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HSSC Staff Nurse practice questions

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Question 1Fundamentals of Nursing

A nurse is preparing to administer a medication via a nasogastric tube. Which action best reflects the principle of maintaining patient safety during this procedure?

  1. Administer the medication rapidly to prevent tube clogging
  2. Flush the tube with sterile water only after giving the drug
  3. Confirm tube position by aspirating gastric contents and checking pH Correct answer.
  4. Verify tube placement by auscultating insufflated air before instillation

Explanation

Current evidence-based practice confirms nasogastric tube position by aspirating gastric contents and testing the pH (typically pH 5.5 or lower for gastric placement), supplemented by other measures as per policy. Auscultating insufflated air is unreliable and no longer recommended as a sole confirmation method. Rapid instillation and delayed flushing both increase risk of clogging and harm.

Question 2Fundamentals of Nursing

Which finding should a nurse document as a normal characteristic of a healing surgical wound on the third postoperative day?

  1. Surrounding skin warm, red, and indurated
  2. Wound edges separated with purulent drainage
  3. Wound edges approximated with minimal serous drainage Correct answer.
  4. Wound bed covered with black necrotic tissue

Explanation

A healing wound by the third postoperative day should show approximated edges and minimal serous drainage as part of normal inflammation and early proliferation. Purulent drainage, spreading erythema with induration, and black necrotic tissue all indicate infection or impaired healing and require further assessment and reporting.

Question 3Fundamentals of Nursing

A nurse is performing a bed bath for a dependent patient. Which action demonstrates correct application of body mechanics?

  1. Bending at the waist with straight legs to reach the patient's feet
  2. Standing on one foot to balance while leaning over the bed rail
  3. Raising the bed to elbow height and keeping feet shoulder-width apart Correct answer.
  4. Twisting the torso while reaching across the bed to wash the far side

Explanation

Raising the bed to a comfortable working height (about elbow level) and maintaining a wide, stable base of support reduce spinal flexion and shear forces. Twisting, bending at the waist with straight legs, and balancing on one foot all increase the risk of musculoskeletal injury to the nurse.

Question 4Fundamentals of Nursing

Which route of transmission describes pathogens spread by contaminated hands of healthcare workers from one patient to another?

  1. Vector-borne transmission
  2. Droplet transmission
  3. Indirect contact transmission Correct answer.
  4. Airborne transmission

Explanation

Indirect contact transmission occurs when a susceptible host touches a contaminated intermediate object or person, such as a healthcare worker's hands. Airborne and droplet transmission involve respiratory particles, and vector-borne transmission involves an insect or arthropod carrier. Hand hygiene interrupts indirect contact transmission.

Question 5Fundamentals of Nursing

A nurse is assessing an adult patient's vital signs. Which respiratory rate should be reported as abnormal for a resting adult?

  1. 28 breaths per minute Correct answer.
  2. 16 breaths per minute
  3. 20 breaths per minute
  4. 12 breaths per minute

Explanation

The normal resting respiratory rate for adults is approximately 12 to 20 breaths per minute. A rate of 28 exceeds this range and indicates tachypnea, which may reflect hypoxia, pain, fever, or metabolic acidosis. Rates of 12, 16, and 20 fall within the normal range.

Question 6Fundamentals of Nursing

A patient is on strict fluid balance monitoring. Which item should the nurse record as intake on the fluid balance chart?

  1. Vomitus collected in an emesis basin
  2. Urine output measured in the graduated container
  3. Ice chips swallowed by the patient Correct answer.
  4. Drainage from a surgical drain

Explanation

All fluids entering the body count as intake, including ice chips, which are recorded as approximately half their volume of water. Urine, vomitus, and drain output are measured as output. Accurate intake-output records support early detection of fluid imbalance.

Question 7Fundamentals of Nursing

A nurse is preparing to give an intramuscular injection to an adult. Which site is preferred for a large-volume injection because it carries the lowest risk of nerve injury?

