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Fiji Nursing Registration Exam study materials
Fiji Nursing Registration Exam study resources

Fiji Nursing Registration Exam practice questions

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Question 1Professional, Ethical and Legal Nursing Practice

Under the Fiji Nursing Council's scope of practice, which action by a registered nurse is most clearly within the professional duty of documentation?

  1. Recording a factual, timed entry of a patient's observed condition and care given Correct answer.
  2. Writing a retrospective entry dated earlier than the actual time of writing
  3. Adding a colleague's signature to a record she asked you to complete for her
  4. Documenting a nursing opinion about a colleague's competence in the patient file

Explanation

Nursing documentation must be contemporaneous, factual and attributable to the person who provided the care, because the record is a legal document used in audits and proceedings. Recording your own observations and interventions at the time they occur satisfies this duty.

Question 2Professional, Ethical and Legal Nursing Practice

A patient tells a registered nurse that she does not want her family informed about her HIV status. What is the nurse's most appropriate professional response?

  1. Record the diagnosis in a prominent place so all staff and visitors can see it
  2. Respect the patient's confidentiality and share information only with the treating team on a need-to-know basis Correct answer.
  3. Tell the family only if they ask directly about her diagnosis
  4. Inform the family discreetly because they are closely involved in her care

Explanation

Confidentiality is a core ethical and legal obligation, and disclosure of sensitive health information requires the patient's consent unless a specific legal exception applies. Sharing only with clinicians directly involved in care respects both the patient's wish and safe care delivery.

Question 3Professional, Ethical and Legal Nursing Practice

Which element is essential for a valid informed consent before a surgical procedure in Fiji?

  1. Verbal agreement given after the patient has been sedated for theatre
  2. A discussion of the nature, risks, benefits and alternatives that the patient understands Correct answer.
  3. Consent obtained from the patient's employer as the paying party
  4. The patient's signature on a form witnessed by any available staff member

Explanation

Informed consent requires that the patient receives adequate information about the procedure, its risks, benefits and alternatives, and freely agrees while competent to do so. A signature alone does not establish that consent was informed.

Question 4Professional, Ethical and Legal Nursing Practice

A registered nurse suspects that a colleague has diverted a patient's oral morphine. What is the nurse's priority professional action?

  1. Wait for several more incidents before reporting so the pattern is proven
  2. Report the concern immediately through the facility's incident and management channels Correct answer.
  3. Confront the colleague privately and agree to keep the matter between them
  4. Remove the colleague from the roster without informing anyone

Explanation

Suspected diversion of controlled medicines is a patient safety and legal matter that must be escalated promptly through formal reporting channels so that patients are protected and an investigation can occur. Nurses are accountable for acting on concerns rather than concealing them.

Question 5Professional, Ethical and Legal Nursing Practice

Which statement best describes the purpose of the Fiji Nursing Council's registration and licensing function?

  1. To negotiate nurses' wages and conditions of employment
  2. To protect the public by ensuring only practitioners who meet required standards are authorised to practise Correct answer.
  3. To represent nurses in disputes with their employers
  4. To manage hospital staffing rosters across the divisions

Explanation

A nursing regulatory authority exists primarily to protect the public by setting standards for entry, ongoing competence and conduct, and by authorising practice. Employment representation and industrial matters sit with unions and employers, not the regulator.

Question 6Professional, Ethical and Legal Nursing Practice

A registered nurse is asked to perform a procedure for which she has received no training and which is outside her competence. What is the most appropriate action?

  1. Perform it under supervision and learn as she goes
  2. Ask an enrolled nurse to perform it instead
  3. Perform it because a doctor has delegated it
  4. Decline, state the limits of her competence, and seek a competent colleague or training Correct answer.

Explanation

A nurse must practise within her competence and is accountable for recognising and declaring limits. Declining and arranging appropriate training or referral protects the patient and is the professionally correct response.

Question 7Professional, Ethical and Legal Nursing Practice

During a shift, a nurse realises she administered a medication to the wrong patient. Which sequence best reflects professional and legal obligations?

