(1st Set)Exam#2 from topics sent by Letecia, Nclex style(KLM)

1. A nurse is preparing to administer an IV piggyback (IVPB) medication of Cefazolin 1 g in 100 mL Normal Saline over 30 minutes to a post-surgical patient. The gravity infusion set has a drop factor of 15 gtt/mL. At what drip rate should the nurse set the manual IV regulator?
   A) 33 gtt/min
   B) 50 gtt/min
   C) 67 gtt/min
   D) 100 gtt/min

CORRECT ANSWER: B) 50 gtt/min

RATIONALE: Formula: (Total Volume in mL / Time in minutes) * Drop Factor (gtt/mL) = Flow Rate (gtt/min). (100 mL / 30 min) * 15 gtt/mL = 3.33 * 15 = 50 gtt/min.

2. A healthcare provider orders Heparin 800 units/hr IV continuous infusion for a patient with deep vein thrombosis. The pharmacy supplies a bag labeled Heparin 25,000 units in 500 mL D5W. At what rate in mL/hr should the nurse set the IV smart pump?
   A) 12 mL/hr
   B) 16 mL/hr
   C) 20 mL/hr
   D) 25 mL/hr

CORRECT ANSWER: B) 16 mL/hr

RATIONALE: Formula: (Desired Dose / Available Dose) * Volume = (800 units/hr / 25,000 units) * 500 mL = 0.032 * 500 = 16 mL/hr.

3. The nurse is preparing to administer Morphine 4 mg IV push to a patient experiencing acute severe pain. The vial on hand is labeled Morphine 10 mg/mL. After calculating the correct dose (0.4 mL), what is the most appropriate action for the nurse regarding the remaining 0.6 mL of morphine in the vial?
   A) Save the remaining 0.6 mL in the medication room for the patient's next scheduled dose.
   B) Discard the remaining 0.6 mL into the sink while another licensed nurse witnesses and documents the waste.
   C) Return the unused portion to the automated medication dispensing cabinet under a single nurse login.
   D) Administer the full 1 mL vial volume to avoid wasting controlled substances.

CORRECT ANSWER: B) Discard the remaining 0.6 mL into the sink while another licensed nurse witnesses and documents the waste.

RATIONALE: Federal law and hospital policy require that any wasted portion of a controlled substance (Schedule II) must be witnessed and documented by two licensed nurses at the time of disposal.

4. While flushing a patient's peripheral IV saline lock prior to administering a compatible IV medication, the nurse encounters significant resistance and the patient reports mild discomfort. What is the nurse's priority action?
   A) Apply firm, steady pressure on the syringe plunger to clear the lumen clot.
   B) Aspirate forcefully to pull back the occluding thrombus into the syringe.
   C) Stop flushing, aspirate for blood return, and if still occluded, remove the catheter and re-site.
   D) Attach a 50 mL IV bag of Normal Saline under gravity pressure to clear the catheter.

CORRECT ANSWER: C) Stop flushing, aspirate for blood return, and if still occluded, remove the catheter and re-site.

RATIONALE: Forcing a flush against resistance can dislodge a clot into the venous circulation or rupture the vein. If gentle aspiration does not yield blood return and resistance persists, the line is occluded and must be replaced.

5. A physician verbally orders 'Furosemide 40 mg IV push STAT' during a busy shift. According to Joint Commission and hospital safety standards, what is the mandatory nursing action prior to drug preparation?
   A) Administer the medication immediately and request a written order at the end of the shift.
   B) Repeat the order verbatim back to the prescriber, obtain confirmation, and document 'read-back'.
   C) Transcribe the order onto the eMAR and ask another staff nurse to sign for the verbal order.
   D) Refuse to accept verbal orders under any clinical circumstance.

CORRECT ANSWER: B) Repeat the order verbatim back to the prescriber, obtain confirmation, and document 'read-back'.

RATIONALE: Verbal orders are permitted in urgent/emergent situations, but safety standards mandate a 'read-back' process where the nurse reads the complete order back to the prescriber to confirm accuracy before administration.

6. A patient is prescribed Amoxicillin 500 mg PO every 8 hours. The medication available is Amoxicillin oral suspension 250 mg/5 mL. The patient asks how many teaspoons (tsp) to take for each dose at home. What is the correct advice?
   A) 1 tsp
   B) 2 tsp
   C) 3 tsp
   D) 4 tsp

CORRECT ANSWER: B) 2 tsp

RATIONALE: Desired dose = 500 mg. Concentration = 250 mg / 5 mL, so 500 mg = 10 mL. Since 1 tsp = 5 mL, 10 mL equals 2 teaspoons.

7. A pediatric patient weighing 33 lb is prescribed Acetaminophen 15 mg/kg PO for fever. The pharmacy provides Acetaminophen liquid 160 mg / 5 mL. How many mL should the nurse administer for a single dose?
   A) 5 mL
   B) 7.0 mL
   C) 7.03 mL
   D) 7.5 mL

CORRECT ANSWER: B) 7.0 mL

RATIONALE: Weight conversion: 33 lb / 2.2 = 15 kg. Total dose: 15 kg * 15 mg/kg = 225 mg. Volume: (225 mg / 160 mg) * 5 mL = 7.03125 mL. Standard clinical rounding for pediatric liquid doses yields 7.0 mL.

8. Which order written on an eMAR violates Institute for Safe Medication Practices (ISMP) standards regarding error-prone abbreviations and symbols?
   A) Levothyroxine 0.05 mg PO daily
   B) Enoxaparin 40 mg SubQ q24h
   C) Regular Insulin 6.0 U SubQ before meals
   D) Lorazepam 1 mg IV push PRN anxiety

CORRECT ANSWER: C) Regular Insulin 6.0 U SubQ before meals

RATIONALE: Using trailing zeros (6.0 instead of 6) and the abbreviation 'U' (which can be misread as 0 or 4) violates ISMP standards. Trailing zeros can be misread as 60 if the decimal point is missed.

9. A patient prescribed extended-release Potassium Chloride (K-Dur 20 mEq ER) informs the nurse, 'These large pills are very difficult to swallow. Can you crush it into my applesauce?' What is the nurse's best response?
   A) 'Yes, I will crush it thoroughly so it mixes easily with your applesauce.'
   B) 'I cannot crush this pill because it is designed to release slowly; crushing it could cause a sudden dangerous potassium spike.'
   C) 'I will dissolve the pill in warm water for 15 minutes before administering it.'
   D) 'You may chew the tablet quickly with a full glass of water.'

CORRECT ANSWER: B) 'I cannot crush this pill because it is designed to release slowly; crushing it could cause a sudden dangerous potassium spike.'

RATIONALE: Extended-release (ER, XL, SR) and enteric-coated (EC) formulations must never be crushed, chewed, or dissolved, as destroying the matrix causes rapid drug absorption ('dose dumping') leading to severe toxicity.

10. The nurse is administering a piggyback IV antibiotic (IVPB) using a gravity drip tubing system. Where should the primary IV fluid container be positioned relative to the secondary antibiotic container?
    A) At the exact same height as the secondary container.
    B) Lower than the secondary container using the extension hook.
    C) Higher than the secondary container to increase primary hydrostatic pressure.
    D) Clamped completely off while hanging at equal height.

CORRECT ANSWER: B) Lower than the secondary container using the extension hook.

RATIONALE: To infuse a secondary IVPB via gravity, the secondary bag must hang higher than the primary bag. Hydrostatic pressure from the higher secondary bag keeps the primary line back-check valve closed until the secondary bag empties.

11. An adult patient admitted with severe dehydration is prescribed an IV infusion of 1,000 mL Normal Saline over 8 hours. The IV pump is unavailable, and the manual tubing drop factor is 20 gtt/mL. What rate in gtt/min is required?
    A) 21 gtt/min
    B) 35 gtt/min
    C) 42 gtt/min
    D) 125 gtt/min

CORRECT ANSWER: C) 42 gtt/min

RATIONALE: Time in minutes = 8 hours * 60 = 480 min. Drip rate = (1000 mL / 480 min) * 20 gtt/mL = 2.083 * 20 = 41.67 -> 42 gtt/min.

