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Egypt Nursing Licensure Exam study materials
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Egypt Nursing Licensure Exam practice questions

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Question 1Fundamentals of Nursing and Basic Nursing Skills

When preparing to administer an intramuscular injection into the ventrogluteal site, the nurse places the palm on the greater trochanter and the index finger on the anterior superior iliac spine. Where should the injection be given?

  1. Two fingerbreadths below the acromion process of the scapula
  2. In the center of the triangle formed by the index finger and the middle finger Correct answer.
  3. In the lower outer quadrant between the trochanter and the posterior iliac spine
  4. Just below the anterior superior iliac spine along the iliac crest

Explanation

The ventrogluteal site is located by placing the palm on the greater trochanter, the index finger on the anterior superior iliac spine, and the middle finger as far back as possible along the iliac crest; the injection goes into the center of the V formed by the index and middle fingers. This site has a thick muscle mass and is free of major nerves and blood vessels, making it preferred for adults and children over seven months.

Question 2Fundamentals of Nursing and Basic Nursing Skills

A patient is admitted with active pulmonary tuberculosis. Which type of precautions should the nurse initiate in addition to standard precautions?

  1. Droplet precautions with a surgical mask within one meter
  2. Contact precautions with gown and gloves for all room entry
  3. Airborne precautions with a fit-tested N95 respirator and negative-pressure room Correct answer.
  4. Protective isolation with a sterile gown for direct care

Explanation

Pulmonary tuberculosis spreads by airborne droplet nuclei that remain suspended and travel on air currents, so airborne precautions are required. This means a negative-pressure room with the door closed, an N95 or higher respirator for caregivers, and patient transport limited with a surgical mask on the patient.

Question 3Fundamentals of Nursing and Basic Nursing Skills

The nurse is calculating the body mass index of an adult who weighs 70 kg and is 1.75 m tall. What is the BMI, and how is it classified?

  1. 20.0, which indicates underweight
  2. 22.9, which falls within the normal range Correct answer.
  3. 25.7, which indicates overweight
  4. 40.0, which indicates obesity

Explanation

BMI is calculated as weight in kilograms divided by height in meters squared: 70 divided by (1.75 x 1.75), or 70 divided by 3.0625, which equals 22.9. A BMI of 18.5 to 24.9 is classified as normal weight, so this patient is within the healthy range.

Question 4Fundamentals of Nursing and Basic Nursing Skills

Which finding should the nurse document as a normal adult respiratory rate?

  1. 24 to 30 breaths per minute
  2. 8 breaths per minute
  3. 35 breaths per minute
  4. 12 to 20 breaths per minute Correct answer.

Explanation

The normal resting respiratory rate for a healthy adult is approximately 12 to 20 breaths per minute, counted for a full 60 seconds. Rates outside this range suggest respiratory compromise, pain, anxiety, or metabolic disturbance and require further assessment.

Question 5Fundamentals of Nursing and Basic Nursing Skills

A patient has a stage 2 pressure injury over the sacrum. Which description best matches this stage?

  1. Intact skin with non-blanchable redness
  2. Partial-thickness loss of skin with a shallow open ulcer or blister Correct answer.
  3. Full-thickness loss with exposed bone, tendon, or muscle
  4. Full-thickness loss with visible subcutaneous fat but no exposed bone

Explanation

A stage 2 pressure injury involves partial-thickness loss of the dermis, presenting as a shallow open ulcer with a pink or red wound bed, or as an intact or ruptured serum-filled blister. Intact skin with non-blanchable redness is stage 1, while deeper tissue exposure defines stages 3 and 4.

Question 6Fundamentals of Nursing and Basic Nursing Skills

The nurse must obtain informed consent for a surgical procedure. Which action is correct?