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

Explanation

The ventrogluteal site is preferred for adults because it is free of major nerves and blood vessels and can accommodate larger volumes. The dorsogluteal site risks sciatic nerve injury, the deltoid accommodates only small volumes, and the vastus lateralis is used mainly in infants and young children.

Question 8Fundamentals of Nursing

Which action should a nurse take first when a patient begins to fall while being transferred from bed to chair?

  1. Attempt to catch the patient and hold them upright
  2. Lower the patient gently to the floor while protecting the head Correct answer.
  3. Call for help and leave the patient standing
  4. Move the chair away to create space

Explanation

When a patient begins to fall, the nurse should protect the patient by lowering them gently to the floor and supporting the head, rather than attempting to catch and hold them upright, which risks injury to both. Calling for help is appropriate but leaving the patient unsupported is unsafe. Post-fall assessment follows.

Question 9Fundamentals of Nursing

A nurse is teaching a patient about a low-sodium diet. Which food should the patient be advised to limit?

  1. Processed canned soup Correct answer.
  2. Fresh cucumber
  3. Fresh apples
  4. Plain steamed rice

Explanation

Processed canned soup is high in sodium because salt is added during processing and as a preservative. Fresh fruits, plain rice, and fresh vegetables are naturally low in sodium. Patients on sodium restriction should be taught to read labels and choose fresh or low-sodium products.

Question 10Fundamentals of Nursing

A patient reports pain rated 7 out of 10. Which nursing action best reflects the principle of individualized pain management?

  1. Documenting the pain score without taking further action
  2. Administering the prescribed analgesic and reassessing the pain after an appropriate interval Correct answer.
  3. Waiting until the next scheduled medication round regardless of the score
  4. Telling the patient that pain medication cannot be given yet

Explanation

Individualized pain management involves administering the prescribed analgesic, then reassessing the pain after an appropriate interval to evaluate effectiveness. Dismissing the report, documenting without action, or rigidly waiting for the scheduled round ignores the patient's reported pain and delays relief.

Question 11Fundamentals of Nursing

A nurse receives a telephone order from a physician. Which action is correct?

  1. Ask another nurse to sign the order later without verification
  2. Accept the order, then read it back to the prescriber for verification Correct answer.
  3. Transcribe the order only after the next shift begins
  4. Write the order and administer the medication without confirmation

Explanation

Telephone orders must be written down and read back to the prescriber to verify accuracy, then countersigned per policy. Administering without verification or delaying verification increases the risk of medication error. A second nurse may verify per policy, but the read-back is the essential safety step.

Question 12Fundamentals of Nursing

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

  1. Disconnecting the catheter from the bag for convenience
  2. Irrigating the catheter routinely every shift
  3. Keeping the drainage bag below the level of the bladder Correct answer.
  4. Cleaning the perineum with alcohol daily

Explanation

Keeping the drainage bag below bladder level prevents backflow of urine into the bladder, reducing infection risk. Routine irrigation, unnecessary disconnection, and alcohol-based perineal cleaning are not recommended and can introduce organisms or cause irritation.

Question 13Fundamentals of Nursing

A patient is prescribed oxygen therapy via nasal cannula at 2 L/min. Which nursing assessment is most important to monitor during therapy?

  1. Urine specific gravity
  2. Daily weight
  3. Respiratory rate and oxygen saturation Correct answer.
  4. Blood glucose level every four hours

Explanation

During oxygen therapy the nurse monitors respiratory rate, oxygen saturation, and work of breathing to evaluate effectiveness and detect deterioration. Blood glucose, daily weight, and urine specific gravity are not directly related to oxygen therapy monitoring.

Question 14Fundamentals of Nursing

A nurse is preparing to insert a peripheral intravenous cannula. Which action best reduces the risk of infection?

