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SNB RN Licensure Exam study materials
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SNB RN Licensure Exam practice questions

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Question 1Nursing Fundamentals and Clinical Practice

A nurse is preparing to administer a medication via a nasogastric tube. Which action should the nurse take first before giving the dose?

  1. Verify tube placement by aspirating gastric contents and checking pH Correct answer.
  2. Crush the tablet and mix it with applesauce
  3. Position the client in a high-Fowler position
  4. Flush the tube with 30 mL of sterile water

Explanation

Verifying tube location before each medication administration prevents instilling medication into the lungs or pleura. Aspirating gastric contents and checking pH, along with other confirmatory measures per policy, establishes placement. Other steps follow once placement is confirmed.

Question 2Nursing Fundamentals and Clinical Practice

Which finding best indicates that a client's oral temperature measurement was obtained correctly with an electronic thermometer?

  1. The probe was held against the buccal mucosa for 30 seconds
  2. The probe was placed under the tongue while the client talked
  3. The probe was placed in the posterior sublingual pocket with lips closed Correct answer.
  4. The client drank cold water immediately before the reading

Explanation

The posterior sublingual pocket contains a rich blood supply and provides the most reliable oral temperature. The lips must stay closed to seal the area and stabilize the reading. Talking, recent cold fluids, or improper probe placement distort results.

Question 3Nursing Fundamentals and Clinical Practice

A nurse is caring for a client with a Stage II pressure injury over the sacrum. Which intervention is most appropriate for promoting healing?

  1. Reposition the client at scheduled intervals and keep the area clean and moist Correct answer.
  2. Massage the reddened area several times daily
  3. Apply a heat lamp to the wound for 20 minutes each shift
  4. Keep the wound open to air at all times

Explanation

Pressure injury healing requires offloading pressure through scheduled repositioning plus a clean, moist wound environment that supports granulation. Massage, heat, and prolonged air exposure can damage tissue or delay healing.

Question 4Nursing Fundamentals and Clinical Practice

A nurse is teaching a client about using a metered-dose inhaler with a spacer. Which statement by the client indicates correct understanding?

  1. I will breathe out fully, then press the canister and breathe in slowly Correct answer.
  2. I will hold the inhaler one inch from my open mouth and spray toward my tongue
  3. I will inhale as fast as I can right after pressing the canister
  4. I will use the inhaler only when I feel short of breath

Explanation

Proper inhaler technique involves exhaling fully, actuating the device at the start of a slow deep inhalation, and holding the breath. A spacer improves delivery and reduces oropharyngeal deposition. Rapid inhalation or poor coordination reduces lung deposition.

Question 5Nursing Fundamentals and Clinical Practice

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

  1. A client who had major hip surgery and is on bed rest Correct answer.
  2. A client who is receiving subcutaneous heparin prophylaxis
  3. A client who is ambulating four times daily after surgery
  4. A client who is wearing intermittent pneumatic compression devices

Explanation

Venous stasis, endothelial injury, and hypercoagulability (Virchow triad) raise DVT risk; major orthopedic surgery combined with immobility creates all three. Early ambulation and mechanical or pharmacologic prophylaxis reduce risk.

Question 6Nursing Fundamentals and Clinical Practice

A nurse receives an order to administer 1,000 mL of normal saline over 8 hours using tubing with a drop factor of 15 gtt/mL. What is the correct flow rate in drops per minute?

  1. 21 gtt/min
  2. 15 gtt/min
  3. 31 gtt/min Correct answer.
  4. 42 gtt/min

Explanation

First find mL per hour (1,000/8 = 125 mL/hr), then mL per minute (125/60 ≈ 2.08). Multiply by the drop factor (2.08 × 15 ≈ 31 gtt/min).

Question 7Nursing Fundamentals and Clinical Practice

A client reports acute chest pain. Which action should the nurse take first?

