Fundamentals in Nursing Answers key with rationale

1. Answer: C

      Rationale: During suctioning, the nurse should monitor the client closely for side effects including hypoxemia, cardiac irregularities resulting from vagal stimulation, mucosal trauma, hypotension and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is oxygenated. Option D is incorrect because before you notify the physician you must first perform your independent nursing interventions.

2. Answer: C

      Rationale: The client should be hyperoxygenated with 100% oxygen before suctioning and if tracheal secretions are thick and not easily removed. A total of 3 to 5 ml of sterile normal saline may be instilled into the trachea (per agency policy) to try to reduce the viscosity of the secretions and stimulate coughing. Suction is not applied during insertion of the catheter, however, intermittent suction and a twirling motion of the catheter are used during withdrawal.

3. Answer: B

      Rationale: Hypoxemia can be caused by prolonged suctioning from stimulation of the pacemaker cells within the heart. A vasovagal response may occur causing bradycardia. The suctioning pass is limited to 15 seconds and the clients is preoxygenated before suctioning

4. Answer: C

      Rationale: The nurse monitors for the adverse effects of suctioning, which include cyanosis, exessively rapid or slow heart rate, or the sudden development of bloody secretions. If they occur, the nurse stops suctioning and reports these signs to the physician immediately. Coughing is a normal response to suctioning for the client with an intact cough reflex, and does not indicate that the client is unable to tolerate the procedure.

5. Answer: B

      Rationale: Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and after suctioning. Option A is incorrect because suction should only be applied while removing the catheter in order to prevent trauma to the trachea. Option C is incorrect because this kind of movement could cause tracheal damage. Option D is incorrect because excessive suctioning irritates the mucosa, which increases secretion production; suction only as needed.

6. Answer: A

      Rationale: With normal breathing, the water level rises with inspiration and falls with expiration. The opposite, falls with inspiration and rises with expiration, occurs when the client is on positive pressure mechanical ventilation. This is an expected normal occurrence in a chest tube drainage system; therefore no action is necessary.

7. Answer: C

      Rationale: Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury.  Option A is unnecessary at this time; the chest tube is occluded and nursing intervention should be attempted first. In option B, checking of vital signs may be done eventually, but this is not the priority at this time. Option d wo0uld compromise aeration of the unaffected lung.

8. Answer: A Rationale: The nurse ensures that all system connections are securely taped to prevent accidental disconnection, and that an occlusive dressing is maintained at the chest tube insertion site. Option B is incorrect because drainage is noted and recorded every hour in the first 24 hours after insertion and every 8 hours thereafter. In option C, it is correct to keep the system below the level of the waist, however, sterile water is added to the suction control chamber only as needed to replace evaporation losses. Option D is incorrect because continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. In addition, monitoring for crepitus is done once every 8 hours.

9. Answer: C

      Rationale: Covering the insertion site with petroleum gauze is a priority nursing measure that prevents air from entering the chest cavity. Notifying the physician in option A should be done after covering the insertion site. Option B is incorrect because inserting a chest tube is not a nursing action. Option D is incorrect because instructing the client to breathe deeply will still cause the air to enter the chest cavity.

10. Answer: D Rationale: Normal functioning of chest tubes is maintained and the drainage system is transported below the level of the chest. Option A is incorrect because chest tubes are not remove during transportation of the client; it can only be removed after the physician is satisfied with the degree of reexpansion. Removing the chest tube from the suction drainage system in option B is incorrect because it will result in an equalization of intrapleural pressures with atmospheric pressures, thus also increasing the risk of pneumothorax. Option C is incorrect because current practice precludes the clamping of the chest tube. It is believed that clamping increases the risk of a tension pneumothorax because air may enter the intrapleural space during inspiration but cannot escape during expiration.

11. Answer: A            Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for a client with emphysema, one of the chronic obstructive pulmonary disease (COPD), because it delivers a precise oxygen concentration. The aerosol mask (B), face tent (C) and tracheostomy collar (D) are also high flow oxygen delivery systems but are most often used to administer high humidity.

12. Answer: B Rationale: Oxygen is used cautiously in a client with emphysema and should not exceed 3 liters per minute. Because of the long-standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, which is the case in a normal respiratory system. Option A is incorrect because 1 liter per minute is too little to deliver enough oxygen concentration. Options C and D are incorrect because they are to high, which could prevent the respiratory drive of the client.

13. Answer: D Rationale: The stimulus to breathe in a client with emphysema is low oxygen levels rather than rising CO₂ levels. Frequent nursing observations are necessary to see how the client handles low-flow oxygen administration. In option A, although humidification will be necessary but this is not the most important nursing intervention.  Option B is incorrect because low-flow oxygen is appropriate and not contraindicated for a client with COPD. In option C, High-Fowler's position may make it easier for the client to breathe, however, the client will assume the position most helpful for him to breathe.

