30 adult nursing items that did not make it onto the site, across 5 sub-sections. Each is shown with the objection that killed it, verbatim.
Read this first
The questions on this page are flawed on purpose. The keyed answers and the reasoning behind them are wrong or unsafe in the way each objection describes. Do not memorise anything here as fact. The verified bank is on the practice pages.
Rejected — do not study this as correctCommunity nursing
A community health nurse makes a home visit to a 72-year-old patient with chronic heart failure. The patient reports feeling well but mentions a few changes. Which finding should the nurse identify as requiring immediate intervention?
AOccasional dry cough that is not accompanied by shortness of breath
BWeight gain of 2.3 kg (5 lb) over the past 2 daysKeyed by the writer
CMild bilateral ankle edema that resolves with leg elevation
DFatigue that occurs after climbing one flight of stairs
What the audit caught
Rationale for Option B contains a logical/mathematical error: it states a gain of 5 lb over 2 days (average 2.5 lb/day) 'exceeds the typical daily reporting threshold of 2–3 lb,' but 2.5 lb falls within the cited 2–3 lb range. The rationale should instead emphasize that meeting the *weekly* threshold (5 lb) in only 2 days indicates a rate of accumulation double the expected safe limit.
Rejected — do not study this as correctCommunity nursing
A community health nurse is planning the initial home visit for a 45-year-old patient newly diagnosed with active pulmonary tuberculosis. The patient lives with his wife and two young children. Which of the following interventions is the priority?
AInstruct the patient to wear a surgical mask when in shared spaces.Keyed by the writer
BArrange for directly observed therapy (DOT) to ensure medication adherence.
CInstruct the patient to collect sputum specimens monthly for culture.
DRefer the family to social services for financial assistance during treatment.
What the audit caught
Option A is clinically suboptimal: The primary infection control priority for active pulmonary TB in the home is respiratory isolation (staying in a separate room, avoiding shared spaces), not merely wearing a mask when in shared spaces. Masking is a secondary measure when separation is not feasible. The option wording implies acceptance of shared space usage.
Rejected — do not study this as correctCommunity nursing
A community health nurse visits a 78-year-old patient with chronic heart failure. The patient reports a 2-kg weight gain over the past 2 days, mild ankle swelling, and increased fatigue. On assessment, the nurse notes bilateral fine crackles in the lung bases and an oxygen saturation of 91% on room air. Which finding requires the most immediate intervention?
AWeight gain of 2 kg in 2 daysKeyed by the writer
BMild bilateral ankle swelling
CBilateral fine crackles in the lung bases
DOxygen saturation of 91% on room air
What the audit caught
Ambiguity between chronic management and acute safety: While weight gain is the primary trigger for outpatient diuretic adjustment, the presence of pulmonary congestion signs (crackles, hypoxia) indicates acute decompensation requiring respiratory intervention (positioning, oxygen, potential ED referral) prior to or concurrent with provider notification.
Rejected — do not study this as correctCommunity nursing
A community health nurse visits a 72-year-old client with heart failure. The client reports a weight gain of 2.3 kg (5 lb) over the past week, a new dry cough at night, bilateral ankle edema, and increased fatigue with usual daily activities. Which finding should the nurse prioritize for immediate intervention?
ANew dry cough at nightKeyed by the writer
BWeight gain of 2.3 kg (5 lb) in one week
CBilateral ankle edema
DIncreased fatigue with usual activities
What the audit caught
Objective vs. Subjective Priority: A weight gain of 2.3 kg (5 lb) in one week is the specific, objective evidence-based threshold (AHA/ACC guidelines) for HF decompensation requiring provider notification. Option A relies on a subjective symptom that may be benign (medication side effect), whereas Option B is definitively pathological in this context.
Rejected — do not study this as correctCommunity nursing
A community health nurse is making an initial home visit to a client newly diagnosed with active pulmonary tuberculosis. The case has not yet been reported to public health authorities. The client lives with a spouse and two young children. Which of the following actions should the nurse take first?
AAdminister bacille Calmette-Guérin (BCG) vaccine to the family members.
BInitiate directly observed therapy (DOT) for the client.
