Question 1

The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from"?

Accepted Answer

Answer reason: An autograft means the tissue used for grafting is taken from the client’s own body. Skin is commonly harvested from an area such as the thigh, ensuring the graft is genetically identical and minimizing risk of rejection.

Question 2

Which finding requires immediate nursing action for a client receiving oxytocin for induction of labor?

Accepted Answer

Answer reason: Contractions every 90 seconds lasting 100 seconds indicate uterine tachysystole, a dangerous complication of oxytocin use. This decreases uteroplacental perfusion and can rapidly cause fetal distress. Oxytocin must be stopped immediately, and corrective actions initiated.

Question 3

Lithotripsy is used for clients suffering from?

Accepted Answer

Answer reason: Lithotripsy uses shock waves to break down renal calculi (kidney stones) into smaller fragments that can be passed more easily through the urinary tract. It is not used for liver disease, myocardial infarction, or nephritis.

Question 4

Which approach is commonly used to treat otosclerosis?

Accepted Answer

Answer reason: Otosclerosis causes fixation of the stapes, leading to conductive hearing loss; the standard treatment is stapedectomy (or stapedotomy with a prosthesis). Antihistamines or corticosteroids do not treat this condition, and cochlear implants are for severe sensorineural hearing loss.

Question 5

Which statement is true regarding balanced skeletal traction? Balanced skeletal traction?

Accepted Answer

Answer reason: Balanced skeletal traction is a type of skeletal traction that uses a pin inserted into the bone—commonly a Steinmann pin—to apply continuous traction. It does not require both legs to be secured, and traction does not heal fractures by itself.

Question 6

In which situation should a nurse plan to administer oxygen to an infant with congestive heart failure (CHF) as prescribed PRN?

Accepted Answer

Answer reason: Feeding increases metabolic demand and oxygen consumption in infants with CHF who tire easily and can become hypoxic. Administering oxygen during feedings reduces cardiac workload and improves oxygenation.

Question 7

The client, admitted 2 days earlier for a lung resection, accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

Accepted Answer

Answer reason: If a chest tube is accidentally dislodged, the priority is to immediately apply an occlusive (petroleum/Vaseline) gauze dressing to prevent air from entering the pleural space and causing a tension pneumothorax. Reinsertion is not a nursing action; the provider is notified after securing the site, and a chest X-ray may follow.

Question 8

A client who had a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system?

Accepted Answer

Answer reason: During transport, a chest tube system may be taken off wall suction and placed on water seal; it should not be clamped because of the risk of tension pneumothorax. Keeping it even with the shoulders is incorrect — it should remain below chest level. Therefore, leave the tube unclamped when disconnecting it from suction.

Question 9

Posterior epistaxis can be managed by which of the following methods?

Accepted Answer

Answer reason: Posterior epistaxis is treated with posterior nasal packing, endoscopic cauterization or ligation of bleeding vessels, or a dedicated epistaxis balloon catheter—thus all listed methods are appropriate.

Question 10

A client has undergone an esophagogastroduodenoscopy. The nurse should place the highest priority on which item as part of the client's care plan?

Accepted Answer

Answer reason: After EGD, the throat is anesthetized; assessing the return of the gag reflex is the priority to prevent aspiration before allowing oral intake. Other actions are secondary or comfort-related.

Question 11

Which action by a patient with an AV shunt indicates a need for further teaching?

Accepted Answer

Answer reason: Blood pressure measurement, venipuncture, and constriction should be avoided on the access arm to prevent thrombosis or damage to the AV shunt/fistula. The other actions are appropriate.

Question 12

A client is scheduled for a lumbar puncture. What position should the nurse instruct the client to assume during the procedure?

Accepted Answer

Answer reason: For a lumbar puncture, flexing the spine widens the intervertebral spaces to facilitate needle insertion and accurate pressure measurement. The standard position is the lateral decubitus position, with the knees drawn to the chest. Sitting may be used but is less preferred unless forward flexion is specified.

Question 13

Under the supervision of a registered nurse, a student nurse is changing the dressing of a 49-year-old woman with a newly inserted peritoneal dialysis catheter. Which of the following activities, if performed by the student nurse after removal of the old dressing, would require intervention by the registered nurse?

