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DHA Nursing Exam study materials
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DHA Nursing Exam practice questions

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Question 1Fundamentals of Nursing and Basic Patient Care

What is the accepted normal resting heart rate range for a healthy adult?

  1. 110 to 150 beats per minute
  2. 30 to 50 beats per minute
  3. 12 to 20 breaths per minute
  4. 60 to 100 beats per minute Correct answer.

Explanation

The normal resting adult heart rate is 60 to 100 beats per minute. Rates below 60 are described as bradycardia and rates above 100 as tachycardia, and either finding requires the nurse to assess the patient for cause and symptoms.

Question 2Fundamentals of Nursing and Basic Patient Care

Which action is the single most effective measure for preventing transmission of microorganisms between patients?

  1. Wearing a surgical mask when walking through the unit
  2. Performing hand hygiene before and after patient contact Correct answer.
  3. Changing the patient's bed linen at the start of every shift
  4. Wearing sterile gloves for every episode of patient contact

Explanation

Hand hygiene is the single most effective intervention for breaking the chain of transmission in health care settings. Gloves do not replace hand hygiene, and linen changes or routine mask use do not reduce organism transfer from the nurse's hands.

Question 3Fundamentals of Nursing and Basic Patient Care

Before administering a scheduled medication, how should the nurse verify the patient's identity?

  1. Two patient-specific identifiers, such as name and date of birth Correct answer.
  2. The patient's hospital number written on the chart
  3. The patient's room number and bed position on the ward
  4. The patient's medical diagnosis and the attending physician's name

Explanation

Safe practice requires at least two patient-specific identifiers, checked directly with the patient or an identification band, before any medication or procedure. Room numbers, bed positions and diagnoses are not unique to one person and cannot confirm identity.

Question 4Fundamentals of Nursing and Basic Patient Care

Which action is correct when disposing of a used hypodermic needle?

  1. Break the needle off the syringe and discard it in a biohazard bag
  2. Place the needle in a red biohazard bag together with used dressings
  3. Recap the needle with two hands and place it in the regular trash
  4. Drop the needle, uncapped, into a sharps container Correct answer.

Explanation

Used needles must go immediately into a puncture-resistant sharps container located at the point of use. Recapping, bending or breaking needles causes needlestick injuries, and soft biohazard bags do not protect against puncture.

Question 5Fundamentals of Nursing and Basic Patient Care

A breathless patient with heart failure is most comfortable sitting upright, and the nurse raises the head of the bed to 60 degrees. Which position should be documented?

  1. Trendelenburg position
  2. Lateral recumbent position
  3. Fowler's position Correct answer.
  4. Prone position

Explanation

Fowler's position raises the head of the bed between 45 and 60 degrees with the knees slightly flexed, and it aids lung expansion and breathing. High-Fowler's uses an even steeper angle, up to about 90 degrees.

Question 6Fundamentals of Nursing and Basic Patient Care

During a blood transfusion the patient develops chills, fever, and flank pain. What is the nurse's first action?

  1. Stop the transfusion and maintain IV access with saline Correct answer.
  2. Give the prescribed antipyretic and continue the transfusion
  3. Obtain a urine specimen before stopping the infusion
  4. Slow the infusion rate and reassess the patient in 15 minutes

Explanation

These findings suggest an acute hemolytic transfusion reaction, which demands immediate cessation of the transfusion. The intravenous line is kept patent with normal saline using new tubing, and the provider and blood bank are notified while the patient is assessed and monitored.

Question 7Fundamentals of Nursing and Basic Patient Care

Which action maintains sterility while setting up a sterile field?

  1. Holding sterile items above waist level, within the border Correct answer.
  2. Reaching across the field with a bare arm to add supplies
  3. Placing sterile items on the outer one-inch border of the drape
  4. Blowing on the field to remove lint before use

Explanation

Anything outside the sterile drape or below waist level is considered contaminated, so sterile items must be kept above the waist and inside the drape's edges. A one-inch margin around the drape is always treated as unsterile.