  1. Document the report and notify the provider at the end of the shift
  2. Assess the pain and obtain a full set of vital signs including oxygen saturation Correct answer.
  3. Give the client a prescribed oral analgesic and reassess in one hour
  4. Obtain a 12-lead ECG after the next scheduled vital signs

Explanation

Acute chest pain requires immediate focused assessment, including vital signs and oxygenation, to identify instability and guide urgent intervention. Delaying assessment or treatment risks missing a life-threatening event.

Question 8Nursing Fundamentals and Clinical Practice

A nurse is performing a sterile dressing change. Which action maintains sterility?

  1. Letting the sterile solution bottle cap rest on the field
  2. Reaching across the sterile field to place supplies
  3. Holding the sterile drape above waist level and away from the body Correct answer.
  4. Turning away from the field to answer a call light

Explanation

A sterile field must stay within the nurse's view and above waist level to remain sterile. Reaching across, turning away, or placing unsterile items on the field contaminates it.

Question 9Nursing Fundamentals and Clinical Practice

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

  1. Disconnecting the tubing to obtain urine samples daily
  2. Irrigating the catheter routinely every shift
  3. Maintaining a closed drainage system and keeping the bag below bladder level Correct answer.
  4. Cleaning the perineum with antiseptic solution each shift

Explanation

A closed system with dependent drainage prevents backflow of contaminated urine and limits entry of organisms. Routine irrigation, unnecessary disconnections, and antiseptic perineal cleaning do not prevent CAUTI and may increase risk.

Question 10Nursing Fundamentals and Clinical Practice

A client is prescribed oxygen at 2 L/min via nasal cannula. Which assessment finding requires immediate intervention?

  1. Oxygen saturation of 89% with increasing work of breathing Correct answer.
  2. Client reports mild nasal dryness
  3. Oxygen saturation of 96% with clear breath sounds
  4. Respiratory rate of 16 breaths per minute

Explanation

A falling oxygen saturation combined with increased work of breathing signals inadequate oxygenation and possible deterioration despite therapy. Stable saturation, normal rate, and mild dryness do not indicate acute compromise.

Question 11Nursing Fundamentals and Clinical Practice

Which instruction should the nurse give a client to obtain a clean-catch midstream urine specimen?

  1. Void into a bedpan and pour the entire volume into the specimen cup
  2. Cleanse the meatus, begin voiding, then collect the middle portion into the container Correct answer.
  3. Collect the first few drops of urine directly into the container
  4. Collect urine from the drainage bag of an indwelling catheter

Explanation

A midstream collection reduces contamination by flushing the distal urethra before the sample is taken. Cleansing the meatus and collecting the middle portion yields the most representative specimen.

Question 12Nursing Fundamentals and Clinical Practice

A nurse is assessing a postoperative client who had general anesthesia. Which finding should be reported to the provider immediately?

  1. Urine output of 40 mL per hour
  2. Respiratory rate of 8 breaths per minute with shallow breathing Correct answer.
  3. Pain rated 4 out of 10 at the incision
  4. Temperature of 37.2°C (99°F)

Explanation

Shallow breathing at 8 breaths per minute suggests respiratory depression from residual anesthesia or opioids and requires urgent intervention. The other findings are within expected postoperative ranges.

Question 13Nursing Fundamentals and Clinical Practice

A nurse is teaching a client about a new prescription for warfarin. Which dietary instruction is most important?

  1. Take the medication with grapefruit juice each morning
  2. Avoid all foods containing vitamin K completely
  3. Increase vitamin K intake when bruising occurs
  4. Keep intake of green leafy vegetables consistent from day to day Correct answer.

Explanation

Vitamin K antagonizes warfarin, so consistent intake stabilizes the INR rather than eliminating or fluctuating intake. Clients should not abruptly change or eliminate vitamin K-rich foods.

Question 14Nursing Fundamentals and Clinical Practice

A client with a new ileostomy is being taught about ostomy care. Which statement indicates the need for further teaching?

