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Kuwait MOH Nurse Exam study materials
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Kuwait MOH Nurse Exam practice questions

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Question 1Fundamentals of Nursing and Basic Nursing Care

A nurse is preparing to administer an intramuscular injection to an adult client. Which site is generally preferred for routine immunizations and most adult IM injections because it carries a low risk of nerve injury?

  1. Ventrogluteal site Correct answer.
  2. Rectus femoris site
  3. Deltoid site
  4. Dorsogluteal site

Explanation

The ventrogluteal site is preferred for adult IM injections because it is well away from major nerves and blood vessels and has a reliable muscle mass. The dorsogluteal site carries sciatic nerve risk, the deltoid is used for smaller volumes, and the rectus femoris is typically an infant site.

Question 2Fundamentals of Nursing and Basic Nursing Care

A client is on strict bed rest. Which nursing action best prevents the development of pressure injuries over the sacrum?

  1. Massaging the reddened area every shift
  2. Applying a heating pad to the area
  3. Keeping the head of the bed elevated at 60 degrees
  4. Repositioning the client at least every two hours Correct answer.

Explanation

Regular repositioning relieves pressure on bony prominences and is the cornerstone of pressure injury prevention. Massage over reddened skin, heat, and prolonged high Fowler positioning all increase tissue damage or shear.

Question 3Fundamentals of Nursing and Basic Nursing Care

The nurse is measuring a client's blood pressure. Which action is correct when the cuff is placed on the client's arm?

  1. Position the cuff so the artery marker aligns with the brachial artery Correct answer.
  2. Have the client hold the arm below heart level
  3. Inflate the cuff rapidly to 300 mmHg regardless of baseline
  4. Place the cuff over the clothing sleeve

Explanation

The cuff bladder must be centered over the brachial artery with the marker aligned to it, and the arm supported at heart level. Cuffs should be on bare skin, inflation should be based on estimated systolic, and the arm should be at heart level.

Question 4Fundamentals of Nursing and Basic Nursing Care

Which technique is correct when the nurse performs hand hygiene with an alcohol-based hand rub?

  1. Apply to wet hands and rub until dry
  2. Apply to dry hands and rub until the product evaporates Correct answer.
  3. Use only when hands are visibly soiled
  4. Rinse hands with water after rubbing

Explanation

Alcohol-based hand rubs are applied to dry hands and rubbed until dry; water dilutes the product and reduces efficacy. They are not used when hands are visibly soiled, in which case soap and water are required.

Question 5Fundamentals of Nursing and Basic Nursing Care

A client is prescribed oxygen at 2 L/min via nasal cannula. Which nursing action is most important during oxygen therapy?

  1. Restrict oral fluids to prevent aspiration
  2. Assess the nares and skin behind the ears regularly Correct answer.
  3. Discontinue oxygen during meals
  4. Keep the client in a supine position at all times

Explanation

Oxygen delivery devices can cause skin breakdown and mucosal drying, so regular assessment of the nares and pressure points is essential. Fluids should be encouraged, positioning should support breathing, and oxygen is not routinely discontinued during meals.

Question 6Fundamentals of Nursing and Basic Nursing Care

The nurse is to obtain a wound culture from an open wound. Which action produces the most accurate specimen?

  1. Swab the crusted edges of the wound
  2. Obtain the specimen after antibiotics have been started
  3. Swab the wound after cleaning the surrounding skin and sampling the wound bed Correct answer.
  4. Collect the specimen after the wound has been irrigated with saline

Explanation

Cleaning surrounding skin and sampling viable wound bed tissue avoids contamination and yields accurate culture results. Irrigation before culture dilutes organisms, crusted edges contain colonizers, and antibiotics reduce recovery of pathogens.

Question 7Fundamentals of Nursing and Basic Nursing Care

A postoperative client has an indwelling urinary catheter. Which nursing action best reduces the risk of catheter-associated urinary tract infection?

  1. Irrigate the catheter every shift
  2. Change the catheter every 24 hours
  3. Keep the drainage bag below the level of the bladder Correct answer.
  4. Disconnect the tubing to obtain urine samples

Explanation

Keeping the drainage bag below bladder level prevents backflow of urine and reduces infection risk. Routine irrigation, unnecessary disconnection, and frequent catheter changes all increase infection risk.

Question 8Fundamentals of Nursing and Basic Nursing Care

The nurse is caring for a client who is at risk for aspiration. Which intervention is most appropriate during feeding?

