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RRB Staff Nurse practice questions

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Question 1Nursing Fundamentals and Principles of Nursing

A nurse is preparing to administer a medication via the intramuscular route. Which site is generally preferred for adult immunizations and most IM injections because it avoids major nerves and blood vessels?

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

Explanation

The ventrogluteal site is preferred for adults and children over 7 months because it lies away from major nerves and blood vessels and has a reliable muscle mass. It is considered the safest IM site for most adult injections.

Question 2Nursing Fundamentals and Principles of Nursing

A nurse is calculating the body mass index of an adult client. Which formula correctly represents BMI when weight is measured in kilograms and height in meters?

  1. Weight divided by height squared Correct answer.
  2. Weight multiplied by height squared
  3. Height squared divided by weight
  4. Weight divided by height

Explanation

BMI is calculated as weight in kilograms divided by the square of height in meters. This normalizes weight for body size and allows classification into underweight, normal, overweight, and obese categories.

Question 3Nursing Fundamentals and Principles of Nursing

During a head-to-toe assessment, a nurse assesses skin turgor by gently pinching the skin. Which finding most reliably indicates adequate hydration in an older adult?

  1. Skin remains tented for several seconds on the forearm
  2. Skin returns quickly to its original shape over the sternum Correct answer.
  3. Skin feels cool and dry on the extremities
  4. Skin over the ankle shows pitting after pressure

Explanation

In older adults, skin turgor is best assessed over the sternum because forearm skin loses elasticity with age. A quick return to shape indicates adequate hydration, whereas tenting suggests dehydration.

Question 4Nursing Fundamentals and Principles of Nursing

A nurse is performing a focused respiratory assessment and notes that the client's oxygen saturation is 88% on room air while resting. Which action should the nurse take first?

  1. Ask the client to perform incentive spirometry once
  2. Raise the head of the bed and apply supplemental oxygen per protocol Correct answer.
  3. Document the value and reassess in four hours
  4. Encourage the client to ambulate in the hallway

Explanation

An oxygen saturation of 88% is below the acceptable range and indicates hypoxemia requiring immediate intervention. Positioning to improve ventilation and initiating supplemental oxygen per protocol are appropriate first actions before further assessment.

Question 5Nursing Fundamentals and Principles of Nursing

A nurse is teaching a client about a low-sodium diet for hypertension. Which food choice indicates the client correctly understands the teaching?

  1. Canned vegetable soup
  2. Pickled cucumbers
  3. Processed deli ham
  4. Fresh grilled chicken with herbs Correct answer.

Explanation

Fresh poultry seasoned with herbs is low in sodium, unlike processed and canned foods. Canned, cured, and pickled products are typically high in sodium and should be limited in a low-sodium diet.

Question 6Nursing Fundamentals and Principles of Nursing

A nurse is preparing to insert a urinary catheter for an adult client. Which action best reduces the risk of catheter-associated urinary tract infection?

  1. Leaving the drainage bag on the floor beside the bed
  2. Irrigating the catheter routinely every shift
  3. Cleaning the meatus with sterile solution and maintaining sterile technique Correct answer.
  4. Using clean rather than sterile gloves during insertion

Explanation

Sterile technique during insertion, including thorough meatal cleansing, is the primary measure to prevent catheter-associated infection. Maintaining a closed drainage system and keeping the bag below bladder level further reduce risk.

Question 7Nursing Fundamentals and Principles of Nursing

A nurse is assessing a client for signs of hypoxia. Which early clinical manifestation should the nurse recognize as most characteristic?

  1. Restlessness and confusion Correct answer.
  2. Decreased respiratory rate
  3. Warm, flushed skin
  4. Bradycardia with hypertension

Explanation

Early hypoxia commonly presents with restlessness, anxiety, and confusion as the brain senses inadequate oxygenation. These subtle neurologic changes often precede more obvious signs such as cyanosis.

