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Afghanistan Nursing Exit Exam study materials
Afghanistan Nursing Exit Exam study resources

Afghanistan Nursing Exit Exam practice questions

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Question 1Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to administer an intramuscular injection to an adult. Which site is preferred when a large volume of medication must be given?

  1. Deltoid site
  2. Dorsal surface of the forearm
  3. Vastus lateralis site of the adult
  4. Ventrogluteal site Correct answer.

Explanation

The ventrogluteal site has a thick muscle mass and lies away from major nerves and blood vessels, making it suitable for larger volumes and irritating medications. The deltoid accepts only small volumes, and the forearm is not an IM site.

Question 2Fundamentals of Nursing and Basic Nursing Skills

A client is on strict fluid restriction. Which nursing action best supports accurate monitoring of intake?

  1. Counting only beverages served at mealtimes
  2. Estimating fluid intake at the end of each shift
  3. Recording all oral fluids, IV fluids, and ice chips consumed Correct answer.
  4. Recording only IV fluid volumes

Explanation

Intake records must include every fluid entering the body, including oral liquids, IV infusions, and melted ice chips, because all contribute to the fluid balance. Selective or delayed recording produces inaccurate totals.

Question 3Fundamentals of Nursing and Basic Nursing Skills

When performing hand hygiene with an alcohol-based rub, which step is essential?

  1. Allowing the hands to dry completely before touching anything Correct answer.
  2. Rinsing the hands with water afterward
  3. Applying the rub only to the palms
  4. Drying the hands with a paper towel

Explanation

Alcohol-based hand rubs must be allowed to dry fully so the product can exert its antimicrobial effect and be removed from the skin. Rubbing the hands dry with a towel removes the product prematurely.

Question 4Fundamentals of Nursing and Basic Nursing Skills

A nurse positions a client in the semi-Fowler position. What is the primary purpose of this position?

  1. To facilitate drainage of cerebrospinal fluid
  2. To reduce pressure on the sacrum
  3. To promote lung expansion and ease breathing Correct answer.
  4. To improve venous return from the legs

Explanation

Semi-Fowler position elevates the head of the bed about 30 to 45 degrees, which lowers the diaphragm and improves ventilation. It is used for clients with respiratory difficulty.

Question 5Fundamentals of Nursing and Basic Nursing Skills

Which finding indicates that a client's wound drain should be assessed more closely?

  1. Sudden increase in bright red drainage Correct answer.
  2. A small amount of serous drainage after ambulation
  3. Serosanguineous drainage on the first postoperative day
  4. A drain secured with a safety pin

Explanation

A sudden increase in bright red drainage may signal hemorrhage and requires immediate assessment and notification of the provider. Expected postoperative drainage is typically serosanguineous and gradually decreases.

Question 6Fundamentals of Nursing and Basic Nursing Skills

What is the correct technique for measuring a client's blood pressure with a manual cuff?

  1. Deflate the cuff in 10 mmHg increments every second
  2. Inflate the cuff to about 30 mmHg above the point where the radial pulse disappears Correct answer.
  3. Place the cuff over the client's clothing for comfort
  4. Inflate the cuff rapidly to 300 mmHg regardless of the client

Explanation

Estimating the systolic pressure by palpation and inflating 30 mmHg above that point prevents missing the auscultatory gap and avoids unnecessary discomfort. Deflation should be slow and steady.

Question 7Fundamentals of Nursing and Basic Nursing Skills

A nurse is teaching a client about using a walker. Which instruction is correct?

  1. Lean the body weight onto the walker's front legs
  2. Lift the walker and place it far ahead of the feet
  3. Step forward first, then move the walker
  4. Move the walker forward first, then step into it Correct answer.

Explanation

With a walker, the device is advanced first and the client then steps into it while keeping the back upright. This sequence maintains stability and prevents falls.

Question 8Fundamentals of Nursing and Basic Nursing Skills

Which action best demonstrates the principle of medical asepsis on a hospital unit?