  1. Encourage talking during meals
  2. Give thin liquids rapidly
  3. Feed the client while lying flat
  4. Position the client upright at 90 degrees and feed slowly Correct answer.

Explanation

An upright position with slow feeding reduces the risk of aspiration. Lying flat, rapid feeding of thin liquids, and talking during meals all increase aspiration risk.

Question 9Fundamentals of Nursing and Basic Nursing Care

Which finding indicates that a client's peripheral intravenous site has infiltrated?

  1. Cool, pale, swollen skin around the site Correct answer.
  2. Warm, reddened skin along the vein
  3. Blood return in the tubing
  4. A brisk flow rate with no complaints

Explanation

Infiltration occurs when fluid enters surrounding tissue, producing cool, pale, and swollen skin. Warmth and redness along the vein suggest phlebitis, and brisk flow with blood return indicates a patent line.

Question 10Fundamentals of Nursing and Basic Nursing Care

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

  1. Fresh green beans
  2. Canned soup Correct answer.
  3. Plain rice
  4. Fresh apples

Explanation

Canned soup is high in sodium because salt is added during processing. Fresh fruits, plain rice, and fresh vegetables are naturally low in sodium.

Question 11Fundamentals of Nursing and Basic Nursing Care

A client is on fall precautions. Which nursing action is most effective in preventing falls?

  1. Applying physical restraints
  2. Placing the call light within the client's reach Correct answer.
  3. Keeping the room dark at night
  4. Keeping all four side rails up at all times

Explanation

Ensuring the call light is within reach allows the client to summon help before attempting unsafe movement. Full side rails, restraints, and dark rooms increase fall risk and are not safe fall-prevention strategies.

Question 12Fundamentals of Nursing and Basic Nursing Care

The nurse is preparing to administer a medication through a nasogastric tube. Which action is correct?

  1. Verify tube placement before administration Correct answer.
  2. Crush enteric-coated tablets and mix with water
  3. Administer all medications together as a single bolus
  4. Flush with a small amount of air after each drug

Explanation

Tube placement must be verified before administering medications to prevent aspiration or misplacement complications. Enteric-coated tablets should not be crushed, medications should be given separately with flushes, and air flushes do not replace water flushes.

Question 13Fundamentals of Nursing and Basic Nursing Care

Which action demonstrates correct body mechanics when the nurse lifts a heavy object?

  1. Bend at the waist and twist the torso
  2. Lift with the arms extended away from the body
  3. Bend the knees, keep the back straight, and hold the object close Correct answer.
  4. Keep the feet close together and reach forward

Explanation

Bending the knees, keeping the back straight, and holding the load close uses the strong leg muscles and reduces spinal strain. Twisting, a narrow stance, and extended arms increase injury risk.

Question 14Fundamentals of Nursing and Basic Nursing Care

The nurse is assessing a client's level of consciousness using a standard scale. Which finding would be scored as the highest level of alertness?

  1. Responds to voice only
  2. Responds spontaneously to pain
  3. Opens eyes to painful stimulus
  4. Opens eyes spontaneously Correct answer.

Explanation

Spontaneous eye opening represents the highest level of arousal on the Glasgow Coma Scale. Responses to voice or pain indicate decreasing levels of consciousness.

Question 15Fundamentals of Nursing and Basic Nursing Care

A client is receiving a blood transfusion. Which finding should the nurse report immediately as a possible transfusion reaction?

  1. Chills, fever, and back pain Correct answer.
  2. A slight increase in appetite
  3. Mild fatigue after the transfusion
  4. A heart rate of 70 beats per minute

Explanation

Chills, fever, and back pain are classic signs of an acute hemolytic transfusion reaction and require immediate stopping of the transfusion and notification of the provider. The other findings are not indicative of a reaction.

Question 16Fundamentals of Nursing and Basic Nursing Care

The nurse is caring for a client with an order for strict intake and output monitoring. Which item should be included in the intake record?

  1. Urine output
  2. Vomitus
  3. Wound drainage
  4. Ice chips Correct answer.

Explanation

Ice chips are considered an oral intake and should be recorded, often as half their volume. Urine, vomitus, and wound drainage are outputs.

Question 17Fundamentals of Nursing and Basic Nursing Care

A client is to receive a subcutaneous injection of insulin. Which angle and site are appropriate for an average adult?

  1. 90 degrees into the dorsogluteal site
  2. 45 degrees into the deltoid
  3. 15 degrees into the forearm
  4. 90 degrees into the abdomen Correct answer.