  1. I will cut the skin barrier to fit closely around the stoma
  2. I will empty the pouch when it is about one-third full
  3. I will inspect the stoma and surrounding skin with each pouch change
  4. I will change the pouch only when it leaks, regardless of the schedule Correct answer.

Explanation

Pouches and barriers are typically changed on a regular schedule (often every few days) to protect skin, not only when leakage occurs. Emptying before the pouch is overfilled, inspecting skin, and fitting the barrier prevent complications.

Question 15Nursing Fundamentals and Clinical Practice

Which action demonstrates correct body mechanics when the nurse moves a client up in bed?

  1. Bending at the waist with the legs straight
  2. Keeping the feet together and twisting at the waist
  3. Raising the bed to waist height and bending the knees before lifting Correct answer.
  4. Pulling the client with outstretched arms away from the body

Explanation

Raising the bed to working height and bending the knees keeps the load close and uses large leg muscles, reducing spinal strain. Twisting, bending at the waist, or reaching away from the body increases injury risk.

Question 16Nursing Fundamentals and Clinical Practice

A nurse is caring for a client receiving a blood transfusion. Which finding should prompt stopping the transfusion immediately?

  1. Blood pressure of 118/76 mm Hg
  2. Mild itching at the venipuncture site
  3. Heart rate of 80 beats per minute
  4. Sudden chills, fever, and low back pain Correct answer.

Explanation

Chills, fever, and flank or low back pain suggest an acute hemolytic transfusion reaction, which requires stopping the transfusion and notifying the provider. Stable vital signs and localized itching are managed differently.

Question 17Nursing Fundamentals and Clinical Practice

A client is on fall precautions. Which intervention is most effective in preventing falls at night?

  1. Applying bilateral wrist restraints
  2. Keeping the call light within reach and offering scheduled toileting Correct answer.
  3. Dimming all lights in the room
  4. Raising all four side rails on the bed

Explanation

Falls often occur when clients attempt to reach the bathroom unassisted. Keeping the call light accessible and providing scheduled toileting address the primary cause while preserving autonomy.

Question 18Nursing Fundamentals and Clinical Practice

A nurse is preparing to give an intramuscular injection to an adult. Which site is preferred for a large-volume medication?

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

Explanation

The ventrogluteal site is preferred for adults because it is free of major nerves and blood vessels and can accommodate larger volumes. The deltoid holds small volumes, and the dorsogluteal site risks sciatic nerve injury.

Question 19Nursing Fundamentals and Clinical Practice

A nurse is assessing a client's level of consciousness. Which finding indicates the earliest sign of increasing intracranial pressure?

  1. A subtle change in level of consciousness or behavior Correct answer.
  2. Fixed and dilated pupils
  3. Absent corneal reflexes
  4. Decerebrate posturing

Explanation

A change in level of consciousness is often the earliest indicator of rising intracranial pressure. Pupillary changes, posturing, and absent reflexes reflect later, more severe deterioration.

Question 20Nursing Fundamentals and Clinical Practice

A nurse is teaching a client with type 2 diabetes about foot care. Which instruction is correct?

  1. Soak the feet in hot water each evening
  2. Cut calluses with a razor at home
  3. Inspect the feet daily, including between the toes, using a mirror Correct answer.
  4. Walk barefoot at home to toughen the skin

Explanation

Daily inspection with a mirror allows early detection of injury, especially when sensation is reduced. Soaking in hot water, walking barefoot, and self-cutting calluses increase the risk of injury and infection.

Question 21Nursing Fundamentals and Clinical Practice

A client is admitted with dehydration. Which assessment finding supports this diagnosis?

  1. Crackles in the lung bases
  2. Weight gain of 2 kg in 24 hours
  3. Bounding pulse and neck vein distention
  4. Poor skin turgor and dry mucous membranes Correct answer.

Explanation

Dehydration reduces interstitial fluid, producing poor skin turgor, dry mucous membranes, and often orthostatic changes. Bounding pulses, distended neck veins, crackles, and rapid weight gain reflect fluid overload.