Question 8Fundamentals of Nursing and Basic Patient Care

Which nursing intervention best reduces fall risk in an older adult admitted with confusion?

  1. Keep all four side rails raised at all times while in bed
  2. Keep the bed in the lowest position with the call light within reach Correct answer.
  3. Place the call light out of reach to prevent the patient tampering with it
  4. Encourage the patient to walk unaided to preserve independence

Explanation

A low bed height with the call light and personal items within reach reduces the likelihood and severity of falls while preserving the patient's ability to summon help. Raising all four side rails acts as a restraint and carries its own injury risk, such as climbing over them.

Question 9Fundamentals of Nursing and Basic Patient Care

Which item is recorded as intake on a 24-hour intake and output record?

  1. Urine emptied from the Foley bag
  2. Ice chips swallowed by the patient Correct answer.
  3. Emesis collected in the basin
  4. Wound drainage on the dressing

Explanation

Intake includes all fluid taken by mouth, including ice chips and fluids taken with medications. Output includes urine, emesis, wound or drain drainage, and liquid stool.

Question 10Fundamentals of Nursing and Basic Patient Care

Which action is required when a patient is placed in a physical restraint?

  1. Leave the patient alone to reduce stimulation from staff
  2. Tie the restraint straps securely to the side rails of the bed
  3. Release and assess circulation and skin at regular intervals Correct answer.
  4. Apply the restraint as tightly as possible to prevent escape

Explanation

Restraints require scheduled release, repositioning, and assessment of circulation, skin integrity, and the continued need for the device. Straps must be attached to a fixed part of the bed frame so the bed can be moved without injury.

Question 11Fundamentals of Nursing and Basic Patient Care

Which method is most reliable for confirming initial placement of a small-bore nasogastric feeding tube?

  1. Asking the patient to speak and noting any hoarseness
  2. Measuring the pH of aspirate together with radiography Correct answer.
  3. Auscultating a whoosh over the epigastrium while injecting air
  4. Placing the tube tip in water and watching for bubbles

Explanation

Radiography remains the reference standard for initial confirmation of a blindly inserted feeding tube, and pH testing of aspirate (typically pH 5.5 or lower for gastric placement) supports bedside assessment. The auscultatory whoosh method is unreliable and no longer recommended.

Question 12Fundamentals of Nursing and Basic Patient Care

A patient has a shallow open ulcer over the sacrum with visible subcutaneous fat and no slough or eschar. How should this pressure injury be classified?

  1. Stage 3 Correct answer.
  2. Stage 1
  3. Stage 2
  4. Stage 4

Explanation

A full-thickness wound that exposes subcutaneous fat, without exposed muscle, bone, or tendon, is a stage 3 pressure injury. Stage 2 involves partial-thickness loss with a shallow open wound or blister, and stage 4 exposes deeper structures.

Question 13Fundamentals of Nursing and Basic Patient Care

A handwritten medication order on the chart is unclear. What is the nurse's best action?

  1. Administer the dose that seems most likely to be correct
  2. Contact the prescriber to clarify the order first Correct answer.
  3. Hold the drug and document that the patient refused it
  4. Ask a colleague to interpret the prescriber's handwriting

Explanation

When any part of an order is unclear, the nurse must clarify it with the prescriber before administration. Guessing the dose or route is a medication error waiting to happen and cannot be justified by another nurse's interpretation.

Question 14Fundamentals of Nursing and Basic Patient Care

When removing personal protective equipment after caring for a patient on contact precautions, which item is removed first?

  1. Face shield
  2. Mask
  3. Gown
  4. Gloves Correct answer.

Explanation

Gloves are the most contaminated item and are removed first, followed by eye protection, then the gown, with the mask or respirator removed last after leaving the room. Hand hygiene follows removal of the equipment.

Question 15Fundamentals of Nursing and Basic Patient Care

What is the most reliable indicator of a patient's pain?

