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ESIC Nursing Officer study materials
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ESIC Nursing Officer practice questions

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Question 1Nursing Foundations and Fundamentals of Nursing

A patient is admitted with a body temperature of 39.4°C. Which nursing term best describes this finding?

  1. Afebrile state
  2. Normal diurnal variation
  3. Hypothermia
  4. Pyrexia Correct answer.

Explanation

Pyrexia (fever) is a core body temperature above the normal range, conventionally above 38°C. A reading of 39.4°C clearly exceeds this threshold and represents a febrile state requiring nursing assessment and monitoring.

Question 2Nursing Foundations and Fundamentals of Nursing

While counting a patient's radial pulse, the nurse notes the rhythm is irregular. What is the most appropriate immediate action?

  1. Recheck the pulse after the patient ambulates
  2. Count the radial pulse for 15 seconds and multiply by four
  3. Auscultate the apical pulse for a full minute Correct answer.
  4. Record the rate and continue routine care

Explanation

An irregular radial pulse may reflect atrial fibrillation or other dysrhythmia, and the apical rate gives the true ventricular rate. Counting apically for a full minute also detects pulse deficit when compared with the radial rate.

Question 3Nursing Foundations and Fundamentals of Nursing

Which site is contraindicated for measuring temperature in a patient who has just undergone rectal surgery?

  1. Oral
  2. Rectal Correct answer.
  3. Axillary
  4. Tympanic

Explanation

The rectal route is avoided after rectal or perineal surgery because insertion risks trauma to the suture line and introduces infection. Alternative sites such as oral, tympanic, or axillary should be selected.

Question 4Nursing Foundations and Fundamentals of Nursing

An adult patient's blood pressure reads 148/94 mmHg on two separate occasions. How should the nurse classify this?

  1. Elevated blood pressure
  2. Stage 1 hypertension Correct answer.
  3. Normal blood pressure
  4. Hypertensive crisis

Explanation

Stage 1 hypertension in adults is a systolic pressure of 130–139 mmHg or diastolic of 80–89 mmHg; however, a systolic of 140–159 or diastolic of 90–99 is also hypertensive and requires clinical confirmation. A consistent reading of 148/94 mmHg falls in the hypertensive range and warrants follow-up.

Question 5Nursing Foundations and Fundamentals of Nursing

A patient with a fractured femur reports sudden chest pain and breathlessness. Which nursing action takes priority?

  1. Document the complaint and continue routine observations
  2. Administer prescribed analgesia and reassess in one hour
  3. Notify the provider immediately and prepare for emergency assessment Correct answer.
  4. Elevate the limb and apply a cold compress

Explanation

Sudden chest pain and dyspnoea after a long-bone fracture raise suspicion of fat embolism or pulmonary embolism, both life-threatening. The nurse must escalate immediately rather than treat the symptom in isolation.

Question 6Nursing Foundations and Fundamentals of Nursing

Which position is most appropriate for a patient with severe dyspnoea from pulmonary oedema?

  1. High Fowler's position Correct answer.
  2. Trendelenburg position
  3. Sims' position
  4. Prone position

Explanation

High Fowler's position lowers diaphragmatic pressure and improves lung expansion, easing breathing in pulmonary oedema. It also reduces venous return to the heart, which decreases pulmonary congestion.

Question 7Nursing Foundations and Fundamentals of Nursing

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

  1. Auscultating a whoosh of air over the epigastrium
  2. Measuring the pH of aspirated fluid Correct answer.
  3. Asking the patient to swallow water during insertion
  4. Checking that the tube markings reach the nostril

Explanation

Aspirated gastric fluid with a pH of 5.5 or below is a reliable indicator of gastric placement. Auscultation of injected air is no longer considered a dependable method because breath sounds can be confused with gastric insufflation.

Question 8Nursing Foundations and Fundamentals of Nursing

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

  1. Strained oatmeal porridge
  2. Vanilla milkshake
  3. Clear apple juice Correct answer.
  4. Cream of tomato soup

Explanation

A clear liquid diet includes items that are transparent and liquid at room temperature, such as clear juices, broth, and gelatin. Apple juice fits this definition, while milk-based or opaque foods do not.

