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Taiwan Registered Nurse Licensing Examination study materials
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Taiwan Registered Nurse Licensing Examination practice questions

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Question 1Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A nurse is preparing to administer a medication via the intramuscular route. Which site is preferred for an adult because it avoids major nerves and blood vessels when correctly located?

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

Explanation

The ventrogluteal site is favored for IM injections in adults because it lies away from major nerves and blood vessels and has a reliable bony landmark (the greater trochanter and anterior superior iliac spine). The dorsogluteal site risks sciatic nerve injury, and the deltoid is limited in volume.

Question 2Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which structure is the functional unit of the kidney responsible for filtration and urine formation?

  1. Nephron Correct answer.
  2. Renal pelvis
  3. Loop of Henle
  4. Glomerulus

Explanation

The nephron is the functional unit of the kidney, comprising the glomerulus, Bowman's capsule, and renal tubules. The other structures are components or collecting regions rather than the whole functional unit.

Question 3Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A nurse is performing hand hygiene. Which action best prevents transmission of microorganisms between patients?

  1. Using alcohol-based hand rub before and after patient contact Correct answer.
  2. Changing gloves without hand hygiene between patients
  3. Rinsing hands with water only between patients
  4. Wearing gloves for all patient contact

Explanation

Hand hygiene before and after patient contact is the single most effective measure to prevent cross-transmission of microorganisms. Gloves do not replace hand hygiene, and water alone does not remove or kill organisms effectively.

Question 4Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which vital sign change is an early compensatory sign of hypovolemic shock?

  1. Increased pulse rate Correct answer.
  2. Bradycardia
  3. Decreased respiratory rate
  4. Widened pulse pressure

Explanation

In early hypovolemia, baroreceptor reflexes increase sympathetic outflow, producing tachycardia as the body attempts to maintain cardiac output. Bradycardia and widened pulse pressure are not early compensatory findings.

Question 5Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which type of immunity results when a person receives preformed antibodies such as immunoglobulin, providing immediate but temporary protection?

  1. Passive artificial immunity Correct answer.
  2. Passive natural immunity
  3. Active artificial immunity
  4. Active natural immunity

Explanation

Passive artificial immunity occurs when preformed antibodies are administered (e.g., immunoglobulin), giving immediate but temporary protection without the person mounting a response. Active immunity requires the host to produce antibodies.

Question 6Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which blood component is primarily responsible for oxygen transport to tissues?

  1. Platelets
  2. Erythrocytes Correct answer.
  3. Leukocytes
  4. Plasma proteins

Explanation

Erythrocytes contain hemoglobin, which binds oxygen in the lungs and releases it in tissues. The other components serve clotting, immune defense, or transport of other solutes.

Question 7Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A nurse is applying a cold compress to a sprained ankle. What is the primary therapeutic effect of cold application in the first 24 hours?

  1. Vasodilation and increased blood flow
  2. Enhanced clot breakdown
  3. Increased tissue metabolism
  4. Vasoconstriction and reduced swelling Correct answer.

Explanation

Cold application causes vasoconstriction, which reduces blood flow, edema, and pain in acute injury. Heat, by contrast, causes vasodilation.

Question 8Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which microorganism shape is described as spherical and typically arranged in clusters?

  1. Coccus Correct answer.
  2. Spirillum
  3. Vibrio
  4. Bacillus

Explanation

Cocci are spherical bacteria; those arranged in clusters include staphylococci. Bacilli are rod-shaped, spirilla are spiral, and vibrios are comma-shaped.

Question 9Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A patient has a prescription for 500 mL of normal saline to infuse over 4 hours using an infusion pump. What flow rate in mL/hour should the nurse set?

  1. 125 mL/hour Correct answer.
  2. 200 mL/hour
  3. 150 mL/hour
  4. 100 mL/hour

Explanation

Flow rate equals total volume divided by total time: 500 mL ÷ 4 hours = 125 mL/hour. The other values result from arithmetic errors.

Question 10Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which electrolyte imbalance is most likely to cause muscle weakness, cardiac dysrhythmias, and a flattened T wave on ECG?

  1. Hyperkalemia
  2. Hypernatremia
  3. Hypercalcemia
  4. Hypokalemia Correct answer.

Explanation

Hypokalemia commonly produces muscle weakness and ECG changes including flattened T waves and prominent U waves. Hyperkalemia instead causes peaked T waves.

Question 11Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A nurse is caring for a patient with a new colostomy. Which assessment finding should the nurse report immediately?

