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MNB/LJM Nursing Examination study materials
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MNB/LJM Nursing Examination practice questions

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Question 1Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to insert a peripheral IV catheter. Which action follows the principle of asepsis during the procedure?

  1. Palpating the cleaned site repeatedly with a bare index finger to confirm the vein
  2. Wearing clean gloves only after the catheter has entered the vein
  3. Applying the tourniquet after the skin has been prepped and dried
  4. Cleaning the insertion site with an antiseptic and allowing it to dry completely before puncture Correct answer.

Explanation

Skin antisepsis requires friction with an approved agent and full air-drying time so the antimicrobial effect develops before the needle punctures the skin. Re-palpating after prep contaminates the field and is avoided unless a sterile glove is used. The tourniquet is applied before prepping so the site is not re-contaminated.

Question 2Fundamentals of Nursing and Basic Nursing Skills

A nurse is measuring a patient's blood pressure with a manual cuff. Which finding indicates the cuff size is too small for the patient's arm?

  1. A reading that is falsely elevated compared with an appropriately sized cuff Correct answer.
  2. A systolic reading equal to the palpated radial pressure
  3. An absent Korotkoff sound during deflation
  4. A reading that is falsely lowered compared with an appropriately sized cuff

Explanation

An undersized bladder does not compress the artery uniformly, so higher pressure is needed to occlude it and the reading is falsely high. The bladder should encircle about 80 percent of the arm circumference. Using the wrong size systematically biases the measurement.

Question 3Fundamentals of Nursing and Basic Nursing Skills

A patient is on strict intake and output measurement. Which item should the nurse record as intake?

  1. Ice chips consumed at the bedside Correct answer.
  2. Blood drawn for laboratory testing
  3. Drainage from a surgical wound
  4. Vomit collected in an emesis basin

Explanation

Ice chips melt to approximately half their volume of water and are counted as oral intake. Emesis, wound drainage, and blood specimens are output or losses. Accurate intake and output records include all routes by which fluid enters the body.

Question 4Fundamentals of Nursing and Basic Nursing Skills

A nurse is repositioning a bedbound patient to prevent pressure injury. Which schedule is appropriate for turning an adult at moderate risk?

  1. Reposition at least every two hours and adjust based on tissue tolerance Correct answer.
  2. Reposition only when the skin shows visible redness
  3. Reposition once per shift unless the patient requests a change
  4. Reposition every eight hours during the night to protect sleep

Explanation

Pressure injury prevention relies on regularly relieving pressure before tissue damage occurs, commonly at least every two hours for adults at risk, with frequency individualized to tissue tolerance and support surface. Waiting for redness means damage has already begun. Shift-length intervals are far too long for a patient at risk.

Question 5Fundamentals of Nursing and Basic Nursing Skills

A nurse is performing hand hygiene with an alcohol-based rub. Which step is essential for effectiveness?

  1. Apply the product only to the palms and backs of the hands
  2. Dry the hands with a paper towel immediately after applying the product
  3. Rinse the hands with water after the rub to remove residue
  4. Rub all surfaces of the hands until the product has dried completely Correct answer.

Explanation

Alcohol-based hand rub must remain on the skin until it evaporates so contact time is sufficient to reduce microorganisms. All surfaces, including fingertips, thumbs, and between fingers, need coverage. Toweling or rinsing removes the product before it has acted.

Question 6Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to administer an intramuscular injection into the ventrogluteal site. How should the nurse locate this site?

  1. Place the palm on the greater trochanter with the index finger on the anterior superior iliac spine and inject in the center of the V formed by the middle finger Correct answer.
  2. Inject two fingerbreadths below the acromion process of the shoulder
  3. Inject into the middle third of the anterior thigh
  4. Inject into the upper outer quadrant of the buttock below the iliac crest

Explanation

The ventrogluteal site is identified by placing the palm on the greater trochanter, the index finger on the anterior superior iliac spine, and the middle finger along the iliac crest, injecting in the center of the V. It is preferred for adults because it is away from major nerves and blood vessels. The dorsogluteal and deltoid sites are located differently.

