Question 1

What is the potassium requirement in mEq/kg for a child?

Accepted Answer

Answer reason: The standard pediatric maintenance potassium requirement is about 1–2 mEq/kg/day; higher amounts risk hyperkalemia.

Question 2

During an intradermal injection, what indicates that the injection has been correctly placed?

Accepted Answer

Answer reason: Correct intradermal placement forms a small, raised wheal or bleb at the skin surface. Redness, pain, or backflow are not indicators of correct placement.

Question 3

Which of the following drugs must not be injected intravenously?

Accepted Answer

Answer reason: Diazepam and ceftriaxone are formulated for IV use when given slowly/appropriately. Diclofenac sodium injection is intended for deep IM use; IV administration of standard diclofenac sodium is contraindicated due to risk of severe local reactions and thrombosis.

Question 4

Why does the nurse hold the gauze pledget against the intramuscular injection site while removing the needle?

Accepted Answer

Answer reason: Applying gauze as the needle is withdrawn provides immediate pressure to seal the needle track and prevent leakage or backflow of medication or blood. It is not to speed absorption or prevent infection.

Question 5

What is the safest way for a nurse to administer intravenous pentamidine to a client with Pneumocystis jiroveci pneumonia?

Accepted Answer

Answer reason: IV pentamidine can cause severe hypotension; to reduce risk it should be infused slowly (at least 60 minutes) with the client lying supine and closely monitored.

Question 6

After administering a subcutaneous injection, what should the nurse do?

Accepted Answer

Answer reason: Post-injection care includes monitoring the site for local reactions such as redness, swelling, or pain. Massaging is contraindicated for many SC medications (e.g., insulin, heparin), and merely documenting without assessment is inadequate.

Question 7

What is the correct route of injection for the purified protein derivative (Mantoux) test?

Accepted Answer

Answer reason: The Mantoux (PPD) test is administered via intradermal injection, typically 0.1 mL into the inner forearm.

Question 8

The physician has ordered 50mEq of potassium chloride for a client with a potassium level of 2.5mEq. The nurse should administer the medication?

Accepted Answer

Answer reason: Potassium chloride must never be given IV push. Typical safe peripheral rate is 10 mEq/hr (up to 20 mEq/hr via central line with monitoring). Therefore 50 mEq should be infused over about 5 hours. The other options are either dangerously rapid or unnecessarily prolonged.

Question 9

Ethiopian oxytocin infusion protocol for induction of labour includes?

Accepted Answer

Answer reason: All listed steps are components of the oxytocin infusion protocol for induction of labor: establish a large-bore IV, perform amniotomy, and prepare/titrate oxytocin in 1 L of NS or RL with adjustments every 30 minutes.

Question 10

Intradermal injection produces a bleb if given at the correct angle of?

Accepted Answer

Answer reason: Intradermal injections are given with the bevel up at a shallow angle of about 5–15 degrees so the needle tip remains within the dermis. Correct placement produces a small wheal or bleb. Using greater angles like 30–60 degrees would penetrate into the subcutaneous tissue, preventing formation of the bleb and altering test accuracy or drug absorption.

Question 11

The recommended angle for intramuscular injection is?

Accepted Answer

Answer reason: Intramuscular injections are delivered at a 90° angle to ensure the needle penetrates through subcutaneous tissue into the muscle for proper absorption. A perpendicular approach minimizes the risk of depositing medication in subcutaneous fat, which can delay absorption and increase irritation. Needle length is chosen based on patient habitus, but the standard angle remains 90°.

Question 12

A patient who has been suffering from severe diarrhea has developed hypokalemia and cardiac arrhythmias as a result. Which of the following treatments would most likely be ordered for this patient to correct the situation?

Accepted Answer

Answer reason: Severe diarrhea can cause significant potassium loss leading to hypokalemia and arrhythmias. Symptomatic or ECG-affected hypokalemia requires rapid replacement with IV potassium while on cardiac monitoring. Oral potassium or diet changes are appropriate for mild, asymptomatic depletion but are too slow for arrhythmias. Observation alone would risk worsening dysrhythmias and hemodynamic instability.