  1. The family's description of the patient's behavior
  2. The patient's own report of the pain Correct answer.
  3. The nurse's observation of the patient's vital signs
  4. Facial grimacing noted during the assessment

Explanation

Pain is a subjective experience, and the patient's self-report is the most reliable indicator whenever the patient can communicate. Observations of behavior and vital signs may support assessment but cannot replace the report.

Question 16Fundamentals of Nursing and Basic Patient Care

Which situation breaches patient confidentiality?

  1. Giving handover to the oncoming nurse at the bedside
  2. Discussing the patient's diagnosis with a friend in the elevator Correct answer.
  3. Documenting the care given in the electronic health record
  4. Reporting a suspected communicable disease to the health department

Explanation

Patient information may be shared only with those who need it for care or as required by law. Discussing a diagnosis in a public space such as an elevator exposes identifying information to people with no need to know.

Question 17Fundamentals of Nursing and Basic Patient Care

Which instruction is essential for a patient receiving home oxygen therapy?

  1. Adjust the flow rate whenever breathing feels difficult
  2. Apply petroleum jelly to the nares to prevent dryness
  3. Keep the oxygen source away from flames and smoking Correct answer.
  4. Store the cylinder lying flat when it is not in use

Explanation

Oxygen supports combustion, so the source must be kept away from open flames, sparks, and smoking materials. Patients should also avoid oil-based products on the face and should never change the prescribed flow rate without direction.

Question 18Fundamentals of Nursing and Basic Patient Care

How should the nurse position a closed urinary drainage bag?

  1. At the level of the bladder to allow gravity flow
  2. On the bed beside the patient's hip
  3. Resting on the floor to keep it steady
  4. Below bladder level, hung on the bed frame Correct answer.

Explanation

The drainage bag must stay below the level of the bladder so urine flows by gravity and does not reflux into the bladder, and it should never touch the floor. The bag is hung on the bed frame rather than on a side rail.

Question 19Fundamentals of Nursing and Basic Patient Care

A patient is 12 hours after abdominal surgery and will not cough because of incisional pain. Which intervention best prevents atelectasis?

  1. Encourage bed rest and limit movement for 24 hours
  2. Restrict oral fluids until bowel sounds return
  3. Give a cough suppressant before breathing exercises
  4. Splint the incision with a pillow while coaching coughing Correct answer.

Explanation

Splinting the incision supports the wound and reduces pain, allowing the patient to take deep breaths and cough effectively to clear secretions and re-expand the lungs. Early ambulation and adequate hydration also help, whereas immobility and suppression of cough promote atelectasis.

Question 20Fundamentals of Nursing and Basic Patient Care

Which set of findings most suggests fluid volume deficit in an adult?

  1. Orthostatic hypotension, tachycardia, oliguria Correct answer.
  2. Bounding pulse, crackles, and rapid weight gain
  3. Bradycardia with hypertension and flushed skin
  4. Jugular venous distension with peripheral edema

Explanation

Volume depletion reduces preload, producing a fall in blood pressure on standing, a compensatory rise in heart rate, and decreased renal perfusion with low urine output. Bounding pulses, crackles, jugular distension, and edema point instead to fluid overload.

Question 21Fundamentals of Nursing and Basic Patient Care

Which technique reflects correct body mechanics when moving a patient up in bed?

  1. Raise the bed to waist height and bend the knees Correct answer.
  2. Keep the feet close together to improve balance
  3. Twist at the waist while pulling the patient toward you
  4. Lean over the bed with the back curved for leverage

Explanation

Working at waist height with the knees bent and the back straight keeps the load close to the nurse's center of gravity and uses the legs rather than the spine. Twisting and leaning over the bed place stress on the back and increase injury risk.

Question 22Fundamentals of Nursing and Basic Patient Care

Which instruction should the nurse give a patient providing a clean-catch midstream urine specimen?

  1. Cleanse the meatus, then collect the midstream portion Correct answer.
  2. Collect the first portion of the stream in the sterile container
  3. Collect the specimen after a bowel movement
  4. Add tap water to the container if the sample is small

Explanation

Cleansing the meatus first and collecting the middle portion of the stream reduces contamination from skin flora and urethral organisms. The first portion is discarded because it carries the heaviest contamination.