  1. Ask the surgeon to answer the patient's questions before the patient signs Correct answer.
  2. Obtain the signature from the patient's adult child when the patient seems anxious
  3. Have the patient sign the form after the nurse explains the risks and benefits
  4. Sign the form as a witness after the patient has already received sedation

Explanation

Informed consent requires that the provider performing the procedure disclose the nature, risks, benefits, and alternatives, and that the patient voluntarily agrees. The nurse's role is to verify understanding, witness the signature, and ensure the surgeon addresses any remaining questions before signing.

Question 7Fundamentals of Nursing and Basic Nursing Skills

When performing a bed bath for a dependent patient, which action best prevents transmission of microorganisms?

  1. Cleaning the eyes from the inner to the outer canthus with separate corners of the cloth Correct answer.
  2. Changing the bath water only at the end of the bath
  3. Using the same washcloth for the face and the perineum
  4. Washing from the perineal area toward the face

Explanation

Cleansing each eye from the inner canthus outward, using a different portion of the cloth, prevents secretions from entering the nasolacrimal duct and avoids cross-contamination between eyes. General bathing also proceeds from cleanest to dirtiest areas, with perineal care performed last.

Question 8Fundamentals of Nursing and Basic Nursing Skills

A patient is receiving a continuous enteral tube feeding. Which nursing action reduces the risk of aspiration?

  1. Positioning the patient flat during the feeding to promote comfort
  2. Keeping the head of the bed elevated 30 to 45 degrees during and after feeding Correct answer.
  3. Checking the gastric residual volume and discarding it routinely
  4. Flushing the tube with 5 mL of water every four hours

Explanation

Elevating the head of the bed 30 to 45 degrees during feeding and for about 30 to 60 minutes afterward uses gravity to keep formula in the stomach and reduces reflux and aspiration. Additional measures include verifying tube placement, monitoring tolerance, and avoiding unnecessary interruption of feedings.

Question 9Fundamentals of Nursing and Basic Nursing Skills

The nurse is preparing to insert a urinary catheter using sterile technique. Which action maintains sterility of the field?

  1. Reaching across the sterile field to arrange supplies
  2. Holding the catheter with sterile gloved hands after it touches the patient's leg
  3. Keeping the sterile drape above waist level and in view at all times Correct answer.
  4. Placing the sterile tray on the patient's bed linens near the edge

Explanation

A sterile field must remain above waist level and within the nurse's full view, because areas below the waist and out of sight are considered contaminated. Reaching across the field and contact with non-sterile surfaces also break sterility.

Question 10Fundamentals of Nursing and Basic Nursing Skills

Which instruction should the nurse give a patient who is learning to use a metered-dose inhaler with a spacer?

  1. Exhale fully into the spacer before each dose
  2. Inhale rapidly and deeply while pressing the canister
  3. Rinse the spacer with soap only once a month
  4. Hold the breath for about 10 seconds after inhaling the medication Correct answer.

Explanation

After a slow, deep inhalation from the spacer, the patient should hold the breath for about 10 seconds so the medication can deposit in the airways. The spacer should be washed regularly according to manufacturer instructions and allowed to air dry.

Question 11Fundamentals of Nursing and Basic Nursing Skills

A patient's pain is described as a deep, aching pain in the right lower abdomen that began after an appendectomy incision healed. This is best classified as which type of pain?

  1. Visceral pain arising from internal organs
  2. Somatic pain arising from skin and subcutaneous tissue
  3. Neuropathic pain caused by nerve damage
  4. Referred pain felt at a site distant from its source Correct answer.

Explanation

Referred pain is perceived at a location other than the site of the painful stimulus, often because visceral and somatic afferents converge on the same spinal segments. Deep aching pain perceived away from the original operative area fits this pattern.

Question 12Fundamentals of Nursing and Basic Nursing Skills

The nurse receives a telephone order for a medication. What is the correct procedure?

  1. Ask another nurse to transcribe the order without reading it back
  2. Repeat the order back to the prescriber and document it for later countersignature Correct answer.
  3. Wait until the prescriber arrives to write the order before giving any drug
  4. Accept the order and administer the drug without written verification

Explanation

Telephone orders must be written down, read back verbatim to the prescriber for verification, and then countersigned by the prescriber within the time frame set by facility policy. This read-back process reduces transcription and medication errors.