12. A nurse enters a patient's room to administer scheduled morning medications. The patient states, 'I feel nauseous and I do not want to take my blood pressure medication today.' Which initial action by the nurse upholds patient rights?
    A) Hide the medication in the patient's breakfast applesauce without telling them.
    B) Respect the refusal, assess the patient's symptoms/vital signs, educate on risks, and notify the prescriber.
    C) Insist that the patient must take the medication because the physician ordered it.
    D) Document that the patient was uncooperative and discard the medication immediately.

CORRECT ANSWER: B) Respect the refusal, assess the patient's symptoms/vital signs, educate on risks, and notify the prescriber.

RATIONALE: Patients have the competent legal right to refuse treatment. The nurse must respect this right, assess the reason for refusal, provide education regarding potential consequences, document the refusal, and inform the healthcare provider.

13. A nurse is injecting IV push Pantoprazole through a primary line infusing Total Parenteral Nutrition (TPN). As the drug enters the Y-site, a cloudy white precipitation forms immediately in the tubing. What is the nurse's priority action?
    A) Speed up the TPN rate to flush the cloudiness quickly into the vein.
    B) Immediately clamp the IV line near the patient access site and stop injecting.
    C) Apply warm compresses over the IV site to dissolve the precipitate.
    D) Aspirate 10 mL from the distal port and continue administering the pantoprazole slowly.

CORRECT ANSWER: B) Immediately clamp the IV line near the patient access site and stop injecting.

RATIONALE: Precipitate formation indicates chemical incompatibility that can cause microemboli, line occlusion, or tissue vascular damage. The nurse must immediately stop the infusion, clamp the line, disconnect the drug, and replace contaminated tubing.

14. What essential safety step must a nurse perform during the second check of medication administration?
    A) Check the medication label against the MAR when removing it from the dispensing drawer/shelf.
    B) Compare the medication label directly against the eMAR after retrieving and preparing the medication.
    C) Scan the patient's ID band and compare the label at the bedside immediately before administration.
    D) Ask the patient to state their name and date of birth before opening the unit-dose package.

CORRECT ANSWER: B) Compare the medication label directly against the eMAR after retrieving and preparing the medication.

RATIONALE: The 3 checks of med administration are: (1) Upon initial retrieval from storage/drawer; (2) After retrieval/preparation, comparing label against the MAR/eMAR; (3) At the bedside right before administration.

15. A patient with renal impairment is prescribed Vancomycin IV. The pharmacist requests a trough level before the 4th dose. When should the nurse draw the blood sample for the Vancomycin trough level?
    A) 30 minutes after completing the Vancomycin IV infusion.
    B) Midway through the 12-hour dosing interval.
    C) Immediately (within 30 minutes) prior to administering the next scheduled dose.
    D) 2 hours following the completion of the dose.

CORRECT ANSWER: C) Immediately (within 30 minutes) prior to administering the next scheduled dose.

RATIONALE: Serum trough levels measure the lowest drug concentration in the bloodstream and must be drawn immediately (typically 30 minutes or less) before administering the next scheduled dose.

16. A nurse is administering a subcutaneous insulin injection to an obese patient using a 5/16-inch (8 mm) needle. At what angle should the needle be inserted into the pinched skin fold?
    A) 15 degrees
    B) 30 degrees
    C) 45 degrees
    D) 90 degrees

CORRECT ANSWER: D) 90 degrees

RATIONALE: For subcutaneous insulin injections, a 90-degree angle is used if 2 inches of tissue can be pinched (standard for short 5/16 inch needles in average to obese adults). A 45-degree angle is used if only 1 inch of tissue can be pinched.

17. A patient is prescribed 1 L of D5W with 20 mEq KCl to infuse over 10 hours. How many mEq of KCl is the patient receiving per hour?
    A) 2 mEq/hr
    B) 5 mEq/hr
    C) 10 mEq/hr
    D) 20 mEq/hr

CORRECT ANSWER: A) 2 mEq/hr

RATIONALE: Total dose = 20 mEq KCl over 10 hours. Rate per hour = 20 mEq / 10 hours = 2 mEq/hr.

18. What action by the nurse represents adherence to Bar-Code Medication Administration (BCMA) protocol?
    A) Scanning all medication packages at the nurse's station counter before entering the patient room.
    B) Scanning the patient's wristband, scanning each individual medication package at the bedside, and verifying matches on the eMAR screen.
    C) Overriding a BCMA safety alert when a drug label barcode fails to scan twice.
    D) Asking a nursing assistant to scan the patient band while the nurse prepares the IV push.

CORRECT ANSWER: B) Scanning the patient's wristband, scanning each individual medication package at the bedside, and verifying matches on the eMAR screen.

RATIONALE: BCMA safety requires scanning the patient's wristband and each medication unit package directly at the bedside in real time to ensure the 'Right Patient' and 'Right Medication' system check.

19. A physician orders Ampicillin 1 g IVPB in 50 mL NS to run over 15 minutes. At what rate in mL/hr should the nurse program the infusion pump?
    A) 100 mL/hr
    B) 150 mL/hr
    C) 200 mL/hr
    D) 300 mL/hr

CORRECT ANSWER: C) 200 mL/hr

RATIONALE: To find mL/hr for an infusion lasting less than an hour: (Volume in mL / Minutes) * 60 minutes = (50 mL / 15 min) * 60 = 3.333 * 60 = 200 mL/hr.

20. Which intravenous access site carries the highest risk of catheter-related bloodstream infection (CRBSI) and should be avoided for central line placement when possible?
    A) Subclavian vein
    B) Internal jugular vein
    C) Femoral vein
    D) Basilic vein (PICC)

CORRECT ANSWER: C) Femoral vein

RATIONALE: CDC and evidence-based guidelines highlight that the femoral site has the highest risk of bacterial contamination and CRBSI due to proximity to the perineum and skin folds, and should be avoided in adults.

21. A patient arrives in the PACU following abdominal surgery under general anesthesia. What is the nurse's priority physical assessment?
    A) Surgical dressing saturation and wound drain output.
    B) Airway patency, respiratory rate, and oxygen saturation.
    C) Level of consciousness and orientation to person, place, and time.
    D) Core body temperature and shivering assessment.

CORRECT ANSWER: B) Airway patency, respiratory rate, and oxygen saturation.

RATIONALE: In accordance with ABC priorities (Airway, Breathing, Circulation), airway patency and respiratory adequacy take absolute precedence over all other postoperative assessments following general anesthesia.

22. Two hours postoperatively, a patient's heart rate increases from 76 to 118 beats/min, blood pressure drops from 128/82 to 90/58 mm Hg, and the surgical drain yields 150 mL of bright red blood in 30 minutes. What complication does the nurse suspect?
    A) Malignant hyperthermia
    B) Hypovolemic shock due to hemorrhage
    C) Deep vein thrombosis (DVT)
    D) Normal emergence response from anesthesia

CORRECT ANSWER: B) Hypovolemic shock due to hemorrhage

RATIONALE: Tachycardia, hypotension, and sudden excessive frank bloody (sanguineous) output are classic manifestations of active hemorrhage leading to hypovolemic shock.

23. During a surgical 'Time-Out' performed in the operating room immediately before the incision, who must participate in verifying the patient identity, surgical site, and procedure?
    A) Only the operating surgeon and scrub nurse.
    B) Only the circulating nurse and anesthesiologist.
    C) The entire surgical team, including surgeon, anesthesia provider, circulating nurse, and scrub personnel.
    D) The surgical holding nurse and patient.

CORRECT ANSWER: C) The entire surgical team, including surgeon, anesthesia provider, circulating nurse, and scrub personnel.

RATIONALE: The Joint Commission Universal Protocol requires an active verbal 'Time-Out' involving the ENTIRE surgical team immediately before surgical incision to confirm correct patient, procedure, and site.

24. A patient scheduled for an elective cholecystectomy expresses anxiety and says, 'I am really not sure what the surgeon is going to remove or how they will do it.' What is the nurse's most appropriate action?
    A) Explain the surgical technique in detail and ask the patient to sign the consent form.
    B) Reassure the patient that everything will be fine and witness the consent signature.
    C) Notify the operating surgeon that the patient requires further explanation before signing the informed consent.
    D) Cancel the surgical case immediately on the operating room schedule.

