NCLEX-RN Nursing — All Questions

A nurse reviews a client's laboratory results. Which serum potassium value is within the normal range?

• a.7.2 mEq/L
• b.6.5 mEq/L
• c.2.8 mEq/L
• d.4.0 mEq/L✓

The normal serum potassium range is approximately 3.5 to 5.0 mEq/L, so 4.0 mEq/L is normal. Values of 6.5 and 7.2 indicate hyperkalemia, and 2.8 indicates hypokalemia.

A client with heart failure gains 3 pounds in two days and has new crackles in the lungs. Which condition does the nurse suspect?

• a.Fluid volume overload✓
• b.Severe hypokalemia
• c.Acute dehydration
• d.Metabolic alkalosis

Rapid weight gain and pulmonary crackles indicate fluid volume overload, common in a heart failure exacerbation. Prompt recognition allows diuretic and fluid management.

A nurse is caring for a client with diabetic ketoacidosis. Which arterial blood gas finding is expected?

• a.Metabolic alkalosis
• b.Respiratory acidosis
• c.Metabolic acidosis✓
• d.Respiratory alkalosis

Diabetic ketoacidosis produces excess ketoacids, causing metabolic acidosis with a low pH and low bicarbonate. Kussmaul respirations develop as compensation.

A client with chronic obstructive pulmonary disease has an oxygen saturation of 90%. Which oxygen delivery approach is appropriate?

• a.Administer high-flow oxygen at 10 L/min to raise the saturation
• b.Place the client on a nonrebreather mask as the routine choice
• c.Withhold oxygen entirely so the respiratory drive is preserved
• d.Provide low-flow oxygen and titrate to the target saturation✓

Clients with COPD are given controlled low-flow oxygen titrated to a target saturation, often around 88 to 92 percent, to avoid suppressing respiratory drive while treating hypoxemia.

A nurse assesses a client with hypocalcemia. Which finding is expected?

• a.Constipation, lethargy, and thirst
• b.Diminished deep tendon reflexes throughout
• c.Warm, dry, and flushed skin and face
• d.Positive Trousseau and Chvostek signs✓

Hypocalcemia increases neuromuscular excitability, producing positive Trousseau and Chvostek signs, muscle cramps, and tingling. Hypercalcemia causes the opposite findings.

A client presents with slurred speech, facial droop, and right-sided weakness. What is the nurse's priority action?

• a.Activate the stroke protocol and note the time of symptom onset✓
• b.Give the client oral fluids to check the swallowing reflex
• c.Administer aspirin immediately, before any brain imaging is done
• d.Encourage the client to rest and reassess in about an hour

These signs suggest an acute stroke. Rapid activation of the stroke protocol and documenting the symptom onset time are critical because treatment such as thrombolytics is time-dependent.

A nurse is caring for a client after a myocardial infarction. Which laboratory marker is most specific for cardiac muscle damage?

• a.Blood urea nitrogen
• b.Troponin✓
• c.Serum sodium
• d.Total white blood cell count

Troponin is the most specific and sensitive biomarker for myocardial injury and rises within hours of an infarction, guiding diagnosis and treatment.

A client has a nasogastric tube to continuous suction and develops muscle weakness. Which disturbance is most likely?

• a.Respiratory acidosis with hypernatremia
• b.Respiratory alkalosis with hypercalcemia
• c.Metabolic alkalosis with hypokalemia✓
• d.Metabolic acidosis with hyperkalemia

Loss of gastric acid and potassium through continuous suction leads to metabolic alkalosis and hypokalemia, which can cause muscle weakness and dysrhythmias.

A nurse reviews an arterial blood gas: pH 7.30, PaCO2 55 mm Hg, HCO3 24 mEq/L. How should the nurse interpret this?

• a.Metabolic alkalosis
• b.Respiratory alkalosis
• c.Metabolic acidosis
• d.Respiratory acidosis✓

A low pH with an elevated PaCO2 and a normal bicarbonate indicates uncompensated respiratory acidosis, often from hypoventilation.

