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NCHK RN(G) LE practice questions

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Question 1Professional Nursing Practice and Ethics

A registered nurse working in Hong Kong receives a cash gift from a client after a successful discharge. Under the professional code of conduct, which action by the nurse is most appropriate?

  1. Accept the gift because the client offered it voluntarily after discharge
  2. Accept the gift and record it as a donation to the hospital
  3. Accept the gift and share it with the ward team to avoid favouritism
  4. Politely decline the gift and explain the professional boundary to the client Correct answer.

Explanation

The professional code of conduct requires nurses to avoid accepting gifts that could create an obligation or the appearance of preferential treatment. Declining politely while explaining the boundary maintains the therapeutic relationship and public trust in the profession.

Question 2Professional Nursing Practice and Ethics

Which principle of biomedical ethics supports a nurse respecting a competent adult client's refusal of a blood transfusion even when the treatment is life-saving?

  1. Justice
  2. Beneficence
  3. Autonomy Correct answer.
  4. Non-maleficence

Explanation

Autonomy is the principle that respects a competent person's right to make decisions about their own body and treatment, including refusal. Beneficence, non-maleficence and justice concern doing good, avoiding harm and fair distribution, not self-determination.

Question 3Professional Nursing Practice and Ethics

A nurse discovers that a colleague has documented a wound dressing change that was never performed. What is the nurse's most appropriate first professional action?

  1. Correct the record personally by writing the accurate entry over the colleague's note
  2. Wait until the next shift to see whether the colleague self-reports
  3. Confront the colleague in front of the client to clarify what happened
  4. Report the falsified documentation to the nurse in charge through the appropriate channel Correct answer.

Explanation

Falsified documentation is a serious professional and patient-safety issue that must be reported promptly through proper channels. The nurse should not alter another clinician's record unilaterally or delay reporting, as both could compromise the integrity of the record and patient safety.

Question 4Professional Nursing Practice and Ethics

A client tells the nurse in confidence that they intend to seriously harm a named family member. How should the nurse respond according to the limits of confidentiality?

  1. Promise to keep the secret on condition that the client seeks counselling
  2. Maintain absolute confidentiality because the disclosure was made in a therapeutic relationship
  3. Explain that confidentiality may be breached to protect the identified person and escalate to the team Correct answer.
  4. Record the disclosure in the notes but take no further action unless harm occurs

Explanation

Confidentiality is not absolute; it is limited by the duty to protect others from serious harm and by legal reporting duties. The nurse should inform the client of these limits and escalate to the team and appropriate authorities.

Question 5Professional Nursing Practice and Ethics

Which statement best describes the nurse's duty of care when delegating a task to a healthcare assistant?

  1. The client's family must consent before any task can be delegated
  2. The delegating nurse remains accountable for assessing the client and for the appropriateness of the delegation Correct answer.
  3. Accountability transfers to the nurse in charge of the shift for all delegated tasks
  4. The healthcare assistant assumes full accountability once the task has been delegated

Explanation

Delegation does not transfer the nurse's accountability; the nurse must assess the client, judge the task appropriate for the delegate's competence, and provide supervision. The delegate is accountable for performing the task correctly but the delegating nurse retains overall responsibility.

Question 6Professional Nursing Practice and Ethics

A client lacks decision-making capacity and has no advance directive. Who is generally responsible for giving consent to treatment on the client's behalf?

  1. Any adult family member who happens to be present at the time
  2. The person legally authorised to act on the client's behalf, such as a guardian or the healthcare team acting in the client's best interests Correct answer.
  3. The nurse caring for the client, who signs the consent form
  4. The most senior doctor on the ward, who signs alone without consultation

Explanation

When a client lacks capacity and no advance directive exists, consent is given by a legally authorised person or through the best-interests decision-making process involving the healthcare team. Nurses do not consent on the client's behalf, and any random relative is not automatically the decision-maker.

Question 7Professional Nursing Practice and Ethics

A nurse notices a colleague appearing impaired by alcohol at the start of a shift. What is the most appropriate immediate action?

  1. Prevent the colleague from providing patient care and report the concern to the nurse in charge immediately Correct answer.
  2. Ignore the observation to avoid damaging the colleague's career
  3. Document the concern in the shift report and discuss it at the next team meeting
  4. Ask the colleague to take a short break and reassess later in the shift

Explanation

Impaired practice poses an immediate risk to patient safety, so the nurse must act at once to remove the colleague from direct care and escalate to the person in charge. Protecting patients takes priority over collegial loyalty.