  1. Performing hand hygiene and using aseptic technique during insertion Correct answer.
  2. Shaving the site before insertion
  3. Reusing the same cannula for a new site
  4. Cleaning the site with an alcohol swab and inserting immediately

Explanation

Hand hygiene and aseptic technique during cannulation are the key measures to prevent bloodstream infection. Cleaning with alcohol and inserting immediately does not allow the antiseptic to dry, shaving can cause microabrasions, and reusing a cannula is unsafe.

Question 15Fundamentals of Nursing

A nurse is assessing an older adult for dehydration. Which finding is most consistent with dehydration in this population?

  1. Increased urine output and clear urine
  2. Bradycardia and peripheral edema
  3. Tachycardia and decreased skin turgor Correct answer.
  4. Moist mucous membranes and weight gain

Explanation

Dehydration in older adults commonly presents with tachycardia and decreased skin turgor, though skin turgor may be less reliable due to age-related changes. Moist membranes with weight gain, bradycardia with edema, and increased clear urine output do not indicate dehydration.

Question 16Fundamentals of Nursing

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

  1. Repositioning the patient every two hours and using a pressure-relieving mattress Correct answer.
  2. Keeping the patient flat on the back at all times
  3. Applying a heating pad to the wound
  4. Massaging the reddened area firmly

Explanation

Pressure injury management includes regular repositioning and pressure-relieving surfaces to offload the area. Massaging reddened skin causes further tissue damage, heat increases metabolic demand and risk, and keeping the patient supine maintains pressure on the sacrum.

Question 17Fundamentals of Nursing

Which statement best describes the purpose of the nursing process's evaluation phase?

  1. Selecting nursing diagnoses and writing goals
  2. Collecting initial data to identify patient problems
  3. Determining whether the care plan achieved the expected outcomes Correct answer.
  4. Implementing the prescribed medical treatments

Explanation

Evaluation determines whether the expected outcomes were met and whether the care plan needs revision. Collecting initial data is assessment, selecting diagnoses and goals is planning, and implementing treatments is the implementation phase.

Question 18Fundamentals of Nursing

A nurse is performing a focused respiratory assessment. Which finding should be reported immediately?

  1. Oxygen saturation of 94% on room air
  2. Occasional dry cough without other symptoms
  3. Use of accessory muscles with a respiratory rate of 32 per minute Correct answer.
  4. Respirations of 16 per minute with clear breath sounds

Explanation

Use of accessory muscles with marked tachypnea indicates increased work of breathing and possible respiratory distress, requiring immediate reporting and intervention. A rate of 16 with clear sounds, saturation of 94%, and an occasional dry cough are not immediate concerns.

Question 19Fundamentals of Nursing

A nurse is teaching a patient how to use a metered-dose inhaler. Which instruction is correct?

  1. Inhale deeply and slowly while activating the inhaler, then hold the breath Correct answer.
  2. Activate the inhaler after completing a full inhalation
  3. Shake the inhaler only after use
  4. Exhale fully after activating the inhaler without inhaling

Explanation

Correct inhaler technique involves exhaling first, then activating the inhaler while inhaling deeply and slowly, followed by holding the breath for about ten seconds. Activating after inhalation or exhaling after activation delivers little medication to the lungs.

Question 20Fundamentals of Nursing

A nurse is caring for a patient with a chest drain following thoracic surgery. Which observation requires immediate action?

  1. Dressing intact around the insertion site
  2. Drainage of 50 mL in the first hour
  3. Fluid level fluctuating in the water-seal chamber with respiration
  4. Continuous bubbling in the water-seal chamber Correct answer.

Explanation

Continuous bubbling in the water-seal chamber suggests an air leak in the system and requires immediate assessment and correction. Tidaling with respiration is expected, moderate early drainage is common, and an intact dressing is reassuring.

Question 21Fundamentals of Nursing

A nurse is assessing a patient for orthostatic hypotension. Which procedure is correct?