Question 7Fundamentals of Nursing and Basic Nursing Skills

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

  1. Irrigating the catheter routinely every shift to keep it patent
  2. Disconnecting the tubing daily to allow the bladder to empty freely
  3. Hanging the drainage bag on the side rail above the bladder
  4. Maintaining a closed drainage system and keeping the bag below bladder level Correct answer.

Explanation

A closed system with the bag below bladder level prevents urine backflow and limits entry of organisms. Routine irrigation and unnecessary disconnections break the closed system and increase infection risk. Gravity drainage depends on the bag remaining lower than the bladder.

Question 8Fundamentals of Nursing and Basic Nursing Skills

A nurse is verifying a patient's identity before giving a medication. Which identifiers are acceptable?

  1. Room number and bed position
  2. Full name and date of birth checked against the identification band Correct answer.
  3. The patient's appearance and stated age
  4. The patient's stated diagnosis and physician name

Explanation

Two independent identifiers, typically full name and date of birth, must be verified against the identification band or barcode before medication administration. Room or bed numbers change and are not unique identifiers. Physical appearance is unreliable and unsafe.

Question 9Fundamentals of Nursing and Basic Nursing Skills

A nurse is assessing a patient who reports new shortness of breath. Which set of vital signs should prompt the most urgent escalation?

  1. Respiratory rate 30 breaths per minute with oxygen saturation 88% on room air Correct answer.
  2. Heart rate 88 beats per minute with blood pressure 124/78 mmHg
  3. Temperature 37.4 degrees Celsius with respiratory rate 16 breaths per minute
  4. Respiratory rate 18 breaths per minute with oxygen saturation 96% on room air

Explanation

A respiratory rate of 30 with saturation of 88 percent indicates significant respiratory compromise and requires immediate assessment and intervention. Normal adult values are roughly 12 to 20 breaths per minute with saturation above 94 percent. The other sets fall within expected ranges.

Question 10Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to give a subcutaneous injection of insulin. Which technique is correct?

  1. Insert the needle at a 15-degree angle without pinching the skin
  2. Insert the needle at a 45- to 90-degree angle into pinched subcutaneous tissue using a short needle Correct answer.
  3. Insert the needle at a 90-degree angle deep into the deltoid muscle
  4. Insert the needle at a 5-degree angle and inject into the dermis

Explanation

Subcutaneous tissue lies beneath the dermis and is reached with a short needle at 45 to 90 degrees, often into tissue gently pinched to lift it away from muscle. Injecting too shallowly deposits drug in the dermis and too deeply reaches muscle, both altering absorption. A 90-degree angle into the deltoid describes an intramuscular route.

Question 11Fundamentals of Nursing and Basic Nursing Skills

A patient with a new colostomy asks how to care for the stoma and pouch. Which instruction is accurate?

  1. Change the pouch only when it leaks, regardless of skin condition
  2. Clean the stoma and surrounding skin with mild soap and water, then dry before applying a new pouch Correct answer.
  3. Leave the skin moist and apply the pouch over wet skin for better adhesion
  4. Scrub the stoma vigorously with alcohol to keep it sterile

Explanation

The stoma and peristomal skin are cleansed gently with mild soap and water and patted dry so the skin barrier adheres properly. Alcohol and vigorous scrubbing damage the mucosa. A pouching system is changed on a schedule and whenever leakage threatens the skin.

Question 12Fundamentals of Nursing and Basic Nursing Skills

A nurse is caring for a patient with dysphagia who is at risk for aspiration. Which action is most appropriate during meals?

  1. Position the patient upright and offer small bites of texture-modified food with chin tuck as directed Correct answer.
  2. Withhold all oral intake without notifying the care team
  3. Place the patient in a semi-reclined position and offer large bites
  4. Encourage the patient to drink thin liquids quickly to clear the throat

Explanation

Upright positioning, small bites, and prescribed texture modification reduce the risk of food entering the airway, and a chin-tuck maneuver may be recommended by speech therapy. Rapid thin-liquid intake and reclined positioning increase aspiration risk. Withholding all intake unilaterally is outside nursing scope and harmful.

