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Lesotho Nursing Council Licensure Examination study materials
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Lesotho Nursing Council Licensure Examination practice questions

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Question 1Fundamentals of Nursing and Nursing Process

A nurse is preparing to insert a nasogastric tube. Which action best demonstrates the principle of maintaining medical asepsis during the procedure?

  1. Wearing a sterile gown and sterile gloves during insertion
  2. Sterilizing the tube with an autoclave before use
  3. Placing the patient in a sterile drape before the procedure
  4. Performing hand hygiene and wearing clean gloves before insertion Correct answer.

Explanation

Nasogastric tube insertion is a clean, not sterile, procedure; medical asepsis focuses on reducing organism transmission through hand hygiene and clean barriers. Sterile technique is reserved for procedures that break the body's primary defenses into sterile tissue.

Question 2Fundamentals of Nursing and Nursing Process

Which finding should the nurse document as a normal expected outcome when assessing a client's level of consciousness?

  1. Client is unresponsive to verbal and painful stimuli
  2. Client opens eyes to voice and answers questions appropriately Correct answer.
  3. Client requires painful stimuli to open eyes
  4. Client is drowsy and confused about time and place

Explanation

An alert client responds to normal voice and is oriented, which reflects intact cerebral function. Responses requiring painful stimulation or unresponsiveness indicate declining consciousness.

Question 3Fundamentals of Nursing and Nursing Process

A nurse is calculating a client's body mass index (BMI). Which data are required?

  1. Height and weight Correct answer.
  2. Blood pressure and pulse
  3. Temperature and respiratory rate
  4. Hemoglobin and hematocrit

Explanation

BMI is derived from a formula using weight in kilograms divided by height in meters squared. It reflects the relationship between body mass and stature.

Question 4Fundamentals of Nursing and Nursing Process

When measuring a client's blood pressure, the nurse should place the cuff at which level relative to the heart?

  1. At the level of the right atrium Correct answer.
  2. At the level of the xiphoid process
  3. Two centimeters above the antecubital fossa
  4. Below the level of the wrist

Explanation

The cuff should be positioned at the same level as the heart (right atrium) to obtain an accurate reading. Cuff placement above or below heart level alters the measured pressure.

Question 5Fundamentals of Nursing and Nursing Process

A nurse is teaching a client about the purpose of the nursing process. Which statement best describes its primary function?

  1. It provides a systematic framework for delivering individualized nursing care Correct answer.
  2. It documents only the tasks performed during a shift
  3. It replaces the physician's medical diagnosis and treatment plan
  4. It guarantees that all client health problems will be resolved

Explanation

The nursing process is a systematic, cyclical method of planning and delivering individualized care that promotes critical thinking. It complements rather than replaces medical practice and does not guarantee outcomes.

Question 6Fundamentals of Nursing and Nursing Process

Which statement by a nursing student indicates correct understanding of the purpose of the planning phase of the nursing process?

  1. It establishes measurable client goals and selects appropriate nursing interventions Correct answer.
  2. It identifies the client's medical diagnosis
  3. It evaluates whether the client met the expected outcomes
  4. It collects subjective and objective data about the client

Explanation

The planning phase prioritizes problems, formulates measurable goals and outcomes, and selects interventions. Data collection belongs to assessment, and evaluation determines goal attainment.

Question 7Fundamentals of Nursing and Nursing Process

A nurse is preparing to perform a bed bath for a dependent client. Which action protects the client's skin integrity during the bath?

  1. Using hot water to improve circulation to the skin
  2. Vigorously rubbing the skin with a coarse towel to remove dead cells
  3. Using lukewarm water and patting the skin dry rather than rubbing Correct answer.
  4. Applying a heavy layer of powder to all skin folds

Explanation

Lukewarm water and gentle patting preserve the skin barrier and reduce friction and moisture loss. Hot water and friction damage the epidermis and increase the risk of breakdown.

Question 8Fundamentals of Nursing and Nursing Process

Which action is the most important step in preventing the spread of infection in a healthcare setting?