  1. Document the event in the notes but omit it from incident reporting to avoid blame
  2. Keep the event confidential to avoid upsetting the patient and family
  3. Assess the patient, inform the treating clinician, document the event and complete an incident report Correct answer.
  4. Complete an incident report only if the patient shows harm

Explanation

After a medication error the nurse's priorities are patient safety, prompt clinical review, honest disclosure and accurate documentation, followed by formal incident reporting for system learning. Reporting is required regardless of whether harm occurred.

Question 8Professional, Ethical and Legal Nursing Practice

A competent adult patient refuses a blood transfusion that the treating team believes is life-saving. What is the nurse's correct understanding of the legal position?

  1. The refusal is valid only if the patient's next of kin also agrees
  2. The team may proceed because the treatment is in the patient's best interests
  3. The refusal must be respected, even if the patient's choice may lead to deterioration Correct answer.
  4. The nurse should obtain a court order before accepting the refusal

Explanation

A competent adult has the right to refuse any treatment, including life-sustaining treatment, and that refusal is legally binding. The care team should ensure the patient is informed and document the decision, but cannot override it.

Question 9Professional, Ethical and Legal Nursing Practice

Which situation most clearly requires the nurse to breach patient confidentiality without consent?

  1. A colleague asks for gossip about a celebrity patient admitted to the ward
  2. The patient's church pastor requests an update on her recovery
  3. A relative wants to know the patient's appointment time
  4. A court order compels disclosure of a patient's clinical records Correct answer.

Explanation

Confidentiality yields to a legally binding court order, and in such cases disclosure is a legal obligation. Other requests are discretionary and generally require the patient's consent or a specific statutory authority.

Question 10Professional, Ethical and Legal Nursing Practice

A nurse is caring for a patient whose cultural beliefs require specific mourning practices after a death. How should the nurse respond professionally?

  1. Ask the family about their needs and accommodate practices where safe and feasible Correct answer.
  2. Follow ward routine strictly because cultural practices are not a clinical matter
  3. Refer all cultural requests to the medical officer to decide
  4. Tell the family that hospital policy overrides cultural needs

Explanation

Culturally safe practice requires the nurse to ask about and respect the patient's and family's beliefs, accommodating them where this does not compromise safety or the care of others. This reflects the principle of respect for persons and Fiji's commitment to culturally appropriate care.

Question 11Professional, Ethical and Legal Nursing Practice

Which action best demonstrates the nurse's role as patient advocate when a patient appears confused about a proposed treatment?

  1. Ask another patient to explain the procedure to her
  2. Explain the treatment again in simple terms and ensure the patient's questions reach the treating clinician Correct answer.
  3. Sign the consent form for the patient to save time
  4. Proceed with the treatment because the doctor has already explained it

Explanation

Advocacy involves ensuring the patient has understandable information and access to the decision-maker so that she can make an informed choice. Re-explaining and facilitating communication with the clinician upholds the patient's autonomy.

Question 12Professional, Ethical and Legal Nursing Practice

A nurse discovers that a patient's file has been accessed by a colleague with no involvement in that patient's care. What is the most appropriate action?

  1. Report the unauthorised access through the facility's privacy or incident process Correct answer.
  2. Confront the colleague publicly on the ward
  3. Ignore it because health staff have general access to all records
  4. Delete the colleague's access log to protect her

Explanation

Accessing records without a legitimate clinical or administrative purpose is a privacy breach that must be reported through formal channels so it can be investigated and remedied. Nurses have an obligation to protect patient information.

Question 13Professional, Ethical and Legal Nursing Practice

Which statement correctly describes the legal significance of nursing care records in Fiji?

  1. They can be destroyed once the patient is discharged
  2. They are only for communication between nurses
  3. They are the personal property of the nurse who wrote them
  4. They are the property of the health facility and may be used as legal evidence Correct answer.