Question 13Fundamentals of Nursing and Basic Nursing Skills

A nurse is teaching a patient about a new prescription for warfarin. Which statement by the patient indicates correct understanding?

  1. I will stop the medication as soon as I feel better
  2. I will take aspirin for headaches without asking my provider
  3. I will double my dose whenever I forget a dose to catch up
  4. I will keep my intake of leafy green vegetables consistent and report unusual bruising or bleeding Correct answer.

Explanation

Warfarin's effect is influenced by vitamin K from leafy greens, so consistent intake helps keep anticoagulation stable, and bleeding precautions are essential. Doubling doses risks dangerous over-anticoagulation. Aspirin adds antiplatelet effect and bleeding risk, and stopping abruptly without direction is unsafe.

Question 14Fundamentals of Nursing and Basic Nursing Skills

A nurse is documenting a fall-risk assessment. Which patient factor most strongly increases fall risk?

  1. Adequate lighting in the patient's room
  2. Recent use of a sedative medication with an unsteady gait Correct answer.
  3. A stable, independent gait with no assistive device
  4. Normal vision corrected with eyeglasses

Explanation

Sedating medications impair alertness and balance, and an unsteady gait adds further risk, making this combination the strongest predictor of falling. Intact gait, corrected vision, and good lighting are protective rather than risk factors. Fall risk is multifactorial but these features are clearly high-risk.

Question 15Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to insert a nasogastric tube for decompression. Which action is correct before insertion?

  1. Measure from the tip of the nose to the earlobe to the xiphoid process to estimate insertion depth Correct answer.
  2. Ask the patient to hyperextend the neck during insertion
  3. Measure from the earlobe to the umbilicus to determine depth
  4. Insert the tube while the patient is lying flat and asleep

Explanation

The nose-earlobe-xiphoid measurement estimates the distance to the stomach so the tube is advanced to the correct depth. Neck hyperextension narrows the esophagus and increases difficulty and injury risk. The patient should be awake and cooperative, often with the head slightly flexed.

Question 16Fundamentals of Nursing and Basic Nursing Skills

A nurse is providing a bed bath to a dependent patient. Which action protects the patient's skin and dignity?

  1. Wash the entire body at once with the patient fully uncovered
  2. Use very hot water to improve cleanliness
  3. Skip perineal care to avoid embarrassing the patient
  4. Expose only the body part being washed and keep the rest covered with a bath blanket Correct answer.

Explanation

Exposing only the area being washed maintains warmth and privacy while reducing unnecessary skin exposure. Very hot water strips protective oils and can burn. Perineal care is a necessary hygiene measure performed professionally with the patient's comfort in mind.

Question 17Fundamentals of Nursing and Basic Nursing Skills

A nurse is assessing a patient with dehydration. Which finding is most consistent with this condition?

  1. Moist mucous membranes with dilute urine
  2. Bounding pulse with clear, pale urine output
  3. Dry mucous membranes with concentrated dark urine and decreased skin turgor Correct answer.
  4. Weight gain of two kilograms over two days

Explanation

Dehydration reduces body water, producing dry mucous membranes, concentrated urine from renal water conservation, and reduced skin turgor. Bounding pulses and dilute urine suggest fluid excess rather than deficit. Rapid weight gain reflects fluid retention.

Question 18Fundamentals of Nursing and Basic Nursing Skills

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

  1. Administer the drug with the feeding running continuously at full rate
  2. Give the medication rapidly to prevent clogging of the tube
  3. Mix the medication directly into the enteral feeding formula
  4. Stop the feeding, verify tube placement, flush with water, give the medication, and flush again Correct answer.

Explanation

Enteral medications are given with the feeding paused, placement confirmed, and water flushes before and after to prevent clogging and drug-food interactions. Mixing drugs into formula alters absorption and can occlude the tube. Rapid administration can cause intolerance.

