Fundamentals of Nursing

St. Louis Review Center, Inc. c.
Use short, jabbing movements of the catheter

6th Flr. G. Tolentino Cor. España, Doña Amparo to loosen secretions
Bldg. Sampaloc Manila
Tel. no. (02) 735-1294 or (02) 736-7410
d. Suction 2 to 3 times in quick succession to
remove secretions
FUNDAMENTALS OF NURSING Situation 2. The nurse is caring for a client

Post-Test Level II- June 2009 with a chest tube drainage system following a
traumatic open chest injury.
Situation 1: Suctioning is the mechanical 6. The nurse notes a fluctuating water level
aspiration of mucous secretions from the on inspiration and expiration in the submerged
tracheobronchial tree by application of tube in the water seal chamber on the chest
negative pressure. Nurses should be tube system. Which nursing action is most
knowledgeable when performing such appropriate?
procedure. a. No action is necessary
b. Encourage coughing and deep breathing
1. The nurse is suctioning a client through c. Suction the client
an endotracheal tube. During the suctioning d. Increase the suction
procedure the nurse notes cardiac 7. During the first 36 hours after the insertion
irregularities on the monitor. Which of the of the chest tube, the nurse assess the
following is the most appropriate nursing function of the three-chamber, closed-chest
intervention? drainage system and notes that the water in
a. Continue to suction the underwater seal tube is not fluctuating.
b. Ensure that the suction is limited to 15 The initial nursing intervention should be to
seconds a. Inform the physician
c. Stop the procedure and reoxygenate the client b. Take the client's vital signs
d. Notify the physician immediately c. Check whether the tube is kinked
2. A nursing instructor is observing a d. Turn the client to the unaffected side
nursing student suctioning a client through a 8. The client's chest tube was attached to a
tracheostomy tube. Which of the following Pleurevac drainage system. As part of routine
observations, if made by the instructor, would nursing care, the nurse would ensure that:
indicate an inappropriate action? a. The connection between the chest tube and the
a. Hyperventilating the client with 100% oxygen drainage system is taped, and that an
before suctioning occlusive dressing is maintained at the
b. Instilling 3 to 5 ml normal saline in the insertion site
tracheostomy tube to loosen secretions b. The amount of chest tube drainage is noted
c. Applying suction during insertion of the and recorded every 24 hours in the client's
catheter record.
d. Applying suction during withdrawal of the c. The suction control chamber has sterile water
catheter added every shift and that the system is kept
3. A nurse is suctioning a client via a below waist level
tracheostomy tube. When suctioning, the d. The water seal chamber has continuous
nurse must limit the suctioning to a maximum bubbling and that monitoring for crepitus is
of: done once a shift.
a. 5 seconds c. 30 seconds 9. When the nurse enters the room of the
b. 15 seconds d. 1 minute client, she notices that the chest tube is
4. A nurse is performing nasotracheal dislodged from the chest. The most
suctioning of a client. The nurse interprets appropriate nursing intervention is to:
that the client is adequately tolerating the a. Notify the physician
procedure if which of the following b. Insert a new chest tube
observations is made? c. Cover the insertion site with petroleum gauze
a. Secretions are becoming bloody d. Instruct the client to breathe deeply until help
b. Heart rate decreases from 78 to 54 beats per arrives
minute 10. The client who has chest tube drainage is
c. Coughing occurs with suctioning to be transported to the X-Ray department in
d. Skin color becomes cyanotic order to assess the degree of lung
5. A client with a pulmonary embolus is reexpansion. To safely transport the client, the
intubated and placed on mechanical nurse would:
ventilation. When suctioning the a. Remove the chest tubes, immediately covering
endotracheal tube, the nurse should: the incision site with a sterile petrolatum
a. Apply suction while inserting the catheter gauze to prevent air from entering the chest.
b. Hyperoxygenate with 100% oxygen before b. Disconnect the drainage bottles from the chest
and after suctioning tubes, covering the catheter tip with a sterile
St. Louis Review Center, Inc-Davao Tel. no. (082) 224-2515 or 222-8732 1
dressing to prevent contamination. colostomy due to severe diverticulitis.
c. Send the client to x-ray with the chest tube 16. Mr. Ginga's physician ordered neomycin
clamped but still attached to the drainage SO4. The purpose of preoperative
system to prevent air from entering the chest administration of neomycin SO4 is to:
wall if the bottles are accidentally broken a. Reduce the risk of postoperative wound
d. Send the client to x-ray with the chest tube infection
attached to the drainage system, taking b. Decrease bacterial count of the colon
precautions to prevent interruption in the c. Reduce the size of a possible tumor before
system. surgery
d. Stimulate peristalsis and facilitate action of
Situation 3. Nurse Gemma is caring for Mr. cleansing enemas
Kyle, a 30 years old man diagnosed with 17. The nurse knows that a colostomy begins
emphysema. Oxygen therapy was functioning:
prescribed by his physician. a. Immediately
11. An oxygen delivery system is prescribed b. 2 to 3 days postoperatively
for Mr. Kyle in order to deliver a precise c. 1 week postoperatively
oxygen concentration. Which of the following d. 2 weeks postoperatively
types of oxygen delivery systems would the 18. Nurse Sagiri is performing a colostomy
nurse anticipate to be prescribed? irrigation on Mr. Ginga. During the irrigation,
a. Venturi mask c. Face tent the client begins to complain of abdominal
b. Aerosol mask d. Tracheostomy collar cramps. Which of the following is the most
12. When caring for Mr. Kyle, the nurse appropriate nursing action?
checks the oxygen flow rate to ensure that it a. Notify the physician immediately
does not exceed: b. Increase the height of the irrigation
a. 1 liter per minute c. Stop the irrigation temporarily
b. 3 liters per minute d. Medicate for pain and resume irrigation
c. 6 liters per minute 19. The nurse is monitoring for stoma
d. 10 liters per minute prolapse, she would observe which of the
13. Supplemental low-flow oxygen therapy following appearances in the stoma if prolapse
was prescribed to Mr. Kyle by his physician. occurred?
Which is the most essential action for the a. Sunken and hidden
nurse to initiate? b. Dark and bluish in color
a. Anticipate the need for humidification c. Narrowed and flattened
b. Notify the physician that this order is d. Protruding and swollen
contraindicated 20. Mr. Ginga is concerned about the odor of
c. Place the client in High-Fowler's position the stool in the ostomy drainage bag. The
d. Schedule nursing care to allow frequent nurse teaches the client to include which of
observations of the client the following foods in the diet to reduce odor?
14. Nurse Gemma explains to Mr. Kyle's a. Yogurt c. Cucumbers
family that humidification is given with b. Broccoli d. Eggs
oxygen administration because:
a. Oxygen is highly permeable in water, thereby Situation 5. A nasogastric tube has been
increasing gaseous diffusion inserted into Mr. Hugh, a 30 year old gangster
b. Oxygen is very drying to the mucous boss, who was admitted due to brain attack
membranes (CVA).
c. The partial pressures of oxygen are increased 21. The physician prescribes that the tube be
by water dilution, allowing more oxygen to attached to intermittent suction. The nurse
reach the alveoli. attaches the suction noting that the pressure
d. Water acts as a carrier substance facilitating should not exceed:
movement of oxygen across the respiratory a. 10 mm Hg c. 25 mm Hg
membrane b. 20 mm Hg d. 30 mm Hg
15. Mr. Kyle's arterial blood gases reveal: pH 22. When caring for a client with a nasogastric
- 7.38; PO2 - 65; PCO2 - 55; HCO3 - 32. The tube attached to suction, the nurse should:
nurse's interpretation of this clients blood a. Irrigate the tube with normal saline
gases is that he has: b. Use sterile technique when irrigating the tube
a. Uncompensated respiratory acidosis c. Withdraw the tube quickly when decompression
b. Compensated respiratory acidosis is terminated
c. Uncompensated metabolic alkalosis d. Allow the client to have small chips of ice or
d. Compensated metabolic alkalosis sips of water unless nauseated
23. Which of the following nursing action will
Situation 4. Mr. Ginga, a 25 year old male relieve discomfort in the nostril with a
client, is scheduled for a temporary nasogastric tube in place?