CORRECT ANSWER: C) Notify the operating surgeon that the patient requires further explanation before signing the informed consent.

RATIONALE: The surgeon/provider has the legal duty to explain the surgical procedure, risks, benefits, and alternatives. If the patient demonstrates a lack of understanding, the nurse must notify the surgeon prior to witnessing consent.

25. A patient undergoing surgery under general anesthesia suddenly develops muscle rigidity, rapid rise in end-tidal CO2, tachypnea, and a rapidly climbing core body temperature (103°F / 39.4°C). What emergency medication must be administered?
    A) Atropine sulfate
    B) Dantrolene sodium
    C) Epinephrine
    D) Neostigmine

CORRECT ANSWER: B) Dantrolene sodium

RATIONALE: Malignant hyperthermia is a life-threatening pharmacogenetic metabolic emergency triggered by volatile inhalational anesthetics and succinylcholine. Dantrolene sodium is the specific skeletal muscle relaxant used to reverse it.

26. A 68-year-old postoperative abdominal surgery patient refuses to perform incentive spirometry because 'it hurts my incision.' What is the nurse's best intervention?
    A) Omit incentive spirometry and encourage bed rest.
    B) Administer prescribed analgesic medication, show the patient how to splint the incision with a pillow, and then assist with spirometry.
    C) Instruct the patient to blow forcefully into the device instead of inhaling slowly.
    D) Notify the physician that the patient is refusing respiratory care.

CORRECT ANSWER: B) Administer prescribed analgesic medication, show the patient how to splint the incision with a pillow, and then assist with spirometry.

RATIONALE: Pre-medicating for pain and teaching incisional splinting (holding a pillow firmly over the abdominal wound) minimizes pain during deep breathing and incentive spirometry, facilitating compliance and preventing atelectasis.

27. A nurse is caring for a patient who had a spinal anesthesia block for a orthopedic procedure. Which assessment finding requires immediate nursing intervention?
    A) Inability to lift the big toe 1 hour post-procedure
    B) Blood pressure drop from 120/78 to 86/50 mm Hg
    C) Mild numbness in both feet
    D) Absence of bowel sounds

CORRECT ANSWER: B) Blood pressure drop from 120/78 to 86/50 mm Hg

RATIONALE: Spinal anesthesia blocks sympathetic vasomotor nerves, causing arterial and venous vasodilation leading to severe hypotension. This requires rapid intervention (IV fluid bolus, vasopressors, head flat/elevation of legs).

28. An adult patient who is competent has a valid Medical Orders for Life-Sustaining Treatment (MOLST) form specifying 'Do Not Resuscitate' (DNR). The patient is undergoing an emergency bowel resection. How is the DNR status managed perioperatively?
    A) The DNR order is automatically voided permanently upon entering the operating room.
    B) The DNR order remains in full effect without discussion during surgery.
    C) The surgeon, anesthesiologist, patient/surrogate explicitly discuss and document whether the DNR order is temporarily suspended or modified during the perioperative period.
    D) The hospital ethics committee must decide the resuscitation status.

CORRECT ANSWER: C) The surgeon, anesthesiologist, patient/surrogate explicitly discuss and document whether the DNR order is temporarily suspended or modified during the perioperative period.

RATIONALE: Policy requires 'required reconsideration' where the surgical and anesthesia team discuss DNR/MOLST status with the patient/surrogate before surgery to clarify which specific life-sustaining measures are acceptable during anesthesia.

29. Which patient statement indicates a clear understanding of preoperative fasting (NPO) guidelines prior to elective surgery under general anesthesia?
    A) 'I drank a large glass of orange juice with pulp 2 hours ago.'
    B) 'I ate a full fried bacon and egg breakfast 4 hours before arriving.'
    C) 'I stopped drinking clear liquids like water 2 hours before my scheduled arrival time.'
    D) 'I can chew mint bubblegum up until I enter the operating room.'

CORRECT ANSWER: C) 'I stopped drinking clear liquids like water 2 hours before my scheduled arrival time.'

RATIONALE: ASA guidelines allow clear liquids (water, fruit juice without pulp, clear tea) up to 2 hours before elective procedures. Heavy meals require 8 hours NPO; gum stimulates gastric acid secretion.

30. On the third postoperative day following an open appendectomy, the nurse assesses the patient's wound. Which finding is the earliest indicator of a localized surgical site infection (SSI)?
    A) Profuse foul-smelling purulent drainage
    B) Increasing localized erythema, warmth, and tenderness along the suture line
    C) Total wound dehiscence
    D) Temperature of 103.8°F (39.9°C) with rigors

CORRECT ANSWER: B) Increasing localized erythema, warmth, and tenderness along the suture line

RATIONALE: Early localized SSI signs include progressive redness (erythema), localized heat, edema, and worsening focal tenderness along the incision line before gross purulence or systemic fever develops.

31. A patient who underwent a hysterectomy 24 hours ago complains of right calf pain and tenderness. The nurse notes mild edema and warmth in the right lower extremity. What is the nurse's priority action?
    A) Massage the right calf vigorously to relieve muscle cramping.
    B) Apply a sequential compression device (SCD) tightly over the right leg.
    C) Elevate the extremity, instruct the patient to remain on bed rest, and notify the healthcare provider.
    D) Assist the patient to ambulate 100 feet down the hallway.

CORRECT ANSWER: C) Elevate the extremity, instruct the patient to remain on bed rest, and notify the healthcare provider.

RATIONALE: Suspected deep vein thrombosis (DVT) requires bed rest and notification of the provider. Massaging the leg or applying active SCD compression over an established clot can dislodge it, causing a fatal pulmonary embolism.

32. What type of surgery is classified as an urgent procedure that requires prompt attention within 24 to 48 hours to preserve health?
    A) Cosmetic rhinoplasty
    B) Emergency repair of a ruptured aortic aneurysm
    C) Acute gallbladder removal for symptomatic cholecystitis
    D) Elective total knee replacement

CORRECT ANSWER: C) Acute gallbladder removal for symptomatic cholecystitis

RATIONALE: Urgent surgeries must be performed within 24–48 hours to preserve patient health (e.g., acute cholecystitis, kidney stones). Ruptured aneurysm is Emergency (immediate); joint replacement is Elective.

33. A patient in the PACU is emerging from general anesthesia and displays agitation, confusion, and disorientation. What is the nurse's initial assessment priority?
    A) Administer a dose of IV haloperidol for acute psychosis.
    B) Assess arterial oxygen saturation with pulse oximetry to rule out hypoxia.
    C) Restrain the patient's wrists to prevent pulling at IV lines.
    D) Call the family into the PACU room to calm the patient.

CORRECT ANSWER: B) Assess arterial oxygen saturation with pulse oximetry to rule out hypoxia.

RATIONALE: Hypoxia is the most dangerous and common cause of postoperative agitation and emergence delirium in the PACU. Oxygenation must always be assessed first before assuming psychological delirium.

34. Which clinical finding in a patient who received spinal anesthesia indicates that the block is wearing off and motor function is returning?
    A) Patient reports a feeling of pins and needles in the shoulders.
    B) Patient is able to bend the knees and touch toes.
    C) Patient demonstrates ability to wiggle the toes and flex the ankles.
    D) Patient regains full urinary continence.

CORRECT ANSWER: C) Patient demonstrates ability to wiggle the toes and flex the ankles.

RATIONALE: Motor recovery following spinal anesthesia progresses from distal to proximal. Wiggling toes and flexing ankles (dorsiflexion) is the earliest objective indicator of motor block regression.

35. A nurse is educating a patient preoperatively about preventing postoperative atelectasis. How often should the patient be instructed to perform incentive spirometry while awake?
    A) 5 to 10 breaths every 1 to 2 hours
    B) 20 deep breaths every 4 hours
    C) 5 breaths once per shift
    D) Only when feeling short of breath

CORRECT ANSWER: A) 5 to 10 breaths every 1 to 2 hours

RATIONALE: Evidence-based postoperative respiratory protocols dictate that patients perform 5 to 10 sustained maximal inspirations using the incentive spirometer every 1 to 2 hours while awake.