14. Answer: B

      Rationale: Humidification of oxygen is extremely important in reducing its drying effects on the mucous membranes of the bronchial tree. Humidification of oxygen is generally provided by a water nebulizer. Options A, C and D are incorrect because oxygen is not highly permeable in water; thus, water tends to inhibit rather that facilitate oxygen diffusion across the respiratory membrane. Humidification expands the volume of the inhaled gas, but by doing so it decreases the partial pressure of the gas in the alveoli.

15.    Answer: B Rationale: To read blood gases, first note the pH. In this case, pH is 7.38, which is within the normal range (7.35-7.45) but is on the acidotic side. Next, look at the PCO₂ and HCO₃ to see which one is causing the shift to acidosis. In this case the PCO₂ is 55 (acidosis) and the HCO₃ is 32 (alkalosis). Therefore, the client has compensated respiratory acidosis because the kidneys have been able to conserve enough bicarbonate to keep pH within normal range. In this case a pH below 7.35 would indicate uncompensated respiratory acidosis, which is in option A. If the client had uncompensated metabolic alkalosis in option C, pH would be above 7.45. If the client had compensated metabolic alkalosis in option D, pH would be between 7.41 and 7.45

16. Answer: B

Rationale: Neomycin sulfate is used preoperatively because it is poorly absorbed in the intestinal tract and acts to decrease the bacteria count in the colon. As a result of this action, postoperative infection is reduced (option A). Option C and D are incorrect because neomycin does not reduce tumor size or directly affects peristalsis.

17. Answer: B

      Rationale: The stoma will begin to secrete mucus within 48 hours, and the proximal loop should begin to drain fecal material within 72 hours. Option A is incorrect because ileostomies not colostomies begin to drain immediately. Options C and D are incorrect because peristalsis generally returns within 48-72 hours postoperatively.

18. Answer: C

      Rationale: If cramping occurs during colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from infusion that is too rapid or is causing too much pressure. Option A is incorrect because the physician does not need to be notified immediately. Option B is incorrect because increasing the height of the irrigation will cause further discomfort. In option D, medicating the client for pain is not the most appropriate action.

19. Answer: D

      Rationale: A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma (option A). Ischemia of the stoma would be associated with dusky or bluish color (option B). A stoma with a narrowed opening, either at the level of the skin or fascia, is said to be stenosed

20.Answer: A

        Rationale: The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor, but is a gas-forming food as well. Broccoli, cucumbers and eggs are gas-forming foods.

21. Answer: C

      Rationale: When gastrointestinal (GI) tubes are attached to suction, it may be continuous or intermittent, with a pressure not exceeding 25 mm Hg. The specific pressure and the intervals are prescribed by the physician. Options A, B and D are incorrect

22. Answer: A Rationale: Patency of the tube should be maintained to ensure continued suction. Use of normal saline prevents fluid and electrolyte disturbances during irrigation. Option B is incorrect because the stomach is not considered a sterile body cavity, so medical asepsis is indicated. Option C is avoided because care must be take to avoid traumatizing the mucosa. Option is incorrect because ice chips and water represent fluid intake, which must be approved by  the physician; being hypotonic in nature, such intake may lower the serum electrolytes. 

23. Answer: C Rationale: Looping the nasogastric tube will prevent pressure on the nares that can cause pain and eventual necrosis. Option A is incorrect because pinning the tube to the client's gown would cause irritation to the nares each time the client moved and might cause dislocation of the tube. In option B, prior to insertion of a nasogastric tube, it is proper to lubricate the tip with viscous xylocaine, but this is not applied to the nostril. In option D, a smaller tube might not be large enough to drain the contents of the stomach and intestine, it might still irritate the nose, and it may not be changed without a doctor's order.

24. Answer: B Rationale: After checking residual feeding contents, the gastric contents are reinstilled into the stomach by removing the syringe plunger and pouring the gastric contents via the syringe into the nasogastric tube. Removal of the contents in option A could disturb the client's electrolyte balance and the contents are not discarded. Gastric contents are are not mixed with formula (option C) or diluted with water (option D)

25. Answer: C Rationale: The presence of a residual of 200 ml or more with a nasogastric tube feeding or 100 ml or more with a gastrostomy tube feeding may indicate impaired absorption; the volume of the next feeding may need to be reduced or the feeding postponed based on the physician's order to reduce the risk for aspiration. Option A evaluates fluid balance and is best performed over a 24-hour period. Option B is a method for evaluating placement. In option D, although weighing the client regularly is important in evaluating overall nutritional progress, it does not provide information about absorption of a particular feeding.

