NCLEX-RN Nursing — All Questions

A nurse must give three oral medications through a client's gastrostomy tube during a continuous tube feeding. Which action is correct?

• a.Give the three medications one after another without flushing between
• b.Add the three medications to the enteral formula bag before hanging it
• c.Give each medication separately, flushing with water between them✓
• d.Mix the three medications and give them in one syringe

ISMP and ASPEN direct the nurse to stop the feeding, flush the tube with water before, between, and after each medication, and prepare and give each medication separately, because combining drugs in one syringe creates a mixture whose compatibility no one has established and is a leading cause of tube occlusion. Adding medications to the formula bag is specifically warned against, since drug-nutrient interactions and blockage follow.

A nurse is giving an intramuscular vaccine in the deltoid to an adult woman who weighs 230 lb (104 kg). Which needle should the nurse select?

• a.A 22- to 25-gauge needle, 1.5 inches long✓
• b.A 20- to 22-gauge needle, 2 inches long
• c.A 23- to 25-gauge needle, 5/8 inch long
• d.A 22- to 25-gauge needle, 1 inch long

CDC's needle-length table specifies a 22- to 25-gauge, 1.5-inch (38 mm) needle for an intramuscular deltoid injection in a woman weighing more than 200 lb, because the needle has to pass through subcutaneous fat and reach muscle. The 1-inch needle is the length listed for adults up to about 152 lb and is the most tempting choice, but at this weight it risks depositing the vaccine subcutaneously, where absorption and the immune response are poorer and local reactions are more common; the 5/8-inch, 23- to 25-gauge needle is the subcutaneous specification.

A nurse is giving a deep intramuscular injection of a dark, staining medication whose label directs that it be given by Z-track. Which action is part of this technique?

• a.Press the skin down over the site and apply a pressure dressing afterward
• b.Displace the skin and tissue laterally, hold it during the injection, then release✓
• c.Pinch the skin and tissue upward and release it just before the needle comes out
• d.Stretch the skin taut over the site and massage the area firmly afterward

The iron dextran labeling describes Z-track as displacement of the skin laterally before injection, and the tissue is held displaced until after the needle is withdrawn so the layers slide back over one another and seal the needle track, which keeps a staining or irritating drug from leaking up into subcutaneous tissue. Pinching tissue upward is the subcutaneous technique, and massaging the site afterward is the most tempting wrong step because it is routine for some injections: here it pushes drug back along the track that the technique was meant to close.

A client with COPD received a scheduled dose of an inhaled short-acting bronchodilator 15 minutes ago. Which finding best indicates the intended response?

• a.The client's oral temperature has fallen from 38.1 C to 37.2 C since the dose
• b.The client reports that the mouth feels less dry than it did before the dose
• c.The client's heart rate has risen from 78 to 96 beats per minute since the dose
• d.The client speaks a full sentence without pausing, and wheezing has decreased✓

A short-acting bronchodilator is given to open the airways, so the evidence that it worked is an airway finding: less wheezing and enough breath to finish a sentence. The rise in heart rate is the most tempting distractor because it is a real, measurable change caused by the drug, but tachycardia is a beta-adrenergic side effect rather than the therapeutic goal, and temperature and mouth dryness measure outcomes the drug was not given to change.

A nurse is orienting a newly hired nurse to the administration of intravenous potassium chloride from a concentrate vial. Which statement by the newly hired nurse indicates correct understanding?

• a.I will give it only as a diluted infusion controlled by a pump.✓
• b.I will push the concentrate slowly over five minutes into a large vein.
• c.I will infuse it undiluted through a central line to protect the veins.
• d.I will regulate the diluted infusion by gravity and count the drip rate.

Potassium chloride concentrate must be diluted before use and infused at a controlled rate, because direct injection of the concentrate may be instantaneously fatal. Giving the concentrate by push or infusing it undiluted through a central line both deliver an undiluted bolus, and gravity tubing cannot guarantee the rate limit.

A client is prescribed 8 units of NPH human insulin and 4 units of regular human insulin, to be mixed in one syringe and given subcutaneously. Which action should the nurse take?

• a.Draw the NPH insulin into the syringe before the regular insulin.
• b.Draw the NPH insulin first and roll the filled syringe between the palms.
• c.Draw the regular insulin first and store the filled syringe for one hour.
• d.Draw the regular insulin into the syringe before the NPH insulin.✓

Both manufacturers' labelling states that when regular human insulin is mixed with NPH, the regular insulin is drawn into the syringe first and the injection is given immediately after mixing. Drawing NPH first risks carrying the cloudy suspension back into the clear regular vial, and holding the mixed syringe for an hour ignores the instruction to inject immediately.

A client's prescriptions include insulin glargine at bedtime and insulin lispro before meals. The bedtime dose is due. Which action should the nurse take?

