(2nd Set)Exam#2 from topics sent by Letecia, Nclex style(KLM)

1. A nurse is caring for a patient receiving a peripheral IV infusion of Vancomycin. During the infusion, the patient reports intense burning and pain at the site. Upon assessment, the nurse notes severe erythema, edema extending 3 inches proximal to the insertion site, and a palpable venous cord. Which action should the nurse take FIRST?
   A) Apply a cold compress to the site and slow the Vancomycin infusion rate by 50%.
   B) Stop the infusion immediately, disconnect the IV tubing, and elevate the extremity.
   C) Flush the IV catheter with 10 mL of 0.9% Normal Saline to test catheter patency.
   D) Administer a prescribed IV antihistamine and re-evaluate the site in 15 minutes.

CORRECT ANSWER: B) Stop the infusion immediately, disconnect the IV tubing, and elevate the extremity.

RATIONALE: The patient is exhibiting signs of Grade 3-4 phlebitis/vesicant irritation (erythema, edema, palpable venous cord). The immediate priority nursing action for any IV complication involving pain, swelling, or phlebitis is to STOP the infusion immediately to prevent further tissue damage, disconnect the tubing, remove the catheter, and elevate the limb.

2. A prescriber orders Diltiazem 15 mg IV push over 2 minutes for a patient with rapid atrial fibrillation. Diltiazem is supplied in a vial labeled 5 mg/mL. The nurse uses a 3 mL syringe. How many mL should the nurse administer every 15 seconds to ensure correct administration speed?
   A) 0.375 mL every 15 seconds
   B) 0.75 mL every 15 seconds
   C) 1.5 mL every 15 seconds
   D) 0.5 mL every 15 seconds

CORRECT ANSWER: A) 0.375 mL every 15 seconds

RATIONALE: First calculate total volume: 15 mg / (5 mg/mL) = 3 mL total dose. Over 2 minutes (120 seconds), there are 8 intervals of 15 seconds (120 / 15 = 8). Divide total volume by intervals: 3 mL / 8 = 0.375 mL every 15 seconds.

3. A nurse prepares to administer IV Morphine 4 mg to a patient in severe pain. Morphine is available in a prefilled tubex syringe containing 10 mg/mL. After preparing the 4 mg (0.4 mL) dose, what is the mandatory protocol for disposing of the remaining 6 mg (0.6 mL)?
   A) Save the remaining 0.6 mL in the medication room lockbox for the patient's next scheduled dose.
   B) Expel the remaining 0.6 mL into the sharps container individually and document the waste later at shift change.
   C) Waste the 0.6 mL into an approved waste receptacle in the presence of a second licensed nurse who co-signs the eMAR.
   D) Flush the remaining 0.6 mL down the clinical sink while the charge nurse observes from the doorway.

CORRECT ANSWER: C) Waste the 0.6 mL into an approved waste receptacle in the presence of a second licensed nurse who co-signs the eMAR.

RATIONALE: Controlled substances (like Morphine) require a physical second-nurse witness during the immediate wasting process prior to administration, with both nurses verifying the amount wasted and co-signing the electronic record.

4. A pediatric patient weighing 33 lb is prescribed Cefdinir 14 mg/kg/day PO divided into two equal doses every 12 hours. Cefdinir oral suspension is supplied as 125 mg/5 mL. How many mL should the nurse administer per dose?
   A) 2.1 mL
   B) 4.2 mL
   C) 8.4 mL
   D) 10.5 mL

CORRECT ANSWER: B) 4.2 mL

RATIONALE: Step 1: Convert weight to kg: 33 lb / 2.2 = 15 kg. Step 2: Calculate total daily dose: 15 kg * 14 mg/kg = 210 mg/day. Step 3: Divide into 2 doses: 210 mg / 2 = 105 mg per dose. Step 4: Calculate volume: (105 mg / 125 mg) * 5 mL = 0.84 * 5 = 4.2 mL per dose.

5. A patient with severe heart failure is ordered 1,000 mL of D5W with 20 mEq KCl to infuse IV over 8 hours. The gravity tubing drop factor is 20 gtt/mL. After 4 hours, the nurse notes that only 300 mL has infused due to an positional kink. What is the nurse's MOST appropriate action?
   A) Recalculate the drip rate for the remaining 700 mL to infuse over the remaining 4 hours and monitor closely.
   B) Increase the infusion rate to double the original drip rate for 2 hours to catch up the fluid deficit.
   C) Recalculate the drip rate based on the prescriber's original 8-hour order parameters and notify the provider of the delay.
   D) Bolus 200 mL rapidly by opening the roller clamp completely, then return to the original rate.

CORRECT ANSWER: C) Recalculate the drip rate based on the prescriber's original 8-hour order parameters and notify the provider of the delay.

RATIONALE: Never 'catch up' IV fluids—especially solutions containing potassium or administered to heart failure patients—due to the risk of fluid overload and lethal hyperkalemia. The nurse unkinks the line, recalculates the safe rate based on orders/policy, and notifies the prescriber.

6. While assessing a patient's peripheral IV site during a continuous infusion of Normal Saline at 125 mL/hr, the nurse notes the skin surrounding the catheter is pale, cool to the touch, and taut with 2+ pitting edema. The patient reports a feeling of tightness. Which complication has occurred?
   A) Phlebitis
   B) Infiltration
   C) Extravasation
   D) Venous thrombosis

CORRECT ANSWER: B) Infiltration

RATIONALE: Infiltration is the inadvertent administration of a non-vesicant solution into surrounding subcutaneous tissue, characterized by pale, cool, taut skin and swelling/edema. (Extravasation involves vesicants causing tissue necrosis; phlebitis is warm, red, and tender).

7. A nurse receives a verbal order over the phone from a physician for an immediate IV dose of Furosemide 40 mg for a patient in acute pulmonary edema. Which action by the nurse strictly complies with Joint Commission safety standards?
   A) Administer the medication immediately and request the physician sign the order within 24 hours.
   B) Write down the order, read back the complete order verbatim to the physician, and receive verbal confirmation.
   C) Repeat the order mentally, pull the medication from the automated dispenser, and reconfirm after administration.
   D) Refuse to accept the verbal order and insist the physician log into the electronic health record to enter it first.

CORRECT ANSWER: B) Write down the order, read back the complete order verbatim to the physician, and receive verbal confirmation.

RATIONALE: For emergency verbal orders, the nurse must execute the mandatory 'Write Down, Read Back, and Confirm' process prior to administration to prevent critical communication errors.

8. A nurse is reviewing a prescriber's handwritten medication orders. Which order is written using correct Joint Commission safety standards and does NOT contain an unapproved abbreviation?
   A) Lorazepam .5 mg PO at bedtime as needed for anxiety
   B) Levothyroxine 50.0 mcg PO every morning before breakfast
   C) Regular Insulin 6 U SC before meals
   D) Enoxaparin 40 mg SC daily at 0900

CORRECT ANSWER: D) Enoxaparin 40 mg SC daily at 0900

RATIONALE: Option D uses safe notation. Option A lacks a leading zero ('.5 mg' should be '0.5 mg'); Option B contains a trailing zero ('50.0 mcg' should be '50 mcg'); Option C uses 'U' which is on the Do Not Use list (must write 'units').

9. A patient is prescribed Potassium Chloride 20 mEq in 100 mL Normal Saline IVPB over 1 hour. The patient's serum potassium level is 3.1 mEq/L. Which administration method is STRICTLY CONTRAINDICATED?
   A) Administering the IVPB via an electronic volumetric infusion pump.
   B) Administering the IVPB via rapid IV push injection using a 10 mL syringe.
   C) Assessing the peripheral IV site for phlebitis prior to initiating the infusion.
   D) Monitoring cardiac rhythm via continuous telemetry during the infusion.

CORRECT ANSWER: B) Administering the IVPB via rapid IV push injection using a 10 mL syringe.

RATIONALE: IV Potassium Chloride MUST NEVER be given as an IV push or bolus, as rapid IV administration causes fatal cardiac arrest. It must always be diluted and infused slowly via an infusion pump.

10. A nurse is assessing an IV catheter site and suspects Speed Shock. Which clinical manifestations support this judgment?
    A) Sudden severe headache, flushing of the face, tightness in the chest, rapid irregular pulse, and severe hypotension.
    B) Sudden dyspnea, cyanosis, hypotension, weak rapid pulse, and a loud churning heart murmur.
    C) Erythema along the vein pathway, purulent drainage at the insertion site, and low-grade fever.
    D) Localized blanching, cool skin temperature, severe tissue sloughing, and absent distal pulse.