26. Answer: A Rationale: The sigmoid and descending colon is located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colon. Acute flexion of the right leg allows for adequate exposure of the anus. Options B, C and D are incorrect positions.

27. Answer: B Rationale: For a high colonic enema, the fluid must extend higher in the colon. If the height of the enema fluid container above the anus is increased, the force and rate of flow also increase. Option A would be too low for a high cleansing enema. Options C and D would be too high and could cause mucosal injury. 

28. Answer: B

      Rationale: The rectal catheter should be inserted approximately 4 inches to pass the rectal sphincters. Option A is incorrect because a catheter inserted just 2 inches will not be passed beyond the rectal sphincters. Options C and D may damage the intestinal mucosa.

29. Answer: B

      Rationale: Pain and cramping are usually due to intestinal spasm and will subside when the enema is stopped briefly. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum (option A). There is no need to discontinue the enema and notify the physician at this time (option D).

30. Answer: C

      Rationale: Prune juice and warm water can be administered prophylactically by the nurse to promote defecation. Prune juice irritates the bowel mucosa, stimulating peristalsis. Increased fiber in the diet may also improve intestinal motility. Options A and D should be avoided because it can promote dependency and can result in electrolyte imbalance. Option B is incorrect because the routine use of laxatives promotes dependency.

31. Answer: D

      Rationale: The nurse should know that deep partial-thickness (second-degree) burns cause severe pain. The nurse should also know that during the first 48 to 72 hours after a serious burn, there is a very poor peripheral circulation due to hypovolemia; therefore, medications should be given via the IV route. PO (option B) and IM (option C) medications are generally contraindicated during this time. To do nothing (option A) would be inappropriate, given the nature and extent of the injuries.

32. Answer: A

      Rationale: To prevent contractures, the affected limb is kept straight (knee extension) and slightly abducted (to prevent pressure in hip joint), and the foot is supported (ankle flexion) to prevent footdrop. Options B, C and D are incorrect because all or part of each response could produce a contracture.

33. Answer: A

      Rationale: Hyponatremia, or decreased serum sodium, may develop in clients with burns because sodium tends to move with water into edema fluids and into denuded areas of the skin. Options B and D are incorrect because both these mechanisms tend to increase sodium reabsorption by the kidney tubules. In option C, inadequate fluid replacement would tend to mask hyponatremia because of hemoconcentration.

34.     Answer: B Rationale: Age is important baseline information because IV infusion rates to maintain appropriate quantity and specific gravity of urinary output differ; for example, 10 to 20 ml/hr for infants versus 50 to 70 ml/hr for adults. Weight is significant if the Evans and Brooke formula is used for fluid replacement therapy. Both of these formulas use both the size of the burn and the weight of the client to calculate the amount of fluid to be replaced. Vital signs and skin turgor are both important measure of the degree or extent of hypovolemia. As dehydration develops, skin turgor becomes poor, mucous membranes dry and the eyeballs feel soft. Likewise, the pulse may become thready and the blood pressure may decrease. Size (weight), as discussed, not sex would determine therapy (option A). Level of mentation in option C is less helpful in this particular situation because of the fear, pain and acute anxiety experienced by some clients. In option D, quantity and specific gravity of urine output are important in assessing the adequacy of fluid replacement rather than as part of the initial assessment

35. Answer: B Rationale: Desperation and panic may strike while the injury is occurring but rarely occur during the recovery period. During the acute stage of burn recovery, anxiety is common due to the stress and pain of injury and dressing changes. Anxiety decreases the individual's ability to perceive situations realistically, which may result in an altered mental state (option A). During the intermediate phase of burn recovery, clients may react to continued pain, changes in body image and financial stress with various psychological responses, ranging from withdrawal and depression (option C) to acting out anger by refusing to cooperate with the medical regimen and by dependency (option D).

36. Answer: B Rationale: The anterior chest, below the clavicle, is the preferred site for checking skin turgor in adults because it is less subject to deterioration of connective tissue. Options A and C are incorrect because the dorsal aspect of the forearm and the back of the hand may both show signs of skin tenting simply as a result of aging. Option D is incorrect because the abdomen is an appropriate place to check for skin turgor in babies, not adults.

37. Answer: D Rationale: The closing of the mitral and tricuspid valves, which constitute the S₁ sound, is best heard at the fifth intercostal space, left sternal border. Option A is incorrect because normal heart sound, S₁ and S₂, are best heard using the diaphragm of the stethoscope. The bell is used when auscultating for extra heart sounds and murmurs. Option B is incorrect because right side0lying is not an appropriate position for auscultating heart sounds. Option C is incorrect because the second heart sound, S₂, is best heard at the second intercostal space, right sternal border.

