Question 1

The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300 mL. The nurse should give priority to?

Accepted Answer

Answer reason: Chest tube drainage of 300 mL/hr post-lung resection is excessive and suggests hemorrhage; the priority is to notify the provider. Milking is not routine, turning position or slowing IV does not address possible bleeding.

Question 2

Phototherapy is used in the treatment of what?

Accepted Answer

Answer reason: Phototherapy converts unconjugated bilirubin to water‑soluble isomers for excretion and is the standard treatment for neonatal hyperbilirubinemia (jaundice), not NEC, polycythemia, or hypocalcemia.

Question 3

When caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse notifies the pediatrician if which of these is noted?

Accepted Answer

Answer reason: Bronze discoloration (bronze baby syndrome) during phototherapy suggests conjugated hyperbilirubinemia/cholestasis and warrants notifying the provider and reassessing therapy. A transient maculopapular rash is common, urine specific gravity of 1.018 is not critical, and an absent Moro reflex is unrelated to phototherapy effects.

Question 4

How much distance should be maintained from the bililight to the neonate, not less than?

Accepted Answer

Answer reason: For conventional phototherapy, the light source should be kept about 45 cm from the neonate to provide effective irradiance while preventing overheating and skin/eye injury. Therefore, the minimum distance is 45 cm.

Question 5

Which colour of light is used to treat neonatal jaundice?

Accepted Answer

Answer reason: Phototherapy for neonatal hyperbilirubinemia uses blue light (about 460–490 nm) to photoisomerize bilirubin into water-soluble forms for excretion.

Question 6

What is the size of the resuscitation face mask for preterm infants?

Accepted Answer

Answer reason: Preterm neonates require a smaller face mask; standard neonatal resuscitation equipment uses size 0 for preterm and size 1 for term infants to ensure an effective seal.

Question 7

What room temperature should be maintained during the period of phototherapy?

Accepted Answer

Answer reason: During neonatal phototherapy the infant is largely undressed, increasing risk of cold stress; a warm ambient room temperature of 28–30°C is recommended to maintain thermoregulation.

Question 8

Phototherapy is indicated for children with?

Accepted Answer

Answer reason: Phototherapy converts unconjugated bilirubin to water‑soluble isomers for excretion, so it is used to treat neonatal hyperbilirubinemia/jaundice. It is not indicated for NEC or hypoglycemia; hemolytic disease may cause jaundice, but the direct indication is hyperbilirubinemia.

Question 9

During phototherapy, the nursing measures include all of the following except?

Accepted Answer

Answer reason: During neonatal phototherapy, maximize skin exposure; infant is usually undressed except for eye protection and genital covering, while hydration and temperature are monitored. Therefore dressing the baby is not an appropriate measure.

Question 10

Which of the following statements is correct regarding phototherapy?

Accepted Answer

Answer reason: Phototherapy for neonatal jaundice uses blue light in the 430–490 nm range; the standard lamp-to-infant distance is about 30–45 cm; and a biliblanket provides undersurface light used along with overhead lights for double-surface phototherapy. Therefore all statements are correct.

Question 11

Which of the following is not a manual mobilization technique used while performing chest physiotherapy?

Accepted Answer

Answer reason: Clapping (percussion) and vibration are manual chest physiotherapy techniques performed by the caregiver, whereas coughing is a patient expiratory maneuver, not a manual mobilization technique.

Question 12

The physician gives an order for a patient with cystic fibrosis to use a positive expiratory pressure (PEP) device to help with airway clearance. As the nurse, which device will you order from the supply?

Accepted Answer

Answer reason: A flutter valve is a handheld PEP device that provides oscillating positive expiratory pressure to mobilize secretions, commonly used in cystic fibrosis for airway clearance. The other devices do not provide PEP for airway clearance.

Question 13

Size of endotracheal tubes used for newborns is?

Accepted Answer

Answer reason: Neonates typically require small uncuffed ETTs: preterm about 2.5 mm ID and term 3.0–3.5 mm. Thus the correct range for newborns is 2.5–3.5 mm.