Question 13

A nurse is caring for a patient receiving total parenteral nutrition (TPN). The nurse will need to do all of the following except?

Accepted Answer

Answer reason: TPN requires meticulous sterile technique and careful handling (including appropriate storage) because it is infused via central access and is highly prone to contamination. Frequent blood glucose monitoring is necessary due to the high dextrose content and risk for hyperglycemia or rebound hypoglycemia if interrupted. Tubing is not changed every 3 hours; it is typically changed at longer, facility-policy intervals (often about every 24 hours) to reduce infection risk and unnecessary line manipulation.

Question 14

Nurse Analiza is administering a medication via the intraosseous route to a child. Intraosseous drug administration is typically used when a child is?

Accepted Answer

Answer reason: Intraosseous (IO) access is an emergency route used when rapid vascular access is needed and IV access cannot be quickly obtained, most commonly during critical illness (e.g., shock, cardiac arrest). In young children, especially under about age 3, peripheral veins can be difficult to cannulate quickly, and the marrow cavity provides a fast, reliable route for fluids and medications. Therefore, the best answer is the option specifying a critically ill child under age 3. The other choices focus on age alone or on older age, which is less characteristic of typical pediatric IO use.

Question 15

What is the safest site for intraosseous access in adults?

Accepted Answer

Answer reason: In adults, the proximal tibia is a commonly recommended and generally safe intraosseous insertion site because it is superficial, has consistent landmarks, and provides rapid access to the central circulation during emergencies when IV access is difficult. Sternal IO can be used with specific devices and training but carries higher risk near mediastinal structures and is not typically considered the safest general site. Distal femur is more commonly used in pediatrics, and the iliac crest is not a standard first-line IO site for emergent access.

Question 16

A client is in ventricular tachycardia and the physician prescribes IV lidocaine (Xylocaine). The nurse plans to dilute the concentrated solution of lidocaine with?

Accepted Answer

Answer reason: 5% Dextrose in water IV lidocaine infusions are commonly prepared in D5W (e.g., 1–4 mg/min maintenance after a bolus) because it is a standard compatible diluent and helps provide a stable admixture for continuous infusion. Normal saline and lactated Ringer’s are not the typical recommended diluents for lidocaine drips in many nursing/NCLEX references. Hypotonic saline (0.45%) is also not preferred for this purpose due to tonicity and compatibility considerations with IV antiarrhythmic infusions.

Question 17

The respiratory care practitioner has received an order to administer 35% oxygen to a post-operative craniotomy patient. The patient is semi-conscious with an irregular breathing pattern. The most appropriate oxygen administration device for this patient would be?

Accepted Answer

Answer reason: This patient requires a precise, fixed FiO2 of 35% despite an irregular respiratory pattern. A Venturi mask delivers an accurately controlled oxygen concentration via air-entrainment, making it appropriate when exact FiO2 is ordered. Nasal cannula and simple masks provide variable FiO2 influenced by tidal volume and inspiratory flow, which becomes unreliable with irregular breathing. Blow-by is not a standard method for controlled oxygen delivery in adults and is unlikely to ensure a consistent 35% FiO2.

Question 18

A client is receiving tube feeding via NG tube and begins vomiting. What is the immediate action?

Accepted Answer

Answer reason: Vomiting during enteral feeding raises immediate concern for aspiration and intolerance, so the priority is to stop the infusion to prevent further gastric distention and regurgitation. After stopping the feeding, the nurse would position the client to protect the airway (e.g., side-lying) and assess for respiratory compromise, tube placement, and residuals per policy. Lowering the head of the bed increases aspiration risk, and flushing can worsen emesis by adding volume.

