CA Funda (2)

A nurse is caring for a patient with suspected extravasation from vesicant chemotherapy. Which action is most important? A. Remove the IV immediately and massage the site B. Stop the infusion but leave the catheter in place to aspirate the drug C. Apply heat to the affected area D. Elevate the extremity and continue infusion

Answer: B Rationale: In extravasation, stop the infusion, leave the catheter, and attempt to aspirate the drug to prevent further tissue damage. ---

Q52. A nurse is preparing to start an IV line in an elderly client with fragile veins. Which cannula size is most appropriate? A. 14G Orange B. 18G Green C. 20G Pink D. 24G Yellow

Answer: D Rationale: 24G Yellow is best for fragile veins in elderly or pediatric patients. ---

Q53. A client is receiving hypotonic IV fluids (0.45% NS). Which complication should the nurse monitor for? A. Hypotension B. Pulmonary edema C. Cellular swelling and possible rupture D. Increased serum sodium

Answer: C Rationale: Hypotonic solutions hydrate cells, which can swell and burst if uncontrolled. ---

Q54. A client receiving IV fluids complains of burning pain, blistering, and tissue necrosis at the insertion site. What complication is this? A. Infiltration B. Extravasation C. Phlebitis D. Hematoma

Answer: B Rationale: Extravasation occurs when vesicant drugs leak into tissue, causing blistering and necrosis. ---

Q55. A nurse is caring for a patient with a blood transfusion running. The patient suddenly develops high fever, chills, and hypotension. What type of reaction is this most likely? A. Allergic reaction B. Hemolytic reaction C. Sepsis D. Circulatory overload

Answer: C Rationale: Septic transfusion reaction occurs when contaminated blood is administered, presenting with fever, chills, and hypotension. ---

Q56. The nurse is teaching about blood types. Which patient is considered a universal recipient? A. Type O negative B. Type A positive C. Type AB positive D. Type B negative

Answer: C Rationale: AB positive individuals can receive any ABO blood type (universal recipient). ---

Q57. The nurse is caring for a patient receiving a platelet transfusion. Which IV set is most appropriate? A. Macrodrip set with filter B. Blood transfusion set with filter C. Infusion pump without filter D. Standard IV set without filter

Answer: B Rationale: Platelets and blood products require a special filter tubing to prevent clots and debris infusion. ---

Q58. The nurse is preparing to insert a urinary catheter. Before insertion, which assessment is most critical? A. Vital signs B. Fluid intake C. Allergies to latex or iodine D. Urine color

Answer: C Rationale: Allergies to latex, iodine, or antiseptics must be checked to prevent anaphylaxis. ---

Q59. A nurse is caring for a patient with a Foley catheter. Which action is appropriate to reduce infection risk? A. Keep the drainage bag above bladder level B. Secure catheter tubing to the thigh C. Empty urine by disconnecting the catheter D. Irrigate catheter daily

Answer: B Rationale: Securing the catheter prevents trauma. The drainage bag should always remain below bladder level to prevent backflow. ---

Q60. A nurse is preparing an enema for a child. How far should the rectal tube be inserted? A. 2.5–3.75 cm (1–1.5 in) B

. 5–7.5 cm (2–3 in) C. 7.5–10 cm (3–4 in) D. 12–15 cm (5–6 in)

Answer: B Rationale: In children, insert the tube 5–7.5 cm (2–3 in). Deeper may cause injury.

Q61–Q70

A nurse is preparing to administer an oil-retention enema. What is the minimum time the patient should retain the solution for effectiveness? A. 5 minutes B. 10 minutes C. 30 minutes D. 30 minutes or more

Answer: D Rationale: Oil-retention enemas should be retained at least 30 minutes or longer to soften feces and lubricate passage. ---

Q62. A nurse is caring for a client with oxygen via nasal cannula at 6 L/min. What is the expected FiO₂ delivered? A. 24% B. 36% C. 45% D. 44%

Answer: D Rationale: Nasal cannula: 2–6 L/min = 24–45% FiO₂. At 6 L/min, FiO₂ ≈ 44%. ---