Question 22Nursing Fundamentals and Clinical Practice

A nurse is preparing to administer a potassium chloride IV infusion. Which action is essential for client safety?

  1. Verify that the potassium is diluted and infused via a pump at the prescribed rate Correct answer.
  2. Administer the dose only when urine output is below 10 mL/hr
  3. Give the potassium undiluted through a peripheral line
  4. Administer the potassium as a rapid IV push

Explanation

IV potassium must be diluted and infused at a controlled rate, typically with a pump, because rapid or concentrated administration can cause fatal dysrhythmias. Adequate renal function should be confirmed before administration.

Question 23Nursing Fundamentals and Clinical Practice

A client is prescribed nothing by mouth before surgery. Which nursing action best supports this order?

  1. Removing the sign to reduce client anxiety
  2. Allowing clear liquids until the client enters the operating room
  3. Encouraging the client to eat a light breakfast
  4. Posting a sign at the bedside and confirming the client understands the restriction Correct answer.

Explanation

Clear communication and client understanding reduce the risk of aspiration during anesthesia. A bedside sign reinforces the restriction, and confirming comprehension ensures adherence.

Question 24Nursing Fundamentals and Clinical Practice

A nurse is caring for a client with a chest tube connected to water-seal drainage. Which finding requires immediate action?

  1. Continuous bubbling in the water-seal chamber Correct answer.
  2. The drainage tubing resting in a dependent loop
  3. Serosanguineous drainage in the collection chamber
  4. Tidaling of fluid in the water-seal chamber with breathing

Explanation

Continuous bubbling in the water-seal chamber suggests an air leak in the system, which can impair lung re-expansion and must be investigated. Tidaling with respiration is expected, and drainage is monitored.

Question 25Nursing Fundamentals and Clinical Practice

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

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

Explanation

Canned soups are high in sodium due to added salt and preservatives and should be limited on a low-sodium diet. Fresh fruits, plain rice, and unsalted vegetables are naturally low in sodium.

Question 26Nursing Fundamentals and Clinical Practice

A nurse is preparing to administer a medication via the subcutaneous route. Which site is most appropriate for this injection?

  1. The dorsogluteal muscle
  2. The deltoid muscle
  3. The abdomen, at least 2 inches from the umbilicus Correct answer.
  4. The ventrogluteal muscle

Explanation

Subcutaneous injections are given into fatty tissue, and the abdomen is a common site when avoiding the umbilicus. Muscle sites are used for intramuscular injections, not subcutaneous.

Question 27Nursing Fundamentals and Clinical Practice

A nurse is caring for a client with a new colostomy. Which statement by the client indicates correct understanding of colostomy care?

  1. I should change the pouch every day to prevent infection.
  2. I should expect the stoma to be pale and dry.
  3. I need to avoid eating any fiber to prevent blockage.
  4. I can use soap and water to clean the skin around the stoma. Correct answer.

Explanation

The skin around the stoma should be cleaned gently with mild soap and water, then dried thoroughly before applying a new pouch. The pouch is typically changed every 3 to 7 days, not daily, and a healthy stoma is moist and red.

Question 28Nursing Fundamentals and Clinical Practice

A nurse is assessing a client who is receiving intravenous fluids. Which finding should the nurse report to the provider immediately?

  1. A respiratory rate of 16 breaths per minute
  2. Clear yellow urine output of 30 mL/hr
  3. Crackles heard in the lung bases Correct answer.
  4. A blood pressure of 118/76 mm Hg

Explanation

Crackles in the lung bases may indicate fluid overload or pulmonary edema, which requires immediate intervention. The other findings are within normal limits.

Question 29Nursing Fundamentals and Clinical Practice

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

  1. Administer premedication as prescribed.
  2. Obtain the client's vital signs for baseline comparison.
  3. Verify the blood product with a second nurse. Correct answer.
  4. Prime the tubing with 0.9% sodium chloride.

