Fundamentals of Nursing - 3

Question 1

A postoperative patient who received an IV opioid is difficult to arouse and has shallow respirations at 6/min. SpO2 is 97% while receiving oxygen at 2 L/min. Which interpretation should guide the nurse's immediate response?

Accepted Answer

Supplemental oxygen may mask hypoventilation; urgent respiratory support and help are needed.

Answer

The oxygen saturation confirms adequate ventilation, so routine monitoring can continue.

Answer

Slow breathing is expected after analgesia when the oxygen saturation remains normal.

Answer

The respiratory rate requires intervention only if oxygen saturation falls below 90%.

Question 2

A newly inserted nasogastric tube yields aspirate with a pH of 6.0. The patient takes a proton pump inhibitor. A colleague reports hearing a 'whoosh' during air insufflation. What should the nurse do before administering feed or medication?

Accepted Answer

Withhold tube use and obtain radiographic confirmation interpreted by a competent clinician.

Answer

Begin feeding because acid-suppressing medication explains the pH.

Answer

Flush the tube with water and repeat the air-auscultation test.

Answer

Accept the whoosh sound as confirmation of gastric placement.

Question 3

Over 6 hours, continuous bladder irrigation delivers 2400 mL of irrigation solution. The drainage bag collects 2850 mL. Assume all irrigation solution is recovered, with no leakage or retention. What is the patient's average hourly urine output after correcting for irrigation?

Accepted Answer

75 mL/hour

Answer

400 mL/hour

Answer

450 mL/hour

Answer

475 mL/hour

Question 4

An older patient with heart failure develops dyspnoea, bilateral crackles, raised jugular venous pressure and a blood pressure increase from 128/76 to 178/96 mmHg during a red-cell transfusion. Fluid balance is positive by 1800 mL. Which reaction is most consistent with these findings?

Accepted Answer

Transfusion-associated circulatory overload

Answer

Transfusion-related acute lung injury

Answer

Acute haemolytic transfusion reaction

Answer

Anaphylactic transfusion reaction

Question 5

A sacral pressure injury whose entire wound base is covered by slough should be documented as Stage 3 if no bone or tendon is visible.

Accepted Answer

False

Question 6

A patient still requires an indwelling urinary catheter. If the catheter and drainage tubing accidentally disconnect and the open connection becomes contaminated, both the catheter and collecting system should be replaced using aseptic technique.

Accepted Answer

True

Question 7

An adult is admitted with suspected infectious pulmonary tuberculosis while diagnostic results are pending. Which infection-control actions are appropriate? Select all that apply.

Accepted Answer

Answer

Wear a fit-tested N95 respirator or appropriate higher-level protection before room entry.

Answer

Place the patient in a positive-pressure protective-environment room.

Answer

Use an airborne infection isolation room with negative pressure and keep the door closed.

Answer

Use a surgical mask instead of a respirator for routine bedside nursing care.

Answer

Have the patient wear a surgical mask, if tolerated, during essential transport outside the room.

Answer

Use Standard Precautions alone until the sputum culture confirms tuberculosis.

Question 8

A patient with a confirmed gastric feeding tube has a prescribed fluid restriction and several enteral medications. Which administration practices are appropriate? Select all that apply.

Accepted Answer

Answer

Mix all medications into the feeding formula to reduce water use.

Answer

Check each medicine's formulation and suitability for administration through the tube.

Answer

Prepare and administer suitable medicines separately.

Answer

Crush all modified-release tablets if the powder is sufficiently diluted.

Answer

Flush before, between and after medicines using volumes agreed within the patient's fluid plan.

Answer

Omit all water flushes because the patient has a fluid restriction.

Question 9

An intubated adult has retained secretions requiring open endotracheal suctioning. Which practices are appropriate? Select all that apply.

Accepted Answer

Answer

Preoxygenate the patient before suctioning.

Answer

Routinely instil normal saline before every suctioning procedure.

Answer

Use sterile technique for open suctioning.

Answer

Limit each application of suction to no more than 15 seconds.

Answer

Choose a suction catheter that occupies approximately 80% of the endotracheal tube lumen.

Answer

Reserve deep suctioning for situations in which shallow suctioning is ineffective.

Question 10

An adult is unresponsive. Scene safety is confirmed, help is activated and a colleague is bringing an AED. No advanced airway is present. Assume assessment confirms cardiac arrest and the AED advises a shock. Arrange the actions.

Accepted Answer

Check breathing and carotid pulse simultaneously for no more than 10 seconds. -> Start CPR with 30 compressions followed by 2 breaths. -> When available, activate the AED and attach pads, minimizing interruptions to CPR. -> Clear the patient for rhythm analysis, then deliver the advised shock safely. -> Immediately resume CPR for 2 minutes, starting with compressions.

Fundamentals of Nursing - 3

A postoperative patient who received an IV opioid is difficult to arouse and has shallow respirations at 6/min. SpO2 is 97% while receiving oxygen at 2 L/min. Which interpretation should guide the nurse's immediate response?

A newly inserted nasogastric tube yields aspirate with a pH of 6.0. The patient takes a proton pump inhibitor. A colleague reports hearing a 'whoosh' during air insufflation. What should the nurse do before administering feed or medication?

Over 6 hours, continuous bladder irrigation delivers 2400 mL of irrigation solution. The drainage bag collects 2850 mL. Assume all irrigation solution is recovered, with no leakage or retention. What is the patient's average hourly urine output after correcting for irrigation?

An older patient with heart failure develops dyspnoea, bilateral crackles, raised jugular venous pressure and a blood pressure increase from 128/76 to 178/96 mmHg during a red-cell transfusion. Fluid balance is positive by 1800 mL. Which reaction is most consistent with these findings?

A sacral pressure injury whose entire wound base is covered by slough should be documented as Stage 3 if no bone or tendon is visible.

A patient still requires an indwelling urinary catheter. If the catheter and drainage tubing accidentally disconnect and the open connection becomes contaminated, both the catheter and collecting system should be replaced using aseptic technique.

An adult is admitted with suspected infectious pulmonary tuberculosis while diagnostic results are pending. Which infection-control actions are appropriate? Select all that apply.

A patient with a confirmed gastric feeding tube has a prescribed fluid restriction and several enteral medications. Which administration practices are appropriate? Select all that apply.

An intubated adult has retained secretions requiring open endotracheal suctioning. Which practices are appropriate? Select all that apply.

An adult is unresponsive. Scene safety is confirmed, help is activated and a colleague is bringing an AED. No advanced airway is present. Assume assessment confirms cardiac arrest and the AED advises a shock. Arrange the actions.

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