  1. Changing gloves between tasks with the same client
  2. Disinfecting the floor of the client's room daily
  3. Performing hand hygiene before and after client contact Correct answer.
  4. Wearing a face mask at all times in the facility

Explanation

Hand hygiene is the single most effective measure for reducing transmission of microorganisms between clients and staff. Other measures are adjunctive and do not replace hand hygiene.

Question 9Fundamentals of Nursing and Nursing Process

A client reports pain rated 8 on a 0-to-10 scale and describes it as sharp and constant. According to the nursing process, this information is best documented in which phase?

  1. Evaluation
  2. Planning
  3. Assessment Correct answer.
  4. Implementation

Explanation

Subjective reports and objective findings gathered from the client constitute assessment data. This information then informs diagnosis, planning, and intervention.

Question 10Fundamentals of Nursing and Nursing Process

A nurse writes the following goal: 'Client will ambulate in the hallway by the end of shift.' Which element is missing that would make this goal measurable and complete?

  1. A specific distance or duration criterion Correct answer.
  2. The client's medical diagnosis
  3. The time the client last ate
  4. The name of the physician ordering ambulation

Explanation

A well-written outcome goal includes a measurable criterion such as distance, time, or frequency so attainment can be evaluated objectively. Without a criterion, evaluation is subjective.

Question 11Fundamentals of Nursing and Nursing Process

During the initial assessment, a nurse observes that a client grimaces when turning in bed but does not verbalize pain. Which action is most appropriate?

  1. Wait for the client to request pain medication
  2. Assume the grimace is related to anxiety and take no action
  3. Document that the client is not experiencing pain
  4. Ask the client directly about pain and use an appropriate pain scale Correct answer.

Explanation

Nonverbal cues such as grimacing are objective indicators that should prompt direct assessment using a validated pain scale. Pain is a subjective experience that requires client report whenever possible.

Question 12Fundamentals of Nursing and Nursing Process

A nurse is preparing to administer an oral medication to a client who is on aspiration precautions. Which action is most appropriate?

  1. Administer the medication while the client is lying flat with the head turned
  2. Position the client upright and offer the medication with a small amount of water Correct answer.
  3. Crush all medications and mix them with thin juice
  4. Place the client in a supine position before giving the medication

Explanation

An upright position with a small amount of water reduces the risk of aspiration during oral medication administration. Supine positioning increases aspiration risk.

Question 13Fundamentals of Nursing and Nursing Process

A nurse is assessing an older adult client's skin turgor to evaluate hydration status. Which site is most reliable in this population?

  1. The dorsum of the foot
  2. The lateral aspect of the forearm
  3. The skin over the sternum or forehead Correct answer.
  4. The back of the hand

Explanation

In older adults, skin elasticity decreases with age, so skin over the hand and forearm is unreliable for turgor assessment. The sternum or forehead provides a more accurate indication of hydration.

Question 14Fundamentals of Nursing and Nursing Process

A nurse is documenting care in the client record. Which entry reflects correct documentation practice?

  1. 'Provider probably ordered the wrong dose.'
  2. 'Client reports incisional pain rated 6/10 at 1400; repositioned and notified provider.' Correct answer.
  3. 'Client was a difficult patient today.'
  4. 'Client seems uncomfortable; will monitor.'

Explanation

Accurate documentation is objective, timely, specific, and includes the client's own report and actions taken. Subjective judgments, vague statements, and speculation are inappropriate.

Question 15Fundamentals of Nursing and Nursing Process

A nurse is implementing a fall-prevention plan for a client at high risk. Which intervention is most directly effective?

  1. Encouraging the client to walk unassisted to the bathroom
  2. Keeping the call light within reach and the bed in the lowest position Correct answer.
  3. Leaving the side rails down to allow independent mobility
  4. Applying physical restraints to all four extremities

Explanation

Keeping the call light accessible and the bed low reduces the likelihood of unassisted attempts to get up and of injury if a fall occurs. Restraints are a last resort and can increase injury risk.