Explanation

Insulin is typically given subcutaneously at a 90-degree angle into sites such as the abdomen. A 45-degree angle is used for thin clients or short needles, and 15 degrees is too shallow.

Question 18Fundamentals of Nursing and Basic Nursing Care

The nurse receives an order for a medication that is unclear. What is the most appropriate action?

  1. Clarify the order with the prescribing provider Correct answer.
  2. Hold the medication and document the order as given
  3. Ask another nurse to guess the dose
  4. Administer the medication as written

Explanation

Unclear or illegible orders must be clarified with the prescriber before administration to ensure client safety. Administering, guessing, or documenting without administering are all unsafe practices.

Question 19Fundamentals of Nursing and Basic Nursing Care

Which client is at greatest risk for developing a deep vein thrombosis during hospitalization?

  1. A client who is well hydrated
  2. A client who performs leg exercises hourly
  3. A client who has been immobilized after hip surgery Correct answer.
  4. A client who ambulates frequently

Explanation

Immobility after major orthopedic surgery is a major risk factor for DVT. Ambulation, hydration, and leg exercises all reduce venous stasis and risk.

Question 20Fundamentals of Nursing and Basic Nursing Care

The nurse is providing oral care to an unconscious client. Which action is most important?

  1. Perform oral care without inspecting the mouth
  2. Position the client in a side-lying position and use suction Correct answer.
  3. Use a toothbrush with the head elevated 90 degrees
  4. Give small sips of water to rinse

Explanation

An unconscious client should be side-lying with suction available to prevent aspiration of secretions during oral care. Oral fluids and an upright position are unsafe for an unconscious client.

Question 21Fundamentals of Nursing and Basic Nursing Care

The nurse is assessing a client's pain using a numeric rating scale. Which statement reflects appropriate use of this tool?

  1. Ask the client to rate pain from 0 to 10, with 0 being no pain Correct answer.
  2. Rate the pain based only on the nurse's observation
  3. Use the scale only for clients who can speak English
  4. Record the rating once per admission

Explanation

The numeric rating scale asks clients to rate pain from 0 (no pain) to 10 (worst pain) and is a self-report tool. Pain should be reassessed regularly and tools adapted for language or cognitive needs.

Question 22Fundamentals of Nursing and Basic Nursing Care

A client has a new colostomy. Which observation should the nurse report to the provider?

  1. Beefy red stoma
  2. Formed stool in the ostomy pouch
  3. Stoma that is dusky and cyanotic Correct answer.
  4. Small amount of serosanguineous drainage at the stoma edge

Explanation

A dusky or cyanotic stoma indicates compromised blood flow and ischemia and must be reported immediately. A beefy red stoma, minimal serosanguineous drainage, and formed stool are expected findings.

Question 23Fundamentals of Nursing and Basic Nursing Care

The nurse is caring for a client with a chest tube. Which finding indicates a problem requiring immediate intervention?

  1. Serosanguineous drainage in the collection chamber
  2. Tidaling of the fluid level with respiration
  3. Oscillation of the fluid level during breathing
  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. Tidaling and oscillation with respiration are normal, and serosanguineous drainage is expected.

Question 24Fundamentals of Nursing and Basic Nursing Care

The nurse is preparing to administer a medication via a peripherally inserted central catheter (PICC). Which action is essential before administration?

  1. Use a small-gauge needle to access the line
  2. Flush with sterile water only
  3. Verify catheter tip placement and patency Correct answer.
  4. Aspirate vigorously to confirm blood return

Explanation

Before using a PICC line, the nurse must confirm correct tip placement and patency to prevent complications. Vigorous aspiration can damage the catheter, and flushing should follow facility protocol with saline.

Question 25Fundamentals of Nursing and Basic Nursing Care

A client is admitted with dehydration. Which assessment finding is most consistent with this condition?

  1. Bounding pulse and moist mucous membranes
  2. Poor skin turgor and dry mucous membranes Correct answer.
  3. Crackles in the lung bases
  4. Peripheral edema and weight gain

Explanation

Dehydration produces poor skin turgor, dry mucous membranes, and often tachycardia and hypotension. Bounding pulses, edema, weight gain, and crackles suggest fluid overload.

Question 26Fundamentals of Nursing and Basic Nursing Care

A nurse is preparing to insert a nasogastric tube for a client who requires enteral feeding. Which action should the nurse take to verify correct placement of the tube before the initial feeding?