A client with cirrhosis develops confusion and asterixis. Which laboratory value best explains these findings?

• a.Decreased serum glucose
• b.Elevated serum ammonia✓
• c.Elevated serum calcium
• d.Decreased white blood cell count

Impaired liver function raises serum ammonia, causing hepatic encephalopathy with confusion and asterixis. Treatment such as lactulose lowers ammonia levels.

A nurse cares for a client with acute kidney injury and a serum potassium of 6.8 mEq/L. Which finding is the priority concern?

• a.Decreased urine output over the past shift
• b.Fatigue that improves with an afternoon rest
• c.Mild peripheral edema of both ankles and feet
• d.Peaked T waves on the electrocardiogram✓

Hyperkalemia can cause life-threatening cardiac dysrhythmias; peaked T waves signal cardiac effects and require immediate intervention. The other findings are important but less urgent.

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

• a.Poor skin turgor and elevated urine specific gravity✓
• b.Moist mucous membranes and brisk capillary refill
• c.Bounding pulse and elevated blood pressure with crackles
• d.Jugular vein distention while sitting upright

Dehydration produces poor skin turgor, dry mucous membranes, and concentrated urine with a high specific gravity. Jugular distention and bounding pulses suggest fluid overload.

A nurse assesses a client with hypothyroidism. Which finding is expected?

• a.Weight loss with marked heat intolerance
• b.Fatigue, cold intolerance, and bradycardia✓
• c.Tachycardia and bulging exophthalmos
• d.Frequent diarrhea and hand tremors

Hypothyroidism slows metabolism, causing fatigue, cold intolerance, weight gain, and bradycardia. Weight loss, heat intolerance, and tachycardia occur in hyperthyroidism.

A client with type 1 diabetes is diaphoretic, shaky, and confused with a blood glucose of 54 mg/dL. What is the priority intervention?

• a.Withhold all food until the provider is notified
• b.Administer long-acting insulin
• c.Encourage the client to exercise
• d.Give 15 grams of a fast-acting carbohydrate✓

These are signs of hypoglycemia. For a conscious client, giving about 15 grams of fast-acting carbohydrate raises the glucose quickly; the level is then rechecked.

A nurse is monitoring a client after a total hip replacement. Which finding suggests a possible pulmonary embolism?

• a.Decreased appetite at the evening meal
• b.Gradual improvement in hip mobility
• c.Sudden dyspnea, chest pain, and tachycardia✓
• d.Mild incisional soreness with movement

Sudden dyspnea, pleuritic chest pain, and tachycardia after orthopedic surgery suggest a pulmonary embolism, a medical emergency requiring immediate action.

A client's laboratory results show a hemoglobin of 7.2 g/dL. Which assessment finding is most consistent with this value?

• a.Bradycardia and hypertension
• b.Increased energy and alertness
• c.Fatigue, pallor, and tachycardia✓
• d.Warm, ruddy skin and bounding pulses

A hemoglobin of 7.2 g/dL indicates anemia, producing fatigue, pallor, and compensatory tachycardia due to reduced oxygen-carrying capacity.

A nurse cares for a client with increased intracranial pressure. Which finding is an early sign?

• a.Fixed, dilated pupils that do not react
• b.Cushing's triad of vital sign changes
• c.Deep coma with no motor response
• d.A change in level of consciousness✓

A change in level of consciousness is the earliest and most sensitive sign of increased intracranial pressure. Fixed pupils and Cushing's triad are late, ominous findings.

A client with Addison's disease is at risk for adrenal crisis. Which finding requires immediate intervention?

• a.Occasional craving for salty foods
• b.Mild fatigue in the afternoon
• c.Slightly bronzed skin creases
• d.Severe hypotension and hyperkalemia✓

Adrenal crisis causes profound hypotension, hyperkalemia, and hyponatremia and is life-threatening, requiring immediate fluids and hydrocortisone. Bronzing and salt craving are chronic features.