36. Which designated surrogate individual holds legal authority to make healthcare decisions for an incapacitated patient when designated in a legally executed document?
    A) The patient's eldest living child
    B) The primary attending physician
    C) The individual named in the patient's Healthcare Proxy (Durable Power of Attorney for Healthcare)
    D) The hospital risk manager

CORRECT ANSWER: C) The individual named in the patient's Healthcare Proxy (Durable Power of Attorney for Healthcare)

RATIONALE: A Healthcare Proxy / Durable Power of Attorney for Healthcare legally designates a specific surrogate decision-maker who assumes authority only when the patient loses decision-making capacity.

37. While assessing a patient's surgical abdominal incision 4 days postoperatively, the nurse notes that the wound edges have separated and 5 inches of small intestine loop is protruding through the wound. What is the nurse's immediate action?
    A) Push the intestine back inside the abdominal cavity using sterile gloved hands.
    B) Cover the exposed bowel with sterile towels saturated with warm Normal Saline and call for immediate surgical intervention.
    C) Apply dry sterile gauze under a tight abdominal binder.
    D) Position the patient high Fowler's and encourage deep coughing.

CORRECT ANSWER: B) Cover the exposed bowel with sterile towels saturated with warm Normal Saline and call for immediate surgical intervention.

RATIONALE: Evisceration is a medical emergency. The nurse must cover protruding organs with sterile towels soaked in warm sterile 0.9% saline, place patient in low Fowler's with knees flexed, keep NPO, and notify surgery immediately.

38. What is the primary operational advantage of Moderate Sedation (Conscious Sedation) during minor outpatient procedures?
    A) The patient requires endotracheal intubation and mechanical ventilation.
    B) The patient maintains an open airway independently and responds purposefully to verbal/tactile commands.
    C) The patient experiences complete muscle paralysis and loss of all reflexes.
    D) The patient remains fully awake without any anterograde amnesia.

CORRECT ANSWER: B) The patient maintains an open airway independently and responds purposefully to verbal/tactile commands.

RATIONALE: Moderate sedation depresses consciousness while allowing the patient to maintain a patent airway independently, retain protective airway reflexes, and respond purposefully to verbal or light tactile stimulation.

39. Which preoperative assessment finding in a patient scheduled for surgery under general anesthesia poses the highest risk for intraoperative adverse drug reactions?
    A) History of mild seasonal allergies treated with cetirizine
    B) Unreported patient use of herbal supplements St. John's Wort and Ginkgo Biloba
    C) Well-controlled hypertension on lisinopril
    D) History of uncomplicated appendectomy 10 years ago

CORRECT ANSWER: B) Unreported patient use of herbal supplements St. John's Wort and Ginkgo Biloba

RATIONALE: Herbal supplements like Ginkgo Biloba increase bleeding risk, and St. John's Wort alters hepatic metabolism of anesthetic agents. Unreported herbals pose significant covert surgical risks.

40. Postoperative voiding must be monitored closely. Within how many hours after catheter removal or surgery should a patient void before evaluating for urinary retention?
    A) 2 to 4 hours
    B) 6 to 8 hours
    C) 12 hours
    D) 24 hours

CORRECT ANSWER: B) 6 to 8 hours

RATIONALE: Patients are expected to void spontaneously within 6 to 8 hours following surgery or removal of an indwelling urinary catheter. Failure to void within 8 hours warrants a bladder scan assessment.

41. A nurse is planning hygiene care for an 84-year-old bedbound patient with dry, fragile skin. Which bathing modification protects skin integrity?
    A) Bathing daily using hot water and antibacterial bar soap.
    B) Bathing twice weekly using warm water, soapless pH-balanced cleanser, and applying emollient lotion immediately after.
    C) Rubbing the skin vigorously with a coarse terrycloth towel to stimulate circulation.
    D) Adding bubble bath oils into a hot tub soak for 30 minutes.

CORRECT ANSWER: B) Bathing twice weekly using warm water, soapless pH-balanced cleanser, and applying emollient lotion immediately after.

RATIONALE: Frequent hot water baths and harsh soaps remove essential epidermal skin lipids. Using warm water, pH-balanced mild cleansers, limiting bath frequency, and applying emollients preserves fragile skin in older adults.

42. What evidence-based practice guideline regarding Chlorhexidine Gluconate (CHG) skin bathing should the nurse follow for a patient with a central venous catheter?
    A) Rinse the skin thoroughly with warm tap water immediately after applying CHG.
    B) Apply CHG cloths above the neck and face area.
    C) Allow the CHG solution to air-dry completely on the skin without rinsing to maintain residual antimicrobial activity.
    D) Dilute CHG with isopropyl alcohol before wiping skin.

CORRECT ANSWER: C) Allow the CHG solution to air-dry completely on the skin without rinsing to maintain residual antimicrobial activity.

RATIONALE: CHG binds to skin proteins providing persistent microbial suppression. It must be allowed to air-dry and should NEVER be rinsed off. CHG should not be used on the face, eyes, or ears.

43. When performing perineal hygiene for an uncircumcised male patient, what sequence of actions must the nurse perform?
    A) Retract the foreskin, cleanse the glans, leave the foreskin retracted to air-dry.
    B) Retract the foreskin gently, cleanse the glans from meatus outward, rinse, and immediately replace the foreskin back over the glans.
    C) Cleanse over the foreskin without retraction to avoid patient pain.
    D) Scrub the meatus vigorously with an alcohol swab.

CORRECT ANSWER: B) Retract the foreskin gently, cleanse the glans from meatus outward, rinse, and immediately replace the foreskin back over the glans.

RATIONALE: Failure to return (replace) the retracted foreskin over the glans penis leads to severe venous congestion, edema, and localized tissue necrosis (paraphimosis).

44. What is the proper direction and technique for cleaning the perineal area of a female patient during bed hygiene?
    A) Wipe from the anal area upward toward the pubic arch using a circular motion.
    B) Wipe from the pubic arch back toward the anal area using a clean section of washcloth for each stroke.
    C) Scrub side-to-side across the labia using a single washcloth corner.
    D) Cleanse the rectal area first, then wash the urethral meatus.

CORRECT ANSWER: B) Wipe from the pubic arch back toward the anal area using a clean section of washcloth for each stroke.

RATIONALE: Cleansing from front to back (pubic arch to anus) prevents contamination of the clean urethral meatus with GI tract fecal bacteria (E. coli), reducing catheter-associated urinary tract infections.

45. A nurse is providing oral care to an unconscious intubated patient. Which position is essential to prevent aspiration during mouth care?
    A) High Fowler's position with head tilted back
    B) Supine position with head elevated 15 degrees
    C) Side-lying (lateral) position with the head turned toward the mattress and bed flat/low
    D) Trendelenburg position

CORRECT ANSWER: C) Side-lying (lateral) position with the head turned toward the mattress and bed flat/low

RATIONALE: Placing an unconscious patient in a lateral side-lying position allows fluid and oral secretions to drain out of the mouth by gravity rather than pooling in the pharynx and causing pulmonary aspiration.

46. A patient with severe peripheral neuropathy from Type 2 Diabetes asks the nurse to trim their thick toenails during morning hygiene. What is the nurse's best action?
    A) Use sharp nail clippers to round the edges deep into the nail borders.
    B) Soak the feet in hot water for 30 minutes, then file nails with a metal file.
    C) File nails straight across gently or consult a podiatrist for professional nail care.
    D) Cut the toenails in a curved V-shape.

CORRECT ANSWER: C) File nails straight across gently or consult a podiatrist for professional nail care.

RATIONALE: Diabetic patients with peripheral neuropathy have impaired healing and sensation. Nails should never be cut deep or rounded at corners; referral to a podiatrist is recommended to prevent accidental tissue injury.