Q63. A client is receiving oxygen through a Venturi mask set at 35%. What flow rate should the nurse set? A. 2 L/min B. 4 L/min C. 6 L/min D. 8 L/min

Answer: D Rationale: For 35% FiO₂, Venturi mask requires 8 L/min flow. ---

Q64. A nurse is suctioning a tracheostomy. What is the maximum time each suction pass should last? A. 5 seconds B. 10 seconds C. 20 seconds D. 30 seconds

Answer: B Rationale: Each suction pass should last no longer than 10 seconds to prevent hypoxia. ---

Q65. A client with a tracheostomy is unable to speak. Which nursing intervention promotes communication? A. Provide a bell or call light within reach B. Suction frequently to maintain airway C. Inflate the cuff during meals D. Limit visitors to reduce anxiety

Answer: A Rationale: Providing a call light or bell ensures the client can communicate needs despite inability to speak. ---

Q66. A nurse is caring for a client with an ileostomy. Which finding is expected? A. Formed stool B. Watery effluent with digestive enzymes C. Mucus only D. Foul odor with solid stool

Answer: B Rationale: Ileostomy output is liquid stool containing digestive enzymes that can irritate skin. ---

Q67. A nurse is teaching colostomy care. At what point should the colostomy pouch be emptied? A. When one-third to one-half full B. Only when completely full C. Once every 12 hours D. Every 3 days

Answer: A Rationale: The pouch should be emptied when one-third to one-half full to prevent leakage and odor. ---

Q68. A client is receiving traction for a femoral fracture. Which finding indicates a complication? A. Weights hanging freely B. Heel elevated slightly off bed C. Skin warm and dry D. Absent pedal pulses

Answer: D Rationale: Absent pulses suggest impaired circulation, requiring immediate intervention. ---

Q69. A client in Russell’s traction asks why the heel is not touching the bed. What is the best response by the nurse? A. “It prevents pressure sores on your heel.” B. “It allows proper alignment of your hip and knee.” C. “It improves blood circulation to your foot.” D. “It helps reduce swelling in your ankle.”

Answer: B Rationale: In Russell’s traction, the heel must be off the bed to maintain correct alignment of hip and knee. ---

Q70. A nurse is preparing to measure the length for an NG tube in an infant. The correct measurement is from: A. Nose → Earlobe → Umbilicus B. Nose → Earlobe → Xiphoid process C. Nose → Earlobe → Midway between umbilicus and xiphoid D. Nose → Mouth → Sternum

Answer: C Rationale: For infants, measure nose → earlobe → midway between umbilicus and xiphoid process.

Q71.
The nurse is preparing to give tube feeding through a nasogastric tube. Which action is most important before feeding?
A. Flush tube with 100 mL water
B. Check for residual gastric content
C. Give the formula cold from refrigerator
D. Position the patient supine

Answer: B
Rationale: Checking for residual prevents aspiration and ensures tolerance of feeding.

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Q72.
A patient is placed on a clear liquid diet. Which food is appropriate?
A. Gelatin
B. Yogurt
C. Pudding
D. Scrambled eggs

Answer: A
Rationale: Gelatin is a clear liquid. Yogurt, pudding, and eggs are full liquid/soft diets.

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Q73.
A nurse is teaching a patient about a soft diet. Which meal selection is appropriate?
A. Fried chicken and corn
B. Scrambled eggs and mashed potatoes
C. Nuts and raw vegetables
D. Steak and salad

Answer: B
Rationale: Soft diets include easily chewed foods like scrambled eggs, mashed potatoes, and soft fruits.

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Q74.
A nurse is reviewing labs. Which sodium level is abnormal?
A. 140 mEq/L
B. 138 mEq/L
C. 150 mEq/L
D. 137 mEq/L

Answer: C
Rationale: Normal sodium: 136–145 mEq/L. A level of 150 is hypernatremia.

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Q75.
A nurse notes a patient has a serum calcium of 6.8 mg/dL. Which assessment is most important?
A. Chvostek’s and Trousseau’s signs
B. Bowel sounds
C. Urine output
D. Reflexes

Answer: A
Rationale: Hypocalcemia may cause tetany, positive Chvostek’s and Trousseau’s signs.