  1. Beefy red stoma that is moist
  2. Small amount of serosanguineous drainage
  3. Stoma that appears dusky and purple Correct answer.
  4. Stoma that is slightly edematous

Explanation

A dusky or purple stoma indicates compromised blood supply (ischemia) and must be reported immediately. A beefy red, moist stoma and mild edema are expected postoperative findings.

Question 12Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which mechanism best explains why a fever develops during an infection?

  1. Decreased metabolic rate of the body
  2. Direct destruction of the hypothalamus
  3. Loss of sweat gland function
  4. Release of pyrogens that reset the hypothalamic set point Correct answer.

Explanation

Infectious agents and immune cells release pyrogens that raise the hypothalamic temperature set point, producing fever. The hypothalamus itself is not destroyed.

Question 13Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A nurse is teaching a patient about a low-sodium diet. Which food choice indicates the patient understands the teaching?

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

Explanation

Fresh meat seasoned with herbs is low in sodium, whereas canned, processed, cured, and pickled foods are typically high in sodium. Choosing fresh foods reflects correct understanding.

Question 14Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which stage of the inflammatory response is characterized by migration of neutrophils to the injury site?

  1. Reparative phase
  2. Maturation phase
  3. Vascular phase
  4. Cellular phase Correct answer.

Explanation

The cellular phase involves leukocyte migration, with neutrophils arriving first to phagocytize organisms and debris. The vascular phase involves vasodilation and increased permeability.

Question 15Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

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

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

Explanation

Loop diuretics such as furosemide cause potassium loss, so serum potassium must be monitored to prevent hypokalemia and dysrhythmias. Bilirubin and amylase are unrelated to diuretic therapy.

Question 16Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which position is most appropriate for a patient experiencing orthopnea from heart failure to improve breathing?

  1. Prone
  2. Flat supine
  3. High Fowler's Correct answer.
  4. Trendelenburg

Explanation

High Fowler's position elevates the head and chest, reducing venous return and relieving dyspnea in orthopnea. Flat, prone, and Trendelenburg positions worsen breathing by increasing venous return and pressure on the diaphragm.

Question 17Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which route of transmission describes an infection spread by a mosquito bite?

  1. Vector-borne Correct answer.
  2. Direct contact
  3. Droplet
  4. Airborne

Explanation

Vector-borne transmission involves an arthropod such as a mosquito carrying the pathogen to a host. Direct contact, droplet, and airborne routes do not involve an intermediate organism.

Question 18Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

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

  1. Bradycardia with hypertension
  2. Poor skin turgor with dry mucous membranes Correct answer.
  3. Bounding pulses
  4. Dependent edema

Explanation

Dehydration reduces interstitial fluid, producing poor skin turgor and dry mucous membranes. Bounding pulses and edema suggest fluid overload instead.

Question 19Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which action is correct when a nurse discovers an unresponsive adult who is not breathing and has no pulse?

  1. Check for a radial pulse for one minute
  2. Wait for the code team to arrive
  3. Give two rescue breaths first
  4. Begin chest compressions immediately Correct answer.

Explanation

For an adult in cardiac arrest, high-quality chest compressions should begin immediately (C-A-B sequence) to maintain circulation. Delaying compressions to give breaths or prolonged pulse checks reduces survival.

Question 20Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which type of hypersensitivity reaction is responsible for anaphylaxis after a penicillin injection?

  1. Type II (cytotoxic) hypersensitivity
  2. Type I (immediate) hypersensitivity Correct answer.
  3. Type III (immune complex) hypersensitivity
  4. Type IV (delayed) hypersensitivity

Explanation

Anaphylaxis is a Type I IgE-mediated immediate hypersensitivity reaction causing rapid mast cell degranulation. The other types involve IgG/IgM or T-cell mechanisms with different timing and manifestations.

Question 21Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A patient is receiving a blood transfusion. Which finding should prompt the nurse to stop the transfusion immediately?

  1. Mild itching at the IV site
  2. Slight fatigue
  3. Temperature rise of 1°C with chills Correct answer.
  4. Blood pressure unchanged

Explanation

Fever with chills during transfusion may indicate a hemolytic or febrile reaction and requires stopping the transfusion and notifying the provider. Mild itching may warrant monitoring, but fever with chills is the more urgent sign.

Question 22Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which structure prevents backflow of blood from the left ventricle into the left atrium?

  1. Mitral valve Correct answer.
  2. Tricuspid valve
  3. Aortic valve
  4. Pulmonary valve

Explanation

The mitral (bicuspid) valve lies between the left atrium and left ventricle and prevents backflow during ventricular systole. The other valves separate different chambers or vessels.