Question 9Nursing Foundations and Fundamentals of Nursing

The nurse is calculating a fluid balance chart. Intake is 2,400 mL and output is 1,950 mL over 24 hours. What is the net balance?

  1. 150 mL negative balance
  2. 450 mL positive balance Correct answer.
  3. 4,350 mL total balance
  4. 450 mL negative balance

Explanation

Net fluid balance is intake minus output: 2,400 minus 1,950 equals 450 mL, and because intake exceeds output the value is a positive balance. Positive balance may indicate fluid retention and should be reported if unexpected.

Question 10Nursing Foundations and Fundamentals of Nursing

Which finding indicates a need to withhold a prescribed dose of digoxin and notify the prescriber?

  1. Respiratory rate of 18 breaths per minute
  2. Serum potassium of 4.2 mEq/L
  3. Blood pressure of 132/84 mmHg
  4. Apical heart rate of 58 beats per minute Correct answer.

Explanation

Digoxin slows conduction through the atrioventricular node, and a bradycardic apical rate (commonly below 60 beats per minute in adults) is a classic reason to hold the dose. The nurse counts the apical pulse for a full minute before administration.

Question 11Nursing Foundations and Fundamentals of Nursing

The 'rights' of medication administration include which element?

  1. Right diagnosis
  2. Right family history
  3. Right insurance
  4. Right route Correct answer.

Explanation

The traditional rights of medication administration include the right patient, drug, dose, route, and time, with documentation and reason often added. Right route ensures the drug is delivered by the intended path, which affects absorption and safety.

Question 12Nursing Foundations and Fundamentals of Nursing

A patient receiving intravenous vancomycin develops flushing of the face and neck with itching during a rapid infusion. What is the most likely cause?

  1. Hypoglycaemic reaction
  2. Infusion-related histamine release Correct answer.
  3. Anaphylaxis to the diluent
  4. Sepsis from the cannula

Explanation

Rapid vancomycin infusion can cause histamine-mediated flushing of the upper body, sometimes called red man syndrome. Slowing the infusion rate usually resolves it, and the reaction is distinguished from true anaphylaxis by absence of airway compromise.

Question 13Nursing Foundations and Fundamentals of Nursing

A pressure injury is noted as a shallow open ulcer with a red-pink wound bed and no slough. How should the nurse stage it?

  1. Stage 2 Correct answer.
  2. Stage 3
  3. Stage 4
  4. Stage 1

Explanation

A stage 2 pressure injury involves partial-thickness loss of skin with a shallow open ulcer and a red-pink bed, without slough. Stage 1 is intact skin with non-blanchable redness, while stages 3 and 4 involve full-thickness loss.

Question 14Nursing Foundations and Fundamentals of Nursing

Which nursing measure is most effective in preventing a pressure injury in an immobile patient?

  1. Repositioning the patient at regular intervals Correct answer.
  2. Applying a heating pad to bony prominences
  3. Keeping the skin dry with alcohol-based rubs
  4. Massaging reddened bony areas vigorously

Explanation

Regular repositioning relieves sustained pressure over bony prominences, which is the primary mechanism of pressure injury formation. Turning schedules are commonly every two hours for high-risk patients and should be documented.

Question 15Nursing Foundations and Fundamentals of Nursing

A surgical wound is assessed 48 hours postoperatively. Which finding should the nurse report as abnormal?

  1. Warmth, spreading redness, and purulent drainage Correct answer.
  2. Mild serous drainage
  3. Approximated wound edges
  4. Slight incisional tenderness

Explanation

Spreading erythema, warmth, and purulent drainage suggest a surgical site infection requiring prompt reporting and possible culture. Normal early healing shows approximated edges with minimal serous drainage and mild tenderness.

Question 16Nursing Foundations and Fundamentals of Nursing

Which technique is correct when performing surgical hand antisepsis before a sterile procedure?