Explanation

Verifying the blood product with a second nurse is a critical safety step to prevent a hemolytic transfusion reaction due to ABO incompatibility. While baseline vital signs and priming with normal saline are important, the two-nurse verification is the essential safety check.

Question 30Nursing Fundamentals and Clinical Practice

A nurse is teaching a client about the use of a metered-dose inhaler (MDI) with a spacer. Which instruction should the nurse include?

  1. Wait 1 minute between puffs of the same medication.
  2. Rinse the mouth with water after using a corticosteroid inhaler. Correct answer.
  3. Inhale quickly and forcefully after activating the inhaler.
  4. Store the inhaler in the refrigerator between uses.

Explanation

Rinsing the mouth after using a corticosteroid inhaler helps prevent oral candidiasis. Inhalers should be inhaled slowly and deeply, and the mouth should be rinsed after corticosteroid use.

Question 31Nursing Fundamentals and Clinical Practice

A nurse is caring for a client who is at risk for pressure injuries. Which intervention is most effective in preventing pressure injuries?

  1. Use a rubber ring cushion when the client is sitting.
  2. Keep the head of the bed elevated at 45 degrees at all times.
  3. Massage reddened areas over bony prominences.
  4. Reposition the client every 2 hours. Correct answer.

Explanation

Repositioning the client at regular intervals relieves pressure on bony prominences and is a cornerstone of pressure injury prevention. Massaging reddened areas, using rubber rings, and maintaining high Fowler's position can increase risk.

Question 32Nursing Fundamentals and Clinical Practice

A nurse is assessing a client's pain. Which finding is most indicative of acute pain?

  1. The client reports pain as 8 on a 0-to-10 scale and is guarding the abdomen. Correct answer.
  2. The client's heart rate is 60 beats per minute and blood pressure is 110/70 mm Hg.
  3. The client has a history of chronic back pain and requests pain medication.
  4. The client is sleeping quietly and denies pain.

Explanation

Acute pain typically produces behavioral and physiologic signs such as guarding and a high pain rating. Chronic pain may not produce the same sympathetic responses, and normal vital signs do not rule out pain.

Question 33Nursing Fundamentals and Clinical Practice

A nurse is preparing to insert a nasogastric tube. Which action should the nurse take to verify correct placement?

  1. Auscultate the abdomen while injecting 10 mL of air.
  2. Secure the tube with tape before verification.
  3. Measure the pH of the aspirated fluid. Correct answer.
  4. Ask the client to drink water during insertion.

Explanation

Measuring the pH of aspirated fluid is the most reliable bedside method to verify nasogastric tube placement; gastric fluid typically has a pH of 5.5 or less. Auscultation is no longer recommended as a sole verification method.

Question 34Nursing Fundamentals and Clinical Practice

A nurse is teaching a client about the use of a cane. Which instruction should the nurse include?

  1. Use the cane only when climbing stairs.
  2. Hold the cane on the stronger side of the body. Correct answer.
  3. Advance the cane at the same time as the weaker leg.
  4. Hold the cane on the weaker side of the body.

Explanation

The cane should be held on the stronger side to provide support and stability while the weaker leg moves. This improves balance and reduces the risk of falls.

Question 35Medical-Surgical Nursing

A nurse is caring for a client 24 hours after an abdominal surgery. Which assessment finding should the nurse report to the surgeon immediately?

  1. Temperature of 38.6°C (101.5°F) with chills Correct answer.
  2. Pain rated 5 out of 10 at the incision
  3. Absent bowel sounds in all quadrants
  4. Serous drainage at the incision edge

Explanation

Fever with chills in the early postoperative period suggests infection or another serious complication and warrants prompt notification of the surgeon. Expected postoperative findings include mild incisional pain, absent or sluggish bowel sounds from anesthesia and opioid use, and small amounts of serous drainage.

Question 36Medical-Surgical Nursing

Which laboratory value is most important for the nurse to monitor in a client receiving furosemide for heart failure?

