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NC1 SET 1

Total questions: 75

Worksheet time: 4hrs 13mins

Name
Class
Date
1.

A patient with severe kyphoscoliosis is breathless lying flat. The nurse elevates the head of bed to 45°. Which physiologic effect best explains the improvement?

a)

Increased functional residual capacity with better alveolar recruitment

b)

Decreased anatomic dead space with reduced tidal volume needs

c)

Reduced pulmonary capillary wedge pressure from venous pooling

d)

Immediate increase in hemoglobin-oxygen affinity at the alveolar level

2.

During septic shock, the nurse notes warm skin and bounding pulses early. Which hemodynamic change best explains this finding?

a)

Systemic vasodilation with decreased afterload and reflex tachycardia

b)

Primary myocardial depression with reduced stroke volume first

c)

Acute rise in venous return due to enhanced skeletal muscle pump

d)

Cerebral vasoconstriction with redistribution of cardiac output

3.

A post-op patient on opioids has RR 8/min and PaCO₂ 60 mmHg. Which medullary mechanism is most depressed?

a)

Ventilatory response to hypercapnia in the central chemoreceptors

b)

Peripheral chemoreceptor response to hypoxemia exclusively

c)

Stretch receptor reflex that terminates inspiration

d)

Voluntary respiratory control originating in the motor cortex

4.

While administering a 1 L NS bolus to a dehydrated adult, which vascular space expands first and most?

a)

Intracellular compartment volume predominantly

b)

Interstitial compartment with minimal change intravascularly

c)

Intravascular (plasma) compartment within the extracellular space

d)

Total body water with equal distribution across all spaces

5.

A client has SIADH from small-cell lung cancer. Which lab pattern is the most consistent?

a)

Serum osmolality high, urine osmolality low, sodium high

b)

Serum osmolality low, urine osmolality high, sodium low

c)

Serum osmolality normal, urine osmolality low, sodium high

d)

Serum osmolality high, urine osmolality high, sodium high

6.

During fast PRBC transfusion, the nurse monitors calcium. Which mechanism makes this physiologic check necessary?

a)

Citrate in stored blood chelates ionized calcium causing hypocalcemia

b)

Hemolysis of donor cells acutely increases serum calcium load

c)

Transfusion raises calcitonin secretion reducing bone resorption

d)

Transfusion lowers parathyroid hormone via volume expansion alone

7.

A runner becomes orthostatic when standing quickly after bed rest. Which immediate physiologic response prevents syncope in most people?

a)

Baroreceptor-mediated sympathetic activation increasing SVR

b)

Increased atrial natriuretic peptide to expand plasma volume

c)

Reduced chemoreceptor firing decreasing ventilation rate

d)

Coronary vasoconstriction to preserve aortic pressure

8.

A patient with COPD uses pursed-lip breathing. Which mechanic best explains reduced dyspnea?

a)

Raised small-airway pressure reduces premature airway collapse

b)

Lowered intrathoracic pressure draws air faster into alveoli

c)

Increased respiratory rate lowers dynamic hyperinflation

d)

Decreased expiratory time reduces gas trapping significantly

9.

The nurse pre-oxygenates for rapid sequence intubation. Which statement best describes the physiologic goal?

a)

Increase alveolar oxygen reservoir by denitrogenation to prolong safe apnea time

b)

Increase dissolved oxygen content to equal bound oxygen on hemoglobin

c)

Induce metabolic alkalosis to improve hemoglobin affinity for oxygen

d)

Reduce cardiac output temporarily to decrease oxygen consumption

10.

An older adult with heart failure develops pulmonary edema. Which mechanisms primarily cause fluid to accumulate in alveoli? Select all that apply.

a)

Increased hydrostatic pressure in pulmonary capillaries

b)

Impaired lymphatic clearance of interstitial fluid

c)

Reduced plasma oncotic pressure from hemoconcentration

d)

Increased capillary permeability from endothelial injury

e)

Decreased alveolar surfactant production lowering surface tension

11.

