Question 1

What is the appropriate solution choice for TURP irrigation?

Accepted Answer

Answer reason: For TURP using bipolar electrosurgery, isotonic normal saline is the preferred irrigant. Plain water is hypotonic and risks hemolysis/TURP syndrome, and glycerol is not a standard irrigant.

Question 2

The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for a gastrostomy tube placement, the PRIORITY is to?

Accepted Answer

Answer reason: Listening for a whoosh over the stomach while insufflating air provides bedside confirmation that the gastrostomy tube is in the stomach. Water testing is unsafe, retracting risks dislodgement, and nose-to-epigastrium measurement applies to NG insertion, not G-tube verification.

Question 3

The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is MOST likely to experience?

Accepted Answer

Answer reason: Radiation therapy commonly causes gastrointestinal upset, with nausea being a frequent side effect. High fever suggests infection, face and neck edema indicates possible SVC syndrome, and night sweats are disease-related B symptoms rather than an effect of radiation.

Question 4

The nurse is caring for a client two hours after a right lower lobectomy. In evaluating the water-seal chest drainage system, it is noted that the fluid level bubbles constantly. On inspecting the chest and tubing, the nurse does not find any air leaks in the system. The NEXT action for the nurse is to?

Accepted Answer

Answer reason: Continuous bubbling in the water‑seal chamber indicates an air leak. After ruling out external system leaks, the likely source is the client, posing risk of lung collapse or mediastinal shift; notify the provider immediately. Do not clamp or irrigate the tube; measuring drainage is not the priority.

Question 5

The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?

Accepted Answer

Answer reason: During chest physiotherapy, percussion should be applied only over lung fields within the rib cage to mobilize secretions and avoid injury to abdominal organs, spine, and kidneys. Coughing is encouraged, therapy is scheduled before meals or 1–2 hours after, and positioning varies by lobe—not always prone.

Question 6

Post-procedure nursing interventions for electroconvulsive therapy include?

Accepted Answer

Answer reason: After ECT the client typically awakens within 20–30 minutes and may be groggy and disoriented; the nurse should remain with the client until oriented. Hard restraints are not appropriate, prolonged sleep is not expected, and memory effects are usually short-term rather than long-term.

Question 7

The nurse, assisting in applying a cast to a client with a broken arm, knows that?

Accepted Answer

Answer reason: Wet plaster casts must be supported with the palms to avoid finger indentations that can create pressure points and skin injury. Do not cover a wet cast while drying and avoid cloth surfaces that can indent or retain heat.

Question 8

The nurse is caring for a 10 month-old infant who is receiving oxygen through a nasal cannula. It is important for the nurse to monitor the child for?

Accepted Answer

Answer reason: With a nasal cannula, mouth breathing reduces effective FiO2 and makes oxygen concentration difficult to control; thus it must be monitored. The other options are not typical concerns specific to nasal cannula use.

Question 9

Following surgery for placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus, the parents question why the infant has a small abdominal incision. The BEST response by the nurse would be to explain that the incision was made in order to?

Accepted Answer

Answer reason: A VP shunt drains cerebrospinal fluid from the ventricles to the peritoneal cavity. A small abdominal incision is needed to pass the distal catheter into the peritoneum.

Question 10

A nurse is caring for a client who has arteriovenous fistula. Which of the following findings should the nurse report?

Accepted Answer

Answer reason: An AV fistula should have a palpable thrill and an audible bruit (swishing). Absence of a bruit suggests thrombosis or occlusion and must be reported. Distention and a swishing sound are expected findings in a mature fistula.

Question 11

A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator. Which of the following statements demonstrates understanding of the teaching?

Accepted Answer

Answer reason: Loose clothing prevents pressure and irritation over the ICD site. Clients should avoid soaking the incision until healed, microwaves are safe with modern ICDs, and cell phones should be used on the opposite side and kept several inches from the device.

Question 12

A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching?

Accepted Answer

Answer reason: After hypospadias repair a urethral stent is left to ensure urine drains freely and to protect the repair. It should not be clamped and should drain into the diaper. Tub baths are avoided until the stent is removed; hydrocortisone cream is not indicated.

Question 13

When preparing the room for a total knee arthroplasty, which of the following items is necessary to occlude blood flow during the surgical procedure?