  1. Scrub hands and forearms with an antimicrobial agent, keeping hands above elbows Correct answer.
  2. Wash hands and arms with soap and water only, then dry with a shared towel
  3. Apply lotion to the hands before donning sterile gloves
  4. Scrub only the palms and fingers for a few seconds

Explanation

Surgical hand antisepsis uses an antimicrobial agent over hands and forearms, and keeping hands above elbows allows water to run from clean to less clean areas. This reduces transient and resident flora before sterile gloving.

Question 17Nursing Foundations and Fundamentals of Nursing

When removing personal protective equipment after caring for a patient on contact precautions, which item is removed first?

  1. Mask
  2. Gown
  3. Eye protection
  4. Gloves Correct answer.

Explanation

Gloves are the most contaminated item and are removed first, followed by eye protection, gown, and finally mask. This sequence minimises self-contamination during doffing.

Question 18Nursing Foundations and Fundamentals of Nursing

A nurse is preparing to administer a subcutaneous injection of insulin. Which angle is generally used for a patient with a normal body build?

  1. 45 degrees
  2. 15 degrees
  3. 30 degrees
  4. 90 degrees Correct answer.

Explanation

For a patient with adequate subcutaneous tissue, insulin is typically given at a 90-degree angle with a short needle. A 45-degree angle may be used for thin patients or those with little subcutaneous fat.

Question 19Nursing Foundations and Fundamentals of Nursing

A patient is scheduled for a blood transfusion. Which action is essential immediately before starting the transfusion?

  1. Warm the blood in a microwave
  2. Prime the tubing with dextrose solution
  3. Verify the blood product and patient identity with a second nurse Correct answer.
  4. Add prescribed medication to the blood bag

Explanation

Two-person verification of patient identity and blood product compatibility is a core safety step that prevents haemolytic transfusion reactions. Baseline vital signs are also recorded before the transfusion begins.

Question 20Nursing Foundations and Fundamentals of Nursing

During a blood transfusion, the patient develops chills, fever, and flank pain. What should the nurse do first?

  1. Slow the transfusion and reassess in 30 minutes
  2. Administer an antipyretic and continue the transfusion
  3. Document the symptoms and monitor vital signs hourly
  4. Stop the transfusion and maintain intravenous access with normal saline Correct answer.

Explanation

Fever, chills, and flank pain during transfusion suggest an acute haemolytic reaction, a medical emergency. The transfusion must be stopped immediately, the line kept patent with normal saline, and the provider notified.

Question 21Nursing Foundations and Fundamentals of Nursing

A patient is prescribed oxygen at 2 litres per minute via nasal cannula. Which nursing action is appropriate?

  1. Use a non-rebreather mask for this flow rate
  2. Encourage the patient to breathe through the mouth only
  3. Apply petroleum jelly to the nares to prevent dryness
  4. Set the flow rate before placing the cannula on the patient Correct answer.

Explanation

The flow rate must be set and checked before applying the device so the patient receives the prescribed concentration. Petroleum-based products are avoided near oxygen because they are flammable.

Question 22Nursing Foundations and Fundamentals of Nursing

A patient has an indwelling urinary catheter. Which intervention best reduces the risk of catheter-associated urinary tract infection?

  1. Routine clamping of the catheter every four hours
  2. Disconnecting the tubing to obtain urine samples
  3. Irrigating the catheter daily with antiseptic
  4. Keeping the drainage bag below the level of the bladder Correct answer.

Explanation

Keeping the drainage bag below bladder level prevents backflow of contaminated urine into the bladder. Maintaining a closed system and removing the catheter as early as possible further reduce infection risk.

Question 23Nursing Foundations and Fundamentals of Nursing

Which finding suggests that a patient is experiencing urinary retention?

  1. Polyuria with dilute urine and thirst
  2. Haematuria with clots and flank pain
  3. Frequent passage of small amounts of urine with suprapubic discomfort Correct answer.
  4. Nocturia twice per night

Explanation

Urinary retention presents with frequent small voidings, suprapubic fullness, and discomfort because the bladder does not empty. A bladder scan or catheterisation may be needed to measure residual volume.