Question 13Fundamentals of Nursing and Basic Nursing Skills

A patient with a new colostomy asks how to care for the stoma. Which statement by the patient indicates correct understanding?

  1. I will wash the stoma with warm water and pat the skin dry before applying a new pouch Correct answer.
  2. I will clean the stoma with alcohol to keep it sterile
  3. I will cut the pouch opening larger than the stoma to avoid irritation
  4. I will change the pouch every day regardless of leakage

Explanation

The stoma is cleaned gently with warm water and the surrounding skin is dried thoroughly before a new pouch is applied, which helps the skin barrier adhere. The opening should be cut to fit the stoma size to protect the skin from effluent.

Question 14Fundamentals of Nursing and Basic Nursing Skills

The nurse is caring for a patient on bed rest. Which intervention is most effective for preventing a deep vein thrombosis?

  1. Restricting oral fluids to reduce the need for repositioning
  2. Massaging the calves vigorously twice per shift
  3. Applying sequential compression devices as prescribed and encouraging ankle exercises Correct answer.
  4. Keeping the legs dependent to promote circulation

Explanation

Sequential compression devices plus active ankle and leg exercises promote venous return and prevent stasis, which is the main mechanism of deep vein thrombosis in immobile patients. Early ambulation and adequate hydration also reduce risk.

Question 15Fundamentals of Nursing and Basic Nursing Skills

Which action is appropriate when moving a patient up in bed with the assistance of a second nurse?

  1. Each nurse pulls the patient by the arms
  2. The patient is dragged across the sheet without a draw sheet
  3. The patient is asked to fold the arms across the chest and assist by pushing with the feet Correct answer.
  4. The nurses stand at the head of the bed and lift with the back muscles

Explanation

Having the patient fold the arms across the chest and push with the feet engages the patient's own strength and reduces the load on the nurses. Nurses should use a draw sheet or slide sheet and maintain a wide base with the bed at a safe working height to protect their backs.

Question 16Fundamentals of Nursing and Basic Nursing Skills

A patient is ordered a 24-hour urine collection. Which instruction is essential for accurate results?

  1. Keep the collection container at room temperature
  2. Stop collecting after 12 hours if the container is nearly full
  3. Collect every voided specimen including the first one of the collection period
  4. Discard the first voided specimen and begin collection with the next void Correct answer.

Explanation

The collection begins by discarding the first voided urine because it reflects urine formed before the start time, and then all subsequent urine for the full 24 hours is collected. The container is kept cool and the full period is completed for valid results.

Question 17Fundamentals of Nursing and Basic Nursing Skills

The nurse observes a colleague about to administer a medication that has not been verified against the patient's identification band. What is the priority action?

  1. Report the colleague to the nursing director immediately
  2. Document the observation in the patient's chart
  3. Interrupt the colleague and ask that the patient be identified before administration Correct answer.
  4. Say nothing because the colleague is more experienced

Explanation

The immediate priority is to prevent the error by stopping the administration and ensuring the patient is identified using at least two identifiers. Reporting and documentation follow after the immediate safety concern is addressed.

Question 18Fundamentals of Nursing and Basic Nursing Skills

Which site is preferred for assessing the pulse of an adult who has collapsed and is unresponsive?

  1. Temporal artery
  2. Radial artery
  3. Pedal artery
  4. Carotid artery Correct answer.

Explanation

The carotid artery is the recommended site for pulse assessment during adult resuscitation because it is central, easily accessible, and reflects cardiac output even when peripheral perfusion is poor. Pulse checks are limited to no more than 10 seconds.