CInstruct the client to wear an N95 respirator at all times.
DNotify the local public health department of the case.Keyed by the writer
What the audit caught
Clinical Priority Hierarchy: Immediate infection control (source control via surgical mask) is the true first safety priority over administrative reporting. The item omits the correct safety intervention, forcing students to choose between incorrect PPE (N95 for patient) and reporting, which compromises the validity of the 'first action' hierarchy.
Rejected — do not study this as correctCommunity nursing
A home health nurse is visiting a 72-year-old patient with a stage 2 pressure injury on the sacrum. The wound bed is clean with granulation tissue, but the periwound skin is macerated. The patient lives alone but receives daily assistance from a family caregiver. Which instruction should the nurse emphasize to prevent wound infection?
AApply a dry gauze dressing and change it twice daily.
BApply a skin barrier wipe to periwound skin and change the dressing when it becomes saturated.Keyed by the writer
CCleanse the wound with hydrogen peroxide and leave it open to air.
DApply a hydrocolloid dressing and change it only when leakage occurs.
What the audit caught
Rationale Contradiction: Option B's rationale claims changing 'when saturated' prevents excessive moisture, while Option D's rationale states waiting until 'leakage' (clinically equivalent to saturation failure) increases infection risk. These statements are mutually exclusive regarding dressing change timing.
Rejected — do not study this as correctCritical care nursing
A nurse in the cardiac surgical intensive care unit is assessing a patient who is 2 days post-coronary artery bypass grafting. The patient suddenly becomes anxious and reports difficulty breathing. The nurse notes a heart rate of 122/min, blood pressure 82/50 mm Hg, distended neck veins, and a 15 mm Hg drop in systolic blood pressure during inspiration. What should the nurse do first?
AAdminister a 500 mL bolus of 0.9% sodium chloride
BNotify the provider and anticipate emergency surgical re-explorationKeyed by the writer
CObtain a stat 12-lead electrocardiogram
DPlace the patient in Trendelenburg position
What the audit caught
Option A Rationale is logically inconsistent and potentially misleading regarding scope of practice: It labels fluid bolus as a 'critical immediate intervention' but prioritizes notification based on 'temporizing vs. definitive' logic rather than stating that fluid administration typically requires a provider order or standing protocol (dependent intervention). In emergency prioritization, independent life-saving measures (or those under standing protocol) often precede or occur concurrently with notification; the rationale should clarify the dependency constraint.
Rejected — do not study this as correctCritical care nursing
A 68-year-old patient is admitted from a long-term care facility with a 2-day history of fever, confusion, and decreased urine output. Vital signs: temperature 38.9°C, heart rate 112/min, blood pressure 88/54 mm Hg, respiratory rate 24/min, oxygen saturation 94% on room air. The nurse suspects sepsis and reviews the following orders: blood cultures, serum lactate, broad-spectrum IV antibiotics, and a 30 mL/kg IV bolus of 0.9% sodium chloride. Which action should the nurse perform first?
AAdminister the 30 mL/kg IV fluid bolus.Keyed by the writer
BObtain blood cultures and a serum lactate level.
CStart the broad-spectrum IV antibiotics.
DInsert an indwelling urinary catheter to monitor output.
What the audit caught
Ambiguity between ABCs prioritization and Surviving Sepsis Campaign (SSC) Hour-1 Bundle list order: The SSC Bundle checklist numerically lists 'Measure Lactate' and 'Obtain Cultures' (Items 1 & 2) before 'Administer 30 mL/kg Crystalloid' (Item 4). While physiological priority (ABCs) favors fluids in hypotension, this creates a defensible argument for Option B in curricula strictly following the Bundle list sequence, leading to potential key controversy.
Rejected — do not study this as correctCritical care nursing
A patient in the intensive care unit had a central venous catheter inserted via the right subclavian vein 2 hours ago. The patient suddenly develops severe dyspnea, chest pain, and a blood pressure of 80/50 mmHg. The nurse auscultates a 'mill-wheel' murmur over the precordium and suspects an air embolism. Which action should the nurse take first?
AClamp the catheter and administer 100% oxygen.Keyed by the writer
BPlace the patient in the left lateral decubitus position with the head down.