  1. Sterilizing all linens before use
  2. Cleaning shared equipment between clients Correct answer.
  3. Using sterile gloves for all client contact
  4. Performing surgical hand scrub before a dressing change

Explanation

Medical asepsis refers to practices that reduce the number and spread of microorganisms, such as cleaning shared equipment between clients. Sterile technique and sterilization belong to surgical asepsis.

Question 9Fundamentals of Nursing and Basic Nursing Skills

A client reports pain rated 8 out of 10 one hour after receiving an analgesic. What is the nurse's priority action?

  1. Document the pain score and wait for the next scheduled dose
  2. Reassess the pain and notify the provider of the unrelieved pain Correct answer.
  3. Encourage the client to sleep to distract from the pain
  4. Tell the client that the medication needs more time

Explanation

Unrelieved severe pain after an appropriate interval requires reassessment and communication with the provider to adjust the plan. Waiting passively delays needed intervention.

Question 10Fundamentals of Nursing and Basic Nursing Skills

A nurse is caring for a client with a new colostomy. Which assessment finding should be reported immediately?

  1. Stoma that is beefy red and moist
  2. Output that is liquid in the first days after surgery
  3. Stoma that is dark purple and dry Correct answer.
  4. Small amount of serosanguineous drainage at the stoma edge

Explanation

A healthy stoma is beefy red and moist. A dark purple, dry, or dusky stoma suggests ischemia and must be reported at once.

Question 11Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to insert a nasogastric tube. Which action confirms correct placement before use?

  1. Auscultating a whoosh of air over the epigastrium
  2. Checking the pH of aspirated gastric contents Correct answer.
  3. Asking the client to speak clearly
  4. Placing the tube tip in water to look for bubbles

Explanation

Testing the pH of aspirated fluid is the most reliable bedside method, with gastric contents typically having a pH of 5.5 or lower. The auscultatory method is unreliable and no longer recommended.

Question 12Fundamentals of Nursing and Basic Nursing Skills

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

  1. Apply petroleum jelly to the nares every shift
  2. Assess the nares and skin behind the ears for irritation Correct answer.
  3. Tape the cannula tightly to the cheeks
  4. Discontinue humidification for all flow rates

Explanation

Oxygen devices can cause skin breakdown and dryness, so the nares and pressure points should be inspected regularly. Petroleum-based products are avoided near oxygen because of fire risk.

Question 13Fundamentals of Nursing and Basic Nursing Skills

A nurse is transferring a client from bed to a chair. Which action best protects both the nurse and the client?

  1. Twisting the torso while supporting the client
  2. Keeping the feet close together during the transfer
  3. Pulling the client by the arms toward the chair
  4. Raising the bed to a comfortable working height and using a gait belt Correct answer.

Explanation

Raising the bed to reduce bending, using a gait belt, and maintaining a wide base of support reduce injury risk for both the client and the nurse. Twisting and pulling by the arms increase strain.

Question 14Fundamentals of Nursing and Basic Nursing Skills

Which client has the highest risk for developing a pressure injury?

  1. A client with hypertension who walks daily
  2. A client with seasonal allergies who is independent in self-care
  3. An older adult who is immobile and incontinent Correct answer.
  4. A young adult with a fractured wrist who is ambulatory

Explanation

Immobility, incontinence, and advanced age are major risk factors for pressure injury because they increase sustained pressure and moisture on the skin. Ambulatory clients with intact mobility have much lower risk.

Question 15Fundamentals of Nursing and Basic Nursing Skills

A nurse is performing a sterile dressing change. Which action breaks sterile technique?

  1. Turning away from the sterile field to answer a question Correct answer.
  2. Reaching around, not over, the sterile field
  3. Keeping the sterile field above waist level
  4. Holding the sterile drape by its edges

Explanation

Turning away from a sterile field exposes it to airborne contamination and breaks technique. The field must remain in view and above waist level at all times.