CORRECT ANSWER: A) Sudden severe headache, flushing of the face, tightness in the chest, rapid irregular pulse, and severe hypotension.

RATIONALE: Speed shock is a systemic reaction occurring when a substance is injected into the circulatory system too rapidly. Symptoms include facial flushing, severe pounding headache, chest tightness, irregular pulse, syncope, and shock.

11. A nurse is preparing to administer an IV piggyback antibiotic. The patient has a primary continuous IV of 0.9% Normal Saline infusing at 75 mL/hr. When setting up the secondary piggyback set using gravity tubing, how should the nurse position the IV bags?
    A) Hang the secondary IVPB bag lower than the primary IV bag using an extension hook.
    B) Hang the secondary IVPB bag higher than the primary IV bag using an extension hook on the primary bag.
    C) Position both the primary bag and secondary IVPB bag at the exact same height on the IV pole.
    D) Disconnect the primary IV tubing completely and connect the secondary IVPB directly to the saline lock.

CORRECT ANSWER: B) Hang the secondary IVPB bag higher than the primary IV bag using an extension hook on the primary bag.

RATIONALE: To infuse a secondary IVPB by gravity, the secondary bag must be hung HIGHER than the primary bag so that hydrostatic pressure closes the back-check valve on the primary line until the secondary bag empties.

12. An adult patient with severe dehydration is ordered 1.5 L of 0.9% Normal Saline IV to infuse over 10 hours. At what hourly rate should the nurse program the infusion pump?
    A) 75 mL/hr
    B) 100 mL/hr
    C) 150 mL/hr
    D) 200 mL/hr

CORRECT ANSWER: C) 150 mL/hr

RATIONALE: Convert 1.5 Liters to mL: 1.5 L * 1,000 mL/L = 1,500 mL. Divide total volume by total hours: 1,500 mL / 10 hours = 150 mL/hr.

13. A patient refuses a scheduled dose of IV Antihypertensive medication, stating, 'That pill makes me feel too dizzy and lightheaded.' What is the nurse's MOST appropriate initial action?
    A) Inform the patient that skipping the dose will cause a stroke and insist they take it.
    B) Respect the refusal, document the refusal immediately, and discard the drawn-up medication.
    C) Assess the patient's current blood pressure and pulse, provide education on the drug, and explore their concerns.
    D) Hide the medication in the patient's IV flush solution so they receive it without experiencing anxiety.

CORRECT ANSWER: C) Assess the patient's current blood pressure and pulse, provide education on the drug, and explore their concerns.

RATIONALE: When a patient refuses medication, the nurse's initial responsibility is to assess the patient's vital signs and clinical status, explore the reasons for refusal, and provide education while upholding the patient's right to refuse.

14. A nurse is preparing an IV infusion of Metronidazole. The drug guide recommends administering 500 mg in 100 mL over 60 minutes. The microdrip tubing has a drop factor of 60 gtt/mL. What drip rate in gtt/min should be set?
    A) 60 gtt/min
    B) 100 gtt/min
    C) 30 gtt/min
    D) 120 gtt/min

CORRECT ANSWER: B) 100 gtt/min

RATIONALE: Drip rate formula: (Volume in mL / Time in minutes) * Drop Factor = (100 mL / 60 min) * 60 gtt/mL = 100 gtt/min. (Note: with microdrip 60 gtt/mL, gtt/min always equals mL/hr).

15. The nurse is inspecting a patient's central venous access device (CVAD) site and notes sudden severe respiratory distress, chest pain, hypotension, and a loud churning murmur over the precordium. The nurse suspects an Air Embolism. In what position should the nurse IMMEDIATELY place the patient?
    A) High Fowler's position with legs dependent.
    B) Trendelenburg position on the left side (left lateral Trendelenburg).
    C) Prone position with head turned to the right.
    D) Supine position with feet elevated 45 degrees.

CORRECT ANSWER: B) Trendelenburg position on the left side (left lateral Trendelenburg).

RATIONALE: For an air embolism, immediately place the patient in Left Lateral Trendelenburg position. This traps the air bubble in the apex of the right ventricle, preventing it from entering the pulmonary artery.

16. A nurse is flushing an intermittent peripheral venous catheter (saline lock) using the SAS (Saline-Administer-Saline) technique. What is the primary purpose of the SECOND saline flush after medication administration?
    A) To dilute the systemic blood concentration of the drug.
    B) To clear any remaining medication from the catheter lumen into the vein and maintain catheter patency.
    C) To anesthetize the vein lumen against vasospasm.
    D) To increase fluid volume in the vascular space.

CORRECT ANSWER: B) To clear any remaining medication from the catheter lumen into the vein and maintain catheter patency.

RATIONALE: The post-medication saline flush clears all residual drug from the dead space of the catheter lumen into the bloodstream and prevents clot formation or drug precipitation.

17. An adult patient is ordered Acetaminophen 1 g PO q6h PRN for fever > 101°F. The patient has received three doses in the past 18 hours and now requests another dose. The nurse notes the patient also received two combination hydrocodone/acetaminophen (5/325 mg) tablets 4 hours ago. What is the nurse's priority action?
    A) Administer the 1 g Acetaminophen as requested since it is within the 6-hour interval.
    B) Calculate total 24-hour acetaminophen intake to ensure it does not exceed the maximum 4,000 mg (4 g) daily limit.
    C) Substitute Aspirin 650 mg for the requested dose without contacting the prescriber.
    D) Administer half the dose (500 mg) to prevent hepatic toxicity.

CORRECT ANSWER: B) Calculate total 24-hour acetaminophen intake to ensure it does not exceed the maximum 4,000 mg (4 g) daily limit.

RATIONALE: Acetaminophen has a strict maximum daily dose limit (4,000 mg / 24 hr for adults; often 3,000 mg in clinical guidelines) to prevent severe hepatotoxicity. The nurse must sum all sources (including combo opioids).

18. A nurse is calculating dosage for a patient ordered 0.125 mg of Digoxin PO daily. Digoxin is available in scored tablets labeled 250 mcg per tablet. How many tablets should the nurse administer?
    A) 0.5 tablet
    B) 1 tablet
    C) 1.5 tablets
    D) 2 tablets

CORRECT ANSWER: A) 0.5 tablet

RATIONALE: Convert 0.125 mg to mcg: 0.125 mg * 1,000 mcg/mg = 125 mcg. Calculate tablets: Desired / Have = 125 mcg / 250 mcg = 0.5 tablet.

19. A nurse is preparing to flush a peripherally inserted central catheter (PICC). Which syringe size MUST the nurse use to flush the line safely and prevent catheter rupture?
    A) 1 mL tuberculin syringe
    B) 3 mL luer-lock syringe
    C) 5 mL standard syringe
    D) 10 mL or larger barrel syringe

CORRECT ANSWER: D) 10 mL or larger barrel syringe

RATIONALE: Smaller syringes (1, 3, or 5 mL) generate excessively high injection pressure (PSI) that can rupture central line lumen walls. Always use a 10 mL or larger syringe for flushing central venous catheters.

20. Which patient action or statement indicates an understanding of Patient Rights regarding prescribed IV therapy?
    A) 'I know I cannot refuse this IV antibiotic because my doctor wrote a legal order for it.'
    B) 'I have the right to know what medication is in this IV bag, its intended purpose, and potential side effects before it infuses.'
    C) 'If I disagree with taking this medication, the nurse can give it to me while I am sleeping.'
    D) 'Patient rights only apply to oral medications, not intravenous fluids or blood products.'

CORRECT ANSWER: B) 'I have the right to know what medication is in this IV bag, its intended purpose, and potential side effects before it infuses.'

RATIONALE: Patient rights mandate informed consent/refusal and the Right to Education regarding the name, purpose, action, and potential adverse effects of any administered treatment.

21. A patient in the PACU following a thyroidectomy suddenly develops noisy, high-pitched crowing inspiratory sounds (stridor), intercostal retractions, and agitation. What is the nurse's IMMEDIATE priority action?
    A) Administer prescribed IV Morphine for surgical incisional pain.
    B) Perform jaw-thrust/chin-lift maneuver, notify the anesthesia provider immediately, and prepare for emergency airway intervention.
    C) Encourage the patient to cough deeply and expectorate secretions into a tissue.
    D) Obtain a 12-lead ECG and draw arterial blood gases (ABGs).