Question 19Fundamentals of Nursing and Basic Nursing Skills

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

  1. Assessing the nares and skin for pressure and ensuring the tubing is not kinked Correct answer.
  2. Setting the flow rate higher than prescribed to improve saturation
  3. Applying petroleum jelly to the nares to prevent dryness
  4. Removing the cannula during meals without notifying the provider

Explanation

Oxygen tubing must remain patent and unkinked, and the nares and skin are assessed for irritation and pressure from the cannula. Petroleum-based products are avoided near oxygen because they are flammable.

Question 20Fundamentals of Nursing and Basic Nursing Skills

A patient is scheduled for surgery and reports taking aspirin daily. Why is this finding important before the procedure?

  1. Aspirin raises blood pressure and must be stopped weeks in advance
  2. Aspirin causes hyperkalemia that must be corrected first
  3. Aspirin interferes with the anesthetic agent's metabolism
  4. Aspirin increases the risk of bleeding during and after surgery Correct answer.

Explanation

Aspirin irreversibly inhibits platelet cyclooxygenase, impairing platelet aggregation for the life of the platelet, so it increases bleeding risk during and after surgery. The provider is notified so the medication can be managed according to the surgical plan.

Question 21Fundamentals of Nursing and Basic Nursing Skills

A patient has been prescribed a clear liquid diet. Which item is appropriate to include?

  1. Oatmeal
  2. Clear broth Correct answer.
  3. Vanilla ice cream
  4. Cream of tomato soup

Explanation

A clear liquid diet includes items that are transparent and liquid at room temperature, such as clear broth, gelatin, clear juices, and tea. It is used to rest the bowel and to prepare for procedures.

Question 22Fundamentals of Nursing and Basic Nursing Skills

The nurse is assessing a patient for dehydration. Which finding is most consistent with this condition?

  1. Bounding pulses and distended neck veins
  2. Moist mucous membranes and copious urine output
  3. Poor skin turgor and concentrated dark urine Correct answer.
  4. Crackles in the lung bases and weight gain

Explanation

Dehydration reduces intravascular volume, producing poor skin turgor, dry mucous membranes, oliguria, and concentrated urine. Vital signs may show tachycardia and hypotension, and intake and output records help confirm the diagnosis.

Question 23Fundamentals of Nursing and Basic Nursing Skills

Which statement about hand hygiene is correct according to standard precautions?

  1. Hand washing is required only after contact with blood
  2. Alcohol rub is effective against Clostridioides difficile spores
  3. Gloves replace the need for hand hygiene between patients
  4. Alcohol-based rub is preferred for routine decontamination when hands are not visibly soiled Correct answer.

Explanation

Alcohol-based hand rub is the preferred method for routine hand decontamination when hands are not visibly soiled, because it is fast and effective against most organisms. Hands must be washed with soap and water when visibly soiled and for spore-forming organisms such as C. difficile.

Question 24Fundamentals of Nursing and Basic Nursing Skills

A patient has an order for a nasogastric tube feeding. Which action confirms initial tube placement before the first feeding?

  1. Auscultating injected air over the epigastrium
  2. Measuring the pH of aspirated gastric fluid Correct answer.
  3. Asking the patient to swallow water
  4. Observing for coughing during insertion

Explanation

Measuring the pH of aspirated fluid is the most reliable bedside method, with a pH of 5.5 or lower supporting gastric placement. Auscultation of injected air is unreliable and no longer recommended as a primary confirmation method.

Question 25Fundamentals of Nursing and Basic Nursing Skills

Which nursing action best promotes sleep hygiene for a hospitalized patient?

  1. Administering a sedative to every patient who reports difficulty sleeping
  2. Keeping the television on for background noise
  3. Encouraging caffeine in the evening to promote alertness
  4. Scheduling vital signs and procedures in clusters to minimize interruptions Correct answer.

Explanation

Clustering care activities reduces sleep interruptions and supports uninterrupted sleep cycles, which promote healing. Environmental measures such as dim lighting, reduced noise, and a comfortable temperature also improve sleep quality.

Question 26Fundamentals of Nursing and Basic Nursing Skills

A patient has an order for a cleansing enema. Which position should the nurse place the adult patient in for administration of the enema?

