Question 1

The nurse is planning care for a client having hysterosalpingography. What is the most important nursing intervention for the nurse to provide?

Accepted Answer

Answer reason: Hysterosalpingography involves instillation of contrast into the uterus and fallopian tubes, and the expected immediate after-effect is drainage of contrast and possible slight spotting. Providing a perineal pad addresses comfort and hygiene while allowing the nurse to observe the amount and character of drainage for early detection of abnormal bleeding. Routine NPO status is not typically required because this is usually performed without general anesthesia, so it is not the key priority. Positioning and prolonged post-procedure bed rest are not standard primary nursing priorities compared with managing expected drainage and monitoring for complications.

Question 2

A client has returned from surgery with continuous bladder irrigation. The nurse is aware that proper maintenance of a continuous bladder irrigation system includes?

Accepted Answer

Answer reason: The goal of continuous bladder irrigation after urologic surgery is to keep the catheter patent and prevent clot formation while minimizing ongoing bleeding. Titrating the irrigation so the urine is light pink indicates sufficient flushing without promoting unnecessary bladder irritation or masking significant hemorrhage. Bright red output suggests heavier bleeding and would prompt assessment and possible provider notification rather than aiming to “maintain” that color. A fixed slow rate is unsafe because the rate should be adjusted based on output color and presence of clots; leakage around the catheter commonly indicates obstruction/spasms and requires checking for kinks and irrigating per protocol, not stopping the system outright.

Question 3

After receiving normal CXR results of the client who had cardiac surgery, the nurse proceeds to remove the client’s chest tubes as prescribed. Which intervention should be the nurse’s priority?

Accepted Answer

Answer reason: Having dressing supplies at the bedside (e.g., petroleum gauze/occlusive dressing) allows rapid, continuous coverage of the insertion site as soon as the tube is pulled, reducing pneumothorax risk. Analgesia and post-removal assessment are important, but they do not mitigate the highest-risk step occurring at the moment of removal. Suction management depends on the provider’s order/system design, but it is not more time-critical than ensuring immediate occlusive coverage at the site.

Question 4

The nurse is evaluating discharge teaching that has been completed for the client following total laryngectomy. Which client statement should the nurse correct?

Accepted Answer

Answer reason:  After a total laryngectomy, the airway is permanently diverted through a stoma, so the opening does not “close” later like a temporary tracheostomy might. Teaching must emphasize lifelong stoma care and airway protection because the client no longer breathes through the nose and mouth. A key safety implication is high drowning risk with swimming or submersion because water can enter directly into the airway. Clients also commonly carry tissues to cover/clean the stoma and should ensure functioning smoke detectors because they lose some upper-airway filtering/humidification and may have reduced ability to smell smoke early.

Question 5

The nurse is caring for the infant with Hirschsprung’s disease. Which statement by the parent indicates understanding of the treatment for Hirschsprung’s disease?

Accepted Answer

Answer reason:  Hirschsprung’s disease is caused by absence of enteric ganglion cells, leading to a nonfunctioning distal segment and functional obstruction. Definitive management is surgical resection of the aganglionic bowel with a pull-through procedure to restore normal motility. Diet changes alone do not correct the underlying anatomic/neurologic defect, and enemas are only a temporary measure for decompression/constipation management prior to definitive therapy. A permanent colostomy is not routinely required; if a stoma is used, it is typically temporary depending on the infant’s condition and surgical plan.

Question 6

The nurse provides teaching to the 9-year-old who is to undergo bone marrow aspiration. Which statement by the child best indicates understanding of the teaching?

Accepted Answer

Answer reason:  After a bone marrow aspiration, immediate care focuses on hemostasis and protecting the puncture site to reduce bleeding and infection risk. A pressure dressing is typically applied and can often be removed later the same day if there is no continued oozing, which reflects accurate understanding of post-procedure care. Bed rest for a fixed period is not universally required for at least an hour; activity is usually limited based on the site and bleeding risk rather than a strict time rule. Avoiding the playroom until tomorrow is unnecessarily restrictive, and the skin prep is an antiseptic solution that does not require showering to remove “dye.”.