A nurse reviews arterial blood gases: pH 7.50, PaCO2 30 mm Hg, HCO3 24 mEq/L. Which condition does this represent?

• a.Acute metabolic acidosis
• b.Metabolic alkalosis
• c.Respiratory alkalosis✓
• d.Respiratory acidosis

An elevated pH with a low PaCO2 and a normal bicarbonate indicates respiratory alkalosis, often caused by hyperventilation.

A client with gastroenteritis has had severe diarrhea for two days. Which electrolyte imbalance is most likely?

• a.Hypokalemia✓
• b.Hyperkalemia
• c.Hypernatremia
• d.Hypercalcemia

Prolonged diarrhea causes significant potassium loss through the stool, leading to hypokalemia, which can produce weakness and cardiac dysrhythmias.

A nurse assesses a client in the compensatory stage of hypovolemic shock. Which finding is expected?

• a.Increased heart rate and cool, clammy skin✓
• b.Slow, deep respirations with a normal pulse
• c.Elevated blood pressure with warm, flushed skin
• d.Bradycardia with warm, dry, pink skin

In compensated shock, the body increases the heart rate and constricts peripheral vessels, producing tachycardia and cool, clammy skin as it attempts to maintain perfusion.

A client with pneumonia has a fever and thick secretions. Which intervention best promotes airway clearance?

• a.Restrict oral fluid intake to reduce sputum production
• b.Keep the client lying flat in bed to conserve energy
• c.Encourage fluids and provide chest physiotherapy as ordered✓
• d.Suppress the productive cough with medication so the client rests

Adequate hydration thins secretions and chest physiotherapy mobilizes them, promoting airway clearance. Restricting fluids and suppressing a productive cough would worsen secretion retention.

A nurse cares for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which finding is expected?

• a.Hyponatremia and fluid retention✓
• b.High serum osmolality
• c.Dehydration and excessive thirst
• d.Hypernatremia and increased urine output

SIADH causes excessive water retention, leading to dilutional hyponatremia, low serum osmolality, and concentrated urine. Fluid restriction is a key treatment.

A client with a history of gout has an elevated serum uric acid level. Which dietary teaching is appropriate?

• a.Avoid all dairy products because they raise uric acid
• b.Restrict water intake to reduce joint swelling
• c.Limit purine-rich foods and increase fluid intake✓
• d.Increase intake of organ meats and shellfish for protein

Limiting purine-rich foods such as organ meats and shellfish and increasing fluids helps lower uric acid and prevent gout attacks. Adequate hydration promotes uric acid excretion.

A nurse reviews a client's coagulation results. Which value indicates the client is at increased risk for bleeding?

• a.Hemoglobin of 14 g/dL
• b.INR of 5.0✓
• c.Platelet count of 250,000/microliter
• d.INR of 1.0

An INR of 5.0 is well above the therapeutic range and indicates a high bleeding risk. An INR of 1.0 and a normal platelet count reflect normal clotting ability.

A client with liver failure has a prolonged prothrombin time. Which nursing action is appropriate?

• a.Implement bleeding precautions and use a soft toothbrush✓
• b.Administer intramuscular injections freely for comfort medications
• c.Ignore minor bruising and gum bleeding as unimportant
• d.Encourage vigorous tooth brushing with a firm-bristled brush

A prolonged prothrombin time indicates impaired clotting, so bleeding precautions such as a soft toothbrush and avoiding unnecessary injections reduce the risk of hemorrhage.

A nurse is caring for a client on the first postoperative day after an open abdominal hysterectomy. The nurse records three sets of vital signs: 0800 — heart rate 86, blood pressure 126/74, respirations 16 0900 — heart rate 104, blood pressure 112/70, respirations 20 1000 — heart rate 124, blood pressure 94/72, respirations 26 The abdominal dressing is dry and intact, and the client is restless. Which action should the nurse take?