Explanation

Clinical records are owned and retained by the health facility as legal documents and may be produced as evidence in investigations or court proceedings. They must be retained according to required periods.

Question 14Professional, Ethical and Legal Nursing Practice

A registered nurse is delegating a task to an enrolled nurse. Which factor is most important in deciding whether delegation is appropriate?

  1. Whether the enrolled nurse is willing to attempt the task
  2. The complexity of the patient's condition and the enrolled nurse's competence and scope Correct answer.
  3. Whether the ward is short-staffed at the time
  4. Whether the patient's family has requested the enrolled nurse

Explanation

Delegation is governed by patient acuity, the delegate's competence and the boundaries of the delegate's scope of practice, while the registered nurse retains accountability for the decision. Willingness alone does not make delegation safe.

Question 15Professional, Ethical and Legal Nursing Practice

A patient with capacity asks the nurse not to discuss his condition in front of his roommate. Which action best respects his rights?

  1. Move the discussion to a private area and limit bedside conversation to essential care Correct answer.
  2. Refuse to discuss anything until the roommate is discharged
  3. Discuss care at the bedside quietly so others cannot hear
  4. Ask the roommate to sign a confidentiality agreement

Explanation

Privacy requires controlling who can overhear personal health information, and a patient with capacity may set conditions on discussion. Moving sensitive conversations to a private space and minimising bedside disclosure respects this right.

Question 16Professional, Ethical and Legal Nursing Practice

A nurse is asked to participate in a research trial involving a new dressing protocol. Which requirement is fundamental before patients are enrolled?

  1. Approval by an appropriate ethics committee and informed, voluntary consent from participants Correct answer.
  2. Approval by the ward manager alone
  3. Verbal agreement from the patient's relatives
  4. A guarantee that the new dressing will be cheaper

Explanation

Research involving human participants requires independent ethical review and informed voluntary consent, with the right to withdraw without affecting care. These safeguards protect participants' rights and welfare.

Question 17Professional, Ethical and Legal Nursing Practice

A dying patient asks the nurse to promise that she will not be resuscitated, but no written do-not-resuscitate order exists. What is the nurse's most appropriate action?

  1. Discuss the request with the treating team promptly and follow the lawful process to document the patient's wishes Correct answer.
  2. Tell the patient that such requests cannot be considered
  3. Make a personal promise and act on it during any arrest
  4. Instruct the family to decide the matter without involving clinicians

Explanation

End-of-life wishes must be verified and documented through the lawful clinical process, and the nurse's role is to advocate for timely discussion and accurate recording. A nurse cannot unilaterally authorise a limitation of treatment.

Question 18Professional, Ethical and Legal Nursing Practice

Two nurses disagree about whether a patient's deteriorating condition warrants escalation. Which approach best reflects professional accountability?

  1. Defer to the more senior nurse regardless of the clinical findings
  2. Wait until the next routine medical round
  3. Escalate using the facility's track-and-trigger or rapid response process and document the concern Correct answer.
  4. Record the disagreement in the notes and take no further action

Explanation

When a patient deteriorates, accountability requires using established escalation pathways, such as early warning tools and rapid response systems, and documenting the concern. Clinical findings, not hierarchy, should determine escalation.

Question 19Professional, Ethical and Legal Nursing Practice

A nurse is offered a gift of cash by a patient's family after discharge. How should the nurse respond to maintain professional boundaries?

  1. Decline politely, explain the professional obligation, and report the offer according to facility policy Correct answer.
  2. Accept it but record it as a donation to the ward
  3. Accept it because gifts are culturally expected in all circumstances
  4. Accept it and share it with the ward staff

Explanation

Accepting cash gifts can create obligations, favouritism or perceptions of impropriety and is generally prohibited by professional and employer policy. Declining respectfully and reporting the offer protects both the nurse and the therapeutic relationship.

Question 20Professional, Ethical and Legal Nursing Practice

A registered nurse in Fiji is completing an incident report after a patient fell while walking unassisted to the bathroom. The patient's daughter asks the nurse to leave the incident report out of the medical record so that it will not be seen by other staff. What is the nurse's most appropriate response?