a. Remove any tape and loosely pin the tube to be administered quickly
his gown b. Clamp the tubing for 30 seconds and restart the
b. Lubricate the nasogastric tube with viscous flow at a slower rate
xylocaine c. Reassure the client and continue the flow
c. Loop the nasogastric tube to avoid pressure d. Discontinue the enema and notify the physician
on the nares 30. With the knowledge that Christopher is
d. Replace the nasogastric tube with a smaller accustomed to taking enemas periodically to
diameter tube avoid constipation, the nurse should:
24. Nurse Naj has aspirated 40 ml of a. Arrange to have enemas ordered
undigested formula from Mr. Hugh's b. Have the physician order a daily laxative
nasogastric tube before administering an c. Offer the client a large glass of prune juice and
intermittent tube feeding. The nurse warm water each morning
understands that before administering the d. Realize that enemas will be necessary because
tube feeding, the 40 ml of gastric aspirate the normal conditioned reflex has been lost
should be:
a. Discarded properly and recorded as output on Situation 7. Ash, 15 years old, is admitted to
the client's I&O record the burn unit in serious condition with deep
b. Poured into the nasogastric tube through a partial-thickness burns over the head, face,
syringe with the plunger removed neck and anterior chest. There are also
c. Mixed with the formula and poured into the second degree burns on the left leg and thigh.
nasogastric tube through a syringe without a 31. On the first night in the hospital, nurse
plunger Misty enters the room and finds Ash crying
d. Diluted with water and injected into the softly and moaning in pain. Recognizing the
nasogastric tube by putting pressure on the extent of the injuries, the nurse should:
plunger a. Do nothing at this time
25. To best evaluate whether a prior feeding b. Offer two acetaminophen (Tylenol) pills as
has been absorbed, the nurse should: ordered and a glass of warm milk
a. Evaluate the intake in relation to the output c. Give an IM injection of 40 mg of meperidine
b. Instill air into the stomach while auscultating HCl (Demerol) as ordered
c. Aspirate for a residual volume and reinstill it d. Inject 25 mg of meperidine HCl (Demerol) as
d. Compare the client's body weight with the ordered via central IV line
baseline data 32. Nurse Misty plans to help prevent
contractures in the burned leg by:
Situation 6. Nurse Gelie is taking care of a. Maintaining abduction of the left leg, extension
Christopher, 22 years old, who is scheduled of the left knee, and flexion of the left ankle
for cleansing enema. b. maintaining adduction of the left leg and
26. Nurse Gelie is preparing to administer a extension of the left knee and ankle
high cleansing enema to Christopher. She c. Maintaining abduction of the left leg and flexion
positions the client in the: of the left knee and ankle
a. Left lateral position with the right leg acutely d. Maintaining adduction of the left leg, flexion of
flexed the left knee, and extension of the left ankle
b. Right Sims' position 33. Hyponatremia may develop in clients with
c. Dorsal recumbent position burns due to:
d. Right lateral position with the left leg acutely a. Displacement of sodium in edema fluids and
flexed loss through denuded areas of the skin
27. The maximum height at which the b. Increased aldosterone secretion
container of fluid should be held when c. Inadequate fluid replacement
administering a high cleansing enema is: d. Metabolic acidosis
a. 30 cm (12 inches) 34. Ash is to receive fluid replacement
b. 37 cm (15 inches) therapy. Besides assessing size and depth of
c. 45 cm (20 inches) the burn, which physical parameters are also
d. 66 cm (26 inches) important baseline data for fluid replacement
28. The length of the rectal catheter that therapy?
should be inserted is: a. Age, sex and vital signs
a. 2 inches c. 6 inches b. Age, weight, vital signs and skin turgor
b. 4 inches d. 8 inches c. Vital signs, level of mentation and urine output
29. Nurse Gelie has administered d. Vital signs and quantity and specific gravity of
approximately half of a high cleansing enema urine
when the client complains of pain and 35. Which behavior is least likely to be
cramping. Which of the following nursing included in the nursing assessment of a client
actions is the most appropriate? with burns during the recovery period?
a. Raise the enema bag so that the solution can a. Anxiety with mild confusion
b. Desperation and panic a. Gary, 78 year old, 3 days after knee surgery
c. Withdrawal and depression whose pain level at 6:00 AM was 3 out of 10
d. Dependency and regression b. May, 45 year old, with diverticulosis who is
scheduled for bowel surgery at 8:00 AM
Situation 8. The first phase of the nursing c. Jessie, 18 years old, with multiple fractures
process is the Assessment. It requires the whose Hct is 32, which is down from 32.5 of
nurse to obtain objective and subjective data the previous day
from primary and secondary sources, to d. Kira, 62 year old, 2 days following bladder
identify and group significant data, as well surgery whose WBC is 11,000
as to communicate this information to other 42. A school bus is involved in a traffic
members of the health team. The information accident at 7:30 AM en route to delivering a
necessary from making nursing decisions is group of children with “special needs” to
obtained through assessment. school. A pediatric emergency team is
36. The best place to assess for dehydration dispatched to the scene of the accident. The
by checking skin turgor in older adults is on registered nurse will give greatest priority to:
the: a. The child with epilepsy who is complaining of
a. Dorsal aspect of the forearm headache
b. Anterior chest, below the clavicle b. The child with diabetes mellitus who is
c. Back of the hand complaining of feeling scared and shaky
d. Abdomen c. The child with rheumatoid arthritis who is
37. When auscultating heart sounds, the complaining of feeling stiff and sore
nurse knows that the first heart sound (S 1) is d. The child with scoliosis who is wearing a
best heard: Milwaukee brace and complaining of shoulder
a. Using the bell of the stethoscope level pain
b. With the client lying on the right side 43. A registered nurse returns to the pediatric
c. At the second intercostal space, right sternal unit from dinner break and receives the
border following report from the LVN/LPN. Which
d. At the fifth intercostal space, left sternal border child should the registered nurse attend to
38. Objective assessment data indicating first?
circulatory overload in a client who has a. A child with epiglottitis and a tracheostomy with
chronic renal failure would include: a neck dressing that is wet and soiled
a. Neck vein distention, apprehension, soft b. A child with acute glomerulonephritis whose
eyeballs urine is bloody
b. Periorbital edema, distended neck veins, c. A child with sickle cell anemia whose PCA
moist crackles (patient-controlled analgesia) medication
c. Increased blood pressure, flattened neck cassette is empty
veins, shock d. A child with pyloric stenosis who has vomited
d. Decreased pulse pressure, cool, dry skin, 44. The nurse finds the client's IV bag empty
decreased skin turgor at change of shift. The RN on the previous
39. Based on the primary cause for skin shift reported that a new 1000 ml bag would
changes in older adults, the initial nursing be hung. The client is in no apparent distress.
assessment of an elderly client with dry skin What is the first priority?
would include: a. Maintain patency of the IV site with a new bag
a. Presence of age spots of solution
b. A diet history b. Check the IV record to see if a new bag was
c. History of prior sun exposure charted
d. Medications taken as a younger adult c. Assess heart and lungs for signs of fluid
40. Which nursing assessment would identify overload
the earliest indication of increasing d. Complete an incident report and notify
intracranial pressure? physician of error
a. Temperature over 102°F 45. The nurse triages clients in the emergency
b. Change in level of consciousness department. Which client should the nurse
c. Widening pulse pressure treat first?