  1. Measure blood pressure once with the patient standing immediately after exercise
  2. Measure blood pressure and pulse with the patient supine, then after standing Correct answer.
  3. Measure blood pressure after the patient has been lying still for thirty minutes
  4. Measure blood pressure only while the patient is seated

Explanation

Orthostatic vital signs are obtained with the patient supine, then after standing, comparing blood pressure and pulse. A drop in systolic pressure of at least 20 mm Hg or diastolic of at least 10 mm Hg on standing suggests orthostatic hypotension. A single seated or post-exercise reading does not assess the response to position change.

Question 22Fundamentals of Nursing

A patient with a new colostomy asks how to care for the stoma. Which response by the nurse is most accurate?

  1. The stoma should be cleaned with alcohol daily
  2. A healthy stoma is red, moist, and may bleed slightly when touched Correct answer.
  3. The stoma should be pale and dry at all times
  4. The stoma bag should be changed every hour

Explanation

A healthy stoma is red and moist and may bleed slightly when touched because it is mucosal tissue. A pale or dry stoma suggests poor perfusion and should be reported. Alcohol is irritating, and hourly bag changes are unnecessary and damaging to the skin.

Question 23Fundamentals of Nursing

A nurse is caring for a patient receiving a blood transfusion. Fifteen minutes into the transfusion the patient develops fever, chills, and flank pain. What is the priority action?

  1. Stop the transfusion immediately and maintain intravenous access with normal saline Correct answer.
  2. Slow the transfusion and reassess in thirty minutes
  3. Increase the rate to complete the transfusion quickly
  4. Continue the transfusion and administer an antipyretic

Explanation

Fever, chills, and flank pain during transfusion suggest an acute hemolytic reaction. The priority is to stop the transfusion immediately, keep the line patent with normal saline using new tubing, and notify the provider and blood bank. Slowing, continuing, or increasing the rate would allow further hemolysis.

Question 24Fundamentals of Nursing

A nurse is calculating a medication dose for a child. The prescription is 15 mg/kg/day divided into three doses. The child weighs 20 kg. How many milligrams should be given per dose?

  1. 50 mg
  2. 100 mg Correct answer.
  3. 300 mg
  4. 150 mg

Explanation

The total daily dose is 15 mg/kg × 20 kg = 300 mg per day. Divided into three doses, each dose is 300 ÷ 3 = 100 mg. Verifying weight-based calculations against safe dose ranges is essential in pediatric medication administration.

Question 25Fundamentals of Nursing

A patient with chronic obstructive pulmonary disease has a prescribed oxygen saturation target of 88% to 92%. The nurse finds the patient drowsy with a saturation of 98% on high-flow oxygen. What is the nurse's best interpretation?

  1. The high saturation confirms adequate ventilation and requires no action
  2. The patient may be retaining carbon dioxide and the oxygen flow should be reduced per prescription Correct answer.
  3. The oxygen flow should be increased further to improve alertness
  4. The drowsiness is unrelated to oxygen therapy and should be ignored

Explanation

In some patients with chronic CO2 retention, excessive supplemental oxygen can worsen hypercapnia and cause drowsiness. The saturation exceeds the prescribed target, so oxygen should be titrated down per prescription with close monitoring and provider notification. Ignoring the change or increasing oxygen would be unsafe.

Question 26Fundamentals of Nursing

A nurse is preparing to perform a surgical hand scrub before assisting in an operating theatre. Which principle of asepsis best explains why the hands are held above the elbows during the scrub and while moving to the sterile gown?

  1. Holding the hands high keeps the sterile gown from touching the unscrubbed upper arms
  2. Microorganisms are shed most heavily from the hands, so gravity must carry them toward the elbows Correct answer.
  3. The skin of the hands is more sensitive to the scrub solution, so raising them reduces chemical irritation
  4. Elevating the hands prevents the nurse from touching the unsterile sink area during the procedure

Explanation

Surgical hand antisepsis relies on the principle that contaminated water and shed organisms move from cleaner to dirtier areas under gravity. Because the hands are scrubbed most thoroughly, they are considered the cleanest part and must remain uppermost, with water running from hands toward elbows. This is why the hands are held above the elbows throughout the scrub and while walking to the gowning area.