Question 8Nursing Fundamentals and Principles of Nursing

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

  1. Massage the reddened area to promote circulation
  2. Apply direct heat to the wound bed
  3. Keep the client flat on the back to protect the wound
  4. Reposition the client at regular intervals and keep the area clean and moist Correct answer.

Explanation

Stage 2 pressure injuries involve partial-thickness skin loss and require offloading pressure, keeping the wound clean, and maintaining a moist healing environment. Regular repositioning relieves pressure and promotes healing.

Question 9Nursing Fundamentals and Principles of Nursing

A nurse is teaching a client about the correct technique for using a metered-dose inhaler. Which step should the nurse include?

  1. Shake the inhaler and exhale fully before actuating it during a slow deep inhalation Correct answer.
  2. Inhale rapidly and shallowly after actuation
  3. Actuate the inhaler while holding the breath
  4. Store the inhaler in the refrigerator between uses

Explanation

Proper inhaler technique involves shaking the device, exhaling fully, actuating while beginning a slow deep inhalation, and holding the breath. This maximizes delivery of medication to the airways.

Question 10Nursing Fundamentals and Principles of Nursing

A nurse is evaluating a client's understanding of a clear liquid diet. Which item should the nurse instruct the client to avoid?

  1. Milk Correct answer.
  2. Plain gelatin
  3. Clear broth
  4. Apple juice

Explanation

A clear liquid diet includes items that are transparent at room temperature, such as broth, juice, and gelatin. Milk is opaque and contains fat and protein, so it is excluded from a clear liquid diet.

Question 11Nursing Fundamentals and Principles of Nursing

A nurse is preparing to administer a blood transfusion. Which action is most important immediately before starting the transfusion?

  1. Begin the transfusion at a rapid rate to save time
  2. Verify the client's identity and blood product with a second nurse at the bedside Correct answer.
  3. Add medications to the blood bag to reduce the number of lines
  4. Warm the blood product in a microwave

Explanation

Bedside verification of client identity and product compatibility by two qualified staff is the critical safety step before transfusion. This prevents hemolytic transfusion reactions from misidentification.

Question 12Nursing Fundamentals and Principles of Nursing

A nurse is assessing a client's level of consciousness using the Glasgow Coma Scale. Which three responses does the scale evaluate?

  1. Respirations, temperature, and pain
  2. Eye opening, verbal response, and motor response Correct answer.
  3. Pupil size, blood pressure, and pulse
  4. Orientation, memory, and judgment

Explanation

The Glasgow Coma Scale scores eye opening, verbal response, and motor response, with a total ranging from 3 to 15. Lower scores indicate more severe neurologic impairment.

Question 13Nursing Fundamentals and Principles of Nursing

A nurse is caring for a client receiving intravenous potassium chloride. Which action is essential to prevent a serious complication?

  1. Give the dose undiluted through a peripheral line
  2. Dilute the dose and infuse it at a controlled rate via a pump Correct answer.
  3. Administer the dose as a rapid IV push
  4. Administer the dose intramuscularly instead

Explanation

IV potassium must be diluted and infused at a controlled rate, typically no faster than 10 mEq per hour, to prevent cardiac arrhythmias. A pump ensures accurate delivery and reduces the risk of rapid infusion.

Question 14Nursing Fundamentals and Principles of Nursing

A nurse is assessing a client with dehydration. Which finding should the nurse expect?

  1. Decreased urine output with concentrated urine Correct answer.
  2. Crackles in the lung bases
  3. Peripheral edema
  4. Bounding pulses

Explanation

Dehydration reduces circulating volume, leading to decreased urine output and concentrated urine as the kidneys conserve water. Other signs include dry mucous membranes, poor skin turgor, and tachycardia.

Question 15Nursing Fundamentals and Principles of Nursing

A nurse is preparing to reposition an immobile client. Which principle should guide the nurse's body mechanics?

  1. Keep the feet close together and bend at the waist
  2. Twist the torso while lifting to save effort
  3. Widen the base of support and bend at the knees while keeping the load close Correct answer.
  4. Lift with the back muscles while holding the breath

Explanation

Safe body mechanics involve a wide base of support, bending at the knees, and holding the load close to the body. These principles reduce spinal strain and the risk of nurse injury.