A client with acute hemorrhage has cool extremities and narrow pulse pressure. Which compensatory change sustains perfusion first?

a)

Peripheral vasoconstriction via sympathetic outflow

b)

Increased urinary sodium excretion to conserve water

c)

Decreased heart rate to lengthen diastolic filling

d)

Immediate rise in erythropoietin to increase oxygen carrying

12.

A patient has metabolic acidosis (pH 7.28, HCO₃⁻ 16). Which expected respiratory response is most accurate?

a)

Reduced tidal volume with normal rate to conserve CO₂

b)

Increased minute ventilation via hyperventilation to lower PaCO₂

c)

Periodic apnea to buffer renal acid excretion

d)

Bronchoconstriction to redirect airflow apically

13.

During isometric handgrip BP rises. Which cardiac variable increases predominantly to raise arterial pressure?

a)

Systemic vascular resistance as afterload rises

b)

End-diastolic volume with fall in afterload

c)

Stroke volume through enhanced venous return only

d)

Coronary flow reduction leading to reflex bradycardia

14.

A patient with hypothyroidism is cold-intolerant and bradycardic. Which primary physiologic deficit explains these signs?

a)

Decreased basal metabolic rate reducing heat production and cardiac output

b)

Increased adrenergic tone raising SVR and pulse pressure

c)

Excess glucocorticoid activity suppressing insulin secretion

d)

Elevated leptin levels enhancing thermogenesis

15.

The nurse evaluates renal autoregulation during hypotension. Which mechanism preserves GFR within limits?

a)

Afferent arteriolar dilation and efferent constriction via RAAS

b)

Systemic venodilation decreasing renal venous return

c)

Prostaglandin-mediated efferent dilation primarily

d)

Baroreflex-mediated tubular water secretion increase

16.

A patient with liver failure bruises easily. Which physiologic change is the best explanation?

a)

Platelet hyperactivity reduces clot formation under shear

b)

Reduced synthesis of clotting factors decreases coagulation

c)

Elevated fibrinogen increases fibrinolysis

d)

Increased vitamin K absorption decreases INR

17.

During prolonged immobility, the nurse plans DVT prophylaxis. Which physiologic risk is most increased?

a)

Venous stasis from reduced calf muscle pump activity

b)

Decreased clotting factors from hepatic suppression

c)

Hyperfibrinolysis from endothelial nitric oxide release

d)

Hypocoagulability from hemodilution in supine position

18.

A client on noninvasive ventilation shows improved oxygenation without higher FiO₂. Which mechanism explains the change?

a)

Recruitment of collapsed alveoli improving V/Q matching

b)

Suppression of hypoxic pulmonary vasoconstriction

c)

Increased physiologic shunt through non-ventilated units

d)

Reduced cardiac output causing lower oxygen extraction

19.

After a large meal, a patient on propranolol has postprandial hypotension. Which physiologic deficit contributes most?

a)

Blunted sympathetic response to splanchnic vasodilation

b)

Excess aldosterone causing inappropriate natriuresis

c)

Vasopressin surge producing mesenteric vasoconstriction

d)

Reactive hyperglycemia raising plasma oncotic pressure

20.

A patient with chronic kidney disease is anemic. Which mechanisms primarily account for this? Select all that apply.

a)

Decreased erythropoietin production by peritubular cells

b)

Increased iron absorption causing sideroblastic changes

c)

Uremic toxins shortening red cell lifespan

d)

Elevated hepcidin reducing iron availability

e)

Enhanced marrow response to hypoxia increasing reticulocytes

21.

A head-injured patient shows rising ICP. Which nursing measures reduce ICP without compromising cerebral perfusion? Select all that apply.

a)

Keep head midline with 30° elevation to promote venous outflow

b)

Avoid fever and treat pain to reduce cerebral metabolic demand

c)

Apply tight cervical collars to stabilize and compress jugulars

d)

Maintain PaCO₂ in normal-low-normal range; avoid sustained hypercapnia

e)

Aggressively hyperventilate to PaCO₂ <25 mmHg for many hours

22.