d. Unequal pupils a. Norman, 27 years old, with right-side chest
pain, shortness of breath and unequal chest
Situation 9.Nurses should develop the skills excursion who was in a motor vehicle accident
on how to prioritize in order to properly b. Mikki, 7 years old, who sustained a scalp
allocate the appropriate care to different laceration in a soccer game. The child is
clients. awake and crying
41. During report from the night shift, the day c. Oak, 82 years old, with chest pain who is pale
nurse receive information on four clients. and diaphoretic
Which client should the nurse assess first? d. Diana, 35 years old, with a compound tibial
fracture
51. Postoperative orders include “IV of D 5 ¼
Situation 10. James, a 17 years old male, is NS at 75 ml per hour.” At 7:00 PM, a new
admitted with a flail chest following an 1000 ml bag of fluid is hung. If the IV infuses
automobile accident. He is very anxious, at the prescribed rate, how much fluid should
dyspneic and in severe pain. He is intubated be left in the bag at 7:00 AM?
with an endotracheal tube and is placed on a a. 100 ml
mechanical ventilator (control mode, positive b. 900 ml
pressure). c. nothing should be left; bag should be empty
46. Which physical finding alerts the nurse to d. not enough information is given to determine
an additional problem in respiratory function? this
a. Dullness to percussion in the third to fifth 52. At 2:30 AM, the nurse hangs a 1000 ml
intercostal space, midclavicular line bottle of IV fluid. If the IV infuses at 110 ml per
b. Decreased paradoxical motion hour as ordered, how much fluid should infuse
c. Louder breath sounds on the right chest by 6:00 AM?
d. pH of 7.36 in arterial blood gases a. 385 ml c. 615 ml
47. The high-pressure alarm sounds on the b. 500 ml d. 740 ml
mechanical ventilator. The nurse prepares to 53. The MD orders an IV of D 5W at 40 ml/hr. A
perform which of the following most 500 ml bag with a pediatric microdrip
appropriate nursing intervention? chamber, is hung at 11:00 AM. At 3:15 PM, the
a. Check for a disconnection nurse notes that the bag has 100 ml left. What
b. Evaluate the tube cuff for a leak should be the nurse's initial action?
c. Notify the respiratory therapist a. Readjust the flow rate to 40 microdrops per
d. Suction the client minute
48. James has had a cuffed endotracheal b. Hang a new 500 ml bag of fluid
tube for 3 days. When the nurse goes to the c. Maintain the flow rate at 20 microdrops per
bedside, the nurse hears the client say “good minute until the IV is back on schedule
morning.” This indicates: d. Notify the physician
a. James is feeling better, is more alert, and is 54. Fluid therapy post-burn may necessitate
appropriately responsive as much as 7 liters of fluid in 24 hours for a 70
b. The cuff on the endotracheal tube is deflated, kg individual. Using a 15 gtt/ml administration
or the tube is misplaced and the nurse set, the drops per minute that the nurse would
should act immediately set to deliver this volume would be:
c. The endotracheal tube needs to be replaced a. 48 gtts/min c. 60 gtts/min
immediately b. 75 gtts/min d. 90 gtts/min
d. The endotracheal tube has migrated to the 55. Upon return from the OR at 11:30 AM, a
right main stem bronchus and the nurse client has 425 ml left in an IV bag of 5%
should obtain a STAT chest x-ray dextrose and ½ NS. The postop MD orders
49. To maintain correct placement of an include “IV to infuse at 320 ml every 8 hours.”
endotracheal tube, the nurse should: When should the nurse anticipate having to
a. Check for cuff pressure periodically change the IV bag?
b. Suction the client PRN a. 3:00 PM c. 9:00 PM
c. X-ray the tube every day b. 6:00 PM d. 12:00 midnight
d. Mark the tube at its insertion point into the
client's mouth or nose Situation 12. A unit of blood is ordered for a
50. Nurse Joy is preparing for the removal of client when the blood pressure drops to
the endotracheal tube (ET) from James. In 90/60.
preparing to assist the physician in this 56. What is the most important safeguard
procedure, which initial nursing action is before administering blood?
most appropriate? a. Refrigerate unit of blood until immediately
a. Suction the ET tube before giving
b. Deflate the cuff b. Agitate the blood so it is well mixed
c. Turn the ventilator to the off position c. Carefully check labeled blood against client';s
d. Obtain a code cart and place it at the bedside wristband
d. Infuse the blood through a blood warmer
Situation 11. To prevent circulatory overload 57. While observing the client throughout a
or underload. The nurse must administer IVF blood transfusion, the nurse should be alert to
medication at the prescribed flow rate – the which possible sign of a hemolytic reaction?
amount of fluid given at a specified time. The a. Urticaria c. Flank pain
nurse should mathematically convert the b. Polyuria d. Hypothermia
rate of infusion prescribed by the physician 58. The nurse knows that after the blood is
into comparable drops per minute. removed from the refrigerator, it should be
transfused within: should the nurse do next?
a. 6 hours c. 4 hours a. Check vital signs
b. 2 hours d. 1 hour b. Increase the flow rate of the IV
59. The nurse knows that the best way to c. Place the child in reverse Trendelenburg
prevent a transfusion reaction when position
administering packed red blood cells to a d. Notify the cardiologist
client is to: 65. An appropriate nursing diagnosis for a
a. Verify the client, unit and donor numbers, type client undergoing a cardiac catheterization is:
of blood product, and expiration date with a. Risk for altered tissue perfusion related to
another RN before hanging the blood bleeding or thrombosis
b. Run the blood slowly for the first 15 minutes b. Risk for altered fluid balance related to diuretic
c. Use y-type tubing to administer the blood action of dye used during the procedure
d. monitor vital signs frequently while the blood is c. Risk for altered acid/base balance related to
infusing vomiting post-procedure
60. A transfusion reaction is suspected. The d. Body image disturbance related to puncture
transfusion is stopped and the MD notified. site and post-procedure limitations.
The next appropriate nursing action would be
to: Situation 14. The administration of medicine is
a. Change all IV tubing to prevent additional a grave responsibility entrusted to the nurse.
infusion of blood cells Nurses are expected to carry out doctor's
b. Keep the IV line open with saline until further orders intelligently, promptly and with
orders extreme accuracy.