Question 19Fundamentals of Nursing and Basic Nursing Skills

A nurse is assessing a patient's pain using a numeric rating scale. The patient reports a score of 8 out of 10. Which action is most appropriate?

  1. Document the score and wait for the next scheduled dose time
  2. Withhold analgesia because the patient is not grimacing
  3. Tell the patient that an 8 is not as high as it could be
  4. Administer the prescribed analgesic and reassess the pain after an appropriate interval Correct answer.

Explanation

The patient's self-report is the most reliable pain indicator, and severe pain warrants the prescribed analgesic with reassessment to confirm effect. Waiting for a scheduled time leaves severe pain untreated. Behavior such as grimacing is not required to validate the report.

Question 20Fundamentals of Nursing and Basic Nursing Skills

A nurse is caring for a patient with an intravenous infusion. Which finding should be reported immediately?

  1. A patent catheter that flushes without resistance
  2. A dry, intact dressing over the insertion site
  3. Swelling, coolness, and pain at the insertion site with slowed flow Correct answer.
  4. Clear fluid infusing at the prescribed rate

Explanation

Swelling, coolness, and pain with slowed flow suggest infiltration or extravasation, in which fluid enters surrounding tissue and can cause serious harm. The infusion must be stopped and reported promptly. The other findings are normal and indicate a functioning line.

Question 21Fundamentals of Nursing and Basic Nursing Skills

A nurse is assessing a patient after a fall. The patient is alert, reports no pain, and has no visible injury, but takes an anticoagulant. Which action is most appropriate?

  1. Help the patient back to bed and reassess only if symptoms appear later
  2. Document that no injury occurred and continue routine care without further assessment
  3. Perform a full neurologic and injury assessment and notify the provider about the anticoagulant use Correct answer.
  4. Apply ice to the head and discharge the patient from further monitoring

Explanation

Anticoagulation raises the risk of concealed bleeding, including intracranial hemorrhage, after a fall even without immediate symptoms. A thorough assessment and provider notification allow appropriate monitoring or imaging. Relying on the absence of pain misses delayed bleeding.

Question 22Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to administer a high-alert medication. Which practice best reduces the risk of a serious error?

  1. Relying on memory of the usual dose for this medication
  2. Skipping the check when the unit is busy to save time
  3. Preparing the medication in advance for several patients at once
  4. Independent double-check of the drug, dose, and pump settings by a second nurse Correct answer.

Explanation

High-alert medications carry a heightened risk of significant harm, so an independent double-check of the drug, dose, and infusion settings by a second qualified clinician is a key safeguard. Preparing doses for multiple patients at once increases mix-ups. Memory and time pressure are not acceptable substitutes for verification.

Question 23Fundamentals of Nursing and Basic Nursing Skills

A nurse is caring for a patient receiving oxygen by nasal cannula who becomes increasingly drowsy with a falling respiratory rate. Which interpretation is most accurate?

  1. The patient is sleeping comfortably and should not be disturbed
  2. The drowsiness is expected and requires no action because oxygen is being given
  3. The falling respiratory rate indicates the oxygen flow should be increased without assessment
  4. The patient may be retaining carbon dioxide and requires prompt assessment and provider notification Correct answer.

Explanation

Increasing drowsiness with a declining respiratory rate in a patient on oxygen can signal carbon dioxide retention and impending respiratory failure, particularly in those with chronic lung disease. Prompt assessment, including oxygenation and ventilation status, and provider notification are needed. Simply raising oxygen without evaluation can worsen retention.

Question 24Fundamentals of Nursing and Basic Nursing Skills

A nurse is teaching a patient how to perform incentive spirometry after abdominal surgery. Which instruction supports effective use?

  1. Sit upright, exhale normally, seal the mouthpiece, and inhale slowly to raise the marker, holding the breath briefly Correct answer.
  2. Lie flat and breathe rapidly through the nose into the device
  3. Perform the exercise once daily to avoid fatigue
  4. Inhale as quickly and forcefully as possible to raise the marker

Explanation

Incentive spirometry works by sustained slow maximal inspiration, which re-expands alveoli and prevents atelectasis, and upright positioning improves lung expansion. Rapid forceful breaths and nasal breathing do not achieve sustained inflation. Frequency should follow the prescribed schedule, typically several times an hour while awake.