Question 23Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A nurse is calculating a drug dose. The order is 0.25 mg and the available concentration is 0.5 mg per 2 mL. How many mL should the nurse administer?

  1. 2 mL
  2. 1 mL Correct answer.
  3. 0.5 mL
  4. 1.5 mL

Explanation

Using ratio-proportion: 0.5 mg/2 mL = 0.25 mg/x mL, so x = (0.25 × 2)/0.5 = 1 mL. The other values reflect calculation errors.

Question 24Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A patient with chronic obstructive pulmonary disease is receiving oxygen. Which finding suggests the oxygen flow rate may be too high?

  1. Improved oxygen saturation to 94%
  2. Increased appetite
  3. Productive cough
  4. Decreased respiratory drive with drowsiness Correct answer.

Explanation

In some COPD patients, excessive supplemental oxygen can blunt hypoxic respiratory drive, causing hypoventilation and drowsiness. A saturation near 94% is generally acceptable and productive cough is unrelated.

Question 25Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A nurse is assessing a patient with suspected compartment syndrome after a forearm fracture. Which finding is the earliest and most reliable indicator?

  1. Paralysis of the hand
  2. Absent radial pulse
  3. Pallor of the fingertips
  4. Pain out of proportion to injury that worsens with passive stretch Correct answer.

Explanation

Pain disproportionate to the injury and increasing with passive stretch of the affected muscle is the earliest and most sensitive sign of compartment syndrome. Pulselessness, pallor, and paralysis are late findings.

Question 26Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which anatomical structure separates the thoracic cavity from the abdominal cavity?

  1. The diaphragm Correct answer.
  2. The peritoneum
  3. The mediastinum
  4. The pleura

Explanation

The diaphragm is a dome-shaped muscle that forms the floor of the thoracic cavity and the roof of the abdominal cavity. It is the primary muscle of respiration and physically divides these two body cavities.

Question 27Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which type of immunity is acquired when a person receives antibodies through breast milk?

  1. Natural active immunity
  2. Natural passive immunity Correct answer.
  3. Artificial passive immunity
  4. Artificial active immunity

Explanation

Passive immunity occurs when antibodies are transferred from another source rather than produced by the person's own immune system. When this transfer happens naturally, such as through breast milk or across the placenta, it is called natural passive immunity.

Question 28Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A patient with a new ileostomy has a liquid stool output of 1200 mL over 24 hours. Which nursing action is most appropriate?

  1. Encourage a diet high in fiber
  2. Apply a tight abdominal binder
  3. Restrict oral fluid intake
  4. Monitor for signs of dehydration and electrolyte imbalance Correct answer.

Explanation

Ileostomy output is normally liquid and can be high in volume, leading to fluid and electrolyte losses. A 24-hour output of 1200 mL places the patient at risk for dehydration and electrolyte imbalance, so monitoring is essential.

Question 29Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which statement about the life cycle of bacteria is true?

  1. Bacteria reproduce by binary fission Correct answer.
  2. Bacteria require a host cell to replicate
  3. Bacteria reproduce by budding
  4. Bacteria reproduce sexually by conjugation

Explanation

Binary fission is the primary method of bacterial reproduction, where one cell divides into two identical daughter cells. This process allows rapid population growth under favorable conditions.

Question 30Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which cellular adaptation is characterized by an increase in the number of cells in a tissue?

  1. Hypertrophy
  2. Atrophy
  3. Hyperplasia Correct answer.
  4. Metaplasia

Explanation

Hyperplasia is an increase in the number of cells in a tissue or organ, often in response to hormonal stimulation or chronic irritation. It differs from hypertrophy, which is an increase in cell size.

Question 31Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

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

  1. Crush the medication into a fine powder
  2. Verify tube placement Correct answer.
  3. Flush the tube with 30 mL of water
  4. Position the patient supine

Explanation

Before administering anything through a nasogastric tube, the nurse must verify that the tube is correctly positioned in the stomach to prevent instillation into the lungs or other unintended locations. This is the priority safety step.

Question 32Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which hormone is primarily responsible for regulating blood glucose by promoting glucose uptake into cells?

  1. Cortisol
  2. Glucagon
  3. Epinephrine
  4. Insulin Correct answer.

Explanation

Insulin, produced by the beta cells of the pancreas, facilitates the uptake of glucose into cells and lowers blood glucose levels. It is the primary hormone for glucose regulation.