• a.Assist the client to use the incentive spirometer for the rapid respirations.
• b.Raise the head of the bed and offer oral fluids to correct the dehydration.
• c.Notify the surgeon at once and prepare for intravenous fluid resuscitation.✓
• d.Give the ordered as-needed analgesic and reassess the vital signs in an hour.

A heart rate and respiratory rate that climb while the systolic pressure falls and the pulse pressure narrows from 52 to 22 mm Hg across three sets is the progression of hemorrhagic shock; tachycardia is the first abnormal vital sign, so by the time the pressure drops the blood loss is already large and surgical evaluation cannot wait. A dry dressing does not exclude intra-abdominal bleeding, and using the spirometer treats the fast breathing as a lung problem while the client continues to bleed.

A nurse is monitoring an adult during a colonoscopy performed with intravenous midazolam and fentanyl. The nurse records: 0930 — respirations 14, oxygen saturation 98% on 2 L nasal cannula, end-tidal carbon dioxide 38 mm Hg 0935 — respirations 10, oxygen saturation 94%, end-tidal carbon dioxide 47 mm Hg 0940 — respirations 7, oxygen saturation 87%, end-tidal carbon dioxide 58 mm Hg The client does not respond to a loud voice. Which action should the nurse take first?

• a.Withhold further sedative, open the airway, and increase the oxygen flow.✓
• b.Raise the head of the bed and ask the endoscopist to hurry the procedure.
• c.Apply a nonrebreather mask and continue the planned sedative dosing.
• d.Give intravenous flumazenil and naloxone before any other intervention.

A falling respiratory rate with a rising end-tidal carbon dioxide and a dropping saturation is progressive sedation-related hypoventilation, so the monitoring nurse stops giving sedative, opens the airway, and increases oxygen — measures that work in seconds and are squarely within the nurse's role. Reversal agents have a place if airway support and stopping the drug do not restore ventilation, but giving them first delays the airway maneuver that actually corrects the problem.

A nurse is caring for a client on the second postoperative day after a bowel resection. The nurse records: 1400 — temperature 37.2 °C (99.0 °F), heart rate 92, blood pressure 122/72, respirations 18 1800 — temperature 38.5 °C (101.3 °F), heart rate 114, blood pressure 106/64, respirations 24 2200 — temperature 39.1 °C (102.4 °F), heart rate 128, blood pressure 88/52, respirations 30 The client is drowsy and answers questions slowly. Which action should the nurse take?

• a.Call the rapid response team and obtain a serum lactate and blood cultures.✓
• b.Hold the morning antihypertensive dose and continue hourly observations.
• c.Give the ordered acetaminophen and recheck the temperature in four hours.
• d.Apply a cooling blanket and restrict oral fluids until the fever breaks.

Fever with worsening tachycardia, a respiratory rate of 30, a systolic pressure that has fallen below 100 mm Hg, and new slowed mentation meets sepsis screening criteria, and a lactate plus blood cultures drawn before antibiotics are the time-critical first steps. Treating the temperature alone with an antipyretic leaves the infection and the developing hypoperfusion untreated while the client keeps deteriorating.

A client with type 2 diabetes who takes metformin is scheduled for a contrast-enhanced computed tomography scan this afternoon. The nurse reviews the serum creatinine record: Monday — 0.9 mg/dL Tuesday — 1.5 mg/dL Wednesday (today) — 2.2 mg/dL The estimated glomerular filtration rate today is 38 mL/min/1.73 m². Which action should the nurse take?

• a.Give the metformin with the scan and recheck the creatinine in two weeks.
• b.Give the metformin dose early so that it clears before the contrast is given.
• c.Hold the metformin for 48 hours after the scan but give today's dose now.
• d.Hold the metformin at the time of the scan and report the rising creatinine.✓

The metformin labeling directs that the drug be discontinued at the time of, or before, an iodinated contrast imaging procedure when the estimated glomerular filtration rate is 30 to 60 mL/min/1.73 m², with the filtration rate re-evaluated 48 hours later before restarting, because contrast-associated kidney injury can precipitate lactic acidosis. Holding it only after the scan leaves metformin on board through the period of greatest renal risk, which is exactly the exposure the warning exists to prevent, and the creatinine that has more than doubled in two days is itself an acute change the provider needs to know about before contrast is given.