Question 14

Airway clearance techniques are used to help move thick mucus out of the lungs of someone with cystic fibrosis. There are various ways to accomplish this. Which of these are airway clearance techniques used in cystic fibrosis?

Accepted Answer

Answer reason: Autogenic drainage, high-frequency chest wall oscillation (vest), and chest physiotherapy/postural drainage are all recognized airway clearance techniques for cystic fibrosis; therefore the best choice is 'All of these.

Question 15

All of the following are essential for an infant with jaundice who is under phototherapy except?

Accepted Answer

Answer reason: Protection of the eyes and usually the genital area plus frequent breastfeeding are standard nursing measures during neonatal phototherapy. Routine bilirubin testing every 6 hours is not essential for all infants and would be excessive; monitoring is done periodically based on clinical need.

Question 16

Is exchange blood transfusion required in a term baby with pathological jaundice when the bilirubin level is more than?

Accepted Answer

Answer reason: In term neonates, exchange transfusion is indicated for severe hyperbilirubinemia (risk of kernicterus) commonly at total serum bilirubin >20 mg/dL; lower thresholds apply to preterm infants.

Question 17

The most confirmatory sign of endotracheal intubation is?

Accepted Answer

Answer reason: Continuous waveform end-tidal CO2 detection (capnography) is the most reliable confirmation of correct endotracheal tube placement; chest rise and auscultation can be misleading, and spirometry is not used for confirmation.

Question 18

A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

Accepted Answer

Answer reason: Gentle, continuous pressure to the lower nasal cartilage helps tamponade the bleeding vessel without causing trauma. In hemophilia, invasive measures like packing should be avoided unless prescribed.

Question 19

What is "Trotter's method of management of epistaxis"?

Accepted Answer

Answer reason: Trotter’s method emphasizes a forward-leaning position with quiet breathing to minimize swallowing blood and to observe bleeding sites, a conservative management for epistaxis.

Question 20

Goal of phototherapy in a newborn is to?

Accepted Answer

Answer reason: Phototherapy converts unconjugated bilirubin into water‑soluble photoisomers (e.g., lumirubin) that can be excreted, thereby lowering serum unconjugated bilirubin. It does not target conjugated bilirubin, and hypothermia or respiratory stability are not the primary goals.

Question 21

A newborn presents with jaundice within 1st 24 hours. His mother's blood group is O+ ve. Next line of management is?

Accepted Answer

Answer reason: Jaundice within the first 24 hours is pathologic, often due to hemolysis such as ABO incompatibility (mother O+). Begin treatment immediately with phototherapy to prevent bilirubin encephalopathy; do not wait for results. Exchange transfusion is reserved for severe levels or failure of phototherapy.

Question 22

In phototherapy unit what is the importance of aluminium foil around the unit?

Accepted Answer

Answer reason: Aluminium foil is used to reflect light back onto the infant, increasing irradiance and effectiveness of phototherapy. Privacy or blocking other lights are not the primary purposes.

Question 23

A client is diagnosed with bladder cancer, and a cystectomy and an ileal conduit are scheduled. What should the nurse plan to do preoperatively?

Accepted Answer

Answer reason: For an ileal conduit, a segment of ileum will be used; preoperative bowel preparation with enemas and cathartics reduces intestinal contents and bacterial load, lowering postoperative infection risk. Fluids should not be restricted, Kegels are irrelevant, and routine conduit irrigation is not taught preoperatively.

Question 24

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: Bile-colored drainage of approximately 500–1000 mL in the first 24 hours from a T-tube after cholecystectomy is expected. No intervention is required other than documenting the output. Clamping or irrigating requires a provider order; notifying the provider is unnecessary for expected findings.

Question 25

The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which post operative prescription should the nurse question and verify?

Accepted Answer

Answer reason: After gastric surgery the NG tube should not be irrigated or repositioned unless specifically directed by the surgeon because it can disrupt the anastomosis. Leg exercises, early ambulation, and coughing/deep breathing are appropriate to prevent postoperative complications.