Accepted Answer

Answer reason: Cleaning from the outer abdomen toward the insertion site carries skin flora toward the catheter, increasing peritonitis risk. Correct technique is to clean from the insertion site outward using sterile motion.

Question 14

The client is receiving electroconvulsive therapy for the treatment of severe depression. Which of the following indicates that the client's ECT has been effective?

Accepted Answer

Answer reason: The therapeutic mechanism of electroconvulsive therapy relies on inducing a controlled generalized (tonic–clonic) seizure lasting approximately 30–60 seconds. This seizure causes neurochemical changes associated with improved mood regulation. Loss of consciousness and transient tachycardia are expected side effects, not the therapeutic goal.

Question 15

The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours after surgery, the drainage unit is full. Which of the following should the nurse do?

Accepted Answer

Answer reason: A wound suction device, such as a Jackson-Pratt or Hemovac, must maintain negative pressure to promote drainage. When the unit fills, it must be emptied using sterile technique to restore suction and prevent backflow or leakage. The amount is then documented as output. Removal is done only by a physician’s order.

Question 16

Which of these statements is not true regarding the management of epistaxis?

Accepted Answer

Answer reason: Anterior nasal packs are typically removed within 24–48 hours; leaving a pack in for 7 days risks infection and tissue necrosis. Prophylactic antibiotics are commonly used when nasal packing is in place, and a Foley catheter can serve as posterior packing.

Question 17

Bone marrow aspiration in children?

Accepted Answer

Answer reason: In children, the preferred and safest site for bone marrow aspiration is the posterior superior iliac crest. The tibia may be used in small infants, while the sternum and ribs are avoided due to the risk of injury.

Question 18

A client with end-stage renal disease is being managed with peritoneal dialysis. If the dialysate return is slowed, the nurse should tell the client to?

Accepted Answer

Answer reason: Sluggish outflow during peritoneal dialysis is commonly due to the catheter tip being against the peritoneum, bowel, or omentum. First, instruct the client to reposition or turn side to side to facilitate drainage. Do not irrigate or manipulate the catheter; skipping the infusion is inappropriate.

Question 19

In order to protect the fistula of a client with chronic renal failure who is receiving hemodialysis, what should the nurse do?

Accepted Answer

Answer reason: Loss of the palpable thrill or audible bruit indicates possible thrombosis or occlusion of the AV fistula, and must be reported immediately to protect the access. Blood pressure measurements and IVs should not be placed in the fistula arm, and option C reverses the correct assessments (should palpate the thrill and auscultate the bruit).

Question 20

The endotracheal tube is inserted into the?

Accepted Answer

Answer reason: An endotracheal tube is inserted through the mouth or nose into the trachea to secure the airway and allow ventilation.

Question 21

The physician has ordered aerosol treatments, chest percussion, and postural drainage for a client with cystic fibrosis. The nurse recognizes that the combination of therapies is intended to?

Accepted Answer

Answer reason: In cystic fibrosis, aerosol therapy (e.g., bronchodilators and mucolytics) opens the airways, while chest percussion and postural drainage mobilize and clear thick secretions. The combined aim is airway dilation and secretion removal.

Question 22

The nurse is caring for a client on a ventilator set to intermittent mandatory ventilation (IMV). The ventilator is set to IMV mode at 8 breaths per minute. The nurse assesses the client's respiratory rate as 13 per minute. These findings indicate that?

Accepted Answer

Answer reason: IMV provides a set number of machine breaths while allowing spontaneous breaths between them. With IMV set to 8/min and a measured rate of 13/min, the extra five breaths are the client's spontaneous breaths.

Question 23

For most patients with known COPD, what is the recommended target oxygen saturation range while awaiting blood gas results during acute exacerbations?

Accepted Answer

Answer reason: During acute COPD exacerbations, titrate oxygen to 88–92% to treat hypoxemia while minimizing the risk of CO2 retention, until ABG results guide further therapy.

Question 24

In a laparoscopic procedure, gas is used to inflate the abdominal wall?