Question 8Professional Nursing Practice and Ethics

Which action best demonstrates the ethical principle of veracity in nursing practice?

  1. Withholding a diagnosis from a client to protect them from distress
  2. Agreeing with whatever the client believes to maintain rapport
  3. Recording a slightly favourable blood pressure to avoid alarming the family
  4. Telling a client honestly that a procedure will be uncomfortable and explaining what to expect Correct answer.

Explanation

Veracity is the duty to tell the truth, which supports informed consent and trust. Honest disclosure about discomfort and expectations respects the client's right to accurate information, whereas withholding or falsifying information violates veracity.

Question 9Professional Nursing Practice and Ethics

A nurse is asked to participate in a research study involving clients on the ward. Which condition is essential before clients can be enrolled?

  1. Verbal agreement from the client's next of kin
  2. A signed consent form obtained by the treating doctor without explanation
  3. Informed voluntary consent obtained after ethics committee approval Correct answer.
  4. Approval by the ward manager alone

Explanation

Research involving human participants requires ethics committee approval and informed voluntary consent, with the right to withdraw. Consent must follow adequate explanation and must not be obtained through coercion or by someone without a proper role in the process.

Question 10Professional Nursing Practice and Ethics

A nurse is caring for a client whose cultural beliefs conflict with a prescribed dietary regimen. What is the most appropriate nursing approach?

  1. Document non-compliance and withdraw from further discussion
  2. Explore the client's beliefs, discuss the conflict with the team, and negotiate a plan that respects culture while addressing clinical needs Correct answer.
  3. Instruct the client that hospital policy overrides personal beliefs
  4. Arrange for the family to persuade the client to comply

Explanation

Culturally safe practice requires the nurse to understand the client's beliefs and negotiate care that balances clinical needs with cultural values. Imposing policy, enlisting family pressure, or withdrawing all undermine respectful, person-centred care.

Question 11Professional Nursing Practice and Ethics

Which situation would most appropriately justify a nurse breaching client confidentiality without consent?

  1. A relative asking about the client's test results out of concern
  2. A court order requiring disclosure of specific records Correct answer.
  3. A colleague asking for details about a mutual acquaintance's admission
  4. A journalist requesting information about a public figure's condition

Explanation

Confidentiality may be overridden where there is a legal obligation, such as a valid court order or statutory reporting duty. Curiosity, media interest, or family concern without the client's authorisation do not justify disclosure.

Question 12Professional Nursing Practice and Ethics

A nurse is asked to witness a client's signature on a consent form. What does the nurse's signature primarily confirm?

  1. That the procedure is clinically indicated and safe
  2. That the client signed voluntarily and appeared to understand the information given Correct answer.
  3. That the nurse has explained the procedure in full
  4. That the client's family agrees with the decision

Explanation

The witness confirms the authenticity of the signature and that the client appeared to sign voluntarily and with understanding. Explaining the procedure and judging clinical indication are the responsibilities of the practitioner obtaining consent, not the witness.

Question 13Professional Nursing Practice and Ethics

A nurse observes another nurse repeatedly making derogatory remarks to a client. Which response best reflects professional obligation?

  1. Mention it informally to other colleagues but take no formal action
  2. Intervene to protect the client and report the behaviour through the appropriate channel Correct answer.
  3. Say nothing because the colleague is more senior
  4. Advise the client to complain to the hospital authority themselves

Explanation

Nurses have a duty to protect clients from harm, including psychological harm and disrespectful conduct, and to report unprofessional behaviour. Seniority does not justify silence, and shifting the burden to the client or gossiping does not meet the duty.

Question 14Professional Nursing Practice and Ethics

Which statement correctly describes the concept of informed consent in nursing practice?

  1. It requires adequate information, competence to decide, and freedom from coercion Correct answer.
  2. It is satisfied by a signature on a form regardless of explanation
  3. It applies only to surgical procedures and not to nursing interventions
  4. It can be given by any relative if the client is anxious

Explanation

Informed consent is a process requiring that the client receives adequate information, has the capacity to decide, and chooses freely without coercion. A signature alone does not constitute informed consent, and the principle applies to nursing interventions as well as surgery.

Question 15Professional Nursing Practice and Ethics

A nurse is caring for a client who requests that no information be shared with family. A family member calls asking for an update. What is the nurse's best response?

