Question 1

A patient with a nasogastric tube begins to vomit large amounts of green fluid. What should the nurse do first?

Accepted Answer

Answer reason: Vomiting may indicate tube displacement or obstruction. Verifying placement and patency is the immediate priority before other actions.
Category reason: This question involves safe management of a therapeutic device.

Question 2

A nurse prepares a patient for postural drainage of the lower lobes. What is the best position?

Accepted Answer

Answer reason: For postural drainage of the lower lobes, gravity is used to help mobilize secretions toward the larger airways for expectoration or suctioning. A head-down tilt (Trendelenburg) promotes drainage from the basal segments of the lower lobes, which are dependent in upright positions. High Fowler’s would make the bases dependent and hinder drainage, and a flat supine position without head-down tilt is less effective for targeting the lower lobes. Side-lying alone is used to target specific segments, but for lower lobes the key element is the head-down positioning.
Category reason: This question tests a nursing intervention/therapeutic procedure—selecting the correct patient position for postural drainage—to reduce respiratory complications and promote airway clearance, fitting Therapeutic Procedures under Reduction of Risk Potential.

Question 3

A client has a chest tube with continuous bubbling in the water seal chamber. What does this indicate?

Accepted Answer

Answer reason: Continuous bubbling in the water-seal chamber signifies that air is entering the drainage system, most commonly from a loose connection or a defect in the system or at the insertion site. Intermittent bubbling can be expected early with coughing or expiration in some setups, but continuous bubbling is abnormal and indicates a system leak. Nursing actions include checking all connections, ensuring the dressing is occlusive, and notifying the provider if the leak source cannot be quickly identified or corrected.
Category reason: This question tests interpretation of a chest tube drainage system finding and the associated patient-care implication, which is a therapeutic procedure and complication monitoring task.

Question 4

A stroke client who was initially on NGT feeding was able to tolerate soft diet so the physician ordered for the removal of it. The nurse would instruct the client to do which of the following before he removes the tube?

Accepted Answer

Answer reason: Holding the breath briefly closes the glottis, which helps reduce the risk of aspiration while the nasogastric tube is being withdrawn through the pharynx. This maneuver also minimizes gagging and prevents the patient from inhaling during removal, decreasing the chance of tube-related airway contamination. A Valsalva maneuver is more relevant for procedures where increased intrathoracic pressure is needed (e.g., central line removal) and is not standard for NGT removal. The other actions do not effectively protect the airway during withdrawal of the tube.
Category reason: This question tests a nurse-performed procedure and patient instruction to prevent complications during removal of a nasogastric tube, aligning with Therapeutic Procedures under Reduction of Risk Potential.

Question 5

A client with a broken clavicle asks why a figure-of-eight brace is applied. What is the best explanation?

Accepted Answer

Answer reason: e." The figure-of-eight brace retracts the shoulders to maintain clavicular alignment and promote proper healing after a fracture. By positioning the shoulder girdle posteriorly, it helps reduce displacement of fracture fragments and supports immobilization. The other options describe unrelated effects (thoracic stabilization, leg immobilization, or primary circulation improvement), which are not the brace’s main therapeutic purpose.
Category reason: This question tests client teaching about the purpose of an orthopedic brace used as a treatment method, which fits Therapeutic Procedures under Reduction of Risk Potential.

Question 6

Position provided to the patient during perineal operation is?

Accepted Answer

Answer reason: It provides optimal exposure of the perineum and genital/anal region by flexing and abducting the hips with legs supported in stirrups, which is required for many perineal and gynecologic procedures. It also facilitates access for antiseptic preparation, draping, and operative instrumentation. Key nursing considerations include preventing nerve injury (e.g., peroneal nerve), avoiding excessive hip flexion/abduction, and ensuring proper padding and alignment.
Category reason: This item tests appropriate patient positioning used for a surgical/therapeutic procedure and related intraoperative safety considerations, aligning with Therapeutic Procedures under Reduction of Risk Potential.

Question 7

As a nurse, you know that the position for June before thoracentesis is?