Question 27Fundamentals of Nursing

A nurse is caring for a patient who has just returned from surgery and is drowsy but responsive. The patient has a prescription for oral analgesia. Which action should the nurse take before administering the medication?

  1. Verify the patient's level of consciousness and ability to swallow safely before giving oral medication Correct answer.
  2. Administer the dose immediately so the analgesic takes effect before the pain worsens
  3. Crush the tablet and mix it with water to make swallowing easier for a drowsy patient
  4. Withhold all analgesia until the patient is fully alert and able to request it

Explanation

Before any oral medication, the nurse must confirm the patient is awake enough to swallow and has an intact gag and cough reflex, because a drowsy patient is at risk of aspiration. Assessing consciousness and swallowing ability is a core part of the rights of medication administration, particularly the right route and patient safety.

Question 28Fundamentals of Nursing

A nurse is documenting care for a patient with a healing surgical wound. Which entry best meets the legal and professional standards for nursing documentation?

  1. 14:00 - Wound edges approximated, no redness or drainage noted; patient denies pain at site; dressing left intact Correct answer.
  2. Wound looks better today, patient seems comfortable, continue plan
  3. Patient's wound is improving nicely after dressing change by nurse
  4. Dressing changed, wound fine, will monitor as needed

Explanation

Legal documentation must be objective, specific, and time-stamped, describing exactly what the nurse observed and did rather than impressions or judgments. The entry recording approximated edges, absence of redness or drainage, and the patient's denial of pain gives measurable, verifiable information. Vague terms such as 'looks better' or 'fine' cannot be defended and are not acceptable in a clinical record.

Question 29Fundamentals of Nursing

A nurse is caring for a patient who is on bed rest and cannot turn independently. Which nursing measure is most effective in preventing pressure injury over the sacrum?

  1. Repositioning the patient at scheduled intervals and keeping the skin clean and dry Correct answer.
  2. Placing the patient in a semi-Fowler position continuously to relieve sacral pressure
  3. Massaging the reddened bony prominence firmly to stimulate blood flow
  4. Applying a heat pack to the sacral area every four hours to improve circulation

Explanation

Pressure injury prevention depends on relieving sustained pressure over bony prominences through regular repositioning, together with skin care that keeps the surface clean, dry, and free of excess moisture. These measures address the mechanical and moisture-related causes of tissue breakdown. Massage over reddened areas and heat application are harmful because they further compromise already ischemic tissue.

Question 30Fundamentals of Nursing

A nurse is reviewing a patient's arterial blood gas results: pH 7.28, PaCO2 55 mmHg, HCO3- 26 mEq/L. The patient has a history of chronic obstructive pulmonary disease and is drowsy. Which interpretation and priority action are most appropriate?

  1. Compensated metabolic alkalosis; restrict oral fluids and monitor electrolytes
  2. Metabolic acidosis; prepare to administer intravenous sodium bicarbonate as prescribed
  3. Respiratory alkalosis; encourage the patient to breathe more slowly into a paper bag
  4. Respiratory acidosis; notify the provider and support ventilation while monitoring respiratory status Correct answer.

Explanation

A pH below 7.35 with a raised PaCO2 above 45 mmHg and a near-normal bicarbonate indicates acute uncompensated respiratory acidosis, reflecting alveolar hypoventilation. In a drowsy patient with COPD this signals worsening ventilatory failure, so the nurse should escalate to the provider and support oxygenation and ventilation while monitoring closely.

Question 31Medical-Surgical Nursing

A patient with acute decompensated heart failure is receiving furosemide. Which assessment finding best indicates that the medication is achieving its intended therapeutic effect?