Accepted Answer

Answer reason: CO2 is the standard gas for creating pneumoperitoneum in laparoscopy because it is nonflammable, highly soluble in blood, and is rapidly eliminated via respiration, reducing the risk of gas embolism.

Question 25

While the nurse is suctioning a tracheostomy tube, the client begins to cough. What is the best action for the nurse to take?

Accepted Answer

Answer reason: Coughing indicates that the catheter is contacting the carina. The correct response is to withdraw slightly and suction while withdrawing, allowing the patient to cough out secretions and preventing airway trauma.

Question 26

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?

Accepted Answer

Answer reason: Post-bronchoscopy, airway compromise due to bronchospasm is an emergency and must be reported immediately. Blood-streaked sputum and a mild cough can be expected; hematuria is unrelated.

Question 27

The nurse is preparing to suction a client via a tracheostomy tube. How long should the nurse plan to limit the suctioning time?

Accepted Answer

Answer reason: Each suction pass should be limited to about 10 seconds to minimize hypoxia and mucosal trauma during tracheostomy suctioning.

Question 28

Which of the following solutions would be best for the nurse to use when cleaning the inner cannula of a tracheostomy tube?

Accepted Answer

Answer reason: Half-strength hydrogen peroxide is commonly used to loosen and remove dried secretions from the tracheostomy inner cannula, followed by a sterile water or saline rinse. Alcohol, iodine, or bleach solutions are irritating and not recommended for the airway.

Question 29

How do you test the placement of an enteral tube?

Accepted Answer

Answer reason: Radiographic confirmation is the gold standard for verifying feeding or enteral tube placement. Bubbling, the absence of respiratory distress, and litmus paper testing are unreliable and not recommended methods.

Question 30

Which of the following positions is indicated during insertion of a nasogastric tube?

Accepted Answer

Answer reason: During NG tube insertion, the patient should be in a high Fowler’s position to reduce aspiration risk and allow easier passage of the tube through the oropharynx into the esophagus.

Question 31

The nurse is giving an end-of-shift report when a client with a chest tube is seen in the hallway with the tube disconnected. What is the most appropriate action?

Accepted Answer

Answer reason: Immersing the tube end in sterile saline establishes a temporary water seal, preventing air from entering the pleural cavity.

Question 32

The nurse is performing discharge teaching for a client after cardiac catheterization. Which statement by the client indicates a need for further teaching?

Accepted Answer

Answer reason: Bleeding after cardiac catheterization requires firm manual pressure and medical assistance, not cold therapy.

Question 33

A client with chest pain is scheduled for cardiac catheterization. Which of the following would the nurse include in the client's care plan?

Accepted Answer

Answer reason: Coughing and deep breathing help clear dye and stabilize catheter positioning during the procedure.

Question 34

For which common dysrhythmia should the nurse carefully monitor the client during suctioning?

Accepted Answer

Answer reason: Airway suctioning can stimulate the vagus nerve, causing reflex bradycardia; this is a well-known complication that nurses monitor for. Tachycardia or PVCs may occur from hypoxia, but bradycardia is the classic, most common response; sick sinus syndrome is a chronic condition.

Question 35

The nurse is providing discharge instructions for a client with an implantable permanent pacemaker. What discharge instruction is an essential part of the plan?

Accepted Answer

Answer reason: Pacemaker clients should check their pulse regularly to monitor device function and report abnormalities. Microwaves and commercial air travel are safe, and complete avoidance of shoulder movement is incorrect; only arm elevation above the shoulder is limited initially.

Question 36

The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via a tracheostomy mask. Assessment reveals a respiratory rate of 40 and an O2 saturation of 88%. The client is restless. Which initial nursing action is most indicated?

Accepted Answer

Answer reason: Tachypnea, restlessness, and an O2 saturation of 88% indicate acute hypoxia. With a tracheostomy, the most immediate action is to ensure airway patency by suctioning secretions before notifying the provider or rechecking values.

Question 37

A client with hepatitis C who has cirrhotic changes has just returned from a liver biopsy. The nurse will place the client in which position?