Question 16Nursing Fundamentals and Principles of Nursing

A nurse is teaching a client about fall prevention at home. Which instruction is most appropriate?

  1. Rise quickly from bed to maintain balance
  2. Use night lights and remove loose rugs from walkways Correct answer.
  3. Wear loose slippers when walking
  4. Keep frequently used items on high shelves

Explanation

Adequate lighting and removing tripping hazards such as loose rugs reduce fall risk in the home. Environmental modification is a key nursing intervention for fall prevention.

Question 17Nursing Fundamentals and Principles of Nursing

A nurse is assessing a postoperative client who reports sudden shortness of breath and chest pain. Which condition should the nurse suspect first?

  1. Atelectasis
  2. Wound dehiscence
  3. Pulmonary embolism Correct answer.
  4. Paralytic ileus

Explanation

Sudden dyspnea and pleuritic chest pain in a postoperative client strongly suggest pulmonary embolism, a life-threatening complication. Immediate notification of the provider and preparation for diagnostic testing are required.

Question 18Nursing Fundamentals and Principles of Nursing

A nurse is preparing to administer an enema to a client. Which position is typically recommended for administering a cleansing enema?

  1. High Fowler position
  2. Trendelenburg position
  3. Prone position
  4. Sims position lying on the left side Correct answer.

Explanation

The left lateral Sims position allows the enema solution to flow along the natural curve of the sigmoid colon. This improves retention and effectiveness of the enema.

Question 19Nursing Fundamentals and Principles of Nursing

A nurse is caring for a client with an indwelling urinary catheter. Which finding should prompt immediate further assessment?

  1. Clear yellow urine draining into the bag
  2. A securely taped catheter without tension
  3. Sudden cessation of urine output with suprapubic discomfort Correct answer.
  4. A drainage bag hanging below bladder level

Explanation

Sudden cessation of urine output with suprapubic discomfort suggests catheter obstruction or bladder spasm and requires prompt assessment. Restoring patency prevents bladder distention and related complications.

Question 20Nursing Fundamentals and Principles of Nursing

A nurse is assessing a client's pain using a numeric rating scale. The client reports a score of 8 out of 10. Which action should the nurse take next?

  1. Administer the prescribed analgesic and reassess after an appropriate interval Correct answer.
  2. Document the score and reassess at the next shift
  3. Encourage the client to ignore the pain
  4. Reassure the client that pain will resolve without intervention

Explanation

A pain score of 8 indicates severe pain requiring intervention. Administering the prescribed analgesic and reassessing after a suitable interval reflects appropriate pain management.

Question 21Nursing Fundamentals and Principles of Nursing

A nurse is preparing a client for surgery and must obtain informed consent. Which element is essential for valid informed consent?

  1. Consent obtained from a family member without client involvement
  2. The client's signature obtained after sedation
  3. The nurse signing on behalf of the client
  4. The provider explaining the procedure, risks, and alternatives to the client Correct answer.

Explanation

Valid informed consent requires the provider to explain the procedure, risks, benefits, and alternatives, and the client to consent voluntarily. The nurse's role is to witness and confirm understanding, not to obtain the consent.

Question 22Nursing Fundamentals and Principles of Nursing

A nurse is assessing a client receiving digoxin. Which finding should the nurse report immediately as a possible sign of toxicity?

  1. Nausea, visual disturbances, and a heart rate of 52 beats per minute Correct answer.
  2. Blood pressure of 118/76 mm Hg
  3. Heart rate of 88 beats per minute
  4. Serum potassium of 4.2 mEq/L

Explanation

Digoxin toxicity commonly presents with nausea, visual changes such as yellow-green halos, and bradycardia. These findings require immediate reporting and withholding of the next dose.

Question 23Nursing Fundamentals and Principles of Nursing

A nurse is caring for a client on bed rest. Which intervention is most effective in preventing deep vein thrombosis?