Question 23Fundamentals of Nursing and Basic Patient Care

Which action is appropriate for a patient during a generalized tonic-clonic seizure?

  1. Give oral fluids as soon as the jerking begins
  2. Insert a padded tongue blade between the teeth
  3. Turn the patient to the side and protect the head Correct answer.
  4. Restrain the limbs firmly to prevent injury

Explanation

Turning the patient to the side maintains an open airway and allows secretions to drain, while padding or supporting the head prevents injury. Nothing should be forced into the mouth, and limbs should never be restrained during the seizure.

Question 24Fundamentals of Nursing and Basic Patient Care

Which technique is correct for a subcutaneous injection of heparin into the abdomen?

  1. Aspirate for blood return before injecting the medication
  2. Massage the site firmly for one minute after withdrawal
  3. Use a 45-degree angle and a 3-mL syringe for the injection
  4. Insert at a 90-degree angle and do not massage Correct answer.

Explanation

Heparin is given subcutaneously at a 90-degree angle into the fatty tissue of the abdomen at least 2 inches from the umbilicus. The site is not aspirated or massaged because both increase the risk of bruising and hematoma.

Question 25Fundamentals of Nursing and Basic Patient Care

An alert, oriented patient refuses an ordered injection. What should the nurse do?

  1. Administer the medication because it was prescribed
  2. Respect the refusal, document it, and inform the provider Correct answer.
  3. Ask the family to persuade the patient to accept it
  4. Give the medication by another route without telling the patient

Explanation

A competent patient has the right to refuse any treatment, and the nurse must honor that decision while documenting the refusal and notifying the provider. Covert administration or pressure from family violates the patient's autonomy.

Question 26Fundamentals of Nursing and Basic Patient Care

Which action by the nurse is most effective in preventing the spread of infection from one patient to another?

  1. Hand hygiene before and after contact Correct answer.
  2. Changing the uniform after every shift
  3. Wearing clean gloves for every task
  4. Wiping the stethoscope once per shift

Explanation

Hand hygiene at the point of care removes transient organisms and is the single most effective measure for interrupting patient-to-patient transmission. Gloves are worn for specific tasks and are never a substitute for hand hygiene, and shared equipment must be cleaned between patients rather than once per shift.

Question 27Fundamentals of Nursing and Basic Patient Care

Which oral temperature reading in an adult is within the normal range?

  1. 39.2 °C (102.6 °F)
  2. 38.0 °C (100.4 °F)
  3. 35.0 °C (95.0 °F)
  4. 36.8 °C (98.2 °F) Correct answer.

Explanation

Normal adult oral temperature is approximately 36.5 to 37.5 °C (97.7 to 99.5 °F), so 36.8 °C falls within range. Values above 38 °C represent fever, and values well below 36 °C indicate hypothermia.

Question 28Fundamentals of Nursing and Basic Patient Care

Which pair of identifiers should the nurse use before giving a medication or treatment?

  1. Diagnosis and attending physician
  2. Full name and date of birth Correct answer.
  3. Room number and bed position
  4. Hospital number and room number

Explanation

Two patient-specific identifiers that are verified against the order and the identification band are required before any medication or procedure. Room and bed assignments are not identifiers because they change and are shared by different patients over time.

Question 29Fundamentals of Nursing and Basic Patient Care

A patient who has been on bed rest for three days reports dizziness when first standing. Which assessment should the nurse perform first?

  1. Take lying and standing vital signs Correct answer.
  2. Auscultate the lung bases while seated
  3. Measure a capillary blood glucose
  4. Send a urine sample for specific gravity

Explanation

Dizziness on assuming an upright position after immobility suggests orthostatic hypotension, which is assessed by comparing blood pressure and pulse with the patient lying and then standing. A drop of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing is significant.