Accepted Answer

Answer reason: After a liver biopsy, placing the client on the right side provides direct pressure over the biopsy site on the liver, reducing the risk of bleeding and a bile leak.

Question 38

The chest tube drainage system has continuous bubbling in the water-seal chamber. When the nurse clamps different areas of the tube to find out where the bubbling stops, he is checking for?

Accepted Answer

Answer reason: Continuous bubbling in the water-seal chamber indicates an air leak; sequential clamping is used to locate the leak along the tubing or system.

Question 39

When suctioning a tracheostomy, the nurse would know that the suction pressure should not exceed?

Accepted Answer

Answer reason: Adult tracheal suctioning pressures are typically 80–120 mmHg; exceeding 120 mmHg increases the risk of mucosal trauma and hypoxemia.

Question 40

Mr. Jose has been admitted to the hospital with a diagnosis of pneumonia and COPD. The physician orders oxygen therapy for him. The most comfortable method of delivering oxygen to Mr. Jose is?

Accepted Answer

Answer reason: A nasal cannula is a low-flow device that is most comfortable, allows eating and talking, and is appropriate for COPD patients who generally require low FiO2. A croupette is for pediatric croup, masks are less comfortable, and a partial rebreather delivers higher FiO2, not typically indicated for COPD.

Question 41

If breath sounds are heard only on the right side after intubation?

Accepted Answer

Answer reason: Unilateral right-sided breath sounds after intubation indicate intubation of the right mainstem bronchus. The immediate corrective action is to withdraw the endotracheal tube slightly and reassess for bilateral breath sounds.

Question 42

What is the best method to confirm the placement of a nasogastric tube?

Accepted Answer

Answer reason: Radiographic verification is the gold standard for confirming NG tube placement and preventing misplacement or aspiration; methods such as auscultation or aspiration are unreliable.

Question 43

A client scheduled for an atherectomy asks the nurse about the procedure. The nurse understands that?

Accepted Answer

Answer reason: An atherectomy physically removes atherosclerotic plaque from blood vessels using a specialized catheter with a cutting or rotating tip.

Question 44

The nurse must know that the most accurate oxygen delivery system available is?

Accepted Answer

Answer reason: A Venturi mask is a high-flow oxygen device that entrains room air to deliver a fixed, precise FiO2 independent of the client’s respiratory rate or pattern; other listed devices provide variable oxygen concentrations.

Question 45

The choice of TURP solution for irrigation time?

Accepted Answer

Answer reason: For continuous bladder irrigation following TURP, isotonic normal saline is the solution of choice because it avoids hemolysis and electrolyte disturbances. Plain water is hypotonic and unsafe; glycerol is not a standard irrigant.

Question 46

What are the indications for double-volume exchange transfusion at birth in infants with Rh isoimmunization?

Accepted Answer

Answer reason: Rapidly rising bilirubin levels indicate hemolysis and risk for kernicterus, requiring exchange transfusion to remove sensitized RBCs and bilirubin.

Question 47

The optimal indication for phototherapy in neonatal jaundice is?

Accepted Answer

Answer reason: Phototherapy is initiated when bilirubin exceeds 15 mg/dL in term infants to prevent kernicterus by enhancing bilirubin breakdown through photo-oxidation.

Question 48

Never leave a tourniquet on for more than what?

Accepted Answer

Answer reason: During venipuncture a tourniquet should not be left in place longer than 1 minute to prevent hemoconcentration and inaccurate lab results.

Question 49

A client is scheduled for a labyrinthectomy to treat Ménière's syndrome. What expected outcome of the procedure should be included in the preoperative teaching?

Accepted Answer

Answer reason: Labyrinthectomy ablates the labyrinth to control severe vertigo in Ménière disease, resulting in loss of hearing in the operated ear. It does not affect pain, cerumen, or sense of smell.

Question 50

Which of the following complications is associated with mechanical ventilation?

Accepted Answer

Answer reason: Mechanical ventilation is associated with stress-related mucosal damage and GI bleeding; thus patients often receive stress-ulcer prophylaxis. It does not cause increased cardiac output, is not a direct cause of immunosuppression, and is not specifically associated with pulmonary emboli.

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