• a.Add the glargine to the running intravenous fluid at bedtime.
• b.Give the glargine in its own syringe, not mixed with another insulin.✓
• c.Mix the glargine with the lispro dose, drawing the lispro up first.
• d.Dilute the glargine with sterile water before drawing the dose.

Insulin glargine labelling directs that it not be diluted or mixed with any other insulin or solution, and that it not be given intravenously, so it is drawn and injected on its own. The lispro is a separate subcutaneous injection, not a syringe partner.

A client on day 6 of a continuous IV heparin infusion has a platelet count of 68,000/mm3; the count before therapy was 210,000/mm3. Which action should the nurse take?

• a.Continue the infusion and request an order for protamine sulfate.
• b.Hold the infusion and report the platelet count to the provider.✓
• c.Continue the infusion and recheck the platelet count in 24 hours.
• d.Slow the infusion by half and apply a pressure dressing to the site.

Heparin labelling directs that heparin be promptly discontinued and the client evaluated for heparin-induced thrombocytopenia if the platelet count falls below 100,000/mm3, so the nurse holds the drug and reports the value. Continuing or merely slowing the infusion leaves the client exposed to the antibody-mediated thrombosis that makes this reaction dangerous.

A client has an indwelling epidural catheter for postoperative analgesia and is receiving subcutaneous enoxaparin. Which finding requires immediate follow-up?

• a.A 2-cm bruise at the abdominal injection site.
• b.New numbness of both legs with an inability to void.✓
• c.An aPTT that is unchanged from the pretreatment value.
• d.Mild soreness at the epidural insertion site.

The boxed warning for enoxaparin describes spinal or epidural hematoma that can cause long-term or permanent paralysis, and directs frequent monitoring for neurological impairment; new bilateral leg numbness with urinary retention is that emergency. An unchanged aPTT is expected, because labelling states the aPTT is not adequate for monitoring enoxaparin.

A mechanically ventilated client in the intensive care unit is receiving a continuous vecuronium infusion. Which action should the nurse take?

• a.Reserve sedation for the times when the client's heart rate climbs above 100.
• b.Give sedation and analgesia, because vecuronium does not relieve pain.✓
• c.Withhold the ordered sedation, because vecuronium produces unconsciousness.
• d.Stop the infusion each shift to assess the client's pain verbally.

Vecuronium labelling states the drug has no known effect on consciousness, the pain threshold, or cerebration, and that administration must be accompanied by adequate anesthesia or sedation. A paralyzed client cannot report pain, so waiting for a verbal report or for a rise in heart rate leaves the client aware and untreated.

During a peripheral infusion of vincristine, a client reports burning at the IV site, and the nurse finds swelling and no blood return. Which action should the nurse take first?

• a.Stop the infusion, leave the catheter in, and aspirate residual drug.✓
• b.Slow the infusion and raise the arm above the level of the heart.
• c.Remove the catheter and apply firm pressure over the swollen area.
• d.Flush the catheter with 10 mL of 0.9% sodium chloride to clear the vein.

Vincristine is a vesicant; the described protocol is to halt and disconnect the infusion while leaving the needle or cannula in position and gently aspirating the extravasated solution without flushing the line. Flushing pushes more vesicant into the tissue, and pulling the catheter first gives up the access needed to aspirate.

A 76-year-old client takes digoxin and furosemide daily and now reports nausea, poor appetite, and yellow-green halos around lights. In addition to the serum digoxin concentration, which laboratory value should the nurse review?

• a.Serum bilirubin level
• b.Serum albumin level
• c.Serum amylase level
• d.Serum potassium level✓

Digoxin labelling lists hypokalemia, hypercalcemia, and hypomagnesemia as conditions that predispose to digoxin toxicity, and a loop diuretic such as furosemide wastes potassium, so the potassium level is the value that explains toxic symptoms at an ordinary dose. Bilirubin, amylase, and albumin do not change digoxin sensitivity.

A client who takes phenytoin for a seizure disorder has a total serum phenytoin concentration of 27 mcg/mL. Which assessment finding should the nurse expect?

• a.Flushing of the face and neck with itching
• b.Yellow-green halos around bright lights
• c.Nystagmus when the eyes track to the side✓
• d.Coarse hand tremor with repeated vomiting

Phenytoin labelling places the usual therapeutic total concentration at 10 to 20 mcg/mL and states that nystagmus on lateral gaze usually appears at 20 mcg/mL, so a level of 27 mcg/mL should produce it. Yellow-green vision suggests digoxin toxicity, coarse tremor with vomiting suggests lithium toxicity, and upper-body flushing follows a rapid vancomycin infusion.