Question 16Fundamentals of Nursing and Nursing Process

A nurse receives a telephone order from a provider. Which action is required to ensure safe practice?

  1. Accept the order and clarify it at the end of the shift
  2. Write the order without repeating it to the provider
  3. Ask another nurse to interpret the order later
  4. Read back the order to the provider and document it promptly Correct answer.

Explanation

Telephone orders must be read back to verify accuracy and documented promptly according to policy. Delaying clarification or interpretation risks medication errors.

Question 17Fundamentals of Nursing and Nursing Process

A nurse is measuring a client's intake and output. Which item should be recorded as output?

  1. Water taken with medications
  2. Ice chips consumed
  3. Urine and emesis Correct answer.
  4. Intravenous fluid infused

Explanation

Output includes measurable losses such as urine, emesis, wound drainage, and stool. Ice chips, IV fluids, and oral water are recorded as intake.

Question 18Fundamentals of Nursing and Nursing Process

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

  1. Maintaining a closed drainage system and keeping the bag below bladder level Correct answer.
  2. Resting the drainage bag on the floor beside the bed
  3. Irrigating the catheter routinely every shift
  4. Disconnecting the tubing to obtain urine samples daily

Explanation

A closed system with the bag below bladder level prevents backflow of urine and reduces bacterial entry. Routine irrigation and unnecessary disconnections increase infection risk.

Question 19Fundamentals of Nursing and Nursing Process

A nurse is teaching a client about deep breathing and coughing exercises after surgery. Which instruction is most appropriate?

  1. Splint the incision with a pillow while coughing Correct answer.
  2. Lie flat and refrain from moving during exercises
  3. Breathe rapidly and shallowly to reduce pain
  4. Avoid coughing unless fever develops

Explanation

Splinting the incision supports the wound, reduces pain, and encourages effective coughing to clear secretions. Shallow breathing and inactivity increase the risk of atelectasis and pneumonia.

Question 20Fundamentals of Nursing and Nursing Process

A nurse is evaluating whether a client has met the outcome 'Client will demonstrate correct use of an incentive spirometer within 24 hours.' Which finding indicates the goal was met?

  1. The nurse performs the exercise for the client each shift
  2. The client states the spirometer is uncomfortable
  3. The client independently performs the technique correctly and explains its purpose Correct answer.
  4. The client refuses to use the device

Explanation

Evaluation confirms goal attainment when the client demonstrates the behavior and understands its rationale. Nurse performance or refusal does not meet a client-centered outcome.

Question 21Fundamentals of Nursing and Nursing Process

A client's care plan lists the nursing diagnosis 'Risk for impaired skin integrity related to immobility.' Which evaluation finding best indicates the plan is effective?

  1. The client reports increased pain at the sacrum
  2. Skin remains intact over pressure points with no redness Correct answer.
  3. The client requests more time in bed
  4. A stage 1 pressure injury develops on the heel

Explanation

For a risk diagnosis, effectiveness is measured by absence of the problem, such as intact skin without pressure-related redness. Development of a pressure injury indicates the plan failed.

Question 22Fundamentals of Nursing and Nursing Process

A nurse is prioritizing care for four clients. Using Maslow's hierarchy, which client need should the nurse address first?

  1. A client asking for a blanket because of feeling cold
  2. A client requesting assistance to telephone family
  3. A client who wants to discuss discharge planning
  4. A client with an oxygen saturation of 86% Correct answer.

Explanation

Physiological needs, especially oxygenation, take priority over safety, belonging, and esteem needs in Maslow's hierarchy. A saturation of 86% signals hypoxia requiring immediate intervention.

Question 23Fundamentals of Nursing and Nursing Process

A nurse receives a client assignment and must delegate tasks to a nursing assistant. Which task is appropriate to delegate?

