Question 1

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

Accepted Answer

Answer reason: With peritoneal dialysis, poor outflow is commonly due to catheter malposition or obstruction by omentum; first-line nursing action is to reposition the client (e.g., turn side to side) to improve drainage. Repositioning the catheter requires a provider; ambulating or sitting is not practical during drainage.

Question 2

A client with chronic renal failure is receiving peritoneal dialysis. During the exchange, the nurse notes that the outflow is less than the inflow. What is the appropriate nursing action?

Accepted Answer

Answer reason: Less outflow than inflow indicates impaired drainage. The first, least invasive action is to assess the system for mechanical obstruction, such as kinks or closed clamps, before repositioning or altering the procedure.

Question 3

A patient returns from surgery. The nurse is doing education on incentive spirometer (IS) use. Which would be the MOST appropriate amount to use the IS?

Accepted Answer

Answer reason: Postoperative teaching for incentive spirometry is typically 10 breaths every hour while awake to prevent atelectasis and pneumonia.

Question 4

The nurse is caring for a client with a nasogastric tube. What is the correct method for verifying the placement of the tube?

Accepted Answer

Answer reason: Bedside verification of NG tube placement is done by checking gastric aspirate pH (typically ≤5 in the stomach). Air auscultation, measuring exposed length, and observing movement are unreliable indicators.

Question 5

Which medical device is used to support or replace kidney function in patients with renal failure?

Accepted Answer

Answer reason: Dialysis machines filter blood to remove waste and excess fluid, replacing kidney function in renal failure. Ventilators support breathing, and an incubator is for neonatal care.

Question 6

What is the priority action for the nurse when a patient with third-degree AV block is prescribed transcutaneous pacing?

Accepted Answer

Answer reason: For emergent transcutaneous pacing, ensuring clean, dry skin optimizes pad adhesion and lowers impedance to achieve reliable electrical capture. Sedation is helpful but should not delay pacing.

Question 7

When performing chest percussion on a child, which technique should the nurse use?

Accepted Answer

Answer reason: Chest physiotherapy uses cupped-hand percussion to create a hollow popping sound over lung segments; slapping is incorrect, the abdomen is not percussed, and a thick blanket would dampen percussion.

Question 8

Which nursing intervention should be included in the client's plan of care during dialysis therapy?

Accepted Answer

Answer reason: Hemodialysis commonly causes rapid fluid shifts and can lead to hypotension; therefore frequent blood pressure monitoring is essential. Limiting visitors, padding side rails, or NPO status are not routine dialysis care.

Question 9

After bronchoscopy, the client is drowsy and has no gag reflex; what is the appropriate nursing action?

Accepted Answer

Answer reason: After bronchoscopy the client may be sedated and lacks a gag reflex, creating high aspiration risk. Placing the client in the lateral position helps protect the airway and allows secretions to drain. Fluids are withheld until the gag reflex returns; suctioning can traumatize the airway; head elevation alone is less protective.

Question 10

The nurse is caring for a client with a nasogastric tube. What is the appropriate action if the tube becomes accidentally dislodged?

Accepted Answer

Answer reason: A dislodged NG tube poses aspiration/misplacement risk. Do not reinsert or secure it without an order; stop using it and notify the provider for replacement and placement verification.

Question 11

Which complication may arise if a client with COPD and coronary artery disease receives a high concentration of oxygen?

Accepted Answer

Answer reason: In COPD, high oxygen can suppress the hypoxic respiratory drive, causing hypoventilation, CO2 retention, and possible apnea.

Question 12

In which position should the nurse place a client who is being prepared to receive an epidural patch for a postlumbar puncture headache?

Accepted Answer

Answer reason: For an epidural blood patch, the client is typically positioned in the lateral decubitus (side-lying) position to flex the spine and open intervertebral spaces for sterile epidural access. The other positions are not standard for this procedure.