  1. Say nothing and hang up to avoid breaching confidentiality
  2. Explain that information cannot be shared without the client's permission and offer to relay a message Correct answer.
  3. Confirm the client's diagnosis but withhold the prognosis
  4. Provide a brief summary because the caller is immediate family

Explanation

The nurse must respect the client's expressed wish and not disclose information without authorisation. Explaining the position politely and offering to pass on a message maintains confidentiality while preserving a respectful relationship with the family.

Question 16Professional Nursing Practice and Ethics

A nurse must allocate limited staff across several clients at the start of a shift. Which approach best reflects the ethical principle of justice?

  1. Give priority to clients who are privately paying
  2. Distribute staff according to assessed clinical need using transparent, consistent criteria Correct answer.
  3. Assign the most staff to the clients who complain most loudly
  4. Rotate assignments randomly without assessing need

Explanation

Justice in resource allocation requires fair, consistent decisions based on clinical need rather than payment, influence, or chance. Transparent criteria ensure equitable treatment and defensible prioritisation.

Question 17Professional Nursing Practice and Ethics

A terminally ill client asks the nurse about the option of refusing further curative treatment. How should the nurse respond?

  1. Acknowledge the client's right to make this decision and arrange discussion with the treating team about options and palliative support Correct answer.
  2. Tell the client that refusing treatment is not permitted once admitted to hospital
  3. Refer the client to a psychiatrist to assess whether the request is rational
  4. Avoid the topic until the family can be present to decide

Explanation

A competent client has the right to refuse treatment, including curative treatment, and the nurse should support informed decision-making and access to palliative care. Labelling the request as irrational, blocking it, or deferring to family undermines autonomy.

Question 18Professional Nursing Practice and Ethics

Which behaviour by a nurse best demonstrates the professional value of integrity?

  1. Admitting a medication error promptly and completing the incident report honestly Correct answer.
  2. Exaggerating the severity of a client's condition to obtain more resources
  3. Blaming a student for an error the nurse made
  4. Omitting a minor error from the record to avoid disciplinary action

Explanation

Integrity involves honesty, transparency, and taking responsibility for one's actions. Promptly admitting an error and reporting it honestly protects patients and reflects professional accountability, whereas concealment, blame-shifting, and exaggeration are dishonest.

Question 19Professional Nursing Practice and Ethics

A nurse is asked to carry out a task for which they feel inadequately trained. What is the most professional response?

  1. Perform the task anyway to avoid appearing incompetent
  2. Ask an unqualified assistant to perform the task instead
  3. Decline the task, state the limits of competence, and request appropriate training or supervision Correct answer.
  4. Perform the task but document that any problems are not the nurse's responsibility

Explanation

Nurses must practise within their scope of competence and are accountable for recognising limits. Declining and seeking training or supervision protects clients and upholds professional standards, whereas proceeding unsafely or passing the task to an unqualified person is unacceptable.

Question 20Professional Nursing Practice and Ethics

A nurse notices that a client's advance directive conflicts with a treatment the medical team wishes to provide. What is the nurse's most appropriate role?

  1. Follow the medical team's instruction without raising the directive
  2. Persuade the client to change the directive to match the team's plan
  3. Advocate for the client's documented wishes and ensure they are communicated and considered by the treating team Correct answer.
  4. Destroy the directive because it is outdated

Explanation

The nurse acts as the client's advocate by ensuring a valid advance directive is communicated and respected in treatment decisions. Ignoring, destroying, or pressuring the client to change the directive would violate the client's autonomy and the nurse's advocacy role.

Question 21Fundamentals of Nursing and Basic Nursing Skills

看護師が手指衛生を行う最も重要な場面はどれか。

  1. 患者の家族と会話した後だけ
  2. 患者のベッドサイドに近づく前と離れた後 Correct answer.
  3. 勤務開始時と終了時の2回だけ
  4. 病棟の廊下を歩いた後だけ

Explanation

手指衛生は患者との接触の前後、すなわち患者ゾーンへの出入りのたびに実施することが原則である。接触前は患者を感染から守り、接触後は医療者自身と環境を守る目的がある。特定の時間帯だけでは十分な予防にならない。

Question 22Fundamentals of Nursing and Basic Nursing Skills

仰臥位の患者の仙骨部に発赤が生じている。褥瘡予防として最も適切な看護介入はどれか。

  1. 発赤部を強くマッサージする
  2. 発赤部をテープで保護する
  3. 水分摂取を制限する
  4. 30度側臥位を取り入れ除圧する Correct answer.

