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CMSRN practice questions

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Question 1Providing Care

A patient has an area over the sacrum that is intact but shows localized nonblanchable erythema. How should the nurse document this finding?

  1. Intact skin with a boggy, fluctuant area of deep purple discoloration
  2. Partial-thickness loss with a shallow open wound
  3. Full-thickness loss with visible subcutaneous fat
  4. Intact skin with a localized area of nonblanchable erythema Correct answer.

Explanation

A stage 1 pressure injury is defined as intact skin with a localized area of nonblanchable erythema that does not resolve with pressure relief. Once the epidermis or dermis is lost, the injury is at least stage 2, and full-thickness loss indicates stage 3 or deeper.

Question 2Providing Care

Which measure best reduces fall risk for an older adult admitted with generalized weakness?

  1. Keep both side rails up at all times regardless of patient preference
  2. Place the bed in the lowest position with the call light within reach Correct answer.
  3. Ask the family to remain at the bedside overnight
  4. Apply a vest restraint whenever the patient attempts to stand

Explanation

Keeping the bed low and the call light accessible addresses the most common fall mechanisms: unassisted transfers and attempts to reach items. Restraints and raised rails are associated with injury and do not substitute for individualized fall precautions.

Question 3Providing Care

A patient reports dizziness when getting out of bed and has a history of falls. Which nursing action is most appropriate?

  1. Measure BP and pulse supine, then after standing 1 to 3 minutes Correct answer.
  2. Give the patient a glass of water and recheck the blood pressure in 1 hour
  3. Keep the patient on strict bed rest until the dizziness resolves
  4. Document the finding as an expected age-related change

Explanation

Orthostatic hypotension is identified by comparing supine and standing blood pressure and pulse after 1 to 3 minutes of upright posture. A drop of at least 20 mm Hg systolic or 10 mm Hg diastolic, or symptoms on standing, confirms the finding and guides fall precautions.

Question 4Providing Care

A patient is prescribed 10 units of regular insulin and 20 units of NPH in one syringe. Which sequence is correct?

  1. Inject air into regular, withdraw NPH, then withdraw regular insulin
  2. Shake both vials vigorously before drawing up either insulin
  3. Inject air into NPH, then into regular; withdraw regular, then NPH Correct answer.
  4. Inject air into regular first, then withdraw regular before NPH

Explanation

Air is injected into the cloudy (NPH) vial first so that the needle never enters the clear regular vial after contacting the modified insulin. The clear insulin is then withdrawn first so the syringe does not carry NPH into the regular vial.

Question 5Providing Care

When is hand hygiene required in routine patient care?

  1. Before and after every contact with a patient Correct answer.
  2. Only when the patient has a known infection
  3. At the start and end of each scheduled shift
  4. Only after contact with blood or body fluids

Explanation

Hand hygiene is performed before touching a patient, before clean or aseptic procedures, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. Transmission-based precautions add to, but do not replace, these routine moments.

Question 6Providing Care

Which source provides the most reliable indicator of a patient's pain intensity?

  1. The patient's facial grimacing
  2. The family's description of the behavior
  3. An elevated heart rate
  4. The patient's own report of the pain Correct answer.

Explanation

Pain is a subjective experience, and self-report is the most reliable measure whenever the patient can communicate. Behavioral and physiologic signs may support assessment in patients who cannot report but do not replace self-report.

Question 7Providing Care

Which method is acceptable for confirming that a newly inserted nasogastric feeding tube is in the stomach?

  1. Confirm placement by the presence of a cough reflex
  2. Verify placement by measuring the tube length at the nares
  3. Auscultate the epigastrium while insufflating 20 mL of air
  4. Check the aspirate pH; 5.5 or lower supports gastric placement Correct answer.

Explanation

Gastric aspirate with a pH of 5.5 or lower supports gastric placement, and pH testing is a recommended bedside adjunct. Radiographic confirmation remains the gold standard for new tubes used for feeding.

Question 8Providing Care

A peripheral IV site is warm, reddened, and tender along the vein, and the patient reports burning during the infusion. What is the nurse's priority action?