Question 7

A 20-year-old client with myasthenia gravis will undergo plasmapheresis. Which action describes the purpose of this procedure?

Accepted Answer

Answer reason: Plasmapheresis therapeutically removes the antibody-containing plasma to rapidly reduce pathogenic antibody levels and improve strength, especially in exacerbations or preoperatively. It does not directly remove lymphocytes (that would be more consistent with certain apheresis or immunosuppressive strategies), and it is not a method for administering anticholinesterase medications. The benefit is typically temporary, so it is used as a bridging or acute stabilization therapy rather than a definitive cure.

Question 8

When teaching the family of a client with C4 quadriplegia how to suction his tracheostomy, the nurse includes which instruction?

Accepted Answer

Answer reason: Tracheostomy suctioning should be time-limited to reduce hypoxemia, vagal stimulation, and mucosal trauma. Limiting each pass to about 10–15 seconds supports adequate oxygenation while still allowing secretion removal. Excessive suction pressure is unsafe (adult trach suction pressures are typically much lower than the value listed), increasing the risk of airway injury and bleeding. Suction is applied intermittently while withdrawing the catheter, not during insertion, to avoid traumatizing the tracheal wall and worsening hypoxia.

Question 9

A client with a pulmonary embolism is scheduled to have an umbrella filter placed in the vena cava. The nurse determines that teaching has been effective when the client states?

Accepted Answer

Answer reason:  An inferior vena cava (IVC) filter is a mechanical device designed to trap emboli from the lower extremities before they reach the pulmonary circulation. It reduces the risk of recurrent pulmonary embolism by catching clots, not by preventing new clot formation. It does not fragment clots into harmless pieces, and it does not deliver anticoagulants or dissolve thrombi. Anticoagulation (when safe) is still typically needed to prevent additional clot propagation.

Question 10

The nurse is providing preoperative teaching for a client with a pulmonary embolism scheduled for an embolectomy. The most appropriate information for the nurse to give the patient is?

Accepted Answer

Answer reason: An embolectomy is a therapeutic surgical procedure performed to remove an obstructing thrombus/embolus from a blood vessel when rapid restoration of perfusion is needed or other therapies are contraindicated/ineffective. In pulmonary embolism, the target vessel is within the pulmonary arterial circulation, so teaching should describe removal from the pulmonary vasculature. Bronchoscopy accesses airways rather than blood vessels, so it cannot remove an intravascular embolus. Statements focusing on removing the clot from the leg or pelvis describe potential sources (e.g., DVT) rather than what the planned procedure is intended to do.

Question 11

The nurse asks a client about an upcoming medical procedure. The client will be undergoing a thoracentesis for a large right pleural effusion. The nurse knows further teaching is necessary when the client states?

Accepted Answer

Answer reason: Thoracentesis is typically performed at the bedside with the client awake, breathing spontaneously, and instructed to remain still to reduce the risk of pleural or lung injury. Routine mechanical ventilation is not required for a standard thoracentesis and would only be relevant in uncommon, critically ill situations. Appropriate teaching includes positioning sitting upright and leaning forward to widen intercostal spaces and facilitate access. Clarifying that imaging (e.g., chest x-ray/ultrasound) helps localize fluid is also consistent with safe preparation, making the ventilator statement the clearest misunderstanding.

Question 12

The nurse prepares a client for a bedside thoracentesis. The nurse helps the client into a sitting position with a pillow placed on top of the overbed table in front of the client for support. The nurse understands that this is the correct client position for a thoracentesis because?

Accepted Answer

Answer reason: Thoracentesis removes pleural fluid, so positioning should promote dependent pooling of fluid and safe access to the pleural space. Sitting upright and leaning forward helps pleural fluid gravitate to the lower (dependent) pleural areas, where the needle is commonly inserted while avoiding the lung tissue. This position also stabilizes the client and widens the intercostal spaces, improving procedural access and reducing complications. Maximal lung expansion is not the primary goal during fluid aspiration and can increase the chance of lung puncture if the lung is more expanded in the field.

Question 13

A client returns from surgery after an abdominal perineal resection. The client has a nasogastric (NG) tube in place that is connected to low suction. After several hours, drainage from the NG tube stops. Which action should the nurse take first?