A patient with right heart failure has elevated JVP and hepatomegaly. Which venous pressure change is primary?

a)

Increased systemic venous pressure with impaired forward flow

b)

Decreased pulmonary capillary pressure with improved LV preload

c)

Reduced right atrial pressure from tricuspid competence

d)

Lowered mean systemic filling pressure improving venous return

23.

A post-op client is hypothermic at 35.0 °C. Which physiologic effect most increases oxygen demand during shivering?

a)

Involuntary skeletal muscle activity increasing metabolic rate

b)

Cutaneous vasodilation raising heat loss and O₂ use

c)

Decreased brown fat thermogenesis in adults

d)

Depression of thyroid axis increasing ATP consumption

24.

A patient receiving loop diuretics develops metabolic alkalosis and hypokalemia. Which renal mechanism is central?

a)

Reduced aldosterone leads to distal H⁺ excretion

b)

Volume contraction activates RAAS increasing distal H⁺ and K⁺ secretion

c)

Inhibited bicarbonate reabsorption in the proximal tubule

d)

Enhanced ammoniagenesis causing systemic acidosis

25.

A trauma patient loses 2 L blood rapidly. Before labs return, which change predicts earliest risk to organ perfusion?

a)

Fall in stroke volume with compensatory tachycardia reducing MAP

b)

Increase in plasma oncotic pressure maintaining capillary refill

c)

Immediate rise in hematocrit from splenic contraction

d)

Sustained urine output due to medullary concentrating power

26.

An older adult with orthostatic hypotension stands and becomes dizzy. Which immediate physiologic change most limits cerebral perfusion in this patient?

a)

Impaired baroreflex-mediated rise in sympathetic tone

b)

Excess atrial natriuretic peptide release on standing

c)

Sudden increase in plasma oncotic pressure with leg pooling

d)

Rapid reduction in arterial oxygen content at the lung

27.

A COPD patient develops acute hypercapnia during a sedated procedure. Which brain region's chemosensitivity is most responsible for the ventilatory drive to CO₂?

a)

Medullary central chemoreceptors sensing CSF pH change

b)

Carotid body glomus cells detecting dissolved oxygen

c)

Pontine pneumotaxic center timing inspiratory off-switch

d)

Cerebral cortex voluntary motor output to diaphragm

28.

A nurse titrates PEEP on a ventilator. Which primary physiologic benefit explains improved oxygenation at constant FiO₂?

a)

Alveolar recruitment that reduces intrapulmonary shunt

b)

Increased anatomic dead space in conducting airways

c)

Reflex bronchoconstriction that redirects flow apically

d)

Decreased venous return that lowers oxygen demand

29.

A trauma patient with hemorrhagic shock has cold, clammy skin. Which neurohormonal mechanism dominates early?

a)

Catecholamine-driven α₁-mediated cutaneous vasoconstriction

b)

Vasopressin-mediated mesenteric vasodilation predominance

c)

Nitric oxide-mediated systemic vasodilation predominance

d)

Insulin surge increasing skeletal muscle blood flow

30.

A patient on high-dose loop diuretics is alkalemic and weak. Which renal and hormonal mechanisms jointly sustain metabolic alkalosis? Select all that apply.

a)

Volume contraction activating RAAS with distal H⁺/K⁺ secretion

b)

Chloride depletion impairing bicarbonate excretion

c)

Increased proximal bicarbonate secretion into tubular lumen

d)

Hypokalemia shifting H⁺ into cells and raising plasma HCO₃⁻

e)

Suppressed aldosterone decreasing distal acid secretion

31.

A patient with acute pancreatitis is NPO and on large-volume IV fluids. Serum calcium drops. Which mechanism best explains the hypocalcemia?

a)

Fat saponification binding ionized calcium in necrotic tissue

b)

Parathyroid hormone overproduction causing renal losses

c)

Calcitonin surge shifting calcium into bone rapidly

d)

Albumin rise reducing total but not ionized calcium

32.

A septic patient is tachypneic with PaO₂ 65 on 60% FiO₂. Which measure most directly reflects impaired oxygen diffusion at the alveolar-capillary membrane?

a)

A-a oxygen gradient widened beyond age-adjusted normal

b)

Mixed venous oxygen saturation elevation from low extraction

c)

PaCO₂ decrease due to hyperventilation from acidosis

d)

Hemoglobin concentration drifting downward with fluids

33.