  1. Developing the client's nursing care plan
  2. Performing the initial admission assessment
  3. Measuring and recording a stable client's vital signs Correct answer.
  4. Evaluating whether the client met the pain goal

Explanation

Delegation to assistive personnel is limited to tasks within their training and scope, such as routine vital signs for stable clients. Assessment, planning, and evaluation require the registered nurse's judgment.

Question 24Fundamentals of Nursing and Nursing Process

A nurse notes that a client's documented care plan no longer matches the client's current condition. Which action reflects the correct use of the nursing process?

  1. Reassess the client and revise the plan based on current findings Correct answer.
  2. Discard the plan and rely on memory
  3. Continue the original plan until discharge
  4. Ask the nursing assistant to rewrite the plan

Explanation

The nursing process is dynamic and cyclical; reassessment should prompt revision of diagnoses, goals, and interventions. Continuing an outdated plan compromises care quality.

Question 25Fundamentals of Nursing and Nursing Process

A nurse is analyzing data for a client who has had no bowel movement in four days, reports abdominal discomfort, and has hypoactive bowel sounds. Which nursing diagnosis is most appropriate?

  1. Imbalanced nutrition: more than body requirements
  2. Diarrhea related to increased bowel motility
  3. Constipation related to decreased bowel motility Correct answer.
  4. Risk for infection related to inadequate hygiene

Explanation

The defining characteristics of infrequent stool, abdominal discomfort, and hypoactive bowel sounds support constipation related to decreased motility. The data do not support diarrhea or infection.

Question 26Fundamentals of Nursing and Nursing Process

A nurse is reviewing the components of the nursing process. Which phase involves collecting subjective and objective data about the client?

  1. Evaluation
  2. Planning
  3. Implementation
  4. Assessment Correct answer.

Explanation

The nursing process begins with assessment, which is the systematic collection of subjective and objective data. Planning involves setting goals and outcomes, implementation is carrying out interventions, and evaluation determines whether goals were met.

Question 27Fundamentals of Nursing and Nursing Process

A nurse is caring for a client who is on strict bed rest. Which action is most important for preventing pressure ulcers?

  1. Applying a heating pad to the sacrum
  2. Massaging reddened areas over bony prominences
  3. Repositioning the client every 2 hours Correct answer.
  4. Limiting the client's fluid intake

Explanation

Repositioning at regular intervals relieves pressure on bony prominences and is a key intervention for pressure ulcer prevention. Massaging reddened areas can cause further tissue damage, heat increases metabolic demand, and limiting fluids can lead to dehydration and impaired skin integrity.

Question 28Fundamentals of Nursing and Nursing Process

A nurse is formulating a nursing diagnosis for a client who is experiencing acute pain. Which component is essential to include in the diagnostic statement?

  1. Etiology (related factors) Correct answer.
  2. Client's cultural background
  3. Medical diagnosis
  4. Nurse's intuition

Explanation

A nursing diagnostic statement includes the problem, the etiology (related factors), and defining characteristics. The etiology identifies the cause or contributing factors that the nurse can address through interventions.

Question 29Fundamentals of Nursing and Nursing Process

A nurse is implementing a care plan for a client with impaired mobility. Which intervention is a direct nursing action?

  1. Assisting the client to perform range-of-motion exercises Correct answer.
  2. Requesting a social work evaluation for home safety
  3. Consulting with the dietitian about nutritional needs
  4. Referring the client to physical therapy

Explanation

Direct nursing actions are interventions performed by the nurse with the client, such as assisting with range-of-motion exercises. Referrals and consultations are indirect actions that involve other members of the healthcare team.

Question 30Fundamentals of Nursing and Nursing Process

A nurse is evaluating a client's response to a new medication. Which finding best indicates that the goal 'Client will report pain relief within 30 minutes of medication administration' has been met?

  1. The nurse documents that the medication was given at the scheduled time.
  2. The nurse observes that the client is sleeping.
  3. The client's family reports that the client seems more comfortable.
  4. The client states that the pain is now a 3 on a 0-to-10 scale. Correct answer.