CORRECT ANSWER: B) Perform jaw-thrust/chin-lift maneuver, notify the anesthesia provider immediately, and prepare for emergency airway intervention.

RATIONALE: Stridor indicates upper airway obstruction or laryngospasm—a life-threatening emergency. Priority is airway management: repositioning airway, emergency call, suction, and preparation for re-intubation.

22. During intraoperative monitoring under general anesthesia, the circulating nurse notes a sudden unexplained rise in end-tidal CO2 (EtCO2), muscle rigidity of the jaw (masseter spasm), and a rapidly rising core body temperature (103.8°F). Which emergency medication must be prepared immediately?
    A) Atropine sulfate
    B) Dantrolene sodium
    C) Epinephrine
    D) Naloxone

CORRECT ANSWER: B) Dantrolene sodium

RATIONALE: The patient is exhibiting classic signs of Malignant Hyperthermia (unexplained hypercarbia, masseter spasm, hyperthermia, rigidity). Dantrolene sodium is the specific skeletal muscle relaxant used to treat MH.

23. A 68-year-old patient who underwent an open colectomy 6 hours ago has a heart rate of 124 beats/min, blood pressure of 84/52 mmHg, urine output of 15 mL/hr over the past 2 hours, and pale, clammy skin. Which postoperative complication should the nurse suspect FIRST?
    A) Paralytic ileus
    B) Hypovolemic shock / internal hemorrhage
    C) Acute urinary retention
    D) Malignant hyperthermia

CORRECT ANSWER: B) Hypovolemic shock / internal hemorrhage

RATIONALE: Tachycardia, hypotension, oliguria (<30 mL/hr), and pale/clammy skin are classic manifestations of hypovolemic shock resulting from surgical hemorrhage or severe fluid deficit.

24. A nurse is performing preoperative teaching for a patient scheduled for an elective total hip arthroplasty under general anesthesia. Which statement by the patient indicates a need for FURTHER instruction?
    A) 'I will use my incentive spirometer 10 times every hour while I am awake after surgery.'
    B) 'I should perform foot ankle-pumps and leg exercises in bed to prevent blood clots.'
    C) 'I will stop drinking clear liquids 2 hours before my scheduled arrival time as directed.'
    D) 'I can take my full dose of aspirin and ibuprofen on the morning of surgery with a sip of water.'

CORRECT ANSWER: D) 'I can take my full dose of aspirin and ibuprofen on the morning of surgery with a sip of water.'

RATIONALE: NSAIDs and Aspirin inhibit platelet aggregation and must be held 7 to 10 days prior to elective surgery to prevent intraoperative and postoperative surgical hemorrhage.

25. A patient is transferred from PACU to the surgical unit following spinal anesthesia. Which assessment finding requires IMMEDIATE intervention by the nurse?
    A) Patient reports inability to feel light touch in the toes 1 hour post-arrival.
    B) Blood pressure drops from 128/82 mmHg to 88/50 mmHg with a heart rate of 52 beats/min.
    C) Patient has not voided 3 hours post-op and bladder scan shows 150 mL.
    D) Patient complains of a mild incisional ache rated 3/10.

CORRECT ANSWER: B) Blood pressure drops from 128/82 mmHg to 88/50 mmHg with a heart rate of 52 beats/min.

RATIONALE: Spinal anesthesia blocks sympathetic vasomotor nerves, leading to venous pooling and severe hypotension/bradycardia. Marked hypotension requires immediate intervention (fluids, vasopressors, leg elevation).

26. Which surgical classification best describes an emergency appendectomy performed for a ruptured appendix?
    A) Elective surgery
    B) Urgent surgery
    C) Emergency surgery
    D) Palliative surgery

CORRECT ANSWER: C) Emergency surgery

RATIONALE: Emergency surgery must be performed immediately without delay to preserve life or limb (e.g., ruptured appendix, massive trauma, repair of expanding abdominal aortic aneurysm).

27. A surgeon explains a complex abdominal procedure to a non-English-speaking patient. Which action by the nurse fulfills legal and ethical obligations regarding Informed Consent?
    A) Ask the patient's 18-year-old bilingual daughter to translate and sign the consent form.
    B) Use a certified medical interpreter to translate the surgeon's explanation and witness the patient's voluntary signature.
    C) Have the patient sign the English consent form since the surgeon already explained it with hand gestures.
    D) Sign the consent form on behalf of the patient as an administrative representative.

CORRECT ANSWER: B) Use a certified medical interpreter to translate the surgeon's explanation and witness the patient's voluntary signature.

RATIONALE: Informed consent requires clear understanding. A certified medical interpreter must be utilized for limited English proficiency patients. Family members should not translate medical consent.

28. What is the nurse's primary legal responsibility when signing a surgical Informed Consent form as a witness?
    A) Verifying that the surgeon explained all surgical risks and alternative treatments accurately.
    B) Confirming that the patient signed the document voluntarily, possesses decision-making capacity, and is the person named.
    C) Guaranteeing that no postoperative surgical complications will occur.
    D) Ensuring that the hospital billing department receives the signed form.

CORRECT ANSWER: B) Confirming that the patient signed the document voluntarily, possesses decision-making capacity, and is the person named.

RATIONALE: The nurse's signature as a witness attests ONLY that the patient signed voluntarily, is competent to sign, and that the signature is authentic. The surgeon remains legally responsible for informing the patient.

29. A patient undergoing emergency trauma surgery has a pre-existing Medical Orders for Life-Sustaining Treatment (MOLST) specifying Do Not Resuscitate (DNR). How is the MOLST order managed during the perioperative period?
    A) The DNR order automatically remains 100% active and unalterable during anesthesia and surgery.
    B) The DNR order is automatically nullified permanently upon admission to the operating room.
    C) A required discussion occurs between the patient/proxy, surgeon, and anesthesiologist to decide whether to suspend or modify the DNR order temporarily during surgery.
    D) The circulating nurse makes the final decision on whether to initiate CPR if cardiac arrest occurs in the OR.

CORRECT ANSWER: C) A required discussion occurs between the patient/proxy, surgeon, and anesthesiologist to decide whether to suspend or modify the DNR order temporarily during surgery.

RATIONALE: Perioperative DNR/MOLST policies require required reconsideration: an explicit discussion between the patient/proxy and surgical/anesthesia team to decide whether DNR orders are temporarily suspended or modified during the procedure.

30. Prior to making the initial surgical incision, the circulating nurse, surgeon, and anesthesia provider pause to perform a mandatory 'Time-Out'. Which items MUST be verified during this protocol?
    A) Correct patient identity, correct surgical procedure, correct surgical site/side, and correct patient positioning.
    B) Patient's insurance coverage, emergency contact phone number, and postoperative discharge transportation.
    C) Surgeon's medical license number, scrub tech certification, and instrument count total.
    D) Patient's room assignment, dietary preferences, and primary care physician name.

CORRECT ANSWER: A) Correct patient identity, correct surgical procedure, correct surgical site/side, and correct patient positioning.

RATIONALE: The Universal Protocol 'Time-Out' immediately before incision requires active verbal agreement by the entire team verifying patient, procedure, site/side, positioning, and required implants/equipment.

31. On the second postoperative day following abdominal surgery, a patient's surgical incision gapes open and loops of small intestine protrude through the wound. What is the nurse's IMMEDIATE sequence of actions?
    A) Push the intestine back into the abdominal cavity gently and apply a tight abdominal binder.
    B) Position the patient in low Fowler's with knees flexed, cover the exposed bowel with sterile towels saturated with warm 0.9% Normal Saline, and call the surgeon immediately.
    C) Place the patient in high Fowler's position, instruct them to cough deeply, and apply dry sterile 4x4 gauze.
    D) Administer oral pain medication, document the finding, and re-assess the wound in 1 hour.

CORRECT ANSWER: B) Position the patient in low Fowler's with knees flexed, cover the exposed bowel with sterile towels saturated with warm 0.9% Normal Saline, and call the surgeon immediately.

RATIONALE: Evisceration is a medical emergency. The nurse places the patient in low Fowler's with knees bent (to reduce abdominal wall tension), covers the viscera with warm sterile saline-soaked towels, maintains NPO status, and calls the surgeon instantly.

32. A nurse is caring for a patient who received Moderate Sedation (Conscious Sedation) for an endoscopic procedure. Which clinical criteria must be met before the patient can be safely discharged home?
    A) Patient is able to ambulate unassisted, vital signs are stable, gag reflex has returned, and a responsible adult is present to drive.
    B) Patient's pain score is 0/10 and patient has voided 1,000 mL of urine.
    C) Patient has slept for 4 continuous hours without verbal stimulation.
    D) Patient promises to drive themselves home slowly and carefully.