Question 25Fundamentals of Nursing and Basic Nursing Skills

A nurse is assessing a patient with a stage 2 pressure injury over the sacrum. Which description is consistent with this stage?

  1. Full-thickness loss with visible subcutaneous fat but no exposed structures
  2. Partial-thickness loss of skin with a shallow open ulcer or intact serum-filled blister Correct answer.
  3. Intact skin with non-blanchable redness
  4. Full-thickness loss with exposed bone, tendon, or muscle

Explanation

A stage 2 pressure injury involves partial-thickness skin loss presenting as a shallow open wound or an intact or ruptured serum-filled blister. Intact skin with non-blanchable redness is stage 1. Full-thickness loss with exposed structures is stage 4, and full-thickness loss with visible fat is stage 3.

Question 26Fundamentals of Nursing and Basic Nursing Skills

A nurse is preparing to perform hand hygiene with an alcohol-based hand rub. Which situation requires the nurse to wash with soap and water instead?

  1. The hands are visibly soiled with blood Correct answer.
  2. The hands are dry and intact before patient contact
  3. The nurse has just removed clean gloves
  4. The nurse is entering the room of a patient in contact precautions

Explanation

Alcohol-based hand rub is effective against many organisms but is not reliable when organic material such as blood, stool, or visible dirt is present, because the soil protects microorganisms and inactivates the product. Soap and water physically remove soil and are required in that situation, and they are also preferred after exposure to spore-forming organisms such as Clostridioides difficile.

Question 27Fundamentals of Nursing and Basic Nursing Skills

A nurse is measuring a patient's blood pressure using an appropriately sized cuff. Which action is correct for an accurate reading?

  1. Deflate the cuff as rapidly as possible to reduce discomfort
  2. Place the cuff over the patient's sleeve to save time
  3. Have the patient hold the arm extended unsupported during inflation
  4. Support the arm at heart level and rest it before inflating Correct answer.

Explanation

The arm should be supported and positioned at the level of the heart, with the patient rested, because arm position above or below heart level changes the measured pressure and an unsupported arm raises it through muscle contraction. Correct cuff size and placement on bare skin are also needed for a valid reading.

Question 28Fundamentals of Nursing and Basic Nursing Skills

A nurse is caring for a patient who has been on bed rest for several days. Which nursing action best supports prevention of deep vein thrombosis?

  1. Applying firm massage to the calves each shift
  2. Keeping the knees flexed on a pillow for comfort
  3. Encouraging the patient to remain still to avoid dislodging clots
  4. Assisting with early ambulation and leg exercises as tolerated Correct answer.

Explanation

Venous stasis is a major contributor to clot formation, so early mobilization and active or passive leg exercises promote venous return and reduce stasis. Massaging the calves is unsafe because it could dislodge an existing thrombus, and prolonged knee flexion impairs venous flow.

Question 29Fundamentals of Nursing and Basic Nursing Skills

A nurse receives a verbal prescription from a physician for a new medication. Which action reflects correct practice for telephone or verbal orders?

  1. Administer the medication first and obtain written confirmation afterward
  2. Ask a nursing assistant to take the order to save the nurse's time
  3. Write the order, read it back to the prescriber, and document it per policy Correct answer.
  4. Accept the order and transcribe it later without reading it back

Explanation

Verbal orders carry a high risk of miscommunication, so the receiving nurse writes the complete order, reads it back to the prescriber for verification, and documents the order and read-back according to facility policy. Only licensed personnel who can verify the order should accept it, and the read-back must occur before the order is carried out.

Question 30Fundamentals of Nursing and Basic Nursing Skills

A nurse is planning care for an older adult patient who is confused and at risk for falls. Which combination of interventions best reflects a restraint-free approach?

