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BNMC Licensing Exam study materials
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BNMC Licensing Exam practice questions

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Question 1Fundamentals of Nursing and Basic Nursing Care

A nurse is preparing to administer a medication and checks the client's identification band against the medication administration record. Which of the following is the primary purpose of this action?

  1. To confirm the client's identity before giving the medication Correct answer.
  2. To determine whether the client has allergies
  3. To verify the medication's expiration date
  4. To document the time the medication was ordered

Explanation

Positive client identification is a core safety step that ensures the right medication is given to the right person. Two identifiers, such as name and date of birth, are compared with the medication record before administration. Allergy status and expiration dates are separate checks that do not replace identity verification.

Question 2Fundamentals of Nursing and Basic Nursing Care

A client has been on bed rest for several days. Which nursing action best helps prevent the formation of pressure injuries?

  1. Repositioning the client at regular scheduled intervals Correct answer.
  2. Keeping the head of the bed elevated at 60 degrees
  3. Applying tight elastic bandages to the legs
  4. Massaging reddened bony prominences firmly

Explanation

Pressure injuries result from prolonged unrelieved pressure over bony prominences, so scheduled repositioning redistributes pressure and restores tissue perfusion. Massaging reddened areas can damage compromised tissue, and high head-of-bed elevation increases shear forces on the sacrum. Tight bandages do not address pressure relief.

Question 3Fundamentals of Nursing and Basic Nursing Care

When performing hand hygiene with an alcohol-based rub, which technique is appropriate?

  1. Apply the product and rub until the hands are completely dry Correct answer.
  2. Apply the product to visibly soiled hands before washing
  3. Rinse the hands with water after the product dries
  4. Rub only the palms and skip the fingertips

Explanation

Alcohol-based hand rub must remain on the skin and be rubbed until dry so that the product has adequate contact time to reduce microorganisms. It should not be used when hands are visibly soiled, in which case soap and water are required. Rinsing removes the product prematurely and reduces effectiveness.

Question 4Fundamentals of Nursing and Basic Nursing Care

A nurse measures a client's blood pressure and obtains 148/92 mm Hg. The client reports no symptoms. What is the most appropriate initial nursing action?

  1. Document the value and take no further action
  2. Recheck the reading after allowing the client to rest quietly Correct answer.
  3. Immediately administer a prescribed antihypertensive
  4. Ask the client to exercise before rechecking

Explanation

A single elevated reading may reflect activity, anxiety, or measurement error, so the standard first step is to let the client rest and repeat the measurement using correct technique. Treatment decisions follow confirmed readings and prescribed orders. Exercise would raise blood pressure further and confound the result.

Question 5Fundamentals of Nursing and Basic Nursing Care

A nurse is caring for a client with an indwelling urinary catheter. Which action helps prevent catheter-associated urinary tract infection?

  1. Disconnecting the tubing to obtain urine samples
  2. Cleaning the perineum with alcohol each shift
  3. Irrigating the catheter routinely every shift
  4. Keeping the drainage bag below the level of the bladder Correct answer.

Explanation

Gravity drainage with the bag below bladder level prevents backflow of contaminated urine into the bladder. Routine irrigation and unnecessary disconnections introduce microorganisms into a closed system. Alcohol is irritating to mucous membranes and is not the standard perineal cleanser.

Question 6Fundamentals of Nursing and Basic Nursing Care

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

  1. Ask the unit clerk to transcribe the order later
  2. Administer the medication before documenting the order
  3. Write the order down, read it back to the prescriber, and have it verified Correct answer.
  4. Wait until the prescriber writes the order in person

Explanation

Telephone orders must be documented immediately and read back to the prescriber to confirm accuracy, then countersigned according to policy. Delaying documentation or delegating transcription to unlicensed staff creates error risk. Medication should not be given before the order is documented and verified.

Question 7Fundamentals of Nursing and Basic Nursing Care

A client is prescribed oxygen therapy. Which safety measure is essential when oxygen is in use?