  1. Ask the client to speak and observe for hoarseness.
  2. Measure the pH of aspirated gastric fluid. Correct answer.
  3. Auscultate the epigastrium while injecting 30 mL of air into the tube.
  4. Place the end of the tube in water and look for bubbles.

Explanation

Measuring the pH of aspirated fluid is the most reliable bedside method for confirming nasogastric tube placement; gastric fluid typically has a pH of 5.5 or lower. Auscultation of injected air is no longer considered reliable because sounds can be transmitted from the esophagus or lungs. Placing the tube in water and looking for bubbles is used to detect esophageal placement during insertion but is not a definitive verification method. Asking the client to speak assesses for vocal cord irritation but does not confirm gastric placement.

Question 27Fundamentals of Nursing and Basic Nursing Care

The nurse is preparing to administer a medication via a peripherally inserted central catheter (PICC). Which action is essential to ensure client safety?

  1. Use a 10-mL syringe to check for blood return.
  2. Flush the catheter with sterile water before administration.
  3. Aspirate gently to confirm blood return before infusing. Correct answer.
  4. Apply firm pressure when flushing to clear any resistance.

Explanation

Aspirating gently to confirm blood return verifies that the catheter is still in the vascular space and functioning properly. Using a 10-mL syringe is recommended for flushing, but checking blood return is the priority safety action. Flushing with sterile water is incorrect because normal saline is used for flushing. Applying firm pressure when flushing is dangerous because it can dislodge a clot and cause embolism.

Question 28Fundamentals of Nursing and Basic Nursing Care

A nurse is performing a sterile dressing change for a client with a surgical wound. Which action demonstrates maintenance of sterile technique?

  1. Reaching across the sterile field to access supplies.
  2. Keeping the sterile field below waist level.
  3. Placing the sterile drape on a dry surface.
  4. Using sterile gloves to touch only sterile items. Correct answer.

Explanation

Sterile gloves must only contact sterile items to prevent contamination of the sterile field. The sterile field should be kept above waist level to remain visible and avoid contamination. Reaching across the sterile field can introduce microorganisms and is not allowed. The sterile drape should be placed on a clean, dry surface; a wet surface can cause contamination through capillary action.

Question 29Fundamentals of Nursing and Basic Nursing Care

The nurse is assessing a client's respiratory status. Which finding should be documented as normal vesicular breath sounds?

  1. Soft, low-pitched sounds heard over most of the lung fields. Correct answer.
  2. Crackling sounds heard at the lung bases.
  3. Medium-pitched sounds heard over the mainstem bronchi.
  4. Loud, high-pitched sounds heard over the trachea.

Explanation

Vesicular breath sounds are soft, low-pitched, and heard over most of the lung fields, especially the periphery. Bronchial breath sounds are loud and high-pitched and are heard over the trachea. Bronchovesicular sounds are medium-pitched and heard over the mainstem bronchi. Crackling sounds are adventitious and indicate fluid or secretions in the airways.

Question 30Fundamentals of Nursing and Basic Nursing Care

A client with a new ileostomy has a pouch that is leaking stool onto the skin. Which nursing action is the priority to prevent skin breakdown?

  1. Change the pouch only when it is full to minimize manipulation.
  2. Clean the skin with alcohol-based wipes before applying a new pouch.
  3. Use a larger pouch to accommodate the increased output.
  4. Apply a skin barrier paste to the peristomal skin before applying a new pouch. Correct answer.

Explanation

Applying a skin barrier paste protects the peristomal skin from stool, which is caustic and can cause breakdown. The pouch should be changed when it is one-third to one-half full or when leaking, not only when full. Alcohol-based wipes can dry and irritate the skin. A larger pouch does not prevent leakage and may increase the risk of skin exposure.

Question 31Medical-Surgical Nursing

A patient with a new colostomy has a stoma that is dark purple and dry 24 hours after surgery. Which action should the nurse take first?

  1. Document the finding as normal
  2. Notify the surgeon immediately Correct answer.
  3. Apply a new ostomy pouch
  4. Irrigate the stoma with saline

Explanation

A healthy stoma is pink to red and moist; dusky, dark purple, or dry tissue suggests ischemia and requires urgent surgical evaluation. Early recognition prevents necrosis and perforation. Normal documentation or pouch changes would delay needed intervention.

Question 32Medical-Surgical Nursing

Which finding is the earliest indicator of increased intracranial pressure in an adult?

  1. Fixed dilated pupils
  2. Change in level of consciousness Correct answer.
  3. Decerebrate posturing
  4. Widened pulse pressure

Explanation

A declining level of consciousness is typically the earliest sign of rising intracranial pressure because cortical function is affected first. Pupillary changes, widened pulse pressure, and posturing occur later as herniation progresses.