38. Answer: B Rationale: Symptoms of circulatory overload result from varying degrees of cardiac decompression, with blood backing up into the pulmonary (moist crackles) and systemic circuits (neck vein distention, dependent edema, periorbital edema and hepatomegaly). Options A, C and D are incorrect because all or part are symptoms of circulatory failure or hypovolemia. Such symptoms include apprehension, soft eyeballs, flattened neck veins, shock, decreased pulse pressure and poor skin turgor

39. Answer: C Rationale: Dry skin is primarily caused by sun exposure experienced during earlier years. Option A is incorrect because age spots are normal skin changes and not a cause of dry skin. In option B, although there are dietary effects on the skin health, this is not the primary cause of dryness. In option D, although medications are known to affect skin elasticity and sensitivity in older years, the effects of medications taken in earlier years have not been verified.

40. Answer: B Rationale: As cerebral hypoxia develops, the client becomes restless and drowsy well before any of the characteristic signs and symptoms of increasing intracranial pressure are present. Options A, C and D are all consistent with increasing intracranial pressure but occur much later, after there has been significant cerebral herniation and distortion of the brain. 

41. Answer: B Rationale: The client is scheduled for surgery; and because all of the other clients are stable, completing preoperative orders for this client is the priority. Option A is incorrect because the client is stable and the pain is not requiring immediate attention. Option C is incorrect because the Hct, while slightly lower than normal, has dropped significantly since the previous test. The level is not life threatening. Option D is incorrect because the WBC level is not elevated significantly to require immediate action by the nurse. It will require monitoring. 

42. Answer: A Rationale: The onset of a headache in a child with epilepsy could precipitate seizure or indicate a closed head injury. The registered nurse will want to assess this child first. Option B is incorrect because feeling scared and shaky is most probably a reaction to the stress of the accident in a child with diabetes mellitus. It is 7:30 AM and this child would have tested the blood glucose level, taken the prescribed amount of insulin and eaten breakfast at home prior to leaving for school. The registered nurse will want to assess this child as priority number 2. Option C is incorrect because feeling stiff and sore in the morning is a common complaint in a child with rheumatoid arthritis. However, this child could have sustained a musculoskeletal injury and should be assessed as priority number 4. Option D is incorrect because shoulder level pain is a common compliant in a child with scoliosis. The Milwaukee brace is used almost exclusively in a child with kyphosis so the registered nurse would expect the pain to be centered in the neck and shoulders. However, this child could have sustained a musculoskeletal injury despite the protection that the brace would have offered and should be assessed as priority number 3.

43. Answer: C Rationale: The focus of care for a child with sickle cell anemia is pain control. The registered nurse will want to assess the child's pain status and reload the medication cassette as soon as possible. This action will be the registered nurse's first priority. Option A is incorrect because the registered nurse would expect that the dressing on a new tracheostomy would require frequent changes. The registered nurse will want to assess the tracheostomy and change the dressing as soon as possible, but this is not the first priority. Option B is incorrect because the registered nurse would expect that the urine produced by a child with acute glomerulonephritis would be bloody (hematuria). The registered nurse will want to assess the urine and compare it to other voided specimen, but this is not the first priority. Option D is incorrect because the registered nurse would expect that vomiting will occur in a child with pyloric stenosis. The registered nurse will want to assess and record the amount of the emesis, but this is not the first priority.

44. Answer: A Rationale: maintaining the iv site access is the priority. The new bag of solution would be started at a rate that keeps the vein open while determining if the 1000 ml bag was ever hung or had rapidly infused. Option B is incorrect because checking the records further delays maintaining patency of the IV site. After the vein is kept open, then the nurse can determine what has occurred. Option C is incorrect as there are no observable signs of distress. A keep-open rate with a new bag of solution will not put the client at risk if the 1000 ml had been infused too rapidly. Option D is incorrect because it would not be the first priority. If the unit was never hung, an incident report would not be completed.

45.Answer: A

      Rationale: Airway or breathing problems should be treated first. Option B, C and D are incorrect because these clients don't have any problem with airway or breathing.

46. Answer: C Rationale: Louder breath sounds on the right side of the chest indicate that the endotracheal tube may be misplaced and is aerating only one lung. Option A is incorrect because dullness to percussion is normal in the third to fifth intercostal spaces as the heart is located there. Option B is incorrect because decreased paradoxical motion is a desired effect when the client has a flail chest. Option D is incorrect because pH of 7.36 is within normal limits.