  1. Massaging the calves vigorously each shift
  2. Applying sequential compression devices and encouraging ankle exercises Correct answer.
  3. Keeping the legs dependent at all times
  4. Restricting oral fluids to reduce blood volume

Explanation

Sequential compression devices and ankle exercises promote venous return and prevent stasis in immobile clients. These measures reduce the risk of deep vein thrombosis.

Question 24Nursing Fundamentals and Principles of Nursing

A nurse is teaching a client about a newly prescribed antihypertensive medication. Which instruction is most important to include?

  1. Double the dose if a dose is missed
  2. Stop the medication once blood pressure normalizes
  3. Rise slowly from sitting or lying to prevent dizziness Correct answer.
  4. Take the medication only when symptoms occur

Explanation

Antihypertensives can cause orthostatic hypotension, so clients should change position slowly to prevent falls. Teaching this safety measure improves adherence and reduces injury risk.

Question 25Anatomy and Physiology

Which formed element of blood is primarily responsible for oxygen transport from the lungs to the tissues?

  1. Erythrocyte Correct answer.
  2. Lymphocyte
  3. Neutrophil
  4. Thrombocyte

Explanation

Erythrocytes contain haemoglobin, which binds oxygen in the pulmonary capillaries and releases it in peripheral tissues. Neutrophils and lymphocytes are leukocytes involved in immune defence, and thrombocytes (platelets) mediate haemostasis. Only the erythrocyte carries the haemoglobin needed for bulk oxygen carriage.

Question 26Anatomy and Physiology

During which phase of the cardiac cycle do the atrioventricular valves close, producing the first heart sound?

  1. Ventricular filling
  2. Isovolumetric ventricular contraction Correct answer.
  3. Atrial systole
  4. Ventricular ejection

Explanation

The first heart sound occurs at the start of ventricular systole when rising ventricular pressure exceeds atrial pressure and the AV valves snap shut. This occurs during isovolumetric contraction, before the semilunar valves open. Atrial systole and ventricular filling keep the AV valves open, while ejection involves open semilunar valves.

Question 27Anatomy and Physiology

Which structure is the primary site of gas exchange in the respiratory system?

  1. Alveolus Correct answer.
  2. Larynx
  3. Trachea
  4. Bronchus

Explanation

Alveoli provide a thin, moist, highly vascular surface where oxygen and carbon dioxide diffuse between air and blood. The trachea, bronchi and larynx are conducting airways that move air but have thick walls unsuited to diffusion. Gas exchange therefore occurs almost entirely at the alveolar membrane.

Question 28Anatomy and Physiology

A patient's blood report shows a haematocrit of 55 percent with normal plasma protein levels. Which interpretation is most appropriate?

  1. The patient is anaemic and requires transfusion
  2. The patient has polycythaemia with increased red cell mass
  3. The patient has dehydration with haemoconcentration Correct answer.
  4. The sample is likely from an arterial line

Explanation

A raised haematocrit with normal plasma protein suggests haemoconcentration from loss of plasma water, as in dehydration. Polycythaemia would typically raise red cell mass but is distinguished by clinical context and red cell indices. Anaemia lowers haematocrit rather than raising it.

Question 29Anatomy and Physiology

Which hormone is released by the posterior pituitary and acts on the collecting ducts to increase water reabsorption?

  1. Antidiuretic hormone Correct answer.
  2. Adrenaline
  3. Atrial natriuretic peptide
  4. Aldosterone

Explanation

Antidiuretic hormone, released from the posterior pituitary, increases aquaporin insertion in collecting duct cells and promotes water reabsorption. Aldosterone acts on the distal tubule to reabsorb sodium, while atrial natriuretic peptide promotes sodium and water excretion. Adrenaline has metabolic and cardiovascular effects rather than direct water reabsorption.

Question 30Anatomy and Physiology

Which part of the nephron is the main site of glucose reabsorption under normal conditions?

  1. Descending limb of the loop of Henle
  2. Distal convoluted tubule
  3. Collecting duct
  4. Proximal convoluted tubule Correct answer.

