Question 1

The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting for performing tracheostomy suctioning on the adult client is?

Accepted Answer

Answer reason: For adult tracheal suctioning, the recommended negative pressure is approximately 80–120 mmHg to effectively clear secretions while minimizing mucosal trauma.

Question 2

A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should?

Accepted Answer

Answer reason: Radiation field marks must be preserved. Soap, lotions, or solvents can remove the markings and irritate the skin. Do not cover with dressings or apply powders/creams unless prescribed.

Question 3

The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should?

Accepted Answer

Answer reason: After transsphenoidal hypophysectomy, monitor for complications including endocrine changes and effects of corticosteroid therapy; blood glucose monitoring is appropriate. Frequent suctioning, Trendelenburg position, and coughing increase risk of bleeding/CSF leak and are contraindicated.

Question 4

A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should?

Accepted Answer

Answer reason: Before hyperbaric oxygen therapy, petroleum-based or occlusive products are avoided due to fire risk and to allow oxygen to reach the wound. The skin should be cleansed with water and patted dry.

Question 5

An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse’s discharge teaching?

Accepted Answer

Answer reason: After hypospadias repair, activities that put pressure on the perineum (e.g., straddle toys like a rocking horse) should be avoided to protect the repair and stent. Warm compresses are not indicated, diapering is allowed (often double-diapering), and no special diet is required.

Question 6

A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will?

Accepted Answer

Answer reason: The modified Blalock–Taussig shunt connects a systemic artery to the pulmonary artery to increase pulmonary blood flow in Tetralogy of Fallot. It is a palliative procedure and does not reverse blood flow, relieve ventricular pressure directly, or eliminate the need for later definitive repair.

Question 7

A client with acute respiratory distress syndrome (ARDS) is placed on mechanical ventilation. To increase ventilation and perfusion to all areas of the lungs, the nurse should?

Accepted Answer

Answer reason: Frequent turning (including prone/supine changes) redistributes ventilation and perfusion, recruits alveoli, and improves V/Q matching in ARDS. Adjusting PEEP requires a provider order, instructing deep breaths is not meaningful on mechanical ventilation, and sedation may improve synchrony but does not directly enhance ventilation to all lung areas.

Question 8

When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find?

Accepted Answer

Answer reason: After extracorporeal shock wave lithotripsy, transient hematuria is expected and should lighten and clear over time. Orange urine suggests phenazopyridine use, and dark red/cloudy or smoky urine suggests complications.

Question 9

Which of the following statements best explains the rationale for placing the client in Trendelenburg position during the insertion of a central line catheter?

Accepted Answer

Answer reason: Trendelenburg increases venous return and distends central veins, making them easier to access and reducing air entry risk. Among the options, this best corresponds to facilitating catheter insertion.

Question 10

What is the name of the tray used for holding surgical instruments?

Accepted Answer

Answer reason: An instrument tray is specifically designed to hold surgical instruments. Sterilization trays are for processing, dissecting trays are for lab dissections, and a kidney tray is an emesis basin.

Question 11

The reasons to actually discontinue the vacuum extraction procedure once it has actually begun are?

Accepted Answer

Answer reason: All listed are standard stop criteria for vacuum-assisted delivery: suspected CPD or fetal scalp trauma, no descent after 2–3 pulls, multiple cup detachments, or exceeding recommended time limits.

Question 12

After completion of peritoneal dialysis, what should the nurse assess the client for?

Accepted Answer

Answer reason: Peritoneal dialysis removes excess fluid; clients typically have a decrease in body weight post-treatment. Hematuria is unrelated, hypertension should improve, and urine output usually does not increase in ESRD.

Question 13

The doctor is preparing to remove chest tubes from the client's left chest. In preparation for the removal, the nurse should instruct the client to?

Accepted Answer

Answer reason: During chest tube removal the client should perform the Valsalva maneuver (hold breath and bear down) to increase intrathoracic pressure and prevent air from entering the pleural space, reducing risk of pneumothorax.

Question 14

The client with cirrhosis is scheduled for a paracentesis. Which instruction should be given to the client before the exam?

Accepted Answer

Answer reason: Before paracentesis the client should void to reduce the risk of bladder perforation. The client is positioned upright, is usually awake with local anesthesia, and medications are not injected to treat cirrhosis during the procedure.

Question 15

The nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?

Accepted Answer

Answer reason: Performing a Valsalva increases intrathoracic pressure and transiently elevates CVP, giving a falsely high reading. The client should rest and breathe normally at end-expiration; other listed actions are appropriate for CVP manometer measurement.

Question 16

A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for?

Accepted Answer

Answer reason: Temporary Buck's traction is commonly ordered to immobilize a suspected femoral fracture and reduce muscle spasm prior to definitive treatment. Trendelenburg is inappropriate, icing the entire extremity is not indicated, and an abduction pillow is for post–hip replacement care.

Question 17

A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The dysrhythmia most commonly seen during suctioning is?

Accepted Answer

Answer reason: Airway suctioning can stimulate the vagus nerve, causing reflex bradycardia—the most common dysrhythmia during suctioning.

