Exit Exam (BSN 366)

Correct Answer: Start two large-bore IVs and review inclusion criteria for IV fibrinolytic therapy.

Why this is Correct:

These signs (unilateral weakness, dysarthria) indicate a likely acute ischemic stroke. Time is critical – “time is brain.” The immediate nursing actions are to secure IV access (ideally two 18G IVs) and begin evaluating for tPA (alteplase) eligibility. Placing two large IVs allows for fluids/meds and drawing labs, and having a spare line for tPA infusion if one line is needed for other meds. Simultaneously, the nurse should quickly assess contraindications (recent surgery, bleeding risk, time of onset) because the stroke team will need that info to decide on thrombolytics. This option captures the urgent tasks of acute stroke protocol that a nurse does within minutes of arrival: IV access, labs, and prepping for possible fibrinolysis. It addresses the emergency nature (starting tPA protocol) rather than a slower approach.

Why Others are Wrong:

Elevate affected side joints: This sounds like a measure to prevent swelling in a paralyzed limb (like elevating an arm/leg). While positioning the weak extremities is part of stroke care to prevent edema, it is not the immediate priority on arrival. The immediate priority is assessing and treating the stroke (brain perfusion), not managing limb positioning. We do worry about limb positioning later, after stabilizing the patient. So this is far less urgent.

Low bed, initiate seizure/fall precautions: Safety is important, but in the first moments of stroke management, the focus is on interventions that could reverse the stroke (like tPA) and diagnostic steps (urgent CT scan). We will keep the bed low and guard for falls, but these are standard precautions that can be done concurrently without much thought. They are not the first or most critical action – they don’t impact the outcome of the stroke itself. The nurse should call a “Code Stroke” and get IVs rather than fiddling with side rails as the number one action.

Place indwelling catheter and measure I&O: In an acute stroke, a Foley catheter is not an immediate concern. In fact, it might be placed later if the patient will get tPA (to avoid them trying to get up to void and for accurate output), but certainly not before IVs or CT. Also, sterile catheter insertion would delay door-to-CT time if done too early. Strict I&O isn’t the priority in hyperacute stroke phase – preserving brain tissue is. So inserting a Foley is low on the list and definitely not “immediate.”

Acute stroke protocol emphasizes fast actions: IV access and tPA evaluation are among the first steps. In the image, emergency staff establish two large-bore IVs and draw blood for labs while assessing stroke onset time and contraindications. This happens even before the CT scan, to save time. Simple safety measures (bed low, seizure precautions) are done quickly, but the critical interventions revolve around enabling potential thrombolytic treatment.

Summary:

Stroke guidelines (AHA/ASA) list obtaining IV access, drawing labs, and evaluating for tPA eligibility as immediate nursing actions upon patient arrival with stroke symptoms. Initiating two IVs is often specifically mentioned to ensure one is available for the tPA infusion. Basic safety (airway, bed position) is also done, but securing IV access and moving toward reperfusion therapy is top priority. Thus, option D is correct.

Correct Answers:

Provide rescue breaths with a manual ventilation bag

Call for rapid response

Apply oxygen via nasal cannula

Give naloxone 2 mg IV

Explanation:

The client is receiving IV morphine, which poses a risk for respiratory depression. Signs like slow or shallow breathing, low oxygen saturation, or decreased responsiveness signal a medical emergency. Rapid intervention is critical to restore breathing and prevent further decline.

Provide rescue breaths with a manual ventilation bag ensures immediate oxygenation if the client’s respirations are too slow or absent, preventing hypoxia while other treatments are initiated.

Call for rapid response allows the rapid response team to provide immediate, advanced interventions to stabilize the patient.

Apply oxygen via nasal cannula helps improve oxygen saturation and supports respiratory function while naloxone begins to work.

Give naloxone 2 mg IV because naloxone is an opioid antagonist that reverses the effects of morphine, helping to restore adequate breathing and consciousness.

Why the Other Options Are Incorrect:

Perform chest compressions is only appropriate if the client is in full cardiac arrest (no pulse). If the client still has a pulse but is experiencing respiratory depression, rescue breathing—not compressions—is the proper first response.