47. Which hygiene intervention is specifically designed to reduce the incidence of Non-Ventilator Hospital-Acquired Pneumonia (NV-HAP) in medical-surgical inpatients?
    A) Daily chlorhexidine foot baths
    B) Meticulous oral hygiene with brushing twice daily and suctioning as needed
    C) Daily hair washing with medicated shampoo
    D) Frequent back massage with emollient lotion

CORRECT ANSWER: B) Meticulous oral hygiene with brushing twice daily and suctioning as needed

RATIONALE: Oral hygiene removes pathogenic oral plaque microflora. Without oral care, bacteria multiply rapidly and are aspirated into the lungs, making oral care a primary intervention against NV-HAP.

48. How should a nurse clean a patient's removable partial dentures during morning care?
    A) Hold dentures over a open dry porcelain sink while scrubbing with hot boiling water.
    B) Line the washbasin or sink with a washcloth/water cushion and scrub dentures using cool/lukewarm water and denture paste.
    C) Soak dentures overnight in pure isopropyl alcohol solution.
    D) Wrap dentures in a dry paper towel and store on the bedside table.

CORRECT ANSWER: B) Line the washbasin or sink with a washcloth/water cushion and scrub dentures using cool/lukewarm water and denture paste.

RATIONALE: Lining the sink with a cloth or water cushions prevents denture breakage if dropped. Boiling water or hot water warps denture plastic, and alcohol damages acrylic.

49. When changing bed linens for a patient who is on strict bed rest, what nursing practice maintains medical asepsis?
    A) Shake dirty linens vigorously in the air to remove crumbs before folding.
    B) Hold soiled linens tightly against the nurse's uniform while carrying them across the room.
    C) Place soiled linens directly into a laundry bag without letting them touch the floor or uniform.
    D) Drop soiled sheets onto the floor temporarily while placing clean fitted sheets.

CORRECT ANSWER: C) Place soiled linens directly into a laundry bag without letting them touch the floor or uniform.

RATIONALE: Soiled linens carry microorganisms. Shaking spreads airborne microbes; holding them against clothing contaminates uniforms; placing them on the floor contaminates room surfaces.

50. An elderly patient with moderate vascular dementia becomes agitated, screams, and pushes the nurse away during a shower. What is the nurse's best approach ('bathing without a battle')?
    A) Call two additional staff members to hold the patient down and complete the shower quickly.
    B) Stop the shower, calm the patient, adapt by offering a warm towel/towel bath while keeping the patient covered.
    C) Administer IV haloperidol and resume the shower in 10 minutes.
    D) Document that the patient refused all personal hygiene permanently.

CORRECT ANSWER: B) Stop the shower, calm the patient, adapt by offering a warm towel/towel bath while keeping the patient covered.

RATIONALE: Person-centered dementia care avoids forced bathing. Using towel baths, warm environment, keeping private areas covered, and adapting to patient comfort preserves dignity and reduces distress.

51. What is the primary cause of Incontinence-Associated Dermatitis (IAD) in bedbound adults?
    A) Mechanical pressure over bony prominences
    B) Chemical skin breakdown caused by prolonged contact with ammonia and enzymes in stool and urine
    C) Bacterial infection from staphylococcus aureus
    D) Systemic allergic reaction to barrier creams

CORRECT ANSWER: B) Chemical skin breakdown caused by prolonged contact with ammonia and enzymes in stool and urine

RATIONALE: IAD (a type of MASD) is an inflammatory skin response caused by chemical irritation when skin is repeatedly exposed to moisture, alkaline urine, and digestive enzymes in liquid stool.

52. How should a nurse perform eye care for a patient who has crusting or dried secretions along the eyelids?
    A) Wipe from the outer canthus inward to the inner canthus using a single cotton ball.
    B) Apply a warm, moist, sterile washcloth to loosen crusts, then wipe gently from inner canthus to outer canthus using a clean section of cloth for each stroke.
    C) Use a dry sterile gauze pad to rub the crusting off firmly.
    D) Instill alcohol-based drops onto the conjunctival sac.

CORRECT ANSWER: B) Apply a warm, moist, sterile washcloth to loosen crusts, then wipe gently from inner canthus to outer canthus using a clean section of cloth for each stroke.

RATIONALE: Wiping from inner to outer canthus prevents pulling debris and microorganisms into the nasolacrimal duct. Warm moist compresses soften crusts without causing corneal abrasion.

53. A patient with a continuous IV line infusing in the left forearm needs a gown change. How should the nurse proceed?
    A) Disconnect the IV tubing from the catheter, change the gown, and reconnect the line.
    B) Remove the gown from the right (unaffected) arm first, then slide the left sleeve off over the IV site and IV container.
    C) Cut the left sleeve of the gown with bandage scissors.
    D) Thread the IV bag through the right sleeve first.

CORRECT ANSWER: B) Remove the gown from the right (unaffected) arm first, then slide the left sleeve off over the IV site and IV container.

RATIONALE: Always undress the unaffected arm first, then slide the gown off the affected arm, threading the IV container and tubing through the sleeve from the inside out to avoid breaking line sterile integrity.

54. What is the recommended water temperature range for a patient's bed bath to ensure safety and comfort without scalding?
    A) 90°F to 95°F (32°C - 35°C)
    B) 105°F to 110°F (40.5°C - 43.3°C)
    C) 120°F to 125°F (48.8°C - 51.6°C)
    D) 130°F to 140°F (54.4°C - 60°C)

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

RATIONALE: Safe bath water temperature for adult bed baths is 105°F to 110°F (40.5°C to 43.3°C) to prevent thermal skin injury, particularly in patients with altered thermal sensation.

55. A patient who is comatose requires frequent eye care. Which intervention prevents corneal ulceration and drying?
    A) Leaving eyelids propped open to allow air drying.
    B) Instilling prescribed artificial tear drops or lubricating ointment and gently closing/patching eyelids if reflexes are absent.
    C) Washing the eyeball surface directly with tap water and soap.
    D) Placing a dry cotton 4x4 gauze pad over open eyes.

CORRECT ANSWER: B) Instilling prescribed artificial tear drops or lubricating ointment and gently closing/patching eyelids if reflexes are absent.

RATIONALE: Loss of corneal blink reflex exposes the cornea to drying, ulceration, and permanent damage. Lubricating ointments/drops and soft eye closure protect corneal integrity.

56. Which nursing intervention provides both psychological relaxation and physical stimulation of localized cutaneous circulation during evening (HS) care?
    A) Vigorous scrubbing of the lower legs
    B) A 3- to 5-minute back massage (effleurage) using warm lotion
    C) Applying ice packs to the lumbar spine
    D) Performing passive range of motion exercises at top speed

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

RATIONALE: Effleurage (long, gliding back strokes) during bedtime care promotes muscle relaxation, reduces anxiety, improves localized skin blood flow, and enhances sleep quality.

57. A nurse observes a nursing assistant preparing to soak the feet of a stroke patient with left-sided hemiplegia. What instruction should the nurse give?
    A) 'Ensure the water is at least 115°F to improve foot circulation.'
    B) 'Do not soak the feet; wash and dry them thoroughly, especially between the toes, to prevent tissue maceration.'
    C) 'Soak the feet for at least 45 minutes to soften calluses.'
    D) 'Apply thick lotion heavily between all the toes after soaking.'

CORRECT ANSWER: B) 'Do not soak the feet; wash and dry them thoroughly, especially between the toes, to prevent tissue maceration.'

RATIONALE: Prolonged soaking causes skin maceration and epidermal breakdown. Lotion should be applied to the tops and soles of feet but NEVER between toes, as trapped moisture fosters fungal growth.

58. What is the primary rationale for performing hair care (brushing and combing) daily for a bedbound patient?
    A) To prevent pediculosis capitis
    B) To distribute natural cutaneous oils along the hair shaft and stimulate scalp blood circulation
    C) To cure scalp seborrheic dermatitis permanently
    D) To decrease systemic core body temperature

CORRECT ANSWER: B) To distribute natural cutaneous oils along the hair shaft and stimulate scalp blood circulation

RATIONALE: Daily brushing prevents tangling/matting, distributes natural scalp sebum along the hair shaft, and stimulates scalp microcirculation.