CAttempt to aspirate air from the catheter.
DNotify the healthcare provider immediately.
What the audit caught
Fatal ambiguity in priority sequence: Reputable guidelines conflict on the 'first' action for venous air embolism. The Infusion Nurses Society (INS) prioritizes clamping, while AACN Critical Care procedures often prioritize positioning (Durant's maneuver) to restore cardiac output in hemodynamically unstable patients, making both Option A and Option B defensibly correct depending on the standard followed.
Rejected — do not study this as correctCritical care nursing
A 65-year-old patient with pneumonia and no history of chronic lung disease is admitted to the ICU with acute respiratory failure. The patient is intubated and placed on assist-control ventilation with the following settings: tidal volume 400 mL, respiratory rate 12 breaths/min, FiO2 0.50. Vital signs are blood pressure 88/52 mm Hg and heart rate 118 bpm. Arterial blood gas results are: pH 7.18, PaCO2 65 mm Hg, HCO3 24 mEq/L, PaO2 70 mm Hg. Which action should the nurse anticipate?
AIncrease FiO2 to 0.70
BIncrease respiratory rate to 16 breaths/minKeyed by the writer
CAdminister sodium bicarbonate intravenously
DSwitch to pressure support ventilation
What the audit caught
Rationale for Option B implies respiratory acidosis is the primary contributor to hypotension ('likely contributing'), whereas in pneumonia-induced shock, sepsis (vasodilation/capillary leak) is the primary etiology; acidosis is an exacerbating factor. This distinction is critical to prevent learners from prioritizing ventilation adjustments over fluid/pressor resuscitation for hemodynamic instability.
Rejected — do not study this as correctCritical care nursing
A nurse is caring for a patient in the intensive care unit who has a central venous catheter inserted in the right subclavian vein. The nurse notes that the catheter hub is disconnected and the line is open to air. The patient suddenly develops dyspnea, chest pain, and hypotension. The nurse suspects a venous air embolism. What is the priority nursing action?
AAdminister high-flow oxygen via a non-rebreather mask.
BPlace the patient in the left lateral Trendelenburg position.
CClamp the central venous catheter.Keyed by the writer
DNotify the healthcare provider of the suspected air embolism.
What the audit caught
Rationale for Option B presents Left Lateral Trendelenburg as a mandatory follow-up ('should be performed'), whereas current evidence-based critical care guidelines (e.g., UpToDate, some INS updates) classify this maneuver as controversial with limited evidence and potential risks (increased ICP, compromised ventilation), making the rationale overly definitive for current practice.
Rejected — do not study this as correctCritical care nursing
A 65-year-old patient with acute respiratory distress syndrome (ARDS) is on volume-controlled mechanical ventilation. The high-pressure alarm suddenly sounds, and the patient becomes cyanotic and diaphoretic. Assessment reveals absent breath sounds on the right, hyperresonance to percussion on the right, distended neck veins, and blood pressure 80/50 mm Hg. Which action should the nurse take first?
AIncrease the FiO2 to 100% and suction the endotracheal tube.
BDisconnect the ventilator and manually ventilate with a bag-valve-mask.
CPrepare the necessary equipment for needle thoracostomy.Keyed by the writer
DAdminister a prescribed fluid bolus of 0.9% sodium chloride.
What the audit caught
Item design flaw: The optimal first-line nursing intervention for suspected tension pneumothorax on a ventilator is immediate disconnection of the ventilator (without manual ventilation) to stop air trapping. This option is absent, forcing a choice between a harmful action (Option B) and passive preparation (Option C) while the ventilator continues to exacerbate the condition.
Rejected — do not study this as correctMedical nursing
A 45-year-old patient is admitted with severe epigastric pain radiating to the back, nausea, and vomiting. Vital signs: BP 90/60 mmHg, HR 110 bpm, RR 22/min, temperature 38.2°C. Laboratory results show elevated serum amylase and lipase. Which nursing action is the priority?
AAdminister prescribed intravenous morphine for pain relief.
BInitiate prescribed intravenous fluid resuscitation with isotonic crystalloid.Keyed by the writer
CInsert a prescribed nasogastric tube for gastric decompression.