Accepted Answer

Answer reason: When NG output stops unexpectedly, the priority is to troubleshoot the external system using the least invasive, safest step. Inspecting the suction setup (tubing connections, dependent loops, and kinks) commonly restores function without risking mucosal injury or tube displacement. Increasing suction can traumatize gastric mucosa and does not correct a mechanical obstruction in the tubing. Irrigation or repositioning should be done only if ordered and after simple equipment problems are ruled out, since these actions can disrupt surgical recovery or introduce complications.

Question 14

As a nurse is inserting a nasogastric tube, the client begins to gag. Which action should the nurse take?

Accepted Answer

Answer reason: Gagging during nasogastric tube insertion is common when the tube reaches the oropharynx and can be reduced by coordinating advancement with swallowing. Pausing helps the client regain control and decreases retching and aspiration risk from continued stimulation. Having the client sip water (if allowed) and swallow closes the epiglottis and guides the tube into the esophagus rather than the airway. In contrast, removing the tube and calling the provider is unnecessary for expected gagging unless there are signs of respiratory distress or inability to advance safely.

Question 15

The nurse is instructing a client with vulvovaginal candidiasis on the use of the prescribed Nystatin vaginal tablets. Which of the following statements indicates that the client needs additional teaching?

Accepted Answer

Answer reason:  Vaginal antifungal tablets are typically inserted at bedtime with the client remaining recumbent afterward to reduce leakage and promote mucosal contact time. Immediately resuming activities can cause the medication to drain out, decreasing local drug exposure and reducing treatment effectiveness. Completing the full course even if symptoms improve is correct to prevent relapse and ensure eradication. Reporting worsening irritation is appropriate because it may indicate intolerance, contact dermatitis, or an alternative diagnosis requiring reassessment.

Question 16

Which statement by a client scheduled for a vasectomy indicates he needs further teaching about the procedure?

Accepted Answer

Answer reason:  Vasectomy does not provide immediate sterility because viable sperm can remain in the vas deferens distal to the ligation for multiple ejaculations. The client must use alternative contraception until follow-up semen analyses confirm azoospermia, otherwise pregnancy risk persists. Post-procedure scrotal icing helps reduce swelling and discomfort and is appropriate teaching. Activity restriction for about a week is standard to reduce bleeding, swelling, and pain, and reversal is possible but not reliably successful.

Question 17

The nurse is helping the client newly diagnosed with obstructive sleep apnea to apply a CPAP mask at bedtime. When asked by the client about the purpose of CPAP, what should the nurse’s best response?

Accepted Answer

Answer reason:  CPAP provides continuous positive airway pressure to “splint” the upper airway open during sleep and improve ventilation. The positive pressure also increases functional residual capacity and helps keep alveoli recruited, which supports more stable gas exchange overnight. It does not breathe for the client (that would describe mechanical ventilation rather than CPAP). CPAP primarily improves oxygenation by preventing airway/alveolar collapse, not by delivering higher oxygen concentration unless supplemental oxygen is specifically added.

Question 18

An 18-year-old client who was involved in a motor vehicle accident is admitted to the hospital with a diagnosis of pneumothorax. A chest tube was inserted and attached to a chest drainage system. The nurse notes bubbling in the water seal chamber and determines further assessment is required. The nurse is aware the bubbling is most likely the result of?

Accepted Answer

Answer reason: Continuous bubbling in the water-seal chamber indicates air is entering the closed chest drainage system somewhere, which is abnormal after initial evacuation of pleural air. This most commonly reflects an air leak from the system connections or from the patient (e.g., ongoing pleural leak), and it requires the nurse to assess tubing connections and the insertion site and to localize the leak. Suction adequacy is assessed in the suction-control chamber (gentle, continuous bubbling if wet suction), not by water-seal bubbling. A kinked tube more often reduces or stops expected tidaling/drainage rather than causing persistent bubbling in the water seal.

Question 19

A nurse receives an order to start an infusion of blood for a client who’s hemorrhaging due to a placenta previa. It is most important for the nurse to obtain which of the following?