  1. Agree to keep the fall undocumented because the patient was not injured and no harm occurred.
  2. Place the incident report in the medical record and remove all mention of the fall from the nursing notes.
  3. Ask the daughter to sign a waiver stating that the family accepts responsibility for the fall.
  4. Explain that the incident report is a quality improvement document kept separate from the clinical record, while the fall itself must still be documented factually in the patient's notes. Correct answer.

Explanation

In Fiji, as in most jurisdictions, the clinical record must contain a factual, contemporaneous account of the fall and the nursing assessment and interventions that followed, because the notes are the legal record of care. Incident reports serve a separate quality and risk management purpose and are handled through the facility's reporting system rather than being filed in the patient's chart. Concealing or altering documentation breaches professional accountability and the Fiji Nursing Council's standards.

Question 21Fundamentals of Nursing and Basic Care

A nurse in a Fiji hospital is preparing to insert a nasogastric tube. Which action best demonstrates the principle of medical asepsis during this procedure?

  1. Swabbing the patient's nostrils with an alcohol wipe after insertion
  2. Sterilising the tube in an autoclave immediately before use
  3. Wearing a sterile gown and sterile gloves during insertion
  4. Performing hand hygiene and wearing clean gloves before insertion Correct answer.

Explanation

Medical asepsis aims to reduce the number and spread of microorganisms, and hand hygiene with clean gloves is the core measure for a clean procedure such as nasogastric tube insertion. Sterile technique is reserved for procedures breaching sterile body cavities, which this is not.

Question 22Fundamentals of Nursing and Basic Care

When measuring a patient's blood pressure using a manual sphygmomanometer, which technique produces the most accurate reading?

  1. Placing the cuff over the patient's sleeve to save time
  2. Inflating the cuff rapidly to 300 mmHg regardless of the patient's baseline
  3. Deflating the cuff at 10 mmHg per second while watching the manometer
  4. Positioning the cuff so its lower edge sits 2 to 3 cm above the antecubital fossa at heart level Correct answer.

Explanation

Correct cuff placement at heart level with the lower edge about 2 to 3 cm above the antecubital fossa ensures the bladder sits over the brachial artery and gives a reliable reading. The arm should be supported and the cuff applied to bare skin.

Question 23Fundamentals of Nursing and Basic Care

A patient is on strict fluid balance monitoring. Which entry should the nurse record in the intake column?

  1. Vomit collected in a bowl
  2. Wound drainage from a drain site
  3. Urine output measured in a catheter bag
  4. Ice chips sucked by the patient Correct answer.

Explanation

Intake includes all fluid entering the body by any route, including ice chips, which are recorded as part of oral intake (often at half volume once melted). Vomit, urine and wound drainage are outputs.

Question 24Fundamentals of Nursing and Basic Care

The nurse is positioning a patient who is unconscious to maintain a patent airway. Which position is most appropriate?

  1. High Fowler's with the neck flexed
  2. Supine with the head flat
  3. Lateral with the head slightly extended and tilted toward the bed Correct answer.
  4. Left lateral with the head dependent

Explanation

An unconscious patient is placed in the lateral (recovery) position with the head slightly extended so that secretions and vomit drain from the mouth rather than being aspirated. The dependent head position allows gravity to clear the airway.

Question 25Fundamentals of Nursing and Basic Care

Which statement correctly describes the recommended sequence for removing personal protective equipment (PPE) after caring for a patient on contact precautions?

  1. Remove mask first, then gloves, then gown, then eye protection
  2. Remove gown, then mask, then gloves, then eye protection
  3. Remove gloves, then gown, then perform hand hygiene, then remove mask and eye protection Correct answer.
  4. Remove eye protection, then gown, then gloves, then mask

Explanation

The safest order removes the most contaminated items first: gloves, then gown, with hand hygiene before removing facial protection, because the face is the last area to be exposed. Gloves and gown are the most heavily contaminated and are removed first.