  1. High Fowler position with legs extended
  2. Left lateral position with the right knee flexed Correct answer.
  3. Prone position with the head turned to one side
  4. Supine position with the head of the bed flat

Explanation

The left lateral (Sims) position allows the solution to flow by gravity along the natural curve of the descending colon and sigmoid, which lie on the left side, so the enema is retained and reaches the intended area. Flexing the right knee relaxes the abdominal muscles and improves comfort and retention.

Question 27Fundamentals of Nursing and Basic Nursing Skills

The nurse is about to give a patient a bedpan. Which action best protects the patient's skin integrity during use?

  1. Position the pan and then raise the head of the bed as high as possible
  2. Place the patient on a plastic-covered pan without padding
  3. Check the skin under the patient and dry it after removing the pan Correct answer.
  4. Lift the patient's hips off the pan and reposition every few minutes

Explanation

Moisture from urine or stool trapped against the skin macerates the epidermis and promotes breakdown, so inspecting and drying the skin after bedpan use is a direct preventive measure. Routine skin assessment after each episode also detects early redness before an ulcer develops.

Question 28Fundamentals of Nursing and Basic Nursing Skills

A patient is receiving a blood transfusion through a peripheral IV. Fifteen minutes after the start, the patient reports chills and flank pain, and the urine in the drainage bag is dark. Which action should the nurse take first?

  1. Administer the prescribed antipyretic and continue the transfusion
  2. Obtain a urine specimen and continue monitoring vital signs
  3. Slow the transfusion rate and reassess the patient in 15 minutes
  4. Stop the transfusion and maintain IV access with normal saline Correct answer.

Explanation

Chills, flank pain, and dark urine suggest an acute hemolytic transfusion reaction, in which incompatible red cells are destroyed. The priority is to stop the blood immediately and keep the vein open with normal saline through new tubing so that circulation is supported while the provider and blood bank are notified.

Question 29Fundamentals of Nursing and Basic Nursing Skills

The nurse is preparing to insert a peripheral IV catheter in an older adult. Which action best reduces the risk of vein damage during insertion?

  1. Apply the tourniquet tightly and leave it in place during insertion
  2. Select a vein in the antecubital fossa over a joint for all patients
  3. Release the tourniquet before advancing the catheter off the stylet Correct answer.
  4. Insert the catheter at a 45-degree angle through the vein

Explanation

Releasing the tourniquet before advancing the catheter reduces the pressure in the vein, which lowers the chance of the catheter piercing the opposite wall and causing infiltration or hematoma. The tourniquet should be released as soon as flashback confirms entry into the vein.

Question 30Fundamentals of Nursing and Basic Nursing Skills

A patient with a tracheostomy is receiving oxygen and has thick secretions. Which action by the nurse best supports effective airway clearance while limiting risk?

  1. Perform suctioning every hour around the clock regardless of breath sounds
  2. Suction for 15 seconds while applying continuous wall suction during withdrawal
  3. Hyperoxygenate the patient, then suction only as far as needed while withdrawing the catheter Correct answer.
  4. Instill 5 mL of normal saline into the tracheostomy before each suction pass

Explanation

Pre-oxygenation prevents hypoxemia during the brief loss of airway, and suctioning only on withdrawal with the catheter inserted no deeper than necessary limits mucosal trauma and hypoxia. Suction should be based on assessed need rather than a fixed schedule.

Question 31Medical-Surgical Nursing

A patient with acute decompensated heart failure has a prescription for furosemide 40 mg IV. Which assessment finding should the nurse report to the prescriber before administering the drug?

  1. Serum sodium 138 mEq/L
  2. Blood pressure 118/72 mmHg
  3. Urine output 60 mL over the last hour
  4. Serum potassium 2.9 mEq/L Correct answer.

Explanation

Loop diuretics such as furosemide cause potassium loss, and a value of 2.9 mEq/L is below the normal range, so giving the drug could worsen hypokalemia and precipitate dysrhythmias. The nurse should hold the dose and notify the prescriber. The other values are within acceptable limits and do not require withholding the drug.