  1. Using petroleum-based ointment on the nares
  2. Posting no-smoking signs and keeping oxygen away from flames Correct answer.
  3. Storing the oxygen cylinder lying flat on the floor
  4. Setting the flow rate higher than prescribed

Explanation

Oxygen supports combustion, so open flames and smoking must be prohibited in the area. Oil-based products can ignite and should not be used near oxygen. Flow rates are set according to prescription, and cylinders must be secured upright.

Question 8Fundamentals of Nursing and Basic Nursing Care

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

  1. Checking the pH of aspirated gastric contents Correct answer.
  2. Asking the client to speak clearly
  3. Auscultating injected air over the abdomen
  4. Observing for a gag reflex

Explanation

Testing the pH of aspirated fluid is the most reliable bedside method, because gastric aspirate is typically acidic. Auscultating injected air is unreliable and can produce misleading sounds even when the tube is misplaced. Speaking and gagging do not confirm tube position.

Question 9Fundamentals of Nursing and Basic Nursing Care

A nurse is teaching a client about a low-sodium diet. Which food choice indicates the client understands the teaching?

  1. Canned soup with crackers
  2. Pickled vegetables with soy sauce
  3. Processed deli meat sandwich
  4. Fresh fruit with unsalted nuts Correct answer.

Explanation

Fresh foods prepared without added salt are naturally low in sodium and are appropriate choices. Processed, canned, pickled, and cured foods are typically high in sodium from preservatives and added salt. Choosing fresh options demonstrates correct understanding of the diet.

Question 10Fundamentals of Nursing and Basic Nursing Care

A client is at risk for falls. Which intervention is most effective for preventing falls at night?

  1. Restraining the client to prevent wandering
  2. Raising all four side rails for safety
  3. Keeping a nightlight on and placing the call light within reach Correct answer.
  4. Keeping the room dark to promote sleep

Explanation

Adequate lighting and easy access to the call light reduce the risk of falls when clients move at night. Restraints and raised side rails increase injury risk and are not acceptable fall precautions. A dark room impairs visibility and raises the risk of tripping.

Question 11Fundamentals of Nursing and Basic Nursing Care

A nurse is assessing a client's pain. Which finding is the most reliable indicator of pain?

  1. The client's self-report of pain Correct answer.
  2. The nurse's estimate based on the diagnosis
  3. The client's heart rate elevation
  4. The client's facial expression

Explanation

Self-report is the most reliable indicator of pain, because pain is a subjective experience that cannot be fully determined by observation. Vital signs and facial expressions may support assessment but do not replace the client's report. Nurses should not estimate pain based on diagnosis alone.

Question 12Fundamentals of Nursing and Basic Nursing Care

A nurse is preparing to give an intramuscular injection to an adult. Which site is generally preferred for routine adult immunizations?

  1. Deltoid site Correct answer.
  2. Ventrogluteal site
  3. Dorsogluteal site
  4. Vastus lateralis site

Explanation

The deltoid muscle is the preferred site for most adult immunizations because it is easily accessible and appropriate for small volumes. The ventrogluteal site is preferred for larger-volume intramuscular injections. The dorsogluteal site carries risk of sciatic nerve injury, and the vastus lateralis is used mainly in infants.

Question 13Fundamentals of Nursing and Basic Nursing Care

A nurse is caring for a client with an IV infusion. The nurse notes swelling, coolness, and pallor at the insertion site. What is the most appropriate action?

  1. Increase the flow rate to clear the line
  2. Apply warm compresses and continue the infusion
  3. Stop the infusion and remove the IV catheter Correct answer.
  4. Recheck the site in one hour

Explanation

Swelling, coolness, and pallor suggest infiltration, in which fluid enters surrounding tissue. The infusion should be stopped and the catheter removed, then the site elevated as appropriate. Continuing or increasing the infusion worsens tissue damage.

