempt to maintain functional residual capacity. These findings require prompt assessment of oxygenation and notification of the provider; they are never normal.
A client receiving total parenteral nutrition suddenly develops muscle weakness and a serum potassium of 3.0 mEq/L. Which intervention does the nurse anticipate?
Answer: A. Administer prescribed potassium replacement
Refeeding can shift potassium into cells, causing hypokalemia. Treatment is potassium replacement. Manifestations include muscle weakness, leg cramps, and a risk of dysrhythmias.
A client is admitted with extensive burns. During the emergent (resuscitative) phase in the first 24 to 48 hours, which fluid and electrolyte change does the nurse expect?
Answer: A. Hyperkalemia and hyponatremia with fluid shifting out of the vasculature
In the emergent phase, increased capillary permeability causes fluid, sodium, and protein to shift from the intravascular space into the interstitium, producing hypovolemia and edema. Potassium leaks from damaged cells, causing hyperkalemia, while sodium is trapped in edema fluid, producing hyponatremia. Hemoconcentration raises the hematocrit. The opposite shifts occur later in the diuretic phase.
A client with a febrile nonhemolytic transfusion reaction develops fever and chills without hemolysis. Which nursing action and future measure are appropriate?
Answer: A. Stop the transfusion and use leukocyte-reduced products for future transfusions
Febrile nonhemolytic reactions are caused by recipient antibodies against donor white blood cells and present with fever and chills. The nurse stops the transfusion to rule out a hemolytic reaction, gives an antipyretic such as acetaminophen as ordered, and for future transfusions leukocyte-reduced (leukocyte-poor) blood products are used to prevent recurrence. Aspirin is generally avoided for fever in clients at bleeding risk.
A nurse is teaching a postpartum client about warning signs to report after discharge. Which sign of secondary postpartum hemorrhage should the nurse emphasize?
Answer: A. A return of heavy, bright red bleeding after lochia had decreased
Secondary (late) postpartum hemorrhage occurs more than 24 hours up to 12 weeks after birth, commonly from retained placental fragments or subinvolution. A sudden return of bright red, heavy bleeding after lochia had lightened is a key sign the client should report.
A nurse observes the fluid in the water-seal chamber of a chest drainage system rising and falling with the client's respirations. How does the nurse interpret this finding?
Answer: A. This is an expected finding called tidaling
Tidaling, the rise and fall of fluid in the water-seal chamber with respiration, is an expected normal finding that reflects pressure changes in the pleural space. Absence of tidaling may mean the lung has reexpanded or the tubing is obstructed or kinked.
Answer all 15 questions to see how you did.
Free to start
Timed mock exams, a rationale on every answer and progress that follows you from web to phone.