Accepted Answer

Answer reason: A large-bore IV (18G) is preferred in active hemorrhage to deliver blood products quickly and to allow concurrent fluids if needed. Packed RBCs should be administered with only 0.9% normal saline using blood administration (Y) tubing; lactated Ringer’s is avoided because calcium can promote clotting in the tubing/filter. A 20G catheter can be too small to achieve the needed flow rate in ongoing obstetric bleeding.

Question 20

The intensive care unit nurse is explaining the procedure for continuous renal replacement therapy (CRRT) to a client with acute renal failure. Which statement best describes how the nurse should tell the client how CRRT will be initiated?

Accepted Answer

Answer reason:  CRRT for acute renal failure is initiated using temporary vascular access because it must provide reliable, high-flow blood removal and return. A double-lumen central venous catheter placed in a large vein (commonly internal jugular or subclavian region) is the standard access used in the ICU for rapid initiation. Abdominal catheters are used for peritoneal dialysis rather than CRRT. Arm fistulas or shunts are typically created for chronic hemodialysis access and are not the usual initial access for urgent CRRT in acute kidney injury.

Question 21

The client is scheduled for application of a cadaver homograft to a burn on the forearm. Which comment by the client demonstrates an accurate understanding of this procedure?

Accepted Answer

Answer reason:  A cadaver homograft (allograft) provides temporary biologic coverage for burns, reducing fluid and heat loss, decreasing pain, and lowering infection risk while the wound bed is prepared for definitive closure. Because it is genetically different tissue, it will eventually be rejected and is not intended as a permanent graft. This makes understanding its temporary protective role the key teaching point. Options implying a self-donor site or choosing another donor site reflect autograft concepts rather than cadaver homograft use, and the statement about no blood-borne disease risk is inaccurate because risk is minimized but not zero.

Question 22

The clinic nurse completed teaching the client with a rotator cuff tear who is being treated conservatively. Which client statement indicates that further teaching is needed?

Accepted Answer

Answer reason:  Conservative management of a rotator cuff tear focuses on pain/inflammation control and functional rehabilitation rather than immediate surgical repair. Assuming a need for an open procedure reflects misunderstanding of the treatment plan and overstates certainty about surgery, since many clients improve with NSAIDs, steroid injection, activity modification, and physical therapy. Acromioplasty is not synonymous with cuff repair, and surgical approach/timing depend on severity, functional deficit, and response to therapy. The other statements align with conservative care teaching, including anti-inflammatory therapy, safe NSAID administration, and gradual strengthening once pain is controlled.

Question 23

The experienced nurse observes the new nurse caring for the client who is in skeletal traction to stabilize a proximal femur fracture prior to surgery. Which observation by the experienced nurse indicates the new nurse needs additional orientation?

Accepted Answer

Answer reason: Detaching or removing weights breaks traction and can worsen displacement, increase pain, and raise neurovascular compromise risk. The correct maintenance approach is to ensure the weights hang freely (not resting on the bed or floor) while keeping them attached as ordered and ensuring ropes run smoothly through pulleys. The other observations describe appropriate traction care (preventing foot drop/pressure, keeping ropes in pulley grooves, and performing regular pin-site care to reduce infection risk).

Question 24

A hospitalized client diagnosed with seizures has a vagus nerve stimulation (VNS) device implanted. The nurse determines that the VNS is working properly when making which observation?

Accepted Answer

Answer reason: Vagus nerve stimulation is an adjunct therapy for refractory epilepsy that delivers programmed impulses, and patients can also use a handheld magnet to trigger an extra stimulation when they sense an aura or at the start of a seizure. Proper function is reflected by the client’s ability to activate the device appropriately to reduce seizure frequency or abort/lessen an impending event. The other choices describe functions of pacemakers/ICDs or claim the device prevents aspiration, which is not a direct or reliable effect of VNS. Nursing evaluation focuses on correct patient use and expected therapeutic effect on seizure activity rather than cardiac rhythm management.

Question 25

The client with newly diagnosed breast cancer asks the nurse to explain the advantages of a sentinel lymph node biopsy (SLNB). Which explanation should the nurse state to the client?