DObtain prescribed blood cultures to identify a possible infectious cause.
What the audit caught
Rationale for Option D states 'Acute pancreatitis is most often caused by... not infection' and 'Blood cultures are not a priority unless... sepsis is suspected.' Given the patient's fever (38.2°C), tachycardia (110 bpm), and hypotension (90/60 mmHg), sepsis is clinically suspected (meets SIRS/sepsis criteria). The rationale risks implying cultures are unnecessary, whereas they are indicated but lower priority than hemodynamic stabilization. The rationale should explicitly state that while cultures may be indicated for suspected sepsis, fluid resuscitation takes precedence per ABCs.
Rejected — do not study this as correctMedical nursing
A 62-year-old man presents to the emergency department with substernal chest pressure radiating to his left arm, diaphoresis, and nausea for the past 45 minutes. His vital signs are BP 150/90 mm Hg, HR 102 bpm, RR 22 breaths/min, and SpO2 96% on room air. A 12-lead ECG shows ST-segment depression in leads V3–V6. The nurse suspects acute coronary syndrome. The patient has no known allergies and no history of bleeding. Which of the following is the priority nursing action?
AAdminister sublingual nitroglycerin 0.4 mg.
BAdminister non-enteric-coated aspirin 162–325 mg to chew.Keyed by the writer
CObtain a second 12-lead ECG in 15 minutes.
DPrepare the patient for immediate percutaneous coronary intervention.
What the audit caught
Option A rationale contains a clinical inaccuracy: It states nitroglycerin can be given 'if pain persists' after aspirin, implying aspirin is trialed for pain relief. Aspirin is antiplatelet and does not relieve ischemic pain; nitroglycerin is indicated for ongoing pain regardless of aspirin's administration, though aspirin is prioritized for mortality benefit.
Rejected — do not study this as correctMedical nursing
A 45-year-old patient is receiving intravenous ceftriaxone for pneumonia. Five minutes into the infusion, the patient develops generalized urticaria, dyspnea, and a blood pressure of 80/50 mm Hg. Which action should the nurse take first?
AAdminister epinephrine 0.3 mg intramuscularly.
BStop the ceftriaxone infusion and maintain IV access with normal saline.Keyed by the writer
CAdminister diphenhydramine 50 mg intravenously.
DAdminister 0.9% sodium chloride 500 mL intravenous bolus.
What the audit caught
Option B's rationale states IV access is maintained to 'ensure a route for emergency medications'; however, the first-line emergency medication for anaphylaxis (epinephrine) is administered intramuscularly, so IV access is not required for the initial dose, making the justification for prioritizing this step before epinephrine clinically imprecise.
Rejected — do not study this as correctMedical nursing
A 55-year-old male presents to the emergency department with severe substernal chest pain radiating to the left arm, diaphoresis, and nausea. An ECG reveals ST-segment elevation in leads II, III, and aVF. Vital signs: BP 100/60 mm Hg, HR 110 bpm, RR 22/min, SpO2 96% on room air. The facility has a STEMI protocol that empowers nurses to activate the catheterization lab. Which action should the nurse take first?
AAdminister sublingual nitroglycerin 0.4 mg for chest pain relief.
BActivate the catheterization lab for primary percutaneous coronary intervention.Keyed by the writer
CAdminister chewed aspirin 324 mg as antiplatelet therapy.
DObtain a right-sided ECG to evaluate for right ventricular infarction.
What the audit caught
Option A rationale states nitroglycerin is 'contraindicated in inferior STEMI'; clinically, it is contraindicated specifically in right ventricular infarction or hypotension (SBP <90 mmHg), not inferior STEMI itself. This perpetuates a misconception that denies pain relief to stable inferior STEMI patients without RV involvement.
Rejected — do not study this as correctMedical nursing
A 25-year-old patient with a history of asthma arrives at the emergency department with acute dyspnea, audible wheezing, and use of accessory muscles. The patient is able to speak only in single words. SpO2 is 88% on room air. Which action should the nurse take first?
AAdminister albuterol via a nebulizer.
BApply oxygen using a non-rebreather mask.Keyed by the writer
CPosition the patient in high Fowler's position.