CORRECT ANSWER: A) Patient is able to ambulate unassisted, vital signs are stable, gag reflex has returned, and a responsible adult is present to drive.

RATIONALE: Discharge criteria post-sedation require baseline vital signs, clear airway/intact gag reflex, alertness, unassisted ambulation, ability to retain fluids, and an accompanying responsible adult.

33. Which clinical assessment finding on Postoperative Day 3 following an open cholecystectomy indicates a potential Surgical Site Infection (SSI) requiring provider notification?
    A) Serosanguineous drainage amounting to 5 mL on the dressing.
    B) Localized erythema extending 2 cm beyond the incision, warmth, foul-smelling purulent exudate, and temperature of 101.4°F.
    C) Mild incisional tenderness during ambulation rated 2/10.
    D) Soft, non-distended abdomen with active bowel sounds in all 4 quadrants.

CORRECT ANSWER: B) Localized erythema extending 2 cm beyond the incision, warmth, foul-smelling purulent exudate, and temperature of 101.4°F.

RATIONALE: SSI manifestations include spreading erythema, warmth, purulent drainage, induration, localized pain, and fever (>100.4°F).

34. A nurse assesses a patient 4 hours post-op following lumbar spinal fusion under general anesthesia. The patient has not voided since surgery. A bladder scan reveals 550 mL of urine. What is the nurse's initial intervention?
    A) Wait another 4 hours to allow natural bladder filling.
    B) Assist the male patient to stand at the bedside or female patient to sit on the bedside commode to attempt voiding.
    C) Immediately insert an indwelling Triple-Lumen Foley catheter without a prescription.
    D) Administer 500 mL IV fluid bolus rapidly to force urination.

CORRECT ANSWER: B) Assist the male patient to stand at the bedside or female patient to sit on the bedside commode to attempt voiding.

RATIONALE: Anesthesia and opioids cause urinary retention. Initial nursing interventions are independent/non-invasive: positioning upright (standing/sitting commode), running water, privacy. If unsuccessful, straight catheterization per order follows.

35. A postoperative patient complains of severe right calf tenderness, warmth, and swelling. What action should the nurse AVOID to prevent a fatal complication?
    A) Elevating the affected right leg on pillows above heart level.
    B) Massaging or rubbing the right calf muscle firmly.
    C) Notifying the primary surgical provider immediately.
    D) Measuring and comparing bilateral calf circumferences.

CORRECT ANSWER: B) Massaging or rubbing the right calf muscle firmly.

RATIONALE: Never massage or compress a calf suspected of deep vein thrombosis (DVT), as mechanical manipulation can dislodge the thrombus, causing a fatal pulmonary embolism.

36. Which nursing intervention effectively prevents postoperative atelectasis and pneumonia in a patient recovering from upper abdominal surgery?
    A) Sustained maximal inspirations using an incentive spirometer 10 times per hour while awake, combined with splinted coughing.
    B) Maintaining strict bed rest in the flat supine position for 48 hours.
    C) Restricting oral fluid intake to less than 1,000 mL daily.
    D) Administering continuous high-dose sedative medications.

CORRECT ANSWER: A) Sustained maximal inspirations using an incentive spirometer 10 times per hour while awake, combined with splinted coughing.

RATIONALE: Incentive spirometry promotes alveolar expansion and surfactant production. Splinting the incision with a pillow allows effective deep breathing and coughing without incisional disruption.

37. A patient scheduled for elective surgery expresses anxiety, stating, 'I'm afraid I won't wake up from the anesthesia.' What is the nurse's MOST therapeutic response?
    A) 'Don't worry, our anesthesiologists are highly trained and nobody dies here.'
    B) 'Tell me more about your specific concerns regarding anesthesia.'
    C) 'You shouldn't feel anxious because general anesthesia is completely safe nowadays.'
    D) 'I will call the doctor to order a strong sedative so you sleep until surgery.'

CORRECT ANSWER: B) 'Tell me more about your specific concerns regarding anesthesia.'

RATIONALE: Open-ended therapeutic communication ('Tell me more…') validates the patient's feelings, encourages expression of fears, and allows the nurse to provide accurate clarification or request an anesthesia consult.

38. What type of regional anesthesia involves injecting a local anesthetic into the subarachnoid space at the lumbar level (L3-L4)?
    A) Epidural anesthesia
    B) Spinal anesthesia
    C) Local infiltration
    D) Nerve block

CORRECT ANSWER: B) Spinal anesthesia

RATIONALE: Spinal anesthesia is an injection into the subarachnoid space (containing CSF). Epidural anesthesia is injected into the epidural space outside the dura mater.

39. A patient recovering from epidural anesthesia reports a severe, throbbing frontal headache that worsens significantly when sitting up and improves when lying flat. What complication is the patient experiencing?
    A) Post-dural puncture (spinal) headache due to CSF leakage.
    B) Malignant hyperthermia crisis.
    C) Hypertensive emergency.
    D) Normal emergence hangover from anesthetic gas.

CORRECT ANSWER: A) Post-dural puncture (spinal) headache due to CSF leakage.

RATIONALE: A post-dural puncture headache occurs when dura is punctured, causing CSF leakage and decreased intracranial pressure. It is characteristically postural (worse upright, relieved lying flat).

40. A nurse is reviewing ethical nursing principles. Which situation represents a breach of Patient Autonomy in the perioperative setting?
    A) Allowing a competent adult patient to refuse blood transfusions based on religious beliefs after full risk disclosure.
    B) Coercing an hesitant patient into signing a surgical consent form by stating the doctor will drop them as a patient if they don't agree.
    C) Protecting patient privacy by drawing curtains during preoperative skin prep.
    D) Providing equal high-quality care to all patients regardless of socioeconomic status.

CORRECT ANSWER: B) Coercing an hesitant patient into signing a surgical consent form by stating the doctor will drop them as a patient if they don't agree.

RATIONALE: Autonomy is the right of self-determination. Coercion or threatening a patient violates autonomy and invalidates legal informed consent.

41. A nurse is bathing an inpatient using Chlorhexidine Gluconate (CHG) 2% impregnated cloths. Which protocol MUST the nurse follow to ensure antimicrobial effectiveness?
    A) Thoroughly rinse the patient's skin with warm tap water immediately after applying CHG.
    B) Allow the CHG solution to air-dry naturally on the skin without rinsing.
    C) Apply CHG cloths directly to the patient's eyes, face, and inner ear canals.
    D) Wash the CHG off using scented alkaline bar soap.

CORRECT ANSWER: B) Allow the CHG solution to air-dry naturally on the skin without rinsing.

RATIONALE: CHG provides persistent cumulative antimicrobial action. It MUST NOT be rinsed off; it must be allowed to air dry naturally. Avoid contact with eyes, face, and inner ears.

42. An 82-year-old bedbound patient with severe xerosis (dry skin) requires daily hygiene care. Which nursing intervention is MOST appropriate for preserving skin integrity?
    A) Bathing the patient daily with hot water and antibacterial soap.
    B) Bathing the patient 2-3 times per week with lukewarm water and a no-rinse, pH-balanced hydrating cleanser, followed by topical emollients.
    C) Vigorous friction scrubbing with a coarse washcloth to exfoliate dry flakes.
    D) Applying pure alcohol to dry skin areas to eliminate surface bacteria.

CORRECT ANSWER: B) Bathing the patient 2-3 times per week with lukewarm water and a no-rinse, pH-balanced hydrating cleanser, followed by topical emollients.

RATIONALE: Frequent full baths with hot water and harsh soaps strip natural epidermal lipids in older adults. Using lukewarm water, mild pH-balanced cleansers, and immediate emollient application prevents xerosis and skin tears.

43. A nurse is providing perineal care to an uncircumcised male patient who is incontinent of stool. Which step is CRITICAL to prevent severe tissue injury?
    A) Retract the foreskin, cleanse the glans penis, and leave the foreskin retracted continuously.
    B) Gently retract the foreskin, cleanse the glans from meatus outward, rinse/dry, and IMMEDIATELY return the foreskin to its natural position over the glans.
    C) Avoid touching or retracting the foreskin under any circumstances.
    D) Cleanse the anal area first, then use the same washcloth to cleanse the glans penis.

CORRECT ANSWER: B) Gently retract the foreskin, cleanse the glans from meatus outward, rinse/dry, and IMMEDIATELY return the foreskin to its natural position over the glans.