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

Explanation

Loop diuretics such as furosemide increase renal potassium excretion and can cause hypokalemia, which predisposes to dysrhythmias, especially in clients on digoxin. Potassium levels guide replacement therapy and dosing decisions.

Question 37Medical-Surgical Nursing

A client with a new ileal conduit has a pouch that will not stay adhered. Which action should the nurse take first?

  1. Ensure the peristomal skin is completely dry before applying the pouch Correct answer.
  2. Place a belt over the pouch to hold it in place
  3. Apply extra skin barrier paste around the stoma
  4. Change the pouch more frequently during the day

Explanation

Moisture on the peristomal skin prevents the adhesive from bonding, so the skin must be cleaned and thoroughly dried before pouch application. Additional paste or a belt will not correct adhesion failure caused by moisture.

Question 38Medical-Surgical Nursing

A client is admitted with diabetic ketoacidosis. Which prescription should the nurse anticipate implementing first?

  1. Sodium bicarbonate infusion
  2. Intravenous 0.9% sodium chloride Correct answer.
  3. Subcutaneous insulin glargine
  4. Oral potassium chloride

Explanation

Initial management of DKA prioritizes rapid isotonic fluid resuscitation with 0.9% sodium chloride to restore intravascular volume before insulin and electrolyte replacement. Insulin is given as an IV infusion, and bicarbonate is reserved for severe acidosis.

Question 39Medical-Surgical Nursing

A client with a chest tube after a thoracotomy has continuous bubbling in the water-seal chamber. What do these findings most likely indicate?

  1. Occlusion of the chest tube
  2. An air leak in the system Correct answer.
  3. Resolution of the pneumothorax
  4. Normal tidal movement of the water seal

Explanation

Continuous bubbling in the water-seal chamber indicates air is escaping into the system, most often from a leak at the insertion site or connections. Normal tidal movement produces intermittent, not continuous, bubbling.

Question 40Medical-Surgical Nursing

A client with chronic kidney disease has a serum potassium of 6.8 mEq/L. Which finding should the nurse assess for as the priority concern?

  1. Cardiac dysrhythmias Correct answer.
  2. Hyperactive bowel sounds
  3. Muscle twitching
  4. Increased urine output

Explanation

Hyperkalemia primarily threatens cardiac conduction and can progress to lethal dysrhythmias such as ventricular fibrillation. Assessment and continuous ECG monitoring take priority over other manifestations.

Question 41Medical-Surgical Nursing

A client is receiving a blood transfusion. Fifteen minutes after it begins, the client reports chills, low back pain, and dark urine. Which action should the nurse take first?

  1. Obtain a urine specimen for culture
  2. Slow the transfusion rate and reassess
  3. Administer the prescribed antihistamine
  4. Stop the transfusion and maintain IV access with normal saline Correct answer.

Explanation

Chills, back pain, and hemoglobinuria suggest an acute hemolytic transfusion reaction, which requires immediately stopping the transfusion and keeping the line patent with normal saline. The provider and blood bank are then notified and the reaction is reported.

Question 42Medical-Surgical Nursing

A client with a new below-the-knee cast reports increasing pain that is unrelieved by the prescribed opioid. What should the nurse do next?

  1. Assess sensation, movement, and capillary refill of the toes Correct answer.
  2. Reassure the client that pain is expected
  3. Apply a warm compress over the cast
  4. Elevate the leg above the level of the heart

Explanation

Unrelieved pain out of proportion to the injury is an early sign of compartment syndrome, so the nurse must assess neurovascular status distal to the cast. Elevation above heart level is contraindicated because it can reduce arterial perfusion.

Question 43Medical-Surgical Nursing

Which client is at highest risk for developing a pressure injury?

  1. A client who is incontinent and immobile after a stroke Correct answer.
  2. A client on bed rest for 24 hours after a cardiac catheterization
  3. A client with a BMI of 32 who ambulates with a walker
  4. A client with a fever who is receiving antibiotics

Explanation

Immobility combined with moisture from incontinence creates sustained pressure and skin breakdown risk, the two strongest contributors to pressure injury. Short-term bed rest and obesity alone carry lower risk.