  1. Ask family to stay awake all night beside the bed without relief
  2. Use a bed alarm, keep the call light within reach, and schedule frequent rounding Correct answer.
  3. Raise all four side rails and leave the patient alone in a dim room
  4. Apply wrist restraints at night so the patient cannot climb out of bed

Explanation

Restraint-free fall prevention relies on environmental and surveillance measures such as bed or chair alarms, easy access to the call light, frequent rounding, and attention to toileting and comfort needs. Restraints and raised side rails do not prevent falls and can cause injury, and they require a specific order and monitoring when used at all.

Question 31Medical-Surgical Nursing (Adult Health)

A client with an acute exacerbation of heart failure has bilateral crackles to the mid-scapula, an SpO2 of 88% on room air, and reports severe dyspnea. Which position should the nurse place the client in first?

  1. High Fowler's position with the legs dependent Correct answer.
  2. Trendelenburg position
  3. Left lateral recumbent position
  4. Supine with the head of the bed flat

Explanation

High Fowler's positioning lowers the diaphragm, reduces venous return to the overloaded heart, and improves ventilation-perfusion matching in pulmonary edema. Upright positioning is the immediate nonpharmacologic action while oxygen and diuretic therapy are prepared.

Question 32Medical-Surgical Nursing (Adult Health)

Which laboratory value should the nurse monitor to evaluate the response to intravenous furosemide in a client with decompensated heart failure?

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

Explanation

Loop diuretics cause urinary potassium loss, so serum potassium is the key electrolyte to trend and replace to prevent hypokalemia-induced dysrhythmias. Daily weights and urine output reflect diuresis, but potassium is the electrolyte most directly threatened by furosemide.

Question 33Medical-Surgical Nursing (Adult Health)

A client is admitted with diabetic ketoacidosis. Which finding should the nurse anticipate on the initial laboratory results?

  1. Arterial pH of 7.22 with a bicarbonate of 12 mEq/L Correct answer.
  2. Arterial pH of 7.50 with a bicarbonate of 36 mEq/L
  3. Arterial pH of 7.38 with a bicarbonate of 25 mEq/L
  4. Arterial pH of 7.48 with a bicarbonate of 30 mEq/L

Explanation

Diabetic ketoacidosis produces a high-anion-gap metabolic acidosis from ketone accumulation, so the pH falls and bicarbonate is consumed as a buffer. Values showing alkalosis or normal acid-base balance are inconsistent with ketoacidosis.

Question 34Medical-Surgical Nursing (Adult Health)

A client with chronic obstructive pulmonary disease has a respiratory rate of 28/min, an SpO2 of 86% on 2 L nasal cannula, and is using accessory muscles. Which action should the nurse take first?

  1. Assess airway patency and breath sounds Correct answer.
  2. Administer a prescribed PRN anxiolytic
  3. Place the client in a supine position
  4. Withhold all oxygen therapy

Explanation

Airway and breathing are the priority in an acute COPD exacerbation, so the nurse first assesses patency, breath sounds, and work of breathing before escalating therapy. Sedatives and supine positioning would worsen hypoventilation.

Question 35Medical-Surgical Nursing (Adult Health)

Which finding is the earliest indicator of hypoxemia in an adult client receiving a blood transfusion?

  1. Bradycardia
  2. Hypertension with flushing
  3. Restlessness and confusion Correct answer.
  4. Decreased urine output

Explanation

Cerebral hypoxia from impaired oxygen delivery manifests early as anxiety, restlessness, and confusion before other signs appear. Transfusion reactions and respiratory compromise should be suspected when mentation changes during infusion.

Question 36Medical-Surgical Nursing (Adult Health)

A client is 24 hours after an acute myocardial infarction. Which assessment finding should prompt the nurse to notify the provider immediately?

  1. Blood pressure of 118/74 mm Hg
  2. Mild incisional discomfort at the catheter site
  3. Heart rate of 78 beats per minute
  4. New bibasilar crackles with an S3 gallop Correct answer.

Explanation

New crackles and an S3 gallop indicate left ventricular failure and developing cardiogenic pulmonary edema after infarction. These signs require urgent evaluation because they signal pump failure.