Explanation

Evaluation compares the client's actual response to the expected outcome. A self-report of reduced pain intensity directly reflects the goal of pain relief. Documentation of administration, family observation, and sleep are indirect or unrelated indicators.

Question 31Medical-Surgical Nursing

A patient is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the therapeutic effect of the drug?

  1. Activated partial thromboplastin time (aPTT) Correct answer.
  2. Platelet count
  3. Prothrombin time (PT)
  4. International normalized ratio (INR)

Explanation

Unfractionated heparin potentiates antithrombin and prolongs the intrinsic clotting pathway, which is measured by the aPTT. The PT and INR reflect the extrinsic pathway and are used to monitor warfarin, not heparin. Platelet count is monitored to detect heparin-induced thrombocytopenia but does not measure anticoagulant effect.

Question 32Medical-Surgical Nursing

A patient with a new ileostomy is being taught about diet. Which instruction should the nurse include to help control output?

  1. Restrict all fluids to 1 liter per day
  2. Drink fluids liberally with meals to soften stool
  3. Increase intake of high-fiber foods such as nuts and raw vegetables
  4. Chew food thoroughly and eat at regular intervals Correct answer.

Explanation

Chewing thoroughly and eating regularly helps the small intestine absorb nutrients and reduces the risk of obstruction with an ileostomy. High-fiber foods such as nuts and raw vegetables can obstruct a new stoma and are usually restricted initially. Fluids are important but should not be taken in large volumes with meals, and severe fluid restriction risks dehydration.

Question 33Medical-Surgical Nursing

A patient with chronic obstructive pulmonary disease has an oxygen saturation of 86% on room air. Which oxygen delivery approach is most appropriate?

  1. Intermittent oxygen only during meals
  2. No oxygen, because it may suppress the respiratory drive
  3. Titrated low-flow oxygen to a target saturation of 88% to 92% Correct answer.
  4. High-flow 100% oxygen by nonrebreather mask

Explanation

In COPD, oxygen should be titrated to a target saturation of about 88% to 92% to correct hypoxemia while avoiding hyperoxia and carbon dioxide retention. High concentrations of oxygen can worsen hypercapnia in patients with chronic retention. Withholding oxygen from a hypoxemic patient is unsafe.

Question 34Medical-Surgical Nursing

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

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

Explanation

A declining level of consciousness is typically the earliest sign of rising intracranial pressure, reflecting impaired cerebral perfusion and function. Pupillary changes, posturing, and Cushing triad (hypertension, bradycardia, irregular respirations) are later, more ominous signs.

Question 35Medical-Surgical Nursing

A patient is admitted with diabetic ketoacidosis. Which order should the nurse implement first?

  1. Begin a 0.9% sodium chloride infusion Correct answer.
  2. Draw serum electrolytes and blood glucose
  3. Administer intravenous regular insulin per protocol
  4. Insert a urinary catheter for strict output measurement

Explanation

Initial management of DKA prioritizes intravascular volume replacement with isotonic saline before insulin, because dehydration and hypoperfusion must be corrected first. Insulin is then given after volume resuscitation and potassium assessment. Electrolytes and glucose are drawn promptly but do not precede fluid resuscitation in priority.

Question 36Medical-Surgical Nursing

A patient is receiving digoxin for heart failure. Which finding should prompt the nurse to hold the dose and notify the provider?

  1. Weight gain of 0.5 kg over one week
  2. Serum potassium of 4.2 mEq/L
  3. Apical heart rate of 52 beats per minute Correct answer.
  4. Blood pressure of 128/76 mm Hg

Explanation

Digoxin slows conduction through the atrioventricular node, and a heart rate below 60 beats per minute is a common reason to withhold the dose pending provider review. Normal potassium and blood pressure do not contraindicate the drug. A small weekly weight change is not an acute concern.

Question 37Medical-Surgical Nursing

A patient is being taught about a low-purine diet for gout. Which food should the patient be advised to limit?