  1. Apply a warm compress and continue the infusion at a slower rate
  2. Flush the catheter with 10 mL of normal saline and reassess
  3. Elevate the arm and document the finding in the chart
  4. Discontinue the IV and restart it in a different vein Correct answer.

Explanation

These findings indicate phlebitis, which requires stopping the infusion and removing the catheter to prevent progression and possible infection. A new site is selected, and warm compresses may be used afterward for comfort.

Question 9Providing Care

During a blood transfusion, the patient develops chills, fever, and flank pain. What is the nurse's first action?

  1. Flush the tubing with the remaining blood to clear the reaction
  2. Give the prescribed antihistamine and continue the transfusion at a slower rate
  3. Stop the transfusion and keep the vein open with 0.9% sodium chloride Correct answer.
  4. Slow the infusion rate and reassess the patient in 15 minutes

Explanation

Fever, chills, and flank or back pain suggest an acute hemolytic transfusion reaction, which can be life threatening. The transfusion is stopped immediately, IV access is maintained with normal saline through new tubing, and the provider and blood bank are notified.

Question 10Providing Care

Which action is correct when caring for a patient with a chest tube connected to a water-seal drainage system?

  1. Strip or milk the tubing every 4 hours to maintain patency
  2. Keep the drainage unit upright and below the level of the chest Correct answer.
  3. Add sterile water to the suction control chamber every shift
  4. Clamp the tubing whenever the patient is repositioned

Explanation

Keeping the unit upright and below chest level allows gravity drainage and prevents fluid from flowing back into the pleural space. Routine clamping is avoided because it can cause a tension pneumothorax.

Question 11Providing Care

A patient with a new ileostomy has peristomal skin that is excoriated and the pouch is leaking. Which action should the nurse take?

  1. Cut the barrier to no more than 1/8 inch larger than the stoma Correct answer.
  2. Clean the stoma with hydrogen peroxide at every pouch change
  3. Change the pouch every day regardless of leakage or the condition of the skin
  4. Apply the new pouch while the peristomal skin is still moist

Explanation

A barrier opening no more than about 1/8 inch beyond the stoma protects skin from effluent while avoiding pressure on the stoma. Leakage and skin breakdown are corrected by proper sizing, a solid skin barrier, and a dry surface before pouch application.

Question 12Providing Care

Which nursing action best prevents catheter-associated urinary tract infection?

  1. Keep the drainage bag below bladder level and off the floor Correct answer.
  2. Irrigate the catheter with sterile saline every shift
  3. Rinse the drainage bag with tap water when it appears cloudy
  4. Disconnect the catheter from the drainage tubing to obtain a urine sample

Explanation

Maintaining a closed system with unobstructed dependent drainage prevents urine reflux and bacterial ascent. Each unnecessary disconnection breaks the closed system and increases infection risk.

Question 13Providing Care

Which finding best distinguishes delirium from dementia in an hospitalized older adult?

  1. Intact attention with a preserved ability to learn new tasks
  2. Acute onset with fluctuating attention and level of awareness Correct answer.
  3. Stable, unchanging confusion that worsens only at night
  4. Gradual, progressive memory loss over several years

Explanation

Delirium develops acutely over hours to days with inattention and a fluctuating course, often triggered by illness, medications, or the hospital environment. Dementia is a chronic, progressive decline in cognition with attention typically preserved until late stages.

Question 14Providing Care

Which task is appropriate for the nurse to delegate to an unlicensed assistive personnel?

  1. Performing the initial admission assessment on a new patient
  2. Teaching a patient how to inject insulin
  3. Obtaining vital signs on a stable patient after a walk Correct answer.
  4. Evaluating whether a patient's pain goal has been met

Explanation

Vital signs on a stable patient are a standard delegated task because the findings are predictable and the skill is within assistive personnel training. Assessment, teaching, and evaluation require the professional nurse's judgment.

Question 15Providing Care

A conscious patient with diabetes has a blood glucose of 52 mg/dL and is diaphoretic and shaky. What should the nurse do first?