Explanation

Glucose is reabsorbed almost entirely in the proximal convoluted tubule via sodium-glucose cotransporters. The descending limb is permeable mainly to water, and the distal tubule and collecting duct handle fine-tuning of sodium, potassium and water under hormonal control. Glucose should not normally reach the collecting duct.

Question 31Anatomy and Physiology

Which enzyme secreted by gastric parietal cells is essential for the absorption of vitamin B12?

  1. Secretin
  2. Intrinsic factor Correct answer.
  3. Gastrin
  4. Pepsin

Explanation

Parietal cells secrete intrinsic factor, which binds vitamin B12 and allows its absorption in the terminal ileum. Pepsin digests proteins, gastrin stimulates acid secretion, and secretin regulates pancreatic bicarbonate output. Without intrinsic factor, B12 absorption fails and pernicious anaemia develops.

Question 32Anatomy and Physiology

Which layer of the gastrointestinal tract wall contains the myenteric plexus responsible for peristalsis?

  1. Submucosa
  2. Muscularis externa Correct answer.
  3. Mucosa
  4. Serosa

Explanation

The myenteric (Auerbach) plexus lies between the circular and longitudinal muscle layers of the muscularis externa and coordinates peristalsis. The submucosal (Meissner) plexus lies in the submucosa and mainly controls secretion and blood flow. The mucosa and serosa do not contain the myenteric plexus.

Question 33Anatomy and Physiology

Which muscle group is the principal inspiratory muscle during quiet breathing?

  1. Internal intercostals
  2. Rectus abdominis
  3. External intercostals
  4. Diaphragm Correct answer.

Explanation

The diaphragm contracts during quiet inspiration, flattening and increasing thoracic volume to draw air in. External intercostals assist by elevating the ribs, but they are not the principal muscle. Internal intercostals and abdominal muscles are mainly expiratory.

Question 34Anatomy and Physiology

A patient has a lesion of the phrenic nerve on one side. Which change is most directly expected?

  1. Loss of taste from the posterior tongue
  2. Loss of sensation over the shoulder
  3. Paralysis of the ipsilateral hemidiaphragm Correct answer.
  4. Inability to adduct the vocal cords

Explanation

The phrenic nerve supplies motor fibres to the diaphragm, so a unilateral lesion paralyses the ipsilateral hemidiaphragm. Shoulder sensation is carried by the supraclavicular nerves, vocal cord adduction by the recurrent laryngeal nerve, and posterior tongue taste by the glossopharyngeal nerve. The phrenic nerve has no role in these functions.

Question 35Anatomy and Physiology

Which type of joint is the shoulder (glenohumeral) joint?

  1. Saddle joint
  2. Ball-and-socket joint Correct answer.
  3. Hinge joint
  4. Pivot joint

Explanation

The glenohumeral joint is a synovial ball-and-socket joint, allowing movement in three planes including flexion, extension, abduction, rotation and circumduction. Hinge joints such as the elbow allow movement in one plane, pivot joints allow rotation, and saddle joints occur at the thumb base. The spherical humeral head within the glenoid cavity defines the ball-and-socket type.

Question 36Anatomy and Physiology

Which bone of the forearm is located on the thumb side in the anatomical position?

  1. Scaphoid
  2. Ulna
  3. Humerus
  4. Radius Correct answer.

Explanation

In the anatomical position the radius lies laterally, on the thumb side, while the ulna lies medially. The humerus is the upper arm bone, and the scaphoid is a carpal bone of the wrist. This lateral position of the radius allows it to rotate over the ulna during pronation.

Question 37Anatomy and Physiology

Which neurotransmitter is released at the neuromuscular junction to stimulate skeletal muscle contraction?

  1. Dopamine
  2. Acetylcholine Correct answer.
  3. GABA
  4. Noradrenaline

Explanation

Motor neurons release acetylcholine at the neuromuscular junction, which binds nicotinic receptors on the motor end plate and triggers depolarisation. Noradrenaline is released at most sympathetic postganglionic endings, dopamine is a central neurotransmitter, and GABA is inhibitory. Acetylcholine is therefore the excitatory transmitter for skeletal muscle.