  1. A weight loss of 1.5 kg over 24 hours with reduced bibasilar crackles Correct answer.
  2. A decrease in serum potassium from 4.2 to 3.4 mEq/L
  3. A decrease in urine output to 20 mL per hour
  4. A rise in serum creatinine from 1.0 to 1.4 mg/dL

Explanation

Loop diuretics such as furosemide relieve pulmonary congestion by promoting diuresis, so falling weight and clearing crackles demonstrate effective decongestion. Potassium loss and rising creatinine are adverse effects rather than evidence of benefit. Oliguria signals failure of therapy or worsening renal perfusion.

Question 32Medical-Surgical Nursing

Which clinical manifestation is most characteristic of early hypoxemia in an adult medical-surgical patient?

  1. Bounding peripheral pulses
  2. Bradycardia with hypertension
  3. Decreased respiratory rate
  4. Restlessness and confusion Correct answer.

Explanation

The brain is highly sensitive to falling oxygen levels, so anxiety, restlessness, and confusion are often the earliest signs of hypoxemia before cyanosis appears. Tachycardia and tachypnea typically accompany early hypoxia rather than bradycardia or slow breathing. Pulse character is not a reliable indicator of oxygenation.

Question 33Medical-Surgical Nursing

A patient is admitted with diabetic ketoacidosis. Which laboratory pattern is expected on presentation?

  1. pH 7.20, bicarbonate 10 mEq/L, positive serum ketones Correct answer.
  2. pH 7.45, bicarbonate 26 mEq/L, positive urine glucose only
  3. pH 7.38, bicarbonate 24 mEq/L, glucose 110 mg/dL
  4. pH 7.50, bicarbonate 30 mEq/L, ketones negative

Explanation

DKA produces a high-anion-gap metabolic acidosis with low bicarbonate and ketone accumulation from unrestrained lipolysis. The pH falls below normal as ketone acids consume bicarbonate. Normal or alkalotic values with normal bicarbonate exclude ketoacidosis.

Question 34Medical-Surgical Nursing

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. Document the finding as a normal postoperative appearance
  3. Gently massage the stoma with warm saline
  4. Apply a tight ostomy belt to support the stoma

Explanation

A dusky, purple, or black stoma suggests ischemia from compromised blood supply and requires urgent surgical evaluation. A healthy stoma is beefy red to pink and moist. Pressure from a tight belt or massage would further impair perfusion.

Question 35Medical-Surgical Nursing

Which finding should the nurse report as a possible sign of compartment syndrome in a patient with a tibial fracture in a cast?

  1. Capillary refill of 2 seconds in the toes
  2. Pain that worsens with passive stretch of the toes Correct answer.
  3. Mild swelling at the cast edges
  4. Pain that is relieved by prescribed analgesia

Explanation

Pain out of proportion to injury and pain provoked by passive stretch are the earliest and most reliable indicators of compartment syndrome. Analgesia often fails to relieve this ischemic pain. Swelling and a 2-second capillary refill are common and not diagnostic.

Question 36Medical-Surgical Nursing

A patient receiving heparin infusion has a platelet count that dropped from 250,000 to 80,000/mm3 on day six of therapy. Which action should the nurse anticipate?

  1. Administer vitamin K to reverse the heparin effect
  2. Transfuse platelets and continue heparin at the current rate
  3. Increase the heparin rate to maintain anticoagulation
  4. Discontinue heparin and notify the provider about heparin-induced thrombocytopenia Correct answer.

Explanation

A greater than 50% platelet drop after several days of heparin suggests heparin-induced thrombocytopenia, an immune-mediated prothrombotic disorder. The standard response is to stop all heparin products and notify the provider for alternative anticoagulation. Platelet transfusion and continuing heparin are unsafe.

Question 37Medical-Surgical Nursing

Which instruction is most important for a patient starting isoniazid therapy for active tuberculosis?

  1. Take the medication only when symptoms flare
  2. Report yellowing of the eyes or dark urine promptly Correct answer.
  3. Double the dose if a dose is missed
  4. Avoid all dairy products while taking the drug

Explanation

Isoniazid is hepatotoxic, so jaundice, dark urine, and right upper quadrant discomfort must be reported immediately. The drug is taken daily for the full regimen regardless of symptom improvement. Doubling doses increases toxicity risk.