RATIONALE: Failure to return the retracted foreskin causes paraphimosis (severe constriction of the glans penis, leading to edema, ischemia, and necrosis).

44. What is the primary rationale for performing meticulous, regular oral hygiene with chlorhexidine or soft swab cleansing on an unconscious or mechanically ventilated patient?
    A) Preventing dental caries and cosmetic discoloration.
    B) Reducing oral bacterial colonization to prevent Ventilator-Associated Pneumonia (VAP) and aspiration pneumonia.
    C) Stimulating salivary gland secretion to improve speech.
    D) Testing the patient's gag reflex during shift changes.

CORRECT ANSWER: B) Reducing oral bacterial colonization to prevent Ventilator-Associated Pneumonia (VAP) and aspiration pneumonia.

RATIONALE: Oropharyngeal secretions in bedridden/ventilated patients harbor pathogenic bacteria. Meticulous oral care significantly reduces bacterial load, preventing aspiration pneumonia and VAP.

45. A nurse is delegating morning hygiene to an unlicensed assistive personnel (UAP) for a patient with moderate Alzheimer's disease who becomes agitated during baths. Which direction by the nurse demonstrates evidence-based 'Bathing Without a Battle' techniques?
    A) 'Force the patient into the shower immediately to get it over with quickly.'
    B) 'Use a warm towel/bag bath, maintain a calm unhurried demeanor, keep the patient covered for warmth, and focus on one body part at a time.'
    C) 'Restrain the patient's wrists gently while washing their face.'
    D) 'Skip hygiene entirely for the next week.'

CORRECT ANSWER: B) 'Use a warm towel/bag bath, maintain a calm unhurried demeanor, keep the patient covered for warmth, and focus on one body part at a time.'

RATIONALE: Person-centered dementia care adapts hygiene to prevent agitation: soft lighting, warmth, towel baths, distraction, washing least sensitive areas first, and respecting patient preferences.

46. When performing perineal care for a female patient, in which direction should the nurse cleanse the perineal tissues?
    A) From the anal area upward toward the pubic symphysis (back to front).
    B) From the pubic symphysis downward toward the anal area (front to back).
    C) In circular motions starting at the anus and moving outward.
    D) Side to side across the labia majora using a single cloth surface.

CORRECT ANSWER: B) From the pubic symphysis downward toward the anal area (front to back).

RATIONALE: Cleansing front to back (least contaminated pubic area to most contaminated anal area) prevents contamination of the urethral meatus with intestinal E. coli bacteria, reducing UTI risk.

47. A nurse is caring for a diabetic patient with peripheral neuropathy. Which foot care practice by the patient requires IMMEDIATE re-education by the nurse?
    A) Inspecting the soles of both feet daily using a handheld mirror.
    B) Soaking feet in warm soapy water for 30 minutes daily to soften calluses, then cutting toenails rounded at the corners with clippers.
    C) Wearing clean, dry cotton socks and well-fitted shoes at all times.
    D) Applying moisturizing lotion to the tops and soles of feet while avoiding between the toes.

CORRECT ANSWER: B) Soaking feet in warm soapy water for 30 minutes daily to soften calluses, then cutting toenails rounded at the corners with clippers.

RATIONALE: Diabetics must NEVER soak feet (causes maceration and infection entry points) and must NEVER cut nails rounded or into corners (causes ingrown nails/ulcers). Nails should be filed straight across.

48. A bedbound patient has continuous IV fluids infusing through a peripheral line in the right forearm. How should the nurse safely remove the patient's soiled hospital gown?
    A) Disconnect the IV line at the catheter hub, remove the gown, and reattach the IV line.
    B) Remove the gown from the uninjured left arm first, then slide the right sleeve off, threading the IV bag and tubing through the right sleeve from inside out.
    C) Cut the right sleeve of the gown open with bandage scissors.
    D) Remove the gown right arm first while holding the IV bag low below the bed.

CORRECT ANSWER: B) Remove the gown from the uninjured left arm first, then slide the right sleeve off, threading the IV bag and tubing through the right sleeve from inside out.

RATIONALE: To maintain sterile line integrity, never disconnect IV lines to change a gown. Remove gown from non-IV arm first, then pass sleeve over IV arm, bag, and tubing from inside to outside.

49. How should a nurse position an unconscious, non-intubated patient to perform oral hygiene safely and prevent aspiration?
    A) High Fowler's position with head tilted backward.
    B) Side-lying (Sims' or lateral) position with the head turned toward the mattress and bed flat or low.
    C) Supine position with head flat on the pillow.
    D) Trendelenburg position with face turned upward.

CORRECT ANSWER: B) Side-lying (Sims' or lateral) position with the head turned toward the mattress and bed flat or low.

RATIONALE: Unconscious patients must be placed in a side-lying position with head turned to the side so fluids and oral secretions drain naturally out of the mouth by gravity rather than being aspirated into lungs.

50. When cleaning a patient's removable complete dentures, which safety precaution prevents accidental breakage?
    A) Holding dentures firmly over a hard porcelain sink filled with boiling water.
    B) Placing a washcloth or towel in the bottom of a sink filled with cool water while brushing.
    C) Soaking dentures in 100% isopropyl alcohol overnight.
    D) Scrubbing dentures with abrasive gritty toothpaste and a hard-bristle brush.

CORRECT ANSWER: B) Placing a washcloth or towel in the bottom of a sink filled with cool water while brushing.

RATIONALE: Lining the sink basin with a washcloth or filling it partially with cool water cushions dentures if dropped, preventing costly fracture.

51. An incontinent patient has red, denuded, painful skin across the perineum and buttocks. The nurse notes diffuse superficial erythema with small satellite lesions. What condition is present?
    A) Stage 3 Pressure Injury
    B) Incontinence-Associated Dermatitis (IAD) with secondary fungal/candidal infection
    C) Deep Tissue Pressure Injury
    D) Venous stasis ulceration

CORRECT ANSWER: B) Incontinence-Associated Dermatitis (IAD) with secondary fungal/candidal infection

RATIONALE: IAD presents as diffuse red denuded skin exposed to moisture/stool. Satellite lesions (small red papules outside the main border) indicate a secondary Candida albicans fungal infection.

52. What is the proper technique for cleansing a patient's eye that has crusting or secretions?
    A) Wipe from the outer canthus inward toward the inner canthus using a dry cotton ball.
    B) Wipe from the inner canthus outward toward the outer canthus using a clean, damp cloth section per stroke.
    C) Irrigate the eye with hot tap water using a 50 mL bulb syringe.
    D) Scrub both eyes back and forth vigorously using a single CHG cloth.

CORRECT ANSWER: B) Wipe from the inner canthus outward toward the outer canthus using a clean, damp cloth section per stroke.

RATIONALE: Wiping from inner to outer canthus prevents pushing debris or microorganism-laden secretions into the nasolacrimal duct.

53. Which hygiene intervention provides both physical cleanliness and promotes systemic muscle relaxation and sleep prior to bedtime?
    A) A brisk cold shower.
    B) A 3- to 5-minute effleurage back massage using warm lotion.
    C) Application of rubbing alcohol to the soles of the feet.
    D) Vigorous passive range-of-motion exercises.

CORRECT ANSWER: B) A 3- to 5-minute effleurage back massage using warm lotion.

RATIONALE: Effleurage (long, smooth, gliding strokes up the spine and down the sides) promotes cutaneous circulation, relieves muscle tension, and induces relaxation.

54. A patient with a new metallic facial piercing is admitted for an MRI scan. What is the nurse's priority action regarding the piercing?
    A) Tape the piercing securely to the skin with paper tape.
    B) Inform the patient that all metallic jewelry must be removed prior to entering the MRI suite to prevent thermal injury and artifact.
    C) Clean the piercing site with hydrogen peroxide and leave it in place.
    D) Apply a magnetic cover over the piercing.

CORRECT ANSWER: B) Inform the patient that all metallic jewelry must be removed prior to entering the MRI suite to prevent thermal injury and artifact.

RATIONALE: Metallic objects pose severe projectile and burn hazards in the strong magnetic field of an MRI and must be removed prior to scanning (a plastic retainer may replace it if needed).

55. Which body area requires special hygiene attention in obese patients (bariatric nursing) to prevent Intertrigo and skin breakdown?
    A) Bony prominences of the elbows.
    B) Deep skin folds (under breasts, abdominal pannus, groin, and axillae).
    C) Palmar surfaces of the hands.
    D) Anterior tibia.

