176Question
A client with a venous ulcer on the lower leg, caused by stasis, has had compression therapy ordered. The nurse obtains an ankle-brachial index before applying the compression wrap. What is the purpose of this test?
- To confirm the diagnosis of venous insufficiency
- To determine whether the ulcer is infected
- To measure how much fluid is retained in the leg
- To screen for significant arterial disease that could make compression unsafe
Show the answer and explanation
Answer: D. To screen for significant arterial disease that could make compression unsafe
Topic: ankle-brachial index before compression
Compression therapy treats venous ulcers but can reduce blood flow if arterial disease is present. The ankle-brachial index compares ankle and arm systolic pressures to detect arterial insufficiency before compression is applied, so that unsafe compression is avoided or modified.
Why the others are wrong
- A – The ankle-brachial index measures arterial flow and does not diagnose venous disease.
- B – Infection is judged by wound assessment and cultures, not by blood pressure ratios.
- C – Edema is judged by inspection, palpation and measurements, not by this index.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
177Question
A client remains comatose after return of spontaneous circulation and temperature control is started. Which nursing action is most appropriate?
- Allow the temperature to rise naturally to prevent shivering
- Monitor core temperature continuously, prevent fever and treat shivering
- Keep the oxygen concentration at 100% for the first day
- Give the family a prognosis during the first day based on the neurologic exam
Show the answer and explanation
Answer: B. Monitor core temperature continuously, prevent fever and treat shivering
Topic: targeted temperature management
After cardiac arrest, fever worsens brain injury. Temperature is controlled with continuous core monitoring, shivering is managed, and oxygen is titrated to avoid both low levels and excess. Prognosis is delayed and multimodal.
Why the others are wrong
- A – Fever worsens neurologic outcome.
- C – Excess oxygen after ROSC can harm; titrate to normal saturation.
- D – Early exams are unreliable because of sedation and temperature management.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
178Question
A resident taking an oral anticoagulant slipped and struck the back of the head on the floor. The resident is alert, has no complaints and has a small bruise. What is the nurse's best action?
- Apply ice and continue routine neurological checks every shift
- Notify the prescriber promptly and begin frequent neurological checks
- Hold the next anticoagulant dose without telling anyone
- Reassess in the morning if the resident has no symptoms
Show the answer and explanation
Answer: B. Notify the prescriber promptly and begin frequent neurological checks
Topic: Anticoagulant use and head injury
Anticoagulated older adults can develop delayed intracranial bleeding after a minor head strike, without early symptoms. Prompt provider notification and frequent neurological monitoring are needed; any decision about the drug belongs to the prescriber.
Why the others are wrong
- A – Ice is comfort, but checks every shift are far too infrequent for this risk.
- C – Holding a dose is a prescriber decision, and silence delays evaluation.
- D – Waiting until morning could miss delayed bleeding; no symptoms does not mean no injury.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
179Question
A client arrives at the emergency department with a harsh, high-pitched sound on each breath, and the nurse can hear the stridor without a stethoscope. Which actions should the nurse take right away?
Select all that apply.
- Stay with the client and call for immediate help from the team
- Obtain a complete history of the illness before taking any other step
- Help the client into an upright position of comfort
- Apply oxygen and ready suction and airway equipment per protocol
- Lay the client flat to listen to the posterior lung fields
- Offer sips of water to soothe the throat
Show the answers and explanation
Answers: A, C and D.
- A – Stay with the client and call for immediate help from the team
- C – Help the client into an upright position of comfort
- D – Apply oxygen and ready suction and airway equipment per protocol
Topic: stridor and airway priority
Stridor signals partial obstruction of the upper airway, which can progress to complete obstruction within minutes. Airway comes first: the nurse stays with the client, summons help, allows a position that eases breathing, and prepares oxygen and airway equipment. Anything that delays this or agitates the client is unsafe.
Why the others are wrong
- B – A full history is taken only after the airway is secured; it delays the response to a threatened airway.
- E – Lying flat can worsen obstruction and increase distress; examination can wait until the airway is safe.
- F – Oral intake risks aspiration and may worsen obstruction; the client should be kept NPO.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
180Question
Which client should the nurse assess first?