Question 26

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?

Accepted Answer

Answer reason: A low-pressure alarm usually indicates disconnection or leak. If the cause cannot be identified immediately, the priority is to ensure oxygenation and ventilation by manually ventilating the client with a resuscitation bag; then troubleshoot the ventilator. Checking vitals or starting CPR are not first actions unless arrest occurs.

Question 27

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client?

Accepted Answer

Answer reason: The Venturi mask delivers a precise, controlled FiO2 via entrainment ports, making it the preferred device for clients with COPD. Face tent, aerosol mask, and tracheostomy collar provide less predictable oxygen concentrations.

Question 28

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?

Accepted Answer

Answer reason: In postural drainage, once positioned the nurse uses chest percussion and vibration to loosen and mobilize secretions for expectoration. The other options are not part of chest physiotherapy steps.

Question 29

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?

Accepted Answer

Answer reason: Effective drainage of tamponade should reverse hypotension; blood pressure rises while signs of tamponade (muffled heart sounds, JVD, dyspnea) improve.

Question 30

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions?

Accepted Answer

Answer reason: Clients with a halo device should not drive at all; the device limits range of motion and may impair reaction time. The other statements reflect appropriate precautions and skin care.

Question 31

Which of the following best explains the ileal conduit surgical procedure?

Accepted Answer

Answer reason: An ileal conduit uses a segment of ileum as a conduit for urine from the ureters to a stoma on the abdominal wall. A describes a bladder opening, B describes ureterosigmoidostomy, and C is incorrect because an ileal conduit is typically permanent.

Question 32

High levels of PEEP can cause which of the following to occur?

Accepted Answer

Answer reason: High PEEP raises intrathoracic pressure, which reduces venous return (preload) and thereby decreases cardiac output.

Question 33

Which position is BEST for a patient undergoing thoracentesis?

Accepted Answer

Answer reason: For thoracentesis, the client should sit upright and lean forward with arms supported to widen intercostal spaces and allow access to the pleural space. Supine, prone, and Trendelenburg hinder the procedure and increase risk.

Question 34

What is the purpose of humidification in tracheostomy care?

Accepted Answer

Answer reason: A tracheostomy bypasses the upper airway, which normally warms and humidifies air. Added humidification prevents drying of mucosa and secretions, reducing plugs.

Question 35

A client is being discharged after lithotripsy for removal of a kidney stone. Which statement by the client indicates understanding of the nurse’s instructions?

Accepted Answer

Answer reason: Post-lithotripsy, clients should strain all urine to collect and save stone fragments for analysis; they do not need to save all urine or stop straining.

Question 36

The nurse is preparing a client for cervical uterine radiation implant insertion. Which will be included in the teaching plan?

Accepted Answer

Answer reason: For intracavitary radiation (sealed source), a Foley catheter is inserted to prevent bladder distention and minimize implant displacement. TV/phone are allowed, a low-residue (not high-fiber) diet is used to reduce bowel movements, and excretions are not radioactive with sealed implants.

Question 37

A pneumonectomy is performed on a client with lung cancer. Which of the following would probably be omitted from the client's plan of care?

Accepted Answer

Answer reason: After a pneumonectomy there is no lung to re-expand, so chest tubes/closed chest drainage are typically not used. Pain control, supplemental oxygen, and coughing/deep-breathing remain part of care.

Question 38

A nurse is assisting the physician with chest tube removal. To remove the chest tube, the client is instructed to?

Accepted Answer

Answer reason: During chest tube removal the client performs a Valsalva maneuver (deep breath, exhale, and bear down) to increase intrathoracic pressure and prevent air entry into the pleural space.

Question 39

A client with epilepsy has a vagal nerve stimulator in place. Which would indicate that the device is working properly?

Accepted Answer

Answer reason: Vagal nerve stimulation commonly causes transient hoarseness/voice change during stimulation, indicating device activity. Hiccups, local vibrations, or loss of radial pulse are not expected signs and could indicate problems.