Accepted Answer

Answer reason: Thoracentesis is facilitated by positioning the client upright to maximize chest expansion and allow pleural fluid to pool dependently for safer needle insertion. The orthopneic (sitting upright, leaning forward with arms supported on an overbed table) position improves ventilation and reduces risk of accidental lung puncture. Low Fowler’s is less optimal for access, knee-chest is inappropriate, and lying on the affected side is not the standard pre-procedure position because it can limit access and ventilation.
Category reason: This question tests a nursing intervention (proper client positioning) to safely prepare for a therapeutic invasive procedure, which fits Therapeutic Procedures under Reduction of Risk Potential.

Question 8

A client with ascites is scheduled for a paracentesis. Which instruction should be given to the client before the procedure?

Accepted Answer

Answer reason: Paracentesis involves needle/catheter entry into the peritoneal cavity to remove ascitic fluid, and an overdistended bladder increases the risk of accidental puncture and bleeding. Having the client void just prior to the procedure reduces this risk and improves procedural safety. The client is typically positioned upright/high Fowler’s rather than flat, and sedation/anesthesia is not routinely required for uncomplicated paracentesis. Medication injection is not a standard feature of the procedure itself; the priority pre-procedure instruction is bladder emptying to prevent injury.
Category reason: This question asks for a nursing pre-procedure instruction to prevent complications during a paracentesis, which is a therapeutic procedure and fits Reduction of Risk Potential.

Question 9

After a lumbar puncture, the nurse should position the client?

Accepted Answer

Answer reason: Keeping the client flat helps reduce cerebrospinal fluid leakage from the puncture site and lowers the risk/severity of a post–lumbar puncture headache. Elevating the head or sitting upright can worsen CSF pressure changes and increase discomfort. Ongoing monitoring for headache, neurologic changes, and signs of CSF leak is also part of safe post-procedure care.
Category reason: This question tests appropriate nursing care following a diagnostic/therapeutic procedure to prevent complications, which fits Therapeutic Procedures under Reduction of Risk Potential.

Question 10

After liver biopsy, which position is used to prevent bleeding?

Accepted Answer

Answer reason: Positioning on the puncture side applies firm pressure to the biopsy site, helping tamponade the tract and reduce the risk of hemorrhage after the procedure. This also helps the liver puncture site seal while the client is monitored for complications such as hypotension, tachycardia, and increasing abdominal pain. Alternative positions do not provide the same direct compression over the right upper quadrant biopsy site.
Category reason: This question tests a specific post-procedure nursing intervention to reduce complication risk after an invasive diagnostic/therapeutic procedure, fitting Reduction of Risk Potential → Therapeutic Procedures.

Question 11

Best position during thoracentesis procedure:

Accepted Answer

Answer reason: This position maximizes chest expansion and widens the intercostal spaces, making pleural fluid access safer and easier. It helps the client remain stable and reduces the risk of accidental lung puncture by optimizing anatomic landmarks. It also supports breathing and comfort during the procedure while facilitating effective drainage.
Category reason: This question focuses on proper patient positioning for a bedside invasive procedure to minimize complications, which is a nursing safety/intervention decision under Therapeutic Procedures.

Question 12

A physician has ordered a 4 year old to receive 40% oxygen therapy. You would recommend which of the following oxygen delivery devices?

Accepted Answer

Answer reason: This question tests selecting an oxygen delivery device capable of delivering a relatively controlled moderate FiO2. An aerosol mask with a jet nebulizer (air-entrainment/nebulizer setup) can provide a predictable oxygen concentration around the ordered 40% when set appropriately, making it suitable for a preschool child. A nasal cannula at 5 L/min provides variable FiO2 and may be poorly tolerated at higher flows, while an oxygen hood is primarily for infants. An oxygen tent delivers less precise FiO2 due to dilution from openings and is not ideal when a specific concentration is prescribed.
Category reason: The item focuses on choosing an appropriate therapeutic oxygen-delivery device to meet a prescribed FiO2 in a child, which is a nursing intervention/therapeutic procedure decision.

Question 13

During the removal of chest tubes, the patient is asked to...?

Accepted Answer

Answer reason: Breath-holding (often after a deep inspiration) increases intrathoracic pressure, which helps reduce the risk of air being sucked into the pleural space during tube removal. This decreases the likelihood of a pneumothorax and supports maintenance of negative intrapleural pressure. Swallowing is unrelated, and active inhalation/exhalation during the pull can promote air entry or destabilize pleural pressures at the moment the tract is open.
Category reason: This item tests safe nursing management of a therapeutic procedure (chest tube removal) to prevent complications such as pneumothorax, which fits Reduction of Risk Potential—Therapeutic Procedures.