Accepted Answer

Answer reason: A pneumatic tourniquet is used during total knee arthroplasty to occlude arterial flow to the limb, providing a bloodless field. Coban and Esmark are elastic wraps (Esmarch exsanguinates but does not maintain occlusion), and stockinette is for draping.

Question 14

A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

Accepted Answer

Answer reason: Humidification adds moisture to the airway, helping liquefy and thin thick tracheal secretions. Chest physiotherapy mobilizes but does not thin secretions; saline lubrication/instillation is not recommended and does not thin secretions; preoxygenation prevents hypoxemia but does not affect secretion viscosity.

Question 15

A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?

Accepted Answer

Answer reason: Cooling with a hypothermia blanket can provoke shivering as a thermoregulatory response, increasing metabolic and oxygen demand. Infection and hypervolemia are not direct effects, and burns are more associated with warming devices.

Question 16

Which ventilator strategy is recommended to prevent ventilator-induced lung injury in patients with ARDS?

Accepted Answer

Answer reason: ARDS requires lung-protective ventilation: low tidal volume (~6 mL/kg predicted body weight) and adequate PEEP to prevent volutrauma and atelectrauma. High Vt or high FiO2 without PEEP increases injury; changing rate alone is insufficient.

Question 17

The nurse is caring for a client who is post-op following a thoracotomy. The client has two chest tubes in place, connected to one chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the MOST appropriate nursing action?

Accepted Answer

Answer reason: Intermittent bubbling in the water-seal chamber with coughing indicates expected air escape after thoracic surgery; the appropriate action is to monitor, not clamp, call the surgeon, or suppress coughing.

Question 18

A 16-year-old female presents with intermittent upper abdominal pain. Endoscopy reveals erythematous gastric mucosa with prominent folds suggestive of gastritis. What is the most appropriate treatment?

Accepted Answer

Answer reason: Gastritis involves inflammation of the gastric mucosa, often associated with excess acid or mucosal injury. First-line therapy includes acid-suppressive medications such as proton pump inhibitors or H2 blockers, which reduce gastric acidity, relieve symptoms, and promote healing.

Question 19

A patient with hydrocephalus requires CSF diversion from the ventricles into the peritoneal cavity. Which procedure accomplishes this?

Accepted Answer

Answer reason: A ventriculoperitoneal (VP) shunt diverts excess cerebrospinal fluid from the cerebral ventricles into the peritoneal cavity, relieving intracranial pressure. It is the most common long-term intervention for hydrocephalus.

Question 20

A nurse is caring for a patient at high risk for aspiration due to impaired swallowing. Which intervention is most effective to reduce aspiration risk?

Accepted Answer

Answer reason: Keeping the patient upright during feeding facilitates safer swallowing, reduces the entry of food or liquid into the airway, and is an evidence-based intervention for aspiration prevention. Supine feeding dramatically increases aspiration risk.

Question 21

A client is receiving oxygen via nasal cannula at 4 L/min. Which nursing action is MOST appropriate?

Accepted Answer

Answer reason: Oxygen tubing and cannula prongs can exert pressure leading to skin irritation and breakdown. Regular assessment allows prompt intervention. Petroleum products are contraindicated due to fire risk, and adjusting oxygen flow requires a provider order.

Question 22

Which resuscitation device allows manual ventilation of a patient by squeezing a self-inflating bag attached to a mask?

Accepted Answer

Answer reason: An Ambu bag is a self-inflating manual resuscitator used to ventilate patients in respiratory distress or arrest.

Question 23

Which procedure drains CSF from the ventricles to the peritoneal cavity?

Accepted Answer

Answer reason: A VP shunt diverts cerebrospinal fluid from the cerebral ventricles into the peritoneal cavity, relieving elevated intracranial pressure.

Question 24

Phototherapy side effect includes?

Accepted Answer

Answer reason: Neonatal phototherapy can lower serum calcium, particularly in preterm infants. Light exposure reduces melatonin and alters hormonal regulation of parathyroid hormone, increasing calcium uptake into bone and resulting in hypocalcemia. Hyperkalemia is not a recognized effect, and hypernatremia is not typical except with significant dehydration. Temperature instability may occur, but the characteristic electrolyte disturbance is hypocalcemia.

Question 25

The first step in AMTSL is?