A nurse evaluates Starling forces in a client with cirrhosis and edema. Which change most strongly favors fluid movement into interstitium?

a)

Low plasma oncotic pressure from hypoalbuminemia

b)

High lymphatic pumping rate in dependent tissues

c)

Increased interstitial hydrostatic pressure with compression

d)

Reduced capillary permeability from endothelial repair

34.

A patient with diabetic ketoacidosis is rapidly hyperventilating. Which arterial blood gas pattern is expected before treatment?

a)

Low pH, low HCO₃⁻, and low PaCO₂

b)

High pH, high HCO₃⁻, and low PaCO₂

c)

Low pH, high HCO₃⁻, and high PaCO₂

d)

Normal pH with low HCO₃⁻, compensated by low PaCO₂

35.

A head-injured patient requires ICP control. Which nursing position best optimizes venous outflow without compromising CPP?

a)

Head midline, HOB ~30°, no neck flexion

b)

Flat supine with pillows under neck to elevate chin

c)

Reverse Trendelenburg 60° with tight cervical collar

d)

High Fowler 90° to maximize gravitational drainage

36.

A sodium level of 118 mEq/L developed gradually over weeks. The patient is awake and asymptomatic. Which safe correction strategies apply? Select all that apply.

a)

Hypertonic saline reserved for severe symptoms or seizures

b)

Limit correction to ≤8-10 mEq/L in 24 hours to avoid ODS

c)

Treat underlying cause and consider careful fluid restriction if appropriate

d)

Rapid normalization to 135 mEq/L within 6 hours to restore tone

e)

Desmopressin is always contraindicated during correction

37.

In myasthenia gravis, which physiological defect at the neuromuscular junction causes fatigable weakness?

a)

Reduced functional acetylcholine receptors on the postsynaptic membrane

b)

Excess acetylcholine release from presynaptic terminals

c)

Increased acetylcholinesterase activity in synaptic cleft

d)

Sodium channel inactivation along the entire motor axon

38.

A patient with carbon monoxide exposure is pink but hypoxic. Which physiologic principle explains low oxygen delivery?

a)

Carboxyhemoglobin reduces O₂-carrying capacity and shifts the dissociation curve left

b)

CO increases dissolved oxygen content sufficiently

c)

CO produces methemoglobin that releases oxygen readily

d)

CO raises PaO₂ above normal by improving diffusion

39.

A nurse notes Kussmaul respirations in uremia. Which purpose does this pattern primarily serve?

a)

Augment CO₂ elimination to compensate metabolic acidosis

b)

Decrease oxygen delivery to slow tissue metabolism

c)

Increase intrathoracic pressure to improve venous return

d)

Prevent atelectasis through reflex bronchoconstriction

40.

A patient on mechanical ventilation develops auto-PEEP (dynamic hyperinflation). Which adjustments most directly reduce auto-PEEP? Select all that apply.

a)

Lower respiratory rate to allow longer expiratory time

b)

Reduce tidal volume and inspiratory time to shorten inspiration

c)

Increase external PEEP far above measured auto-PEEP

d)

Treat airflow obstruction and suction secretions as indicated

e)

Raise inspiratory flow to lengthen inspiratory time

41.

After a large protein meal, a patient with normal physiology demonstrates increased thermogenesis. Which mechanism accounts for this postprandial rise?

a)

Specific dynamic action increasing metabolic rate for substrate processing

b)

Enhanced brown adipose tissue activity in all adults

c)

Immediate thyroid hormone surge from intestinal absorption

d)

Rapid sympathetic withdrawal increasing heat production

42.

A patient with metabolic alkalosis from prolonged vomiting arrives hypotensive. Which physiologic steps correct the alkalosis? Select all that apply.

a)

Isotonic saline to restore volume and chloride for renal HCO₃⁻ excretion

b)

Potassium repletion to reduce renal ammoniagenesis and H⁺ loss

c)

Hyperventilation to raise PaCO₂ and increase pH further

d)

Loop diuretics to accelerate distal hydrogen loss

e)

Acetazolamide despite volume depletion

43.