Accepted Answer

Answer reason: Sentinel lymph node biopsy identifies the first draining node(s) from the tumor to assess for metastatic spread. If the sentinel node is negative, a full axillary lymph node dissection can often be avoided, decreasing surgical morbidity such as lymphedema, nerve injury, and reduced shoulder mobility. SLNB is primarily a staging and risk-reduction procedure rather than a method to ensure wider tumor excision. It also does not determine whether hormonal therapy is needed, which depends on receptor status and overall staging.

Question 26

The new nurse is telling the experienced nurse about treatments that the HCP discussed with the parents of the child who has thalassemia major. Which statement by the new nurse should the experienced nurse question?

Accepted Answer

Answer reason: Thalassemia major is an inherited hemoglobin synthesis disorder causing chronic hemolytic anemia from ineffective erythropoiesis, not an immune/toxin-mediated process that can be treated by removing plasma components. Plasmapheresis is used for select conditions involving pathogenic antibodies, immune complexes, or certain plasma-borne toxins, and it does not address the underlying globin-chain defect. Regular packed RBC transfusions every 2–4 weeks are standard supportive therapy to maintain hemoglobin and suppress excessive marrow expansion. Splenectomy can be considered for hypersplenism/symptomatic splenomegaly, and hematopoietic stem cell transplant can be curative in appropriate candidates.

Question 27

The nurse is developing a teaching plan for the pediatric client and the child’s parents for home peritoneal dialysis (PD). Which statement should the nurse omit from the teaching plan?

Accepted Answer

Answer reason:  Peritoneal dialysate should be warmed to near body temperature before infusion to reduce abdominal discomfort, prevent hypothermia, and avoid vasoconstriction that can impair peritoneal blood flow and diffusion. Teaching to infuse cooled solution is unsafe and could increase pain and decrease dialysis efficiency. In PD, solution commonly flows in by gravity, dwells for a prescribed (often variable) time, and drains out, which aligns with the other options. Sterile technique and use of a surgically implanted catheter are essential to reduce peritonitis risk, further supporting that the “cooled solution” statement is the one to omit.

Question 28

The nurse is instructing a nursing assistant on the proper care of a client in Buck’s extension traction following a fracture of the left fibula. Which of the following observations would indicates that teaching has been effective?

Accepted Answer

Answer reason: Traction is only effective when a constant, uninterrupted pulling force is maintained in proper alignment. Allowing the weights to hang freely maintains the prescribed traction force and prevents loss of reduction. Lifting the weights (even briefly) removes the traction force and can worsen alignment and pain. External rotation is not a goal of Buck’s traction and can contribute to malalignment; ankle/foot exercises may be appropriate but do not demonstrate correct traction setup and maintenance.

Question 29

The nurse collects a urine specimen from a client's indwelling urinary catheter. Which method is the correct procedure for obtaining a urine specimen from an indwelling urinary catheter?

Accepted Answer

Answer reason: Specimens from an indwelling catheter should be obtained using aseptic technique from the designated sampling port to minimize contamination and reduce catheter-associated infection risk. Disinfecting the port and withdrawing urine with a sterile syringe provides a fresh, uncontaminated sample from the closed system. Collecting from the drainage bag can yield stale urine with bacterial growth, producing inaccurate results. Disconnecting tubing breaks the closed drainage system and increases infection risk. Removing and re-catheterizing is unnecessary and adds trauma and infection risk.

Question 30

The nurse is instructing a client with chronic obstructive pulmonary disease (COPD) how to perform pursed-lip breathing. The nurse determines the client understands the instructions when the nurse observes the client?

Accepted Answer

Answer reason: Pursed-lip breathing creates back-pressure in the airways during exhalation, helping prevent small-airway collapse and reducing air trapping in COPD. An upright position optimizes diaphragmatic movement and lung expansion, supporting better ventilation. Slow exhalation through partially closed lips prolongs expiratory time and improves removal of trapped air, easing dyspnea. Lying flat can worsen ventilation mechanics, and breath-holding or forceful exhalation can increase work of breathing and dynamic hyperinflation.