Question 32Medical-Surgical Nursing

A patient with chronic obstructive pulmonary disease is prescribed oxygen therapy. Which delivery target is safest for this patient based on the hypoxic drive concept?

  1. Maintain an SpO2 of 100% at all times
  2. Keep the flow at 10 L/min by mask continuously
  3. Aim for an SpO2 of 70-75%
  4. Titrate to an SpO2 of 88-92% Correct answer.

Explanation

In patients with chronic hypercapnia, high oxygen concentrations can suppress the hypoxic drive and worsen carbon dioxide retention. Current practice targets an SpO2 of 88-92% and titrates oxygen to that range. This preserves oxygenation while avoiding over-oxygenation.

Question 33Medical-Surgical Nursing

A patient is admitted with a suspected acute myocardial infarction. Which laboratory marker is most specific for myocardial injury and is used to confirm the diagnosis?

  1. C-reactive protein
  2. Serum amylase
  3. Erythrocyte sedimentation rate
  4. Troponin I Correct answer.

Explanation

Cardiac troponin I and T are highly specific to myocardial tissue and rise within hours of injury, making them the preferred markers for acute myocardial infarction. C-reactive protein and ESR reflect inflammation, and amylase reflects pancreatic function.

Question 34Medical-Surgical Nursing

A patient with a new diagnosis of type 1 diabetes mellitus asks why insulin is needed. Which response by the nurse is accurate?

  1. Diet alone is sufficient because type 1 diabetes is mild
  2. You can stop insulin once your blood glucose normalizes
  3. Insulin will cure the diabetes permanently after one year of use
  4. Your pancreas no longer produces enough insulin, so insulin must be replaced Correct answer.

Explanation

Type 1 diabetes results from autoimmune destruction of pancreatic beta cells, so endogenous insulin production is lost and lifelong exogenous insulin is required. Insulin controls glucose but does not cure the disease, and it cannot be stopped when glucose normalizes.

Question 35Medical-Surgical Nursing

A patient is receiving a blood transfusion. Which finding should alert the nurse to a possible acute hemolytic reaction?

  1. Chills, flank pain, and dark urine Correct answer.
  2. Gradual weight gain over one week
  3. Mild itching at the IV site
  4. A blood pressure of 130/80 mmHg

Explanation

Acute hemolytic transfusion reactions present with fever, chills, flank or back pain, and hemoglobinuria producing dark urine. The nurse should stop the transfusion immediately and maintain IV access. Itching and gradual weight gain suggest other problems such as allergy or fluid overload.

Question 36Medical-Surgical Nursing

A patient with a casted lower leg reports severe pain that is not relieved by the prescribed analgesic. Which action should the nurse take first?

  1. Apply an ice pack and reassess in one hour
  2. Notify the prescriber of possible compartment syndrome Correct answer.
  3. Administer the next scheduled analgesic dose early
  4. Elevate the leg above heart level and document

Explanation

Unrelieved severe pain out of proportion to the injury is an early sign of compartment syndrome, a surgical emergency. The nurse must report immediately so that the cast can be assessed and pressure relieved. Delaying intervention risks permanent nerve and muscle damage.

Question 37Medical-Surgical Nursing

Which position is most appropriate for a patient immediately after a lumbar puncture?

  1. Prone with the head turned
  2. Trendelenburg position for 24 hours
  3. Flat supine for several hours Correct answer.
  4. High Fowler position

Explanation

Lying flat after a lumbar puncture reduces the risk of a post-dural puncture headache caused by cerebrospinal fluid leakage. The patient is typically kept supine for a period of hours and encouraged to increase oral fluids. High Fowler positioning may worsen the headache.

Question 38Medical-Surgical Nursing

A patient with end-stage renal disease is scheduled for hemodialysis. Which assessment is most important before the treatment?