Question 38Medical-Surgical Nursing

A patient with an acute exacerbation of asthma has a peak expiratory flow at 40% of personal best and is using accessory muscles. Which medication should the nurse prepare to administer first?

  1. Oral prednisone
  2. Inhaled salmeterol
  3. Intravenous furosemide
  4. Inhaled albuterol via nebulizer Correct answer.

Explanation

A short-acting beta-2 agonist such as albuterol provides rapid bronchodilation and is first-line for acute bronchospasm. Systemic corticosteroids are added but act over hours. Long-acting agents are for maintenance, not rescue.

Question 39Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.8 mEq/L and peaked T waves on the cardiac monitor. Which order should the nurse implement first?

  1. Give oral sodium bicarbonate
  2. Administer sodium polystyrene sulfonate orally
  3. Give intravenous calcium gluconate Correct answer.
  4. Encourage a high-potassium diet

Explanation

Intravenous calcium stabilizes the myocardial membrane within minutes and is the immediate priority when hyperkalemia produces ECG changes. Potassium-shifting and potassium-removing therapies follow but act more slowly. A high-potassium diet would worsen the arrhythmia risk.

Question 40Medical-Surgical Nursing

Which assessment finding is most consistent with a tension pneumothorax in a patient after central line insertion?

  1. Bilateral crackles with pink frothy sputum
  2. Sudden bradycardia with warm dry skin
  3. Tracheal deviation toward the unaffected side with hypotension Correct answer.
  4. Gradual onset of productive cough over days

Explanation

Tension pneumothorax produces rising intrathoracic pressure with tracheal shift away from the affected side, hypotension, and severe respiratory distress. It is an emergency requiring immediate decompression. Bilateral crackles and pink sputum suggest pulmonary edema, not pneumothorax.

Question 41Medical-Surgical Nursing

A patient with cirrhosis has ascites and is prescribed spironolactone. Which monitoring parameter is most important?

  1. Serum amylase
  2. Urine specific gravity only
  3. Peak expiratory flow
  4. Serum potassium and renal function Correct answer.

Explanation

Spironolactone is a potassium-sparing diuretic, so hyperkalemia and worsening renal function are key risks, especially in cirrhosis. Electrolytes and creatinine must be monitored regularly. Amylase and peak flow are unrelated to this therapy.

Question 42Medical-Surgical Nursing

A patient is 12 hours post abdominal surgery and reports sudden shortness of breath with a heart rate of 118/min. Which action should the nurse take first?

  1. Ambulate the patient in the hallway
  2. Withhold pain medication
  3. Encourage a large meal to increase energy
  4. Apply supplemental oxygen and notify the provider Correct answer.

Explanation

Sudden dyspnea with tachycardia after surgery raises concern for pulmonary embolism, so oxygen and prompt provider notification are the immediate steps. Ambulation and eating are unsafe during acute respiratory distress. Analgesia is unrelated to the deterioration.

Question 43Medical-Surgical Nursing

Which teaching point is essential for a patient with a new colostomy before discharge?

  1. Inspect the peristomal skin for redness or breakdown daily Correct answer.
  2. Limit fluids to 500 mL per day
  3. Irrigate the colostomy every two hours
  4. Avoid all physical activity for six months

Explanation

Peristomal skin breakdown from leakage is a common complication, so daily inspection and proper appliance fit are essential teaching points. Output and fluid needs vary, and normal activity is encouraged. Frequent irrigation is not routine for a new colostomy.

Question 44Medical-Surgical Nursing

A patient with a spinal cord injury at T4 develops a pounding headache, blood pressure of 210/110 mm Hg, and profuse sweating. What should the nurse do first?

  1. Raise the head of the bed to 90 degrees Correct answer.
  2. Place the patient in Trendelenburg position
  3. Insert a urinary catheter without an order
  4. Administer a prescribed antipyretic

Explanation

These findings indicate autonomic dysreflexia, and the first action is to sit the patient upright to lower blood pressure through orthostatic pooling. The nurse then identifies and removes the trigger, such as a distended bladder. Trendelenburg worsens the hypertension.