59. A patient with a fresh facial piercing (nose stud) asks how to clean the site during daily facial hygiene. What is the correct nursing advice?
    A) Cleanse with hydrogen peroxide 3 times daily and twist the jewelry rapidly.
    B) Cleanse gentle with warm water and mild soap or normal saline, remove crusts, and avoid harsh chemicals like alcohol.
    C) Remove the jewelry daily and boil it in water.
    D) Apply antibiotic ointment heavily inside the nostril.

CORRECT ANSWER: B) Cleanse gentle with warm water and mild soap or normal saline, remove crusts, and avoid harsh chemicals like alcohol.

RATIONALE: Piercing sites should be cleaned with normal saline or mild soap/water. Harsh agents like alcohol or peroxide dry tissue and delay epithelialization.

60. Which bed position is best suited for performing oral hygiene on a conscious patient who can swallow safely?
    A) Flat supine position
    B) High Fowler's position (60 to 90 degrees)
    C) Trendelenburg position
    D) Prone position

CORRECT ANSWER: B) High Fowler's position (60 to 90 degrees)

RATIONALE: High Fowler's position prevents accidental aspiration of fluid or toothpaste and allows optimal movement during brushing and rinsing.

61. The nurse assesses a sacral lesion on a bedbound patient. The skin is intact with a localized area of dark red discoloration that does not blanch when light finger pressure is applied. How should the nurse document this pressure injury?
    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 presents as intact or nonintact skin with localized persistent nonblanchable deep red, maroon, or purple discoloration resulting from intense pressure/shear at the bone-muscle interface.

62. An assessment of a patient's heel reveals a 2 cm shallow open ulcer with a red-pink wound bed without slough or bruising. The dermis is exposed. What stage is this pressure injury?
    A) Stage 1
    B) Stage 2
    C) Stage 3
    D) Stage 4

CORRECT ANSWER: B) Stage 2

RATIONALE: Stage 2 is partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister.

63. A full-thickness tissue loss pressure injury over the ischial tuberosity displays visible subcutaneous adipose (fat) tissue and epibole (rolled wound edges). Bone, tendon, and muscle are not visible. How should the nurse stage this wound?
    A) Stage 2
    B) Stage 3
    C) Stage 4
    D) Unstageable

CORRECT ANSWER: B) Stage 3

RATIONALE: Stage 3 is full-thickness skin loss where subcutaneous fat is visible in the ulcer, and granulation tissue and epibole are often present. Bone, muscle, tendon, ligament, or cartilage are NOT exposed.

64. A nurse examines a pressure injury over the sacrum and notes exposed, directly palpable muscle tissue and visible tendon. Slough is present on part of the wound bed. What stage is this injury?
    A) Stage 2
    B) Stage 3
    C) Stage 4
    D) Unstageable

CORRECT ANSWER: C) Stage 4

RATIONALE: Stage 4 pressure injury involves full-thickness skin and tissue loss with directly visible or palpable fascia, muscle, tendon, ligament, cartilage, or bone.

65. A full-thickness pressure injury on a patient's trochanter is 100% covered by thick, adherent black eschar and yellow slough. The wound depth cannot be measured. How should the nurse stage this wound?
    A) Stage 3
    B) Stage 4
    C) Unstageable
    D) Deep Tissue Pressure Injury

CORRECT ANSWER: C) Unstageable

RATIONALE: If slough or eschar completely obscures the base of a full-thickness tissue ulcer so that true anatomical depth cannot be determined, the wound is classified as Unstageable.

66. An elderly bedbound patient has a dry, dark, intact, adherent eschar on the left heel with no redness, edema, or drainage surrounding it. What is the evidence-based management for this heel wound?
    A) Apply surgical debridement immediately to cut away the eschar.
    B) Apply wet-to-dry Dakin's dressings to soften the eschar.
    C) Leave the dry intact eschar undisturbed as a natural protective biological cover.
    D) Apply a hydrogel dressing to promote autolytic debridement.

CORRECT ANSWER: C) Leave the dry intact eschar undisturbed as a natural protective biological cover.

RATIONALE: Current NPIAP guidelines specify that stable, dry, adherent, intact eschar on the heels or ischemic limbs without erythema or fluctuance should NOT be debrided or softened; it serves as the body's natural cover.

67. A nurse calculates a patient's Braden Scale score upon admission. The subscale scores are: Sensory Perception 2, Moisture 2, Activity 1, Mobility 2, Nutrition 2, Friction/Shear 2 (Total = 11). How should the nurse interpret this risk level?
    A) No risk (Braden 19-23)
    B) Moderate risk (Braden 13-14)
    C) High risk (Braden 10-12)
    D) Very high risk (Braden 9 or lower)

CORRECT ANSWER: C) High risk (Braden 10-12)

RATIONALE: Braden scale scoring interpretation: 15-18 = Mild Risk; 13-14 = Moderate Risk; 10-12 = High Risk; 9 or lower = Very High Risk.

68. Which laboratory value indicates severe protein-calorie malnutrition placing a patient at extreme risk for impaired skin integrity and delayed pressure injury healing?
    A) Serum Albumin 2.6 g/dL (Normal 3.5 - 5.0 g/dL)
    B) Blood Urea Nitrogen (BUN) 14 mg/dL
    C) Serum Potassium 4.2 mEq/L
    D) Hemoglobin 14.0 g/dL

CORRECT ANSWER: A) Serum Albumin 2.6 g/dL (Normal 3.5 - 5.0 g/dL)

RATIONALE: Hypoalbuminemia (< 3.2-3.5 g/dL) is a major biochemical marker for severe protein depletion, causing tissue edema and severely compromising tissue repair and pressure injury defense.

69. To prevent shearing forces on the sacrum and coccyx of a bedbound patient, at what maximum angle should the head of the bed be maintained during routine rest?
    A) 15 degrees
    B) 30 degrees
    C) 45 degrees
    D) 90 degrees

CORRECT ANSWER: B) 30 degrees

RATIONALE: Elevating the head of the bed above 30 degrees causes the body to slide downward, creating shearing forces that stretch and tear deep microvascular capillaries over the sacrum.

70. What is the standard repositioning schedule for a bedbound patient and a chair-bound patient, respectively?
    A) Every 4 hours in bed; every 2 hours in chair
    B) Every 2 hours in bed; every 1 hour in chair
    C) Every shift (8 hours) in bed; every 4 hours in chair
    D) Only when the patient requests a position change

CORRECT ANSWER: B) Every 2 hours in bed; every 1 hour in chair

RATIONALE: Bedbound patients must be repositioned at least every 2 hours (q2h); chair-bound patients experience higher concentrated ischial pressure and must be repositioned or weight-shifted every 1 hour (q1h).

71. A nurse is positioning a bedbound patient in the 30-degree lateral side-lying position. Where should pillows be placed to prevent direct bone-on-bone pressure?
    A) Under the head only
    B) Between the knees/ankles, behind the back, and under the upper arm
    C) Under the sacrum directly
    D) Under the trochanter directly

CORRECT ANSWER: B) Between the knees/ankles, behind the back, and under the upper arm

RATIONALE: Pillows tucked behind the back maintain the 30-degree tilt (avoiding direct pressure on the trochanter), while pillows between knees and ankles prevent bony prominence friction/pressure.

72. Why are synthetic donut-shaped (ring) foam cushions strictly contraindicated for pressure injury prevention?
    A) They cause excessive sweating.
    B) They focus high ring pressure on surrounding tissue, causing venous congestion and localized ischemia in the center.
    C) They are too expensive for hospital use.
    D) They slip off chairs too easily.

CORRECT ANSWER: B) They focus high ring pressure on surrounding tissue, causing venous congestion and localized ischemia in the center.

RATIONALE: Donut cushions compress surrounding blood vessels in a tight ring, restricting blood flow to the central tissue area and worsening tissue ischemia.

73. How should a nurse properly offload (float) a patient's heels to prevent heel pressure injuries?
    A) Place a rolled towel directly under both heels.
    B) Place a pillow lengthwise under the patient's lower legs (calves) so the heels hang freely in the air.
    C) Elevate the foot of the bed 45 degrees.
    D) Apply tight compression stockings over the feet.