Question 33Medical-Surgical Nursing

A patient with heart failure is prescribed furosemide. Which laboratory value should the nurse monitor most closely?

  1. Serum potassium Correct answer.
  2. Serum bilirubin
  3. Serum calcium
  4. Serum creatinine only

Explanation

Loop diuretics such as furosemide cause potassium loss, and hypokalemia can precipitate dysrhythmias, especially in patients on digoxin. Potassium should be monitored and replaced as ordered.

Question 34Medical-Surgical Nursing

A patient is receiving a blood transfusion and develops fever, chills, and flank pain shortly after it begins. What is the nurse's priority action?

  1. Stop the transfusion and maintain IV access Correct answer.
  2. Recheck the vital signs in 15 minutes
  3. Administer the prescribed antipyretic
  4. Slow the transfusion rate

Explanation

Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction, which requires immediately stopping the transfusion while keeping the IV line patent with normal saline. The provider and blood bank must then be notified.

Question 35Medical-Surgical Nursing

Which position is most appropriate for a patient immediately after a lumbar laminectomy?

  1. Prone with pillows under the abdomen
  2. High Fowler with knees flexed
  3. Side-lying with the legs drawn up
  4. Flat supine with the head slightly elevated Correct answer.

Explanation

After lumbar surgery, a flat or slightly elevated supine position with a log-roll technique protects the surgical site and keeps the spine aligned. Prone or sharply flexed positions increase tension on the incision.

Question 36Medical-Surgical Nursing

A patient with type 1 diabetes has a blood glucose of 42 mg/dL and is conscious and able to swallow. Which action should the nurse take?

  1. Recheck glucose in one hour
  2. Start an IV dextrose infusion
  3. Give 15 g of oral carbohydrate Correct answer.
  4. Administer the next insulin dose

Explanation

For a conscious patient with hypoglycemia who can swallow, the rule of 15 applies: give about 15 g of fast-acting oral carbohydrate and recheck glucose in 15 minutes. IV dextrose is reserved for unresponsive patients or those unable to swallow.

Question 37Medical-Surgical Nursing

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

  1. Jugular venous distention
  2. Hepatomegaly
  3. Dependent peripheral edema
  4. Crackles and orthopnea Correct answer.

Explanation

Left-sided heart failure causes pulmonary congestion, producing crackles, dyspnea, and orthopnea. Right-sided failure produces systemic venous congestion such as edema, JVD, and hepatomegaly.

Question 38Medical-Surgical Nursing

A patient with a chest tube has continuous bubbling in the water-seal chamber. What does this indicate?

  1. Normal tidal movement
  2. An air leak in the system Correct answer.
  3. The suction is set too low
  4. The lung has fully re-expanded

Explanation

Continuous bubbling in the water-seal chamber indicates an air leak somewhere in the system, such as at the insertion site or tubing connections. Intermittent bubbling with respiration is normal, but continuous bubbling requires investigation.

Question 39Medical-Surgical Nursing

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which oxygen delivery approach is safest?

  1. Oxygen only during meals
  2. High-flow oxygen at 10 L/min via mask
  3. No supplemental oxygen unless unconscious
  4. Controlled low-flow oxygen to keep SpO2 near 88-92% Correct answer.

Explanation

In COPD with chronic hypercapnia, uncontrolled high-flow oxygen can worsen carbon dioxide retention and respiratory drive. Target saturation is typically 88-92% using controlled low-flow oxygen.

Question 40Medical-Surgical Nursing

Which symptom is most commonly associated with hyperthyroidism?

  1. Weight loss and heat intolerance Correct answer.
  2. Cold intolerance and dry skin
  3. Constipation and lethargy
  4. Weight gain and bradycardia

Explanation

Hyperthyroidism increases metabolic rate, producing weight loss despite appetite, heat intolerance, tachycardia, and anxiety. Weight gain, cold intolerance, and bradycardia reflect hypothyroidism.

Question 41Medical-Surgical Nursing

A patient with acute pancreatitis is prescribed nothing by mouth with IV fluids. What is the primary rationale for this intervention?

  1. To increase intestinal motility
  2. To promote gastric acid production
  3. To prevent aspiration pneumonia
  4. To reduce pancreatic enzyme stimulation Correct answer.

Explanation

Keeping the patient NPO rests the pancreas and reduces stimulation of pancreatic enzyme secretion, which decreases autodigestion and pain. IV fluids maintain hydration while the gland recovers.