Explanation

褥瘡予防の基本は圧力の分散と除圧であり、30度側臥位は仙骨部の圧を軽減する体位として推奨される。発赤部のマッサージは組織をさらに損傷するため行わない。栄養と水分の維持も重要であり制限は逆効果となる。

Question 23Fundamentals of Nursing and Basic Nursing Skills

成人患者の口腔温を測定する際の正しい方法はどれか。

  1. 測定前に冷水を飲ませる
  2. 食後すぐに測定する
  3. 舌下に先端を置き口を閉じる Correct answer.
  4. 測定中は会話を促す

Explanation

口腔温は舌下のポケットに体温計の先端を置き、口を閉じて測定するのが正確な方法である。冷水や食事は口腔内温度を変化させるため、測定前の摂取は避ける。会話や口呼吸は測定値を不安定にする。

Question 24Fundamentals of Nursing and Basic Nursing Skills

成人の安静時における正常な呼吸数の範囲はどれか。

  1. 12〜20回/分 Correct answer.
  2. 32〜40回/分
  3. 24〜30回/分
  4. 6〜10回/分

Explanation

成人の安静時の正常な呼吸数は一般に1分間に12〜20回程度とされる。10回未満は徐呼吸、24回以上は頻呼吸として観察を強化する目安となる。呼吸数は全身状態の変化に先行して変動することがある。

Question 25Fundamentals of Nursing and Basic Nursing Skills

経鼻胃管から経腸栄養を投与する直前に行う確認として最も重要なものはどれか。

  1. 胃管の先端位置を確認する Correct answer.
  2. ベッドの高さを確認する
  3. 患者の爪を観察する
  4. 栄養剤の色を確認する

Explanation

経腸栄養の投与前に胃管の先端が胃内に正しく留置されていることを確認しないと、誤嚥や気道への注入の危険がある。位置確認は吸引やpH測定など施設の手順に従って行う。投与中の体位管理も誤嚥予防に重要である。

Question 26Fundamentals of Nursing and Basic Nursing Skills

成人男性患者に導尿を行う際、カテーテル挿入前に尿道口の消毒で正しいのはどれか。

  1. 同じ綿球で往復して拭く
  2. 消毒せず潤滑剤のみ塗る
  3. 中心から外側へ円を描くように拭く Correct answer.
  4. 外側から内側へ一方向に拭く

Explanation

尿道口の消毒は汚染の少ない中心から外側へ向けて行い、清潔域を保つ。外側から内側へ拭くと汚染を中心に持ち込む恐れがある。綿球は一方向に使用し、往復や使い回しは避ける。

Question 27Fundamentals of Nursing and Basic Nursing Skills

成人患者の上腕で血圧を測定する際、マンシェットの適切な巻き方はどれか。

  1. 肩の高さに巻く
  2. 肘窩の真上にマンシェットの下端を重ねる
  3. 手首に巻く
  4. 肘窩より2〜3cm上に下端を合わせる Correct answer.

Explanation

上腕での血圧測定では、マンシェットの下端を肘窩より約2〜3cm上に合わせ、心臓の高さに保つ。位置がずれると聴診部位や圧迫部位が不適切となり測定誤差が生じる。マンシェットの幅も上腕周囲に適したものを選ぶ。

Question 28Fundamentals of Nursing and Basic Nursing Skills

転倒リスクの高い高齢患者の病室環境として最も適切なものはどれか。

  1. 床に物を置いて動線を塞ぐ
  2. ナースコールを手の届く位置に置く Correct answer.
  3. 夜間は照明をすべて消す
  4. ベッドを高い位置に固定する

Explanation

転倒予防には、患者が援助を求めやすいようナースコールを手の届く位置に置くことが重要である。ベッドは低くし、移動の動線に障害物を置かない。夜間は足元灯などを用いて安全な照度を確保する。

Question 29Fundamentals of Nursing and Basic Nursing Skills

手術後の患者に深呼吸と咳嗽を促す最も大きな目的はどれか。

  1. 無気肺や肺炎を予防する Correct answer.
  2. 尿量を増やす
  3. 創部の痛みを完全に除く
  4. 腸蠕動を抑制する

Explanation

術後の深呼吸と咳嗽は肺胞を拡張させ、分泌物の排出を促すことで無気肺や術後肺炎の予防に寄与する。咳嗽時は創部を手で支えるよう指導し、疼痛管理と組み合わせる。早期離床も呼吸器合併症の予防に有効である。

Question 30Fundamentals of Nursing and Basic Nursing Skills

成人患者に浣腸を行う際の体位として一般的なのはどれか。

  1. 立位
  2. 仰臥位
  3. 腹臥位
  4. 左側臥位 Correct answer.