Question 14

A client with ascites is scheduled for a paracentesis. Which instruction should be given to the client before the procedure?

Accepted Answer

Answer reason: Paracentesis involves inserting a needle/catheter into the peritoneal cavity to remove fluid, and a distended bladder increases the risk of accidental puncture during needle insertion. Having the client void just before the procedure helps keep the bladder decompressed and reduces injury risk. This is a standard pre-procedure safety step along with positioning and monitoring for hypotension after large-volume fluid removal.
Category reason: This question tests nursing pre-procedure teaching and safety measures to reduce complications during a therapeutic invasive procedure (paracentesis), which aligns with Therapeutic Procedures under Reduction of Risk Potential.

Question 15

A client with a fractured femur is placed in skeletal traction. What is the primary purpose of this intervention?

Accepted Answer

Answer reason: b) Align the fracture and reduce muscle spasms Skeletal traction provides a continuous pulling force to maintain proper bone alignment and stabilize the fracture. By counteracting muscle spasm and shortening, it reduces pain and helps prevent further tissue and neurovascular injury. This stabilization supports safe immobilization while definitive healing or surgical management occurs.
Category reason: This item tests understanding of a nursing therapeutic procedure (skeletal traction) and its intended clinical effect to reduce risk of complications and maintain alignment, which fits Therapeutic Procedures under Reduction of Risk Potential.

Question 16

A 63-year-old client with cirrhosis underwent paracentesis today. Which assessment finding alerts the nurse that the procedure was successful?

Accepted Answer

Answer reason: Paracentesis removes ascitic fluid from the peritoneal cavity, so an objective indicator of effective fluid removal is a measurable drop in body weight and often reduced abdominal girth. In contrast, a substantial blood pressure decrease suggests hypovolemia or fluid shifts and is a potential complication rather than a marker of success. A new urge to urinate is not a reliable outcome measure, and “no residual obtained” does not indicate that ascites was effectively drained.
Category reason: This item tests nursing evaluation of outcomes and monitoring after a therapeutic procedure (paracentesis) to determine effectiveness and detect complications, which fits Therapeutic Procedures under Reduction of Risk Potential.

Question 17

A nurse is caring for a patient who has just undergone a lumbar puncture. Which position should the nurse encourage the patient to assume after the procedure?

Accepted Answer

Answer reason: D. Flat in the supine position Remaining flat after a lumbar puncture helps reduce continued cerebrospinal fluid leakage from the puncture site, which lowers the risk of a post–dural puncture headache. It also supports hemostasis and reduces strain at the insertion area during the immediate recovery period. Elevating the head can worsen headache symptoms, and the side-lying knees-drawn-up position is primarily used to facilitate the procedure rather than post-procedure recovery.
Category reason: This question tests a nursing intervention to prevent complications after a diagnostic/therapeutic procedure (lumbar puncture), which fits Reduction of Risk Potential under Therapeutic Procedures.

Question 18

Which tube is used for suctioning the airway?

Accepted Answer

Answer reason: Airway suctioning is performed with a suction catheter (for tracheal suctioning) or a Yankauer tip (for oral/pharyngeal secretions) connected to suction tubing. A Foley catheter is designed for urinary bladder drainage, and an NG tube is for gastric decompression/feeding, not airway clearance. An endotracheal tube provides a secured airway for ventilation; suctioning is done through it using a suction catheter rather than using the tube itself as the suction device.
Category reason: This question tests selection of the correct clinical device used in a patient-care procedure (airway suctioning), which aligns with nursing-focused therapeutic procedures rather than foundational biomedical science.

Question 19

Which solution is used for eye irrigation?

Accepted Answer

Answer reason: Eye irrigation requires an isotonic, non-irritating solution to flush debris or chemicals while minimizing additional tissue injury. Normal saline is sterile and compatible with ocular tissues, making it the standard choice for irrigation. Alcohol, hydrogen peroxide, and iodine are caustic/irritating to the cornea and conjunctiva and can worsen chemical injury. In emergencies, copious irrigation with sterile saline is performed promptly while further evaluation and treatment are arranged.
Category reason: This item tests the appropriate nursing procedure/solution selection for a therapeutic intervention (eye irrigation) to reduce injury risk and complications, fitting Therapeutic Procedures under Reduction of Risk Potential.