Question 14Fundamentals of Nursing and Basic Nursing Care

A nurse is teaching a client to use a metered-dose inhaler. Which technique indicates correct use?

  1. Activating the device after exhaling completely and holding breath for 10 seconds
  2. Breathing rapidly after activating the device
  3. Inhaling slowly and deeply while activating the device Correct answer.
  4. Inhaling through the nose while activating the device

Explanation

Slow, deep inhalation while activating the device allows medication to reach the lower airways. The client should then hold the breath to allow deposition. Rapid breathing and nasal inhalation reduce delivery to the lungs.

Question 15Fundamentals of Nursing and Basic Nursing Care

A client is on strict intake and output monitoring. Which item should the nurse count as intake?

  1. Ice chips consumed Correct answer.
  2. Wound drainage
  3. Emesis
  4. Urine output

Explanation

Intake includes all fluids entering the body, and ice chips are counted as part of oral intake. Urine output, wound drainage, and emesis are measured as output. Accurate intake and output records require counting all oral, intravenous, and enteral sources.

Question 16Fundamentals of Nursing and Basic Nursing Care

A nurse is performing a sterile dressing change. Which action maintains sterility?

  1. Holding sterile supplies above the waist and within view Correct answer.
  2. Keeping the sterile field at chest level while turning the back
  3. Turning away from the field to reach for supplies
  4. Touching only the outer edges of the sterile drape

Explanation

Sterile items must remain above waist level and within the nurse's view to prevent contamination from contact with unsterile surfaces. Reaching across or turning away from the field increases contamination risk. The edges of a sterile drape are considered unsterile.

Question 17Fundamentals of Nursing and Basic Nursing Care

A nurse is caring for a client who is receiving a blood transfusion. Which finding requires immediate intervention?

  1. Fever, chills, and lower back pain Correct answer.
  2. Urine output of 40 mL per hour
  3. A hemoglobin level of 9 g/dL
  4. Mild itching at the IV site

Explanation

Fever, chills, and back pain may indicate an acute hemolytic transfusion reaction, which requires stopping the transfusion immediately and notifying the provider. Mild itching may suggest a mild allergic reaction that is monitored closely. Hemoglobin and urine output values alone do not signal an acute reaction.

Question 18Fundamentals of Nursing and Basic Nursing Care

A nurse is teaching a client about safe use of a walker. Which instruction is correct?

  1. Move the walker forward, then step into it Correct answer.
  2. Hold the walker at arm's length in front
  3. Lift the walker while stepping forward
  4. Lean the body weight onto the walker's front legs

Explanation

The walker is advanced first, and the client then steps into it while bearing weight through the arms. The client should not lift the walker while stepping or lean excessive body weight onto the front legs. Holding the walker too far forward reduces stability.

Question 19Fundamentals of Nursing and Basic Nursing Care

A nurse is assessing a client for dehydration. Which finding is most consistent with this condition?

  1. Peripheral edema
  2. Dry mucous membranes and poor skin turgor Correct answer.
  3. Bounding pulses and hypertension
  4. Crackles in the lung bases

Explanation

Dehydration reduces fluid volume, producing dry mucous membranes, poor skin turgor, and concentrated urine. Bounding pulses, crackles, and edema suggest fluid overload rather than depletion. Assessment findings should be interpreted together with vital signs and laboratory values.

Question 20Fundamentals of Nursing and Basic Nursing Care

A nurse is preparing to administer an enteral feeding through a nasogastric tube. Which action is correct?

  1. Rapidly instill the formula to save time
  2. Elevate the head of the bed during and after the feeding Correct answer.
  3. Place the client flat during the feeding
  4. Check residual volume only after the feeding

Explanation

Elevating the head of the bed reduces the risk of aspiration during and after enteral feeding. The client should remain upright for a period after the feeding. Rapid instillation and delayed residual checks increase the risk of aspiration and intolerance.

Question 21Fundamentals of Nursing and Basic Nursing Care

A nurse is caring for a client who is confused and attempting to get out of bed. Which action is the priority?