Question 30Fundamentals of Nursing and Basic Patient Care

A patient with worsening shortness of breath is lying flat and reports more difficulty breathing. Which position should the nurse help the patient into?

  1. Trendelenburg with legs elevated
  2. Prone with the head turned to one side
  3. High-Fowler with arms supported Correct answer.
  4. Supine with a pillow under the head

Explanation

An upright high-Fowler position allows the diaphragm to descend and increases lung expansion, which relieves dyspnea. Supporting the arms on pillows also helps the accessory muscles work more effectively.

Question 31Fundamentals of Nursing and Basic Patient Care

Which instruction should the nurse give a patient using an incentive spirometer?

  1. Blow out forcefully into the mouthpiece
  2. Take several rapid shallow breaths
  3. Use the device only when short of breath
  4. Inhale slowly and hold the breath Correct answer.

Explanation

The device encourages sustained maximal inspiration: the patient inhales slowly and deeply to raise the piston, holds the breath for about three to five seconds, then exhales normally. Sessions are scheduled regularly, not only when symptoms appear.

Question 32Fundamentals of Nursing and Basic Patient Care

Before administering digoxin, the nurse finds an apical pulse of 52 beats per minute. What is the correct action?

  1. Give half the ordered dose
  2. Recheck the radial pulse after ten minutes
  3. Give the dose and recheck in one hour
  4. Withhold the dose and call the prescriber Correct answer.

Explanation

Digoxin slows conduction through the atrioventricular node, and an adult apical pulse below 60 beats per minute is a standard reason to hold the dose and notify the prescriber. The nurse never adjusts a prescribed dose independently.

Question 33Fundamentals of Nursing and Basic Patient Care

Which action is correct when applying a cold pack to a patient's sprained ankle?

  1. Leave the pack in place for 60 minutes
  2. Place the pack directly on the skin
  3. Wrap the pack in cloth for 20 minutes Correct answer.
  4. Apply the pack over an open wound

Explanation

Cold reduces edema and pain, but a cloth barrier is needed to protect the skin, and applications are generally limited to about 20 minutes at a time. Prolonged or unprotected cold exposure can cause tissue injury.

Question 34Fundamentals of Nursing and Basic Patient Care

Which step is correct when a patient uses a metered-dose inhaler with a spacer?

  1. Hold the spacer away from the mouth
  2. Press the canister twice in quick succession
  3. Inhale slowly after the canister is pressed Correct answer.
  4. Rinse the spacer in hot water after each use

Explanation

With a spacer, the canister is actuated and the patient then takes a slow, deep breath and holds it for about ten seconds so the drug reaches the lower airways. Puffs are given one at a time with roughly 30 to 60 seconds between them.

Question 35Fundamentals of Nursing and Basic Patient Care

The nurse counts an apical pulse of 96 beats per minute and a radial pulse of 76 beats per minute in a patient with an irregular rhythm. How should these findings be interpreted?

  1. A pulse deficit exists and should be reported Correct answer.
  2. The radial rate should be counted again first
  3. The radial count is the more reliable rate
  4. The two rates normally differ by this amount

Explanation

A pulse deficit is the difference between the apical and radial rates and reflects beats that are too weak to produce a palpable peripheral pulse. It is commonly seen with atrial fibrillation and other irregular rhythms and is documented and reported.

Question 36Fundamentals of Nursing and Basic Patient Care

A patient who received IV morphine 20 minutes ago is drowsy but arouses to voice. The surgeon asks the nurse to obtain the patient's signature on a surgical consent form. What is the nurse's best action?

  1. Ask a family member to sign as witness
  2. Obtain the signature and chart the drowsiness
  3. Delay the consent and inform the surgeon Correct answer.
  4. Obtain the signature while the patient is alert

Explanation

Valid informed consent requires that the patient understands the procedure, risks, and alternatives, which opioid-induced drowsiness can impair. The nurse witnesses the signature rather than obtaining consent, so the surgeon should be informed and consent deferred until the patient is fully alert.