Question 16Fundamentals of Nursing and Basic Nursing Skills

A client has a prescription for a subcutaneous injection of insulin. Which technique is correct?

  1. Massage the site firmly after injection
  2. Aspirate before injecting the medication
  3. Use a 3-inch needle for the abdomen
  4. Insert the needle at a 45- to 90-degree angle into the tissue Correct answer.

Explanation

Subcutaneous tissue is reached with a short needle inserted at a 45- to 90-degree angle, depending on tissue thickness. Aspiration and vigorous massage are not recommended for insulin.

Question 17Fundamentals of Nursing and Basic Nursing Skills

A nurse is documenting care. Which entry reflects correct documentation practice?

  1. "Client reported pain 6/10; repositioned and reassessed at 4/10 after 30 minutes." Correct answer.
  2. "Client was fine during the shift."
  3. "Client was given pain medication as needed by previous nurse."""
  4. "Client seemed uncomfortable, probably in pain."

Explanation

Objective, specific, and timely documentation includes the client's report, the nursing action, and the outcome of reassessment. Vague or judgmental language is not acceptable.

Question 18Fundamentals of Nursing and Basic Nursing Skills

Which action is correct when a nurse finds a client lying on the floor after an unwitnessed fall?

  1. Document the fall only at the end of the shift
  2. Leave the client alone to get the charge nurse
  3. Lift the client back into bed immediately
  4. Assess the client for injury before moving them Correct answer.

Explanation

After a fall, the client is assessed for injury before any movement, and the provider is notified. Immediate lifting can worsen spinal or head injuries.

Question 19Fundamentals of Nursing and Basic Nursing Skills

A nurse is teaching a client how to perform a return demonstration of self-catheterization. What does this method best evaluate?

  1. The client's willingness to follow the plan
  2. The client's level of anxiety before the procedure
  3. The client's understanding of the disease process
  4. The client's ability to perform the skill correctly Correct answer.

Explanation

A return demonstration is a psychomotor evaluation method that confirms the client can actually perform the procedure. Verbal teaching alone does not verify skill competence.

Question 20Fundamentals of Nursing and Basic Nursing Skills

A client is on bed rest. Which intervention best prevents deep vein thrombosis?

  1. Massaging the calves firmly each shift
  2. Encouraging ankle pumps and leg exercises while in bed Correct answer.
  3. Placing a pillow under the knees to relax the legs
  4. Keeping the legs dependent for long periods

Explanation

Active leg exercises and ankle pumps promote venous return and help prevent stasis in immobile clients. Pillows under the knees and dependent positioning impair circulation.

Question 21Fundamentals of Nursing and Basic Nursing Skills

A nurse receives a telephone order for a medication. Which action is correct?

  1. Ask a colleague to verify the order later
  2. Write the order using an abbreviation for the drug name
  3. Accept the order and administer the drug before documenting
  4. Write the order, read it back to the prescriber, and document it Correct answer.

Explanation

Telephone orders must be written down, read back to the prescriber for verification, and documented with the prescriber's name and time. Abbreviations that can be misread are avoided.

Question 22Fundamentals of Nursing and Basic Nursing Skills

A client has a prescription for a rectal temperature. Which situation makes this route inappropriate?

  1. The client had recent rectal surgery Correct answer.
  2. The client is alert and oriented
  3. The client is on a clear liquid diet
  4. The client has a fever

Explanation

The rectal route is contraindicated after rectal surgery, with diarrhea, or in clients with bleeding disorders because of the risk of injury. Another route should be selected.

Question 23Fundamentals of Nursing and Basic Nursing Skills

A nurse notes a client's intake and output: 1,200 mL oral intake, 500 mL IV fluid, 900 mL urine, and 300 mL emesis. What is the net fluid balance?

  1. 800 mL positive
  2. 500 mL positive Correct answer.
  3. 300 mL negative
  4. 1,700 mL positive

Explanation

Total intake is 1,200 plus 500, or 1,700 mL. Total output is 900 plus 300, or 1,200 mL. The net balance is 1,700 minus 1,200, or 500 mL positive.