Question 20

To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure?

Accepted Answer

Answer reason: This helps the client maintain controlled ventilation and relaxation during bronchoscope insertion, reducing anxiety and gagging. It supports oxygenation and promotes a steady respiratory pattern while the airway is being stimulated. The other options are ineffective or unsafe: breath-holding can worsen hypoxemia, and muscle tensing or fist clenching do not meaningfully improve tolerance of an airway procedure.
Category reason: This is about preparing a client for a bronchoscopy and teaching actions to reduce procedural risk and improve tolerance, which fits nursing care around therapeutic procedures.

Question 21

Scenario: A patient has a Jackson-Pratt (JP) drain after abdominal surgery. The nurse observes decreased drainage and tension on the tubing. What is the nurse’s priority action?

Accepted Answer

Answer reason: Tension on the tubing with decreased output suggests a mechanical obstruction such as a clot or kink, which can be addressed immediately by restoring patency of the drain. Stripping (per facility policy) helps clear clots in the lumen and re-establish continuous drainage to reduce the risk of fluid accumulation and infection. Removing the drain is not a nursing priority action and risks tissue injury. Notifying the surgeon is appropriate if patency cannot be restored or drainage remains abnormal after troubleshooting.
Category reason: This item tests an immediate nursing action to maintain patency and function of a postoperative surgical drain, which is a therapeutic procedure aimed at preventing complications.

Question 22

Best position for a client undergoing paracentesis (removal of ascitic fluid).

Accepted Answer

Answer reason: This position allows ascitic fluid to pool in the dependent lower abdomen, improving access to the peritoneal cavity and facilitating more complete drainage. It also helps the client tolerate the procedure by supporting ventilation compared with lying flat when abdominal distention is significant. Prone and left lateral positions do not optimize dependent pooling for typical puncture sites, and supine positioning is less preferred because it can worsen dyspnea and reduce procedural access in tense ascites.
Category reason: This question tests safe client positioning during a bedside invasive intervention to minimize complications and optimize procedural success, which aligns with Therapeutic Procedures under Reduction of Risk Potential.

Question 23

The nurse is preparing a client for a renal biopsy. The best position for the procedure is ?

Accepted Answer

Answer reason: This position exposes the posterior flank where the kidney is most accessible for a percutaneous biopsy and helps stabilize the kidney against the posterior abdominal wall. The pillow supports the abdomen and reduces lumbar lordosis, improving access and minimizing movement during needle insertion. Supine, lateral, or semi-Fowler’s positions do not provide optimal posterior access and can increase technical difficulty and risk of complications.
Category reason: This question tests safe preparation and positioning for an invasive bedside procedure to reduce risk and facilitate correct performance, which fits Therapeutic Procedures under Reduction of Risk Potential.

Question 24

Scenario: A nurse inserts a nasogastric (NG) tube for enteral feeding. Q. What is the most reliable method to confirm placement before feeding?

Accepted Answer

Answer reason: Bedside methods like asking the patient, observing emesis, or insufflating air with auscultation are unreliable and can miss respiratory or esophageal malposition. The safest standard for initial verification of tube location is radiographic confirmation, especially prior to first feeding, because it directly visualizes the tube path and tip. Gastric pH testing provides supportive evidence at the bedside but should not replace radiography when establishing initial placement to prevent aspiration and pulmonary complications.
Category reason: This question tests the nurse’s safest procedure to verify NG tube placement before initiating enteral feeding, which is a patient-safety intervention within therapeutic procedures and complication prevention.

Question 25

During a pelvic exam under spinal anesthesia, what position should be used?