Print an electrocardiogram (ECG) strip is not a priority in this situation. Although cardiac monitoring is useful, printing an ECG strip does not address the immediate respiratory issue and does not contribute to resolving the acute situation.

Correct Answer: A semi-private room on a surgical unit

Explanation:

A semi-private room on a surgical unit is the most appropriate setting for a postpartum patient with an infected surgical wound. Surgical units are equipped with staff experienced in managing postoperative complications, including wound infections. These units are designed to closely monitor surgical patients and implement infection control protocols effectively. Although the room is semi-private, proper precautions such as hand hygiene, wound care, and potential isolation protocols ensure patient safety and reduce the risk of spreading infection. The surgical environment provides optimal care for her recovery.

Why the other options are incorrect:

A negative pressure room

Negative pressure rooms are specifically designed for patients with airborne transmissible diseases such as tuberculosis, measles, or varicella. These rooms help prevent the spread of pathogens through the air by maintaining lower air pressure inside the room. This patient's surgical wound infection is not airborne, so a negative pressure room is unnecessary and would misallocate a specialized resource intended for those with contagious respiratory illnesses. Using this room inappropriately can also reduce availability for patients who actually need airborne precautions.

A postpartum room in the birthing center

While it may seem logical to place a postpartum patient in the birthing center, this area is primarily for mothers recovering from uncomplicated deliveries. This patient’s condition—an infected cesarean wound—requires specialized postoperative care that the birthing center may not be equipped to provide. Additionally, the presence of an infection poses a potential risk to other postpartum women and vulnerable newborns in the unit, making this setting inappropriate both from a care and infection control perspective.

A private room on a medical unit

Though a private room may offer infection control advantages, a general medical unit lacks the specialized staff and resources needed to manage surgical wound infections effectively. Surgical units are better suited for handling complications following operations, including infection surveillance and wound management. A common misconception is that any private room is automatically the best option for infection control, but the clinical context and staff expertise are equally, if not more, important in determining appropriate placement.

The correct answer is:

Prepare for rapid sequence intubation.

Explanation:

The patient’s presentation—low oxygen saturation (78%), increased heart and respiratory rates, and difficulty being aroused—suggests an acute respiratory crisis, likely due to a severe COPD exacerbation leading to hypoxia and respiratory failure. Rapid Sequence Intubation (RSI) is the gold standard in such situations, providing a secured airway, enabling ventilation, and ensuring adequate oxygenation. In emergency scenarios, RSI is essential to prevent further respiratory deterioration and protect the patient from complete airway collapse, which is a risk in severe hypoxia and failure to ventilate.

Why the Other Options Are Incorrect:

Increase the oxygen delivery by 10%

While it may seem logical to increase the oxygen flow, this intervention will not resolve the root cause of the patient's problem: compromised airway management. The patient’s oxygen saturation of 78% indicates that oxygen delivery alone is insufficient. In this case, intubation is needed to ensure airway protection and adequate ventilation, as increasing oxygen alone will not address the underlying cause of respiratory failure.

Administer PRN nebulizer treatment

Although nebulizer treatments are commonly used in managing COPD exacerbations, they are ineffective in addressing a life-threatening respiratory crisis where the patient's airway is compromised, and ventilation is inadequate. The primary issue here is respiratory failure, not simply bronchospasm or airway narrowing, which nebulizers target. The immediate need is to secure the airway, making intubation the priority.

Complete neurological assessment

Although neurological assessments are vital in some scenarios, this patient's presentation points to respiratory failure rather than a primary neurological issue. Their difficulty in arousing and hypoxia are likely due to insufficient oxygenation rather than a neurological cause. The urgency is to manage the airway and breathing, making respiratory intervention the priority over a neurological evaluation at this moment.

The correct answers are:

Eat more canned vegetables

Consume foods with saturated fat

Use a salt substitute

Explanation:

These three statements indicate a need for further education because they reflect misunderstandings about proper dietary practices for managing coronary artery disease. Managing this condition requires limiting sodium and saturated fat intake while promoting heart-healthy choices.