47. Answer: D Rationale: When the high-pressure alarm sounds on a mechanical ventilator, it is most likely due to an obstruction. The obstruction can be caused by the client biting on the tube, kinking of the tubing or mucus plugging requiring suctioning. It is also important to check the tubing for the presence of any water and determine if the client is out of rhythm with breathing with the ventilator. Options A and B are incorrect because a disconnection or a cuff leak can cause sounding of the low-pressure alarm. Option C is incorrect because the respiratory therapist would be notified if the nurse could not determine the cause of the alarm.

48. Answer: B Rationale: Being able to hear the client's voice indicates that the cuff on the tube is deflated, or he tube is misplaced.. Option A is incorrect because the client should not be able to audibly speak if the cuff on the endotracheal tube has adequately sealed the trachea, and if the tube is correctly placed just above the carina. Option C is incorrect because, in this case, the cuff pressure should be checked first, and the position of the tube evaluated to determine the need for a new tube. Option D is incorrect because the client would more likely not exhibit, or have greatly diminished breath sounds on the left, if the tube had migrated to the right side of the lung.

49. Answer: D Rationale: Marking the insertion point of the tube provides a reference point for determining if the tube has moved in or out. Option A is incorrect because measuring cuff pressure verifies that the cuff is inflated to the correct pressure; it gives no information about the placement of the tube. Option B is incorrect because suctioning the client does not help maintain placement of the tube. Option C is incorrect because x-raying the tube is done after initial placement of the tube, or if there is reason to suspect that the tube is misplaced.

50. Answer: A Rationale: Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first and then the cuff is deflated (option B) and the tube is removed. Option D is incorrect because there is no reason to have a code cart placed at the bedside. This may cause alarm and concern in the client. Additionally, the necessary resuscitative equipment should have already been at the client's bedside. 

Fundamentals in Nursing Questions

Situation 1: Suctioning is the mechanical aspiration of mucous secretions from the tracheobronchial tree by application of negative pressure. Nurses should be knowledgeable when performing such procedure.


1. The nurse is suctioning a client through an endotracheal tube. During the suctioning procedure the nurse notes cardiac irregularities on the monitor. Which of the following is the most appropriate nursing intervention?
a. Continue to suction
b. Ensure that the suction is limited to 15 seconds
c. Stop the procedure and reoxygenate the client
d. Notify the physician immediately


2. A nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which of the following observations, if made by the instructor, would indicate an inappropriate action?
a. Hyperventilating the client with 100% oxygen before suctioning
b. Instilling 3 to 5 ml normal saline in the tracheostomy tube to loosen secretions
c. Applying suction during insertion of the catheter
d. Applying suction during withdrawal of the catheter


3. A nurse is suctioning a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning to a maximum of:
a. 5 seconds   c. 30 seconds
b. 15 seconds d. 1 minute


4. A nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which of the following observations is made?
a. Secretions are becoming bloody
b. Heart rate decreases from 78 to 54 beats per minute
c. Coughing occurs with suctioning
d. Skin color becomes cyanotic

5. A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, the nurse should:
a. Apply suction while inserting the catheter
b. Hyperoxygenate with 100% oxygen before and after suctioning
c. Use short, jabbing movements of the catheter to loosen secretions
d. Suction 2 to 3 times in quick succession to remove secretions


Situation 2. The nurse is caring for a client with a chest tube drainage system following a traumatic open chest injury.
6. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber on the chest tube system. Which nursing action is most appropriate?
a. No action is necessary
b. Encourage coughing and deep breathing
c. Suction the client
d. Increase the suction

7. During the first 36 hours after the insertion of the chest tube, the nurse assess the function of the three-chamber, closed-chest drainage system and notes that the water in the underwater seal tube is not fluctuating. The initial nursing intervention should be to
a. Inform the physician
b. Take the client's vital signs
c. Check whether the tube is kinked
d. Turn the client to the unaffected side

8. The client's chest tube was attached to a Pleurevac drainage system. As part of routine nursing care, the nurse would ensure that:
a. The connection between the chest tube and the drainage system is taped, and that an occlusive dressing is maintained at the insertion site
b. The amount of chest tube drainage is noted and recorded every 24 hours in the client's record.
c. The suction control chamber has sterile water added every shift and that the system is kept below waist level
d. The water seal chamber has continuous bubbling and that monitoring for crepitus is done once a shift.