A nurse is monitoring a client at 39 weeks' gestation who is in active labor. No oxytocin is infusing. The fetal monitor shows a baseline of 140 beats/min with a gradual fall in the fetal heart rate to 110 beats/min whose lowest point occurs after the peak of each contraction, returning to baseline after the contraction ends. Which action should the nurse take first?

• a.Record the pattern and reassess the fetal heart rate in thirty minutes.
• b.Apply a fetal scalp electrode to obtain a clearer tracing of the pattern.
• c.Turn the client onto her side to relieve pressure on the vena cava.✓
• d.Ask the client to begin pushing with the next contraction to speed birth.

A gradual deceleration whose nadir falls after the peak of the contraction is a late deceleration, which reflects uteroplacental insufficiency; the first intrauterine resuscitation measure is maternal repositioning to a lateral or knee-chest position, which relieves caval compression and increases uteroplacental blood flow. Waiting thirty minutes to reassess treats a pattern associated with developing fetal acidemia as though it were benign.

A nurse reviews the electronic fetal monitor strip of a client in active labor. The baseline fetal heart rate is 138 beats/min, variability is 10 beats/min, accelerations are present, and the fetal heart rate falls gradually with each contraction and reaches its lowest point at the same time as the peak of the contraction. Which action should the nurse take?

• a.Place the client in a knee-chest position and call the birth attendant.
• b.Continue the current plan of care and keep monitoring the tracing.✓
• c.Give the client a bolus of lactated Ringer's and apply oxygen by mask.
• d.Prepare the client for an immediate operative birth in the delivery room.

A baseline of 110 to 160 beats/min, moderate variability of 6 to 25 beats/min, accelerations, and decelerations whose nadir coincides with the peak of the contraction describe early decelerations within a Category I tracing, which is normal and calls for no intervention. Early decelerations come from fetal head compression rather than from reduced placental perfusion, so repositioning, fluids, and oxygen would be treating a problem this strip does not show.

A nurse is teaching an adult who is scheduled for an elective knee replacement under general anesthesia about fasting before the operation. Which statement by the client indicates that the teaching has been effective?

• a.I can have a glass of milk up to two hours before my surgery.
• b.I can have a light breakfast up to two hours before my surgery.
• c.I have to stop drinking water at midnight the night before surgery.
• d.I can drink clear apple juice up to two hours before my surgery.✓

Current anesthesia fasting guidance permits clear liquids — water, pulp-free juice, black coffee or tea — until 2 hours before induction, while a light meal requires about 6 hours and milk is not a clear liquid because it slows gastric emptying. The older blanket rule of nothing by mouth after midnight leaves clients needlessly thirsty and dehydrated and is no longer the standard.

A nurse enters a client's room to witness the signature on a surgical consent form. The client says, 'I agreed to this, but I still do not know whether they are taking out the whole gallbladder or only the stones.' Which action should the nurse take?

• a.Stop the signing and ask the surgeon to return to explain the operation.✓
• b.Ask the client's adult daughter to sign the consent form for the client.
• c.Describe the two operations to the client and then witness the signature.
• d.Witness the signature and record the client's questions in the chart.

Disclosing the nature, risks, benefits, and alternatives of a procedure is the responsibility of the clinician who will perform it, and the nurse's signature attests only that the client signed voluntarily; a client who cannot say what operation is planned is not yet informed, so the surgeon must finish the discussion first. The nurse reinforces and clarifies what the surgeon explained but cannot substitute her own explanation for that disclosure, and a competent adult's consent cannot be handed to a relative.

A nurse teaches a client to use an incentive spirometer after upper abdominal surgery. Which statement by the client indicates that the teaching has been effective?

• a.I will blow out hard and fast into the mouthpiece ten times.
• b.I will use the device once each morning before I eat breakfast.
• c.I will inhale slowly and hold the breath for about three seconds.✓
• d.I will lie flat on my back so that my lungs can expand more fully.