- Day 2 after appendectomy, pain 4 out of 10
- COPD, oxygen saturation 90%
- After hip surgery, new restlessness, saturation 86%
- Diabetes, asking for a breakfast tray
Show the answer and explanation
Answer: C. After hip surgery, new restlessness, saturation 86%
Topic: Post-operative pulmonary embolism
The client shows new restlessness and an oxygen saturation of 86%, indicating acute hypoxemia and possible pulmonary embolism, which requires immediate assessment before other less critical concerns.
Why the others are wrong
- A – Pain score 4/10 is moderate; not life‑threatening.
- B – Saturation 90% is low but stable without distress.
- D – Breakfast request is non‑urgent; vital signs are stable.
Remember: Low O2 + restlessness = immediate assessment.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
181Question
A client tells the nurse, 'I've been sad for weeks, I can't sleep, and I've started giving my things away because I won't need them.' Which response is the priority?
- Are you taking any medication for how you are feeling?
- Are you having thoughts of ending your life?
- Have you talked with a counselor about this?
- Tell me more about how the sadness affects your day.
Show the answer and explanation
Answer: B. Are you having thoughts of ending your life?
Topic: suicide risk screening
Giving away possessions, insomnia and prolonged sadness are warning signs of suicide risk. The nurse asks directly and calmly about suicidal thoughts. Asking does not plant the idea, and the answer determines the need for immediate safety measures.
Why the others are wrong
- A – Medication history is important but does not address immediate risk.
- C – Asking about counseling delays the safety assessment.
- D – Exploring the mood is useful, but the safety question must come first when warning signs are present.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
182Question
A nurse is monitoring a client two hours after extubation. Which findings require immediate intervention?
Select all that apply.
- An occasional cough producing a small amount of white sputum
- Stridor audible without a stethoscope
- A mildly hoarse voice with a sore throat
- Oxygen saturation of 95% on 2 L/min by nasal cannula, unchanged since extubation
- Oxygen saturation falling from 96% to 88% on the same oxygen setting
- New restlessness with use of accessory muscles
Show the answers and explanation
Answers: B, E and F.
- B – Stridor audible without a stethoscope
- E – Oxygen saturation falling from 96% to 88% on the same oxygen setting
- F – New restlessness with use of accessory muscles
Topic: post-extubation warning signs
Stridor suggests airway swelling, a falling saturation shows worsening gas exchange, and new restlessness with accessory muscle use signals increased work of breathing and hypoxia. These indicate impending respiratory failure and require immediate action.
Why the others are wrong
- A – A mild productive cough helps clear secretions.
- C – Hoarseness and throat soreness are common after a breathing tube and need monitoring only.
- D – A stable, acceptable saturation does not need emergency action.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
183Question
A client was freed after being trapped under debris for several hours. The urine is dark reddish-brown and the serum creatine kinase is markedly elevated. Which action is the priority?
- Give isotonic intravenous fluids as ordered to maintain high urine output, and monitor potassium and ECG
- Restrict fluids to protect the kidneys
- Administer an NSAID for pain
- Apply warm compresses to the limbs
Show the answer and explanation
Answer: A. Give isotonic intravenous fluids as ordered to maintain high urine output, and monitor potassium and ECG
Topic: rhabdomyolysis
Crush injury releases myoglobin and potassium, which can cause kidney failure and hyperkalemia. Aggressive isotonic fluid resuscitation protects the kidneys, and the nurse monitors urine output, potassium and ECG.
Why the others are wrong
- B – Fluid restriction increases the risk of kidney injury.
- C – NSAIDs are nephrotoxic.
- D – Warmth does not address kidney injury and can raise tissue demand.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
184Question
A school nurse is told by a student that a classmate has posted online that he plans to hurt others at school on Friday, and the student asks the nurse to keep it secret. What should the nurse do?