9. When the nurse enters the room of the client, she notices that the chest tube is dislodged from the chest. The most appropriate nursing intervention is to:
a. Notify the physician
b. Insert a new chest tube
c. Cover the insertion site with petroleum gauze
d. Instruct the client to breathe deeply until help arrives


10. The client who has chest tube drainage is to be transported to the X-Ray department in order to assess the degree of lung reexpansion. To safely transport the client, the nurse would:
a. Remove the chest tubes, immediately covering the incision site with a sterile petrolatum gauze to prevent air from entering the chest.
b. Disconnect the drainage bottles from the chest tubes, covering the catheter tip with a sterile dressing to prevent contamination.
c. Send the client to x-ray with the chest tube clamped but still attached to the drainage system to prevent air from entering the chest wall if the bottles are accidentally broken
d. Send the client to x-ray with the chest tube attached to the drainage system, taking precautions to prevent interruption in the system.

Situation 3. Nurse Gemma is caring for Mr. Kyle, a 30 years old man diagnosed with emphysema. Oxygen therapy was prescribed by his physician.
11. An oxygen delivery system is prescribed for Mr. Kyle in order to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?
a. Venturi mask  c. Face tent
b. Aerosol mask d. Tracheostomy collar


12. When caring for Mr. Kyle, the nurse checks the oxygen flow rate to ensure that it does not exceed:
a. 1 liter per minute
b. 3 liters per minute
c. 6 liters per minute
d. 10 liters per minute


13. Supplemental low-flow oxygen therapy was prescribed to Mr. Kyle by his physician. Which is the most essential action for the nurse to initiate?
a. Anticipate the need for humidification
b. Notify the physician that this order is contraindicated
c. Place the client in High-Fowler's position
d. Schedule nursing care to allow frequent observations of the client

14. Nurse Gemma explains to Mr. Kyle's family that humidification is given with oxygen administration because:
a. Oxygen is highly permeable in water, thereby increasing gaseous diffusion
b. Oxygen is very drying to the mucous membranes
c. The partial pressures of oxygen are increased by water dilution, allowing more oxygen to reach the alveoli.
d. Water acts as a carrier substance facilitating movement of oxygen across the respiratory membrane



15. Mr. Kyle's arterial blood gases reveal: pH - 7.38; PO2 - 65; PCO2 - 55; HCO3 - 32. The nurse's interpretation of this clients blood gases is that he has:
a. Uncompensated respiratory acidosis
b. Compensated respiratory acidosis
c. Uncompensated metabolic alkalosis
d. Compensated metabolic alkalosis


Situation 4. Mr. Ginga, a 25 year old male client, is scheduled for a temporary colostomy due to severe diverticulitis.
16. Mr. Ginga's physician ordered neomycin SO4. The purpose of preoperative administration of neomycin SO4 is to:
a. Reduce the risk of postoperative wound infection
b. Decrease bacterial count of the colon
c. Reduce the size of a possible tumor before surgery
d. Stimulate peristalsis and facilitate action of cleansing enemas


17. The nurse knows that a colostomy begins functioning:
a. Immediately
b. 2 to 3 days postoperatively
c. 1 week postoperatively
d. 2 weeks postoperatively


18. Nurse Sagiri is performing a colostomy irrigation on Mr. Ginga. During the irrigation, the client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?
a. Notify the physician immediately
b. Increase the height of the irrigation
c. Stop the irrigation temporarily
d. Medicate for pain and resume irrigation


19. The nurse is monitoring for stoma prolapse, she would observe which of the following appearances in the stoma if prolapse occurred?
a. Sunken and hidden
b. Dark and bluish in color
c. Narrowed and flattened
d. Protruding and swollen

20. Mr. Ginga is concerned about the odor of the stool in the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?
a. Yogurt c. Cucumbers
b. Broccoli d. Eggs


Situation 5. A nasogastric tube has been inserted into Mr. Hugh, a 30 year old gangster boss, who was admitted due to brain attack (CVA).
21. The physician prescribes that the tube be attached to intermittent suction. The nurse attaches the suction noting that the pressure should not exceed:
a. 10 mm Hg c. 25 mm Hg
b. 20 mm Hg d. 30 mm Hg


22. When caring for a client with a nasogastric tube attached to suction, the nurse should:
a. Irrigate the tube with normal saline
b. Use sterile technique when irrigating the tube
c. Withdraw the tube quickly when decompression is terminated
d. Allow the client to have small chips of ice or sips of water unless nauseated
relieve discomfort in the nostril with a nasogastric tube in place?
a. Remove any tape and loosely pin the tube to his gown
b. Lubricate the nasogastric tube with viscous xylocaine
c. Loop the nasogastric tube to avoid pressure on the nares
d. Replace the nasogastric tube with a smaller diameter tube