Question 18

The nurse is performing discharge instruction to a client with an implantable defibrillator. What discharge instruction is essential?

Accepted Answer

Answer reason: Microwaves and commercial air travel are safe with an ICD. The arm should not be immobilized; only avoid lifting the arm above shoulder level while leads heal. To minimize electromagnetic interference, use a cell phone on the side opposite the device (typically the right side for left-sided implants).

Question 19

A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan?

Accepted Answer

Answer reason: After a lobectomy, chest tubes are routinely used to drain air and fluid and allow the remaining lung to re-expand. Tracheostomy and Swan-Ganz monitoring are not routine, and vigorous chest physiotherapy is typically not immediate post-op.

Question 20

The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?

Accepted Answer

Answer reason: For cervical traction with Crutchfield tongs, a torque wrench must be kept at the bedside to tighten/loosen the pins and release traction quickly in an emergency. Wire cutters are for wired jaws; forceps and a regular screwdriver are not indicated.

Question 21

The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?

Accepted Answer

Answer reason: Accidental chest tube removal risks rapid air entry and tension pneumothorax. The immediate nursing action is to apply an occlusive petroleum gauze dressing to seal the site; then notify the provider. Nurses do not reinsert chest tubes, and ordering an x-ray or calling the doctor comes after securing the site.

Question 22

A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?

Accepted Answer

Answer reason: After an amniotomy, the expected normal finding is a moderate amount of clear amniotic fluid. Greenish fluid indicates meconium, a cord segment suggests prolapse, and FHR of 160 bpm is borderline tachycardia rather than the expected baseline.

Question 23

An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks the nurse when the tube can be used for feeding. The nurse's BEST response is that?

Accepted Answer

Answer reason: Post–gastrostomy placement, the tube is left to gravity drainage to decompress the stomach for about 24 hours to prevent tension and aspiration. Feeding should start only after gastric contents and air have been drained.

Question 24

The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by?

Accepted Answer

Answer reason: Preoxygenating with 100% oxygen before and after suctioning prevents hypoxemia during the procedure. The other options prolong suctioning or use excessive pressure, increasing hypoxia risk.

Question 25

The nurse is planning care for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of the following should be a PRIORITY nursing goal following cast application?

Accepted Answer

Answer reason: Immediately after cast application, the top priority is maintaining circulation and neurovascular status to prevent ischemia and permanent damage. Other goals are secondary.

Question 26

The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid?

Accepted Answer

Answer reason: A straight chair causes hip and knee flexion, which can kink or compress an axillo‑popliteal bypass graft and impair blood flow. Reclining or supine positions do not place the same stress on the graft.

Question 27

The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9-year-old child has been avulsed ("knocked out"). After recovering the tooth, the INITIAL response should be to?

Accepted Answer

Answer reason: For an avulsed permanent tooth, the priority is to gently rinse the tooth with water or saline to remove debris and immediately reinsert it into the socket to preserve periodontal ligament viability. Handling must be by the crown only.

Question 28

Which gas is used for inflation of the abdominal wall during a laparoscopy procedure?

Accepted Answer

Answer reason: Carbon dioxide is the standard gas for creating pneumoperitoneum in laparoscopy because it is noncombustible, highly soluble, and rapidly absorbed, reducing the risk of gas embolism and allowing safe use with electrocautery.

Question 29

What is the best procedure to remove an embedded intrauterine contraceptive device (IUCD) in the uterus with a missing thread?

Accepted Answer

Answer reason: Hysteroscopy allows direct visualization inside the uterus to locate and retrieve an embedded IUCD when threads are missing. Laparoscopy is for extrauterine/perforated devices; colposcopy and cystoscopy are unrelated.

Question 30

In a client diagnosed with myasthenia gravis treated with plasma therapy, which improvement indicates the therapy was effective?

Accepted Answer

Answer reason: Plasmapheresis removes circulating anti–ACh receptor antibodies, leading to rapid improvement of ocular weakness in myasthenia gravis. Resolution or improvement of ptosis indicates effective therapy.

Question 31

Which of the following types of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage?

Accepted Answer

Answer reason: Extensive skin damage contraindicates skin traction (Buck's, Bryant, Russell). Ninety–ninety is skeletal traction commonly used for pediatric femoral fractures.

Question 32

The nurse is caring for a client with a T-tube following a cholecystectomy, one-day postoperatively. The nurse would EXPECT which the following color of drainage from the client's T-tube?

Accepted Answer

Answer reason: A T-tube drains bile from the biliary tract after cholecystectomy; bile is typically green, so green drainage is expected.

Question 33

The nurse is caring for a client with a chest tube. The nurse knows that this client MUST have what type of dressing?

Accepted Answer

Answer reason: Chest tube insertion sites require an airtight (occlusive) dressing to prevent air from entering the pleural space and causing loss of lung re-expansion.

Question 34

The nurse is caring for a client with a pneumothorax. The nurse expects the client to have a chest tube inserted because?