Question 24Nursing Foundations and Fundamentals of Nursing

A patient has not had a bowel movement for four days and reports hard, dry stools. Which nursing measure is most appropriate initially?

  1. Administer a stimulant suppository without assessment
  2. Increase dietary fibre and fluid intake and encourage ambulation Correct answer.
  3. Perform digital disimpaction immediately
  4. Restrict oral fluids to reduce stool volume

Explanation

Constipation with hard stools is first managed by increasing fibre, fluids, and activity, which promote peristalsis and soften stool. Pharmacologic or manual interventions follow if these measures fail.

Question 25Nursing Foundations and Fundamentals of Nursing

A nurse is teaching a patient about fall prevention at home. Which instruction is most important?

  1. Use night lights and remove loose rugs from walkways Correct answer.
  2. Store frequently used items on high shelves
  3. Walk in stockinged feet for better grip
  4. Avoid using assistive devices indoors

Explanation

Removing trip hazards and improving lighting are evidence-based measures that reduce falls in the home. Night lights help prevent falls during nocturnal toileting, a common time for falls.

Question 26Nursing Foundations and Fundamentals of Nursing

A nursing officer is preparing to perform a bed bath for a stable, conscious patient who can cooperate. Which principle should guide the sequencing of the procedure?

  1. Begin with the perineal area so that it is completed while the patient is freshest
  2. Wash the cleanest areas first and move toward the perineal area last Correct answer.
  3. Change the bath water only after the entire body has been washed
  4. Wash the face and legs alternately to save time

Explanation

Bed bathing follows a clean-to-dirty sequence so that microorganisms from the perineal and anal regions are not carried to the face, eyes, or breaks in the skin. The face and upper body are washed first, the perineal area is attended to last, and water is changed when it becomes soiled or cool. This principle reflects basic infection prevention applied to a routine hygiene procedure.

Question 27Nursing Foundations and Fundamentals of Nursing

A patient is to receive a bed bath and the nurse must maintain patient privacy and dignity. Which action best meets this requirement?

  1. Expose only the body part being washed and keep the rest covered with a bath blanket Correct answer.
  2. Close the room door but leave curtains open so the patient can see the corridor
  3. Wash the whole body quickly with the gown removed to reduce procedure time
  4. Ask the patient to remain uncovered so the skin can be inspected throughout

Explanation

Maintaining privacy means exposing only the area being cleansed while the remainder of the body stays covered with a bath blanket, and keeping doors or curtains closed. This preserves warmth as well as dignity. Full or prolonged exposure is unnecessary and undermines the patient's comfort and privacy.

Question 28Nursing Foundations and Fundamentals of Nursing

A nursing officer is preparing a sterile field on a table for a dressing change. Which action maintains the sterility of the field?

  1. Reach across the sterile field with the bare arm to position an item
  2. Hold sterile items above the field and place them gently on the centre of the drape Correct answer.
  3. Turn away from the field to open a sterile package toward the body
  4. Place sterile items on the outer one-inch border of the sterile drape

Explanation

Sterile items are dropped or placed onto the centre of the sterile field from above, avoiding contact with the outer border, which is considered unsterile. The nurse should not reach across the field, because the arm passes over the sterile area and risks contamination. Packages are opened away from the body and toward the field without turning away.

Question 29Nursing Foundations and Fundamentals of Nursing

A patient is receiving a continuous enteral feed through a nasogastric tube. Which nursing action best reduces the risk of aspiration?

  1. Elevate the head of the bed to 30 to 45 degrees during and after feeding Correct answer.
  2. Check the gastric residual volume and discard the aspirate
  3. Position the patient supine during the feeding
  4. Flush the tube with 10 mL of air before each feeding

Explanation

Elevating the head of the bed to about 30 to 45 degrees during feeding and for a period afterwards reduces the chance of gastric contents entering the airway. Supine positioning increases aspiration risk, and routine discarding of gastric aspirate is not recommended because it can contribute to electrolyte loss. Correct tube placement and monitoring tolerance also support safe feeding.