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Q76.
The nurse is reviewing a patient’s ABG and notes metabolic acidosis. Which finding is expected?
A. Deep, rapid breathing (Kussmaul’s respirations)
B. Shallow, slow breathing
C. Respiratory arrest
D. Bradypnea with apnea

Answer: A
Rationale: Kussmaul’s respirations are compensatory for metabolic acidosis.

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Q77.
A nurse is reviewing a patient’s CBC. Which finding suggests infection?
A. WBC 9,000/mm³
B. WBC 15,000/mm³
C. Platelets 250,000/µL
D. Hemoglobin 14 g/dL

Answer: B
Rationale: Normal WBC: 5,000–10,000/mm³. 15,000 suggests infection.

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Q78.
A patient has triglycerides of 280 mg/dL. What is the correct interpretation?
A. Normal
B. Borderline high
C. High
D. Critically low

Answer: C
Rationale: Normal triglycerides:

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Q79.
A client receiving IV therapy complains of redness, pain, and warmth along the vein. What is this complication?
A. Infiltration
B. Hematoma
C. Phlebitis
D. Air embolism

Answer: C
Rationale: Phlebitis is inflammation of the vein with pain, redness, and tenderness.

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Q80.
The nurse notes a client with IV fluids is short of breath with crackles. What is the immediate action?
A. Increase IV rate
B. Stop infusion immediately
C. Slow IV to KVO rate
D. Lower patient’s head

Answer: C
Rationale: Crackles indicate fluid overload. Slow the infusion to KVO, then notify HCP.

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Q81.
A nurse is transfusing blood. Which is the most important nursing action during the first 15 minutes?
A. Stay with patient and monitor closely
B. Increase rate if no reaction occurs
C. Take vitals every hour
D. Administer antihistamines prophylactically

Answer: A
Rationale: Most transfusion reactions occur within first 15 minutes, so constant monitoring is vital.

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Q82.
A client’s potassium is 6.2 mEq/L. Which ECG change is most concerning?
A. Tall peaked T waves
B. Flat P waves
C. Prolonged QT interval
D. Short PR interval

Answer: A
Rationale: Hyperkalemia causes tall, peaked T waves and can lead to cardiac arrest.

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Q83.
A client has a platelet count of 50,000/µL. Which is the priority nursing intervention?
A. Monitor for bleeding and institute fall precautions
B. Start iron supplementation
C. Encourage fluid intake
D. Restrict dietary potassium

Answer: A
Rationale: Thrombocytopenia increases bleeding risk. Safety and bleeding precautions are priority.

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Q84.
A nurse is preparing to administer oxygen using a non-rebreather mask. Which finding indicates correct use?
A. Bag completely deflates on inspiration
B. Bag partially inflates at all times
C. Flow rate set at 2 L/min
D. Valves are taped open

Answer: B
Rationale: The reservoir bag must remain partially inflated to deliver high FiO₂ (60–100%).

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Q85.
A nurse is caring for a patient with an NG tube. The patient starts coughing and choking during insertion. What should the nurse do first?
A. Continue inserting quickly
B. Withdraw the tube slightly and pause
C. Remove the tube completely
D. Have the patient lie flat

Answer: B
Rationale: If gagging occurs, withdraw slightly and pause to allow recovery before proceeding.

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Q86–Q100

Q86.
A client has uric acid of 0.60 mmol/L. What does this indicate?
A. Normal
B. High
C. Low
D. Critically low

Answer: B
Rationale: Normal uric acid: 0.18–0.48 mmol/L. 0.60 indicates hyperuricemia.

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Q87.
A patient with colostomy asks when it will begin functioning after surgery. The nurse responds:
A. 12–24 hours
B. 1–2 days
C. 3–6 days
D. 7–10 days

Answer: C
Rationale: A new colostomy usually functions 3–6 days postoperatively.

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Q88.
A patient has a tracheostomy with cuff. What is the purpose of the cuff?
A. To maintain airway patency
B. To prevent aspiration and air leaks
C. To provide humidification
D. To reduce infection risk

Answer: B
Rationale: The cuff prevents aspiration and air leakage between tube and trachea.