Question 24Fundamentals of Nursing and Basic Nursing Skills

A nurse is caring for a client with an indwelling urinary catheter. Which action best reduces the risk of catheter-associated infection?

  1. Irrigating the catheter routinely every shift
  2. Maintaining a closed drainage system and keeping the bag below the bladder Correct answer.
  3. Disconnecting the tubing to obtain urine samples
  4. Changing the catheter every 24 hours

Explanation

A closed system with the drainage bag below bladder level prevents backflow of urine and entry of organisms. Routine irrigation, frequent changes, and disconnections increase infection risk.

Question 25Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to give a medication through a nasogastric tube. Which action is correct?

  1. Mix all medications together in one syringe
  2. Give the medications while the client is flat in bed
  3. Flush the tube with water before and after each medication Correct answer.
  4. Crush enteric-coated tablets before administration

Explanation

Flushing before and after each medication prevents clogging and interactions between drugs. Each medication is given separately, and enteric-coated or extended-release forms are not crushed.

Question 26Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to perform hand hygiene with an alcohol-based rub. Which action is correct?

  1. Dry the hands with a paper towel immediately after applying the product
  2. Rinse the hands with water first, then apply the product
  3. Apply the product only to the palms and backs of the hands
  4. Apply the product to dry hands and rub until the hands are dry Correct answer.

Explanation

Alcohol-based hand rubs are most effective when applied to dry hands and rubbed over all surfaces until the product evaporates completely. Pre-wetting the hands with water dilutes the product and reduces its antimicrobial effect. Covering all surfaces, including fingertips, thumbs, and between the fingers, is required for effective antisepsis.

Question 27Fundamentals of Nursing and Basic Nursing Skills

A nurse is measuring a client's oral temperature. Which action is correct?

  1. Place the thermometer in the posterior sublingual pocket and leave it until it signals completion Correct answer.
  2. Place the thermometer against the buccal mucosa and remove it after 30 seconds
  3. Ask the client to bite gently on the thermometer to hold it in place
  4. Take the reading immediately after the client has drunk a cup of hot tea

Explanation

The posterior sublingual pocket has a rich blood supply and provides the most reliable oral temperature reading. The device should remain in place until it signals that the reading is complete. Recent ingestion of hot or cold fluids alters the reading, so a waiting period is needed.

Question 28Fundamentals of Nursing and Basic Nursing Skills

A nurse is caring for a client who is unconscious and has a prescription for oral care every 4 hours. Which action is safest?

  1. Turn the client to the side and use a small amount of fluid with suction available Correct answer.
  2. Use a firm toothbrush and scrub the tongue vigorously
  3. Perform oral care without suction equipment to avoid stimulating the gag reflex
  4. Place the client flat on the back and irrigate the mouth with a syringe

Explanation

An unconscious client cannot protect the airway, so positioning on the side allows fluid to drain and reduces aspiration risk. Suction must be immediately available. Gentle cleansing of the mouth and teeth is performed without forcing large volumes of fluid into the oral cavity.

Question 29Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to reposition a client who is unable to assist. Which action best reduces friction and shear on the skin?

  1. Pull the client by the shoulders toward the head of the bed
  2. Use a draw sheet and lift the client rather than drag across the linens Correct answer.
  3. Raise the head of the bed to 90 degrees before moving the client
  4. Apply lotion to the sheets to allow the client to slide more easily

Explanation

Friction and shear injure skin when the body is dragged across a surface. Using a draw sheet and lifting the client distributes force and minimizes this mechanical trauma. Keeping the linens dry and avoiding sliding reduce the risk of skin breakdown.

Question 30Fundamentals of Nursing and Basic Nursing Skills

A nurse is reviewing a client's medication administration record and notices that a prescribed dose is ten times the usual dose for that drug. Which action should the nurse take first?