Accepted Answer

Answer reason: Active management of the third stage of labor begins with administration of a uterotonic, most commonly oxytocin, within the first minute after birth to promote strong uterine contractions and prevent atony. Controlled cord traction follows once the uterus is contracted, and uterine massage is performed after placental delivery. Therefore, the first step is injection of oxytocin.

Question 26

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

Accepted Answer

Answer reason: ECT’s therapeutic effect requires induction of a generalized tonic–clonic (grand mal) seizure of adequate duration. Loss of consciousness occurs from anesthesia and does not indicate effectiveness. Tachycardia and vomiting are potential physiological responses or adverse effects, not markers of successful treatment.

Question 27

Accurate placement of nasogastric tube is checked by all of the methods except?

Accepted Answer

Answer reason: Correct NG-tube placement is confirmed by radiography (gold standard) or by aspirating gastric contents and verifying an acidic pH, which suggests gastric location. These methods reduce the risk of pulmonary misplacement and aspiration. Palpation of the stomach does not provide information about tube tip location and is not an accepted method for confirmation. Therefore, palpation is the exception.

Question 28

The quickest and most effective method of removing uremic waste products from the body when the kidneys are unable to do so in cases of hyperkalaemia, hypercalcaemia, hepatic coma and uraemia is?

Accepted Answer

Answer reason: Hemodialysis rapidly clears uremic toxins and corrects life‑threatening electrolyte abnormalities such as hyperkalemia and severe hypercalcemia when kidneys fail. It provides the fastest solute clearance compared with peritoneal dialysis, which is slower and less efficient in emergencies. Paracentesis and pericardiocentesis remove fluid from the abdomen and pericardial sac, respectively, and do not treat uremia or electrolyte derangements.

Question 29

Vasectomy is done under _____?

Accepted Answer

Answer reason: Vasectomy is a minor outpatient procedure typically performed using local infiltration anesthesia (e.g., lidocaine) to numb the scrotal tissues and vas deferens. General or spinal anesthesia is unnecessary for most cases and would add avoidable risks and resource use. Performing it without anesthesia would be painful and not standard practice.

Question 30

To prepare a 56-year-old male patient with ascites for paracentesis, the nurse?

Accepted Answer

Answer reason: Before paracentesis, the bladder should be emptied to reduce the risk of accidental bladder puncture when inserting the needle/catheter into the peritoneal cavity. This is a key safety preparation step for an invasive therapeutic procedure. NPO status is not routinely required for paracentesis, and lying flat may worsen respiratory comfort in ascites. Standard positioning is typically upright/high Fowler’s or as ordered, not specifically on the right side.

Question 31

Nose packing is done to control—?

Accepted Answer

Answer reason: Nasal packing is a therapeutic procedure used to control epistaxis by applying direct pressure to bleeding vessels in the nasal mucosa. It is commonly used when simple measures (e.g., compression, topical vasoconstrictors) are insufficient or when posterior bleeding is suspected. It does not treat ear infection or eye injury, and it is not primarily used for throat bleeding (although blood may drain into the throat from the nose). Therefore, the best answer is nose bleeding.

Question 32

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?

Accepted Answer

Answer reason: For thoracentesis, the preferred position is sitting upright and leaning slightly forward with arms supported, which widens the intercostal spaces and stabilizes the patient for needle insertion. This position also helps the pleural fluid collect dependently, facilitating drainage and reducing risk of lung injury. Supine or side-lying positions are less optimal and are typically reserved only when the patient cannot sit up. Therefore, supporting the arms on an overbed table in an upright position is the safest and most effective choice.

Question 33

The Suction pressure for performing nasopharyngeal suctioning through a wall based suction unit in an adult patient should be adjusted to?

Accepted Answer

Answer reason: For adult nasopharyngeal (and generally airway) suctioning with wall suction, the recommended negative pressure is typically about 100–120 mmHg to effectively remove secretions while minimizing mucosal trauma and hypoxemia. Higher settings (e.g., 140–150 mmHg) increase the risk of airway mucosal damage and bleeding. Lower ranges (60–80 or 40–50 mmHg) are more consistent with pediatric/infant suctioning or may be insufficient for adult secretions.

Question 34

Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to?