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Q89.
A client has hemoglobin of 6.5 g/dL. What is the priority intervention?
A. Encourage oral fluids
B. Prepare for packed RBC transfusion
C. Administer diuretics
D. Monitor blood glucose

Answer: B
Rationale: Severe anemia requires packed RBC transfusion to restore oxygen carrying capacity.

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Q90.
A patient with suspected CHF has crackles and dyspnea. Which IV fluid should be avoided?
A. 0.9% NS
B. D5W
C. Lactated Ringer’s
D. 5% Dextrose in 0.9% NS

Answer: D
Rationale: Hypertonic solutions (e.g., D5NS) increase fluid volume and risk fluid overload in CHF.

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Q91.
A patient develops fever, anxiety, and urticaria 10 minutes after blood transfusion. What is the priority action?
A. Stop the transfusion immediately
B. Administer antihistamine
C. Continue transfusion at slower rate
D. Notify physician while transfusion continues

Answer: A
Rationale: Any transfusion reaction requires stopping transfusion immediately before further treatment.

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Q92.
A nurse is preparing to collect a urine culture from a client with Foley catheter. Which step is correct?
A. Drain urine from bag into sterile container
B. Use sterile syringe to aspirate urine from sampling port
C. Remove catheter and collect first voided urine
D. Disconnect catheter from tubing and collect

Answer: B
Rationale: Sterile aspiration from sampling port is correct method for urine culture.

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Q93.
A nurse is caring for a client receiving oxygen via simple face mask at 10 L/min. What is expected FiO₂?
A. 24–45%
B. 35–65%
C. 60–100%
D. 21%

Answer: B
Rationale: Simple face mask: 8–12 L/min = 35–65% FiO₂.

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Q94.
A client with an ileostomy is at greatest risk for which imbalance?
A. Hypernatremia
B. Hypokalemia
C. Hypercalcemia
D. Hypermagnesemia

Answer: B
Rationale: Ileostomy output contains large amounts of potassium → risk for hypokalemia.

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Q95.
A patient has hematocrit of 25%. What is the most appropriate therapy?
A. Platelet transfusion
B. Packed RBC transfusion
C. Albumin infusion
D. Normal saline infusion

Answer: B
Rationale: Low hematocrit = anemia. Packed RBC transfusion restores red cell mass.

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Q96.
A patient is being taught about preventing CAUTI. Which statement shows correct understanding?
A. “I should keep the drainage bag above bladder level.”
B. “I should keep a closed drainage system.”
C. “I should disconnect the bag to empty it.”
D. “I should clamp the tubing often.”

Answer: B
Rationale: Maintaining a closed system prevents bacterial entry and infection.

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Q97.
A client is prescribed D10W infusion. Which is the priority assessment?
A. Breath sounds
B. Neurologic status and blood glucose
C. Urine output
D. Bowel sounds

Answer: B
Rationale: Dextrose solutions can alter blood glucose levels → monitor neuro and glucose.

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Q98.
A patient receiving oxygen asks why a Venturi mask is used instead of nasal cannula. The best response is:
A. “It’s more comfortable.”
B. “It provides precise oxygen concentration.”
C. “It delivers more humidity.”
D. “It is cheaper than other devices.”

Answer: B
Rationale: Venturi masks deliver precise FiO₂ regardless of client’s breathing pattern.

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Q99.
A client on traction for femoral fracture asks why weights cannot touch the floor. What is the nurse’s best response?
A. “Because the weights will become contaminated.”
B. “It will interfere with the pulling force.”
C. “It may increase your risk of bleeding.”
D. “It will make you more uncomfortable.”

Answer: B
Rationale: Weights must hang freely to maintain continuous pulling force.

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Q100.
A nurse is preparing colostomy care. How much larger should the appliance opening be compared to stoma size?
A. Equal size
B. 0.3 cm (1/8 in) larger
C. 1 cm larger
D. Smaller than stoma

Answer: B
Rationale: Appliance should be 0.3 cm larger to prevent trauma and skin irritation.