Explanation

浣腸では直腸とS状結腸の走行に沿って溶液が入りやすいよう、一般的に左側臥位をとる。右側臥位では注入した液が保持されにくい。体位は患者の状態に応じて調整し、羞恥への配慮も行う。

Question 31Fundamentals of Nursing and Basic Nursing Skills

成人患者の筋肉内注射における部位として、坐骨神経損傷のリスクを避けるために選択するのはどれか。

  1. 膝窩部
  2. 上腕の内側
  3. 臀筋の内側下部
  4. 臀筋の外側上部 Correct answer.

Explanation

臀部への筋肉内注射では、坐骨神経を避けるため外側上部（上外方四分円）を選択する。内側下部は坐骨神経や血管に近く損傷の危険がある。部位の選択は患者の体格や筋肉量も考慮する。

Question 32Fundamentals of Nursing and Basic Nursing Skills

意識レベルの評価で用いられるJapan Coma Scale（JCS）について正しいのはどれか。

  1. 数値が大きいほど意識障害が重い Correct answer.
  2. 0点が最も深い昏睡を示す
  3. 小児専用の評価尺度である
  4. 数値が大きいほど意識障害が軽い

Explanation

JCSは意識障害の程度をI桁（覚醒）、II桁（刺激で覚醒）、III桁（覚醒しない）で表し、数値が大きいほど意識障害が重い。0は覚醒している状態を示す。小児には主にJapan Coma Scale for childrenなど別の配慮が必要である。

Question 33Fundamentals of Nursing and Basic Nursing Skills

患者が胸痛を訴えているときの看護師の初期対応として最も優先されるのはどれか。

  1. 痛みの性状と持続時間を確認し循環動態を観察する Correct answer.
  2. 痛みが治まるまで待って記録する
  3. まず食事の摂取を勧める
  4. 運動を促して反応を見る

Explanation

胸痛は心筋梗塞など緊急性の高い疾患を示すことがあり、性状・持続時間の確認と同時にバイタルサインや循環動態の観察を行う。必要に応じて医師への報告や心電図モニタリングを準備する。運動や食事の勧めは症状を悪化させうる。

Question 34Fundamentals of Nursing and Basic Nursing Skills

経口薬を投与する際、患者の安全を守るために最初に行うべき確認はどれか。

  1. 薬を砕いてから名前を確認する
  2. 配薬カートの配置を確認する
  3. 患者の好みの味を確認する
  4. 薬剤名・用量・投与経路・時間・患者を照合する Correct answer.

Explanation

与薬では薬剤名、用量、投与経路、投与時間、患者の5つの正しい確認（5R）を投与前に照合することが基本である。患者本人の識別はリストバンドなどで確実に行う。確認を後回しにすると誤薬の危険が高まる。

Question 35Fundamentals of Nursing and Basic Nursing Skills

輸液ポンプを使用中、アラームが鳴り続けている。看護師が最初に行うべき行動はどれか。

  1. 患者と輸液ラインの状態を確認する Correct answer.
  2. アラームを消して様子を見る
  3. ポンプの電源を切る
  4. 次の勤務者に任せる

Explanation

輸液ポンプのアラームは閉塞や気泡混入、滴下異常などを示すため、まず患者の状態と輸液ラインを観察する。原因を確認せずアラームを消すと、輸液の中断や合併症の見逃しにつながる。対応後は記録と報告を行う。

Question 36Fundamentals of Nursing and Basic Nursing Skills

成人患者の導尿カテーテル留置中、尿路感染予防として適切なのはどれか。

  1. 接続部を頻回に外して洗浄する
  2. 尿バッグを膀胱より高く吊るす
  3. 毎日カテーテルを交換する
  4. 閉鎖式ドレナージを保ち尿バッグを膀胱より低く保つ Correct answer.