  1. Ask another nurse to check on the client later
  2. Raise all four side rails
  3. Stay with the client and use least restrictive safety measures Correct answer.
  4. Apply wrist restraints immediately

Explanation

Staying with the client and using the least restrictive measures protects safety while respecting the client's rights. Restraints and raised side rails are restrictive measures that require specific justification and carry risk. Leaving the client alone increases the risk of injury.

Question 22Fundamentals of Nursing and Basic Nursing Care

A nurse is preparing to perform a bed bath for a client. Which action promotes client dignity?

  1. Discussing the client's condition with visitors during the bath
  2. Keeping the door open for ventilation
  3. Washing the entire body at once to save time
  4. Exposing only the area being washed and covering the rest Correct answer.

Explanation

Exposing only the area being cleansed and covering the rest preserves privacy and warmth during bathing. Washing the whole body at once exposes the client unnecessarily. Keeping the door open and discussing condition with visitors violate privacy and confidentiality.

Question 23Fundamentals of Nursing and Basic Nursing Care

A nurse is assessing a client's respiratory status. Which finding should be reported to the provider immediately?

  1. Oxygen saturation of 97% on room air
  2. Respiratory rate of 28 with accessory muscle use Correct answer.
  3. Respiratory rate of 16 with clear breath sounds
  4. Occasional dry cough after activity

Explanation

A respiratory rate of 28 with accessory muscle use indicates increased work of breathing and possible respiratory distress, which requires prompt reporting. The other findings are within expected limits or are not immediately concerning. Early recognition of distress allows timely intervention.

Question 24Fundamentals of Nursing and Basic Nursing Care

A nurse is teaching a client about preventing constipation. Which instruction is most appropriate?

  1. Increase dietary fiber and fluid intake Correct answer.
  2. Limit physical activity to reduce strain
  3. Decrease fluid intake to reduce bloating
  4. Use laxatives daily as a preventive measure

Explanation

Fiber adds bulk and fluid softens stool, together promoting regular bowel elimination. Physical activity also supports bowel function, so limiting it is counterproductive. Daily laxative use is not recommended as a preventive measure.

Question 25Fundamentals of Nursing and Basic Nursing Care

A nurse is preparing to administer a subcutaneous injection of insulin. Which action is correct?

  1. Aspirate before injecting the insulin
  2. Insert the needle at a 45- to 90-degree angle depending on tissue Correct answer.
  3. Massage the site vigorously after injection
  4. Use the same site for every injection

Explanation

Subcutaneous injections are given at an angle based on the client's tissue thickness, typically 45 to 90 degrees. Massaging and aspirating are not recommended for insulin and can alter absorption. Rotating sites prevents lipohypertrophy and ensures consistent absorption.

Question 26Fundamentals of Nursing and Basic Nursing Care

A nurse is preparing to reposition a client who is immobile and cannot assist. Which technique best protects both the nurse and the client?

  1. Raising the bed to waist height and using a draw sheet with help from a second caregiver Correct answer.
  2. Grasping the client under the arms and lifting the torso off the mattress
  3. Reaching across the bed with feet together to slide the client sideways
  4. Bending at the waist and pulling the client toward the head of the bed quickly

Explanation

Safe client handling relies on keeping the work at waist height, keeping the client close to the nurse's body, and using assistive devices and additional staff to reduce friction and spinal load. Raising the bed and using a draw sheet with a partner distributes force and limits shear injury to the client's skin.

Question 27Fundamentals of Nursing and Basic Nursing Care

A nurse is measuring a client's blood pressure using an upper-arm cuff. Which action is correct?

  1. Positioning the cuff so the artery marker aligns with the brachial artery and the cuff is at heart level Correct answer.
  2. Placing the cuff over the client's sleeve to save time
  3. Having the client sit with the arm extended below the level of the heart
  4. Inflating the cuff rapidly to 300 mm Hg on every client

Explanation

Accurate blood pressure measurement requires the cuff bladder centered over the brachial artery with the marker aligned, the cuff at heart level, and the arm supported. Correct positioning prevents falsely high or low readings caused by hydrostatic effects and improper bladder placement.