  1. Give the next scheduled dose of insulin and encourage a meal
  2. Withhold all carbohydrate until the blood glucose returns to normal
  3. Start an IV line and give 50% dextrose as the first action
  4. Give 15 g of fast-acting carbohydrate; recheck glucose in 15 minutes Correct answer.

Explanation

For a conscious patient with hypoglycemia, the rule is 15 g of rapid-acting carbohydrate followed by rechecking the glucose in 15 minutes and repeating if still low. Once glucose is in range, a snack or meal containing protein and carbohydrate is provided.

Question 16Providing Care

Which statement about intravenous potassium chloride is correct?

  1. Add potassium to a hanging IV bag and gently rock the bag to mix it
  2. Infuse undiluted potassium through a central line only
  3. Give the dose by slow IV push over 5 minutes
  4. Infuse diluted potassium using an infusion pump at the prescribed rate Correct answer.

Explanation

IV potassium must be diluted and infused with an infusion pump at a controlled rate because rapid administration can cause fatal arrhythmias. It is never given by IV push, and it is not added to hanging bags because mixing cannot be verified.

Question 17Providing Care

Which intervention is required while a patient is physically restrained?

  1. Tie the restraint straps to the side rail for quick release
  2. Check circulation, skin, and need at least every 15 minutes Correct answer.
  3. Obtain a new order every 48 hours
  4. Remove the restraint for 15 minutes every 4 hours

Explanation

Physical restraints require frequent monitoring of circulation, skin integrity, and continued need, generally at least every 15 minutes, with release and range of motion at regular intervals. Orders are time limited and must be renewed per policy, typically every 24 hours for adults.

Question 18Providing Care

Which intervention helps prevent deep vein thrombosis in a postoperative patient?

  1. Place a pillow under the knee to relieve calf discomfort
  2. Apply compression devices as prescribed and encourage ankle pumps Correct answer.
  3. Keep the patient on bed rest with the legs in a dependent position
  4. Massage the calves for 5 minutes each shift to promote venous return

Explanation

Mechanical prophylaxis with intermittent pneumatic compression plus early ambulation and ankle exercises promotes venous return and reduces stasis. Calf massage and knee pillows that compress the popliteal area may increase clot risk.

Question 19Providing Care

Which instruction should the nurse give a patient using an incentive spirometer after abdominal surgery?

  1. Exhale forcefully into the device 10 times every hour
  2. Use the device only when shortness of breath occurs
  3. Coach slow, deep inhalation to a sustained maximal breath, then hold Correct answer.
  4. Set the device so that the patient inhales through the nose

Explanation

Incentive spirometry sustains maximal lung inflation to prevent atelectasis, so the patient inhales slowly and deeply and holds the breath for several seconds. It is used routinely, not only when symptoms appear, and it is not an exhalation exercise.

Question 20Providing Care

Which technique is correct when suctioning a patient with an artificial airway?

  1. Limit each pass to 10 to 15 seconds and hyperoxygenate between passes Correct answer.
  2. Use the largest suction catheter that will fit into the patient's airway
  3. Apply continuous suction while inserting the catheter
  4. Suction routinely every hour regardless of assessment findings

Explanation

Suction passes are limited to about 10 to 15 seconds to limit hypoxemia, and the patient is hyperoxygenated before and between passes. Suction is applied only during withdrawal and is performed when clinically indicated.

Question 21Providing Care

Which cuff management practice is correct for a patient with a tracheostomy who is receiving mechanical ventilation?

  1. Maintain cuff pressure near 20 to 30 cm H2O and monitor it regularly Correct answer.
  2. Inflate the cuff only during meals and suctioning
  3. Deflate the cuff completely whenever the patient is repositioned
  4. Keep the cuff inflated to the highest pressure the patient tolerates

Explanation

Cuff pressure is kept within roughly 20 to 30 cm H2O to seal the airway for ventilation while preserving tracheal capillary perfusion. Pressures are measured with a cuff manometer at regular intervals and after changes in the patient's condition.