Question 38Anatomy and Physiology

A patient with a lesion in the cerebellum would most likely show which abnormality?

  1. Intention tremor and ataxia Correct answer.
  2. Memory loss and disorientation
  3. Loss of pain and temperature sensation
  4. Hyperreflexia with spastic paralysis

Explanation

The cerebellum coordinates movement and balance, so lesions produce intention tremor, ataxia and dysmetria. Loss of pain and temperature sensation follows damage to spinothalamic pathways, memory loss reflects cortical or limbic damage, and spastic paralysis with hyperreflexia indicates upper motor neuron lesions. Cerebellar signs are therefore mainly motor coordination deficits.

Question 39Anatomy and Physiology

Which cranial nerve is responsible for the gag reflex when the posterior pharynx is stimulated?

  1. Glossopharyngeal nerve Correct answer.
  2. Optic nerve
  3. Hypoglossal nerve
  4. Facial nerve

Explanation

The glossopharyngeal nerve carries the afferent limb of the gag reflex from the posterior pharynx, with the vagus nerve providing the efferent motor response. The facial nerve supplies facial expression and anterior tongue taste, the hypoglossal nerve controls tongue movement, and the optic nerve carries vision. The glossopharyngeal nerve is therefore the sensory limb tested in the gag reflex.

Question 40Anatomy and Physiology

Which hormone from the thyroid gland lowers blood calcium levels?

  1. Thyroxine
  2. Cortisol
  3. Parathyroid hormone
  4. Calcitonin Correct answer.

Explanation

Calcitonin, secreted by thyroid parafollicular C cells, inhibits osteoclast activity and lowers serum calcium. Parathyroid hormone raises calcium by promoting bone resorption and renal reabsorption. Thyroxine regulates metabolism, and cortisol is a glucocorticoid with metabolic and anti-inflammatory actions.

Question 41Anatomy and Physiology

A patient is given a drug that blocks beta-1 adrenergic receptors. Which effect is most expected?

  1. Pupillary dilation
  2. Bronchodilation
  3. Reduced heart rate and contractility Correct answer.
  4. Increased gastric acid secretion

Explanation

Beta-1 receptors are concentrated in the heart, so blockade reduces heart rate and contractility. Bronchodilation is mediated by beta-2 receptors, gastric acid secretion is mainly vagal and histaminergic, and pupillary dilation is an alpha-1 effect. Beta-1 blockade therefore chiefly produces negative chronotropic and inotropic effects.

Question 42Anatomy and Physiology

Which blood vessel carries deoxygenated blood from the right ventricle to the lungs?

  1. Pulmonary artery Correct answer.
  2. Pulmonary vein
  3. Superior vena cava
  4. Aorta

Explanation

The pulmonary artery carries deoxygenated blood from the right ventricle to the lungs, making it an exception to the rule that arteries carry oxygenated blood. The pulmonary veins return oxygenated blood to the left atrium, the aorta distributes oxygenated blood to the body, and the superior vena cava drains systemic venous blood to the right atrium.

Question 43Anatomy and Physiology

Which component of the conduction system initiates the normal cardiac impulse?

  1. Bundle of His
  2. Purkinje fibres
  3. Atrioventricular node
  4. Sinoatrial node Correct answer.

Explanation

The sinoatrial node in the right atrium has the highest intrinsic rate and acts as the normal pacemaker. The atrioventricular node delays the impulse before conduction continues to the bundle of His and Purkinje fibres. These distal structures conduct or delay impulses but do not normally initiate them.

Question 44Anatomy and Physiology

During a routine check, a patient's spirometry shows a reduced FEV1/FVC ratio with increased residual volume. Which pattern does this most suggest?