c. Arrange for the laboratory to pick up the 66. The nurse realizes that the wrong
remaining unit of blood medication was given to a client. The nurse
d. Collect a urine specimen from the client immediately informs the nursing supervisor
and begins the hospital's protocol regarding
Situation 13.Brock, a 3 year old toddler, is medication errors. The nurse is
scheduled for cardiac catheterization. demonstrating:
61. The most appropriate preparatory nursing a. Competence c. Reliability
intervention would be to: b. Professionalism d. Accountability
a. Explain the procedure to the toddler in simple 67. A client who is confused and agitated is
sentences just before giving the preoperative refusing to take PO medications. The nurse
sedation can:
b. Bring a puppet in the evening before the a. Inform the physician
procedure and show the toddler where the b. Explain to the client the benefits of taking the
catheter will be inserted medications and the consequences of not
c. Read a story to the toddler about a child who taking them
has a cardiac catheterization c. Withhold the medications, document them as
d. Show the toddler a model of the heart not given, and try to give them later when the
62. Nurse Joy reviews the chart of Brock client is calmer
following cardiac catheterization and notes d. Ask several other nurses to help restrain the
the ejection fraction is 0.3 or 30% of normal. client while the nurse puts the pills in the
The nurse would expect the plan of care to client's mouth
focus on: 68. When giving medications to older adults,
a. Management of pain from angina episodes the nurse knows that medication dosages
b. Inability to perform self-care caused by fatigue should generally be:
c. Impaired motor and sensory function in a. One-half to two-thirds of the dose used for
extremities younger people
d. Reducing risk of stroke (brain attack) from b. The same as used for younger people
hypertension c. One-third to one-half of the dosage used for
63. Thirty minutes after cardiac younger people
catheterization, Brock's blood pressure d. Three-fourths of the dose used for younger
begins to drop. Which potential complication people
explains this? 69. Physician orders the elixir form of a
a. Absent distant pulses medication. The nurse, familiar only with the
b. Increased pain at puncture site injectable form of the medication, believes the
c. Nausea order is incorrect. The nurse should:
d. Bleeding or hematoma at the puncture site a. Ask the two physicians who are currently on the
64. Two hours after Brock returns to the unit unit whether the medication should be given
following cardiac catheterization, the as the nurse understood the order
dressing is soaked with bright-red blood. b. Ask the head nurse if the order is correct
Nurse Joy first reinforces the dressing. What c. Call the physician who ordered the medication
d. Contact the nursing supervisor about the a. 10 to 15 minutes c. 50 to 60 minutes
problem b. 20 to 30 minutes d. More than 1 hour
70. A nurse gave a client the wrong
medication. The client was seriously injured. Situation 16. Max, a toddler, who fractured his
The client sued. Who will most likely be held right femur in a car accident is admitted to the
liable? hospital and placed in Bryant's traction.
a. The nurse 76. During the first night in the hospital, the
b. No one, because it was just an accident toddler lies still in the crib, sucks a thumb, and
c. The hospital occasionally sobs quietly in a monotone voice.
d. The nurse and the hospital The nurse should interpret these behaviors to
mean that the toddler:
Situation 15. Nurse Joy is taking care of a. Wants the mother
Dawn, 40 years old, who is scheduled for b. Might prefer to sleep in bed
peritoneal dialysis. c. Probably does not sleep through the night at
71. Following the insertion of a catheter into home
the abdominal cavity, warmed dialyzing d. May be experiencing painful muscle spasms
solution is allowed to run rapidly (10 to 20 due to the fracture
minutes) into the abdominal cavity. The nurse 77. The nursing assistant caring for Max
warmed the solution to body temperature to reports that the child's buttocks are resting on
prevent abdominal pain and to: the mattress. The nurse would be most correct
a. Expand the molecules and increase the in telling the nursing assistant that:
osmotic gradient a. This is where the buttocks should be
b. Increase peritoneal vessels, thereby b. The buttocks should be slightly off the mattress
increasing urea clearance c. This is the responsibility of the nurse
c. Decrease the likelihood of peritonitis due to d. the child will need special skin care to avoid
constriction of peritoneal vessels pressure areas or breakdown
d. Expedite the movement of the dialyzing solute 78. In considering the equipment for Bryant's
into the abdomen traction, nurse Jenny should expect to see:
72. The drainage period during peritoneal a. A Kirschner wire in the fractured femur
dialysis generally takes 20 minutes, though b. A Steinmann pin in the fractured femur
this may vary from client to client. If fluid is c. Adhesive material taped to the skin of both legs
not draining properly, the nurse can facilitate d. Adhesive material taped to the skin of the
return by: fractured leg only
a. Turning the client to a prone position 79. Which nursing diagnosis requires the
b. Manipulating the indwelling catheter nurse to function collaboratively to achieve the
c. Elevating the head of the bed, thereby best outcome for the child?
increasing intra-abdominal pressures a. Risk for impaired skin integrity
d. Elevating the foot of the bed, thereby b. Pain (acute)
increasing abdominal pressures and gravity c. Impaired physical mobility
flow d. Risk for fracture deformity
73. The effectiveness of peritoneal dialysis 80. The most effective nursing intervention to
will be measures by: assist Max in maintaining a sense of control
a. Serum potassium less than 3.5 mEq/L and while hospitalized is to:
serum sodium greater than 148 mEq/L a. Have friends and classmates visit
b. Unchanged quantity and specific gravity of b. Have the child life specialist visit the child on a
urine daily basis
c. BUN less than 20 mg/dl, serum creatinine less c. Allow the child to make as many choices as
than 1.2 mg/dl possible
d. Moderately soft abdomen and dullness on d. Allow the child to freely pick and choose what
percussion to do or not do
74. Which signs and symptoms are least
likely to occur during peritoneal dialysis if Situation 17. Nurses should be knowledgeable
fluid drainage is inadequate? on how to prevent the occurrence or spread of
a. A negative balance between the amount infection.
drained and the amount instilled 81. The nurse is demonstrating the use of
b. Confusion, lethargy, and coma surgical asepsis when:
c. Moist crackles and rhonchi a. Wearing clean gloves to change linens
d. Flattened neck veins in a supine position b. Cleaning the client's skin with povidone/iodine
75. Care of Dawn, who is on peritoneal and alcohol before inserting an intravenous
dialysis must allow a dwell time, or catheter
equilibration period, of the dialyzing fluid, c. Putting on a HEPA mask when entering the
which is normally: room of a client with tuberculosis
d. Placing a used syringe in a sharps container. a. Prevent bleeding by applying pressure to the
82. The nurse uses sterile technique to esophageal varices
change a soiled dressing on a surgical b. Prevent accumulation of blood in the GI tract,
wound. Which element of the chain of which could precipitate hepatic coma
infection is broken? c. Stop bleeding by applying pressure to the
a. Transmission c. Host cardiac portion of the stomach and against the
b. Infectious agent d. Reservoir esophageal varices
83. Which nursing action is intended to d. Reduce transfusion requirements
prevent a nosocomial infection? 89. Nurse Tamara checks Kitana's room to
a. Wearing a mask when changing the dressing ensure that which of the following priority
on the client's central line items is at the bedside?
b. rinsing the suction catheter with normal saline a. An irrigation set c. A Kelly clamp
after suctioning the client's tracheostomy b. A pair of scissors d. An obturator
tube 90. The physician has left orders to deflate
c. Wearing clean gloves to remove the lunch tray Kitana's Sengstaken-Blakemore tube for 5
of a client with hepatitis A minutes every 12 hours to prevent esophageal
d. Wearing clean gloves to empty a wound drain erosion. Two hours following the second
84. Which characteristic of aging puts the inflation, Kitana suddenly becomes severely
client at increased risk for infection? dyspneic and dusky. The nurse should:
a. Increased production of saliva a. Call a code blue (cardiac arrest)
b. Increased cough effort b. Deflate the balloons
c. Increased cell-mediated immunity c. Decrease the traction on the tube where it
d. Thinning of the skin enters the nose
85. Which client is at greatest risk for d. Irrigate the tube with ice-cold saline to facilitate
infection? movement of the balloons into the stomach
a. Roldan, 18 years old, with a surgical repair of
a torn knee ligament Situation 19. Nutrition is a basic need that
b. Oni, 45 years old, with an uncomplicated must be met for all clients. Nurses must have
appendectomy the knowledge required to educate and care
c. Jing, 52 years old, with diabetes for healthy clients, as well as clients with
d. Angela, 67 years old, with broken hip nutritional needs or disorders requiring
alterations in dietary measures.
Situation 18. Nurse Tamara is taking care of 2 91. A client who is obese has begun a diet that
clients with tubes in a semi-private room at includes protein, fats and no carbohydrates.
St. Catherine's Ward. One client, Aaliyah, 27 The best response by the nurse to this client
years old, is scheduled for an insertion of a would be:
Miller-Abbott tube. The other client, Kitana, a. “If it works I'll recommend it to other clients.”
30 years old, admitted with bleeding b. “Sufficient fluids will be needed to prevent
esophageal varices who has a Sengstaken- acidosis.”