Question 22Providing Care

A patient with suspected sepsis has a lactate of 3.2 mmol/L and a blood pressure of 88/52 mm Hg. Which action is most consistent with current sepsis care?

  1. Give a fluid bolus only after the central venous pressure is measured
  2. Start antibiotics after the lactate level has normalized
  3. Obtain blood cultures and start broad-spectrum antibiotics within 1 hour Correct answer.
  4. Wait for culture results before starting any antibiotic therapy

Explanation

In sepsis, cultures are drawn promptly and broad-spectrum antibiotics are started within 1 hour, along with crystalloid resuscitation for hypotension or elevated lactate. Lactate is a marker for resuscitation, not a prerequisite for treatment.

Question 23Providing Care

Which technique yields the most useful specimen when culturing an open wound?

  1. Collect the specimen from the drainage in the old dressing
  2. Obtain the specimen from the wound edge after a betadine scrub
  3. Swab the surface exudate before cleansing the wound
  4. Cleanse with saline and sample viable tissue from the wound base Correct answer.

Explanation

Wound cultures are most reliable when taken from viable tissue in the cleaned wound base, avoiding surface colonization and exudate. Antiseptics such as betadine can inhibit organism growth and should not be used before sampling.

Question 24Providing Care

A patient taking warfarin reports knee pain and asks about an over-the-counter pain reliever. Which response is best?

  1. Stop the warfarin for 3 days whenever an NSAID is taken
  2. Double the warfarin dose to offset the NSAID interaction
  3. Avoid NSAIDs because of additive bleeding risk; use acetaminophen Correct answer.
  4. Take an NSAID with food and continue the warfarin as prescribed

Explanation

NSAIDs inhibit platelet function and irritate the gastric mucosa, adding to warfarin's anticoagulant effect and increasing bleeding risk. Acetaminophen is the preferred analgesic, though high doses taken regularly can also raise the INR and warrant monitoring.

Question 25Providing Care

A patient receiving total parenteral nutrition at 100 mL/hour becomes diaphoretic and tremulous, and the glucose is 54 mg/dL after the bag runs dry and the infusion is interrupted. What is the priority action?

  1. Give the scheduled dose of sliding-scale insulin
  2. Encourage a high-protein snack and continue to monitor the glucose
  3. Restart the TPN at twice the prescribed rate to catch up
  4. Treat the hypoglycemia per protocol and notify the provider about the TPN Correct answer.

Explanation

Abrupt interruption of a high-dextrose TPN infusion can cause rebound hypoglycemia, so treatment follows the hypoglycemia protocol while the provider is notified and the TPN is resumed or replaced as prescribed. TPN rates are never increased to catch up, and insulin would worsen the situation.

Question 26Providing Care

Before entering a patient's room, the nurse notices a small amount of blood on the hands. Which action should the nurse take?

  1. Use an alcohol-based hand rub and proceed into the room.
  2. Put on gloves without washing the hands.
  3. Wash the hands with soap and water before providing care. Correct answer.
  4. Wipe the hands with a paper towel and then use hand rub.

Explanation

Visible soiling with blood requires handwashing with soap and water because alcohol-based rubs are not reliable when organic material is present. Gloves are not a substitute for cleaning contaminated hands.

Question 27Providing Care

Which action best verifies the correct identity of a patient before administering a scheduled medication?

  1. Confirm the patient's identity by reading the room number.
  2. Ask the patient whether they are the person named on the medication record.
  3. Check the name on the medication label against the name on the door card.
  4. Compare the armband and ask the patient to state name and date of birth. Correct answer.

Explanation

Two patient identifiers are required before medication administration, and at least one should be directly confirmed with the patient or a reliable source. Checking the armband while asking the patient to state name and date of birth meets this standard.

Question 28Providing Care

A patient is immobile after a stroke and cannot turn independently. How often should the nurse reposition the patient to help prevent pressure injury?

  1. Every 4 hours
  2. Every 8 hours
  3. Only when the patient reports discomfort
  4. At least every 2 hours Correct answer.