Question 26Fundamentals of Nursing and Basic Care

A patient with a new colostomy asks how to care for the stoma. Which instruction should the nurse give?

  1. Apply a tight belt over the stoma to keep the pouch secure
  2. Wash the stoma with warm water and mild soap, then pat dry Correct answer.
  3. Clean the stoma with alcohol wipes until it is shiny
  4. Change the pouch every day regardless of leakage

Explanation

A colostomy stoma is cleaned gently with warm water and mild soap, then patted dry before applying a new pouch. The skin around the stoma should be assessed for irritation, and the pouch is changed when it leaks or according to the manufacturer's guidance, not daily by default.

Question 27Fundamentals of Nursing and Basic Care

The nurse is preparing to administer a subcutaneous injection of insulin. Which site and technique is correct?

  1. Anterolateral thigh with a 25-gauge needle at 45 to 90 degrees Correct answer.
  2. Dorsogluteal site with a 23-gauge needle at 90 degrees
  3. Deltoid muscle with a 21-gauge needle at 90 degrees
  4. Ventral forearm with a 25-gauge needle at 15 degrees

Explanation

Subcutaneous injections use short, fine needles (typically 25 to 27 gauge) inserted at 45 to 90 degrees into sites with adequate subcutaneous fat, such as the anterolateral thigh or abdomen. The angle depends on the patient's tissue thickness.

Question 28Fundamentals of Nursing and Basic Care

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

  1. Clear beef broth Correct answer.
  2. Full-cream milk
  3. Orange juice with pulp
  4. Mashed banana

Explanation

A clear liquid diet includes fluids that are transparent at room temperature, such as clear broth, water, and clear juices without pulp. Milk, pulpy juice, and mashed foods are not clear liquids.

Question 29Fundamentals of Nursing and Basic Care

The nurse is caring for a patient with a urinary catheter. Which action best reduces the risk of catheter-associated urinary tract infection?

  1. Keeping the drainage bag below the level of the bladder and off the floor Correct answer.
  2. Disconnecting the catheter from the bag to empty it frequently
  3. Clamping the catheter for two hours each shift to test bladder tone
  4. Irrigating the catheter daily with antiseptic solution

Explanation

Maintaining a closed system with the drainage bag below bladder level and off the floor prevents backflow of contaminated urine into the bladder. Routine irrigation and unnecessary disconnection break the closed system and increase infection risk.

Question 30Fundamentals of Nursing and Basic Care

A patient reports pain and the nurse assesses the site of a peripheral intravenous cannula. Which finding requires immediate removal of the cannula?

  1. Mild redness at the puncture site with a palpable cord
  2. Clear fluid leaking from the dressing
  3. A small bruise around the insertion site
  4. Cool, pale skin distal to the site with pain on flushing Correct answer.

Explanation

Cool pale skin distally with pain on flushing suggests infiltration or occlusion and requires immediate cessation of the infusion and removal of the cannula. Redness with a palpable cord may indicate phlebitis and also warrants removal, but the combination of poor perfusion and pain on flushing is the most urgent.

Question 31Fundamentals of Nursing and Basic Care

Which action demonstrates correct body mechanics when the nurse assists a patient to move up in bed?

  1. Bending at the waist and twisting to reach the patient
  2. Raising the bed to waist height and bending the knees Correct answer.
  3. Keeping feet close together and leaning over the bed
  4. Pulling the patient by the arms while standing at the head of the bed

Explanation

Raising the bed to a comfortable working height and bending the knees keeps the load close to the nurse's centre of gravity and uses the strong leg muscles. Twisting, bending at the waist, and pulling by the arms increase injury risk.

Question 32Fundamentals of Nursing and Basic Care

A patient is admitted with a suspected fractured femur. Which nursing action is the priority during initial assessment?