Blakemore tube inserted. c. “Any plan you think might work will be
86. Nurse Tamara assists a physician with supported.”
the insertion of a Miller-Abbott tube. After d. “Another client lost 90 pounds on the same
insertion of the tube, the nurse would assist diet.”
Aaliyah to which of the following positions? 92. The client has begun a low carbohydrate
a. On the right side diet for weight loss. Which group of foods
b. On the left side would the nurse recommend for the diet?
c. Prone a. Ham, butter, cheese and lettuce
d. Left lateral Sim's position b. Bread, pasta, corn and milk
87. Which statement by Nurse Tamara c. oatmeal, split pea soup and canned pears
accurately describes the Miller-Abbott tube? d. Fruitcake, applesauce and lima beans
a. A double-lumen tube, with one lumen leading 93. A client has been placed on a high protein
to the inflatable balloon and the other lumen diet. Which food would the nurse suggest this
used for aspiration client select?
b. A plastic or rubber tube with holes near its tip a. Rice (1 cup) c. Cheddar cheese (1 oz)
facilitating withdrawal of fluids from the b. Eggnog (8 oz) d. Broccoli (1 cup)
stomach 94. Small, frequent feedings of which type of
c. A single-lumen, saline-, air-, or water-weighted diet would the nurse recommend for clients
tube approximately 6 feet long experiencing dumping syndrome?
d. A 10 foot-long rubber tube with a saline, air, or a. Low protein, high fat, low carbohydrate diet
water bag at its end b. High protein, high fat, high carbohydrate diet
88. Nurse Tamara knows that a Sengstaken- c. High protein, high fat, low carbohydrate diet
Blakemore tube is primarily used to: d. Low protein, low fat, high carbohydrate diet
95. The nurse knows that a person who is on help him be complete, he is not a
a bland diet may lack which essential whole man.”
nutrient?
a. Vitamin C c. Protein
b. Carbohydrates d. Vitamin A
Situation 20. Nurse Alsea is assisting in

planning care for Thesara, 30 years old,
scheduled for insertion of a tracheostomy.
96. What equipment would nurse Alsea plans
to have at the bedside when the client
returns from surgery?
a. Oral airway
b. Epinephrine
c. Obturator
d. Tracheostomy tube with the next larger size
97. A preoperative nursing priority for a client
having a tracheostomy is:
a. Establishing postoperative communication
b. Drawing blood from serum-electrolyte and
blood gas determinations
c. Inserting a Foley catheter and attaching it to
dependent drainage
d. Doing a surgical prep of the neck and upper
chest wall
98. Nurse Alsea is preparing to change the
neck ties on the tracheostomy tube. To
perform this procedure, the nurse would
most appropriately plan to:
a. Remove the old ties, clean the site and then
apply the new ties
b. Obtain a second health care team member
to assist
c. Call the physician for assistance in
changing the ties
d. Call the respiratory therapy department for
assistance in changing the ties
99. Nurse Alsea is preparing to suction
Thesara through a tracheostomy tube. The
nurse avoids which of the following when
performing this procedure?
a. Moistening the catheter tip in sterile saline
solution before suctioning
b. Pre-oxygenating the client before
suctioning
c. Introducing the catheter into the
tracheostomy tube using a sterile gloved
hand
d. Placing suction on the catheter while
introducing the catheter into the
tracheostomy tube
100. Nurse Alsea plans to apply suction during
the withdrawal of the catheter for a period of
time no greater than:
a. 10 seconds c. 25 seconds
b. 20 seconds d. 30 seconds
“Unless and until each man is

prepared to be the skill of others to
RATIONALE
Situation 1.
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. (Saunders, 2nd Edition)
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. (Saunders, 2nd Edition)
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. (Saunders, 2nd Edition)
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.
(Saunders, 2nd Edition)
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. (Mosby, 18th Edition, 2006)
Situation 2.
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. (Saunders,
2nd Edition)
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. (Mosby, 18 th Edition, 2006)
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. (Saunders, 2nd Edition)
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. (NSNA NCLEX-RN Review, 4 th
Edition, 2000)
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. (Davis's NCLEX RN Success, 2nd Edition, 2006)
Situation 3.
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. (Saunders, 2 nd
Edition)
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. (NSNA NCLEX-RN Review,
4th Edition, 2000)
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. (Davis's NCLEX
RN Success, 2nd Edition, 2006)
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 PCO 2 and HCO3
to see which one is causing the shift to acidosis. In this case the PCO 2 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 (Davis's NCLEX RN Success, 2nd Edition, 2006)
Situation 4.
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. (Davis's NCLEX RN
Success, 2nd Edition, 2006)
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. (Davis's NCLEX
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. (Saunders, 2nd Edition)
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 (option C). (Saunders, 2nd Edition)
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. (Saunders, 2 nd
Edition)
Situation 5.
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. (Saunders, 2 nd
Edition)
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. (Mosby, 18th Edition, 2006)
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. (NSNA
NCLEX-RN Review, 4th Edition, 2000)
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). (Saunders, 2 nd Edition)
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. (Mosby,
18th Edition, 2006)
Situation 6.
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. (Saunders, 2 nd Edition)
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. (Mosby, 18 th Edition, 2006)
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.
(Mosby, 18th Edition, 2006)
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. (Mosby,
18th Edition, 2006)
Situation 7.
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. (Davis's NCLEX RN Success, 2 nd
Edition, 2006)
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. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
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. (Davis's NCLEX RN
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. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
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). (Davis's
NCLEX RN Success, 2nd Edition, 2006)
Situation 8.
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.
(Davis's NCLEX RN Success, 2nd Edition, 2006)
37. Answer: D
Rationale: The closing of the mitral and tricuspid valves, which constitute the S 1 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, S 2, is best heard at the
second intercostal space, right sternal border. (Davis's NCLEX RN Success, 2nd Edition,
2006)
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 (Davis's NCLEX RN Success, 2 nd
Edition, 2006)
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. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
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. (Davis's NCLEX RN Success, 2nd Edition, 2006)
Situation 9.
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. (Davis's NCLEX RN Success, 2nd Edition, 2006)
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. (Davis's
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. (Davis's
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. (Davis's
Situation 10.
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. (NSNA NCLEX-RN Review, 4th Edition, 2000)
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. (Saunders, 2nd Edition)
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. (Davis's NCLEX RN Success, 2 nd
Edition, 2006)
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. (Davis's NCLEX RN Success, 2nd Edition, 2006)
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.
Situation 11.
51. Answer: A
Rationale: If the IV infuses at the prescribed rate of 75ml per hour from 7:00 PM to 7:00
AM, or 12 hours, 75 ml x 12 hours = 900 ml infused. If a 1000 ml bag were hung and 900
ml infused, 1000 – 900 = 100 ml left in the bag. Options B and C are incorrect calculations.
Option 4 is incorrect because there is enough information to determine the answer.
52. Answer: A
Rationale: If the IV infuses at the proper rate, 110 ml per hour, from 2:30 AM to 6:00 AM,
110 ml x 3.5 hours = 385 ml infused. Options B, C and D are incorrect calculations.