During exercise, what change most increases oxygen extraction by active skeletal muscle?

a)

Rightward shift of the oxyhemoglobin curve from ↑CO₂/↑H⁺/↑temperature

b)

Leftward shift of the curve improving arterial saturation

c)

Decreased capillary surface area for diffusion

d)

Reduced 2,3-BPG concentration in red blood cells

44.

A patient with Addison disease presents with orthostasis and hyperkalemia. Which hormone deficiency explains both?

a)

Aldosterone deficiency causing salt wasting and ↓K⁺ excretion

b)

Excess cortisol causing renal vasoconstriction

c)

Elevated catecholamines increasing K⁺ uptake

d)

Thyroxine deficiency reducing Na⁺ reabsorption

45.

A patient with acute hypocalcemia after thyroid surgery is numb around the lips and has carpopedal spasm. Which membrane change explains tetany?

a)

Lowered threshold potential increases neuronal excitability

b)

Hyperpolarized resting potential blocks repetitive firing

c)

Inhibited sodium channels reducing depolarization speed

d)

Increased chloride conductance stabilizing membranes

46.

A client with ARDS has refractory hypoxemia. Which ventilatory strategies improve oxygenation safely? Select all that apply.

a)

Higher PEEP to recruit alveoli with cautious hemodynamic monitoring

b)

Low tidal volume ventilation to limit volutrauma

c)

Routine respiratory alkalosis to PaCO₂ <25 mmHg for hours

d)

Prone positioning to enhance V/Q matching

e)

Rapid fluid boluses to raise pulmonary capillary hydrostatic pressure

47.

A patient with right mainstem bronchus intubation suddenly shows left-sided absent breath sounds and hypoxemia. Which physiology explains the desaturation?

a)

Shunt from nonventilated left lung with ongoing perfusion

b)

Dead space from perfused right lung without ventilation

c)

Enhanced diffusion capacity from unilateral ventilation

d)

Alveolar hyperventilation raising PaO₂ in the left lung

48.

A client with liver failure has ascites and low serum sodium. Which primary mechanism explains the hyponatremia?

a)

Non-osmotic vasopressin release due to effective arterial volume depletion

b)

Renal resistance to vasopressin causing free-water loss

c)

Increased distal sodium delivery with osmotic diuresis

d)

Hypothalamic suppression of thirst from cytokines

49.

A patient on propofol infusion develops hypotension. Which physiologic effects of propofol contribute? Select all that apply.

a)

Arterial and venous vasodilation reducing preload and afterload

b)

Myocardial depressant effects lowering stroke volume

c)

Increased sympathetic tone raising systemic resistance

d)

Cerebral vasoconstriction increasing mean arterial pressure

e)

Strong mineralocorticoid effect expanding plasma volume

50.

During fever, which hypothalamic change drives the observed rise in core temperature?

a)

Set-point elevation in the preoptic area mediated by prostaglandin E₂

b)

Direct muscle stimulation without neural mediation

c)

Peripheral vasodilation to conserve metabolic heat

d)

Sudden pituitary ACTH suppression lowering heat loss

51.

You receive handoff for four clients at shift start. Which client should the nurse assess first?

a)

Post-op day 1 with controlled pain who requests a shower after breakfast

b)

New admission with COPD who is drowsy and has SpO₂ 89% on 2 L/min

c)

Stable heart failure client asking about low-sodium meal options

d)

Post-fall client with normal

52.

New admission with COPD who is drowsy and has SpO₂ 89% on 2 L/min. What is the safest action?

a)

Infuse by gravity with the roller clamp fully open

b)

Use an infusion pump and follow max rate policy with cardiac monitoring

c)

Mix with IV push saline to expedite correction

d)

Hang piggyback above a maintenance bag and titrate by symptoms

53.

A client with advanced COPD is short of breath at rest and anxious. Which initial positioning is best?

a)

High Fowler's with arms supported on overbed table for accessory use

b)

Flat supine with a single thin pillow under the head

c)

Side-lying with legs elevated to 30 degrees

d)

Trendelenburg position to increase diaphragmatic excursion

54.