Eat more canned vegetables:

Canned vegetables often contain high levels of sodium, which can increase blood pressure and worsen coronary artery disease. Excessive sodium intake contributes to fluid retention and hypertension, placing additional strain on the cardiovascular system. Instead, clients should be encouraged to choose fresh or frozen vegetables, or low-sodium canned options.

Consume foods with saturated fat:

Saturated fats, found in animal products like red meat, butter, and full-fat dairy, contribute to increased low-density lipoprotein (LDL) cholesterol levels. Elevated LDL cholesterol promotes plaque buildup in the arteries, increasing the risk of heart disease. Clients should be instructed to limit saturated fat intake and opt for healthier fats like unsaturated fats from avocados, nuts, and olive oil.

Use a salt substitute:

Many salt substitutes contain potassium chloride, which can be dangerous for clients with coronary artery disease, particularly those taking medications like ACE inhibitors or potassium-sparing diuretics. Excess potassium can lead to hyperkalemia, which poses a serious risk to heart health. Clients should be encouraged to flavor food using herbs, spices, or lemon juice instead.

Why the Other Options Are Incorrect:

Keep a food diary:

This is a correct practice. Keeping a food diary helps clients track their eating habits, recognize patterns, and identify areas for improvement. It also allows healthcare providers to monitor dietary adherence and suggest modifications to promote heart health"

Walk 30 minutes per day:

This is a correct practice. Engaging in regular physical activity, such as walking, helps lower blood pressure, reduce cholesterol levels, and maintain a healthy weight. The American Heart Association recommends at least 150 minutes of moderate-intensity exercise per week to support cardiovascular health.

Include oatmeal for breakfast:

This is a correct practice. Oatmeal is rich in soluble fiber, which helps lower LDL cholesterol. Incorporating fiber-rich foods like oatmeal into the diet supports heart health by reducing cholesterol absorption in the bloodstream.

Summary:

The statements that require additional education are "Eat more canned vegetables," "Consume foods with saturated fat," and "Use a salt substitute." These behaviors can increase the risk of worsening coronary artery disease. Effective education should focus on reducing sodium and saturated fat intake while encouraging heart-healthy alternatives like fresh produce, unsaturated fats, and safe seasoning options.

Correct Answer: Increase in size.

Rationale:

Aortic valve stenosis results in an obstruction of blood flow from the left ventricle to the aorta, causing the left ventricle to work harder to push blood through the narrowed valve. To compensate for this increased workload, the myocardial cells in the left ventricle undergo hypertrophy, which means they increase in size. This is the body's compensatory mechanism to maintain adequate stroke volume and cardiac output despite the obstruction, leading to thickening and enlargement of the heart muscle.

Explanation of Other Options:

Decrease in length:

This is not a typical response to increased cardiac workload. Instead of decreasing in length, myocardial cells increase in size due to hypertrophy, which is a response to the increased demands placed on the heart.

Increase in number:

Cardiac hypertrophy involves an increase in the size of individual myocardial cells, not the multiplication of cells. While the heart muscle grows thicker, the number of myocardial cells does not increase as part of this adaptive response.

Decrease in excitability:

Although chronic cardiac stress and hypertrophy can lead to changes in the heart's electrical conduction, a decrease in excitability is not the primary response to increased workload. Instead, hypertrophy occurs to enhance the heart's ability to maintain adequate cardiac output.

 Correct Answer: Get an eye exam with an ophthalmologist annually.

Why this is Correct:

People with diabetes need yearly dilated eye exams to catch diabetic retinopathy early​

High blood sugar can damage retinal vessels, so seeing an ophthalmologist every year helps prevent vision loss. An annual eye exam is a standard recommendation for diabetic clients and shows the patient understands long-term complication prevention

By saying they will get yearly eye exams, the client demonstrates knowledge of necessary routine care (similar to how they should also get annual foot exams, etc.).