Question 13

What is the most appropriate position for a client post-lumbar puncture who reports a severe headache?

Accepted Answer

Answer reason: Post–lumbar puncture headache is due to CSF leakage; keeping the client flat reduces CSF loss and meningeal traction, helping relieve the headache. Head elevation tends to worsen it.

Question 14

What is the method used to extract stomach contents especially when someone has ingested extractable poison?

Accepted Answer

Answer reason: Gastric lavage is the procedure for removing stomach contents after toxic ingestion. Intubation protects the airway, urinary catheterization drains the bladder, and endoscopy is for visualization rather than extraction.

Question 15

What is the primary purpose of an AV shunt in a patient with renal failure?

Accepted Answer

Answer reason: An AV shunt (fistula or graft) creates high-flow vascular access specifically for hemodialysis; it is not used to raise blood pressure, give routine medications, or improve limb circulation.

Question 16

Why is the dialysis solution warmed before use in peritoneal dialysis?

Accepted Answer

Answer reason: Dialysate is warmed to body temperature to prevent abdominal cramping and discomfort by relaxing abdominal muscles and preventing vasoconstriction; it is not for potassium shifting or body warming.

Question 17

Which solution is used for bladder irrigation if there is a contraindication to normal saline (NS)?

Accepted Answer

Answer reason: When NS cannot be used, 0.25% acetic acid is an accepted bladder irrigant that helps reduce bacterial growth and encrustation. Silver nitrate is caustic and not routine; 5% dextrose is inappropriate; NS is contraindicated per stem.

Question 18

When a patient's nasogastric (NG) tube stops draining, what is the nurse's first action?

Accepted Answer

Answer reason: Stopped drainage may indicate displacement or occlusion. The priority is to verify correct NG tube placement and patency before flushing, retracting, or clamping to prevent aspiration or injury.

Question 19

What is the name of the procedure used to remove fluid or air from the pleural space via a needle?

Accepted Answer

Answer reason: Thoracentesis is needle aspiration of the pleural space to remove air or fluid. Paracentesis is for peritoneal fluid, pericardiocentesis for pericardial fluid, and tracheostomy is a surgical airway.

Question 20

A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is?

Accepted Answer

Answer reason: Red granulation tissue in a stage III pressure ulcer should be protected and kept moist to promote epithelial migration; debridement agents (wet-to-dry, hydrogen peroxide, debriding granules) would damage healthy tissue. A moist saline dressing maintains an optimal moist environment.

Question 21

The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is?

Accepted Answer

Answer reason: After ESWL, increased fluid intake promotes passage of stone fragments and helps prevent formation of new calculi.

Question 22

A client with emphysema has been receiving oxygen at 3L per minute by nasal cannula. The nurse knows that the goal of the client’s oxygen therapy is achieved when the client’s PaO2 reading is?

Accepted Answer

Answer reason: For COPD/emphysema, oxygen therapy aims to correct hypoxemia without suppressing ventilatory drive; target PaO2 is around 60 mm Hg (SaO2 ~88–92%). Thus 50–60 mm Hg is the appropriate goal.

Question 23

The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to?

Accepted Answer

Answer reason: Proper chest percussion uses cupped hands to create an air cushion and effective vibration; the heel of the hand is incorrect. Percussion should be done before meals or 1–2 hours after, and positions are changed frequently, not every 20 minutes.

Question 24

A client with end-stage renal failure receives hemodialysis via an arteriovenous fistula (AV) placed in the right arm. When caring for the client, the nurse should?

Accepted Answer

Answer reason: For an AV fistula, the nurse assesses patency by auscultating for a bruit (and palpating a thrill). Blood pressures, venipunctures, and flushing the fistula are contraindicated in the access limb to prevent damage or thrombosis.

Question 25

Which item is most important for the nurse to place at the client's bedside prior to a paracentesis procedure?