Explanation

留置カテーテルでは閉鎖式ドレナージを維持し、尿バッグを膀胱より低く保つことで逆行性感染を防ぐ。接続部を頻回に外すと微生物の侵入経路となる。不要になったら早期に抜去することも重要である。

Question 37Fundamentals of Nursing and Basic Nursing Skills

終末期患者の口腔ケアの目的として最も適切なのはどれか。

  1. 経口摂取を強制する
  2. 体温を上昇させる
  3. 意識を覚醒させる
  4. 口腔内の乾燥と不快感を和らげる Correct answer.

Explanation

終末期の口腔ケアは、乾燥や口臭、疼痛などの不快感を和らげ、安楽を保つことを目的とする。摂取を強制したり意識を変えるための処置ではない。保湿剤やスポンジブラシを用い、患者の苦痛を最小限にする。

Question 38Fundamentals of Nursing and Basic Nursing Skills

患者の体格に比べて大きすぎる血圧マンシェットを使用した場合、測定値に生じる影響はどれか。

  1. 実際より高く測定される
  2. 測定値に影響しない
  3. 脈拍が測定できなくなる
  4. 実際より低く測定される Correct answer.

Explanation

マンシェットが上腕周囲に対して大きすぎると、動脈を圧迫する圧が過小となり、実際より低い血圧が測定される。逆に小さすぎる場合は高く測定される。適切なサイズの選択が正確な測定の前提である。

Question 39Fundamentals of Nursing and Basic Nursing Skills

成人患者の腋窩温測定について正しいのはどれか。

  1. 腋窩を汗で濡らしたまま測定する
  2. 腋窩を乾燥させ体温計を当て密着させる Correct answer.
  3. 測定中は腕を大きく動かす
  4. 測定時間は1秒で十分である

Explanation

腋窩温は汗を拭いて乾燥させ、体温計の先端を腋窩の中心に当て、上腕を体側に密着させて測定する。汗や隙間は外気の影響を招き、低い値となりやすい。機器に定められた測定時間を守る必要がある。

Question 40Fundamentals of Nursing and Basic Nursing Skills

成人患者の点滴静脈内注射で、穿刺部に腫脹と冷感がみられた。考えられる状態と対応はどれか。

  1. 輸液速度を上げて流れを良くする
  2. 血管外漏出であり、直ちに輸液を中止し医師に報告する Correct answer.
  3. 正常な反応であり、そのまま継続する
  4. 穿刺部を温めてから継続する

Explanation

穿刺部の腫脹や冷感は、針先が血管外に外れ薬液が組織に漏れている血管外漏出を示す。直ちに輸液を中止し、針を抜かずに医師へ報告して指示を受ける。放置すると組織障害が拡大する。

Question 41Fundamentals of Nursing and Basic Nursing Skills

寝たきりの患者を仰臥位から側臥位へ体位変換する際、看護師が腰痛を予防するための原則はどれか。

  1. 患者から離れて腕の力だけで引く
  2. 腰を曲げたまま素早く引き上げる
  3. 体位変換を中止する
  4. ベッドの高さを腰の高さに合わせ重心を近づける Correct answer.

Explanation

体位変換ではベッドを腰の高さに調整し、患者にできるだけ近づいて重心を安定させ、下肢の力を使って動かすことが腰部負担の軽減につながる。腰を曲げたままの引き上げや、腕力だけに頼る方法は腰痛の原因となる。

Question 42Fundamentals of Nursing and Basic Nursing Skills

成人患者の酸素療法で、鼻カニューレを使用する際の留意点として正しいのはどれか。

  1. 酸素は可燃性であるため火気を避ける Correct answer.
  2. 酸素は爆発性であり静電気を発生させる
  3. 加湿は常に不要である
  4. 酸素流量は患者の希望のみで決める

Explanation

酸素はそれ自体は燃えないが支燃性が高く、火気の近くでは燃焼を助長するため、火気を避け喫煙禁止などの安全対策が必要である。流量は医師の指示と患者の状態に基づいて調整する。高流量では加湿を検討する。

Question 43Fundamentals of Nursing and Basic Nursing Skills

術前患者への説明のうち、術後の呼吸器合併症予防として適切なのはどれか。

  1. 咳嗽時は創部を圧迫しないよう指導する
  2. 痛みがあっても深呼吸と咳嗽を続けるよう指導する Correct answer.
  3. 術後はできるだけ安静を保ち体動を避ける
  4. 水分摂取を控えるよう指導する

Explanation

術後の深呼吸と咳嗽は分泌物の貯留を防ぎ、無気肺や肺炎の予防に重要である。咳嗽時は創部を手や枕で支える方法を指導すると痛みが軽減する。早期離床と適切な水分摂取も呼吸器合併症の予防に役立つ。