Question 44Medical-Surgical Nursing

A client with type 1 diabetes reports sweating, tremor, and confusion. The client is awake and able to swallow. What should the nurse give first?

  1. A high-protein snack
  2. 15 grams of a fast-acting carbohydrate Correct answer.
  3. A glass of whole milk
  4. The scheduled dose of insulin

Explanation

These signs indicate hypoglycemia, and the conscious client who can swallow should receive 15 grams of fast-acting carbohydrate followed by rechecking glucose in 15 minutes. Protein and fat slow absorption and are not first-line treatment.

Question 45Medical-Surgical Nursing

A client is prescribed digoxin. Which finding should prompt the nurse to withhold the dose and notify the provider?

  1. Heart rate of 92 beats per minute
  2. Blood pressure of 128/76 mm Hg
  3. Apical pulse of 48 beats per minute Correct answer.
  4. Serum potassium of 4.2 mEq/L

Explanation

Digoxin slows conduction through the AV node, and a pulse below 60 beats per minute signals possible toxicity or excessive bradycardia, so the dose is held. The nurse counts the apical pulse for a full minute before administration.

Question 46Medical-Surgical Nursing

A client with a pulmonary embolism is started on a heparin infusion. Which laboratory value should the nurse monitor to evaluate therapeutic effect?

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

Explanation

Unfractionated heparin therapy is titrated to the aPTT, which reflects the intrinsic clotting pathway that heparin affects. INR is used for warfarin, and D-dimer supports diagnosis rather than titration.

Question 47Medical-Surgical Nursing

A client with an acute exacerbation of heart failure is prescribed furosemide and reports increasing shortness of breath. Which nursing action is most appropriate?

  1. Withhold oxygen therapy to assess baseline status
  2. Restrict all oral fluids to zero
  3. Encourage the client to lie flat for lung expansion
  4. Place the client in a high Fowler position Correct answer.

Explanation

High Fowler positioning reduces venous return and improves lung expansion, easing dyspnea in pulmonary congestion. Oxygen is provided as prescribed, and fluids are restricted per orders rather than eliminated entirely.

Question 48Medical-Surgical Nursing

A client has a new colostomy and states, "I will never be able to go out in public again." Which response by the nurse is most therapeutic?

  1. "You can always wear loose clothing to hide the pouch."
  2. "Many clients feel this way at first, so it is normal."
  3. "You should not worry; most people adjust quickly."
  4. "Tell me more about what concerns you about going out." Correct answer.

Explanation

An open-ended invitation to explore the client's specific concerns supports coping and identifies concrete teaching needs. Minimizing or generalizing the client's feelings blocks expression.

Question 49Medical-Surgical Nursing

A client with a spinal cord injury at T4 suddenly develops a severe pounding headache, diaphoresis, and a blood pressure of 210/120 mm Hg. What should the nurse do first?

  1. Administer a prescribed analgesic
  2. Raise the head of the bed to a sitting position Correct answer.
  3. Check the blood pressure in the other arm
  4. Apply a cool cloth to the forehead

Explanation

These findings indicate autonomic dysreflexia, and the first action is to sit the client upright to lower blood pressure while identifying and removing the triggering stimulus, often bladder distention. Analgesics do not reverse the hypertensive crisis.

Question 50Medical-Surgical Nursing

A client with an acute ischemic stroke is being assessed for thrombolytic therapy. Which finding is an absolute contraindication?

  1. History of intracranial hemorrhage Correct answer.
  2. Blood glucose of 130 mg/dL
  3. Age of 68 years
  4. Blood pressure of 168/92 mm Hg

Explanation

Prior intracranial hemorrhage is an absolute contraindication to thrombolysis because of the risk of fatal bleeding. Blood pressure must be controlled but levels above 185/110 are a relative issue, and age and moderate hyperglycemia do not preclude treatment.