Question 33Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A patient is scheduled for surgery and the nurse is reviewing the surgical consent form. Which action is most appropriate?

  1. Explain the surgical procedure and risks to the patient
  2. Sign the consent form on behalf of the patient if the patient is anxious
  3. Witness the patient's signature after the surgeon has obtained informed consent Correct answer.
  4. Obtain the patient's signature before the surgeon explains the procedure

Explanation

The nurse's role in informed consent is to witness the patient's signature and ensure that the consent is voluntary and that the patient understands the information provided by the surgeon. The surgeon is responsible for explaining the procedure, risks, and benefits.

Question 34Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which assessment finding indicates that a patient is experiencing inadequate oxygenation?

  1. Oxygen saturation of 95% on room air
  2. Confusion and restlessness Correct answer.
  3. Respiratory rate of 16 breaths per minute
  4. Pink mucous membranes

Explanation

Confusion and restlessness are early signs of cerebral hypoxia, indicating inadequate oxygenation to the brain. Other signs of inadequate oxygenation include tachycardia, dyspnea, and cyanosis.

Question 35Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which statement about the transmission of HIV is correct?

  1. HIV is transmitted through sharing food utensils
  2. HIV is transmitted through casual contact such as hugging
  3. HIV is transmitted through mosquito bites
  4. HIV is transmitted through unprotected sexual intercourse Correct answer.

Explanation

HIV is transmitted through contact with infected blood, semen, vaginal secretions, or breast milk, most commonly through unprotected sexual intercourse or sharing needles. Casual contact, mosquito bites, and sharing utensils do not transmit HIV.

Question 36Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A nurse is caring for a patient with a pressure injury. Which factor is most likely to delay wound healing?

  1. Regular repositioning
  2. Adequate protein intake
  3. Poor tissue perfusion Correct answer.
  4. Moist wound environment

Explanation

Poor tissue perfusion reduces the delivery of oxygen and nutrients to the wound, impairing the healing process. Adequate nutrition, pressure relief, and a moist wound environment promote healing.

Question 37Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which pain assessment tool is most appropriate for a 4-year-old child?

  1. Verbal descriptor scale
  2. Visual analog scale
  3. Numeric rating scale
  4. Wong-Baker FACES scale Correct answer.

Explanation

The Wong-Baker FACES scale uses facial expressions to help young children communicate their pain level and is appropriate for children as young as 3 years. The other scales require numerical or abstract thinking beyond the developmental level of most 4-year-olds.

Question 38Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A patient receiving chemotherapy has a neutrophil count of 500/mm³. Which instruction is most important for the nurse to include in teaching?

  1. Exercise vigorously to boost immunity
  2. Avoid crowds and people with infections Correct answer.
  3. Take a daily multivitamin
  4. Increase intake of fresh fruits and vegetables

Explanation

A neutrophil count of 500/mm³ indicates severe neutropenia, placing the patient at high risk for infection. Avoiding crowds and sick contacts is crucial to reduce exposure to pathogens.

Question 39Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

Which mechanism best explains how a fever develops during an infection?

  1. Increased blood flow to the skin
  2. Decreased metabolic rate
  3. Release of pyrogens that reset the hypothalamic set point Correct answer.
  4. Direct stimulation of the hypothalamus by bacteria

Explanation

Fever occurs when pyrogens (such as cytokines) are released in response to infection and reset the hypothalamic set point to a higher temperature. This triggers heat conservation and production mechanisms.

Question 40Basic Nursing Science (fundamentals, anatomy/physiology, microbiology, pathology)

A nurse is reviewing a patient's arterial blood gas results: pH 7.30, PaCO2 50 mm Hg, HCO3- 24 mEq/L. Which acid-base imbalance is present?

  1. Respiratory alkalosis
  2. Respiratory acidosis Correct answer.
  3. Metabolic acidosis
  4. Metabolic alkalosis

Explanation

The pH is below 7.35, indicating acidosis. The PaCO2 is elevated above 45 mm Hg, indicating a respiratory cause, and the HCO3- is normal, suggesting no metabolic compensation yet. Therefore, the results indicate respiratory acidosis.

Question 41Medical-Surgical Nursing

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

  1. Mild ankle edema
  2. Hemoglobin of 9.2 g/dL
  3. Peaked T waves on the cardiac monitor Correct answer.
  4. Blood pressure of 148/88 mm Hg

Explanation

Hyperkalemia depolarizes cardiac membranes and can progress to ventricular dysrhythmias and cardiac arrest, so ECG changes such as peaked T waves are the most urgent finding. The other findings are chronic or less immediately life-threatening in this context.