The pharmacy sends vancomycin 1 g in 250 mL of dextrose 5% in water labelled to infuse over 30 minutes. Which action should the nurse take?

• a.Start the infusion as sent and draw a trough level 30 minutes afterward.
• b.Question the rate, since a dose is infused over at least 60 minutes.✓
• c.Infuse it by gravity and count the drip rate every 15 minutes.
• d.Premedicate with diphenhydramine and infuse the dose over 30 minutes.

Vancomycin labelling directs that each dose be given at no more than 10 mg/min or over a period of at least 60 minutes, because rapid infusion can cause exaggerated hypotension and flushing of the upper body. Premedicating does not make an unsafe rate safe, and a trough drawn immediately after the dose does not address the rate at all.

A client who had a mechanical mitral valve replacement is taking warfarin. Today's INR is 1.6. How should the nurse interpret this result?

• a.Below the target range of 2.5 to 3.5 for a mechanical mitral valve✓
• b.Within the target range of 1.5 to 2.0 for a mechanical mitral valve
• c.Within the target range of 1.6 to 2.5 for a mechanical mitral valve
• d.Above the target range of 1.0 to 1.5 for a mechanical mitral valve

Warfarin labelling sets a target INR of 3.0 with a range of 2.5 to 3.5 for a mechanical mitral valve, so an INR of 1.6 is subtherapeutic and leaves the client at risk for valve thrombosis. The lower ranges offered belong to no labelled warfarin indication; even venous thromboembolism and atrial fibrillation are anticoagulated to 2.0 to 3.0.

A client takes lithium carbonate at 0800 and at 2000. The provider orders a serum lithium level. When should the nurse arrange the blood draw?

• a.Just before the 0800 dose, 8 to 12 hours after the evening dose✓
• b.Just after the 2000 dose, at the end of the dosing day
• c.One hour after the 0800 dose, when absorption is complete
• d.At about 1400, roughly midway between the two scheduled doses

Lithium labelling directs that blood samples be drawn immediately prior to the next dose, 8 to 12 hours after the previous dose, when concentrations are relatively stable. A sample drawn soon after a dose reflects the absorption peak and can look falsely toxic, which may lead to an unnecessary dose reduction.

A client with heart failure takes lisinopril daily and has a new prescription for spironolactone. This morning's serum potassium is 5.9 mEq/L. Which action should the nurse take?

• a.Give both drugs and add an oral potassium supplement at noon.
• b.Hold the spironolactone and report the potassium result.✓
• c.Hold the lisinopril and give the spironolactone as prescribed.
• d.Give the spironolactone and recheck the potassium in 3 days.

Spironolactone is contraindicated in hyperkalemia, and its labelling warns that the risk rises when it is combined with an ACE inhibitor such as lisinopril; a potassium of 5.9 mEq/L is above the upper limit of normal, so the dose is held and reported. Substituting one of the two drugs for the other still adds a potassium-raising agent to an already elevated level.

A client with rheumatoid arthritis is going home on oral methotrexate. Which statement by the client indicates that the teaching about the regimen was effective?

• a.I take one tablet each morning with my breakfast.
• b.I take an extra dose on days my joints ache more.
• c.I have my blood counts checked once a year.
• d.I take the whole dose on one day each week.✓

Methotrexate for rheumatoid arthritis is prescribed once weekly, and the labelling states plainly that mistaken daily use of the recommended dose has led to fatal toxicity, so taking the full amount on a single day of the week shows the teaching took hold. Daily or extra dosing is the dangerous error the warning exists for, and blood counts are followed at least monthly during therapy rather than yearly.

A client with severe preeclampsia is receiving IV magnesium sulfate. The nurse finds the patellar reflex absent, respirations 10 breaths per minute, and urine output 20 mL over the past hour. Which action should the nurse take first?

• a.Stop the magnesium infusion and prepare to give calcium gluconate.✓
• b.Continue the infusion and recheck the patellar reflex in one hour.
• c.Give a 500 mL fluid bolus and recheck the urine output in 2 hours.
• d.Increase the magnesium rate and turn the client onto her left side.

Magnesium sulfate labelling names the presence of the patellar reflex, respirations of about 16 or more per minute, and urine output of 100 mL every 4 hours as indicators of a safe regimen, and directs that an injectable calcium salt be immediately available to counteract magnesium intoxication. Continuing or increasing the infusion while reflexes are gone risks respiratory paralysis.

A client who received naloxone for respiratory depression after a dose of extended-release morphine is now awake with a respiratory rate of 16. Which action should the nurse take?

• a.Restart the morphine infusion at half of the previous rate.
• b.Give the next morphine dose now that the client is awake.
• c.Document the recovery and resume routine shift assessments.
• d.Keep monitoring, since the morphine may outlast the naloxone.✓

Naloxone labelling warns that the duration of action of most opioids may exceed that of naloxone, so respiratory and central nervous system depression can return after an initial improvement and the client needs continued surveillance and possibly repeat doses. Returning to routine assessments or redosing the opioid treats the improvement as permanent.