Question 30Nursing Foundations and Fundamentals of Nursing

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

  1. Administer intravenous calcium gluconate as prescribed to protect the myocardium Correct answer.
  2. Withhold all medications and repeat the ECG in four hours
  3. Give oral potassium supplements to correct the electrolyte imbalance
  4. Encourage a high-potassium diet to support cardiac function

Explanation

Severe hyperkalaemia with ECG changes is a cardiac emergency, and intravenous calcium gluconate is given first to stabilise the myocardium while measures to shift and remove potassium are arranged. Potassium supplements and high-potassium foods would worsen the condition. Delaying action while awaiting a repeat ECG risks a fatal arrhythmia.

Question 31Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.9 mEq/L and peaked T waves on ECG. Which intravenous medication is given first to stabilize the myocardial membrane?

  1. Sodium bicarbonate 7.5%
  2. Regular insulin with dextrose
  3. Sodium polystyrene sulfonate
  4. Calcium gluconate 10% Correct answer.

Explanation

Calcium gluconate acts within minutes to antagonize the cardiotoxic effect of hyperkalemia at the myocardial membrane, protecting against lethal arrhythmia while definitive potassium-lowering therapy is arranged. It does not lower serum potassium itself, so it must be followed by insulin-dextrose, bicarbonate, or a potassium binder.

Question 32Medical-Surgical Nursing

A patient in diabetic ketoacidosis is started on an insulin infusion. Which laboratory value must be checked before the infusion begins and monitored as insulin is given?

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

Explanation

Insulin drives potassium into cells along with glucose, so a patient with DKA can develop dangerous hypokalemia once insulin is started even if the initial potassium appears normal or high. Potassium is replaced when the level falls below about 5.2 mEq/L and is checked every few hours during treatment.

Question 33Medical-Surgical Nursing

A patient is admitted with acute decompensated heart failure. Which position best supports oxygenation while awaiting diuresis?

  1. Flat supine with legs elevated
  2. High Fowler position with legs dependent Correct answer.
  3. Prone position with head turned
  4. Trendelenburg position

Explanation

Sitting upright with the legs dependent reduces venous return to the right heart and relieves pulmonary congestion, improving ventilation-perfusion matching and ease of breathing. This orthopneic posture is a first-line nursing measure in acute pulmonary edema.

Question 34Medical-Surgical Nursing

A patient with an acute myocardial infarction reports sudden tearing chest pain radiating to the back, and the blood pressure differs by 25 mm Hg between arms. Which complication should the nurse suspect?

  1. Aortic dissection Correct answer.
  2. Esophageal spasm
  3. Pulmonary embolism
  4. Pericarditis

Explanation

Tearing pain radiating to the back with an interarm blood pressure differential is the classic presentation of aortic dissection, a vascular emergency requiring urgent imaging and blood pressure control. Pericarditis pain is pleuritic and positional, and pulmonary embolism typically causes dyspnea and pleuritic pain without a large interarm gradient.

Question 35Medical-Surgical Nursing

Which finding is the earliest indicator of increased intracranial pressure in a postoperative neurosurgical patient?

  1. Change in level of consciousness Correct answer.
  2. Decerebrate posturing
  3. Cushing triad
  4. Fixed dilated pupils

Explanation

A declining level of consciousness is the earliest and most reliable sign of rising intracranial pressure, appearing before brainstem compression produces pupillary or postural changes. Fixed pupils, posturing, and Cushing triad are late, ominous signs of herniation.

Question 36Medical-Surgical Nursing

A patient with a traumatic brain injury has a Glasgow Coma Scale score of 7. Which nursing action takes priority?

  1. Prepare for endotracheal intubation Correct answer.
  2. Perform passive range-of-motion exercises
  3. Administer a scheduled laxative
  4. Reposition the patient prone

Explanation

A Glasgow Coma Scale score of 8 or less indicates coma with loss of airway protective reflexes, so securing the airway with endotracheal intubation is the immediate priority. Other nursing measures proceed only after airway and ventilation are assured.

Question 37Medical-Surgical Nursing

A patient with status epilepticus is receiving intravenous lorazepam. Which monitoring parameter is most important immediately after administration?