DObtain a sample for arterial blood gas analysis.
What the audit caught
Ambiguity exists between Options A and B regarding priority; current guidelines (GINA/NAEPP) recommend simultaneous administration, and some emergency protocols prioritize early bronchodilators to resolve the underlying V/Q mismatch causing hypoxemia, making the 'first' action debatable without further stem clarification.
Rejected — do not study this as correctMedical nursing
A 45-year-old female with a history of Graves' disease is brought to the emergency department with a temperature of 39.8°C, heart rate 140/min, blood pressure 150/90 mm Hg, and confusion. She reports not taking her antithyroid medications for several weeks. The nurse anticipates which of the following orders to be implemented first?
AAdminister propylthiouracil (PTU) orally
BAdminister propranolol intravenously
CApply a cooling blanket
DAdminister intravenous normal salineKeyed by the writer
What the audit caught
Rationale for Option B claims beta-blockade may precipitate cardiovascular collapse in a 'dehydrated patient' without acknowledging the stem's hypertensive vitals (150/90 mm Hg), which indicate compensated hemodynamics and reduce the immediate risk of collapse, making the rationale misleading for this specific scenario.
Rejected — do not study this as correctMental/psychiatric nursing
A 45-year-old patient with major depressive disorder is receiving fluoxetine 40 mg daily and tramadol for chronic back pain. The patient becomes agitated, diaphoretic, and confused. Vital signs: temperature 38.9°C (102°F), heart rate 110/min, blood pressure 150/90 mm Hg. The nurse notes hyperreflexia and sustained ankle clonus. Which action should the nurse take first?
AAdminister a PRN dose of lorazepam as prescribed for agitation.Keyed by the writer
BApply a cooling blanket and monitor temperature every 15 minutes.
CHold all serotonergic medications (fluoxetine and tramadol) and notify the healthcare provider.
DEncourage oral fluid intake to prevent dehydration from diaphoresis.
What the audit caught
Ambiguity between Option A and Option C: Standard nursing prioritization for adverse medication events typically favors 'Hold medication and Notify Provider' (Option C) as the primary safety intervention. While benzodiazepines are clinically critical for hyperthermia, the item lacks context on whether scheduled doses are due immediately, making 'Hold' a defensibly correct safety action per general nursing heuristics.
Rejected — do not study this as correctMental/psychiatric nursing
A 28-year-old patient with schizophrenia has been taking haloperidol 5 mg twice daily for 2 weeks. The patient has a PRN order for benztropine. The nurse notes a shuffling gait, masked facies, and cogwheel rigidity. Which of the following actions should the nurse take?
AAdminister the prescribed PRN benztropine.Keyed by the writer
BHold the next dose of haloperidol and notify the healthcare provider.
CRequest an order for diphenhydramine.
DEncourage the patient to increase fluid intake.
What the audit caught
Rationale B factual error: States 'While nurses can hold medications for safety concerns,' implying independent authority to cancel scheduled antipsychotics for EPS. Nurses generally require a provider order or standing protocol to hold scheduled psychotropic medications for side effects; the priority is administering available PRN and notifying the provider.
Rejected — do not study this as correctMental/psychiatric nursing
A 35-year-old patient with major depressive disorder has been taking fluoxetine 40 mg daily for 6 months. Two days ago, the patient started taking over-the-counter St. John's wort for "extra mood support." The patient is brought to the emergency department by a family member who reports the patient has become increasingly agitated, confused, and has been sweating profusely. On assessment, the nurse notes temperature 38.9°C (102°F), heart rate 110 bpm, blood pressure 150/90 mm Hg, dilated pupils, hyperreflexia, and inducible clonus. Which action should the nurse take first?
AAdminister lorazepam to manage agitation and clonus.
BInstruct the family member to stop giving the patient St. John's wort, ensure no further fluoxetine is administered, and notify the healthcare provider immediately.Keyed by the writer
CObtain a urine drug screen to confirm the presence of St. John's wort.
DApply cooling blankets and monitor temperature every 15 minutes.