Accepted Answer

Answer reason: During paracentesis the client commonly experiences nausea; having an emesis basin at the bedside is an immediate safety and comfort need. Tape measure and scale are for pre/post measurements, and BP cuff is routine but not as immediately essential as the emesis basin at bedside.

Question 26

After a renal biopsy, how should the nurse position the client?

Accepted Answer

Answer reason: After a renal biopsy, placing the client on the affected side for 30–60 minutes applies direct pressure to the biopsy site, reducing the risk of bleeding. Other positions do not provide hemostasis.

Question 27

The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to?

Accepted Answer

Answer reason: Securing the new tie before removing the old tie maintains stabilization of the tracheostomy and prevents accidental decannulation. Having help or holding the tube are supportive measures, and suturing is not routine.

Question 28

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 per hour is excessive and suggests possible hemorrhage after lung resection. The priority is to immediately notify the provider. Milking the tube is not recommended; repositioning or slowing IV fluids will not address the potential bleeding.

Question 29

A client with Parkinson’s disease is scheduled for stereotactic surgery. Which finding indicates that the surgery had its intended effect?

Accepted Answer

Answer reason: Stereotactic procedures for Parkinson’s (e.g., thalamotomy/DBS) aim to reduce severe, medication‑refractory tremors and dyskinesias. They do not restore dopamine or serotonin production, and many clients still need medication.

Question 30

Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should?

Accepted Answer

Answer reason: Acticoat (silver-impregnated) dressings must be kept moist with sterile water to activate antimicrobial silver. Normal saline can inactivate silver, and frequent changes (e.g., each shift) are unnecessary; these dressings are typically changed every few days.

Question 31

The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should?

Accepted Answer

Answer reason: Before paracentesis the bladder should be emptied to prevent accidental puncture; providing a urinal facilitates voiding. Shaving is unnecessary, extra fluids are not indicated, and ordering ultrasound is not a nursing responsibility.

Question 32

The nurse caring for a client with chest tubes notes that the Pleurevac’s collection chambers are full. The nurse should?

Accepted Answer

Answer reason: When the chest tube collection chamber is full, the closed drainage system must be replaced with a new sterile unit to maintain function and sterility. Do not attempt to empty it with a syringe, add water to the suction-control chamber, or milk the tubing.

Question 33

The nurse is teaching a client with peritoneal dialysis how to manage exchanges at home. The nurse should tell the client to notify the doctor immediately if?

Accepted Answer

Answer reason: Cloudy peritoneal effluent indicates peritonitis, a serious complication of peritoneal dialysis that requires immediate provider notification. Slower return, tugging sensation, and fullness can occur and are typically managed with repositioning or monitoring.

Question 34

The physician has ordered continuous bladder irrigation for a client following a prostatectomy. The nurse should?

Accepted Answer

Answer reason: For continuous bladder irrigation, the solution bag should be hung about 2–3 ft above the bladder to allow gravity flow without excessive pressure. The tubing should be primed to avoid air, sterile technique is required (not clean), and the line should not be intermittently clamped.

Question 35

Skeletal traction is applied to the right femur of a client injured in a fall. The primary purpose of the skeletal traction is to?

Accepted Answer

Answer reason: Skeletal traction applies a continuous pulling force directly to the bone via pins or wires, primarily to maintain alignment and realign bone fragments in long-bone fractures such as the femur.

Question 36

A client has returned from having a bronchoscopy. Before offering the client sips of water, the nurse should assess the client's?

Accepted Answer

Answer reason: After bronchoscopy the throat is anesthetized; oral intake is unsafe until the gag reflex returns to prevent aspiration. Therefore, assess the gag reflex before giving water.

Question 37

The physician has inserted an esophageal balloon tamponade in a client with bleeding esophageal varices. The nurse should maintain the esophageal balloon at a pressure of?

Accepted Answer

Answer reason: Esophageal balloon tamponade pressures are typically maintained around 25 mmHg (not to exceed ~40 mmHg) to control variceal bleeding while limiting ischemic injury. Among the options, 20–25 mmHg is the appropriate range.