CORRECT ANSWER: B) Deep skin folds (under breasts, abdominal pannus, groin, and axillae).

RATIONALE: Intertrigo is an inflammatory skin condition caused by skin-on-skin friction and trapped moisture in deep intertriginous skin folds, predisposing to fungal infection.

56. A nurse is assisting a female patient with a bed bath. The patient asks, 'Why do you wash my face first before anything else?' How should the nurse respond?
    A) 'Face washing is done first because it is the cleanest area, preventing transfer of body bacteria to the eyes and face.'
    B) 'It is just an arbitrary rule we follow in nursing school.'
    C) 'Washing the face first wakes you up so you can help me.'
    D) 'We wash face first so we can use the dirtiest water on your face.'

CORRECT ANSWER: A) 'Face washing is done first because it is the cleanest area, preventing transfer of body bacteria to the eyes and face.'

RATIONALE: Hygiene proceeds from cleanest areas to dirtiest areas to prevent cross-contamination of delicate structures like eyes and face.

57. What is the recommended water temperature range for a patient's complete bed bath to ensure safety and comfort?
    A) 90°F to 95°F (32.2°C to 35°C)
    B) 105°F to 110°F (40.5°C to 43.3°C)
    C) 120°F to 125°F (48.8°C to 51.6°C)
    D) 70°F to 80°F (21.1°C to 26.6°C)

CORRECT ANSWER: B) 105°F to 110°F (40.5°C to 43.3°C)

RATIONALE: Water temperature for bed baths should be comfortably warm, between 105°F and 110°F (40.5°C - 43.3°C), to prevent thermal skin injury or chilling.

58. A nurse assesses a patient's oral cavity and notes white, curd-like patches on the tongue and buccal mucosa that bleed when scraped with a tongue depressor. What condition is present?
    A) Dental plaque
    B) Oral Candidiasis (Thrush)
    C) Gingivitis
    D) Leukoplakia

CORRECT ANSWER: B) Oral Candidiasis (Thrush)

RATIONALE: Oral thrush (Candidiasis) presents as creamy white cottage-cheese-like patches on oral mucosa that reveal red bleeding surfaces when scraped.

59. Which action by a nurse helps preserve a patient's dignity and autonomy during personal hygiene care?
    A) Performing the entire bath rapidly without talking to the patient.
    B) Closing room doors/curtains, keeping unwashed body parts covered with a bath blanket, and encouraging the patient to perform as much self-care as possible.
    C) Leaving the room door open so staff can enter freely.
    D) Refusing to let the patient choose when they want to bathe.

CORRECT ANSWER: B) Closing room doors/curtains, keeping unwashed body parts covered with a bath blanket, and encouraging the patient to perform as much self-care as possible.

RATIONALE: Dignity and independence are preserved by providing privacy, exposing only the body part being cleaned, and fostering self-care.

60. What is the primary purpose of early morning (AM) care provided prior to breakfast?
    A) Administering all daily IV push medications.
    B) Assisting with toileting, washing face and hands, and providing oral hygiene to refresh the patient for breakfast.
    C) Changing all surgical dressings.
    D) Performing complete linen changes and bed disinfection.

CORRECT ANSWER: B) Assisting with toileting, washing face and hands, and providing oral hygiene to refresh the patient for breakfast.

RATIONALE: Early morning care prepares the patient for breakfast by assisting with elimination, hand/face washing, and oral care.

61. A nurse assesses a bedbound patient's sacrum and observes a localized area of intact skin with nonblanchable erythema. The area is firm and warmer than surrounding tissue. How should the nurse stage this pressure injury?
    A) Stage 1 Pressure Injury
    B) Stage 2 Pressure Injury
    C) Deep Tissue Pressure Injury
    D) Unstageable Pressure Injury

CORRECT ANSWER: A) Stage 1 Pressure Injury

RATIONALE: Stage 1 is defined as intact skin with localized nonblanchable erythema (does not turn white when pressed). Changes in temperature, firmness, or sensation may precede visual color changes.

62. Assessment of a patient's ischial tuberosity reveals a shallow open ulcer with a red-pink viable wound bed, without slough or bruising. Slough is absent and subcutaneous fat is NOT visible. How should the nurse stage this injury?
    A) Stage 1 Pressure Injury
    B) Stage 2 Pressure Injury
    C) Stage 3 Pressure Injury
    D) Stage 4 Pressure Injury

CORRECT ANSWER: B) Stage 2 Pressure Injury

RATIONALE: Stage 2 is partial-thickness skin loss with exposed dermis. The wound bed is viable, pink/red, moist, and may present as an intact or ruptured serum-filled blister. Subcutaneous fat is NOT visible.

63. A nurse evaluates a pressure injury on a patient's trochanter. The wound exhibits full-thickness skin loss where subcutaneous fat is visible, with rolled wound edges (epibole) and small patches of yellow slough. Bone, tendon, and muscle are NOT exposed. What stage is this injury?
    A) Stage 2 Pressure Injury
    B) Stage 3 Pressure Injury
    C) Stage 4 Pressure Injury
    D) Deep Tissue Pressure Injury

CORRECT ANSWER: B) Stage 3 Pressure Injury

RATIONALE: Stage 3 is full-thickness loss of skin in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled edges) are often present. Fascia, muscle, tendon, ligament, or bone are NOT exposed.

64. A deep wound over a patient's sacrum presents with full-thickness tissue loss. The nurse can directly visualize and palpate the sacral bone and underlying muscle. Slough and undermining are present. What is the correct staging?
    A) Stage 3 Pressure Injury
    B) Stage 4 Pressure Injury
    C) Unstageable Pressure Injury
    D) Deep Tissue Pressure Injury

CORRECT ANSWER: B) Stage 4 Pressure Injury

RATIONALE: Stage 4 is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone.

65. A pressure ulcer on a patient's heel is completely covered by 100% thick, adherent, black necrotic eschar. Tissue depth cannot be determined. How should the nurse stage this wound?
    A) Stage 3 Pressure Injury
    B) Stage 4 Pressure Injury
    C) Unstageable Pressure Injury
    D) Deep Tissue Pressure Injury

CORRECT ANSWER: C) Unstageable Pressure Injury

RATIONALE: Unstageable pressure injury is full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

66. A dark-skinned patient presents with intact skin over the heel that is dark purple/maroon in color, feels boggy, and contains a dark blood-filled blister resulting from shear force. How is this injury classified?
    A) Stage 1 Pressure Injury
    B) Stage 2 Pressure Injury
    C) Deep Tissue Pressure Injury (DTPI)
    D) Unstageable Pressure Injury

CORRECT ANSWER: C) Deep Tissue Pressure Injury (DTPI)

RATIONALE: DTPI is intact or nonintact skin with localized area of persistent, nonblanchable deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.

67. What exception exists regarding the debridement of eschar on pressure injuries?
    A) Stable, dry, adherent, intact eschar on the heels without erythema or fluctuance should NOT be debrided.
    B) Eschar over the sacrum should never be debrided.
    C) All eschar anywhere on the body must be debrided within 24 hours.
    D) Eschar should only be debrided if the patient has diabetes.

CORRECT ANSWER: A) Stable, dry, adherent, intact eschar on the heels without erythema or fluctuance should NOT be debrided.

RATIONALE: Stable, dry, adherent, intact eschar on the heels serves as the body's natural (biological) cover and should not be softened or debrided unless clinical signs of infection occur.

68. A Braden Scale assessment yields a total score of 11 for an elderly bedbound patient. How should the nurse interpret this score?
    A) No risk for pressure injury
    B) Mild risk for pressure injury
    C) Moderate risk for pressure injury
    D) High risk for pressure injury

CORRECT ANSWER: D) High risk for pressure injury

RATIONALE: Braden Scale interpretation: 19-23 = No risk; 15-18 = Mild risk; 13-14 = Moderate risk; 10-12 = High risk; <= 9 = Very high risk. A score of 11 represents High Risk.

69. Which laboratory serum value indicates significant nutritional deficiency that impairs tissue healing and increases pressure injury risk?
    A) Serum Albumin < 3.2 g/dL (or Prealbumin < 15 mg/dL)
    B) Serum Sodium > 145 mEq/L
    C) Serum Potassium > 5.0 mEq/L
    D) Blood Urea Nitrogen (BUN) < 10 mg/dL

CORRECT ANSWER: A) Serum Albumin < 3.2 g/dL (or Prealbumin < 15 mg/dL)

RATIONALE: Protein is essential for tissue repair and collagen synthesis. Serum Albumin < 3.2 g/dL or Prealbumin < 15 mg/dL signals protein-calorie malnutrition and high risk for pressure injury.