What the audit caught
Option B rationale contains a scope of practice error: It states the nurse must notify the provider to 'obtain orders for... cooling.' Active cooling measures for significant hyperthermia (38.9°C/102°F) are typically independent nursing interventions or standing protocols in emergency settings and should not be delayed while waiting for a provider's order.
Rejected — do not study this as correctMental/psychiatric nursing
A 28-year-old patient with schizophrenia has been taking clozapine for 6 months. The nurse reviews today's complete blood count (CBC) results: white blood cell count 1,800/mm³ (normal 4,500–11,000/mm³) and absolute neutrophil count 900/mm³ (normal 1,500–8,000/mm³). The patient is afebrile and reports no symptoms. Which action should the nurse take first?
AAdminister the clozapine as scheduled and recheck the CBC in 1 week.
BHold the clozapine and notify the healthcare provider immediately.Keyed by the writer
CAdminister the clozapine and encourage increased fluid intake.
DHold the clozapine and administer a prescribed antipyretic.
What the audit caught
Option B rationale and Teaching Point inaccurately state monitoring is 'daily... until ANC ≥1,500/mm³' after resumption criteria are met. Per current FDA Clozapine REMS guidelines, monitoring is daily *during interruption*, but after resumption (allowed at ANC ≥1,000/mm³), monitoring frequency is weekly for 4 weeks, not daily until 1,500/mm³.
Rejected — do not study this as correctMental/psychiatric nursing
A 28-year-old patient with schizophrenia is admitted to the psychiatric unit. The patient appears agitated, is mumbling, and intermittently tilts the head as if listening. The nurse observes the patient suddenly clench both fists. Which nursing action is the priority?
AAsk the patient to describe what the voices are saying.
BUse a calm, non-threatening approach and offer to discuss what is bothering the patient.Keyed by the writer
CAdminister the prescribed PRN haloperidol immediately.
DInstruct the patient firmly to unclench the fists and go to their room.
What the audit caught
Option B text lacks explicit safety measures (e.g., maintaining distance, positioning near exit, or calling for assistance) which are the true priority when 'suddenly clenches fists' indicates imminent physical threat; relying on the rationale to supply safety context creates a disconnect between the option text and safe practice.
Rejected — do not study this as correctMental/psychiatric nursing
A 28-year-old patient with major depressive disorder is brought to the emergency department by family. The patient has been taking fluoxetine 40 mg daily for 6 months and was recently started on tramadol for back pain. The patient is agitated, diaphoretic, and has a temperature of 39.2°C. On assessment, the nurse notes hyperreflexia and inducible clonus in the lower extremities. Which action should the nurse take first?
ARequest an order for lorazepam to manage agitation.
BHold the fluoxetine and tramadol and notify the healthcare provider.
CObtain a urine drug screen to check for other serotonergic substances.
DApply external cooling measures to reduce the patient's temperature.Keyed by the writer
What the audit caught
Rationale factual error: The item claims severe hyperthermia requiring aggressive cooling priority starts at >38.5°C; current toxicology guidelines (UpToDate, Boyer NEJM) reserve aggressive external cooling for temperatures >40°C to 41°C, prioritizing benzodiazepines and discontinuation for moderate hyperthermia (39.2°C).
Rejected — do not study this as correctSurgical nursing
A nurse is caring for a client who is 4 days post-operative following an exploratory laparotomy. While the client is coughing, the nurse observes a loop of intestine protruding from the abdominal wound. Which of the following actions should the nurse take first?
AApply a sterile saline-moistened dressing to the wound.Keyed by the writer
BPlace the client in a low Fowler's position with knees slightly flexed.
CNotify the surgeon immediately.
DAdminister prescribed pain medication.
What the audit caught
Option B rationale and Teaching Point state 'Low Fowler's position' reduces abdominal tension; however, current majority evidence-based guidelines (e.g., Saunders, Potter & Perry, Lippincott) specify 'Supine with knees flexed' to minimize gravitational pull on exposed viscera, as head elevation in Fowler's positions may increase intra-abdominal pressure and protrusion risk.
Rejected — do not study this as correctSurgical nursing
A 58-year-old patient is 2 days post-op following an open colectomy. The patient has been tolerating clear liquids but now reports persistent nausea. The nurse auscultates absent bowel sounds in all four quadrants and notes abdominal distension. Which action should the nurse take first?