Correct technique is a slow, deliberate inhalation through the mouthpiece with a breath hold of at least 2 to 3 seconds at full inspiration, roughly ten breaths every hour while awake, done sitting or standing upright. Blowing out into the device reverses the manoeuvre — the spirometer trains inspiration in order to re-expand collapsed alveoli, not forced exhalation.

A nurse is preparing to transfer clients out of the post-anesthesia care unit. Which client should the nurse recognize as not yet ready to leave the unit?

• a.A client whose shivering resolved after warmed blankets were applied.
• b.A client whose midazolam was reversed with flumazenil ten minutes ago.✓
• c.A client who is awake and oriented with stable vital signs after knee repair.
• d.A client who reports incisional pain of 3 of 10 after receiving morphine.

Flumazenil's effect can wear off before the benzodiazepine it reversed, so the labeling directs monitoring for resedation and respiratory depression for an appropriate period of up to 120 minutes; ten minutes is nowhere near long enough to call the client recovered. Being awake and oriented with stable vital signs, having pain controlled, and having shivering resolve are the expected recovery findings and do not by themselves hold up transfer.

A nurse is preparing to assist with a bedside procedure for which the client will receive moderate sedation. Which action is essential before the first dose of sedative is given?

• a.Confirm that the client's family has received the recovery instructions.
• b.Confirm that the client has emptied the bladder within the past hour.
• c.Confirm that the client's last solid meal was more than two hours ago.
• d.Confirm that oxygen, suction, and reversal agents are at the bedside.✓

Rescue capability — supplemental oxygen, suction, airway equipment, and reversal agents immediately at hand — must be in place before sedation starts, because respiratory depression and airway obstruction are the expected complications and are managed in seconds. A recent solid meal is the opposite of what is wanted, since elective sedation follows roughly a 6-hour fast for solids and 2 hours for clear liquids.

An adult walks into the emergency department reporting crushing chest pressure that started 40 minutes ago. Within what time frame should the nurse ensure that a 12-lead electrocardiogram is obtained and interpreted?

• a.Within 30 minutes of the client's arrival in the department.
• b.Within 10 minutes of the client's arrival in the department.✓
• c.Within 60 minutes of the client's arrival in the department.
• d.After the first troponin result returns from the laboratory.

For anyone with symptoms suggesting acute coronary syndrome, the 12-lead electrocardiogram should be obtained and interpreted by a trained clinician within 10 minutes of arrival, because it is what identifies ST-elevation infarction and starts the clock on reperfusion. Waiting for troponin delays that decision, and a conventional troponin can still be normal in the first hours after symptom onset.

A nurse is about to obtain a capillary blood glucose reading from an adult who has just finished peeling and eating an orange. Which action should the nurse take?

• a.Wait two hours after the fruit, then obtain the capillary blood sample.
• b.Wipe the fingertip twice with an alcohol swab and let it air dry completely.
• c.Draw the sample from the arm above the client's running intravenous line.
• d.Wash the client's hands with soap and water before the fingertip puncture.✓

Sugar left on the skin after handling fruit produces a falsely high capillary glucose, and washing the hands with water is what removes it; in the study that described this effect, wiping the fingertip with an alcohol swab, even repeatedly, did not correct the false elevation. Delaying the test for two hours would return a value that no longer answers the question the provider ordered.

A nurse is caring for a client two hours after a cardiac catheterization performed through the right femoral artery. Which finding requires immediate follow-up?

• a.New flank and back pain with a heart rate that has risen to 118.✓
• b.Bruising and mild tenderness around the femoral puncture site.
• c.A 2 cm area of dried blood on the dressing over the puncture site.
• d.Voiding of 450 mL of clear yellow urine since the procedure ended.