  1. Respiratory rate and oxygen saturation Correct answer.
  2. Serum creatinine
  3. Blood glucose every 15 minutes
  4. Urine output

Explanation

Benzodiazepines such as lorazepam depress the central nervous system and can cause respiratory depression and hypoventilation, so respiratory rate and oxygen saturation must be monitored closely. Airway support equipment should be at the bedside during administration.

Question 38Medical-Surgical Nursing

A patient with myasthenia gravis develops worsening ptosis, dysphagia, and shallow breathing over several hours. Which condition should the nurse anticipate?

  1. Thyroid storm
  2. Cholinergic crisis from excess pyridostigmine
  3. Guillain-Barre syndrome
  4. Myasthenic crisis Correct answer.

Explanation

Rapid worsening of bulbar and respiratory muscle weakness in myasthenia gravis suggests myasthenic crisis, a respiratory emergency requiring urgent assessment of vital capacity and possible ventilatory support. Cholinergic crisis would present with muscarinic excess such as bradycardia, diarrhea, and excessive secretions rather than pure weakness.

Question 39Medical-Surgical Nursing

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

  1. Clamp the chest tube immediately
  2. Milk the tubing toward the drainage unit
  3. Increase the suction pressure
  4. Assess the insertion site and tubing for an air leak Correct answer.

Explanation

Continuous bubbling in the water-seal chamber indicates an air leak, which may come from the lung, the insertion site, or loose connections. The nurse first inspects the insertion site and the tubing connections to locate and correct the leak; clamping is avoided because it can cause tension pneumothorax.

Question 40Medical-Surgical Nursing

Which instruction should the nurse give a patient using a metered-dose inhaler with a spacer for asthma?

  1. Wait about one minute between puffs of the same medication Correct answer.
  2. Store the inhaler in the refrigerator
  3. Inhale rapidly and forcefully during actuation
  4. Rinse the spacer with soap after every use

Explanation

Waiting approximately 30 to 60 seconds between puffs allows the first dose to reach the airways and the lungs to reopen, improving delivery of the second dose. Spacers are rinsed weekly with mild soap and air-dried, not washed after each use.

Question 41Medical-Surgical Nursing

A patient with an acute exacerbation of COPD has an oxygen saturation target of 88% to 92%. Which delivery device is most appropriate?

  1. Non-rebreather mask at 15 L/min
  2. Nasal cannula at 6 L/min
  3. Simple face mask at 10 L/min
  4. Venturi mask Correct answer.

Explanation

A Venturi mask delivers a precise, controlled fraction of inspired oxygen, which is essential when a specific saturation target must be maintained in a patient at risk of carbon dioxide retention. High-flow devices without precise control can overshoot the target range.

Question 42Medical-Surgical Nursing

A patient with a new ileostomy has liquid output of 1,800 mL in 24 hours. Which complication should the nurse monitor for?

  1. Constipation
  2. Hypovolemia and hypokalemia Correct answer.
  3. Hyperkalemia and fluid overload
  4. Metabolic alkalosis from gastric loss

Explanation

Ileostomy effluent is rich in water, sodium, and potassium, so high output causes volume depletion and hypokalemia. The nurse monitors intake and output, daily weights, and electrolytes, and reports output above about 1,000 to 1,200 mL per day.

Question 43Medical-Surgical Nursing

Which assessment finding is most concerning in a patient two days after abdominal surgery?

  1. Serous drainage at the incision
  2. Absent bowel sounds with a rigid, distended abdomen Correct answer.
  3. Temperature of 37.8 C
  4. Request for pain medication

Explanation

Absent bowel sounds together with a rigid, distended abdomen suggest paralytic ileus or a surgical complication such as perforation or peritonitis and requires urgent evaluation. Serous drainage, low-grade fever, and controlled pain are common and expected after abdominal surgery.

Question 44Medical-Surgical Nursing

A patient with acute pancreatitis is prescribed nothing by mouth with nasogastric suction. Which nursing measure best relieves pain?