  1. Assess pupillary reaction to light
  2. Check for pedal edema only
  3. Auscultate the arteriovenous fistula for a bruit Correct answer.
  4. Measure the abdominal girth

Explanation

A functioning arteriovenous fistula is essential for dialysis access, and the nurse verifies patency by auscultating a bruit and palpating a thrill. A silent fistula indicates thrombosis and must be reported before cannulation. Abdominal girth and pupil checks are unrelated to dialysis access.

Question 39Medical-Surgical Nursing

A patient is admitted with an acute exacerbation of asthma. Which finding indicates a life-threatening deterioration requiring immediate intervention?

  1. Use of accessory muscles with speaking in full sentences
  2. Respiratory rate of 22 breaths/min
  3. Audible wheezing on expiration
  4. Silent chest with minimal breath sounds Correct answer.

Explanation

A silent chest indicates such severe airflow obstruction that air is no longer moving, which is a pre-arrest finding. Audible wheezing actually reflects some airflow, and a rate of 22 with full sentences is less concerning. The nurse should call for emergency support immediately.

Question 40Medical-Surgical Nursing

A patient with cirrhosis has increasing ascites and a serum albumin of 2.1 g/dL. Which intervention should the nurse anticipate?

  1. Intravenous albumin infusion with a diuretic Correct answer.
  2. Fluid restriction to 500 mL/day
  3. Immediate paracentesis without diuretics
  4. A high-protein enteral feeding tube

Explanation

Hypoalbuminemia reduces plasma oncotic pressure and contributes to ascites, so intravenous albumin combined with a diuretic helps mobilize fluid. A feeding tube is not the first intervention for ascites, and paracentesis is used for relief or diagnosis rather than as initial therapy.

Question 41Medical-Surgical Nursing

A patient with a chest tube after a thoracotomy has continuous bubbling in the water-seal chamber. What is the nurse's priority action?

  1. Clamp the chest tube immediately
  2. Reposition the patient onto the affected side
  3. Add sterile water to the suction-control chamber
  4. Assess the tube connections for an air leak Correct answer.

Explanation

Continuous bubbling in the water-seal chamber suggests an air leak in the system, so the nurse inspects the tubing and connections from the patient to the drainage unit. Clamping is dangerous because it can cause tension pneumothorax. Suction-control and water-seal chambers have different functions.

Question 42Medical-Surgical Nursing

A patient receiving digoxin reports nausea, vomiting, and visual changes described as yellow halos. Which action should the nurse take?

  1. Encourage the patient to eat a low-potassium diet
  2. Increase the dose to improve symptom control
  3. Hold the digoxin and check the serum digoxin level Correct answer.
  4. Administer the next dose as scheduled

Explanation

Nausea, vomiting, and visual disturbances such as yellow-green halos are classic signs of digoxin toxicity. The nurse should withhold the drug, obtain a serum level, and notify the prescriber. A low-potassium diet would worsen toxicity risk.

Question 43Medical-Surgical Nursing

A patient with an acute ischemic stroke is being assessed for thrombolytic therapy. Which finding is an absolute contraindication?

  1. Recent gastrointestinal hemorrhage Correct answer.
  2. Blood pressure of 150/90 mmHg
  3. Onset of symptoms 2 hours ago
  4. Age of 70 years

Explanation

Active or recent gastrointestinal bleeding is an absolute contraindication to thrombolysis because of the risk of catastrophic hemorrhage. A blood pressure of 150/90 mmHg is below the treatment threshold, symptom onset within 2 hours is favorable, and age alone does not exclude therapy.

Question 44Medical-Surgical Nursing

A patient with a new ileostomy has liquid output of 1,500 mL per day. Which nursing concern is highest priority?

  1. Risk for constipation
  2. Risk for excessive weight gain
  3. Risk for fluid and electrolyte imbalance Correct answer.
  4. Risk for urinary retention

Explanation

Ileostomy output is rich in water and electrolytes, and losses exceeding about 1,000 mL per day can cause dehydration and hypokalemia. Monitoring intake, output, and electrolyte values is the priority. Constipation and urinary retention are not expected with a new ileostomy.