  1. Reduce the dose to the usual amount and give it as ordered
  2. Administer the dose as prescribed and document the client's response
  3. Withhold the medication and contact the prescriber to verify the order Correct answer.
  4. Ask a colleague to give the medication so a second nurse is involved

Explanation

A dose that is grossly outside the usual range is a potential prescribing error, and the nurse is accountable for questioning unclear or unsafe orders. The medication is withheld while the prescriber is contacted and the order is clarified. Administering or altering a dose without verification places the client at risk.

Question 31Medical-Surgical Nursing

A client is receiving intravenous heparin. Which laboratory value should the nurse monitor to evaluate the therapeutic effect of the drug?

  1. Activated partial thromboplastin time (aPTT) Correct answer.
  2. International normalized ratio (INR)
  3. Serum potassium level
  4. Platelet count

Explanation

Heparin prolongs the intrinsic coagulation pathway, which is reflected by the aPTT; therapy is titrated to a target aPTT range. INR reflects the extrinsic pathway and is used to monitor warfarin. Platelets are monitored for heparin-induced thrombocytopenia but do not measure anticoagulant effect.

Question 32Medical-Surgical Nursing

A client with a new colostomy is learning about stoma care. Which statement by the client indicates correct understanding?

  1. I will cut the skin barrier opening larger than the stoma.
  2. I will change the pouch every day whether it leaks or not.
  3. I will clean the skin around the stoma with mild soap and water. Correct answer.
  4. I should expect the stoma to look pale and dry.

Explanation

Peristomal skin is gently cleansed with mild soap and water and patted dry before applying the barrier. A healthy stoma is moist and red to pink, not pale and dry. The barrier opening should match the stoma size, not exceed it, to protect skin.

Question 33Medical-Surgical Nursing

A client with type 1 diabetes has a blood glucose of 52 mg/dL and is alert and able to swallow. What should the nurse give first?

  1. A dose of oral metformin
  2. A high-protein snack without carbohydrate
  3. 10 units of regular insulin subcutaneously
  4. 15 g of a fast-acting oral carbohydrate Correct answer.

Explanation

For conscious hypoglycemia, the rule of 15 applies: give about 15 g of fast-acting carbohydrate and recheck glucose in 15 minutes. Insulin and metformin lower glucose further and are contraindicated. Protein alone is too slow to raise glucose acutely.

Question 34Medical-Surgical Nursing

Which finding is the earliest sign of increased intracranial pressure in an adult?

  1. Absent corneal reflex
  2. Decerebrate posturing
  3. Fixed dilated pupils
  4. Change in level of consciousness Correct answer.

Explanation

A decline in level of consciousness is typically the earliest indicator of rising intracranial pressure. Pupillary changes, posturing, and absent brainstem reflexes are later signs of herniation. Frequent neurologic assessment detects the change early.

Question 35Medical-Surgical Nursing

A client with chronic kidney disease is prescribed erythropoietin. Which parameter should the nurse monitor most closely?

  1. Serum calcium
  2. Serum amylase
  3. Urine specific gravity
  4. Hemoglobin level Correct answer.

Explanation

Erythropoietin stimulates red blood cell production, so hemoglobin and hematocrit are monitored to assess response and avoid excessive elevation. Calcium, amylase, and urine specific gravity are unrelated to the drug's effect.

Question 36Medical-Surgical Nursing

A client is in the first 24 hours after an acute myocardial infarction. Which nursing action best reduces myocardial oxygen demand?

  1. Keeping the head of bed elevated above 60 degrees
  2. Promoting rest and limiting visitors Correct answer.
  3. Withholding prescribed nitroglycerin
  4. Encouraging ambulation in the hallway

Explanation

Rest reduces heart rate and workload during the acute phase of infarction. Activity and high-Fowler positioning increase cardiac workload, and nitroglycerin is given as prescribed to reduce preload.

Question 37Medical-Surgical Nursing

Which client is at highest risk for developing a pressure injury?