- Report it immediately to the school administrator or threat assessment team
- Promise to keep the information confidential to protect the student who came forward
- Speak privately with the classmate first to judge whether he is serious about the plan
- Wait to see whether the student reports additional warning signs before taking any action
Show the answer and explanation
Answer: A. Report it immediately to the school administrator or threat assessment team
Topic: reporting a threat of school violence
A specific threat to harm others is an emergency that must be reported at once through the school's threat assessment process and, as directed, to law enforcement. Confidentiality does not cover a risk to others.
Why the others are wrong
- B – Safety of others outweighs a promise of secrecy; the nurse cannot agree to hold a threat.
- C – Confronting a potentially dangerous student alone risks harm and delays official action.
- D – Delay can allow harm to occur when a specific threat has already been made.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
185Question
A nurse teaches an older adult how to prevent falls at home. Which statement by the client indicates a need for further teaching?
- I wear sturdy shoes with non-slip soles, even indoors.
- I sit on the side of the bed for a minute before standing.
- I use my walker outside but skip it in my apartment.
- I turn on the lamp by my bed before I stand up at night.
Show the answer and explanation
Answer: C. I use my walker outside but skip it in my apartment.
Topic: evaluating fall-prevention teaching
Assistive devices should be used whenever the client is up, including at home, because most falls occur indoors. Sturdy shoes, adequate lighting and slow position changes are correct prevention strategies.
Why the others are wrong
- A – Appropriate footwear reduces the risk of slipping.
- B – This reduces dizziness caused by changes in position.
- D – Good lighting helps avoid trips.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
186Question
A nurse assesses the fingers of a client with long-standing COPD. The angle between the nail plate and the proximal nail fold has increased, the nail base feels spongy and the fingertips look bulbous. What do these findings represent?
- Koilonychia (spoon nails) caused by iron deficiency
- Clubbing associated with chronic hypoxia
- Beau's lines caused by a past severe illness
- Paronychia caused by infection of the nail fold
Show the answer and explanation
Answer: B. Clubbing associated with chronic hypoxia
Topic: digital clubbing
Clubbing flattens the normal nail angle to about 180 degrees or more, softens the nail bed and enlarges the fingertips. It is linked to chronic hypoxia from conditions such as COPD, lung cancer and cyanotic heart disease.
Why the others are wrong
- A – Spoon nails curve upward and are concave, without a spongy base or bulbous tip.
- C – Beau's lines are horizontal grooves across the nail.
- D – Paronychia is a red, swollen, tender nail fold.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
187Question
A client with a suspected thoracic spine injury must be turned to allow examination of the back. Which technique is most appropriate?
- Have the client roll toward the nurse by pulling on the near shoulder
- Use a log-roll with one person controlling the head and directing the team to turn the whole body as one unit
- Ask the client to bend the knees and twist the hips to the side
- Lift the client by the shoulders and hips and slide the client off the board
Show the answer and explanation
Answer: B. Use a log-roll with one person controlling the head and directing the team to turn the whole body as one unit
Topic: log-roll technique
Spinal motion restriction requires the head, shoulders, trunk and pelvis to move together in neutral alignment. One person holds the head and gives the command so that all move in unison.
Why the others are wrong
- A – Pulling on the shoulder rotates the upper spine ahead of the pelvis.
- C – Bending the knees and twisting causes spinal rotation.
- D – Lifting and sliding the client without a coordinated, aligned technique risks flexion or twisting.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
188Question
A client with right-sided facial droop after a stroke has dysphagia. Which actions should the nurse take to reduce the risk of aspiration during meals?
Select all that apply.
- Offer thin liquids with a straw to speed up drinking
- Encourage the client to talk during the meal to stay alert
- Give larger forkfuls so the meal is finished before it gets cold
- Keep the client upright for 30 minutes after eating
- Place food on the unaffected side of the mouth
- Seat the client fully upright for meals
Show the answers and explanation
Answers: D, E and F.
- D – Keep the client upright for 30 minutes after eating
- E – Place food on the unaffected side of the mouth
- F – Seat the client fully upright for meals
Topic: safe feeding after stroke with dysphagia
An upright position uses gravity to guide food down the esophagus, placing food on the stronger side lets the client control it, and staying upright afterward reduces reflux and aspiration. Thin liquids, talking while eating and large bites increase risk.
Why the others are wrong
- A – Thin liquids and straws are more likely to be aspirated.