Question 38

The nurse on an orthopedic unit is assigned to care for four clients with displaced bone fractures. Which client will not be treated with the use of traction?

Accepted Answer

Answer reason: Traction is commonly used for femur and cervical spine fractures and may be used for humeral fractures (e.g., Dunlop traction). Ankle fractures are typically managed with immobilization or ORIF rather than traction.

Question 39

The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client before removing the drain?

Accepted Answer

Answer reason: During chest tube (Davol) removal, the client is instructed to hold their breath/perform Valsalva to increase intrathoracic pressure and prevent air from entering the pleural space, reducing risk of pneumothorax.

Question 40

A client returns from surgery with a total knee replacement. Which of the following findings requires immediate nursing intervention?

Accepted Answer

Answer reason: Immediately post–total knee replacement, CPM settings start at low flexion and are advanced gradually. A setting of 90° flexion is excessive early on and risks tissue injury or compromise of the prosthesis, requiring prompt adjustment. The other findings are expected/manageable without urgent intervention.

Question 41

The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the?

Accepted Answer

Answer reason: For accurate CVP measurement, the zero reference point is leveled with the right atrium at the phlebostatic axis (4th intercostal space at the mid-axillary line).

Question 42

The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should?

Accepted Answer

Answer reason: Before ECT a blood pressure cuff is applied and inflated on one extremity to help observe seizure activity after the muscle relaxant is given. Anticonvulsants would inhibit the therapeutic seizure; shellfish allergy is irrelevant; a tourniquet is not the recommended method.

Question 43

After the physician performs an amniotomy, the nurse's first action should be to assess the?

Accepted Answer

Answer reason: After amniotomy the priority is to assess fetal heart rate to detect cord prolapse or fetal distress; this takes precedence over cervical checks, maternal vitals, or discomfort.

Question 44

A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant's traction. Which finding by the nurse indicates that the traction is working properly?

Accepted Answer

Answer reason: In Bryant’s traction for young children, hips are flexed at 90° and the child’s buttocks should be slightly elevated off the bed to provide countertraction, indicating proper function. Pins are not used (it is skin traction).

Question 45

A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?

Accepted Answer

Answer reason: Controls are placed distal/out of the client’s reach (e.g., at the foot of the bed) to prevent the client from changing settings and to ensure safe, proper use. The CPM does not allow ambulation, pain is managed and alignment checked rather than routinely stopping the device, and it does not replace post-discharge physical therapy.

Question 46

The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?

Accepted Answer

Answer reason: Chest tubes remove air, blood, and serous fluid from the pleural space to restore negative pressure and allow lung re-expansion, which is the primary rationale.

Question 47

The client with a pacemaker should be taught to?

Accepted Answer

Answer reason: Clients with pacemakers should check their pulse daily to verify the device is firing and maintaining the prescribed rate. Microwaves are safe with modern pacemakers, daily BP checks are not specifically required, and ankle edema is not a primary pacemaker-specific teaching point.

Question 48

The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?

Accepted Answer

Answer reason: Multiple fractures in the foot often require surgical fixation; K-wires stabilize fragmented bones. A spica cast is for hip/femur injuries, a simple plaster cast suits uncomplicated single fractures, and a gauze dressing alone is inadequate.

Question 49

A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to?

Accepted Answer

Answer reason: A Jackson-Pratt is a closed-suction drain used to remove blood/serous fluid from the operative site to prevent accumulation and promote healing. It is not for keeping the bile duct open or preventing dressing changes.

Question 50

A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by?

Accepted Answer

Answer reason: Hemodialysis removes uremic wastes and excess fluid by filtering blood across a semipermeable (dialyzing) membrane. It does not remove plasma proteins; water passage alone is not the mechanism, and removing acids would raise, not lower, pH.

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