  1. Positioning the patient flat and prone
  2. Maintaining the semi-Fowler position with knees flexed Correct answer.
  3. Encouraging deep coughing every hour
  4. Applying a heating pad to the epigastrium

Explanation

Pancreatic rest reduces enzyme secretion, and a semi-Fowler position with the knees flexed decreases tension on the abdominal wall and relieves pain. Heat application is avoided because it can increase pancreatic blood flow and enzyme activity.

Question 45Medical-Surgical Nursing

A patient with cirrhosis has ascites and is prescribed spironolactone. Which parameter best indicates the diuretic is effective?

  1. Serum bilirubin trend
  2. Daily weight and abdominal girth Correct answer.
  3. Serum creatinine once weekly
  4. Blood pressure every shift

Explanation

In ascites management, daily weight and abdominal girth directly reflect fluid mobilization and are the most reliable bedside indicators of diuretic response. A safe target is roughly 0.5 kg per day in patients without peripheral edema.

Question 46Medical-Surgical Nursing

A patient receiving a blood transfusion develops fever, chills, and flank pain 15 minutes into the infusion. What is the nurse's first action?

  1. Slow the transfusion and reassess in 15 minutes
  2. Give acetaminophen and continue the transfusion
  3. Flush the tubing to clear the reaction
  4. Stop the transfusion and maintain intravenous access with normal saline Correct answer.

Explanation

Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction, which can progress to shock and renal failure. The transfusion must be stopped immediately while intravenous access is preserved with normal saline, and the provider and blood bank are notified.

Question 47Medical-Surgical Nursing

A patient with severe anemia has a hemoglobin of 6.5 g/dL and reports fatigue and dyspnea on exertion. Which nursing intervention is most appropriate?

  1. Encourage vigorous ambulation to build endurance
  2. Cluster care activities and allow rest periods Correct answer.
  3. Apply supplemental heat to the extremities
  4. Restrict oral fluids to 1 L per day

Explanation

With marked anemia, oxygen-carrying capacity is reduced, so the nurse conserves energy by grouping care and scheduling rest to reduce oxygen demand. Activity is progressed gradually as the hemoglobin rises with treatment.

Question 48Medical-Surgical Nursing

A patient with neutropenia after chemotherapy has a temperature of 38.4 C. Which action should the nurse take?

  1. Obtain blood cultures and notify the provider for immediate antibiotics Correct answer.
  2. Encourage fresh flowers and fruit to improve morale
  3. Place the patient in a room with another neutropenic patient
  4. Give an antipyretic and recheck the temperature in four hours

Explanation

Fever in a neutropenic patient is an oncologic emergency because infection can progress rapidly with few localizing signs. Blood cultures are drawn and broad-spectrum antibiotics started promptly, ideally within one hour of fever onset.

Question 49Medical-Surgical Nursing

A patient with end-stage renal disease misses a hemodialysis session and presents with dyspnea, pulmonary crackles, and a 3 kg weight gain. Which finding indicates fluid overload?

  1. Serum potassium of 4.0 mEq/L
  2. Hemoglobin of 10 g/dL
  3. Bibasilar crackles and jugular venous distention Correct answer.
  4. Blood pressure of 118/70 mm Hg

Explanation

Crackles and jugular venous distention are classic signs of volume overload from missed dialysis, reflecting pulmonary congestion and elevated right heart pressures. Rapid removal of fluid during dialysis is then required with close monitoring for hypotension.

Question 50Medical-Surgical Nursing

A patient with a spinal cord injury at T4 develops a pounding headache, profuse sweating, and a blood pressure of 210/120 mm Hg. What should the nurse do first?

  1. Place the patient supine and elevate the legs
  2. Sit the patient upright and check for bladder distention Correct answer.
  3. Administer a prescribed analgesic
  4. Apply a cool compress to the forehead

Explanation

These findings indicate autonomic dysreflexia, a hypertensive emergency triggered by a noxious stimulus below the injury level, most often bladder distention. Sitting the patient upright lowers blood pressure through orthostatic pooling while the trigger is identified and relieved.