CORRECT ANSWER: B) Place a pillow lengthwise under the patient's lower legs (calves) so the heels hang freely in the air.

RATIONALE: Floating heels involves placing a pillow under the calves to elevate heels completely off the mattress surface, eliminating all localized heel pressure.

74. What physical mechanism distinguishes friction from shear in skin trauma?
    A) Friction damages deep muscle tissue; shear affects superficial dermis.
    B) Friction is mechanical rubbing of epidermis against a surface; shear is sliding of deeper tissue layers while surface skin remains fixed.
    C) Friction is caused by urine moisture; shear is caused by heat.
    D) Friction and shear are identical physical forces.

CORRECT ANSWER: B) Friction is mechanical rubbing of epidermis against a surface; shear is sliding of deeper tissue layers while surface skin remains fixed.

RATIONALE: Friction is a superficial force occurring when skin rubs against bedsheets (causing abrasion); shear occurs when skin remains fixed to sheets while skeletal structures slide, tearing deep blood vessels.

75. A nurse presses a finger against a reddened sacral area on a light-skinned patient and notices that the red area turns pale (white) before returning to red when released. How should the nurse document this finding?
    A) Nonblanchable erythema (Stage 1 Injury)
    B) Reactive hyperemia (blanchable erythema)
    C) Deep Tissue Pressure Injury
    D) Ecchymosis

CORRECT ANSWER: B) Reactive hyperemia (blanchable erythema)

RATIONALE: Reactive hyperemia is a normal physiological blood flow rebound following temporary ischemia. It turns white (blanches) when pressed and resolves when pressure is relieved, unlike Stage 1 (nonblanchable).

76. What role does microclimate play in pressure injury development?
    A) Ambient room temperature determines bone density.
    B) Accumulated moisture and elevated temperature at the skin-support surface interface soften stratum corneum, increasing vulnerability to shear and pressure.
    C) Humidity in the room prevents bacterial growth.
    D) Microclimate affects pulmonary respiratory rate.

CORRECT ANSWER: B) Accumulated moisture and elevated temperature at the skin-support surface interface soften stratum corneum, increasing vulnerability to shear and pressure.

RATIONALE: Microclimate refers to local temperature and humidity at the skin-mattress boundary. Excess heat and moisture (maceration) weaken skin resistance to pressure and shear.

77. Which subscale is included in the Braden Scale for pressure injury risk assessment?
    A) Heart rate variability
    B) Sensory perception
    C) Serum glucose level
    D) History of previous surgery

CORRECT ANSWER: B) Sensory perception

RATIONALE: The 6 Braden Scale subscales are: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction & Shear.

78. An elderly patient admitted with hip fracture is incontinent of stool and urine. Which nursing care combination provides optimal pressure injury and skin protection?
    A) Cleanse skin with harsh soap, dry vigorously, leave skin exposed to air.
    B) Cleanse promptly with pH-balanced no-rinse cleanser, apply moisture barrier cream, turn q2h, and place supportive pressure-redistribution mattress.
    C) Apply alcohol rubs to the sacrum q4h.
    D) Place 4 disposable plastic underpads under the sacrum.

CORRECT ANSWER: B) Cleanse promptly with pH-balanced no-rinse cleanser, apply moisture barrier cream, turn q2h, and place supportive pressure-redistribution mattress.

RATIONALE: Combining prompt hygienic moisture management, barrier protection, scheduled turning, and pressure-redistribution surfaces addresses both moisture and pressure etiology.

79. When assessing skin on a dark-skinned patient for early pressure injury, what physical assessment signs should the nurse evaluate instead of blanchable erythema?
    A) Skin pallor and loss of hair growth
    B) Localized changes in skin temperature (warmth/coolness), tissue consistency (induration/firmness/bogginism), and localized pain
    C) Presence of dark freckles
    D) Capillary refill speed in fingernails

CORRECT ANSWER: B) Localized changes in skin temperature (warmth/coolness), tissue consistency (induration/firmness/bogginism), and localized pain

RATIONALE: In dark-skinned patients, erythema is difficult to detect visually. Nurses must palpate for localized heat or coolness, tissue firmness (induration) or softness (bogginism), and assess for localized pain.

80. What specialized support surface is indicated for a patient with multiple Stage 3/4 pressure injuries on multiple turning surfaces?
    A) Standard hospital mattress
    B) Egg-crate foam mattress overlay
    C) Advanced Air-fluidized or Low-air-loss dynamic mattress system
    D) Firm orthopedic mattress

CORRECT ANSWER: C) Advanced Air-fluidized or Low-air-loss dynamic mattress system

RATIONALE: Dynamic low-air-loss or air-fluidized therapy beds continuously redistribute body pressure and control skin microclimate moisture, indicated for severe stage 3/4 or unstageable pressure injuries.

81. A patient's surgical incision is closed in the operating room using staples and silk sutures. The wound edges are neatly approximated. By which intention will this wound heal?
    A) Primary intention
    B) Secondary intention
    C) Tertiary intention
    D) Quaternary intention

CORRECT ANSWER: A) Primary intention

RATIONALE: Primary intention healing occurs in clean surgical wounds where wound edges are cleanly approximated with sutures, staples, or glue, resulting in minimal tissue loss and minimal scarring.

82. A patient has a large pressure ulcer left open to heal from the bottom up by filling with red granulation tissue. By which intention is this wound healing?
    A) Primary intention
    B) Secondary intention
    C) Tertiary intention
    D) Delayed primary intention

CORRECT ANSWER: B) Secondary intention

RATIONALE: Secondary intention occurs in wounds involving significant tissue loss (e.g., pressure ulcers, severe lacerations) where edges cannot be approximated. The wound heals by forming granulation tissue from the base upward.

83. A contaminated traumatic wound is initially cleansed and left open for 4 days to allow infection and edema to resolve before the surgeon suturing it closed. What is this healing process called?
    A) Primary intention
    B) Secondary intention
    C) Tertiary intention (Delayed Primary Closure)
    D) Reflexive closure

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

RATIONALE: Tertiary intention (delayed primary closure) occurs when a contaminated wound is left open deliberately for several days to allow infection/edema to subside, and then surgically closed.

84. What primary cellular event occurs during the Inflammatory Phase (Days 1 to 4) of wound healing?
    A) Collagen remodeling and scar contraction
    B) Influx of white blood cells (neutrophils and macrophages) to ingest bacteria and cellular debris
    C) Rapid epithelial re-surfacing
    D) Re-alignment of collagen fibers along stress lines

CORRECT ANSWER: B) Influx of white blood cells (neutrophils and macrophages) to ingest bacteria and cellular debris

RATIONALE: The inflammatory phase is dominated by leukocyte and macrophage activity that cleanses the wound bed through phagocytosis and releases growth factors to signal repair.

85. During wound assessment, the nurse observes bright, beefy red, moist tissue composed of new capillaries and fibroblasts filling the base of a healing ulcer. How should the nurse document this tissue?
    A) Slough
    B) Eschar
    C) Granulation tissue
    D) Epibole

CORRECT ANSWER: C) Granulation tissue

RATIONALE: Granulation tissue is healthy, highly vascular connective tissue that is pink or beefy red, moist, and bleeds easily, forming the foundation for wound healing during the proliferative phase.

86. A nurse assesses drainage from a fresh surgical drain and notes that it is clear, thin, and watery straw-colored. What type of exudate is this?
    A) Sanguineous
    B) Serous
    C) Serosanguineous
    D) Purulent

CORRECT ANSWER: B) Serous

RATIONALE: Serous exudate is clear, watery fluid derived from the serous portion of blood serum.

87. The nurse notes pinkish-thin watery drainage composed of a mixture of clear serum and light red blood cells on a surgical dressing. How should this exudate be documented?
    A) Serous
    B) Sanguineous
    C) Serosanguineous
    D) Purulent

CORRECT ANSWER: C) Serosanguineous

RATIONALE: Serosanguineous drainage is a pale, pink, watery mixture of clear serous fluid and red blood cells, commonly seen in surgical wounds.