Question 31

A 24-year-old female client is diagnosed with acute lymphoblastic leukemia and requires an allogeneic bone marrow transplant. The nurse determines the client understands the treatment when the client states?

Accepted Answer

Answer reason: Conditioning therapy (high-dose chemotherapy, sometimes with total body irradiation) is required before an allogeneic bone marrow transplant to eradicate malignant cells and suppress the recipient’s immune system to allow engraftment. This statement demonstrates understanding of the essential sequence of treatment and the purpose of pre-transplant preparation. In contrast, fertility is often impaired by conditioning regimens, so expecting pregnancy afterward reflects a key misconception. Nausea is a common adverse effect of high-dose chemotherapy regardless of prior history, and length of hospitalization varies based on complications and engraftment rather than a fixed 2-week minimum.

Question 32

A percutaneous transluminal coronary angioplasty (PTCA) is performed on the client with a myocardial infarction to?

Accepted Answer

Answer reason: PTCA is a reperfusion therapeutic procedure that mechanically dilates a stenosed or occluded coronary artery, restoring myocardial perfusion and limiting infarct size. It addresses the core MI problem—acute coronary obstruction—by improving coronary blood flow via balloon angioplasty (often with stent placement). Bypass is achieved with CABG surgery rather than PTCA, so that option describes a different intervention. Ablation targets dysrhythmias and does not revascularize ischemic myocardium, and preventing heart failure is an indirect potential benefit rather than the primary procedural purpose.

Question 33

The client with cirrhosis is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) placement. The nurse realizes the client does not understand the procedure when the client makes which statement?

Accepted Answer

Answer reason:  TIPS is a minimally invasive interventional radiology procedure performed via venous access (typically the internal jugular vein), not an open abdominal surgery. Its purpose is to reduce portal hypertension, which lowers the risk of recurrent variceal bleeding. By decompressing portal pressures, it can also help manage refractory ascites, though it is not guaranteed to eliminate it entirely. A key complication is shunt stenosis/occlusion over time, which is why ongoing surveillance is needed.

Question 34

The experienced nurse is orienting the new nurse to the care of clients with CRF. Which statement made by the new nurse should the experienced nurse correct?

Accepted Answer

Answer reason: " Peritoneal dialysis drainage is expected to vary because net ultrafiltration removes additional fluid along with the dialysate. Therefore, outflow commonly exceeds inflow when fluid removal occurs, and it may be less if there is retained fluid or catheter/positioning issues, so “should equal” is an unsafe absolute. The nurse should instead assess trends, clarity of effluent, patient weight, edema, and ensure ordered dwell times and correct catheter function. By contrast, emphasizing higher protein intake is generally appropriate on peritoneal dialysis because protein is lost in the effluent.

Question 35

The nurse completes teaching the parent of the child with asthma about the peak flow meter. Which statement indicates that the teaching was effective?

Accepted Answer

Answer reason:  Peak expiratory flow monitoring requires a standardized technique to make readings reliable for asthma self-management decisions. The child should be upright and the indicator reset to the start position before each attempt so the measurement reflects maximal forced expiration rather than posture-related restriction or a prior value. Clearing secretions first can reduce falsely low values caused by mucus obstruction, improving the usefulness of the reading for assessing airway status. Options describing lying flat, testing after exercise, or recording infrequently would increase variability and reduce the value of trending results for early detection of worsening asthma.

Question 36

TWO hours after admitting the client to a post-surgical unit following a nephrectomy, the client states feeling nauseated. The nurse notes minimal drainage from the NG tube. Which action should the nurse take first?

Accepted Answer

Answer reason: Verifying patency by irrigating and confirming return addresses the likely cause of reduced drainage and helps prevent gastric distention and vomiting/aspiration. Calling the provider is not the first action when a common, correctable equipment issue can be assessed and managed promptly. Repositioning the tube by pulling it out is not the initial step because it risks malposition; patency/return should be checked first per NG tube management protocols.

Question 37

A nurse prepares a client for computed tomography (CT) scan with intravenous (IV) iodinated contrast. The nurse should take which action?