Accepted Answer

Answer reason: Spinal anesthesia causes lower-extremity motor and sensory blockade, so the client must be positioned in a way that permits the exam while maintaining stability and preventing falls or injury. The standard position for pelvic examination is supine with hips and knees flexed and thighs abducted, which provides optimal visualization and access to the perineum and cervix. Other positions (knee-chest or Sims’) are used for specific rectal/gynecologic procedures but are not the routine, safest setup for a pelvic exam with neuraxial anesthesia. Proper support of legs and careful repositioning are important to avoid hypotension and nerve/pressure injury while anesthetized.
Category reason: This asks for the appropriate patient positioning for a pelvic exam performed under spinal anesthesia, which is a procedural care decision aimed at minimizing complications during a therapeutic/diagnostic procedure.

Question 26

During percutaneous liver biopsy, the client should be positioned?

Accepted Answer

Answer reason: This position helps widen the intercostal spaces and provides better access to the liver while minimizing movement during needle insertion. It also promotes patient stability and facilitates maintaining a consistent respiratory pattern, reducing the risk of injury to adjacent structures. Other positions can hinder access to the biopsy site or increase risk by altering organ alignment.
Category reason: This item tests safe nursing management of a biopsy procedure and appropriate patient positioning to reduce complications, which fits Therapeutic Procedures under Reduction of Risk Potential.

Question 27

Procedure for pediatric suction :-

Accepted Answer

Answer reason: Suctioning the mouth before the nose reduces the risk of triggering a reflex gasp/inspiration from nasal stimulation that could pull oral secretions into the airway and worsen aspiration risk. This sequence supports safer airway clearance and decreases potential complications such as hypoxia or aspiration. Choosing the nose first can increase the chance of aspiration because nasal suction may stimulate inhalation while the mouth is still full of secretions.

Question 28

The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about?

Accepted Answer

Answer reason: This directly supports assessment of global pump performance and guides titration of fluids and vasoactive medications in critically ill patients. While stroke volume can be derived from cardiac output and heart rate, it is not the primary direct readout taught as the key purpose. “Venous pressure” is more consistent with central venous pressure monitoring using a central venous catheter rather than the defining function of a PA catheter.

Question 29

A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position?

Accepted Answer

Answer reason:  Lumbar puncture requires maximal flexion of the spine to widen the intervertebral spaces and make needle insertion into the subarachnoid space safer and easier. The lateral recumbent “fetal” position flexes the hips, knees, and neck, opening the lumbar vertebral spaces while keeping the patient stable. This positioning also helps the client remain still, reducing risk of traumatic tap or nerve irritation. Prone or Trendelenburg positioning does not optimize lumbar flexion and can increase discomfort and procedural difficulty. A simple side-lying position without spinal flexion is inadequate for best landmark exposure.

Question 30

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

Accepted Answer

Answer reason: The lateral recumbent “fetal” position with knees-to-chest and neck flexed provides this flexion and helps the client remain still during needle insertion. This positioning also supports accurate opening pressure measurement when CSF pressure is obtained in the lateral position. Options involving prone positioning or minimal hip support do not reliably open the lumbar spaces and are not standard for safe, effective LP performance.

Question 31

A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of?

Accepted Answer

Answer reason: Limiting each suction pass to about 10 seconds (often cited as 10–15 seconds, with many exams using 10 seconds as the maximum) minimizes interruption of oxygenation and ventilation through the tracheostomy. Longer durations such as 30 seconds or 1 minute substantially increase the risk of oxygen desaturation and hemodynamic instability. Very short times like 5 seconds may be insufficient to clear secretions effectively, especially when secretions are thick, but safety standards still prioritize a strict upper time limit per pass.

Question 32

Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?

Accepted Answer

Answer reason: This indicates the system is patent and the tube is functioning, so the appropriate nursing action is ongoing monitoring rather than urgent intervention. The nurse would be more concerned about continuous bubbling (air leak) or sudden cessation of tidaling with signs of respiratory distress, which would prompt troubleshooting and notification. Reinforcing an occlusive dressing is indicated when there is suspected air entry around the insertion site, and deep breathing may be encouraged for lung expansion but does not address the normal assessment finding being asked about.

Question 33

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

Accepted Answer

Answer reason: Continuous bubbling in the water-seal chamber indicates air is entering the drainage system somewhere, which is the hallmark of an air leak. Intermittent bubbling may occur normally with coughing or exhalation early after insertion, but constant bubbling is abnormal and requires troubleshooting connections, tubing, and the insertion site. A pneumothorax is the underlying condition often being treated, but the device finding of constant bubbling specifically points to leakage in the system rather than diagnosing the patient. An obstructed tube more typically presents with absent tidaling, rising drainage in tubing, or signs of poor lung re-expansion, not persistent bubbling.