70. To prevent shearing forces on the sacrum of a bedbound patient, at what maximum elevation angle should the nurse maintain the head of the bed (HOB)?
    A) 15 degrees
    B) 30 degrees
    C) 60 degrees
    D) 90 degrees

CORRECT ANSWER: B) 30 degrees

RATIONALE: Elevating the head of the bed higher than 30 degrees causes the skeleton to slide downward while skin remains fixed against sheets, creating shearing forces that tear deep capillaries.

71. What is the minimum repositioning frequency for a bedbound patient to prevent pressure injury development?
    A) Every 30 minutes
    B) Every 2 hours
    C) Every 4 hours
    D) Every shift (8 hours)

CORRECT ANSWER: B) Every 2 hours

RATIONALE: Bedbound patients must be repositioned at least every 2 hours (q2h) to relieve pressure over bony prominences. (Chair-bound patients require repositioning every 1 hour).

72. A nurse is positioning a patient in a 30-degree lateral inclined position. Which bony prominences are relieved of direct weight-bearing pressure in this position?
    A) Greater trochanter and sacrum
    B) Patella and tibia
    C) Occiput and sternum
    D) Medial malleolus and clavicle

CORRECT ANSWER: A) Greater trochanter and sacrum

RATIONALE: The 30-degree lateral tilted position avoids direct pressure on the sacrum posteriorly and the greater trochanter laterally.

73. How should a nurse properly offload pressure from a bedbound patient's heels?
    A) Place a donut-shaped ring cushion directly under the calcaneus.
    B) Place pillows under the patient's calves lengthwise to 'float' the heels completely off the mattress.
    C) Elevate the foot of the bed 90 degrees.
    D) Place a heavy sandbag directly on top of the feet.

CORRECT ANSWER: B) Place pillows under the patient's calves lengthwise to 'float' the heels completely off the mattress.

RATIONALE: Floating heels by placing pillows under calves ensures total pressure relief over calcaneus bony prominences. Donut cushions are contraindicated as they restrict blood flow.

74. How does a nurse differentiate Reactive Hyperemia from a Stage 1 Pressure Injury over a reddened bony prominence?
    A) Reactive hyperemia blanches (turns white) when finger pressure is applied and resolves within 60-90 minutes; Stage 1 does not blanch.
    B) Reactive hyperemia is dark purple; Stage 1 is yellow.
    C) Reactive hyperemia is always painful; Stage 1 has no sensation.
    D) Reactive hyperemia involves muscle necrosis; Stage 1 is superficial.

CORRECT ANSWER: A) Reactive hyperemia blanches (turns white) when finger pressure is applied and resolves within 60-90 minutes; Stage 1 does not blanch.

RATIONALE: Reactive hyperemia is a normal physiological flush of blood returning to ischemic tissue that BLANCHES with pressure. Stage 1 erythema is NONBLANCHABLE.

75. When assessing a dark-skinned patient for early signs of pressure injury, which assessment techniques are MOST reliable?
    A) Relying solely on skin color changes under bright fluorescent lighting.
    B) Palpating for changes in skin temperature (warmth or coolness), edema, tissue induration (firmness), and localized pain.
    C) Applying alcohol rubs to see if the skin turns pale.
    D) Staging cannot be performed on dark-skinned individuals.

CORRECT ANSWER: B) Palpating for changes in skin temperature (warmth or coolness), edema, tissue induration (firmness), and localized pain.

RATIONALE: In dark skin, nonblanchable erythema may not be visually apparent. Assessing localized warmth/coolness, induration, boggy texture, tautness, and pain is crucial.

76. Why are synthetic 'donut' ring cushions strictly CONTRAINDICATED for pressure injury prevention?
    A) They cost too much money.
    B) They concentrate pressure on surrounding blood vessels, impeding venous return and accelerating tissue ischemia in the center.
    C) They cause allergic contact dermatitis in all patients.
    D) They cause hyperthermia.

CORRECT ANSWER: B) They concentrate pressure on surrounding blood vessels, impeding venous return and accelerating tissue ischemia in the center.

RATIONALE: Donut cushions create a ring of high pressure that restricts venous outflow and microvascular perfusion, worsening localized tissue hypoxia.

77. What mechanical mechanism causes a Friction injury?
    A) Deep tissue sliding over fixed bone.
    B) Two surfaces rubbing against one another, stripping the superficial epidermal skin layer (e.g., dragging a patient across bedsheets).
    C) Exposure to acidic urine.
    D) Systemic bacterial infection.

CORRECT ANSWER: B) Two surfaces rubbing against one another, stripping the superficial epidermal skin layer (e.g., dragging a patient across bedsheets).

RATIONALE: Friction is a mechanical force when skin rubs against external surfaces (sheets), removing epidermis like a 'sheet burn'.

78. A patient sitting in a wheelchair should be instructed or assisted to shift their weight at what time interval?
    A) Every 15 minutes
    B) Every 2 hours
    C) Every 4 hours
    D) Once per day

CORRECT ANSWER: A) Every 15 minutes

RATIONALE: Chair-bound patients experience high pressure on ischial tuberosities; they should shift weight every 15 minutes and be repositioned by staff at least every 1 hour.

79. What role does excess skin moisture (from diaphoresis or incontinence) play in pressure injury formation?
    A) Moisture strengthens the stratum corneum.
    B) Moisture macerates the skin, softening epidermal tissue and increasing susceptibility to friction and shear breakdown.
    C) Moisture prevents bacterial growth.
    D) Moisture increases skin elasticity ten-fold.

CORRECT ANSWER: B) Moisture macerates the skin, softening epidermal tissue and increasing susceptibility to friction and shear breakdown.

RATIONALE: Prolonged moisture softens collagen fibers (maceration), eroding skin resistance to mechanical shear and friction.

80. What is the primary purpose of applying a transparent film dressing (e.g., Tegaderm) over a Stage 1 pressure injury?
    A) Debriding thick eschar.
    B) Absorbing massive purulent exudate.
    C) Protecting the intact skin from friction and shear while allowing visual inspection.
    D) Packing deep tissue undermining.

CORRECT ANSWER: C) Protecting the intact skin from friction and shear while allowing visual inspection.

RATIONALE: Transparent films are semi-permeable, occlusive, water-resistant dressings that reduce friction and allow continuous visualization of Stage 1 intact skin.

81. A surgical incision closed cleanly with staples on the day of surgery heals by which intention?
    A) Primary Intention
    B) Secondary Intention
    C) Tertiary Intention (Delayed Primary)
    D) Quaternary Intention

CORRECT ANSWER: A) Primary Intention

RATIONALE: Primary intention healing occurs in clean wounds with well-approximated edges (sutured or stapled), resulting in minimal tissue loss, rapid healing, and minimal scarring.

82. A large pressure injury allowed to heal open from the bottom up by filling with red granulation tissue heals by which intention?
    A) Primary Intention
    B) Secondary Intention
    C) Tertiary Intention
    D) Direct Intention

CORRECT ANSWER: B) Secondary Intention

RATIONALE: Secondary intention occurs in wounds with significant tissue loss and unapproximated edges. Healing takes longer as the wound fills with granulation tissue, forming a larger scar.

83. A contaminated abdominal wound is intentionally left open for 5 days to allow edema and infection to resolve, and then sutured closed. What intention of wound healing is this?
    A) Primary Intention
    B) Secondary Intention
    C) Tertiary Intention (Delayed Primary Closure)
    D) Immediate Closure

CORRECT ANSWER: C) Tertiary Intention (Delayed Primary Closure)

RATIONALE: Tertiary intention occurs when a contaminated wound is purposefully left open to drain and heal initially, then sutured closed once infection/edema subsides.

84. During which phase of wound healing do fibroblasts synthesize collagen and capillary buds form, producing beefy-red granulation tissue?
    A) Hemostasis Phase
    B) Inflammatory Phase
    C) Proliferation Phase
    D) Maturation / Remodeling Phase

CORRECT ANSWER: C) Proliferation Phase

RATIONALE: The Proliferation Phase (days 3-24) is characterized by fibroblast activity, collagen deposition, angiogenesis, and granulation tissue formation.