Accepted Answer

Answer reason: In a pneumothorax, air in the pleural space raises intrathoracic pressure and collapses the lung. A chest tube removes this air, re-establishing normal negative intrathoracic pressure and allowing lung re-expansion. The other options are incorrect regarding cause, indication, or effect on pressure.

Question 35

Which of the following should be obtained from a client PRIOR to having electroconvulsive therapy?

Accepted Answer

Answer reason: Pre-ECT preparation includes obtaining spinal x-rays to identify vertebral pathology and reduce fracture risk during the induced seizure.

Question 36

The nurse is caring for a client with a hemopneumothorax. The client has a chest tube. The nurse would EXPECT which of the following color of drainage?

Accepted Answer

Answer reason: Hemo indicates blood in the pleural space; chest tube drainage from a hemopneumothorax is expected to be red.

Question 37

A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client knowing that gradual emptying is preferred over complete emptying because it?

Accepted Answer

Answer reason: Rapid decompression of a markedly distended bladder can trigger hypotension and shock from sudden changes in intra-abdominal pressure; gradual drainage reduces this risk.

Question 38

A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?

Accepted Answer

Answer reason: Dialysis removes solutes and corrects electrolyte and uremic abnormalities (e.g., hyperkalemia, hypernatremia, high creatinine) but does not correct anemia; low hemoglobin requires EPO or transfusion.

Question 39

A client is scheduled for a Percutaneous Transluminal Coronary Angioplasty (PTCA). The nurse knows that a PTCA is the?

Accepted Answer

Answer reason: PTCA is balloon angioplasty performed via cardiac catheterization to compress atherosclerotic plaque against the arterial wall and improve coronary blood flow; it is not surgical repair, a defibrillator placement, or an imaging test.

Question 40

A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure?

Accepted Answer

Answer reason: A Swan-Ganz (pulmonary artery) catheter measures pulmonary artery and wedge pressures, which reflect left ventricular preload and thus left heart function. Right heart function is assessed by CVP.

Question 41

When suctioning a client's tracheostomy, the nurse should instill saline in order to?

Accepted Answer

Answer reason: Instilling sterile saline helps thin and loosen tracheal secretions, making them easier to remove with suction. It does not oxygenate, prevent aspiration, or primarily reduce discomfort.

Question 42

Which of the following oxygen delivery systems would the nurse apply that would provide the HIGHEST concentrations of oxygen to the client?

Accepted Answer

Answer reason: A non-rebreather mask uses a reservoir bag and one-way valves to prevent room air entrainment, allowing the highest delivered FiO2 (up to near 100%), higher than Venturi, partial rebreather, or simple face mask.

Question 43

A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just three months ago. The nurse would anticipate the physician ordering?

Accepted Answer

Answer reason: Recurrent pulmonary emboli despite prior therapy indicate need for inferior vena cava filter placement (vena caval interruption) to trap emboli from the legs. Embolectomy is reserved for massive/life‑threatening PE, increasing INR to 3–4 increases bleeding risk without addressing recurrence, and thrombolytics are for acute massive PE, not prevention.

Question 44

Milking of a drainage tube will create which type of pressure?

Accepted Answer

Answer reason: Milking/stripping a drainage tube generates high negative pressure within the system, which is why it is generally avoided due to potential tissue injury.

Question 45

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

Accepted Answer

Answer reason: High Fowler’s position aligns the oropharynx and esophagus, facilitates swallowing during tube passage, and reduces aspiration risk during NG tube insertion.

Question 46

A patient has a Levin tube connected to intermittent low suction. At 7 AM, the nurse charts that there is 235 cc of greenish drainage in the suction container. At 3 PM, the nurse notes that there is 445 cc of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 cc of normal saline, as ordered by the physician. What is the actual amount of drainage from the nasogastric tube for the 7 to 3 shift?

Accepted Answer

Answer reason: Net container increase = 445 − 235 = 210 cc. Subtract the 60 cc of irrigant instilled (30 cc × 2) to get true gastric drainage: 210 − 60 = 150 cc.

Question 47

A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is to?

Accepted Answer

Answer reason: A Miller-Abbott tube is a double-lumen nasointestinal tube used for intestinal decompression in small-bowel obstruction, removing gas and fluid from the small intestine. The stomach decompression option refers to NG tubes; the others are not primary purposes.

Question 48

Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?

Accepted Answer

Answer reason: Clearing or improvement of adventitious breath sounds on auscultation directly indicates that secretions were removed and airway patency improved, making it the most accurate assessment of suctioning effectiveness.

Question 49

The nurse is caring for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why he has to have the CBI. Which of the following responses by the nurse is BEST?

Accepted Answer

Answer reason: After TURP, continuous bladder irrigation prevents clot formation and obstruction, maintaining catheter patency so urine continues to flow. Option 3 best reflects this purpose.

Question 50

What is the most common complication of electroconvulsive therapy (ECT)?

Accepted Answer

Answer reason: ECT most commonly causes short-term memory impairment, particularly retrograde amnesia for events prior to treatment; psychosis or depression are not typical complications.

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