Accepted Answer

Answer reason: A 20-gauge catheter is a common minimum size used for many contrast-enhanced CT protocols to ensure reliable delivery. Asking about shellfish is an outdated proxy; the clinically relevant history is prior contrast reaction and other allergy/asthma history, not seafood allergy alone. Fluids should be encouraged (as ordered and if not contraindicated) to support renal clearance of contrast rather than decreased after the procedure.

Question 38

The nurse is teaching a client scheduled for a vaginal and cervical colposcopy with biopsy. Which of the following information should the nurse include?

Accepted Answer

Answer reason: Colposcopy is typically an outpatient procedure performed without general anesthesia, so routine pre-procedure NPO status is not required. Needing a driver is not standard unless sedation/anxiolytics are used. Contrast dye and associated metallic taste are not part of colposcopy/biopsy preparation or expected effects.

Question 39

While scheduling a client for thoracentesis, the nurse understands which of the following is the most preferred position for the procedure?

Accepted Answer

Answer reason: Thoracentesis is safest and most effective when the patient’s chest is positioned to maximize pleural space access and keep the diaphragm and lung bases dependent. Sitting upright and leaning forward spreads the ribs, stabilizes the torso, and helps fluid pool dependently, improving needle access while lowering risk of lung puncture. This position also supports ventilation compared with supine positions, which can reduce accessible fluid and increase dyspnea. Options that place the patient flat or prone do not optimally open intercostal spaces and can increase procedural difficulty and complication risk.

Question 40

While scheduling a client for a thoracentesis, the nurse understands which of the following is the most preferred position for the procedure?

Accepted Answer

Answer reason: Thoracentesis is safest and most effective when the client is positioned to widen the intercostal spaces and allow pleural fluid to pool dependently for easier access. Sitting upright and leaning forward stabilizes the thorax, improves ventilation, and helps keep the needle entry site away from the diaphragm and abdominal organs. Supine or prone positioning reduces access to the posterior/lateral pleural space and can increase risk of organ injury or respiratory compromise. Lying on the affected side is used after the procedure to help seal the puncture site and reduce air leak risk, not as the preferred position for needle insertion.

Question 41

A nurse cares for an adult client who develops a pleural effusion and has a chest tube placed to drain the fluid. Which action does the nurse take in management of the chest tube?

Accepted Answer

Answer reason: Maintaining a patent, unobstructed drainage system is the key principle of safe chest tube management so pleural fluid/air can evacuate and lung re-expansion can occur. Keeping the tubing straight and free of dependent loops prevents backflow, occlusion, and impaired drainage that can worsen respiratory status. Stripping tubing is not routinely recommended because it can create excessive negative pressure and cause tissue trauma; it is done only if specifically prescribed and per policy. Clamping a chest tube without a specific order risks tension pneumothorax, and dressings should be occlusive/secure rather than loose to prevent air entry and infection.

Question 42

The nurse observes a coworker who is inserting a nasogastric tube. Which of the following actions by the staff member would require the nurse to intervene?

Accepted Answer

Answer reason: Standard practice is to confirm placement first (per policy, e.g., radiographic confirmation initially and/or checking gastric aspirate pH and other approved bedside checks) before using or flushing the tube. Flushing may be appropriate only after placement is verified and the tube is cleared for use. The other actions listed are consistent with typical insertion technique, including NEX measurement and advancing while the client swallows to facilitate esophageal passage.

Question 43

The nurse is teaching a client who is scheduled for a percutaneous kidney biopsy. Which of the following information should the nurse include?

Accepted Answer

Answer reason: ” A percutaneous renal biopsy carries a significant risk of bleeding from the highly vascular kidney, so post-procedure positioning focuses on hemostasis and minimizing movement at the puncture site. Keeping the client flat (often with ordered pressure/sandbag and bed rest) reduces the chance of hemorrhage and helps detect early complications like flank pain, hypotension, and hematuria. Applying heat is inappropriate because it can promote vasodilation and potentially worsen bleeding; pain is typically managed with prescribed analgesics and monitoring. Return of gag reflex is teaching for procedures involving throat anesthesia/sedation affecting airway reflexes, not for a kidney biopsy. Immediate resumption of regular activities is unsafe because activity restrictions are commonly required to reduce delayed bleeding.