Accepted Answer

Answer reason: If the chest drainage system becomes disconnected, the priority is to quickly re-establish a water seal to prevent air from being sucked back into the pleural space and causing/worsening a pneumothorax. Placing the distal end of the chest tube into sterile water provides an immediate temporary water seal until a new sterile drainage system can be connected. Calling the provider or replacing the system comes after stabilizing the airway/breathing risk. A sterile dressing over the disconnection site is indicated for chest tube removal or if the tube dislodges from the chest wall, not for a disconnection in the tubing.

Question 35

A nurse is caring for a client who has a temperature of 39.7°C (103.5°F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?

Accepted Answer

Answer reason: Hypothermia (cooling) blankets can cause skin injury due to prolonged contact with a very cold surface and reduced tissue perfusion, leading to thermal injury (cold burns/frostbite-like damage) and pressure-related injury. Therefore, the nurse should frequently assess skin integrity, temperature, and perfusion and ensure proper barrier use per protocol. Shivering is an expected physiologic response to cooling rather than the primary adverse effect, and infection or hypervolemia are not typical direct complications of a hypothermia blanket.

Question 36

In Buck's traction, the nurse should include which in the plan of care?

Accepted Answer

Answer reason: In Buck's traction, the weights must hang freely to provide a constant, effective traction force and maintain alignment. Resting the weights on the floor or bed alters the amount of traction and can worsen pain or displacement. Weights are not routinely removed because that disrupts traction and can cause loss of reduction. Heat near the traction area is not a standard traction care measure and may increase swelling or compromise skin integrity.

Question 37

A client with a hip fracture is placed in Buck's traction preoperatively. What is the primary purpose of this traction?

Accepted Answer

Answer reason: Buck's traction is a temporary, preoperative skin traction used to reduce muscle spasm and maintain the injured extremity in proper alignment and relative immobilization. This helps decrease pain and prevents further displacement of the fractured hip while awaiting surgery. It is not intended to promote definitive bone healing (that requires fixation) or to strengthen muscles. Preventing foot drop is a nursing care goal while in traction, but it is not the primary purpose of Buck's traction itself.

Question 38

Nurse Patel is measuring the central venous pressure of Mr. Lawson. She needs to correctly position the manometer. Where should Nurse Patel place the zero mark of the manometer?

Accepted Answer

Answer reason: For accurate central venous pressure (CVP) measurement, the manometer must be leveled (zeroed) at the phlebostatic axis, which approximates the level of the right atrium. This reference point is typically the 4th intercostal space at the mid-axillary line in a supine patient. Zeroing elsewhere (PMI, Erb’s point, tail of Spence) would not align with right atrial pressure and would yield incorrect CVP readings.

Question 39

What is the best position for a patient undergoing peritoneal dialysis to enhance fluid inflow and outflow?

Accepted Answer

Answer reason: Semi-Fowler's/Fowler's or sitting upright promotes optimal distribution of dialysate within the peritoneal cavity and uses gravity to improve drainage through the catheter, enhancing both inflow and outflow. Supine with legs raised can increase abdominal pressure and may impede flow. Prone positioning risks kinking or compressing the catheter and is uncomfortable/unsafe. Left lateral is not the standard position to maximize overall inflow and outflow for routine exchanges.

Question 40

How can we confirm the position of NG tube after insertion?

Accepted Answer

Answer reason: The most reliable method to confirm initial NG tube placement is radiographic verification (X-ray), which can directly show the tube tip location in the stomach/intestine and rule out respiratory placement. Air insufflation with auscultation is not sufficiently accurate and can be misleading, risking feeding/medication into the lungs. Dipping the tube tip in a bowl of butter is not an accepted clinical verification method. Therefore, “all the above” is incorrect because not all listed methods are valid or safe.

Question 41

While suctioning a tracheostomy, suction should be applied for how long?

Accepted Answer

Answer reason: During tracheostomy suctioning, each suction pass should be brief (generally no longer than about 10 seconds) to minimize hypoxemia, vagal stimulation (bradycardia), and mucosal trauma. Longer suction times increase oxygen desaturation and can worsen respiratory distress. The nurse should pre-oxygenate as indicated and allow time between passes for the client to recover oxygenation.

Question 42

Length of insertion of NG is measured from....?

Accepted Answer

Answer reason: For nasogastric (NG) tube insertion, the standard method to estimate insertion length is the NEX measurement: nose (tip) to ear lobe (tragus) to xiphoid process. This approximates the distance from the nares through the nasopharynx and esophagus into the stomach. Measuring only nose-to-xiphoid can underestimate the needed length, increasing risk of malposition. The NEX approach supports safer placement as part of the procedure prior to confirming placement per policy.