  1. Removing the splint to inspect the skin every 15 minutes
  2. Encouraging the patient to bear weight to test stability
  3. Assessing distal pulses, sensation, and colour of the affected limb Correct answer.
  4. Applying a heating pad to the affected thigh

Explanation

With a suspected fracture, neurovascular assessment distal to the injury (pulses, sensation, colour, temperature, capillary refill) is the priority because impaired circulation or nerve function requires urgent intervention. Heat, weight-bearing, and repeated splint removal are unsafe.

Question 33Fundamentals of Nursing and Basic Care

The nurse is documenting care in the patient's record. Which entry meets the standards of accurate documentation?

  1. 'At 14:00 patient reported pain 7/10 in right lower abdomen; doctor notified at 14:10.' Correct answer.
  2. 'Patient was difficult and refused everything today.'
  3. 'Patient appears to be in pain, will monitor.'
  4. 'Patient seems unwell, probably needs review.'

Explanation

Accurate documentation records objective, factual information including time, the patient's own report, and actions taken, such as notifying the doctor. Subjective judgements and vague descriptions are not acceptable.

Question 34Fundamentals of Nursing and Basic Care

A patient is receiving oxygen via a nasal cannula at 2 litres per minute. Which nursing consideration is most important?

  1. Checking that the cannula prongs are positioned in the nares and the tubing is not kinked Correct answer.
  2. Ensuring the humidifier is filled with sterile water for low-flow oxygen
  3. Applying petroleum jelly to the nostrils to prevent dryness
  4. Setting the flow rate higher than prescribed if the patient feels breathless

Explanation

The priority is confirming correct placement and an unobstructed circuit so the prescribed flow reaches the patient. Petroleum-based products near oxygen are a fire hazard, and flow rates must follow the prescription.

Question 35Fundamentals of Nursing and Basic Care

A patient is ordered a wound dressing change using clean technique. Which action is correct?

  1. Cleaning the wound from the surrounding skin toward the centre
  2. Using the same gauze to clean the wound and then the surrounding skin
  3. Cleaning from the least contaminated area to the most contaminated area Correct answer.
  4. Applying the dressing without cleaning if the wound looks clean

Explanation

Wound cleaning proceeds from the least contaminated to the most contaminated area, working from the wound centre outward, so that organisms are not carried into the wound. A new gauze is used for each stroke.

Question 36Fundamentals of Nursing and Basic Care

A patient with a nasogastric tube for enteral feeding is at risk of aspiration. Which action best reduces this risk?

  1. Positioning the patient supine during the feed to promote comfort
  2. Checking residual volume every four hours and discarding it
  3. Flushing the tube with 50 mL of water before each feed
  4. Keeping the head of the bed elevated at 30 to 45 degrees during and after feeding Correct answer.

Explanation

Elevating the head of the bed to at least 30 to 45 degrees during feeding and for about 30 minutes afterwards uses gravity to reduce reflux and aspiration. Supine positioning and unnecessary residual checks increase risk.

Question 37Fundamentals of Nursing and Basic Care

The nurse is caring for a patient with a stage 2 pressure injury over the sacrum. Which intervention is most appropriate?

  1. Applying a heat lamp to the area for 20 minutes each shift
  2. Keeping the area moist with an appropriate dressing and repositioning regularly Correct answer.
  3. Leaving the area open to air at all times
  4. Massaging the area vigorously to stimulate circulation

Explanation

Stage 2 pressure injuries involve partial-thickness skin loss and heal best in a moist wound environment with an appropriate dressing, combined with regular repositioning to relieve pressure. Massage, heat, and prolonged exposure to air impair healing.

Question 38Fundamentals of Nursing and Basic Care

A patient is prescribed a blood transfusion. Fifteen minutes after starting the transfusion, the patient develops fever, chills, and flank pain. What is the nurse's priority action?

  1. Administer an antihistamine and continue the transfusion
  2. Slow the transfusion and reassess in 30 minutes
  3. Increase the flow rate to finish the unit quickly
  4. Stop the transfusion, maintain venous access with normal saline, and notify the doctor immediately Correct answer.