Question 34

A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the client's aspirate. Which of the following pH levels should the nurse identify as an indication of correct placement of the tube?

Accepted Answer

Answer reason: 4.0 Gastric contents are typically acidic due to hydrochloric acid, so a low aspirate pH supports that the tube is in the stomach rather than the respiratory tract. A pH around 4 is consistent with gastric placement in many clients, especially when not receiving acid-suppressing therapy. Higher values such as 7–8 are more consistent with respiratory secretions or intestinal contents and therefore do not reliably indicate gastric location. Because NG tube misplacement can cause serious complications (e.g., aspiration), an acidic pH is used as a bedside safety check to reduce risk before using the tube.

Question 35

Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube?

Accepted Answer

Answer reason: Irrigation directly addresses the most common cause of loss of function—occlusion from thick gastric contents, medications, or feeding residue—while also allowing reassessment of resistance and return. Continuous low-intermittent suction is used for decompression but does not reliably prevent occlusion and can worsen mucosal irritation if relied on as a “patency” strategy. Oral/nasal suctioning is for airway/comfort, and fecal occult blood testing is unrelated to NG tube function.

Question 36

A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube?

Accepted Answer

Answer reason: The standard bedside measurement is NEX (nose-to-earlobe-to-xiphoid), which approximates the path the tube travels to gastric placement. Measuring only nose-to-xiphoid or ear-to-xiphoid underestimates length and increases the risk of high esophageal positioning and aspiration. Extending the measurement to the umbilicus is used for longer tubes intended for post-pyloric/intestinal placement and would overestimate length for a gastric small-bore tube.

Question 37

A 68-yr old man with left retinal detachment is scheduled for sclera bulking and cryopexy and pneumatic retinopexy. Preoperatively, the nurse prepares the patient for post operatively expectations by explaining that,?

Accepted Answer

Answer reason: This makes strict head positioning (often face-down or directed positioning) and activity limitation a key postoperative expectation to maintain the bubble’s effect and reduce risk of redetachment. A bilateral patch is not routinely required, and indefinite dark glasses are not a standard requirement. Vision prognosis varies and may improve, so counseling that vision will not return is not an appropriate universal expectation statement.

Question 38

The nurse is discussing possible treatment options of a female patient with heavy menstrual bleeding causing anemia due to fibroids. Which surgical procedure would be contraindicated if the patient wishes to have children?

Accepted Answer

Answer reason: Removal of the uterus permanently eliminates the ability to conceive and carry a pregnancy, so it is contraindicated in someone who wants children. In contrast, procedures aimed at treating fibroids while leaving the uterus in place may allow future fertility, even if they can still affect pregnancy outcomes. Imaging studies are not surgical treatments and do not inherently conflict with fertility goals.

Question 39

After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is?

Accepted Answer

Answer reason: This is critical to prevent serious complications such as pulmonary placement and aspiration pneumonia when feedings or medications are administered. Auscultation of an air bolus is unreliable and can sound “normal” even when the tube is in the respiratory tract. Aspiration of gastric contents may be helpful as a bedside check, but it can be falsely reassuring or unobtainable and is not as definitive as imaging after insertion.

Question 40

Which type 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: A 90-90 (90/90) traction setup is commonly used for pediatric femur fractures to maintain alignment with the hip and knee flexed while applying traction via a pin and weights. This directly fits a child with extensive skin damage where skin traction methods are not appropriate. Buck's and Russell are skin traction methods, so they are poor choices when significant skin injury is present. Bryant traction is typically reserved for much younger/smaller children and also commonly involves skin traction, making it less suitable here.

Question 41

Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes?

Accepted Answer

Answer reason: This approach confirms correct steps such as site selection, proper needle angle, dose preparation, rotation of sites, and safe sharps disposal, and it allows immediate correction to prevent hypo/hyperglycemia from dosing errors. Questioning and written tests assess knowledge but cannot verify manual competence. Having another diabetic assist may offer support but is not as reliable or standardized for assessing safe, accurate injection performance.