Question 28Fundamentals of Nursing and Basic Nursing Care

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

  1. Disconnecting the tubing from the catheter daily to check for sediment
  2. Irrigating the catheter routinely every shift to keep it patent
  3. Cleaning the perineal area with an antiseptic solution twice daily
  4. Keeping the drainage bag below the level of the bladder and off the floor Correct answer.

Explanation

Maintaining a closed, dependent drainage system prevents urine from flowing back into the bladder, which is a key mechanism of infection. The bag must stay below bladder level and never touch the floor, and the system should remain closed unless clinically necessary.

Question 29Fundamentals of Nursing and Basic Nursing Care

A nurse is caring for a client who has just returned from surgery and is drowsy but arousable. Which nursing action takes priority?

  1. Assisting the client to ambulate to the bathroom
  2. Administering the prescribed oral pain medication immediately
  3. Documenting the client's dietary preferences for the next meal
  4. Performing a focused respiratory assessment including rate, depth, and airway patency Correct answer.

Explanation

After surgery and sedation, the highest priority is airway and breathing because depressed consciousness and residual anesthesia can cause obstruction or hypoventilation. A focused respiratory assessment guides any needed repositioning, stimulation, or oxygen therapy before other tasks.

Question 30Fundamentals of Nursing and Basic Nursing Care

A nurse is reviewing a client's medication administration record and notes a prescribed dose that is far above the usual range. Which action should the nurse take first?

  1. Ask the client whether the dose looks correct before giving it
  2. Administer the dose as prescribed and document the concern in the shift report
  3. Give half of the prescribed dose and monitor the client's response
  4. Withhold the medication and contact the prescriber to clarify the order Correct answer.

Explanation

When an order appears unsafe or outside accepted practice standards, the nurse must withhold the medication and clarify with the prescriber, because the nurse is accountable for safe administration. Administering a known questionable dose exposes the client to harm and does not satisfy the duty to advocate.

Question 31Medical-Surgical Nursing

A client with a new ileostomy has liquid stool output of 1,200 mL in 24 hours. Which priority assessment should the nurse make?

  1. Stoma color and moisture
  2. Abdominal wound appearance
  3. Serum potassium and fluid status Correct answer.
  4. Daily weight trend only

Explanation

High-output ileostomies cause loss of sodium, potassium, and water, leading to hypovolemia and electrolyte imbalance. The nurse should monitor electrolytes, intake and output, and signs of dehydration before other assessments.

Question 32Medical-Surgical Nursing

Which finding best indicates that a client with a chest tube for a pneumothorax has had a therapeutic response?

  1. Rise and fall of fluid in the water-seal chamber with breathing
  2. Continuous bubbling in the water-seal chamber
  3. Absence of tidaling and stable breath sounds Correct answer.
  4. Reduced bubbling in the suction-control chamber

Explanation

Tidaling stops once the pleural space re-expands and the lung is sealed against the chest wall. Stable breath sounds with no tidaling suggest resolution of the pneumothorax.

Question 33Medical-Surgical Nursing

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

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

Explanation

Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction, which requires stopping the transfusion immediately. IV access is kept patent with saline while the provider is notified.

Question 34Medical-Surgical Nursing

Which instruction should the nurse give a client scheduled for a colonoscopy with moderate sedation?

  1. Take aspirin the morning of the procedure
  2. Withhold all antihypertensive medications
  3. Eat a light breakfast before arriving
  4. Arrange a ride home and avoid driving for 24 hours Correct answer.

Explanation

Sedation impairs reflexes and judgment, so clients must have a responsible adult escort and avoid driving afterward. Antihypertensives are generally continued with sips of water unless the provider says otherwise.

Question 35Medical-Surgical Nursing

A client with acute pancreatitis reports severe epigastric pain radiating to the back. Which intervention should the nurse anticipate first?