85. How long can the Maturation (Remodeling) Phase of wound healing last following a major surgical injury?
    A) 24 to 48 hours
    B) 3 to 5 days
    C) 3 weeks to 1-2 years
    D) Exactly 10 days

CORRECT ANSWER: C) 3 weeks to 1-2 years

RATIONALE: The Maturation Phase begins around 3 weeks post-injury and continues for up to 1 to 2 years, during which collagen is reorganized and scar tissue gains tensile strength (up to 80% original).

86. A nurse assesses a surgical drain and notes clear, pale amber, thin, watery fluid. How should the nurse document this exudate?
    A) Serous drainage
    B) Sanguineous drainage
    C) Serosanguineous drainage
    D) Purulent drainage

CORRECT ANSWER: A) Serous drainage

RATIONALE: Serous exudate is clear, watery plasma derived from blood serum.

87. A surgical wound dressing on Postoperative Day 1 is saturated with bright red, thick bloody drainage. How should the nurse document this finding?
    A) Serous
    B) Sanguineous
    C) Purulent
    D) Catarrhal

CORRECT ANSWER: B) Sanguineous

RATIONALE: Sanguineous exudate consists of large numbers of red blood cells, indicating fresh active bleeding.

88. Drainage described as pale pink, thin, and watery (a mixture of serum and red blood cells) is documented as:
    A) Serous
    B) Purulent
    C) Serosanguineous
    D) Fibrinous

CORRECT ANSWER: C) Serosanguineous

RATIONALE: Serosanguineous drainage is a mixture of clear serum and red blood cells, appearing light pink to pale red.

89. A nurse removes a wound dressing and observes thick, opaque, yellow-green drainage with a foul odor. What type of exudate is this?
    A) Serous
    B) Sanguineous
    C) Serosanguineous
    D) Purulent

CORRECT ANSWER: D) Purulent

RATIONALE: Purulent drainage consists of dead white blood cells, cellular debris, and liquefied bacteria, indicating infection. It is thick, yellow/green, and foul-smelling.

90. According to the RYB (Red-Yellow-Black) Wound Color Code system, what is the primary goal for a wound that presents with yellow slough?
    A) Protect fragile tissue by gentle handling.
    B) Cleanse the wound and debride slough using appropriate dressings or irrigation.
    C) Debride black eschar surgically.
    D) Dry out the wound with heat lamps.

CORRECT ANSWER: B) Cleanse the wound and debride slough using appropriate dressings or irrigation.

RATIONALE: RYB priorities: RED = Protect; YELLOW = Cleanse (remove slough/exudate); BLACK = Debride (remove necrotic eschar).

91. How does a Jackson-Pratt (JP) drain maintain continuous wound suction?
    A) By connecting to a wall-mounted vacuum regulator set at -120 mmHg.
    B) By manually compressing the flexible bulb after emptying and inserting the plug to create low negative pressure.
    C) Gravity drainage into a leg bag.
    D) Air pressure from a motor pump.

CORRECT ANSWER: B) By manually compressing the flexible bulb after emptying and inserting the plug to create low negative pressure.

RATIONALE: Closed suction drains (JP and Hemovac) rely on manual compression of the reservoir bulb or accordion chamber to create continuous low negative suction.

92. What safety device prevents a flat, open Penrose drain from slipping backwards into the deep wound cavity?
    A) A suture tying it to the abdominal skin.
    B) A sterile safety pin placed through the exposed end of the drain outside the wound.
    C) A plastic clamp attached to the bedsheets.
    D) A piece of paper tape.

CORRECT ANSWER: B) A sterile safety pin placed through the exposed end of the drain outside the wound.

RATIONALE: A sterile safety pin is inserted through the outer portion of a Penrose drain to prevent the flexible rubber tube from retracting into the wound.

93. A nurse is caring for a patient with Negative Pressure Wound Therapy (NPWT / Wound V.A.C.). What mechanism promotes accelerated wound healing?
    A) High positive pressure expands the wound margins.
    B) Continuous controlled negative pressure pulls wound edges together, removes exudate/infectious material, and stimulates microvascular granulation.
    C) Constant infusion of antibiotic liquid into the wound bed.
    D) Drying out the wound surface completely.

CORRECT ANSWER: B) Continuous controlled negative pressure pulls wound edges together, removes exudate/infectious material, and stimulates microvascular granulation.

RATIONALE: NPWT applies negative pressure (vacuum) to a foam dressing, removing excess fluid, reducing bacterial load, drawing wound edges together, and stimulating cell mitosis and perfusion.

94. Which clinical situation represents a STRICT CONTRAINDICATION for applying Negative Pressure Wound Therapy (NPWT)?
    A) Stage 3 pressure injury with moderate serosanguineous exudate.
    B) Presence of necrotic eschar/slough in the wound bed, exposed blood vessels/organs, or active wound hemorrhage.
    C) Dehisced abdominal incision.
    D) Non-healing diabetic foot ulcer.

CORRECT ANSWER: B) Presence of necrotic eschar/slough in the wound bed, exposed blood vessels/organs, or active wound hemorrhage.

RATIONALE: NPWT contraindications include untreated osteomyelitis, necrotic tissue/eschar, exposed arteries/veins/organs, active bleeding, or malignancy in the wound.

95. What is the correct technique for obtaining a wound culture swab from an infected open pressure ulcer?
    A) Swab old purulent exudate pooled in the wound basin before cleaning.
    B) Cleanse the wound thoroughly with 0.9% Normal Saline first, then press a sterile swab into viable, clean granulation tissue in a Z-pattern.
    C) Swab intact periwound skin margins.
    D) Swab dry black eschar.

CORRECT ANSWER: B) Cleanse the wound thoroughly with 0.9% Normal Saline first, then press a sterile swab into viable, clean granulation tissue in a Z-pattern.

RATIONALE: To identify true pathogens rather than surface colonizers: flush wound with saline first, then rotate swab over clean, viable granulation tissue using the Levine Z-technique.

96. When irrigating an open wound, in which direction should the nurse direct the flow of irrigation solution?
    A) From the dirtiest area to the cleanest area.
    B) From the cleanest area (least contaminated) to the dirtiest area (most contaminated).
    C) In rapid circular scrubbing motions.
    D) Bottom to top against gravity.

CORRECT ANSWER: B) From the cleanest area (least contaminated) to the dirtiest area (most contaminated).

RATIONALE: Irrigate from cleanest to most contaminated area to avoid flushing bacteria or debris into uninfected tissue.

97. What equipment setup provides safe, effective wound irrigation pressure (4 to 15 psi) without causing tissue trauma?
    A) High-pressure wall suction tubing set to 200 mmHg.
    B) A 35 mL syringe equipped with a 19-gauge angiocatheter or needleless cannula.
    C) A 5 mL syringe with a fine 25-gauge needle.
    D) A 100 mL bulb syringe held 2 feet above the wound.

CORRECT ANSWER: B) A 35 mL syringe equipped with a 19-gauge angiocatheter or needleless cannula.

RATIONALE: A 35 mL syringe with a 19-gauge catheter delivers ~8 psi of pressure—the evidence-based gold standard for effective debris removal without damaging granulation cells (safe range 4-15 psi).

98. A nurse notes that the skin surrounding a patient's leg ulcer is white, waterlogged, softened, and wrinkled. How should the nurse document this periwound condition?
    A) Induration
    B) Maceration
    C) Erythema
    D) Desiccation

CORRECT ANSWER: B) Maceration

RATIONALE: Maceration is tissue softening and breakdown resulting from prolonged exposure to excess moisture (wound exudate or urine), appearing white, boggy, and fragile.

99. What type of dressing is MOST appropriate for a dry, painful wound requiring autolytic debridement and moisture rehydration?
    A) Alginate dressing
    B) Hydrogel dressing
    C) Dry 4x4 gauze dressing
    D) Hydrocolloid powder

CORRECT ANSWER: B) Hydrogel dressing

RATIONALE: Hydrogels are high-water-content polymer dressings that donate moisture to dry wound beds, soothing pain and facilitating autolytic debridement.

100. An alginate dressing (derived from seaweed) is specifically indicated for which type of wound?
     A) Dry, necrotic eschar with zero drainage.
     B) Moderate to heavily exudating wounds and bleeding cavity wounds.
     C) Intact Stage 1 pressure injuries.
     D) Clean, superficial abrasions.

CORRECT ANSWER: B) Moderate to heavily exudating wounds and bleeding cavity wounds.

RATIONALE: Alginate dressings absorb up to 20 times their weight in exudate, forming a moist gel bed, and have subtle hemostatic properties for heavily exudating wounds.