The nurse prepares to insert a nasogastric tube in a lethargic stroke client with impaired gag. Which immediate priority will reduce aspiration risk?

a)

Place client in right lateral position with head neutral

b)

Verify gag and cough; request x-ray confirmation after placement

c)

Ask client to drink water with straw during insertion

d)

Lubricate tube and aim posteriorly while client is supine

55.

A client receiving morphine PCA is difficult to arouse, RR 8/min, SpO₂ 88% on room air. What should the nurse do first?

a)

Stop the PCA, stimulate, provide oxygen, and prepare naloxone per protocol

b)

Document findings and reassess in thirty minutes

c)

Ask the family to hold the handset and observe closely

d)

Increase IV fluids to enhance drug metabolism

56.

You're precepting a new nurse on high-alert medication safety. Which actions are required before administering IV insulin on a med-surg unit? Select all that apply.

a)

Use a programmable infusion device with guardrails enabled

b)

Perform an independent double-check of drug, dose, and concentration

c)

Prepare insulin in a non-labeled syringe to avoid delays

d)

Confirm the most recent capillary glucose with a time stamp

e)

Prime the tubing with heparinized saline to prevent clotting

57.

Your client with a chest tube to water-seal has continuous bubbling in the water-seal chamber. What is the best initial action?

a)

Clamp the tube and leave it clamped for one hour

b)

Inspect system for air leaks from connections to client

c)

Raise the collection chamber to chest level to reduce flow

d)

Add sterile water to suction control chamber to stop bubbling

58.

A client with Clostridioides difficile infection is incontinent. Which PPE and isolation are appropriate during in-room care and linen handling?

a)

Surgical mask and eye shield; airborne isolation

b)

Gown and gloves for all contact; dedicated equipment; soap-and-water hand hygiene

c)

N95 respirator; negative pressure room

d)

Gloves only; alcohol sanitizer preferred after doffing

59.

A client admitted for DVT refuses subcutaneous heparin for VTE prophylaxis, stating, "I only want pills." What is the nurse's best first response?

a)

Explore concerns, teach risk/benefit, and collaborate on acceptable options

b)

Document refusal and stop offering the medication

c)

Request a sitter to convince the client to accept injections

d)

Threaten discharge against medical advice if refusal continues

60.

A new graduate prepares to insert a urinary catheter in a female client. Which steps maintain sterile technique? Select all that apply.

a)

Place the kit on a clean, dry surface and open away then toward self

b)

Use non-dominant hand to separate labia and keep that hand "contaminated"

c)

Advance catheter until urine flows, then a bit further before inflating balloon

d)

Drape sterile field, then reposition client without changing gloves

e)

Inflate balloon if resistance is felt before urine appears

61.

You must prioritize fall prevention for a post-op older adult who insists on walking to the bathroom alone. Which nursing action is most effective?

a)

Raise all side rails and apply soft wrist restraints

b)

Offer a scheduled rounding plan with timely toileting and a gait belt

c)

Turn off bed alarm to reduce noise and confusion

d)

Dim lights at night to promote uninterrupted sleep

62.

A nurse documents "client noncompliant with diet" after a brief teaching session. Which documentation is most appropriate instead?

a)

"Client refused instructions and will likely continue current diet."

b)

"Client stated cost concerns; verbalized understanding but cannot purchase recommended foods."

c)

"Client unwilling; teach-back not necessary due to time."

d)

"Client argumentative and difficult to educate."

63.

Which actions are required before blood transfusion initiation? Select all that apply.

a)

Verify order, consent, and compatibility with a second qualified verifier

b)

Assess baseline vitals and lung sounds before hanging blood

c)

Spike the unit and start before returning from the bedside check

d)

Use appropriate filter tubing and start slowly while observing

e)

Hang with lactated Ringer's to reduce viscosity

64.

A client receiving enteral tube feeding via pump has sudden coughing and drop in SpO₂. What is the priority nursing action?

a)

Stop the feeding, assess airway and tube position, and place on lateral side

b)

Increase the rate to shorten feeding time and reduce aspiration risk

c)

Add thickener to the formula and continue the current rate

d)

Flush the tube with 100 mL water to clear any obstruction

65.