Question 19

A nurse is preparing to administer a chemotherapeutic agent via intraperitoneal (IP) therapy. In which position should the nurse plan to place the client before administering this therapy?

Accepted Answer

Answer reason: Elevating the head of bed helps reduce upward pressure of intra-abdominal fluid on the diaphragm, improving ventilation and comfort during and after instillation. It also lowers aspiration risk if nausea occurs, which is common with chemotherapeutic agents. Trendelenburg can worsen diaphragmatic compression and respiratory compromise, making it a poorer safety choice.

Question 20

A 14 year-old African American female is admitted to the emergency department accompanied by her mother. The client is crying and states her pain as severe 10/10. The client has no medical history at this time. What orders should the nurse anticipate as being executed as a priority?

Accepted Answer

Answer reason: Starting IV access allows immediate treatment and facilitates further evaluation; opioids such as morphine are an appropriate first-line choice for severe pain when titrated and monitored. IV fluids are commonly initiated in the ED for potential dehydration, stress response, or evolving complications and also ensure a reliable route for medications. Oxygen by non-rebreather is reserved for hypoxemia/respiratory distress and is not indicated solely for pain without signs of compromised oxygenation. Screening for drug abuse and reviewing labs may be important later, but they should not delay urgent pain management and stabilization.

Question 21

The nurse is caring for a client in critical condition requiring several medications. The nurse understands which route of administration would be recommended for this client?

Accepted Answer

Answer reason: This route provides the fastest systemic effect and supports continuous infusions and frequent dose adjustments for unstable clients. It also allows administration of multiple compatible medications and fluids through venous access, which is commonly required in critical care. Oral dosing is often unreliable due to impaired perfusion, altered mental status, or NPO status, and IM/subQ absorption can be unpredictable in shock or vasoconstriction.

Question 22

The nurse is preparing an insulin infusion for a client in diabetic ketoacidosis (DKA). Which of the following would be the appropriate type of insulin to use for I.V. infusion?

Accepted Answer

Answer reason: Short-acting regular insulin is the standard insulin used for continuous IV infusion in DKA because it has reliable onset/offset when given IV and can be adjusted hourly based on glucose and anion gap response. Long-acting insulin glargine and intermediate-acting NPH are not used IV due to delayed, prolonged, and less controllable action profiles. Rapid-acting analogs like lispro are primarily intended for subcutaneous use and are not the typical choice for IV infusion protocols compared with regular insulin.

Question 23

A client who receives total parenteral nutrition (TPN) will most likely require which medication on a routine basis?

Accepted Answer

Answer reason: TPN solutions are dextrose-rich and commonly cause hyperglycemia even in clients without prior diabetes due to high glucose load and stress-related insulin resistance. Routine management often includes scheduled insulin (added to the TPN bag or given via sliding-scale/infusion) with frequent blood glucose monitoring to maintain safe glycemic control. Sodium supplementation is individualized based on electrolyte trends and is not routinely required for all TPN clients. A loop diuretic or a broad-spectrum antibiotic would only be indicated for specific comorbid conditions or complications, not as standard TPN therapy.

Question 24

Postoperative care of a child with a ruptured appendix should include which treatment or intervention?

Accepted Answer

Answer reason: The child is typically kept NPO initially and may have ileus, nausea, or poor absorption, making IV therapy the safest and most reliable route early after surgery. A 7–10 day course is commonly used in complicated appendicitis to ensure adequate treatment of polymicrobial infection. Oral-only therapy is generally insufficient immediately after rupture/operation, and positioning alone does not address the primary infectious risk.

Question 25

What is the most important nursing intervention for a child with lead poisoning who must undergo chelation therapy with edetate calcium disodium?

Accepted Answer

Answer reason: Prepare the child for I.V. fluid therapy. Chelation with edetate calcium disodium forms complexes that are primarily eliminated by the kidneys, so maintaining adequate hydration is critical to support renal clearance and reduce nephrotoxicity risk. I.V. fluids help ensure sufficient urine output during therapy and facilitate excretion of the lead-chelator complex. Bed rest and prolonged hospitalization are not inherently required and do not address the highest physiologic risk of treatment. While injections may occur depending on the regimen, this is less clinically important than protecting renal function and promoting safe elimination.