  1. Organ meats such as liver Correct answer.
  2. White rice
  3. Fresh apples
  4. Olive oil

Explanation

Purines are metabolized to uric acid, and organ meats are among the richest dietary sources, so they should be limited in gout. Fruits, refined grains, and most oils are low in purines and do not raise uric acid appreciably.

Question 38Medical-Surgical Nursing

A patient has a chest tube connected to a water-seal drainage system. The nurse observes continuous bubbling in the water-seal chamber. What is the most appropriate interpretation?

  1. The suction is set too low
  2. The tube should be clamped immediately and left clamped
  3. This is expected and indicates the system is working
  4. There is an air leak in the system or from the lung Correct answer.

Explanation

Continuous bubbling in the water-seal chamber indicates air is entering the system, either from a leak in the tubing or connections or from an ongoing pleural air leak. Intermittent bubbling with coughing or exhalation is normal, but continuous bubbling requires assessment for a leak. Clamping a chest tube without an order can cause tension pneumothorax.

Question 39Medical-Surgical Nursing

A patient with acute pancreatitis is prescribed nothing by mouth and nasogastric suction. Which nursing action best promotes comfort and pancreatic rest?

  1. Encourage small sips of clear fluids
  2. Apply warm compresses to the abdomen during pain
  3. Administer prescribed analgesics and maintain NPO status Correct answer.
  4. Place the patient in a supine position after meals

Explanation

Pancreatic rest is achieved by keeping the patient NPO and providing analgesia, which reduces pancreatic enzyme secretion and pain. Fluids by mouth stimulate enzyme release and should be avoided during the acute phase. Positioning and heat do not rest the pancreas.

Question 40Medical-Surgical Nursing

Which instruction should the nurse give a patient scheduled for a colonoscopy regarding bowel preparation?

  1. Take iron supplements to prevent anemia during preparation
  2. Follow the prescribed clear-liquid diet and bowel-cleansing regimen Correct answer.
  3. Stop all medications including antihypertensives
  4. Eat a normal breakfast on the morning of the procedure

Explanation

Adequate bowel cleansing requires adherence to the prescribed clear-liquid diet and laxative preparation so the mucosa can be visualized. Iron supplements darken stool and impair visualization and are usually stopped beforehand. Antihypertensives are generally continued, and a normal breakfast would defeat the preparation.

Question 41Medical-Surgical Nursing

A patient is 24 hours after a total hip replacement. Which action should the nurse include in the plan of care to prevent dislocation?

  1. Allow the patient to bend the hip beyond 90 degrees to stretch
  2. Maintain an abduction pillow between the legs when in bed Correct answer.
  3. Encourage crossing the legs at the knees when sitting
  4. Position the patient on the operative side immediately after surgery

Explanation

An abduction pillow keeps the legs apart and prevents adduction, which is a primary mechanism of hip prosthesis dislocation. Crossing the legs, flexing the hip beyond 90 degrees, and lying on the operative side early all increase dislocation risk.

Question 42Medical-Surgical Nursing

A patient with a spinal cord injury at T6 suddenly reports a severe pounding headache and has a blood pressure of 200/110 mm Hg with bradycardia. What should the nurse do first?

  1. Check the blood glucose level
  2. Raise the head of the bed to a sitting position Correct answer.
  3. Apply sequential compression devices to the legs
  4. Give a prescribed analgesic for headache

Explanation

These findings suggest autonomic dysreflexia, a life-threatening emergency triggered by a noxious stimulus below the injury level. The first action is to sit the patient upright to lower blood pressure while identifying and removing the trigger, such as a full bladder. Analgesics and glucose checks do not address the hypertensive crisis.

Question 43Medical-Surgical Nursing

A patient is in the early postoperative period after abdominal surgery and reports sudden shortness of breath and chest pain. Which complication should the nurse suspect first?

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

Explanation

Sudden dyspnea and pleuritic chest pain after surgery suggest pulmonary embolism, a venous thromboembolism that can be fatal and requires immediate evaluation. Atelectasis causes gradual hypoxemia and fever but not typically acute chest pain. Dehiscence and ileus present with wound or abdominal findings, not acute respiratory distress.