Retroperitoneal hemorrhage after femoral access shows itself as back or flank pain with tachycardia and hemodynamic change, often with no visible swelling at the groin, so an unremarkable-looking site does not rule it out and this combination needs urgent evaluation and imaging. A little dried blood on the dressing and local bruising are common findings that can be watched, and good urine output is reassuring.

A nurse is monitoring a client who had a thoracentesis of the right pleural space thirty minutes ago. Which finding should the nurse report to the provider immediately?

• a.Sudden shortness of breath with absent breath sounds on the right.✓
• b.A dry cough that began as the pleural fluid was being withdrawn.
• c.A small amount of serous drainage seen on the puncture site dressing.
• d.Discomfort at the puncture site rated 3 on a 0 to 10 scale.

Pneumothorax is the most common complication of thoracentesis and appears during or shortly after the procedure as new dyspnea and pleuritic pain with diminished or absent breath sounds over the punctured side; it needs prompt imaging and may require a chest tube. A dry cough as fluid is drawn off and mild soreness at the site are expected and do not indicate a collapsed lung.

A nurse assesses a client four hours after a long leg cast was applied for a tibial fracture. Which finding requires immediate action?

• a.Toes that are pink and warm with capillary refill of about two seconds.
• b.A cast that still feels warm and slightly damp four hours after it was applied.
• c.Reports of itching under the cast at the level of the mid-calf area.
• d.Calf pain that increases with passive toe extension and continues after opioids.✓

Pain out of proportion to the injury that is worsened by passive stretch of the muscles in the compartment and is not relieved by opioids is the earliest reliable sign of acute compartment syndrome; the cast must be released and the surgeon notified, because fasciotomy is time-critical. Pulselessness and pallor are late findings, so pink warm toes with normal capillary refill do not make this pain safe to observe.

A client who had a flexible bronchoscopy with topical lidocaine sprayed to the throat one hour ago asks the nurse for a drink of water. Which action should the nurse take?

• a.Tell the client that oral fluids are withheld until the next morning.
• b.Raise the head of the bed fully and give small sips of cool water.
• c.Test for return of the gag reflex before giving anything by mouth.✓
• d.Give ice chips first because they are less likely to be aspirated.

Topical anesthetic relaxes the pharyngeal and laryngeal muscles and blunts the gag and cough reflexes, so anything swallowed before those reflexes return can be aspirated; the nurse checks that the gag reflex has come back before offering fluids. Ice chips and sitting upright do not restore the protective reflex, and keeping the client fasting until morning is far longer than the anesthetic effect lasts.

A client who had a right modified radical mastectomy with axillary lymph node dissection two years ago now has a continuous IV infusion running in the left antecubital vein. The surgeon's orders state that the right arm is not to be used for venipuncture. The nurse must obtain a venous blood specimen. Which site should the nurse use?

• a.A vein in the left hand, distal to the infusion, 2 minutes after it is paused✓
• b.A vein in the right antecubital fossa, on the arm that has no infusion running
• c.The existing IV catheter in the left arm, drawn back while fluid is infusing
• d.A vein in the left upper arm, proximal to the infusion, while it keeps running

The arm on the side of a mastectomy with lymph node dissection is avoided for venipuncture because lymphatic drainage is impaired, so drawing from the right arm is not an option here. Blood is not drawn proximal to (above) a running infusion because the sample is diluted by the infusate; when the opposite arm is unusable, the accepted alternative is a site distal to the IV after the infusion has been stopped for at least 2 minutes, with the first volume discarded. Pausing the line and drawing immediately is not enough — the infusate has to clear the vein first.

A nurse is performing a single venipuncture to collect a set of blood cultures, a prothrombin time in a light blue sodium citrate tube, and a complete blood count in a lavender EDTA tube. In which order should the nurse fill the containers?

• a.The blood culture bottles, then the lavender EDTA tube, then the light blue citrate tube
• b.The light blue citrate tube, then the blood culture bottles, then the lavender EDTA tube
• c.The blood culture bottles, then the light blue citrate tube, then the lavender EDTA tube✓
• d.The lavender EDTA tube, then the light blue citrate tube, then the blood culture bottles

In the CLSI order of draw, culture bottles are filled first to protect sterility, and the sodium citrate tube precedes the EDTA tube. Filling EDTA before citrate lets EDTA carry over on the needle; EDTA binds calcium and falsely prolongs coagulation results, which is why swapping those two tubes is the most tempting wrong sequence.