Question 42

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

Accepted Answer

Answer reason: Its limited, targeted use may be considered when thick, tenacious secretions are obstructing the airway and suctioning alone cannot clear them. In that setting the goal is to help dislodge an adherent plug so the airway can be cleared. It does not prevent aspiration, and it typically increases coughing rather than decreasing discomfort.

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 3 months ago. The nurse would anticipate the health care provider ordering?

Accepted Answer

Answer reason: Inferior vena cava interruption (e.g., IVC filter/ligation) is a therapeutic procedure used when emboli recur or when anticoagulation is inadequate/contraindicated, reducing risk of future life-threatening PE. Thrombolytics are typically reserved for massive PE with hemodynamic instability and do not address ongoing recurrent embolization risk in a stable patient. Embolectomy is invasive and generally reserved for massive PE or failed thrombolysis rather than recurrent episodes without evidence of acute collapse.

Question 44

A patient has recovered and it is time for the physician to pull the chest tube out. During the procedure, the nurse instructs the patient to?

Accepted Answer

Answer reason: Performing a Valsalva maneuver (bearing down while holding the breath) increases intrathoracic pressure during chest tube removal, which helps prevent air from being sucked into the pleural space. This reduces the risk of pneumothorax as the tube is withdrawn and the insertion site is immediately sealed with an occlusive dressing. Instructions such as inhaling or taking deep breaths can lower intrathoracic pressure at points in the respiratory cycle and increase the chance of air entry. Calm coaching is helpful, but the key safety instruction is the brief Valsalva/held-breath maneuver at the moment of removal.

Question 45

The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood?

Accepted Answer

Answer reason: Drawing the specimen shortly before the next scheduled infusion best reflects that minimum concentration at steady state. Obtaining levels after the infusion would represent peak/post-distribution concentrations and can lead to inappropriate dose reductions. Correct timing supports safe therapeutic drug monitoring, especially because vancomycin accumulation increases risk of nephrotoxicity.

Question 46

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 depends on producing a controlled generalized seizure of adequate duration under anesthesia and neuromuscular blockade. The presence of a generalized (grand mal) seizure indicates the stimulus successfully induced the intended physiologic response required for antidepressant benefit. Loss of consciousness is expected from anesthesia, not from treatment effectiveness. Vomiting and tachycardia are potential adverse effects/physiologic responses and do not demonstrate that the key therapeutic endpoint (a generalized seizure) occurred.

Question 47

The nurse is caring for a client with a tracheostomy who requires suctioning. Which of the following actions by the nurse would indicate correct technique?

Accepted Answer

Answer reason: Proper tracheostomy suctioning minimizes mucosal trauma and hypoxemia by avoiding suction on insertion and preventing the catheter tip from abrading the carina. Advancing to the premeasured depth and then withdrawing slightly before applying suction helps prevent direct suctioning against the tracheal wall. In contrast, 160 mm Hg is generally too high for adult tracheal suction (typical adult range is about 100–120 mm Hg), increasing bleeding and mucosal injury risk. Suction should be applied only while withdrawing and for a brief duration (about 10–15 seconds), making a 25-second pass unsafe.

Question 48

What is the most important nursing action when measuring a pulmonary capillary wedge pressure (PCWP)?

Accepted Answer

Answer reason: The highest-priority nursing action is therefore minimizing balloon inflation time and immediately deflating once the wedge value is obtained to reduce life-threatening complications. Having the client bear down (Valsalva) can transiently alter intrathoracic pressure and hemodynamics, producing inaccurate readings and is not a safety priority. Supine positioning and line flushing are supportive actions, but neither addresses the immediate risk created by balloon inflation.

Question 49

An adult client is admitted to the nursing care unit with intestinal obstruction and has a Miller-Abbott tube in place. How should the nurse assess for proper placement and function of the tube?

Accepted Answer

Answer reason: Safe verification of enteric tube position centers on objective, reproducible measures that reflect whether the tube has migrated. Marking/centimeter checks at the naris (or documented insertion length) allow the nurse to detect displacement, which can lead to ineffective decompression or malposition. Air insufflation with auscultation is unreliable and can falsely suggest correct placement even when the tube is not in the GI tract. While monitoring for respiratory compromise is important for safety, it does not confirm correct GI placement or ongoing function of the tube.