Explanation

Immobile patients should be repositioned on a scheduled basis, generally at least every 2 hours, to relieve pressure over bony prominences. The interval may be individualized, but it should not be based only on patient complaint.

Question 29Providing Care

A patient is receiving supplemental oxygen by nasal cannula. Which instruction should the nurse include in teaching?

  1. Store the oxygen cylinder lying flat on its side.
  2. Do not use the oxygen near open flames or while smoking. Correct answer.
  3. You can smoke only when the oxygen is turned off.
  4. You may use petroleum jelly inside your nostrils to prevent dryness.

Explanation

Oxygen supports combustion, so flames, sparks, and smoking must be kept away from the oxygen source at all times. Petroleum-based products should also be avoided because they can ignite in an oxygen-enriched environment.

Question 30Providing Care

A patient begins to have a generalized tonic-clonic seizure. Which action should the nurse take first?

  1. Protect the patient's head and turn the patient onto the side. Correct answer.
  2. Insert a tongue blade between the patient's teeth.
  3. Restrain the patient's arms and legs.
  4. Leave the patient alone to obtain help.

Explanation

During a seizure, the priority is to protect the patient from injury and maintain airway patency by turning the patient to the side to allow secretions to drain. Objects should never be forced into the mouth, and restraints can cause injury.

Question 31Providing Care

Which action is most important for preventing falls in an older adult who is confused and hospitalized?

  1. Apply bilateral wrist restraints at night.
  2. Encourage the patient to walk unassisted to maintain strength.
  3. Raise all four side rails to keep the patient in bed.
  4. Keep the bed in the lowest position with the call light within reach. Correct answer.

Explanation

A low bed and easy access to the call light reduce the likelihood that a confused patient will attempt an unsafe climb out of bed. Restraints and raised side rails do not prevent falls and may increase injury risk.

Question 32Providing Care

A patient is prescribed a corticosteroid metered-dose inhaler. Which instruction should the nurse give?

  1. Rinse the mouth with water after using the inhaler. Correct answer.
  2. Use the inhaler only when symptoms are severe.
  3. Use a spacer only with bronchodilator inhalers.
  4. Take a deep breath and hold it for 1 second after each puff.

Explanation

Rinsing the mouth after using a corticosteroid inhaler reduces the risk of oral candidiasis and local irritation. A spacer may be used with corticosteroid inhalers as well as bronchodilator inhalers.

Question 33Providing Care

After drawing blood from a patient's antecubital vein, which action should the nurse take?

  1. Apply a warm compress to the site.
  2. Massage the site to promote circulation.
  3. Bend the patient's arm sharply at the elbow.
  4. Apply firm pressure to the site with gauze for several minutes. Correct answer.

Explanation

Direct firm pressure over the venipuncture site for several minutes helps prevent hematoma formation and bleeding. The arm should not be bent sharply, and the site should not be massaged.

Question 34Providing Care

A patient has a new order for digoxin. Before administering the dose, which assessment is essential?

  1. Auscultate the lungs for crackles.
  2. Count the apical pulse for one full minute. Correct answer.
  3. Measure the urine specific gravity.
  4. Check the blood glucose level.

Explanation

Digoxin slows conduction through the heart, so the apical pulse is assessed for a full minute before administration. The dose is typically held when the adult apical rate is below 60 beats per minute or per the prescriber's parameters.

Question 35Providing Care

A patient is receiving a continuous IV infusion of unfractionated heparin. Which laboratory result should the nurse monitor to evaluate the therapeutic effect?

  1. Activated partial thromboplastin time (aPTT) Correct answer.
  2. Serum creatinine
  3. International normalized ratio (INR)
  4. Platelet count

Explanation

The aPTT is used to monitor and adjust unfractionated heparin therapy because heparin prolongs the intrinsic clotting pathway. The INR is used to monitor warfarin, and platelets are monitored for heparin-induced thrombocytopenia rather than therapeutic effect.

Question 36Providing Care

A patient with angina takes sublingual nitroglycerin and reports chest pain rated 7 out of 10. After one dose, the pain is unchanged after 5 minutes. What should the nurse instruct the patient to do next?