A provider orders a urine culture for a client whose indwelling urinary catheter was inserted three days ago. How should the nurse obtain the specimen?

• a.Separate the catheter from the drainage tubing and collect urine from the open end
• b.Clamp the drainage tubing for two hours and then empty the bag into the container
• c.Pour urine collected in the drainage bag into a sterile specimen container at the bedside
• d.Disinfect the needleless sampling port and aspirate fresh urine with a sterile syringe✓

CDC directs that a small volume of fresh urine for urinalysis or culture be aspirated from the needleless sampling port with a sterile syringe after the port is disinfected. Urine standing in the drainage bag is contaminated and yields a misleading culture, and opening the catheter–tubing junction breaks the closed system, which raises the risk of catheter-associated infection.

On postoperative day 2 after open reduction of a femur fracture, a client remains hemodynamically stable with adequate urine output. The indwelling catheter placed in surgery is still draining, and the off-going nurse reports it is being kept because the client is incontinent. Which action should the nurse take?

• a.Replace the catheter and drainage bag now, and again every seven days after that
• b.Irrigate the catheter with sterile normal saline once a shift to keep it draining
• c.Request an order to remove the catheter and start a scheduled toileting plan✓
• d.Keep the catheter in place to protect the surgical incision from urine contact

CDC lists management of incontinence as an inappropriate indication for an indwelling catheter and states that catheters should be left in place only as long as needed, so advocating for removal is the intervention here. Changing catheters and bags at fixed intervals and routine irrigation are both specifically not recommended and do nothing to lower infection risk.

A client is 6 hours into a 24-hour urine collection when the nursing assistant reports that one voiding was accidentally flushed down the toilet. Which action should the nurse take?

• a.Continue the collection and send it with a note that one voiding was not saved
• b.Continue the collection and extend the ending time by 6 hours to make up for it
• c.Discard the collection, restart it, and record a new start time on the container✓
• d.Continue the collection and document the estimated volume of the voiding that was lost

A 24-hour collection measures the total amount of a substance excreted over an exact timed interval, so any voiding that is not in the container makes the total falsely low and the collection must be started over. Estimating or documenting the lost volume is tempting but cannot reconstruct it, and extending the end time changes the interval the result is calculated against.

A nurse teaches a female client how to collect a clean-catch midstream urine specimen at the clinic. Which statement indicates that the teaching was effective?

• a.I'll wipe from front to back, then collect everything I pass from start to finish
• b.I'll hold my labia apart, wipe from front to back, then catch urine from mid-stream✓
• c.I'll wipe from front to back, then catch the last urine after my bladder empties
• d.I'll wipe from back to front, then catch the very first urine that leaves my body

Separating the labia and wiping front to back keeps perineal flora away from the urethral opening, and letting the first portion of the stream clear the urethra before collecting is what makes the specimen midstream. Collecting the first urine washes urethral contaminants straight into the cup, and wiping back to front carries organisms from the anus toward the urethra.

A nurse instructs a client on collecting an expectorated sputum specimen for culture. Which statement by the client indicates a need for further teaching?

• a.I'll rinse my mouth with plain water, then breathe deeply and cough hard
• b.I'll collect it first thing in the morning, before I eat or drink anything at all
• c.I'll keep coughing until I've brought up about a teaspoon of thick material
• d.I'll gargle with my antiseptic mouthwash right before I cough the specimen up✓

Mouthwash and toothpaste contain antimicrobials that alter the organisms in the sample, so the mouth is rinsed with plain water only; that statement shows the teaching did not take. Early-morning collection captures secretions pooled overnight, and roughly 5 mL of thick material from a deep cough distinguishes true sputum from watery saliva.