Question 37Medical-Surgical Nursing

Which respiratory rate for a resting, healthy adult is within the normal range?

  1. 30 to 40 breaths/min
  2. 8 to 14 breaths/min
  3. 20 to 28 breaths/min
  4. 12 to 20 breaths/min Correct answer.

Explanation

Normal resting respiratory rate for adults is 12 to 20 breaths per minute; rates outside this range suggest respiratory or metabolic compromise. Rate is counted for a full minute because breathing is irregular. Tachypnea and bradypnea are defined by deviation from this range.

Question 38Medical-Surgical Nursing

A client with acute pulmonary edema is severely dyspneic and cannot lie flat. Which position should the nurse use?

  1. Left lateral recumbent
  2. Trendelenburg position
  3. Supine with legs elevated
  4. High Fowler's position Correct answer.

Explanation

Sitting upright increases lung volume by allowing the diaphragm to descend and reduces venous return, easing pulmonary congestion. Supine and head-down positions worsen venous return to the lungs and intensify dyspnea. Orthopnea is relieved by an upright posture.

Question 39Medical-Surgical Nursing

Which set of findings is most consistent with hypoglycemia in an adult?

  1. Diaphoresis and tremors Correct answer.
  2. Flushed, warm, dry skin
  3. Bradycardia with hypertension
  4. Deep, rapid respirations

Explanation

Hypoglycemia triggers a sympathetic adrenergic response producing sweating, tremor, palpitations, and anxiety, followed by neuroglycopenic symptoms such as confusion. These signs appear early and should prompt immediate glucose measurement and treatment. Dry flushed skin and deep respirations belong to the hyperglycemic picture.

Question 40Medical-Surgical Nursing

The nurse is monitoring an adult's urine output. Which hourly volume is the minimum expected to maintain adequate renal perfusion?

  1. 5 mL/hr
  2. 30 mL/hr Correct answer.
  3. 10 mL/hr
  4. 15 mL/hr

Explanation

An adult should produce at least 30 mL of urine per hour (about 0.5 mL/kg/hr), which reflects adequate renal blood flow and glomerular filtration. Volumes persistently below this suggest hypovolemia or renal injury and require evaluation. Output is measured hourly in acutely ill clients so trends can be detected early.

Question 41Medical-Surgical Nursing

A client begins a generalized tonic-clonic seizure while lying in bed. What is the nurse's first action?

  1. Give the prescribed anticonvulsant by mouth
  2. Cushion the head and remove nearby hazards Correct answer.
  3. Restrain the client's arms and legs
  4. Insert a padded tongue blade between the teeth

Explanation

Priority during a seizure is preventing injury: support the head, lower the client to a safe surface, and clear hard objects away. Nothing is placed in the mouth because of the risk of broken teeth, airway obstruction, and injury to the nurse. Restraints increase the risk of fracture and prolong the seizure.

Question 42Medical-Surgical Nursing

Which food should the nurse recommend to a client who needs to increase dietary potassium?

  1. White bread
  2. White rice
  3. Canned green beans
  4. Baked potato with skin Correct answer.

Explanation

Potatoes, especially with the skin, are among the richest common food sources of potassium, along with bananas, oranges, dried fruit, and tomatoes. Refined grains and canned vegetables are low in potassium, and canned products often carry added sodium. Food sources are preferred over supplements unless the deficit is severe.

Question 43Medical-Surgical Nursing

What is the primary purpose of using an incentive spirometer after abdominal surgery?

  1. To strengthen the diaphragm muscle
  2. To prevent atelectasis Correct answer.
  3. To measure peak expiratory flow
  4. To loosen secretions in the airways

Explanation

Sustained maximal inspiration re-expands alveoli and prevents alveolar collapse, which is the main goal after surgery and anesthesia. It does not measure airflow obstruction or directly mobilize secretions, although deep breathing assists clearance. Frequent use, about 10 breaths per hour while awake, is most effective.

Question 44Medical-Surgical Nursing

Which finding at a peripheral IV site indicates infiltration?

