Title RECALLS 7 - NP4 - SC ✅

hypotensive (BP 80/50 mmHg, HR 122/min). What is the nurse’s priority intervention? A. Insert a large-bore IV line and prepare for fluid resuscitation B. Prepare the patient for colonoscopy C. Position the patient flat and keep NPO D. Administer an antiemetic 17. A patient with cirrhosis and esophageal varices suddenly begins vomiting bright red blood. The nurse notes confusion and a distended abdomen with ascites. Which intervention is most important? A. Insert a nasogastric tube for gastric lavage B. Place the patient in a high Fowler’s position and give oxygen C. Administer oral vitamin K to reduce bleeding D. Encourage fluids to maintain hydration 18. A 43-year-old woman with peptic ulcer disease complains of sudden, severe abdominal pain radiating to the shoulder, with a rigid abdomen. Her blood pressure is 90/60 mmHg, and pulse is 118/min. What is the nurse’s best immediate action? A. Administer an antacid and reassess pain B. Insert a nasogastric tube and prepare for surgery C. Give oral sucralfate to coat the stomach lining D. Encourage fluids to prevent dehydration 19. A client with hepatic encephalopathy is increasingly drowsy and has asterixis (flapping tremor). The family asks why the client is receiving lactulose. What is the nurse’s best explanation? A. “It helps stop bleeding from the liver.” B. “It reduces fluid buildup in your abdomen.” C. “It decreases ammonia levels that affect brain function.” D. “It stimulates your liver to regenerate.” 20. A post-gastrectomy client develops dizziness, tachycardia, and diaphoresis 20 minutes after eating. What is the nurse’s priority action? A. Encourage fluids during meals to improve digestion B. Place the patient in a recumbent position and monitor C. Give an immediate dose of insulin D. Offer a snack high in simple carbohydrates Situation: You are the charge nurse in a busy medical-surgical unit supervising a mixed team of registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs). Your priority is to ensure safe delegation, ethical practice, and proper patient education while handling time-sensitive tasks. 21. A nursing assistant reports a blood pressure of 90/60 mmHg on a post-op client who is pale and diaphoretic. What is the nurse’s first action? A. Reassess the blood pressure manually. B. Document the finding in the chart. C. Ask the NA to recheck it in 15 minutes. D. Notify the provider immediately without reassessing. 22. A nurse delegates feeding a stroke client with dysphagia to an NA. Which instruction is most important? A. “Feed them quickly to reduce fatigue.” B. “Keep them upright at 90 degrees during and after feeding.” C. “Offer thin liquids between each bite.” D. “Use a straw for easier fluid intake.” 23. An LPN asks which tasks they can perform. Which assignment is appropriate? A. Developing a new care plan for a client with sepsis. B. Administering oral antibiotics to a stable client. C. Performing the initial admission assessment. D. Teaching a client about insulin self-administration. 24. During rounds, you find a confused client attempting to pull out their IV line. What is the best immediate nursing action? A. Apply wrist restraints immediately. B. Reorient the client and offer a distraction. C. Document the incident only. D. Assign a staff member to sit with the client. 25. Which situation demonstrates advocacy? A. Supporting a client’s decision to refuse chemotherapy despite family pressure. B. Telling the client that the doctor’s orders cannot be changed. C. Encouraging a client to “just do what the doctor says.” D. Reminding a client that they have no right to refuse life-saving treatment. Situation: You are mentoring a new graduate nurse who struggles with ethical dilemmas, patient teaching, and infection control practices. Your role is to guide safe practice and reinforce core nursing principles. 26. A client says, “I don’t want CPR if I stop breathing.” Which action is most appropriate? A. Document the client’s statement as a DNR order. B. Inform the provider to discuss advance directives. C. Encourage the client to reconsider. D. Tell the family to decide what’s best. 27. Which infection control practice is correct when caring for a client with C. diff.? A. Use alcohol-based sanitizer after removing gloves. B. Wear a mask when within 3 feet of the client. C. Use soap and water handwashing after glove removal. D. Double-glove during all patient care. 28. A nurse educator teaches the principle of fidelity. Which statement shows understanding? A. “I will respect my client’s right to refuse treatment.” B. “I will keep promises and follow through with care I commit to.” C. “I will ensure that resources are distributed fairly.” D. “I will avoid harming my clients.” 29. Which teaching method is best for an older adult with mild hearing loss? A. Providing written instructions in large print. B. Speaking rapidly to finish instructions quickly. C. Turning away from the client while speaking. D. Increasing environmental noise for stimulation. 30. A client refuses a prescribed blood transfusion due to religious beliefs. Which is the nurse’s best response? A. “You must accept this treatment to save your life.” B. “Tell me more about your concerns and beliefs.” C. “I will explain why your family wants you to take it.” D. “You don’t have the right to refuse lifesaving care.” Situation: You are leading an ethics seminar for nurses, highlighting real clinical scenarios to help staff correctly identify ethical principles. 31. A nurse allows a competent client to sign an informed refusal form after explaining all potential consequences. Which principle is primarily upheld? A. Justice B. Autonomy C. Veracity D. Fidelity 32. A nurse documents all assessments truthfully and refrains from altering records, even under pressure. This best reflects: A. Veracity and fidelity B. Beneficence and justice C. Autonomy and non-maleficence D. Privacy and confidentiality 33. While caring for two patients, one wealthy and one homeless, the nurse provides equal attention and resources. Which principle applies? A. Justice B. Beneficence C. Autonomy D. Fidelity 34. After giving the wrong medication, the nurse immediately informs the client and provider, then completes an incident report. Which principle is shown? A. Non-maleficence B. Autonomy C. Veracity a. Privacy 35. A nurse follows through with a promise to return with pain medication within 10 minutes. This reflects: A. Justice B. Fidelity C. Privacy D. 