Why Others are Wrong:

Using salt, herbs, and spices will improve food flavor: This doesn’t address diabetes management. In fact, diabetics should limit salt to help blood pressure, and flavoring food (while fine) isn’t a key teaching point for DM control. It misses critical aspects like carbohydrate monitoring or foot care, so it doesn’t indicate true understanding.

Arrange diet around three regular meals a day: Diabetes meal planning is more nuanced. Simply eating three set meals may not be ideal for blood sugar control. Some patients do better with smaller, frequent meals or carb counting. This answer doesn’t reflect specific diabetic diet education (like balancing carbs) – it’s too generic.

Inspect feet every month: Diabetics must inspect their feet daily, not monthly! Daily foot checks catch cuts or sores early (since neuropathy may prevent feeling injuries). A monthly check is far too infrequent and would concern the nurse that the client didn’t grasp foot care teaching.

Summary 

Diabetic clients should have yearly eye exams to screen for retinopathy​. They also need daily foot inspections (not monthly) to catch sores early. Good diabetes management includes regular screenings and daily self-care routines. The American Diabetes Association recommends annual ophthalmologic exams for diabetics to prevent complications like blindness​. It also stresses daily foot care and frequent monitoring of diet and blood sugar – making option B the only statement showing correct understanding.

Correct Answer: Serum lithium level of 1.6 mEq/L

Explanation:

A serum lithium level of 1.6 mEq/L is above the therapeutic range of 0.6 – 1.2 mEq/L and indicates potential lithium toxicity. Lithium, commonly used to treat bipolar disorder, has a narrow therapeutic window, meaning that levels above the upper limit can quickly become toxic. Early symptoms of toxicity include gastrointestinal distress (nausea, vomiting, diarrhea), tremors, slurred speech, and unsteady gait. As the toxicity progresses, more severe symptoms like seizures and coma may occur. Therefore, a serum lithium level of 1.6 mEq/L is the most urgent finding that requires immediate medical intervention to prevent further complications.

Why the other options are incorrect:

Blood alcohol level of 0.09% (90 mmol/L):

While this blood alcohol level is above the legal driving limit (0.08%), it does not indicate an immediate medical emergency. Although alcohol consumption can impair judgment and may exacerbate psychiatric symptoms, it is not as urgent as lithium toxicity, which can cause life-threatening effects if untreated.

Six hours of sleep in the past three days:

Sleep deprivation is a concern, particularly in individuals with bipolar disorder, as it can trigger manic episodes. However, while it may worsen psychiatric symptoms, it does not pose an immediate physical danger compared to lithium toxicity, which can rapidly lead to severe complications.

Weight loss of 10 pounds in the past month:

Significant weight loss can be a sign of inadequate nutrition, mania, or medication side effects. While it warrants further investigation, it is not an urgent issue requiring immediate intervention like lithium toxicity. Weight loss typically needs ongoing monitoring, but it does not present an immediate risk to life or physical health in the way that high lithium levels do.

Correct Answer: Intensity of pain.

In acute pancreatitis, pain is one of the most prominent and debilitating symptoms. Managing pain is the highest priority because uncontrolled pain can worsen the client’s condition, impede rest and recovery, and contribute to complications such as increased stress and poor digestion. Assessing the intensity of pain allows the nurse to determine the need for pain management interventions, ensuring the client is as comfortable as possible and helping prevent further complications.

Why the Other Options Are Incorrect:

History of alcohol intake:

While alcohol use is a significant risk factor for acute pancreatitis, it is not the most urgent issue to address during the admission interview. The immediate concern is the client’s acute symptoms, especially pain. The nurse will assess alcohol history but should focus first on managing pain.=

Time of last meal:

Although the time of the last meal is important for considering dietary management and preparing for potential treatments like fasting, it does not take precedence over immediate concerns like pain management. Addressing acute symptoms such as pain is more critical in the initial stages.

Frequency of vomiting:

Vomiting often occurs in acute pancreatitis, but while it can lead to dehydration or electrolyte imbalances, it is secondary to pain management. Once the pain is under control, vomiting and its associated complications can be managed more effectively.