AAdminister the prescribed antiemetic for nausea.
BNotify the healthcare provider of the assessment findings.Keyed by the writer
CEncourage the patient to ambulate to stimulate peristalsis.
DInsert a nasogastric tube to decompress the stomach.
What the audit caught
Ambiguity between Options B and C: Current Enhanced Recovery After Surgery (ERAS) protocols prioritize ambulation as a first-line independent intervention for postoperative ileus. Prioritizing a dependent action (notify provider) over a safe independent action (ambulation) creates a defensible alternative correct answer, violating the 'single best answer' principle.
Rejected — do not study this as correctSurgical nursing
A 68-year-old patient is 2 days post-operative following a total hip replacement. The patient suddenly develops sharp, pleuritic chest pain, shortness of breath, and a respiratory rate of 28 breaths per minute. Oxygen saturation drops from 96% to 88% on room air. The nurse suspects a pulmonary embolism. Which action should the nurse take first?
AAdminister prescribed PRN morphine for chest pain.
BAdminister high-flow oxygen via non-rebreather mask.Keyed by the writer
CEncourage deep breathing and coughing to clear the airway.
DPlace the patient in Trendelenburg position to improve venous return.
What the audit caught
Option D rationale misalignment: The option text states the intent is to 'improve venous return,' but the rationale refutes it based on 'diaphragm pressure.' In PE specifically, increased venous return is contraindicated due to the risk of dislodging additional thrombi; the rationale should address this PE-specific risk to fully refute the option's logic.
Rejected — do not study this as correctSurgical nursing
A nurse is caring for a 68-year-old patient who underwent a total hip arthroplasty 24 hours ago. The patient is alert, vital signs are stable, and pain is controlled. Which intervention is most effective in preventing deep vein thrombosis?
AAdminister prescribed enoxaparin 40 mg subcutaneously.Keyed by the writer
BAssist the patient to ambulate with a walker.
CApply sequential compression devices to both legs.
DElevate the affected leg on two pillows.
What the audit caught
Rationale A cites 'current ACCP guidelines' as support; the primary ACCP CHEST guidelines for VTE prophylaxis are from 2012 (9th Ed), which is outdated for a 2024 exam item, and newer AAOS (2021) guidelines emphasize multimodal prophylaxis without ranking enoxaparin specifically as superior to all other pharmacologic agents (e.g., DOACs).
Rejected — do not study this as correctSurgical nursing
A 72-year-old male is 6 hours post-op from a transurethral resection of the prostate (TURP) performed with 1.5% glycine irrigation. He now has continuous bladder irrigation with normal saline. He becomes restless, confused, and reports nausea. Vital signs: BP 158/92 mm Hg, HR 54 bpm, RR 20/min. Which complication should the nurse suspect?
ABladder perforation
BTransurethral resection (TUR) syndromeKeyed by the writer
CUrinary tract infection
DPulmonary embolism
What the audit caught
Rationale Factual Accuracy (Option A): The rationale states bladder perforation causes 'peritoneal signs.' Extraperitoneal bladder perforation (the most common type in TURP) presents with suprapubic pain and distension but typically lacks peritoneal signs (rigidity/rebound), which are specific to intraperitoneal perforation.
Rejected — do not study this as correctSurgical nursing
A patient is 12 hours post-operative following a right modified radical mastectomy with a Jackson-Pratt drain in place. The nurse notes that the drain's bulb is fully expanded and there is no drainage visible in the tubing. The patient reports mild discomfort at the surgical site. What should the nurse do first?
ANotify the surgeon about the drain status immediately.
BEmpty and measure the drainage, clean the port, and recompress the bulb.Keyed by the writer
CRemove the drain and apply a sterile dressing.
DAdminister pain medication for the reported discomfort.
What the audit caught
Option B and its rationale describe a sequence that violates standard aseptic technique for closed suction drains. The evacuation port must be cleaned with alcohol *before* opening to empty, not after. Cleaning after emptying fails to prevent introducing pathogens into the system during the opening step (CDC/INS guidelines).