  1. Redness and warmth along the vein
  2. A blood return in the tubing
  3. Serous drainage at the insertion site
  4. Cool, pale swelling at the site Correct answer.

Explanation

Infiltration is leakage of fluid into surrounding tissue, producing coolness, pallor, swelling, and discomfort at the site. The nurse stops the infusion, removes the catheter, and elevates the extremity. Warmth, redness, and tenderness along the vein instead suggest phlebitis.

Question 45Medical-Surgical Nursing

A client is 6 hours post-thyroidectomy. Which finding requires immediate notification of the provider?

  1. Stridor with each breath Correct answer.
  2. Serosanguineous drainage on the dressing
  3. Mild incisional pain with swallowing
  4. Complaint of a sore throat

Explanation

Stridor suggests laryngeal edema or tracheal compression from postoperative bleeding, an airway emergency that can progress rapidly. The nurse stays with the client, keeps suction and emergency airway equipment available, and calls the surgeon at once. Minor drainage, sore throat from intubation, and incisional pain are expected after this surgery.

Question 46Medical-Surgical Nursing

Which finding is the earliest and most reliable indicator of acute compartment syndrome in a casted leg?

  1. Pain with passive stretch of the toes Correct answer.
  2. Numbness over the toes
  3. Mottled, pale, cool skin below the cast
  4. Absence of the pedal pulse

Explanation

Pain that is disproportionate and intensifies with passive stretching of the muscles in the affected compartment is the earliest sign of rising tissue pressure. Pulselessness and skin changes occur late, and nerve deficits such as numbness indicate prolonged ischemia. The nurse compares neurovascular checks with the baseline and reports changes immediately.

Question 47Medical-Surgical Nursing

The nurse notes continuous bubbling in the water seal chamber of a client's chest tube system. What does this indicate?

  1. An air leak in the system Correct answer.
  2. A blocked chest tube
  3. Normal tidal movement of the water
  4. An expected finding after 24 hours

Explanation

Continuous bubbling means air is entering the system somewhere between the client and the water seal, so the nurse inspects the tubing, connections, and insertion site. Intermittent bubbling with coughing or exhalation is expected while a pneumothorax is resolving. A blocked tube would show absent tidaling without bubbling.

Question 48Medical-Surgical Nursing

Before administering digoxin, the nurse assesses an apical pulse of 52 beats/min. What is the appropriate action?

  1. Give the dose with food to reduce bradycardia
  2. Hold the dose and notify the provider Correct answer.
  3. Give half of the prescribed dose
  4. Give the dose and recheck the pulse in 1 hour

Explanation

Digoxin slows conduction through the atrioventricular node, and an apical pulse below 60 beats/min in an adult signals possible toxicity; the dose is withheld and the prescriber notified. The nurse counts the apical pulse for a full minute before each dose. Serum digoxin level and potassium are also evaluated.

Question 49Medical-Surgical Nursing

Which medication is the antidote for unfractionated heparin overdose?

  1. Protamine sulfate Correct answer.
  2. Vitamin K
  3. Naloxone
  4. Flumazenil

Explanation

Protamine sulfate binds heparin and neutralizes its anticoagulant effect, and it is given for serious bleeding or marked elevation of the activated partial thromboplastin time. Vitamin K reverses warfarin, naloxone reverses opioids, and flumazenil reverses benzodiazepines. Each antidote is specific to its drug class.

Question 50Medical-Surgical Nursing

A client with acute pancreatitis reports severe abdominal pain. Which nursing action best promotes comfort?

  1. Ambulate the client frequently
  2. Encourage the client to drink liberal amounts of clear fluids
  3. Position the client with knees flexed toward the chest Correct answer.
  4. Apply a warm compress to the abdomen

Explanation

Flexing the knees toward the chest reduces tension on the abdominal wall and relieves pain in pancreatitis. Oral intake is withheld during acute episodes to rest the pancreas, and heat is avoided because it can worsen inflammation. Analgesics and careful fluid replacement are also part of management.