- B – Talking while eating raises the risk of aspiration.
- C – Large boluses are harder to swallow safely; small bites are advised.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
189Question
A nurse is taking the health history of a client admitted with sepsis. The client's 12-year-old daughter, who has been staying at the bedside, makes several comments to the nurse. Which comment should the nurse follow up on first?
- "I have been cooking dinner and doing the laundry since Mom got sick, and I am really tired."
- "I am scared the doctors will not tell me the truth about what is going on."
- "If Mom dies, I do not want to keep living without her."
- "I have not been able to finish any homework since she came in."
Show the answer and explanation
Answer: C. "If Mom dies, I do not want to keep living without her."
Topic: child's statement suggesting self-harm risk
A statement that the child would not want to go on living if the parent dies is a possible expression of suicidal ideation. Safety is the highest priority, so the nurse asks directly about thoughts of self-harm, stays with the child, and involves the provider and social work. The other comments show stress, fear and role strain that need support but are not an immediate threat to life.
Why the others are wrong
- A – Caregiver strain in a child needs attention and help, but it is not an immediate risk to life.
- B – Fear about being misinformed calls for honest, age-appropriate information, which can follow the safety concern.
- D – Missed schoolwork is a stress to address later with the school and family.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
190Question
A nurse is preparing a physical examination for a client who disclosed a history of sexual assault. Which actions reflect a trauma-informed approach?
Select all that apply.
- Explain each step before it happens and ask permission before touching
- Ask the client to describe the assault in detail to complete the history
- Agree on a signal the client can use to pause or stop the examination
- Ask the client to undress fully at the start to save time
- Offer the choice of having a support person or chaperone present
- Use a fast routine without comments so the client is not distracted
Show the answers and explanation
Answers: A, C and E.
- A – Explain each step before it happens and ask permission before touching
- C – Agree on a signal the client can use to pause or stop the examination
- E – Offer the choice of having a support person or chaperone present
Topic: trauma-informed physical examination
Trauma-informed care restores a sense of safety, choice and control. The nurse explains, asks consent, gives the client control through a stop signal, and offers a support person. Requiring details, full undressing or silent speed removes control.
Why the others are wrong
- B – Retelling the assault is not needed for the examination and can retraumatize.
- D – Full undressing at once removes control; clothing is removed only as needed.
- F – Silent speed leaves the client unsure of what is happening and reduces control.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
191Question
During a multiple-casualty event the nurse uses the START method. A client cannot walk because of an ankle injury, breathes at 22/min, has a radial pulse with capillary refill under 2 seconds, and follows simple commands. Which tag applies?
- Black (expectant)
- Red (immediate)
- Green (minor)
- Yellow (delayed)
Show the answer and explanation
Answer: D. Yellow (delayed)
Topic: START triage
In START, people who cannot walk but breathe at 30 or fewer per minute, have good perfusion and follow commands are tagged yellow (delayed). Red is for respirations above 30, poor perfusion or inability to follow commands. Green is for those who can walk.
Why the others are wrong
- A – Black is for no breathing after airway repositioning.
- B – Red needs respirations over 30, no radial pulse or slow refill, or inability to follow commands.
- C – Green is for those who can walk.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
192Question
A client is receiving norepinephrine through a peripheral intravenous catheter. The nurse sees blanching, coolness and swelling around the site. What should the nurse do first?
- Remove the catheter immediately and apply a warm compress
- Slow the infusion rate and reassess in 30 minutes
- Flush the line with saline to clear the drug
- Stop the infusion, leave the catheter in place, and notify the provider for antidote and care per policy
Show the answer and explanation
Answer: D. Stop the infusion, leave the catheter in place, and notify the provider for antidote and care per policy
Topic: vasopressor extravasation
Vasopressor extravasation causes tissue ischemia and can cause necrosis. The infusion is stopped, and the catheter is left in place so residual drug can be aspirated and a local antidote can be given as ordered.
Why the others are wrong
- A – Removing the catheter first loses the route for aspiration and antidote.
- B – Slowing still delivers drug into tissue.
- C – Flushing forces more drug into the tissue.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
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