Question 44Medical-Surgical Nursing

Which assessment finding is characteristic of hypocalcemia after thyroidectomy?

  1. Hypertension with tachycardia
  2. Positive Chvostek sign Correct answer.
  3. Warm, flushed skin
  4. Hyperactive deep tendon reflexes absent

Explanation

Accidental parathyroid injury during thyroidectomy can cause hypocalcemia, producing neuromuscular irritability such as a positive Chvostek or Trousseau sign, tingling, and tetany. Hypertension and tachycardia are not typical, and warm flushed skin is unrelated.

Question 45Medical-Surgical Nursing

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

  1. Administer oral potassium chloride
  2. Administer a loop diuretic only after dialysis
  3. Encourage a high-potassium diet
  4. Give intravenous calcium gluconate Correct answer.

Explanation

Severe hyperkalemia threatens cardiac conduction, and intravenous calcium gluconate is given first to stabilize the myocardium while measures to shift and remove potassium are initiated. Oral potassium would worsen the problem. Diuretics may be used but do not provide immediate cardiac protection.

Question 46Medical-Surgical Nursing

A patient with an acute exacerbation of asthma is using accessory muscles and has a peak expiratory flow below baseline. Which medication should the nurse expect to administer for rapid relief?

  1. Inhaled albuterol Correct answer.
  2. Oral prednisone
  3. Inhaled fluticasone
  4. Oral montelukast

Explanation

Short-acting beta-2 agonists such as albuterol provide rapid bronchodilation and are the first-line rescue medication for acute bronchospasm. Montelukast and fluticasone are controller medications without rapid onset. Prednisone reduces inflammation but does not relieve bronchospasm immediately.

Question 47Medical-Surgical Nursing

A patient is receiving a blood transfusion. Ten minutes into the infusion the patient develops fever, chills, and flank pain. What should the nurse do first?

  1. Document the reaction and continue the transfusion as ordered
  2. Administer the prescribed antihistamine and continue the transfusion
  3. Slow the transfusion rate and reassess in 15 minutes
  4. Stop the transfusion and maintain intravenous access with normal saline Correct answer.

Explanation

Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction, which requires immediately stopping the transfusion and keeping the line patent with normal saline to treat shock. The blood bank and provider are notified and the unit is returned for investigation. Slowing or continuing the transfusion allows further hemolysis.

Question 48Medical-Surgical Nursing

A patient is admitted with a suspected bowel obstruction and has vomiting and abdominal distention. Which finding should the nurse report immediately?

  1. Bowel sounds that are high-pitched and tinkling
  2. Mild nausea relieved by antiemetics
  3. Absence of bowel sounds with a rigid, board-like abdomen Correct answer.
  4. Passage of a small amount of flatus

Explanation

A rigid, board-like abdomen with absent bowel sounds suggests peritonitis or perforation, a surgical emergency that must be reported at once. High-pitched tinkling sounds are typical of mechanical obstruction and are expected. Mild nausea and passage of flatus do not indicate deterioration.

Question 49Medical-Surgical Nursing

Which laboratory value is most important for the nurse to monitor in a patient taking furosemide?

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

Explanation

Furosemide is a loop diuretic that causes potassium loss, so hypokalemia is a common and dangerous adverse effect. Calcium, bilirubin, and amylase are not the primary electrolytes affected by loop diuretics.

Question 50Medical-Surgical Nursing

A patient with a new below-the-knee amputation has a rigid, tense, and painful residual limb. What should the nurse do first?

  1. Elevate the limb and notify the provider immediately Correct answer.
  2. Loosen the compression bandage and reassess in an hour
  3. Apply a warm compress and massage the limb
  4. Encourage the patient to bear weight on the limb

Explanation

A rigid, tense, and painful residual limb suggests compartment syndrome or hematoma, which threatens tissue viability and requires immediate provider notification. Warm compresses and massage can worsen bleeding, and delayed reassessment risks tissue loss.