24. Nurse Naj has aspirated 40 ml of undigested formula from Mr. Hugh's nasogastric tube before administering an intermittent tube feeding. The nurse understands that before administering the tube feeding, the 40 ml of gastric aspirate should be:
a. Discarded properly and recorded as output on the client's I&O record
b. Poured into the nasogastric tube through a syringe with the plunger removed
c. Mixed with the formula and poured into the nasogastric tube through a syringe without a plunger
d. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger



25. To best evaluate whether a prior feeding has been absorbed, the nurse should:
a. Evaluate the intake in relation to the output
b. Instill air into the stomach while auscultating
c. Aspirate for a residual volume and reinstill it
d. Compare the client's body weight with the baseline data

Situation 6. Nurse Gelie is taking care of Christopher, 22 years old, who is scheduled for cleansing enema.
26. Nurse Gelie is preparing to administer a high cleansing enema to Christopher. She positions the client in the:
a. Left lateral position with the right leg acutely flexed
b. Right Sims' position
c. Dorsal recumbent position
d. Right lateral position with the left leg acutely flexed


27. The maximum height at which the container of fluid should be held when administering a high cleansing enema is:
a. 30 cm (12 inches)
b. 37 cm (15 inches)
c. 45 cm (20 inches)
d. 66 cm (26 inches)


23. Answer: C Rationale: Looping the nasogastric tube inserted is:
a. 2 inches c. 6 inches
b. 4 inches d. 8 inches


29. Nurse Gelie has administered approximately half of a high cleansing enema when the client complains of pain and cramping. Which of the following nursing actions is the most appropriate?
a. Raise the enema bag so that the solution can be administered quickly
b. Clamp the tubing for 30 seconds and restart the flow at a slower rate
c. Reassure the client and continue the flow
d. Discontinue the enema and notify the physician

30. With the knowledge that Christopher is accustomed to taking enemas periodically to avoid constipation, the nurse should:
a. Arrange to have enemas ordered
b. Have the physician order a daily laxative
c. Offer the client a large glass of prune juice and warm water each morning
d. Realize that enemas will be necessary because the normal conditioned reflex has been lost


Situation 7. Ash, 15 years old, is admitted to the burn unit in serious condition with deep partial-thickness burns over the head, face, neck and anterior chest. There are also second degree burns on the left leg and thigh.
31. On the first night in the hospital, nurse Misty enters the room and finds Ash crying softly and moaning in pain. Recognizing the extent of the injuries, the nurse should:
a. Do nothing at this time
b. Offer two acetaminophen (Tylenol) pills as ordered and a glass of warm milk
c. Give an IM injection of 40 mg of meperidine HCl (Demerol) as ordered
d. Inject 25 mg of meperidine HCl (Demerol) as ordered via central IV line

32. Nurse Misty plans to help prevent contractures in the burned leg by:
a. Maintaining abduction of the left leg, extension of the left knee, and flexion of the left ankle
b. maintaining adduction of the left leg and extension of the left knee and ankle
c. Maintaining abduction of the left leg and flexion of the left knee and ankle
d. Maintaining adduction of the left leg, flexion of the left knee, and extension of the left ankle

33. Hyponatremia may develop in clients with burns due to:
a. Displacement of sodium in edema fluids and loss through denuded areas of the skin
b. Increased aldosterone secretion
c. Inadequate fluid replacement
d. Metabolic acidosis

34. Ash is to receive fluid replacement therapy. Besides assessing size and depth of the burn, which physical parameters are also important baseline data for fluid replacement therapy?
a. Age, sex and vital signs
b. Age, weight, vital signs and skin turgor
c. Vital signs, level of mentation and urine output
d. Vital signs and quantity and specific gravity of urine

35. Which behavior is least likely to be included in the nursing assessment of a client with burns during the recovery period?
a. Anxiety with mild confusion
b. Desperation and panic
c. Withdrawal and depression
d. Dependency and regression

Situation 8. The first phase of the nursing process is the Assessment. It requires the nurse to obtain objective and subjective data from primary and secondary sources, to identify and group significant data, as well as to communicate this information to other members of the health team. The information necessary from making nursing decisions is obtained through assessment.
36. The best place to assess for dehydration by checking skin turgor in older adults is on the:
a. Dorsal aspect of the forearm
b. Anterior chest, below the clavicle
c. Back of the hand
d. Abdomen

37. When auscultating heart sounds, the nurse knows that the first heart sound (S1) is best heard:
a. Using the bell of the stethoscope
b. With the client lying on the right side
c. At the second intercostal space, right sternal border
d. At the fifth intercostal space, left sternal border


38. Objective assessment data indicating circulatory overload in a client who has chronic renal failure would include:
a. Neck vein distention, apprehension, soft eyeballs
b. Periorbital edema, distended neck veins, moist crackles
c. Increased blood pressure, flattened neck veins, shock
d. Decreased pulse pressure, cool, dry skin, decreased skin turgor

39. Based on the primary cause for skin changes in older adults, the initial nursing assessment of an elderly client with dry skin would include:
a. Presence of age spots
b. A diet history
c. History of prior sun exposure
d. Medications taken as a younger adult


40. Which nursing assessment would identify the earliest indication of increasing intracranial pressure?
a. Temperature over 102°F
b. Change in level of consciousness
c. Widening pulse pressure
d. Unequal pupils

Situation 9.Nurses should develop the skills on how to prioritize in order to properly allocate the appropriate care to different clients.