  1. Encourage a high-fat diet to stimulate digestion
  2. Apply a heating pad to the abdomen
  3. Administer IV fluids and provide pain control Correct answer.
  4. Place the client in a supine position

Explanation

Acute pancreatitis is managed with aggressive IV fluid resuscitation and analgesia to rest the pancreas. Oral intake is withheld initially to reduce pancreatic stimulation.

Question 36Medical-Surgical Nursing

A client with a new below-the-knee amputation has a rigid dressing. Which finding requires immediate notification of the provider?

  1. Drainage saturation of the dressing within one hour Correct answer.
  2. Serosanguineous drainage on the first day
  3. Mild incisional pain controlled by medication
  4. Phantom limb sensation

Explanation

Rapid saturation of the dressing suggests active hemorrhage and possible hypovolemia. The surgeon must be notified promptly for evaluation and possible reoperation.

Question 37Medical-Surgical Nursing

Which client is at highest risk for developing pressure injury on the sacrum?

  1. A client who is incontinent and immobile after a stroke Correct answer.
  2. A client with pneumonia receiving IV antibiotics
  3. A client with a fractured femur in traction
  4. A client who had a laparoscopic cholecystectomy

Explanation

Immobility combined with moisture from incontinence greatly increases skin breakdown risk over the sacrum. Shear, friction, and prolonged pressure are the key contributors.

Question 38Medical-Surgical Nursing

A client with heart failure is prescribed furosemide. Which laboratory value should the nurse monitor most closely?

  1. Serum albumin
  2. Serum potassium Correct answer.
  3. Serum calcium
  4. Serum bilirubin

Explanation

Loop diuretics increase renal potassium excretion and can cause hypokalemia, which predisposes to dysrhythmias. Potassium levels are checked and replaced as needed.

Question 39Medical-Surgical Nursing

A client with a new tracheostomy is being suctioned. Which action should the nurse take?

  1. Suction for 30 seconds on each pass
  2. Apply suction while inserting the catheter
  3. Hyperoxygenate before and limit suction to 10 to 15 seconds Correct answer.
  4. Instill 5 mL of saline to loosen secretions

Explanation

Suctioning removes oxygen along with secretions, so preoxygenation and short passes prevent hypoxemia. Prolonged suction also risks mucosal trauma and bradycardia.

Question 40Medical-Surgical Nursing

A client is admitted with diabetic ketoacidosis. Which finding should the nurse expect?

  1. Blood glucose 90 mg/dL and urine ketones negative
  2. pH 7.20 and bicarbonate 10 mEq/L Correct answer.
  3. pH 7.50 and bicarbonate 32 mEq/L
  4. Serum potassium 2.0 mEq/L with alkalosis

Explanation

DKA produces a metabolic acidosis with low pH and low bicarbonate from ketone accumulation. Glucose is elevated and ketones are present in blood and urine.

Question 41Medical-Surgical Nursing

A client with a spinal cord injury at T4 suddenly reports a pounding headache and has a blood pressure of 210/110 mm Hg. What should the nurse do first?

  1. Check the bladder for distention
  2. Raise the head of the bed to 90 degrees Correct answer.
  3. Give a PRN analgesic
  4. Document the finding and recheck in 15 minutes

Explanation

These signs indicate autonomic dysreflexia, a life-threatening emergency. Sitting the client upright lowers blood pressure while the noxious stimulus, often a full bladder, is identified and removed.

Question 42Medical-Surgical Nursing

Which dietary teaching should the nurse give a client with chronic kidney disease who is not on dialysis?

  1. Increase potassium-rich foods
  2. Increase phosphorus-rich dairy foods
  3. Limit protein and sodium intake Correct answer.
  4. Drink at least 4 liters of fluid daily

Explanation

Reduced kidney function requires limiting protein to decrease nitrogenous waste and limiting sodium to control fluid retention and blood pressure. Potassium and phosphorus are also often restricted.