You must delegate one task to an experienced UAP on a busy unit. Which assignment is appropriate?

a)

Ambulate a stable post-op client with a gait belt and report fatigue

b)

Teach use of an incentive spirometer after abdominal surgery

c)

Assess pain level before and after PRN analgesia

d)

Adjust oxygen flow to maintain target saturation

66.

You prepare to give oral digoxin to a heart failure client with apical pulse 50/min and new nausea. What is the best action?

a)

Administer as scheduled and document the slow pulse

b)

Hold the dose, assess ECG and electrolytes, and notify provider

c)

Give double dose later if pulse returns above 60

d)

Provide ginger ale and recheck pulse in 6 hours

67.

A client with dementia becomes agitated during morning care and strikes out. Which initial approach is most effective?

a)

Pause the task, reduce stimuli, use calm validation, and try again with one-step cues

b)

Continue quickly to finish before agitation escalates

c)

Apply restraints to complete morning hygiene safely

d)

Turn on bright lights and reorient loudly to time and place

68.

A nurse is teaching a family home oxygen safety. Which statements are correct? Select all that apply.

a)

Keep oxygen at least 3 meters from open flames and heat sources

b)

Use water-based lubricants; avoid petroleum products near cannula

c)

Secure cylinders upright and check for kinks and leaks routinely

d)

Store tanks in closets under bedding to prevent theft

e)

Smoke only in well-ventilated areas away from the concentrator

69.

A client on contact precautions asks, "Why are you washing with soap and water instead of sanitizer?" The best response is:

a)

Alcohol irritates my skin less than soap in this case

b)

"Soap and water remove C. difficile spores better than sanitizer."

c)

Our unit requires soap after any patient contact

d)

It is more professional to use soap during outbreaks

70.

While hanging enteral meds via a feeding tube, which step prevents drug-formula interactions?

a)

Stop feed, flush, give one medication at a time, and flush between each

b)

Mix all crushed meds with formula to mask taste

c)

Add extended-release capsules to warm formula

d)

Resume feeding concurrently to maintain continuous flow

71.

A client with a large sacral pressure injury needs a dressing change. Which analgesic timing is most appropriate?

a)

Administer ordered analgesic 30 minutes before the procedure

b)

Give analgesic after assessment to evaluate baseline pain

c)

Reserve analgesics for the wound packing step only

d)

Avoid analgesics to maintain accurate pain scores

72.

A nurse is preparing for sterile wound irrigation at the bedside. Which steps maintain asepsis? Select all that apply.

a)

Position a waterproof pad and mask/eye protection for splash

b)

Pour sterile solution without touching the bottle tip to the field

c)

Irrigate from least contaminated to most contaminated area

d)

Use tap water in a clean syringe for deep tunneling wounds

e)

Reuse the sterile basin if only you touched it previously

73.

A post-op client reports 10/10 pain 20 minutes after IV morphine. Vitals: BP 124/78, HR 86, RR 16, SpO₂ 97%. Best next action?

a)

Validate pain, reassess surgical site and PCA history, and consider multimodal adjuncts per orders

b)

Administer additional morphine IV without reassessment

c)

Withhold all analgesics to avoid respiratory depression

d)

Tell the client to use guided imagery instead of medication

74.

During SBAR handoff, which content reflects effective “Assessment”?

a)

“BP 90/58 after standing; likely orthostatic hypotension from diuretics.”

b)

“Admitted yesterday; spouse at bedside and very supportive.”

c)

“Please see orders from cardiology and pharmacy today.”

d)

“I think she might be depressed from her diagnosis.”

75.

The nurse prepares to administer rapid-acting insulin for a client who just received a covered tray. Which safety check is most critical before giving the dose?

a)

Confirm that the client is alert and ready to begin eating now

b)

Verify the client’s last bowel movement within 24 hours

c)

Ask whether the client prefers warm or cold meals

d)

Reweigh the client to confirm the dose per kilogram