  1. Take an antacid and rest until the pain subsides.
  2. Call 911 for emergency medical help. Correct answer.
  3. Take two more tablets at once and then call the provider.
  4. Wait another 15 minutes to see whether the pain resolves.

Explanation

If angina pain is unrelieved or worsening 5 minutes after one sublingual nitroglycerin dose, emergency medical help should be summoned. Delay in seeking care increases the risk of myocardial damage.

Question 37Providing Care

The nurse is preparing to administer a cleansing enema to an adult patient. Which position is best?

  1. High Fowler's position
  2. Right lateral position with the head elevated
  3. Prone position
  4. Left lateral position with the right knee flexed Correct answer.

Explanation

The left lateral position with the right knee flexed allows the enema solution to flow by gravity into the descending colon and rectum. High Fowler's and prone positions do not promote retention of the solution.

Question 38Providing Care

A patient with a new colostomy asks when the pouch should be emptied. Which response is best?

  1. Empty the pouch only once every 24 hours.
  2. Wait until the pouch is completely full to reduce pouch changes.
  3. Empty the pouch only when stool leaks from the seal.
  4. Empty the pouch when it is about one-third to one-half full. Correct answer.

Explanation

Ostomy pouches should be emptied when they are about one-third to one-half full to prevent excessive weight, leakage, and skin breakdown. Waiting until the pouch is full or leaking increases the risk of seal failure.

Question 39Providing Care

A patient is receiving a warm compress to the lower back. Which action should the nurse take?

  1. Check the skin under the compress every 5 to 10 minutes. Correct answer.
  2. Keep the compress in place continuously for 1 hour.
  3. Apply the compress directly to bare skin for 45 minutes.
  4. Place an ice pack over the compress to protect the skin.

Explanation

Warm applications can cause burns, so the skin should be assessed frequently, approximately every 5 to 10 minutes, and the application is generally limited to 20 to 30 minutes. A barrier should be used between the heat source and the skin.

Question 40Providing Care

A patient is using a cold pack on a sprained ankle. Which instruction should the nurse give?

  1. Limit cold application to about 20 minutes at a time. Correct answer.
  2. Leave the cold pack in place for 60 minutes at a time.
  3. Apply the cold pack directly against the skin.
  4. Use the cold pack only after the swelling has resolved.

Explanation

Cold application helps reduce pain and swelling after a sprain but should generally be limited to about 20 minutes at a time to prevent tissue damage. A cloth barrier should be placed between the cold pack and the skin.

Question 41Providing Care

A patient is using patient-controlled analgesia (PCA) with morphine. Which action is correct?

  1. Press the button for the patient during painful procedures.
  2. Set the PCA to deliver a continuous dose whenever the patient is uncomfortable.
  3. Teach the patient that only the patient should press the PCA button. Correct answer.
  4. Allow a family member to press the button when the patient is asleep.

Explanation

PCA is designed so that only the patient activates the dose button, which helps prevent overdose from proxy dosing. Family members and nurses should not press the button for the patient.

Question 42Providing Care

A patient who self-administers insulin asks why injection sites should be rotated. Which explanation is best?

  1. Rotating sites helps prevent lipohypertrophy and uneven insulin absorption. Correct answer.
  2. Rotating sites allows the use of expired insulin safely.
  3. Rotating sites eliminates the need to monitor blood glucose.
  4. Rotating sites prevents the insulin from becoming contaminated.

Explanation

Repeated injections into the same site can cause lipohypertrophy or scarring, which leads to erratic insulin absorption. Rotating sites helps maintain consistent absorption and prevents skin changes.

Question 43Providing Care

A patient with a new colostomy reports excessive gas. Which dietary instruction should the nurse provide?

  1. Limit gas-forming foods such as beans and broccoli. Correct answer.
  2. Drink fluids only with meals.
  3. Eat quickly to reduce swallowed air.
  4. Increase intake of carbonated beverages.