Question 45Medical-Surgical Nursing

A patient with type 2 diabetes is admitted with a blood glucose of 620 mg/dL, dehydration, and a serum osmolality of 340 mOsm/kg. Which condition should the nurse suspect?

  1. Diabetic ketoacidosis
  2. Hypoglycemia
  3. Lactic acidosis
  4. Hyperosmolar hyperglycemic state Correct answer.

Explanation

Marked hyperglycemia with profound dehydration and high osmolality, without prominent ketosis, characterizes hyperosmolar hyperglycemic state. Diabetic ketoacidosis typically shows ketones and acidosis. Hypoglycemia would show a low glucose, and lactic acidosis is not defined by hyperglycemia.

Question 46Medical-Surgical Nursing

A patient with a spinal cord injury at T6 develops a pounding headache, profuse sweating, and a blood pressure of 210/120 mmHg. What is the nurse's first action?

  1. Place the patient flat and administer an analgesic
  2. Sit the patient upright and check for bladder distention Correct answer.
  3. Give a warm blanket and encourage fluids
  4. Massage the legs to promote circulation

Explanation

These findings indicate autonomic dysreflexia, a hypertensive emergency triggered by noxious stimuli below the injury level, most often bladder distention. Sitting the patient upright lowers blood pressure while the cause is identified and removed. The other actions do not address the trigger and may worsen the episode.

Question 47Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.8 mEq/L and peaked T waves on the ECG. Which prescribed intervention should the nurse administer first?

  1. Oral sodium polystyrene sulfonate
  2. A loop diuretic by mouth
  3. Intravenous calcium gluconate Correct answer.
  4. A phosphate binder with meals

Explanation

Severe hyperkalemia with ECG changes is a cardiac emergency, and intravenous calcium stabilizes the myocardium immediately while other measures lower the potassium. Oral potassium binders and diuretics work too slowly for an acute crisis. A phosphate binder has no role in treating hyperkalemia.

Question 48Medical-Surgical Nursing

A patient is 24 hours after abdominal surgery and reports sudden shortness of breath and pleuritic chest pain. Which action should the nurse take first?

  1. Administer a prescribed stool softener
  2. Ambulate the patient in the hallway
  3. Apply supplemental oxygen and notify the provider Correct answer.
  4. Auscultate bowel sounds for 5 minutes

Explanation

Sudden dyspnea and pleuritic pain after surgery suggest pulmonary embolism, so the priority is oxygenation and urgent provider notification. Ambulation, stool softeners, and prolonged bowel assessment delay treatment of a potentially fatal condition.

Question 49Medical-Surgical Nursing

A patient with rheumatoid arthritis is started on methotrexate. Which instruction is most important for the nurse to include?

  1. Drink alcohol daily to protect the liver
  2. Double the dose if a dose is missed
  3. Take folic acid as prescribed and report mouth sores or fever Correct answer.
  4. Stop the drug when joint pain improves

Explanation

Methotrexate can cause bone marrow suppression and mucositis, and folic acid supplementation reduces some adverse effects. Patients must report signs of infection or mouth sores promptly. Doubling doses, self-discontinuation, and alcohol use are unsafe.

Question 50Medical-Surgical Nursing

A patient with an acute exacerbation of ulcerative colitis has 12 bloody stools per day and a hemoglobin of 8 g/dL. Which nursing action is priority?

  1. Monitor for signs of hypovolemic shock and report tachycardia Correct answer.
  2. Restrict all oral fluids
  3. Encourage a high-fiber diet to firm the stool
  4. Administer a prescribed antidiarrheal without a prescription

Explanation

Frequent bloody stools with anemia place the patient at risk for hypovolemia and hemorrhage, so the nurse monitors vital signs and reports tachycardia or falling blood pressure. High-fiber foods and antidiarrheals can worsen an acute flare, and total fluid restriction is not appropriate.