Question 43

The nurse is caring for a client immediately after a liver biopsy. To reduce the risk of complications, which position should the nurse place the client in?

Accepted Answer

Answer reason: After a liver biopsy, the priority is to prevent bleeding by applying pressure to the biopsy site. Positioning the client on the right side places the liver (biopsied organ) dependent, helping compress the puncture tract and reduce hemorrhage and bile leak risk. A small pillow or towel provides additional localized pressure. Supine, left side-lying, or upright positions provide less direct compression of the liver biopsy site.

Question 44

Yankauer suction tip is used in?

Accepted Answer

Answer reason: A Yankauer is a rigid suction tip primarily used for oropharyngeal suctioning to remove secretions from the mouth and upper airway. In patients with an artificial airway (e.g., tracheostomy), it can be used to clear pooled oral secretions and reduce aspiration risk. It is not used for lumbar puncture, bladder catheterization, or laparoscopy, which involve different equipment and procedural techniques.

Question 45

What is the generally recommended maximum suction pressure when performing endotracheal suctioning on an adult patient?

Accepted Answer

Answer reason: For adult endotracheal suctioning, the typical recommended suction pressure range is about 80–120 mmHg to effectively remove secretions while minimizing mucosal trauma. Higher pressures increase the risk of airway mucosal injury, bleeding, atelectasis, and hypoxemia due to excessive negative pressure. Lower pressures may be inadequate for secretion clearance in an adult-sized airway. Therefore, 80–120 mmHg is the best choice among the options.

Question 46

What does intermittent bubbling in the water seal chamber of a chest tube most likely indicate?

Accepted Answer

Answer reason: Intermittent bubbling in the water seal chamber is typically expected and reflects air exiting the pleural space during exhalation or coughing as the pneumothorax resolves. The key abnormal finding would be continuous bubbling in the water seal chamber, which suggests an air leak in the system (or from the patient). A dislodged tube would more likely present with loss of drainage/changes in tidaling and acute respiratory compromise rather than intermittent bubbling. A “full drainage system” is not assessed by water-seal bubbling; drainage amount is monitored in the collection chamber and many systems are not “emptied” but replaced when full.

Question 47

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

Accepted Answer

Answer reason: In a chest drainage system, intermittent bubbling in the water-seal chamber can be expected early on as air leaves the pleural space, but continuous bubbling usually indicates an air leak in the system (e.g., loose connections or leak at the insertion site). The safest immediate nursing action is to assess and troubleshoot the system for an air leak rather than increasing suction. Clamping the tube is generally avoided unless briefly and specifically ordered for troubleshooting because it can precipitate a tension pneumothorax.

Question 48

What is the purpose of straining urine in a patient with suspected renal stones?

Accepted Answer

Answer reason: To collect stone fragments for analysis Straining urine allows retrieval of passed calculi or fragments so they can be sent for stone analysis (composition). Identifying the stone type (e.g., calcium oxalate, uric acid, struvite, cystine) guides targeted prevention strategies such as dietary changes and specific medications. Hematuria and urine output can be assessed without straining, and hygiene is not the primary clinical purpose.

Question 49

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

Accepted Answer

Answer reason: For thoracentesis, positioning should promote comfort, allow access to the pleural space, and reduce risk of complications such as pneumothorax. If the client cannot sit upright leaning forward (often preferred), a side-lying position with the unaffected side down and the head elevated helps expose the affected side for needle insertion. This positioning also supports ventilation and helps the client maintain a stable posture during the procedure. The other options do not optimize pleural access or are inappropriate for a sterile thoracentesis approach.

Question 50

What is the recommended patient position for nasogastric (NG) tube placement?

Accepted Answer

Answer reason: High Fowler’s position (upright at 90 degrees) High Fowler’s best aligns the oropharynx and esophagus to facilitate NG tube passage and uses gravity to reduce aspiration risk if gagging or emesis occurs. This upright posture also promotes patient comfort and cooperation during swallowing, which helps the tube advance correctly. Semi-Fowler’s may be used if the patient cannot tolerate full upright positioning, but it is not the optimal recommended position among the choices. Supine with head tilted back and prone positioning increase risk of airway misplacement and aspiration and are not standard for NG insertion.

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