  1. Restrictive lung disease
  2. Normal lung function
  3. Obstructive lung disease Correct answer.
  4. Hyperventilation syndrome

Explanation

A reduced FEV1/FVC ratio with air trapping and increased residual volume is characteristic of obstructive disease such as asthma or COPD. Restrictive disease lowers total lung capacity but preserves or raises the FEV1/FVC ratio. Normal function and hyperventilation do not produce this combination of findings.

Question 45Medical-Surgical Nursing

A patient with acute decompensated heart failure is receiving furosemide. Which laboratory value should the nurse monitor most closely to detect a common adverse effect of this therapy?

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

Explanation

Loop diuretics such as furosemide increase renal potassium excretion, so hypokalemia is a frequent and clinically important adverse effect that can precipitate dysrhythmias, especially in patients also taking digoxin. Potassium is therefore the priority electrolyte to trend alongside renal function and daily weights.

Question 46Medical-Surgical Nursing

A patient is admitted with an acute asthma exacerbation and is receiving nebulized albuterol. Which assessment finding indicates the medication is producing the intended therapeutic response?

  1. Increased drowsiness and reduced respiratory effort
  2. Development of fine bibasilar crackles
  3. Reduced wheeze with improved peak expiratory flow Correct answer.
  4. Slowing of the heart rate below 60 beats per minute

Explanation

Albuterol is a short-acting beta-2 agonist that relaxes bronchial smooth muscle, so the expected response is decreased wheezing, easier air movement, and improved peak flow. Reassessing air entry and objective airflow measures, not just subjective comfort, confirms bronchodilation.

Question 47Medical-Surgical Nursing

A patient with a new ileostomy is being taught about output and fluid balance. Which statement by the patient indicates correct understanding?

  1. I can stop drinking fluids if my bag fills quickly.
  2. I should expect a liquid output and watch for signs of dehydration. Correct answer.
  3. I should restrict all fluids to keep the output low.
  4. My stool will become firm and formed within a few days.

Explanation

Ileostomy effluent is liquid to semi-liquid because the colon, which normally reabsorbs water, has been bypassed or removed. High-volume output places the patient at risk for dehydration and electrolyte loss, so monitoring intake, output, and signs of hypovolemia is essential teaching.

Question 48Medical-Surgical Nursing

A patient is scheduled for surgery and reports an allergy to shellfish. Which preoperative concern is most relevant for the nurse to communicate to the surgical team?

  1. Risk of anaphylaxis to propofol induction
  2. Contraindication to peripheral intravenous cannulation
  3. Need to avoid all opioid analgesics
  4. Possible cross-reactivity with iodinated contrast or topical antiseptics containing iodine Correct answer.

Explanation

Shellfish allergy has been associated with reactions to iodinated contrast media and iodine-containing skin preparations, so the team should be alerted to allow premedication or an alternative agent. Documenting and communicating the allergy supports safe medication and procedure planning.

Question 49Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.8 mEq/L. Which action should the nurse take first?

  1. Obtain a 12-lead ECG and notify the provider immediately Correct answer.
  2. Encourage a high-potassium diet
  3. Administer a potassium-sparing diuretic
  4. Document the value and recheck in 24 hours

Explanation

Hyperkalemia of this magnitude can cause life-threatening dysrhythmias, so the priority is to assess cardiac conduction with an ECG and urgently notify the provider for treatment such as calcium, insulin with glucose, or a potassium binder. Assessment and escalation come before routine documentation.

Question 50Medical-Surgical Nursing

A patient with type 1 diabetes is found sweating, tremulous, and confused with a capillary glucose of 52 mg/dL. The patient is alert and able to swallow. Which action should the nurse take first?

  1. Give 15 grams of a fast-acting oral carbohydrate and recheck in 15 minutes Correct answer.
  2. Administer the next scheduled dose of long-acting insulin
  3. Start a continuous insulin infusion
  4. Encourage a high-fiber, low-sugar snack

Explanation

Symptomatic hypoglycemia in an alert patient who can swallow is treated with the rule of 15: about 15 grams of fast-acting carbohydrate, then recheck the glucose in 15 minutes and repeat if still low. Rapid correction prevents neuroglycopenic injury and seizures.