41. During report from the night shift, the day nurse receive information on four clients. Which client should the nurse assess first?
a. Gary, 78 year old, 3 days after knee surgery whose pain level at 6:00 AM was 3 out of 10
b. May, 45 year old, with diverticulosis who is scheduled for bowel surgery at 8:00 AM
c. Jessie, 18 years old, with multiple fractures whose Hct is 32, which is down from 32.5 of the previous day
d. Kira, 62 year old, 2 days following bladder surgery whose WBC is 11,000


42. A school bus is involved in a traffic accident at 7:30 AM en route to delivering a group of children with “special needs” to school. A pediatric emergency team is dispatched to the scene of the accident. The registered nurse will give greatest priority to:
a. The child with epilepsy who is complaining of headache
b. The child with diabetes mellitus who is complaining of feeling scared and shaky
c. The child with rheumatoid arthritis who is complaining of feeling stiff and sore
d. The child with scoliosis who is wearing a Milwaukee brace and complaining of shoulder level pain



43. A registered nurse returns to the pediatric unit from dinner break and receives the following report from the LVN/LPN. Which child should the registered nurse attend to first?
a. A child with epiglottitis and a tracheostomy with a neck dressing that is wet and soiled
b. A child with acute glomerulonephritis whose urine is bloody
c. A child with sickle cell anemia whose PCA (patient-controlled analgesia) medication cassette is empty
d. A child with pyloric stenosis who has vomited


44. The nurse finds the client's IV bag empty at change of shift. The RN on the previous shift reported that a new 1000 ml bag would be hung. The client is in no apparent distress. What is the first priority?
a. Maintain patency of the IV site with a new bag of solution
b. Check the IV record to see if a new bag was charted
c. Assess heart and lungs for signs of fluid overload
d. Complete an incident report and notify physician of error


45. The nurse triages clients in the emergency department. Which client should the nurse treat first?
a. Norman, 27 years old, with right-side chest pain, shortness of breath and unequal chest excursion who was in a motor vehicle accident
b. Mikki, 7 years old, who sustained a scalp laceration in a soccer game. The child is awake and crying
c. Oak, 82 years old, with chest pain who is pale and diaphoretic
d. Diana, 35 years old, with a compound tibial fracture


Situation 10. James, a 17 years old male, is admitted with a flail chest following an automobile accident. He is very anxious, dyspneic and in severe pain. He is intubated with an endotracheal tube and is placed on a mechanical ventilator (control mode, positive pressure).
46. Which physical finding alerts the nurse to an additional problem in respiratory function?
a. Dullness to percussion in the third to fifth intercostal space, midclavicular line
b. Decreased paradoxical motion
c. Louder breath sounds on the right chest
d. pH of 7.36 in arterial blood gases

47. The high-pressure alarm sounds on the mechanical ventilator. The nurse prepares to perform which of the following most appropriate nursing intervention?
a. Check for a disconnection
b. Evaluate the tube cuff for a leak
c. Notify the respiratory therapist
d. Suction the client


48. James has had a cuffed endotracheal tube for 3 days. When the nurse goes to the bedside, the nurse hears the client say “good morning.” This indicates:
a. James is feeling better, is more alert, and is appropriately responsive
b. The cuff on the endotracheal tube is deflated, or the tube is misplaced and the nurse should act immediately
c. The endotracheal tube needs to be replaced immediately
d. The endotracheal tube has migrated to the right main stem bronchus and the nurse should obtain a STAT chest x-ray


49. To maintain correct placement of an endotracheal tube, the nurse should:
a. Check for cuff pressure periodically
b. Suction the client PRN
c. X-ray the tube every day
d. Mark the tube at its insertion point into the client's mouth or nose


50. Nurse Joy is preparing for the removal of the endotracheal tube (ET) from James. In preparing to assist the physician in this procedure, which initial nursing action is most appropriate?
a. Suction the ET tube
b. Deflate the cuff
c. Turn the ventilator to the off position
d. Obtain a code cart and place it at the bedside