Question 26

A client receives partial parenteral nutrition (PPN). The nurse notes the fluid has a dextrose content of 30%. Which nursing action takes priority?

Accepted Answer

Answer reason: PPN is intended for peripheral administration and therefore must have lower osmolarity; a dextrose concentration of 30% is consistent with hypertonic TPN formulations and poses high risk of phlebitis and tissue injury if infused peripherally. The immediate priority is to prevent ongoing harm by stopping the infusion while maintaining IV access per facility protocol (e.g., saline at KVO through a new compatible line if ordered). After stopping, the nurse should promptly notify the provider/pharmacy to clarify and obtain the correct formulation/route. Simply slowing the rate or assuming it is normal does not adequately mitigate the risk from an inappropriate solution for peripheral infusion.

Question 27

A child with diabetic ketoacidosis is to receive a continuous infusion of insulin for a blood glucose level of 780 mg/dl. The nurse reviews the orders and would administer which solution?

Accepted Answer

Answer reason: Insulin infusions are prepared in isotonic fluid (commonly 0.9% normal saline) to support intravascular volume during initial resuscitation. Long-acting (Ultralente) and intermediate/long-acting suspensions (NPH, PZI) are not appropriate for IV infusion due to delayed, unreliable absorption and incompatibility with infusion titration needs. Dextrose-containing fluids are typically added later when glucose falls (e.g., ~250–300 mg/dL) to prevent hypoglycemia while continuing to clear ketones, not as the initial insulin carrier solution at a glucose of 780 mg/dL.

Question 28

A client has recently undergone central line placement. The client complains of shortness of breath and right-sided chest pain. Vital signs are blood pressure 98/50 mm Hg, pulse rate 110 beats/minute, and respiratory rate 36 breaths/minute. Which action should the nurse take first?

Accepted Answer

Answer reason: Acute dyspnea and pleuritic chest pain after central line placement suggests an iatrogenic pneumothorax or air embolism with impaired oxygenation and evolving respiratory compromise. Using ABCs, the nurse’s priority is to support breathing immediately by providing supplemental oxygen to improve oxygen delivery and reduce hypoxemia while further interventions are arranged. Calling the provider and obtaining imaging are important, but they do not correct the immediate ventilation/oxygenation problem. Preparing for a chest tube may be needed if pneumothorax is confirmed or unstable, but initiating oxygen is the fastest, safest first action within nursing scope.

Question 29

The nurse teaches an elderly client about the use of subcutaneous therapy (hypodermoclysis) for fluid infusion. Which statement by the client indicates an understanding of the therapy?

Accepted Answer

Answer reason: Hypodermoclysis is the subcutaneous infusion of isotonic fluids for mild-to-moderate dehydration when IV access is difficult, and safety screening includes assessing bleeding risk because tissue bleeding/hematoma can occur at the insertion site. The client’s statement reflects understanding of an important contraindication/precaution relevant to this route of fluid administration. In contrast, it does not deliver large volumes rapidly, so claims of “massive amounts” are incorrect. It also typically uses a small-gauge needle/catheter rather than a large-sized needle, and it is not intended for prolonged, indefinite use without reassessment.

Question 30

The nurse is caring for a client with hemophilia who is experiencing a joint bleed (hemarthrosis). Which of the following nursing actions is appropriate?

Accepted Answer

Answer reason: Hemarthrosis in hemophilia is treated by promptly replacing the missing coagulation factor to stop ongoing intra-articular bleeding and prevent progressive joint damage. Administering factor concentrate (e.g., factor VIII for hemophilia A or factor IX for hemophilia B) addresses the underlying deficiency and is the priority intervention. NSAIDs such as ketorolac impair platelet function and increase bleeding risk, so they are avoided; pain control is typically with acetaminophen and supportive measures. Joint aspiration is not a first-line nursing action and can worsen bleeding or introduce infection unless specifically ordered for complications. During an acute bleed, the joint should be rested/immobilized rather than exercised; ROM is introduced only after bleeding is controlled.