Question 40

Which intervention should a nurse include in the care of a client in the immediate post-cardiac catheterization period?

Accepted Answer

Answer reason: After cardiac catheterization, the priority is to assess the vascular access site for bleeding or hematoma to prevent hemorrhage. The stated VS frequency (every 30 min) is not immediate phase care (should be more frequent initially). Prone positioning is incorrect; clients are kept supine with the affected leg straight. NPO is not required postprocedure.

Question 41

What is the nursing priority when caring for a patient who has received a temporary pacemaker following third-degree AV block?

Accepted Answer

Answer reason: With a temporary pacemaker after third-degree AV block, the immediate priority is ensuring effective pacing. Verifying the integrity and securement of pacing wires prevents loss of capture and life-threatening bradyarrhythmias.

Question 42

A client returns to the unit after placement of a split-thickness autograft to a burn on the right arm; which intervention does the nurse give the highest immediate priority?

Accepted Answer

Answer reason: Immediately after a skin autograft, the priority is to immobilize the grafted area to prevent shearing and bleeding so the graft can adhere, reducing risk of graft failure. Pain management and monitoring are important but not the highest immediate priority; light exposure is not critical.

Question 43

During peritoneal dialysis, if the nurse observes that the flow of dialysate stops before all the solution has drained out, what should the nurse do?

Accepted Answer

Answer reason: Poor dialysate outflow is commonly due to catheter tip occlusion by the omentum or malposition. The first nursing action is to reposition the client (turn side to side) to reestablish flow; do not manipulate the catheter, and walking or sitting are not first-line.

Question 44

Which statement by the parents of a 2-week-old infant with clubfoot indicates a need for further teaching regarding this disorder?

Accepted Answer

Answer reason: Clubfoot is treated with early serial casting (Ponseti method) with casts changed about weekly. Saying a new cast is needed in 1 month reflects incorrect understanding.

Question 45

What discharge teaching should the nurse provide to a client with a fractured right ankle in a short leg cast to prevent complications?

Accepted Answer

Answer reason: Elevation above heart level reduces edema and pain and helps prevent complications such as impaired circulation or compartment syndrome. Weight bearing requires a provider order; burning/tingling are warning signs to report; trimming a cast is not advised by clients.

Question 46

What is the best management option for a 24-year-old woman at 6 weeks gestation with a 3-cm unruptured ectopic pregnancy, BhCG 16,000 mIU/mL, and no fetal cardiac motion?

Accepted Answer

Answer reason: With BhCG 16,000 mIU/mL, medical therapy with methotrexate has a high failure rate; stable, unruptured ectopic pregnancy is best managed surgically. Laparoscopic salpingostomy is the preferred option. The methotrexate options list incorrect dosing (30 mg/m2 or flat 50 mg).

Question 47

What is the next appropriate nursing action when a client's chest tube has dislodged and is lying on the floor?

Accepted Answer

Answer reason: A chest tube that has come out of the chest requires immediately covering the insertion site with a sterile (preferably occlusive, taped on 3 sides) dressing to prevent air entry and tension pneumothorax. Submerging the tube in water applies when the tube is disconnected from the drainage system but still in the client.

Question 48

In planning care for a client who has had a posterior fossa (infratentorial) craniotomy, which positioning action is contraindicated?

Accepted Answer

Answer reason: After posterior fossa (infratentorial) craniotomy the client is kept flat or side-lying with the neck neutral and turned as a unit to prevent increased ICP and protect the surgical site. Elevating the HOB to 30 degrees is avoided in the immediate postoperative period.

Question 49

During hyperbaric oxygen therapy for a client diagnosed with both a wound infection and osteomyelitis, which priority intervention should the nurse implement?

Accepted Answer

Answer reason: ABCs priority: during hyperbaric oxygen therapy the critical nursing action is to verify effective oxygen delivery; sedation and IV access are secondary, and family support is non-urgent.

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