Question 50

A nurse is assisting a physician with chest tube removal. Which instructions must be given to the client?

Accepted Answer

Answer reason: Chest tube removal risks air being drawn into the pleural space if intrathoracic pressure becomes negative during inspiration. Having the client perform a breath-hold/forced exhalation maneuver increases intrathoracic pressure at the moment of removal, helping prevent air entry and reducing the risk of recurrent pneumothorax. This instruction is time-critical and is coordinated with immediate occlusive dressing application to maintain a closed system. Simply keeping still may help comfort but does not address the key physiologic risk. Rapid breathing or slow exhalation without generating positive pressure can allow air to be entrained into the pleural cavity.

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A patient with a nasogastric tube begins to vomit large amounts of green fluid. What should the nurse do first?

A nurse prepares a patient for postural drainage of the lower lobes. What is the best position?

A client has a chest tube with continuous bubbling in the water seal chamber. What does this indicate?

A stroke client who was initially on NGT feeding was able to tolerate soft diet so the physician ordered for the removal of it. The nurse would instruct the client to do which of the following before he removes the tube?

A client with a broken clavicle asks why a figure-of-eight brace is applied. What is the best explanation?

Position provided to the patient during perineal operation is?

As a nurse, you know that the position for June before thoracentesis is?

A client with ascites is scheduled for a paracentesis. Which instruction should be given to the client before the procedure?

After a lumbar puncture, the nurse should position the client?

After liver biopsy, which position is used to prevent bleeding?

Best position during thoracentesis procedure:

A physician has ordered a 4 year old to receive 40% oxygen therapy. You would recommend which of the following oxygen delivery devices?

During the removal of chest tubes, the patient is asked to...?

A client with ascites is scheduled for a paracentesis. Which instruction should be given to the client before the procedure?

A client with a fractured femur is placed in skeletal traction. What is the primary purpose of this intervention?

A 63-year-old client with cirrhosis underwent paracentesis today. Which assessment finding alerts the nurse that the procedure was successful?

A nurse is caring for a patient who has just undergone a lumbar puncture. Which position should the nurse encourage the patient to assume after the procedure?

Which tube is used for suctioning the airway?

Which solution is used for eye irrigation?

To help Fernan better tolerate the bronchoscopy, you should instruct him to practice which of the following prior to the procedure?

Scenario: A patient has a Jackson-Pratt (JP) drain after abdominal surgery. The nurse observes decreased drainage and tension on the tubing. What is the nurse’s priority action?

Best position for a client undergoing paracentesis (removal of ascitic fluid).

The nurse is preparing a client for a renal biopsy. The best position for the procedure is ?

Scenario: A nurse inserts a nasogastric (NG) tube for enteral feeding. Q. What is the most reliable method to confirm placement before feeding?

During a pelvic exam under spinal anesthesia, what position should be used?

During percutaneous liver biopsy, the client should be positioned?

Procedure for pediatric suction :-

The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about?

A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position?

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of?

Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the client's aspirate. Which of the following pH levels should the nurse identify as an indication of correct placement of the tube?

Which nursing intervention is most appropriate to maintain the patency of a client's nasogastric tube?

A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube?

A 68-yr old man with left retinal detachment is scheduled for sclera bulking and cryopexy and pneumatic retinopexy. Preoperatively, the nurse prepares the patient for post operatively expectations by explaining that,?

The nurse is discussing possible treatment options of a female patient with heavy menstrual bleeding causing anemia due to fibroids. Which surgical procedure would be contraindicated if the patient wishes to have children?

After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is?

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

Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes?

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

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 3 months ago. The nurse would anticipate the health care provider ordering?

A patient has recovered and it is time for the physician to pull the chest tube out. During the procedure, the nurse instructs the patient to?

The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab for them to collect the blood?

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

The nurse is caring for a client with a tracheostomy who requires suctioning. Which of the following actions by the nurse would indicate correct technique?

What is the most important nursing action when measuring a pulmonary capillary wedge pressure (PCWP)?

An adult client is admitted to the nursing care unit with intestinal obstruction and has a Miller-Abbott tube in place. How should the nurse assess for proper placement and function of the tube?

A nurse is assisting a physician with chest tube removal. Which instructions must be given to the client?

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