53. Answer: A
Rationale: If the IV infused at the correct rate of 40 ml/hr from 11:00 AM to 3:15 PM, the
client should have received 170 ml of IV fluid; because the client has received twice the
prescribed amount, the nurse should first correct the rate, then notify the physician (option
D). (The nurse should also check at this time to see if the IV line is being affected by the
position of the limb). If, after contacting the physician, a new rate is ordered, only then
would the nurse adjust the rate to a level lower than originally prescribed (option C). Option
B is incorrect because there is no reason to hang a new bag at this time. (Davis's NCLEX
54. Answer: B
Rationale: Calculating the correct rate requires computation of the hourly volume (290 ml)
and the minute volume (5 ml), and then multiplying the rate, in ml/min, by the drop factor
(15 gtt/ml). (The hourly and minute volumes have been rounded to the nearest whole
number). Options A and C are not fast enough to deliver this large a volume in the
prescribed period. Option D is too rapid. A quick method of computing the drip rate is to
use the first two numbers in the 24-hour fluid volume (i.e., 7000 ml in 24 hours = 70
gtt/min). This shortcut may be useful when initially starting an infusion, before
mathematically calculating the rate. Use only with 15 gtt/ml factor. (Davis's NCLEX RN
55. Answer: C
Rationale: Per MD order, the IV should infuse at 320 ml every 8 hours, or 40 ml per hour.
Thus, if there is 425 ml left in the IV and it runs at 40 ml per hour, the present bag should
last 10 hours, or from 11:30 AM to 9:30 PM. The nurse should plan to change the bag at
9:00 PM, before it runs out completely. Options A and B are incorrect because changing it
earlier would waste IV fluid, which is costly. Option D is incorrect because changing it later
would mean the iv would run out completely, which may result in an embolism or a clogged
IV line. (Davis's NCLEX RN Success, 2nd Edition, 2006)
Situation 12.
56. Answer: C
Rationale: Some of the most serious reactions occurring with blood transfusions are the
result of human error. To reduce human error, it is essential for 2 nurses to verify that the
client's name and hospital number on the blood bag correspond exactly to that on the
wristband. Options A, B and D are incorrect because although they are proper safeguards,
they are not the first priority. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
57. Answer: C
Rationale: Signs and symptoms of hemolytic reaction usually include: chills, shaking,
fever, red (or black) urine, headache, and flank pain. Option A is incorrect because urticaria
is not a common sign in a hemolytic reaction, although it is common in an allergic reaction.
Options B and D are incorrect because neither polyuria nor hypothermia is a common sign
in a hemolytic reaction. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
58. Answer: C
Rationale: Refrigerating blood assists in delaying the growth of bacteria. The blood must
be administered within 4 hours, not 6 hours (option A), but not within 1 and 2 hours
because it would be so rapid that the client may experience overload (options B and D).
59. Answer: A
Rationale: Verifying the correct information prevents transfusion reactions. Option B is
incorrect because running the blood slowly at first, which is correct technique, will help
minimize a transfusion reaction, but won't prevent a reaction. Option C is incorrect
because y-type tubing is used to facilitate the administration of normal saline immediately
before and after the transfusion, but does not prevent a transfusion reaction. Option D is
incorrect because frequent vital signs help detect the presence of a transfusion reaction,
and although appropriate, will not prevent a reaction. (Davis's NCLEX RN Success, 2 nd
Edition, 2006)
60. Answer: B
Rationale: The priority is to keep the IV site open. Medications may need to be given to
reverse the client's untoward reaction to the transfusion. Options A, C and D will eventually
be done, but not before the patency of the IV is determined and maintained. (Davis's
Situation 13.
61. Answer: A
Rationale: The toddler does not have the concept of time. It would be most appropriate to
explain the procedure as simply as possible to the toddler immediately before giving the
preoperative sedation. If the explanation is given to the toddler any earlier than that, it will
not be remembered and possibly may not be understood. Option B is incorrect because
the toddler does not have a concept of time. The toddler would enjoy the puppet but the
next day would not remember the explanation of the procedure. This intervention would be
better for a preschooler who does have a concept (although limited) of time. Option C is
incorrect because the toddler does not have the attention span nor cognitive abilities
necessary to understand being read a story about the heart. This intervention would be
better for the young school-age child. Option D is incorrect because the toddler does not
have the cognitive abilities necessary to correlate the model of the heart to the procedure
that will take place. This intervention would be better for the older school-age child.
62. Answer: B
Rationale: The cardiac output is significantly reduced and perfusion will be impaired.
Leading to almost overwhelming fatigue. Option A is incorrect because the ejection fraction
is measuring cardiac output, not coronary artery disease. Systemic perfusion will be
compromised and the client will experience extreme fatigue. Option C is incorrect because
the problem is not neurological. Option D is incorrect because the client's blood pressure
will be low, not high. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
63. Answer: D
Rationale: Loss of circulating volume from the puncture site or into tissues surrounding
the site can result in decreased blood pressure. Option A is incorrect because absent distal
pulses indicate a blockage in the artery, but will not necessarily be accompanied by
decreased blood pressure. Option B and C are incorrect because increased pain and
nausea are more likely to result in increased blood pressure. (Davis's NCLEX RN Success,
2nd Edition, 2006)
64. Answer: A
Rationale: After marking the original dressing (to indicate the extent of the bleeding0 and
reinforcing the dressing (to prevent infection0, the nurse should check the vital signs to
determine if the bleeding episode has had any effect on the child's physiological status.
Option B is incorrect because in general the nurse should never change the flow rate of
the IV without a physician's order. Option C and D are incorrect because after checking the
vital signs, depending on the status of the bleeding and the vital signs, the nurse might
change the client's position and notify the cardiologist. (Davis's NCLEX RN Success, 2 nd
Edition, 2006)
65. Answer: A
Rationale: A major artery, usually the femoral artery, is punctured to perform this
procedure; bleeding and thrombosis are 2 of the major risk factors for cardiac
catheterization. Option B is incorrect because IV fluid is administered to the client during
the procedure, the client is generally allowed to eat after the procedure, and PO fluids are
encouraged to flush the dye out of the client's system. Option C is incorrect because
vomiting is not a common reaction to cardiac catheterization;and, if it occurs, can be
relieved with adequate fluid and antiemetics. Option D is incorrect because body image
disturbance is not generally associated with cardiac catheterization. (Davis's NCLEX RN
Situation 14.
66. Answer: D
Rationale: Nurses are answerable for their actions. Accountability does not mean that the
nurse acted correctly or incorrectly, competently or incompetently, but that the nurse is
answerable. Option A is incorrect because there is insufficient information in the scenario
to determine the nurse's competence; the nurse could be viewed as incompetent because
the error was made; however, the circumstances of the error are unknown. Option B is
incorrect because “professionalism' is a broad term that encompasses many values
essential to nursing. Option C is incorrect because reliability refers to the degree to which
the nurse can be counted upon to act correctly. If this nurse reliably follows agency
protocol for medication errors, the question must be asked: how often does this nurse
commit medication errors? (Davis's NCLEX RN Success, 2 nd Edition, 2006)
67. Answer: C
Rationale: Clients have the right to refuse treatment, even if they are confused and
disoriented. Also remember that it is important to document the medications as “not given”
and the reason. Option A is incorrect because, although the physician should be notified
that the client is confused and agitated, the physician cannot order the client to take the
medications. It is the nurse's responsibility to administer the medications. Option B is
incorrect because, although clients should be informed about their medications, a client
who is confused may have difficulty understanding the information. Option D is incorrect
because using force (“restrain the client”) to get the client to take the medications is called
assault and battery, and is illegal, even with a client who is confused. (Davis's NCLEX RN
68. Answer: C
Rationale: Research and current practice follow a guide that says “start low and go slow”
for all medications for older adults. The dosage may start at 1/3 and move up to ½ of the
dose for a younger person. Option A is incorrect because research in the past 10 years
has shown that older bodies generally require one-half of the dose of a younger body
because of changes in metabolism, distribution, and absorption. Option B is incorrect
because the older adult generally needs a lower dose because of changes in the ability to
metabolize the drug. Option D is incorrect because the dosage is generally about 50% of
the dose for a younger person. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
69. Answer: C
Rationale: The nurse would be negligent for any untoward effects of the drug if she or he
failed to contact the physician who ordered the drug before the nurse administered it.