Question 43Medical-Surgical Nursing

A client is one day postoperative after an open reduction and internal fixation of the femur and reports severe pain unrelieved by opioids, with pallor and paresthesia of the limb. What is the priority action?

  1. Massage the calf to improve circulation
  2. Notify the provider immediately Correct answer.
  3. Reassess pain in one hour
  4. Elevate the limb above the heart and apply ice

Explanation

Unrelieved pain with pallor and paresthesia suggests compartment syndrome, a surgical emergency. The provider must be notified immediately for possible fasciotomy to prevent tissue necrosis.

Question 44Medical-Surgical Nursing

A client with atrial fibrillation is started on warfarin. Which instruction is most important?

  1. Increase leafy green vegetables in the diet
  2. Use a soft toothbrush and electric razor Correct answer.
  3. Stop the drug when bruising occurs
  4. Take aspirin for headaches without asking

Explanation

Warfarin increases bleeding risk, so clients should use soft toothbrushes and electric razors to prevent injury. Consistent vitamin K intake and avoiding unapproved aspirin are also important.

Question 45Medical-Surgical Nursing

A client with a chest tube has the tube accidentally disconnected from the drainage system. What should the nurse do first?

  1. Reconnect it to a new system immediately
  2. Clamp the tube near the client
  3. Ask the client to cough
  4. Submerge the tube end in sterile water Correct answer.

Explanation

If the tube disconnects, placing the end in sterile water creates a water seal that prevents air from entering the pleural space. Clamping risks tension pneumothorax.

Question 46Medical-Surgical Nursing

A client with cirrhosis has ascites and is prescribed spironolactone. Which finding indicates a therapeutic response?

  1. Decreased urine output
  2. Weight loss of 2 kg over several days Correct answer.
  3. Increased abdominal girth
  4. Serum potassium of 6.0 mEq/L

Explanation

Gradual weight loss reflects mobilization of ascitic fluid with diuretic therapy. Spironolactone is a potassium-sparing diuretic, so potassium must be monitored for hyperkalemia.

Question 47Medical-Surgical Nursing

Which client should the nurse assess first after receiving a handoff report?

  1. A client with a healed surgical incision asking for pain medication
  2. A client with chronic obstructive pulmonary disease requesting a breathing treatment
  3. A client with a new onset of confusion and oxygen saturation of 88% Correct answer.
  4. A client awaiting discharge instructions

Explanation

New confusion with hypoxemia suggests acute deterioration, possibly hypoxia or delirium from a physiologic cause. This unstable client takes priority over routine requests.

Question 48Medical-Surgical Nursing

A client with a new colostomy has a stoma that is dark purple and dry. What should the nurse do?

  1. Document it as a normal finding
  2. Notify the provider immediately Correct answer.
  3. Irrigate the stoma with saline
  4. Apply lubricant and reassess in 24 hours

Explanation

A dark purple, dry stoma indicates ischemia and possible necrosis from compromised blood supply. The provider must be notified urgently for surgical evaluation.

Question 49Medical-Surgical Nursing

A client is receiving total parenteral nutrition. Which action is essential?

  1. Change the bag every 72 hours
  2. Administer other medications through the same line
  3. Check blood glucose regularly and taper the infusion gradually Correct answer.
  4. Flush the line with heparin every shift only

Explanation

TPN contains high dextrose, causing hyperglycemia, so glucose is monitored and insulin adjusted. Abrupt discontinuation can cause hypoglycemia, so the infusion is tapered.

Question 50Medical-Surgical Nursing

A client with a head injury has a Glasgow Coma Scale score that dropped from 14 to 9. What is the priority action?

  1. Recheck the score in one hour
  2. Reposition the client to the side
  3. Document the change in the chart
  4. Notify the provider and prepare for airway support Correct answer.

Explanation

A GCS of 9 or below indicates severe neurologic impairment and risk of airway compromise. The provider must be notified and airway protection prepared.