Question 45Medical-Surgical Nursing

Which early sign suggests that a patient receiving total parenteral nutrition is developing refeeding syndrome?

  1. Rising serum phosphate with hypertension
  2. Increased urine output with hypernatremia
  3. Elevated serum albumin with bradycardia
  4. Falling serum phosphate, potassium, and magnesium Correct answer.

Explanation

Refeeding syndrome causes intracellular shifts of phosphate, potassium, and magnesium as insulin rises with renewed glucose intake, producing hypophosphatemia and hypokalemia. These electrolyte drops require close monitoring and correction. Rising phosphate is the opposite of the expected pattern.

Question 46Medical-Surgical Nursing

A patient with an acute ischemic stroke has a blood pressure of 200/110 mm Hg and is not receiving thrombolytics. Which action is appropriate?

  1. Administer a rapid-acting antihypertensive to lower pressure to 120/80 mm Hg
  2. Encourage the patient to ambulate to reduce pressure
  3. Give aspirin immediately without an order
  4. Notify the provider and monitor closely per protocol Correct answer.

Explanation

In acute ischemic stroke without thrombolysis, permissive hypertension is often maintained to preserve cerebral perfusion, so the provider should be notified and pressure monitored per protocol. Aggressive lowering risks extending the infarct. Nursing actions require orders for medications.

Question 47Medical-Surgical Nursing

A patient with a new below-the-knee amputation reports phantom limb pain. Which response by the nurse is most appropriate?

  1. Acknowledge the pain as real and administer prescribed gabapentin Correct answer.
  2. Tell the patient the pain is imaginary and will stop
  3. Encourage the patient to ignore the sensation
  4. Apply ice directly to the residual limb for pain relief

Explanation

Phantom limb pain is a real neuropathic phenomenon, and treatment includes agents such as gabapentin along with reassurance. Dismissing the pain damages trust and delays relief. Ice applied directly to the residual limb can impair healing.

Question 48Medical-Surgical Nursing

Which finding in a patient with a chest tube for a pneumothorax requires immediate intervention?

  1. Continuous bubbling in the water-seal chamber Correct answer.
  2. Serosanguineous drainage of 50 mL in the first hour
  3. Tidaling of fluid in the water-seal chamber with breathing
  4. Chest tube secured with tape at the insertion site

Explanation

Continuous bubbling in the water-seal chamber suggests an air leak in the system, which impairs re-expansion of the lung and must be investigated immediately. Intermittent tidaling with respiration is expected. Moderate serosanguineous drainage is common post-insertion.

Question 49Medical-Surgical Nursing

A patient with type 2 diabetes is prescribed metformin. Which instruction should the nurse include?

  1. Increase alcohol intake to improve glucose control
  2. Take the drug only when blood glucose exceeds 300 mg/dL
  3. Expect frequent hypoglycemia when taking it alone
  4. Stop the drug before any contrast dye procedure and report it to the provider Correct answer.

Explanation

Metformin carries a risk of lactic acidosis, especially with impaired renal perfusion, so it is typically held before iodinated contrast studies. It is taken regularly rather than episodically. Hypoglycemia is uncommon when used alone, and alcohol should be limited.

Question 50Medical-Surgical Nursing

A patient with gastroesophageal reflux disease asks about lifestyle changes. Which recommendation is most appropriate?

  1. Elevate the head of the bed and avoid late meals Correct answer.
  2. Eat a large meal immediately before bedtime
  3. Drink several cups of coffee before sleep
  4. Lie flat for one hour after eating

Explanation

Head-of-bed elevation and avoiding meals close to bedtime reduce acid reflux by limiting gastric pressure and nocturnal regurgitation. Large late meals, lying flat after eating, and caffeine all promote reflux. These measures complement acid-suppressing medication.