Options B and D are incorrect because the court stated that it was the responsibility of the
nurse to clarify the order with the physician involved, not with other nurses. Option A is
incorrect because the doctors on the unit are not the ones who wrote the order. (Davis's
70. Answer: 4
Rationale: Both the nurse and the hospital can be sued for damages if a mistake the
nurse makes injures the client. The nurse is always responsible for his or her own actions.
The hospital, as the employer, will be vicariously liable under the respondeat superior
doctrine - the employer is liable for the negligent conduct of its nurses when the act was
committed within the scope of employment. Options A and c are incomplete. Option B is
incorrect. (Davis's NCLEX RN Success, 2nd Edition, 2006)
Situation 15.
71. Answer: B
Rationale: The dialysate is warmed to body temperature before administration to minimize
discomfort and optimize clearance of waste products. Warming the fluid tends to dilate the
peritoneal vessels, increasing the amount of urea that passes through the membrane. It
has little effect on the osmotic gradient (option A), does not prevent peritonitis, which is
secondary to infection (option C), and does not speed infusion time (option D), although it
does make it more comfortable. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
72. Answer: C
Rationale: The cumulative inflow and outflow records should show an outflow equal to or
in excess of the amount instilled. The amount of excess outflow allowed is also determined
by the physician; this rarely exceeds 200 ml per cycle. Occasionally, drainage is less than
expected. Nursing measures to enhance outflow include turning the client from side to
side, elevating the head of the bed (increases intra-abdominal pressures), and/or gently
massaging the abdomen. If the problem continues, notify the physician before initiating
another cycle; the physician may attempt to clear the catheter by rotation or by probing it
for fibrin clots (option B). Options A and D will not improve flow. (Davis's NCLEX RN
73. Answer: C
Rationale: A BUN of less than 20 mg/dl and serum creatinine less than 1.2 mg/dl would be
optimal measures for this client (that is, within normal range). Options A, B and D are
incorrect because a serum potassium of less than 3.5 mEq/L would be indicative of
hypokalemia and a serum sodium above 148 mEq/L indicates hypernatremia (option A);
quantity of urine output should increase to over 500 ml/24 hours (option B); and the
abdomen should be soft and tympanic to percussion; so dullness to percussion] in the
abdomen is consistent with fluid excess (option D). (Davis's NCLEX RN Success, 2 nd
Edition, 2006)
74. Answer: D
Rationale: Flattened neck veins in a supine position are characteristic of hypovolemia.
Inadequate drainage would result in fluid retention and hypervolemia. Indications of fluid
retention include inadequate fluid drainage (Option A, greater intake than output),
increased blood pressure, and signs of congestive heart failure, for example, distended
neck veins, increased dependent edema, crackles (option C), and decreased mentation
(option B). (Davis's NCLEX RN Success, 2nd Edition, 2006)
75. Answer: B
Rationale: Generally, the dwell time of the dialysate is 20 to 30 minutes, occasionally
longer. The dwell time as well as the instillation and outflow times are prescribed by the
physician according to the client's needs. 10 to 15 minutes (option A) is too short a time to
allow for diffusion of waste products. Equilibrium between dialysate and body fluids occurs
in 15 to 30 minutes. Longer times (options C and D) are not necessary. (Davis's NCLEX
Situation 16.
76. Answer: A
Rationale: Toddlers will most liekly experience separation anxiety when separated srom
parents. In the “despair” phase, the child appears to be mourning the apparent loss of the
parent, as evidenced by nonverbal behavior cues such as monotone crying, regressive
behavior (thumb sucking) and sleep disturbances. If this child were experiencing muscle
spasms to to his fracture (option D), he would most likely cry out in severe pain
intermittently. The other explanations for his behavior (options B and C) do not take his
developmental level into account. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
77. Answer: B
Rationale: In Bryant's traction, the hips and buttocks should be raised slightly (1 inch
above the mattress, not resting on the mattress (option A), for the traction to be effective.
Option C is incorrect because although the nurse is ultimately responsible, the nursing
assistant should be commended for having brought this concern to the nurse's attention.
Option D is incorrect because although it is true that this child will need special skin care
due to prolonged immobility, the nurse should first take measures to correct the problem
with the traction. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
78. Answer: C
Rationale: Bryant's traction is a form of skin traction used in infants and toddlers with
fractured femurs; when applied correctly, adhesive material should be taped to the skin of
both legs. Options A and B are incorrect because skeletal traction in the form of a
Kirschner wire or Steinmann pins is not used in Bryant's traction. Option D is incorrect
becausee adhesive material should be taped to the skin of both legs, not only one leg.
79. Answer: B
Rationale: Pain management requires the nurse and physician to collaborate to achieve
optimal relief for the client. The use of analgesics for pain requires a physician's order. The
nurse assesses the client's response to drug therapy and alerts the MD to needed
changes. The nurse may also recommend non-drug interventions to promote client comfort
(massage, progressive relaxation) options A and C are manageable by independent
nursing actions – careful assessment, ROM, proper positioning. Option D is not a nursing
diagnosis, but a medical problem to be corrected by surgery. (Davis's NCLEX RN Success,
2nd Edition, 2006)
80. Answer: C
Rationale: It allows the child to have a say in what happens and thus assists the child to
maintain a sense of control. Obviously, the choices offered to the child would be assessed
for appropriateness by the nurse and the parents. Option A is incorrect because, while the
response in itself is a good idea, it will provide needed socialization for the child rather than
assisting the child to maintain a sense of control. Option B is incorrect because it will
provide needed emotional release and diversion for the child rather than assisting the child
to maintain a sense of control. Option D is incorrect because it implies that the child will not
have limits set. This could be detrimental to the child's recovery. (Davis's NCLEX RN
Situation 17.
81. Answer: B
Rationale: The answer involves the removal of microorganisms prior to entering sterile
tissue. Option A is incorrect because using clean gloves is part of standard precautions
used for every client, but is not surgical aseptic technique. Option C is incorrect because
the HEPA mask prevents the transmission of microorganisms from the client to the nurse.
Option D is incorrect because disposing of a used syringe in a sharps container is part of
standard precautions, not surgical aseptic technique. (Davis's NCLEX RN Success, 2 nd
Edition, 2006)
82. Answer: D
Rationale: The dressing acts as a reservoir for the infectious agent. Changing the
dressing disrupts the reservoir. Option A, B and C are incorrect because the dressing is a
reservoir. (Davis's NCLEX RN Success, 2nd Edition, 2006)
83. Answer: A
Rationale: The mask prevents the transmission of microorganisms from the nurse to the
client's central line. Option B is incorrect because rinsing the suction catheter serves to
keep the suction tubing patent, and is not an action associated with infection control.
Option C is incorrect because wearing clean gloves to remove the lunch tray prevents
transmission of microorganisms from the client to the nurse, who act as a carrier. Option D
is incorrect because wearing clean gloves prevents transmission of microorganisms from
the client to the nurse. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
84. Answer: D
Rationale: Skin thins as the client ages, predisposing the client to skin tears and pressure
ulcers, which dramatically reduce the skin's ability to act as a barrier to infection. Options
A, B and C are incorrect because saliva production, cough effort and cell-mediated
immunity decreases with age, not increases. (Davis's NCLEX RN Success, 2 nd Edition,
2006)
85. Answer: D
Rationale: This client has 3 risk factors: age, the stress of an injury and immobility with the
broken hip. Options A and B are incorrect because these clients has only 1 risk factor:
surgical repair which involves an incision into sterile tissues. Option C is incorrect because
this client has only 1 risk factor: diabetes, a chronic disease. (Davis's NCLEX RN Success,
2nd Edition, 2006)
Situation 18.