Question 37Medical-Surgical Nursing (Adult Health)

Which client is at highest risk for developing a stress ulcer?

  1. A client with mild seasonal allergic rhinitis
  2. A client recovering from an uncomplicated ankle sprain
  3. A client with well-controlled hypertension
  4. A client in the intensive care unit with a major burn injury Correct answer.

Explanation

Major burns, shock, and critical illness cause splanchnic hypoperfusion and are classic risk factors for stress-related mucosal injury. Prophylactic acid suppression is commonly used in these clients.

Question 38Medical-Surgical Nursing (Adult Health)

A client with a new ileostomy has liquid output of 1,800 mL in 24 hours. Which nursing action is most appropriate?

  1. Administer a prescribed antidiarrheal without assessment
  2. Encourage oral fluids containing electrolytes Correct answer.
  3. Measure output weekly
  4. Restrict all oral intake

Explanation

High-output ileostomies cause fluid and electrolyte losses, so isotonic electrolyte-containing fluids are encouraged while output is monitored. Antidiarrheals require provider orders and assessment of cause before use.

Question 39Medical-Surgical Nursing (Adult Health)

A client with a serum potassium of 6.8 mEq/L has peaked T waves on the cardiac monitor. Which prescribed intervention should the nurse anticipate giving first?

  1. Subcutaneous insulin with oral glucose
  2. Oral sodium polystyrene sulfonate
  3. Oral potassium chloride
  4. Intravenous calcium gluconate Correct answer.

Explanation

Calcium stabilizes the myocardium immediately by antagonizing potassium's effect on the cell membrane, making it the first-line agent when ECG changes are present. Insulin-glucose and binders shift or remove potassium but act more slowly.

Question 40Medical-Surgical Nursing (Adult Health)

A client with acute kidney injury has a creatinine rise from 1.0 to 3.2 mg/dL over two days. Which finding most concerns the nurse?

  1. Urine output of 15 mL/hour for the past 6 hours Correct answer.
  2. Temperature of 37.0°C
  3. Respiratory rate of 16/min
  4. Serum sodium of 138 mEq/L

Explanation

Oliguria below 0.5 mL/kg/hour signals worsening renal perfusion and impending fluid overload in acute kidney injury. The nurse must report sustained low output promptly.

Question 41Medical-Surgical Nursing (Adult Health)

A client is receiving a continuous heparin infusion. Which laboratory result requires immediate intervention?

  1. Hemoglobin of 13.5 g/dL
  2. Activated partial thromboplastin time of 55 seconds
  3. Platelet count of 250,000/mm3
  4. Activated partial thromboplastin time of 120 seconds with new gum bleeding Correct answer.

Explanation

A markedly prolonged aPTT with new bleeding indicates over-anticoagulation and risk of hemorrhage, so the infusion is held and protamine sulfate may be required. The target aPTT is typically 1.5 to 2.5 times control.

Question 42Medical-Surgical Nursing (Adult Health)

A client with type 1 diabetes is found diaphoretic, tremulous, and confused. Which action should the nurse take first?

  1. Encourage a high-protein snack only
  2. Administer the scheduled insulin dose
  3. Check the capillary blood glucose Correct answer.
  4. Give a dose of oral metformin

Explanation

The signs suggest hypoglycemia, and confirming the glucose guides immediate treatment with a fast-acting carbohydrate or glucagon. Giving insulin or metformin before verification could be fatal.

Question 43Medical-Surgical Nursing (Adult Health)

A client with a chest tube after a lobectomy has continuous bubbling in the water-seal chamber. What is the nurse's priority action?

  1. Assess the insertion site and tubing for an air leak Correct answer.
  2. Milk the tubing vigorously
  3. Lower the drainage system below the bed
  4. Clamp the chest tube immediately

Explanation

Continuous bubbling in the water-seal chamber suggests an air leak, so the nurse assesses the insertion site, connections, and tubing before intervening. Clamping can cause tension pneumothorax and is avoided unless ordered.