Question 44

The nurse is providing a training inservice on chest tube management to staff nurses in the cardiothoracic surgery intensive care unit. Which statement should the nurse include in the training?

Accepted Answer

Answer reason: In a wet suction chest drainage system, intermittent bubbling in the water-seal chamber reflects air exiting the pleural space, which is an expected finding when there is a pneumothorax that is resolving. Continuous bubbling would raise concern for an air leak in the system or from the patient, so staff should differentiate expected intermittent bubbling from abnormal continuous bubbling. Routine stripping of tubing is avoided because it can create high negative intrathoracic pressures and damage lung tissue. Large ongoing output such as 250 mL/hr is not “normal” and can signal hemorrhage, and if a tube dislodges from the chest the priority is to apply an occlusive dressing to the insertion site rather than placing the tube end in water.

Question 45

A nurse is preparing to insert a nasogastric tube into a client. The nurse places the client in which position for insertion?

Accepted Answer

Answer reason: Sitting in a high Fowler’s position also aligns the pharynx and esophagus more favorably, facilitating passage of the tube while allowing the client to swallow as the tube advances. Compared with low Fowler’s or supine, the elevated head of bed decreases the likelihood that secretions or gastric contents will be aspirated if gagging or vomiting occurs. Side-lying positions are used more for feeding/placement after insertion or for specific clinical situations, not as the standard initial insertion position.

Question 46

The nurse has taught a client scheduled for a liver biopsy. Which of the following statements by the client would indicate a correct understanding of the teaching?

Accepted Answer

Answer reason: Holding the breath briefly during needle insertion reduces diaphragmatic movement and helps keep the liver still, lowering the risk of laceration and hemorrhage. This instruction is a common safety step for percutaneous liver biopsy performed with local anesthesia and light sedation rather than general anesthesia. In contrast, avoiding acetaminophen for a week is not the key pre-procedure teaching; the major bleeding risk is from anticoagulants/antiplatelets (e.g., aspirin, warfarin) and abnormal coagulation labs. After the procedure, clients are typically kept on bed rest and monitored for bleeding; aggressive coughing and deep breathing is not emphasized immediately because it can increase discomfort and potentially stress the puncture site.

Question 47

For several weeks prior to a scheduled cardioversion, the patient should take which type of medication?

Accepted Answer

Answer reason: Anticoagulants are commonly prescribed for several weeks before elective cardioversion, especially in atrial fibrillation, to reduce the risk of thromboembolism. Cardioversion can dislodge an atrial thrombus and lead to stroke if the patient is not properly anticoagulated. The other medication classes do not serve this preventive purpose.

Question 48

A client has been diagnosed with a benign lung tumor and asks the nurse how it will be treated. What is the best response by the nurse?

Accepted Answer

Answer reason: Benign lung tumors are typically managed with surgical removal when treatment is indicated, with the goal of preserving as much healthy lung tissue as possible. Radiation and chemotherapy are generally reserved for malignant conditions. Observation alone may be appropriate in some asymptomatic cases, but the standard treatment approach—when intervention is needed—is conservative surgical excision.

Question 49

A 3-day-old neonate needs phototherapy for hyperbilirubinemia. What is a priority of care for a neonate receiving phototherapy?

Accepted Answer

Answer reason: Phototherapy uses high-intensity light that can injure the neonate’s retina if the eyes are not covered. Eye protection is therefore a primary safety intervention and must be maintained at all times during therapy.

Question 50

Initial treatment for tetanus in a fully immunized person with a puncture wound is?

Accepted Answer

Answer reason: In a fully immunized individual, the priority initial management of a tetanus-prone wound is thorough wound cleaning and debridement to remove necrotic tissue and reduce anaerobic conditions that allow Clostridium tetani to proliferate. Tetanus immune globulin is typically reserved for individuals with incomplete or unknown immunization status. A tetanus booster (toxoid) may be considered depending on the timing of the last dose, but the immediate first step is proper wound care. Antibiotics like penicillin may be used adjunctively but are not the primary initial intervention.

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