Question 42Medical-Surgical Nursing

Which client is at highest risk for developing a pulmonary embolism after surgery?

  1. A client ambulating on postoperative day one
  2. A client who had a minor outpatient procedure
  3. A client receiving intermittent pneumatic compression devices
  4. A client with a history of deep vein thrombosis who remains on bed rest Correct answer.

Explanation

Prior venous thromboembolism plus immobility are two strong risk factors that combine to substantially raise the risk of pulmonary embolism. Early ambulation and mechanical prophylaxis reduce risk.

Question 43Medical-Surgical Nursing

A client is receiving intravenous heparin. Which laboratory value should the nurse monitor to evaluate therapeutic effect?

  1. International normalized ratio
  2. Prothrombin time
  3. Activated partial thromboplastin time Correct answer.
  4. Platelet count

Explanation

Unfractionated heparin enhances antithrombin activity, and its effect is measured by the activated partial thromboplastin time, which should be kept in the therapeutic range. INR and PT reflect warfarin therapy, not heparin.

Question 44Medical-Surgical Nursing

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

  1. Start an intravenous line for dextrose
  2. Administer the next scheduled dose of insulin
  3. Give 15 g of a fast-acting oral carbohydrate Correct answer.
  4. Encourage the client to lie down and rest

Explanation

For a conscious client with hypoglycemia who can swallow, the rule of 15 applies: give about 15 g of fast-acting carbohydrate and recheck glucose in 15 minutes. Waiting or giving insulin would worsen hypoglycemia.

Question 45Medical-Surgical Nursing

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

  1. Hepatomegaly
  2. Dependent peripheral edema
  3. Crackles and orthopnea Correct answer.
  4. Distended neck veins

Explanation

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

Question 46Medical-Surgical Nursing

A client with a new colostomy asks how to care for the stoma. Which instruction is appropriate?

  1. Clean the stoma with alcohol-based wipes
  2. Gently wash the stoma with warm water and pat dry Correct answer.
  3. Scrub the stoma vigorously to remove mucus
  4. Apply the pouch while the skin is wet

Explanation

The stoma is mucosal tissue and should be cleaned with mild soap and warm water, then patted dry before applying the pouch. Alcohol and scrubbing irritate the stoma, and the skin must be dry for the pouch to adhere.

Question 47Medical-Surgical Nursing

A client is scheduled for a cardiac catheterization using a femoral approach. Which instruction should the nurse give before the procedure?

  1. Discontinue all antihypertensive medications
  2. Plan to walk immediately after the procedure
  3. Expect to go home without post-procedure monitoring
  4. Avoid eating or drinking as ordered before the test Correct answer.

Explanation

Cardiac catheterization typically requires nothing by mouth beforehand per protocol, and the client must be monitored after the procedure for bleeding and dysrhythmias. Ambulation is restricted for a period after femoral access.

Question 48Medical-Surgical Nursing

A client is receiving a blood transfusion and develops fever, chills, and flank pain. What is the nurse's first action?

  1. Stop the transfusion and maintain intravenous access Correct answer.
  2. Slow the transfusion rate
  3. Give a prescribed antipyretic and continue
  4. Recheck vital signs in one hour

Explanation

These findings suggest an acute hemolytic transfusion reaction, which requires immediately stopping the transfusion while keeping the line open with normal saline. Continuing or slowing the transfusion allows further hemolysis.

Question 49Medical-Surgical Nursing

A client with an acute exacerbation of asthma has a respiratory rate of 32/min and audible wheezing. Which finding indicates the treatment is effective?

  1. Restlessness and confusion
  2. Oxygen saturation falling from 94% to 88%
  3. Decreased wheezing with improved air entry Correct answer.
  4. Increasing use of accessory muscles

Explanation

Improved air entry with decreasing wheeze and a calmer respiratory pattern indicate bronchodilation and improved airflow. Increasing work of breathing or falling saturation signals worsening obstruction.

Question 50Medical-Surgical Nursing

A client with cirrhosis has ascites and is prescribed spironolactone. Which assessment is most important for the nurse to monitor?

  1. Deep tendon reflexes
  2. Visual acuity
  3. Serum calcium
  4. Serum potassium and renal function Correct answer.

Explanation

Spironolactone is a potassium-sparing diuretic, so hyperkalemia and changes in renal function are the key monitoring concerns, especially in clients with cirrhosis. Other parameters are not the primary risk of this drug.