  1. A client with a healing surgical incision who walks daily
  2. A client who is immobile and incontinent of urine Correct answer.
  3. A client with a BMI of 24 who is ambulatory
  4. A client who uses a walker and eats a full diet

Explanation

Immobility and moisture from incontinence are major risk factors for pressure injury because they combine sustained pressure with skin breakdown. Ambulatory clients without moisture or immobility have much lower risk.

Question 38Medical-Surgical Nursing

A client is receiving a blood transfusion. Which finding should prompt the nurse to stop the transfusion immediately?

  1. Temperature rise of 1.5 degrees C with chills Correct answer.
  2. Mild itching at the IV site
  3. A hemoglobin of 8 g/dL
  4. Complaint of a mild headache

Explanation

Fever with chills suggests a hemolytic or febrile transfusion reaction; the transfusion must be stopped at once and the provider notified. Mild itching may be an allergic reaction requiring assessment, but fever with chills is the classic stop-and-report sign. Headache alone and a low hemoglobin are not acute reaction indicators.

Question 39Medical-Surgical Nursing

A client with an ileal conduit has a new urostomy pouch. Which instruction is most important for the nurse to include?

  1. Clean the stoma with alcohol each day.
  2. Empty the pouch when it is one-third to one-half full. Correct answer.
  3. Apply a new pouch every 12 hours.
  4. Restrict fluids to 1 L per day.

Explanation

Emptying the pouch before it becomes heavy prevents leakage and skin breakdown and reduces weight on the stoma. Pouches are usually changed every few days, alcohol is irritating to stoma mucosa, and fluids should not be restricted.

Question 40Medical-Surgical Nursing

A client with a chest tube after thoracotomy has continuous bubbling in the water-seal chamber. What should the nurse do first?

  1. Add sterile water to the water-seal chamber
  2. Reposition the client onto the affected side
  3. Clamp the chest tube immediately
  4. Assess the insertion site and tubing for an air leak Correct answer.

Explanation

Continuous bubbling in the water-seal chamber indicates an air leak, so the nurse assesses the insertion site and tubing connections first. Clamping is dangerous because it can cause tension pneumothorax. Adding water is done only when the water level is low, and positioning does not fix a leak.

Question 41Medical-Surgical Nursing

A client is prescribed digoxin. Which finding should the nurse report before giving the dose?

  1. Serum potassium of 4.2 mEq/L
  2. Complaint of mild constipation
  3. Blood pressure of 128/76 mm Hg
  4. Apical heart rate of 58 beats per minute Correct answer.

Explanation

Digoxin slows conduction, and a heart rate below 60 beats per minute is a reason to hold the dose and notify the provider. Normal potassium and blood pressure do not contraindicate the drug. Constipation is not a typical reason to withhold digoxin.

Question 42Medical-Surgical Nursing

A client with acute pancreatitis is admitted with severe epigastric pain. Which nursing intervention is most appropriate initially?

  1. Maintain NPO status and administer prescribed IV fluids Correct answer.
  2. Provide a high-fat diet to stimulate digestion
  3. Apply cold packs to the abdomen
  4. Encourage frequent ambulation to relieve pain

Explanation

Acute pancreatitis is managed initially with bowel rest (NPO) and IV fluid resuscitation to reduce pancreatic stimulation and maintain volume. A high-fat diet stimulates enzyme secretion, ambulation does not relieve pancreatic pain, and cold packs are not standard therapy.

Question 43Medical-Surgical Nursing

A client with a new below-the-knee amputation reports phantom limb pain. Which response by the nurse is most appropriate?

  1. Phantom pain means the stump is infected.
  2. Phantom pain is not real and will go away on its own.
  3. Phantom pain requires immediate surgical revision.
  4. Phantom pain is a common real phenomenon and can be treated. Correct answer.

Explanation

Phantom limb pain is a well-recognized real phenomenon after amputation and can be managed with medications and other therapies. It does not indicate infection or require surgery, and dismissing it as unreal is incorrect.