A postoperative client who received IV midazolam and IV hydromorphone is difficult to arouse with a respiratory rate of 7. Flumazenil is prescribed. Which understanding should guide the nurse's care?

• a.It reverses the hydromorphone and leaves the midazolam fully active.
• b.It reverses both drugs, so no other reversal agent is needed.
• c.It will work only after the hydromorphone has been fully metabolized.
• d.It reverses the midazolam but has no effect on the hydromorphone.✓

Flumazenil labelling states that it reverses the sedative effects of benzodiazepines and does not reverse the effects of opioids, so opioid-related respiratory depression persists and naloxone may still be required. Labelling also directs monitoring for resedation for up to 120 minutes after flumazenil is given.

Fifteen minutes into a transfusion of packed red blood cells, a client has shaking chills, flank pain, dark red urine, and a temperature that has risen from 37.6 C to 39.1 C. Which action should the nurse take first?

• a.Change the infusing solution to lactated Ringer's and continue the unit slowly.
• b.Stop the transfusion and keep the vein open with 0.9% sodium chloride through new tubing.✓
• c.Give the prescribed antipyretic and continue the transfusion at the ordered rate.
• d.Slow the transfusion to 50 mL per hour and recheck the temperature and pulse in 15 minutes.

When a transfusion reaction occurs the transfusion must be discontinued immediately; fresh tubing and 0.9% sodium chloride preserve venous access without delivering any more of the implicated unit, and these findings suggest an acute hemolytic reaction. Lactated Ringer's contains calcium and should not be infused through the same tubing as a citrated blood component.

An 82-year-old client with chronic anemia and heart failure receives 2 units of packed red blood cells over 2 hours. One hour later the client has dyspnea, crackles, jugular venous distention, blood pressure 178/96 mm Hg, and oxygen saturation 87%. Which complication do these findings most suggest?

• a.Transfusion-associated circulatory overload✓
• b.Acute hemolytic transfusion reaction
• c.Febrile nonhemolytic transfusion reaction
• d.Transfusion-related acute lung injury

Circulatory overload follows volumes or rates the heart cannot accommodate and shows hydrostatic pulmonary edema with hypertension and jugular venous distention, and the elderly and clients with chronic anemia or cardiac disease are at particular risk. Transfusion-related acute lung injury also causes hypoxemia within 6 hours but produces noncardiogenic edema with hypotension rather than the volume-overload picture described.

A nurse is 10 minutes into a client's first intravenous dose of a cephalosporin antibiotic. Which finding requires immediate intervention?

• a.A blood pressure of 126/78 and a pulse of 94
• b.Hoarseness and wheezing with swollen lips✓
• c.A small bruise where the catheter was inserted
• d.A dull headache that began before the infusion

Mucosal swelling together with airway findings such as hoarseness and wheezing minutes after a drug exposure meets the clinical criteria for anaphylaxis, so the infusion is stopped and intramuscular epinephrine, 0.3 to 0.5 mL of the 1:1,000 concentration into the mid-outer thigh, is given without delay; antihistamines are adjuncts whose benefit in anaphylaxis is unproven and they do not protect the airway. The other findings are unremarkable vital signs, a local mark at the insertion site, and a symptom that started before the drug was hung.

A client's continuous parenteral nutrition bag empties and the replacement bag is delayed in the pharmacy. For which complication should the nurse assess this client?

• a.Hypernatremia with dry mucous membranes
• b.Hypercalcemia with severe muscle weakness
• c.Hyperkalemia with peaked T waves on the ECG
• d.Hypoglycemia with diaphoresis and tremor✓

Sudden discontinuation of parenteral nutrition can lead to hypoglycemia, because circulating insulin remains high after the concentrated dextrose infusion stops. The nurse checks a capillary glucose, watches for diaphoresis and tremor, and obtains the replacement solution without delay.

A nurse enters the room of a client using an intravenous patient-controlled analgesia pump and finds the client's daughter pressing the demand button while the client sleeps. Which action should the nurse take?

• a.Stop the daughter and teach that only the client presses the button.✓
• b.Tell the daughter to press it once an hour through the overnight shift.
• c.Thank the daughter for helping the client stay ahead of the pain overnight.
• d.Ask the daughter to press it only when the client moans in pain.

Dosing by anyone other than the client removes the built-in safeguard that a sedated client cannot press the button, and this practice has been documented to cause respiratory depression. Teaching the family before and during therapy that only the client presses the button is the intervention; setting a schedule for the daughter keeps the hazard in place.

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.