Explanation

Fever, chills, and flank pain suggest an acute haemolytic transfusion reaction, which is life-threatening. The transfusion must be stopped immediately, intravenous access maintained with normal saline using new tubing, and the doctor notified urgently while vital signs are monitored.

Question 39Fundamentals of Nursing and Basic Care

An older patient is admitted with dehydration. Which assessment finding is the most reliable indicator of fluid status in this patient?

  1. Urine colour alone
  2. Daily weight measured at the same time each morning Correct answer.
  3. Skin turgor over the sternum
  4. Presence of thirst

Explanation

Daily weight is the most reliable measure of fluid balance because it reflects changes in total body water; skin turgor is less reliable in older adults due to reduced skin elasticity, and thirst and urine colour are subjective or influenced by other factors.

Question 40Fundamentals of Nursing and Basic Care

A patient with a tracheostomy is being suctioned. Which action is correct?

  1. Instilling 5 mL of normal saline before each suction to loosen secretions
  2. Applying suction continuously while inserting the catheter
  3. Applying suction only while withdrawing the catheter and limiting each pass to 10 to 15 seconds Correct answer.
  4. Suctioning for 30 seconds on each pass

Explanation

Suction is applied only during withdrawal so that oxygen is not removed from the airway during insertion, and each pass is limited to about 10 to 15 seconds to prevent hypoxia. Routine saline instillation is not recommended.

Question 41Medical-Surgical Nursing (Adult Health)

A postoperative patient on the surgical ward has a chest drain in situ following a lobectomy. During handover, which finding should the nurse report to the surgical team immediately?

  1. Continuous bubbling in the water-seal chamber with each breath Correct answer.
  2. Bubbling in the water-seal chamber that stops after 48 hours
  3. Serous oozing at the drain insertion site covered with a gauze dressing
  4. Drainage of 80 mL of blood-stained fluid in the first 24 hours

Explanation

Continuous bubbling in the water-seal chamber indicates an air leak from the pleural space or a loose connection, which can progress to a tension pneumothorax and requires urgent assessment. Intermittent bubbling only on coughing is expected, but constant bubbling with every breath signals an ongoing leak that must be investigated and the tubing checked for disconnection.

Question 42Medical-Surgical Nursing (Adult Health)

A patient with chronic kidney disease has a serum potassium of 6.8 mmol/L and peaked T waves on the ECG. Which action should the nurse anticipate first?

  1. Giving oral sodium polystyrene sulfonate
  2. Administering intravenous calcium gluconate Correct answer.
  3. Preparing the patient for urgent haemodialysis
  4. Commencing a low-potassium diet

Explanation

Peaked T waves with hyperkalaemia indicate myocardial instability, and intravenous calcium gluconate is given first to stabilise the myocardium by antagonising potassium's effect on the heart. Potassium-lowering measures such as insulin-dextrose, salbutamol, or dialysis follow once cardiac protection is achieved.

Question 43Medical-Surgical Nursing (Adult Health)

Which assessment finding is most characteristic of left-sided heart failure?

  1. Dependent peripheral oedema
  2. Jugular venous distension
  3. Hepatomegaly with ascites
  4. Orthopnoea with bibasal crackles Correct answer.

Explanation

Left-sided heart failure causes pulmonary congestion, producing dyspnoea, orthopnoea, and fine bibasal crackles as fluid accumulates in the alveoli. Right-sided failure instead produces systemic venous congestion such as peripheral oedema, jugular venous distension, and hepatomegaly.

Question 44Medical-Surgical Nursing (Adult Health)

A patient with a new ileostomy has a stoma that appears dark purple and dusky two hours after surgery. What is the nurse's priority action?

  1. Notify the surgeon immediately Correct answer.
  2. Apply a warm compress to the stoma
  3. Document the colour and reassess in four hours
  4. Change the appliance and reassess in the morning

Explanation

A dusky, dark purple stoma suggests ischaemia from compromised blood supply and is a surgical emergency requiring immediate notification of the surgeon. Normal stomas are pink to red and moist; discolouration can progress to necrosis if not corrected promptly.