88. A wound assessment reveals thick, opaque, yellow-green drainage with a foul odor. How should the nurse classify this exudate?
    A) Serous
    B) Sanguineous
    C) Serosanguineous
    D) Purulent

CORRECT ANSWER: D) Purulent

RATIONALE: Purulent drainage is thick, opaque fluid containing dead white blood cells, cellular debris, and liquefied bacteria (pus), indicating infection.

89. According to the RYB (Red-Yellow-Black) Wound Color Code system, what is the primary clinical objective for a wound classified as 'Yellow'?
    A) Protect fragile tissue gently.
    B) Cleanse yellow slough and absorb excess exudate.
    C) Debride thick black eschar immediately.
    D) Apply dry gauze dressings only.

CORRECT ANSWER: B) Cleanse yellow slough and absorb excess exudate.

RATIONALE: In the RYB color system: Red = Protect (granulation); Yellow = Cleanse (slough/exudate); Black = Debride (necrotic eschar).

90. How does a Jackson-Pratt (JP) drain maintain suction to pull fluid from a surgical site?
    A) It relies entirely on gravity drainage into a collection bag placed on the floor.
    B) It connects to an electric wall-mounted suction canister set to -120 mm Hg.
    C) The flexible bulb is manually compressed flat before closing the port cap, creating continuous low negative pressure suction.
    D) A manual hand pump is squeezed every 15 minutes.

CORRECT ANSWER: C) The flexible bulb is manually compressed flat before closing the port cap, creating continuous low negative pressure suction.

RATIONALE: JP drains (and Hemovacs) are closed suction systems that rely on manual compression of the bulb/reservoir to generate continuous gentle negative pressure.

91. What safety step must a nurse ensure when caring for a patient with a passive Penrose drain?
    A) Connect the Penrose drain tube directly to wall suction.
    B) Verify that a sterile safety pin is inserted through the outer end of the drain to prevent it from slipping inside the wound.
    C) Compress the outer rubber tube flat every 2 hours.
    D) Clamp the Penrose drain tightly with a hemodialysis clip.

CORRECT ANSWER: B) Verify that a sterile safety pin is inserted through the outer end of the drain to prevent it from slipping inside the wound.

RATIONALE: A Penrose drain is an open passive drain. A sterile safety pin is placed through the external end to prevent the soft rubber tube from retracting back into the wound cavity.

92. How does Negative Pressure Wound Therapy (NPWT / Wound V.A.C.) accelerate wound healing?
    A) By keeping the wound dry through hot air circulation.
    B) By applying continuous localized subatmospheric pressure that draws wound edges together, removes exudate/edema, and stimulates granulation tissue growth.
    C) By flushing antibiotic solution continuously into the wound.
    D) By freezing infected tissue cells.

CORRECT ANSWER: B) By applying continuous localized subatmospheric pressure that draws wound edges together, removes exudate/edema, and stimulates granulation tissue growth.

RATIONALE: NPWT applies negative pressure via a foam dressing, removing interstitial fluid, reducing localized bacterial burden, pulling wound margins together, and promoting microvascular granulation.

93. Which condition represents an absolute contraindication for applying Negative Pressure Wound Therapy (NPWT)?
    A) Chronic Stage 3 pressure ulcer with moderate serosanguineous drainage
    B) Presence of necrotic eschar in the wound bed, untreated osteomyelitis, or exposed major blood vessels
    C) Dehisced abdominal incision
    D) Debridable surgical wound

CORRECT ANSWER: B) Presence of necrotic eschar in the wound bed, untreated osteomyelitis, or exposed major blood vessels

RATIONALE: NPWT is strictly contraindicated over necrotic tissue/eschar, untreated osteomyelitis, active bleeding, exposed organs/nerves/blood vessels, or malignant wounds.

94. When cleansing a linear surgical incision, what technique maintains sterile surgical field principles?
    A) Cleanse from the outer edges inward toward the center incision line.
    B) Cleanse directly down the center incision line (cleanest area) first, then wipe outward from least contaminated to most contaminated using a fresh swab for each stroke.
    C) Scrub back and forth across the incision line vigorously with one gauze pad.
    D) Cleanse from bottom to top in a circular motion.

CORRECT ANSWER: B) Cleanse directly down the center incision line (cleanest area) first, then wipe outward from least contaminated to most contaminated using a fresh swab for each stroke.

RATIONALE: Wound cleansing proceeds from least contaminated area (the incision itself) outward to most contaminated area (periwound skin), using a new sterile swab/gauze for every single stroke.

95. What technique must the nurse use when obtaining a wound culture specimen from an open infected ulcer?
    A) Swab the outer skin edge and old pooled purulent drainage directly.
    B) Cleanse the wound thoroughly with sterile 0.9% Normal Saline to remove surface debris, then rotate the swab firm over clean, viable granulation tissue in a Z-pattern.
    C) Dip the culture swab into the drainage collection bag.
    D) Rub the swab across black dry eschar.

CORRECT ANSWER: B) Cleanse the wound thoroughly with sterile 0.9% Normal Saline to remove surface debris, then rotate the swab firm over clean, viable granulation tissue in a Z-pattern.

RATIONALE: Wound cultures must reflect actual tissue pathogens, not superficial colonizers. The nurse cleanses surface debris first with normal saline, then swabs viable granulation tissue.

96. What term describes the softening and whitish breakdown of periwound skin caused by prolonged exposure to excess wound exudate?
    A) Induration
    B) Maceration
    C) Granulation
    D) Dehiscence

CORRECT ANSWER: B) Maceration

RATIONALE: Maceration is tissue softening and epidermal disintegration caused by continuous exposure to moisture (wound exudate, urine, sweat), turning periwound skin white, soft, and fragile.

97. A nurse is performing a wet-to-damp dressing change on an open wound with yellow slough. What is the primary purpose of this dressing type?
    A) To seal the wound completely from air
    B) To provide mechanical non-selective debridement of necrotic slough as the damp gauze dries and adheres to debris
    C) To encourage bacterial growth
    D) To deliver continuous topical oxygen

CORRECT ANSWER: B) To provide mechanical non-selective debridement of necrotic slough as the damp gauze dries and adheres to debris

RATIONALE: Wet-to-damp (or wet-to-dry) gauze dressings trap necrotic debris in the gauze mesh as it dries, mechanically debriding the wound bed upon removal.

98. During wound irrigation using a 35 mL syringe and 19-gauge angiocatheter, what psi pressure range is achieved to clean the wound without causing tissue trauma?
    A) 1 to 2 psi
    B) 4 to 15 psi
    C) 25 to 30 psi
    D) 50 psi

CORRECT ANSWER: B) 4 to 15 psi

RATIONALE: Safe, effective wound irrigation requires 4 to 15 psi of pressure (achieved using a 35 mL syringe with a 19-gauge needle/catheter) to remove bacteria and debris without damaging fragile granulation tissue.

99. What systemic factor significantly delays wound healing in a patient with poorly controlled diabetes mellitus?
    A) Hypoxia and microvascular collagen deposition failure due to hyperglycemia and impaired leukocyte phagocytosis
    B) Excessive skin oil production
    C) Elevated serum calcium levels
    D) Accelerated epithelialization

CORRECT ANSWER: A) Hypoxia and microvascular collagen deposition failure due to hyperglycemia and impaired leukocyte phagocytosis

RATIONALE: Hyperglycemia impairs neutrophil phagocytosis, alters small blood vessel circulation (microvascular disease), reduces oxygen delivery, and impairs collagen synthesis, markedly delaying healing.

100. How does a hydrocolloid dressing promote autolytic debridement and wound healing?
     A) It dries out the wound bed completely.
     B) It forms an occlusive, moist environment that traps body's endogenous enzymes to naturally liquefy necrotic tissue.
     C) It requires daily changing and harsh tape removal.
     D) It injects exogenous collagen into the wound bed.

CORRECT ANSWER: B) It forms an occlusive, moist environment that traps body's endogenous enzymes to naturally liquefy necrotic tissue.

RATIONALE: Hydrocolloid dressings are occlusive/semi-occlusive dressings that maintain a moist environment, allowing natural endogenous enzymes in wound fluid to break down necrotic tissue (autolytic debridement).