Question 31

Mr. K is a 54-year old male and has a history of depression, schizophrenia, and hypertension. He weighs 75 kg. He is brought to the emergency department after he was rescued from his burning house after trying to commit suicide. Upon his arrival to the Trauma room, paramedics tell you that he has superficial partial thickness burns to his head and neck, trunk, and both of his arms, as well as deep partial thickness burns to his right leg. He was found unconscious, breathing, but with an oxygen saturation of 63% on room air. Calculate the volume of IV fluid Mr. K should receive in the first 8 hours of his care. Select one?

Accepted Answer

Answer reason: Estimated %TBSA: head/neck 9% + trunk 36% + both arms 18% + one leg 18% = 81% (adult Rule of Nines), and burn depth given (partial thickness) qualifies for fluid calculation. Total 24-hr fluid = 4 × 75 × 81 = 24,300 mL, with half given in the first 8 hours from time of burn. Therefore first-8-hour volume is 12,150 mL; normal saline is not preferred for initial large-volume burn resuscitation due to hyperchloremic metabolic acidosis risk.

Question 32

The nurse notes that a client who received 1000 mL of parenteral nutrition over the past 24 hours has 200 mL remaining in the infusion bag. Which action will the nurse take when changing the solution?

Accepted Answer

Answer reason: Parenteral nutrition solutions are high in dextrose and are a significant infection risk, so they should not hang longer than the ordered schedule (typically 24 hours) regardless of remaining volume. The priority is to discontinue and replace the bag/tubing per policy to reduce microbial growth and central-line contamination risk. Trying to “catch up” by infusing the remainder faster can cause hyperglycemia and fluid shifts and is not an appropriate correction for an under-infused bag. A provider call is unnecessary because the safe, standard nursing action is to change the solution on time and then assess/document why the full volume was not delivered (e.g., interruptions, pump settings).

Question 33

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediate action does the RN take to correct the problem?

Accepted Answer

Answer reason: A fully deflating reservoir indicates the delivered flow is inadequate for the client’s inspiratory demand, risking entrainment of room air and reduced FiO2. Increasing the oxygen flow immediately restores reservoir volume and maximizes oxygen delivery in acute respiratory distress. Tightening straps addresses leaks but does not correct insufficient reservoir flow, and opening ports would further lower delivered FiO2.

Question 34

Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour?

Accepted Answer

Answer reason: IV lipid emulsions commonly contain egg phospholipids as an emulsifier, making egg allergy a key pre-infusion safety screen to prevent hypersensitivity reactions. Verifying allergy history is an immediate nursing responsibility before starting the infusion and aligns with medication/infusion safety principles. Diabetes is not an absolute contraindication to lipid infusion; glucose monitoring and insulin titration are handled separately if TPN is used. Lipids can be infused via peripheral access in many protocols (depending on concentration/osmolality and institutional policy), so a central line is not universally required, and insulin should not be added to lipid emulsions without a specific order and compatibility guidance.

Question 35

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN?

Accepted Answer

Answer reason: TPN is a high-dextrose, nutrient-rich IV solution that provides an excellent medium for microbial growth, so infection prevention is a primary safety priority. Strict aseptic technique during bag changes, tubing connections, and catheter access reduces risk of central line–associated bloodstream infection. Enteral routes like NG or gastrostomy tubes are not “parenteral” and are inappropriate for TPN administration. Bowel sounds are irrelevant to IV infusion safety, and routine peripheral administration is not appropriate for standard TPN due to hyperosmolarity and thrombophlebitis risk (PPN is a different, lower-osmolar formulation).

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