86. Answer: A
Rationale: A Miller-Abbott tube is an intestinal tube that has a double-lumen, one for a
mercury balloon and the other for suction or drainage. After insertion of the tube, the tube
is allowed to advanced over several hours. The client is positioned on the right side to
facilitate passage through the pylorus of the stomach and into the small intestine. Options
B, C and D are incorrect positions. (Saunders, 2 nd Edition)
87. Answer: A
Rationale: Miller-Abbott tube is a double-lumen tube, with one lumen leading to the
inflatable balloon and other lumen used for aspiration of intestinal contents. Option B is
incorrect because it is an example of a Levin tube, used for gastric suction. Option C is
incorrect because it is an example of a Harris tube. Option D is incorrect because it is a
Cantor tube, both used for intestinal decompression, like the Miller-Abbott. (Davis's NCLEX
88. Answer: C
Rationale: The Sengstaken-Blakemore tube is a triple-lumen tube composed of a catheter
that goes to the stomach for suctioning, a lumen that ends in a gastric balloon and a lumen
that ends in an esophageal balloon. The primary purpose of this tube is to stop bleeding by
applying pressure to the cardiac portion of the stomach and against the esophageal
varices. Thus, option A is only partially correct. The secondary purposes of the tube are (a)
to prevent accumulation of blood in the gastrointestinal tract (option B), which could
precipitate hepatic coma, and (b) to reduce blood transfusion requirements (option D).
89. Answer: B
Rationale: When a client has a Sengstaken-Blakemore tube, a pair of scissors must be
kept at the client's bedside at all times. The client needs to be observed for sudden
respiratory distress that occurs if the gastric balloon ruptures and the entire tube moves
upward. If this occurs, the RN is notified immediately and the balloon lumens will be cut.
Option A is incorrect because an irrigation set may be kept at bedside, but is not the priority
item. Options C and D are incorrect because a Kelly clamp and an obturator are kept at
bedside of a client with tracheostomy. (Saunders, 2 nd Edition)
90. Answer: B
Rationale: Symptoms of severe respiratory distress indicate that the tube has dislodged
and is obstructing the airway. Reestablishing an airway is the first priority: Deflate the
balloons using a syringe. Following deflation, the doctor should be notified to assess the
client's condition and determine ongoing medical therapy. A code blue (option A) would be
called only after establishing the airway. Traction on the Sengstaken-Blakemore tube
should be increased or decreased (Option C) only by the attending physician. Iced saline
(option D) is no longer used for irrigation during active bleeding and this problem is
respiratory, not hemorrhagic. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
Situation 19.
91. Answer: B
Rationale: Acidosis will occur from fat metabolism. Fluids are essential to prevent damage
to the kidneys. The nurse should determine if the client's physician is aware of this dietary
change because a diet without carbohydrates is not considered healthy. Some complex
carbohydrates are recommended so that fat during burning can occur without acidosis.
Option A is incorrect because a diet with no carbohydrates is generally not recommended.
Some carbohydrates are needed to prevent acidosis from occurring as a result of fat
metabolism. Extremes in dietary modification should not be recommended without
consultation with a client's physician. Option C is incorrect because the nurse has the
responsibility to ensure that the client is not at risk for adverse effects from an unhealthy or
extreme weight loss program. Option D is incorrect because the nurse should not reinforce
a diet that is not balanced and has the potential for adverse consequences. (Davis's
92. Answer: A
Rationale: A low carbohydrate diet will be high in protein and fats. Option B is incorrect
because because the diet is extremely high in carbohydrates. Breads that are 100% whole
grain, and identified as complete protein breads, may be included in the diet. Option C is
incorrect because cereals, creamed soups and canned fruits are all high in carbohydrates.
Option D is incorrect because the candied fruits in fruitcake and the sugar in applesauce
would not be on the diet. Fruits are generally restricted, although some are lower in
carbohydrate and may be included. (Davis's NCLEX RN Success, 2 nd Edition, 2006)
93. Answer: B
Rationale: Eggs and milk are two sources of protein with the highest biological values
(high-quality proteins). Eggnog (8 oz) contains 15 g protein. Rice (option A) contains only 4
g, cheddar cheese (option C) contains only 7 g and broccoli (option D) contains only 5 g.
Meat, fish, and legumes contains more protein than does eggnog, but their percent of
protein utilization is lower, making them almost equal in value to eggnog. (Davis's NCLEX
94. Answer: C
Rationale: The symptoms of dumping syndrome are most likely to occur following the
ingestion of large amounts of sugars or carbohydrates. Therefore a diet that is high in
protein and fats and low in carbohydrates is recommended, to reduce symptomatology and
to provide the client with essential energy requirements. Options A and D are incorrect
because they do not supply sufficient protein for energy and tissue repair. High protein
intake is essential after surgery and most prolonged illnesses for rebuilding tissue. Option
B is incorrect because they list high carbohydrates. (Davis's NCLEX RN Success, 2 nd
Edition, 2006)
95. Answer: A
Rationale: The client should be given diluted orange juice to ensure an adequate supply of
ascorbic acid (Vitamin C). Options B, C and D are incorrect because carbohydrates,
protein and Vitamin A can be easily obtained by ensuring a variety of foods in the bland
diet. (Davis's NCLEX RN Success, 2nd Edition, 2006)
Situation 20.
96. Answer: C
Rationale: A replacement tracheostomy tube of the same size and an obturator are kept at
the bedside at all time in case the tracheostomy tube is dislodged. Additionally, a curved
hemostat that could be used to hold the trachea open if dislodgement occurs should also
be kept at the bedside. Options A and B are incorrect because an oral airway and
epinephrine would not be needed. Option D is incorrect because a tracheostomy tube of
the same size is needed. (Saunders, 2nd Edition)
97. Answer: A
Rationale: Since tracheostomy inhibits the clients from talking, it is essential to establish a
mode of postoperative communication so that the client can express needs. The mode
chosen should be communicated to the rest of the staff so that the approach to the client is
consistent. Blood work (option B) may or may not be ordered before tracheostomy, though
blood gas analysis is frequently ordered to establish baseline data in order to evaluate the
effectiveness of the intervention. Inserting a Foley catheter (option C) is not a priority
unless urinary output has decreased. A standard surgical prep (option D), cleansing and
shaving the operative area, is not done before tracheostomy. However, the physician does
cleanse the area with an antiseptic before performing the tracheostomy. (Davis's NCLEX
98. Answer: B
Rationale: It is best to have two people help change the ties at the tracheostomy. The
movement of the tube can easily cause the client to cough and expel the tube from the
stoma. Removing the old ties, cleaning the site, then applying the new ties (option A) is not
appropriate because if the client coughs, the tube could be expelled. Option C is incorrect
because this procedure is a nursing procedure; therefore it is not appropriate to call the
physician. In option D, although the respiratory therapist can assist in changing the ties, it
is not necessary to specifically call the therapist for the procedure. (Saunders, 2 nd Edition)
99. Answer: D
Rationale: Suction is not placed on the catheter when the catheter is introduced into the
tracheostomy tube. Suction draws out oxygen and placing suction on the catheter at this
time could traumatize tracheal tissue. Options A, B and C are appropriate components of
the plan of care for suctioning. (Saunders, 2nd Edition)
100. Answer: A
Rationale: During suctioning, the nurse would apply suction during the withdrawal of the
catheter for a period of 5 to 10 seconds. Suction applied longer that this time (options B,
C and D) can cause hypoxia in the client. (Saunders, 2 nd Edition)

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Use short, jabbing movements of the catheter

FUNDAMENTALS OF NURSING Situation 2. The nurse is caring for a client

Situation 20. Nurse Alsea is assisting in

“Unless and until each man is

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