Question 44Medical-Surgical Nursing (Adult Health)

A client with a new tracheostomy is being suctioned. Which action is correct?

  1. Hyperventilate the client with 100% oxygen for 10 minutes before suctioning
  2. Apply suction only while withdrawing the catheter Correct answer.
  3. Apply suction continuously during insertion
  4. Insert the catheter with suction on for 30 seconds

Explanation

Suction is applied intermittently only during withdrawal to limit mucosal trauma and hypoxemia. Each pass should last no more than 10 to 15 seconds with preoxygenation as needed.

Question 45Medical-Surgical Nursing (Adult Health)

A client with cirrhosis has ascites and a serum albumin of 2.1 g/dL. Which finding most suggests the client is developing hepatic encephalopathy?

  1. Asterixis and increasing confusion Correct answer.
  2. Palmar erythema
  3. Spider angiomata
  4. Bilateral ankle edema

Explanation

Asterixis and altered mentation reflect the accumulation of ammonia and other neurotoxins in hepatic encephalopathy. Edema and vascular skin changes are signs of chronic liver disease but not of encephalopathy.

Question 46Medical-Surgical Nursing (Adult Health)

A client is admitted with an acute exacerbation of multiple sclerosis and reports new numbness and weakness. Which nursing intervention is most appropriate?

  1. Apply hot packs to the affected limbs
  2. Restrict fluid intake to prevent bladder symptoms
  3. Encourage vigorous exercise to maintain strength
  4. Allow scheduled rest periods and assist with activities as needed Correct answer.

Explanation

Energy conservation with scheduled rest reduces fatigue and prevents exacerbation of symptoms in demyelinating disease. Heat can worsen conduction deficits, and vigorous exercise may increase fatigue.

Question 47Medical-Surgical Nursing (Adult Health)

A client with an acute ischemic stroke has a blood pressure of 220/120 mm Hg and is not a candidate for thrombolysis. Which action should the nurse anticipate?

  1. Lowering the pressure rapidly to 120/80 mm Hg
  2. Administering prescribed antihypertensives to lower the pressure gradually Correct answer.
  3. Giving a bolus of intravenous fluids
  4. Withholding all antihypertensives

Explanation

Permissive hypertension maintains cerebral perfusion in acute ischemic stroke, but pressures above roughly 220/120 mm Hg are treated with gradual reduction to avoid hypoperfusion. Rapid normalization can extend the infarct.

Question 48Medical-Surgical Nursing (Adult Health)

A client is 12 hours after a total hip arthroplasty. Which finding should the nurse report immediately?

  1. Temperature of 37.2°C
  2. Serosanguineous drainage on the dressing
  3. Sudden shortness of breath with a heart rate of 118/min Correct answer.
  4. Pain rated 5 of 10 at the incision

Explanation

Sudden dyspnea with tachycardia after hip surgery suggests a pulmonary embolism and requires urgent assessment and provider notification. Expected incisional drainage, pain, and low-grade temperature do not carry the same urgency.

Question 49Medical-Surgical Nursing (Adult Health)

A client with a new colostomy has a stoma that is dark purple and dry. What is the nurse's priority action?

  1. Notify the provider of possible ischemia Correct answer.
  2. Document the finding as normal
  3. Irrigate the stoma with saline
  4. Apply petroleum jelly to the stoma

Explanation

A healthy stoma is beefy red and moist; a dark purple, dry stoma signals ischemia and must be reported immediately. Prompt surgical evaluation may be needed to prevent necrosis.

Question 50Medical-Surgical Nursing (Adult Health)

A client with severe acute pancreatitis has a serum calcium of 7.2 mg/dL. Which finding should the nurse monitor for?

  1. Hypertension with bradycardia
  2. Hyperreflexia with clonus
  3. Polyuria with polydipsia
  4. Positive Trousseau's sign Correct answer.

Explanation

Hypocalcemia from fat saponification in pancreatitis produces neuromuscular irritability, demonstrated by Trousseau's and Chvostek's signs. Tetany and seizures are risks if calcium is not corrected.