Question 44Medical-Surgical Nursing

A client with heart failure is prescribed furosemide. Which electrolyte imbalance should the nurse anticipate?

  1. Hypernatremia
  2. Hyperkalemia
  3. Hypokalemia Correct answer.
  4. Hypercalcemia

Explanation

Loop diuretics such as furosemide increase renal potassium loss and commonly cause hypokalemia. They do not typically cause hyperkalemia, hypernatremia, or hypercalcemia; potassium levels are monitored and replaced as needed.

Question 45Medical-Surgical Nursing

A client with a tracheostomy is being suctioned. Which action should the nurse take to reduce the risk of hypoxia?

  1. Use the largest catheter that fits the airway
  2. Suction continuously for 30 seconds
  3. Instill normal saline before each pass
  4. Hyperoxygenate before and after suctioning Correct answer.

Explanation

Hyperoxygenation before and after suctioning prevents hypoxemia from airway occlusion and removal of oxygen. Suction passes should be limited to about 10 to 15 seconds, and routine saline instillation is not recommended.

Question 46Medical-Surgical Nursing

A client is admitted with a suspected peptic ulcer and reports black, tarry stools. Which finding should the nurse document?

  1. Steatorrhea
  2. Hematochezia
  3. Melena Correct answer.
  4. Hematemesis

Explanation

Melena is black, tarry stool caused by digested blood from upper gastrointestinal bleeding. Hematemesis is vomited blood, hematochezia is bright red rectal bleeding, and steatorrhea is fatty stool.

Question 47Medical-Surgical Nursing

A client with a new diagnosis of hypertension asks about lifestyle changes. Which recommendation is most strongly supported?

  1. Reduce dietary sodium and increase physical activity Correct answer.
  2. Increase sodium intake to 4 g daily
  3. Stop all medications once blood pressure normalizes
  4. Drink two glasses of wine daily

Explanation

Sodium restriction and regular physical activity are core lifestyle measures that lower blood pressure. Increasing sodium and daily alcohol raise blood pressure, and antihypertensives must not be stopped without provider guidance.

Question 48Medical-Surgical Nursing

A client with a casted lower leg reports severe pain that is not relieved by prescribed analgesia and numbness of the toes. What should the nurse do first?

  1. Encourage the client to wiggle the toes to improve circulation
  2. Elevate the leg above heart level and reassess in one hour
  3. Apply a heating pad to the casted leg
  4. Notify the provider immediately for possible compartment syndrome Correct answer.

Explanation

Unrelieved severe pain and numbness in a casted extremity suggest compartment syndrome, a surgical emergency requiring immediate provider notification. Elevation above heart level can reduce arterial perfusion, heat is inappropriate, and toe exercises do not relieve compartment pressure.

Question 49Medical-Surgical Nursing

A client with COPD has a prescribed oxygen therapy. Which oxygen delivery approach is safest?

  1. Withhold oxygen unless the client is unconscious
  2. High-flow oxygen at 10 L/min via mask
  3. Use 100% oxygen continuously
  4. Titrate oxygen to a target saturation of 88% to 92% Correct answer.

Explanation

In COPD with chronic hypercapnia, oxygen is titrated to a saturation of about 88% to 92% to avoid worsening hypercapnia while correcting hypoxemia. High-flow or 100% oxygen can suppress respiratory drive, and withholding oxygen is unsafe.

Question 50Medical-Surgical Nursing

A client with a spinal cord injury at T4 suddenly develops a severe headache, hypertension, and bradycardia. What should the nurse suspect?

  1. Neurogenic shock
  2. Autonomic dysreflexia Correct answer.
  3. Pulmonary embolism
  4. Septic shock

Explanation

Autonomic dysreflexia occurs after injuries above T6 and presents with severe hypertension, pounding headache, and bradycardia, often triggered by bladder or bowel distension. The nurse should sit the client upright and identify and remove the trigger. Neurogenic shock causes hypotension and bradycardia without severe hypertension.