Question 42Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.9 mEq/L. Which finding should the nurse anticipate?

  1. U waves on ECG
  2. Prolonged QT interval
  3. Prominent P waves
  4. Peaked T waves on ECG Correct answer.

Explanation

Hyperkalemia causes tall, peaked T waves and can progress to widened QRS and dysrhythmias. Peaked T waves are the classic early ECG change and require urgent treatment.

Question 43Medical-Surgical Nursing

Which instruction should the nurse give a patient starting warfarin therapy?

  1. Increase intake of green leafy vegetables
  2. Double the dose if a dose is missed
  3. Take aspirin for any minor pain
  4. Use a consistent diet and report unusual bleeding Correct answer.

Explanation

Warfarin interacts with vitamin K in green leafy vegetables, so intake should be consistent rather than increased or eliminated. Patients should report bleeding and avoid aspirin unless prescribed because of additive bleeding risk.

Question 44Medical-Surgical Nursing

A patient with a suspected hip fracture has the leg externally rotated and shortened. Which action is appropriate during transfer?

  1. Support the affected limb and avoid weight bearing Correct answer.
  2. Apply traction by pulling the affected leg
  3. Flex the hip to 90 degrees for comfort
  4. Have the patient bear weight as tolerated

Explanation

A suspected hip fracture requires immobilization and avoidance of weight bearing to prevent displacement and further injury. The limb should be supported and movement minimized until surgical evaluation.

Question 45Medical-Surgical Nursing

Which early sign of compartment syndrome should the nurse assess for after a lower leg fracture?

  1. Severe pain out of proportion to injury Correct answer.
  2. Cool, pale toes
  3. Diminished pedal pulse
  4. Loss of sensation in the foot

Explanation

The earliest and most reliable sign of compartment syndrome is severe pain that is disproportionate to the injury and worsens with passive stretch. Pulselessness, pallor, and sensory loss are late findings.

Question 46Medical-Surgical Nursing

A patient has a new diagnosis of epilepsy and is prescribed phenytoin. Which instruction is most important?

  1. Skip doses when seizure-free
  2. Maintain good oral hygiene and gum care Correct answer.
  3. Take the medication with grapefruit juice
  4. Stop the drug if a rash appears without telling anyone

Explanation

Phenytoin commonly causes gingival hyperplasia, so meticulous oral hygiene and regular dental care are important. The drug should never be stopped abruptly, and grapefruit juice can alter levels.

Question 47Medical-Surgical Nursing

Which finding in a patient with a head injury requires immediate intervention?

  1. Clear fluid draining from the nose Correct answer.
  2. One episode of nausea
  3. Sleepiness after a long day
  4. Mild headache relieved by rest

Explanation

Clear fluid from the nose or ears may be cerebrospinal fluid, indicating a basilar skull fracture and risk of meningitis. The nurse should test for glucose and notify the provider immediately.

Question 48Medical-Surgical Nursing

A patient with an ileostomy has had high-volume liquid output for two days. Which complication should the nurse monitor for?

  1. Respiratory acidosis and hypercalcemia
  2. Fluid volume deficit and metabolic acidosis Correct answer.
  3. Hyperkalemia and fluid overload
  4. Metabolic alkalosis and hypertension

Explanation

High-output ileostomies lose large amounts of sodium, potassium, and bicarbonate-rich fluid, leading to dehydration and metabolic acidosis. Monitoring intake, output, and electrolytes is essential.

Question 49Medical-Surgical Nursing

Which assessment finding is most consistent with a pneumothorax?

  1. Bilateral crackles
  2. Sudden sharp chest pain and decreased breath sounds on one side Correct answer.
  3. Bradycardia and hypertension
  4. Productive cough with pink sputum

Explanation

A pneumothorax typically causes sudden pleuritic chest pain, dyspnea, and absent or decreased breath sounds on the affected side. Tracheal deviation may occur with tension pneumothorax.

Question 50Medical-Surgical Nursing

A patient is receiving vancomycin intravenously and reports flushing and itching during the infusion. What is the nurse's best action?

  1. Slow the infusion rate and notify the provider Correct answer.
  2. Increase the rate to finish quickly
  3. Administer oral antihistamine and continue at the same rate
  4. Stop the infusion and call a code

Explanation

Flushing and itching during rapid vancomycin infusion suggest vancomycin infusion reaction (red man syndrome), which is managed by slowing the rate. The provider should be notified and the patient monitored.