Question 44Fundamentals of Nursing and Basic Nursing Skills

高齢患者のスキンケアで、皮膚の乾燥を防ぐために適切なのはどれか。

  1. 入浴後に保湿剤を塗布する Correct answer.
  2. 乾燥を避けるため入浴を中止する
  3. 熱い湯で長時間入浴する
  4. 石けんを頻回に使用する

Explanation

高齢者の皮膚は皮脂分泌が減少し乾燥しやすいため、入浴後に保湿剤を塗布してバリア機能を保つことが有効である。熱い湯や頻回の石けん使用は皮脂を奪い乾燥を悪化させる。清潔の保持と保湿の両立が基本となる。

Question 45Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.9 mEq/L and peaked T waves on ECG. Which action should the nurse take first?

  1. Give oral sodium polystyrene sulfonate
  2. Administer intravenous calcium gluconate as prescribed Correct answer.
  3. Obtain a repeat serum potassium level
  4. Encourage a high-fiber diet

Explanation

Peaked T waves with severe hyperkalemia indicate cardiac membrane instability and risk of lethal arrhythmia. Intravenous calcium stabilizes the myocardium immediately, acting within minutes, and is always the first intervention. Potassium-lowering measures such as cation exchange resins act too slowly to protect the heart acutely.

Question 46Medical-Surgical Nursing

Which finding is most characteristic of hypocalcemia?

  1. Flushed skin with hyperthermia
  2. Trousseau sign with carpopedal spasm Correct answer.
  3. Polyuria with dilute urine
  4. Bradycardia with hypertension

Explanation

Low serum calcium increases neuromuscular excitability, producing Trousseau sign (carpal spasm with a blood pressure cuff inflated above systolic pressure) and Chvostek sign. These are classic bedside indicators of hypocalcemia. The other findings do not reflect calcium deficit.

Question 47Medical-Surgical Nursing

A patient receiving furosemide has a serum potassium of 3.1 mEq/L. Which assessment finding should the nurse anticipate?

  1. Deep rapid respirations
  2. Hyperreflexia and tetany
  3. Hypertension and facial flushing
  4. Muscle weakness and flattened T waves Correct answer.

Explanation

Loop diuretics such as furosemide promote renal potassium loss, causing hypokalemia. Low potassium hyperpolarizes muscle membranes, producing weakness, diminished reflexes, and flattened or inverted T waves with U waves on ECG. Tetany is a calcium or magnesium phenomenon, not potassium.

Question 48Medical-Surgical Nursing

Which manifestation should the nurse expect in a patient with syndrome of inappropriate antidiuretic hormone (SIADH)?

  1. Concentrated urine with low serum osmolality Correct answer.
  2. Dilute urine with high serum osmolality
  3. Increased thirst with water craving
  4. Hypernatremia with polyuria

Explanation

In SIADH, excess antidiuretic hormone causes excessive renal water reabsorption, producing concentrated urine and dilutional hyponatremia with low serum osmolality. The patient typically has no thirst drive and may show confusion or seizures as sodium falls.

Question 49Medical-Surgical Nursing

A patient with type 1 diabetes has a blood glucose of 480 mg/dL, pH 7.18, and deep rapid respirations. Which intervention is the priority?

  1. Begin an intravenous insulin infusion with fluid replacement Correct answer.
  2. Give intravenous sodium bicarbonate
  3. Encourage oral fluids and rest
  4. Administer subcutaneous sliding-scale insulin

Explanation

Diabetic ketoacidosis requires a continuous intravenous insulin infusion plus aggressive isotonic fluid resuscitation to close the anion gap and restore volume. Subcutaneous insulin is unreliable in the setting of dehydration and poor perfusion. Bicarbonate is rarely indicated and only for extreme acidosis.

Question 50Medical-Surgical Nursing

A patient with type 2 diabetes taking metformin reports fatigue and has a lactate level of 5 mmol/L. Which action should the nurse take?

  1. Encourage increased exercise
  2. Administer the next dose with food
  3. Withhold the metformin and notify the provider Correct answer.
  4. Reassure the patient that this is expected

Explanation

Metformin can precipitate lactic acidosis, especially with renal impairment, sepsis, or hypoperfusion. An elevated lactate with malaise warrants holding the drug and immediate provider notification. Continuing the drug risks worsening acidosis.