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B. Demonstrating mood improvement in one week C. Verbalizing no plan for self-harm D. Participating in recreational activities 58. Which medication is most likely prescribed for acute alcohol withdrawal? A. Disulfiram B. Lorazepam C. Haloperidol D. Lithium 59. A nurse notes a client smiling while reporting sadness and hopelessness. This is known as: A. Flat affect B. Incongruent affect C. Restricted affect D. Blunted affect 60. A nurse teaching a group about stress explains that the fight-or-flight response initially causes: A. Bradycardia and pupil constriction B. Increased HR, BP, and dilated pupils C. Increased digestion and urine output D. Decreased blood glucose and muscle tension Situation: You are caring for clients with schizophrenia and psychotic disorders. Your role includes recognizing priority symptoms, preventing harm, and reinforcing medication adherence. 61. Which is the best response to a client experiencing auditory hallucinations? A. “I hear the voices too.” B. “That’s not real, ignore them.” C. “I know the voices seem real to you; what are they saying?” D. “You need to focus on reality now.” 62. Which assessment finding indicates benzodiazepine toxicity? A. Hyperreflexia and hypertension B. Respiratory depression and confusion C. Tinnitus and blurry vision D. Abdominal cramps and diarrhea 63. A client with dementia suddenly becomes more confused at night. This is called: A. Echolalia B. Perseveration C. Sundowning D. Confabulation 64. A nurse is reinforcing teaching about buspirone. Which statement indicates understanding? A. “I can take it as needed for anxiety attacks.” B. “It will start working in 1–2 days.” C. “I might feel dizzy but it’s not addictive.” D. “I need to avoid grapefruit juice.” 65. Which finding indicates serotonin syndrome? A. Hypothermia and depression B. Muscle rigidity, high fever, and confusion C. Bradycardia and excessive sleepiness D. Enlarged pupils and orthostatic hypotension Situation: You are addressing cognitive disorders and side effects of psychotropic medications, focusing on early complication detection and therapeutic approaches. 66. A nurse notices a client with dementia fabricating stories. This is known as: A. Perseveration B. Confabulation C. Flight of ideas D. Circumstantiality 67. Which therapeutic approach is best for a paranoid client refusing food? A. Offer food in sealed containers B. Force-feed for nutrition\ C. Ignore food concerns and focus on medication D. Restrict interaction until trust is gained 68. A nurse suspects neuroleptic malignant syndrome (NMS). Which symptom supports this? A. Sudden severe hypertension and headache B. High fever, muscle rigidity, altered consciousness C. Pinpoint pupils and respiratory depression D. Flushed skin and diarrhea 69. Which intervention is most appropriate for a client with moderate anxiety? A. Use a calm voice and explore feelings B. Avoid discussion until anxiety subsides C. Provide written instructions only D. Confront all irrational thoughts immediately 70. Which sign is associated with alcohol withdrawal rather than intoxication? A. Slurred speech and unsteady gait B. Bradycardia and hypotension C. Tremors and hypertension D. Pinpoint pupils and drowsiness Situation: You are assigned to clients with mood disorders, substance abuse issues, and risk for harm to self or others. Early identification and safety measures are essential. 71. A client in lithium therapy develops diarrhea, tremors, and confusion. What is the priority action? A. Document and continue monitoring B. Give an anti-diarrheal and fluids C. Hold the lithium and notify the provider D. Encourage a salty snack 72. Which behavior is expected in borderline personality disorder? A. Rigid perfectionism B. Intense, unstable relationships and fear of abandonment C. Lack of remorse for wrongdoing D. Detachment and restricted emotions 73. Which client statement reflects improved coping after depression treatment? A. “I still don’t feel like doing anything.” B. “I called a friend to go for a walk.” C. “Nothing will ever change for me.” D. “I can’t make any decisions.” 74. Which lab must be monitored for clients on valproic acid? A. Liver function tests B. Renal function C. Electrolytes D. Thyroid function tests 75. A client taking clozapine develops fever and sore throat. What is the priority action? A. Administer acetaminophen and fluids B. Hold the medication and get a CBC C. Reassure and continue treatment D. Schedule an outpatient follow-up Situation: You are working in an ICU responding to multiple cardiac arrests. Your role includes medication preparation, safe administration, and understanding their effects during code situations. 76. During a cardiac arrest, the first-line medication for asystole is: A. Epinephrine B. Amiodarone C. Atropine D. Dopamine 77. Which statement best explains the action of epinephrine during cardiac arrest? A. Increases vagal tone and decreases HR B. Enhances myocardial contractility and peripheral vasoconstriction C. Slows conduction through the AV node D. Decreases myocardial oxygen demand 78. The recommended route for epinephrine during code if IV/IO access is unavailable is: A. Oral B. Endotracheal (ET) tube C. Intramuscular deltoid D. Subcutaneous 79. What is the primary indication for atropine during a code? A. Ventricular fibrillation B. Pulseless electrical activity C. Symptomatic bradycardia D. Supraventricular tachycardia 80. Amiodarone is used during ACLS primarily for: A. Refractory VF/pulseless VT 4 | Page