Question 45Medical-Surgical Nursing (Adult Health)

Which laboratory value is most useful in monitoring a patient receiving intravenous heparin therapy?

  1. Prothrombin time
  2. Activated partial thromboplastin time Correct answer.
  3. Platelet count
  4. International normalised ratio

Explanation

Heparin enhances antithrombin activity in the intrinsic pathway, so the activated partial thromboplastin time is used to titrate unfractionated heparin to a therapeutic range. The INR and prothrombin time monitor warfarin, which acts on the extrinsic pathway.

Question 46Medical-Surgical Nursing (Adult Health)

A patient with a fractured femur develops sudden dyspnoea, confusion, and a petechial rash over the chest and axillae after a long bone injury. Which complication should the nurse suspect?

  1. Fat embolism syndrome Correct answer.
  2. Hypovolaemic shock
  3. Pulmonary thromboembolism
  4. Compartment syndrome

Explanation

The triad of respiratory distress, neurological changes, and a petechial rash appearing after long bone fracture is classic for fat embolism syndrome. Petechiae result from fat microemboli occluding dermal capillaries, which distinguishes this from venous thromboembolism.

Question 47Medical-Surgical Nursing (Adult Health)

A patient with type 1 diabetes is found drowsy with a blood glucose of 2.6 mmol/L. The patient is able to swallow safely. What should the nurse give first?

  1. An intramuscular injection of glucagon
  2. 15–20 g of fast-acting oral carbohydrate Correct answer.
  3. A subcutaneous dose of rapid-acting insulin
  4. A high-protein snack such as cheese

Explanation

For a conscious patient able to swallow, hypoglycaemia is treated with 15–20 g of rapidly absorbed carbohydrate such as glucose tablets or sweetened juice, followed by rechecking glucose after 15 minutes. Protein and fat slow absorption and are unsuitable for initial correction.

Question 48Medical-Surgical Nursing (Adult Health)

A patient with an acute exacerbation of asthma has a peak expiratory flow at 40% of predicted and is speaking in short phrases. Which finding would most concern the nurse?

  1. Respiratory rate of 22 breaths per minute
  2. Use of accessory muscles
  3. Heart rate of 96 beats per minute
  4. Silent chest on auscultation Correct answer.

Explanation

A silent chest indicates minimal air movement due to severe bronchospasm or mucus plugging and is a life-threatening sign of impending respiratory failure. Accessory muscle use and tachypnoea are expected in moderate exacerbations, but loss of breath sounds signals deterioration.

Question 49Medical-Surgical Nursing (Adult Health)

Which instruction should the nurse give a patient scheduled for a colonoscopy with conscious sedation?

  1. Eat a light breakfast two hours before arrival
  2. Drive yourself home if you feel fully alert
  3. Arrange for a responsible adult to escort you home Correct answer.
  4. Take regular aspirin on the morning of the procedure

Explanation

Sedation impairs judgement and reaction time for up to 24 hours, so patients must arrange a responsible adult to accompany them home and remain with them. Aspirin and other anticoagulants are usually withheld per protocol, and fasting is required before sedation.

Question 50Medical-Surgical Nursing (Adult Health)

A patient with a new tracheostomy becomes restless with oxygen saturation falling to 88%. On assessment, the nurse notes diminished breath sounds bilaterally. What should the nurse do first?

  1. Suction the tracheostomy
  2. Remove the inner cannula and inspect the airway Correct answer.
  3. Auscultate the chest again after repositioning
  4. Increase the oxygen flow rate

Explanation

Restlessness, falling saturations, and diminished breath sounds suggest an obstructed tracheostomy, and the first step is to remove the inner cannula to relieve a mucus plug and inspect the airway. Suctioning follows if secretions are present, but a blocked cannula must be cleared to restore ventilation.