Explanation

Gas-forming foods and carbonated beverages can increase ostomy gas, so patients are often advised to limit them and to eat slowly with the mouth closed. Fluids should be encouraged throughout the day to maintain stool consistency.

Question 44Providing Care

A nurse collects a blood specimen for laboratory testing. When should the specimen label be applied?

  1. After the specimen reaches the laboratory
  2. At the end of the shift when all specimens are labeled
  3. At the patient's bedside immediately after collection Correct answer.
  4. Before entering the patient's room

Explanation

Specimen labels should be applied at the bedside immediately after collection to prevent misidentification. Prelabeling specimens or delaying labeling increases the risk of patient identification errors.

Question 45Providing Care

A patient who takes metformin is scheduled for a CT scan with iodinated contrast. Which action should the nurse anticipate?

  1. Withhold all fluids for 24 hours after the scan.
  2. Continue metformin without any change.
  3. Hold metformin after the contrast and resume when renal function is stable, per order. Correct answer.
  4. Give an extra dose of metformin before the scan.

Explanation

Iodinated contrast can transiently impair kidney function and increase the risk of lactic acidosis in patients taking metformin. Metformin is typically held around the time of contrast and restarted only after renal function is confirmed to be stable.

Question 46Providing Care

A patient has an irregular radial pulse. Which action should the nurse take to assess for a pulse deficit?

  1. Count the radial pulse for 15 seconds and multiply by four.
  2. Count the apical pulse for 30 seconds and multiply by two.
  3. Auscultate the apical pulse while another nurse counts the radial pulse simultaneously. Correct answer.
  4. Measure the blood pressure in both arms at the same time.

Explanation

A pulse deficit is the difference between the apical and radial rates, so both must be counted at the same time for a full minute. This assessment helps identify ineffective cardiac contractions.

Question 47Providing Care

A patient has a cast on the lower leg after a fracture. Which finding is most concerning for compartment syndrome?

  1. A temperature of 99.1°F (37.3°C)
  2. Severe pain that is not relieved by pain medication Correct answer.
  3. Mild itching under the cast
  4. Slight swelling of the toes

Explanation

The earliest and most reliable sign of compartment syndrome is severe pain out of proportion to the injury that is not relieved by analgesics. Pulselessness and pallor are late findings and should not be awaited.

Question 48Providing Care

A patient with a spinal cord injury at T6 reports a sudden severe headache and has a blood pressure of 210/110 mm Hg. Which action should the nurse take first?

  1. Massage the patient's legs to improve circulation.
  2. Give a prescribed antihypertensive and wait 30 minutes.
  3. Place the patient flat and administer a prescribed analgesic.
  4. Raise the head of the bed to 90 degrees and check for a full bladder. Correct answer.

Explanation

These findings suggest autonomic dysreflexia, a medical emergency triggered by a noxious stimulus below the injury level, most often bladder distention. The patient should be positioned upright immediately and the stimulus identified and relieved.

Question 49Providing Care

A patient with a traumatic brain injury has increased intracranial pressure. Which action should the nurse include in care?

  1. Maintain the head of the bed at 30 degrees with the head in midline. Correct answer.
  2. Keep the head of the bed flat at all times.
  3. Flex the patient's neck during repositioning.
  4. Cluster all nursing care into one long session.

Explanation

Elevating the head of the bed about 30 degrees with the head in midline promotes venous drainage from the brain and helps lower intracranial pressure. Neck flexion, hip flexion, and clustering care can raise intracranial pressure.

Question 50Providing Care

A patient with prolonged vomiting has a serum potassium of 2.9 mEq/L. Which assessment finding is most consistent with this value?

  1. Muscle twitching and a peaked T wave on ECG
  2. Hypertension and bradycardia
  3. Muscle weakness and a flattened T wave on ECG Correct answer.
  4. Increased deep tendon reflexes and tetany

Explanation

Hypokalemia can cause muscle weakness, fatigue, and cardiac dysrhythmias, with ECG changes such as flattened or inverted T waves and U waves. Peaked T waves are associated with hyperkalemia.