CA Funda

Q1.
A patient receiving IV fluids suddenly develops chest pain, tachycardia, hypotension, and cyanosis. The nurse suspects an air embolism. What is the priority nursing action?
A. Notify the healthcare provider immediately
B. Clamp the IV tubing and place the patient on the left side in Trendelenburg position
C. Start CPR
D. Administer oxygen by non-rebreather mask

Answer: B
Rationale: Left-side Trendelenburg traps the air in the right atrium and prevents it from entering the pulmonary artery. Clamping prevents more air entry. Oxygen may follow, but positioning is priority.

Q2.
A nurse is caring for a client with a 1000 mL IV of 5% dextrose in 0.9% sodium chloride. After 45 minutes, the client develops a pounding headache, dyspnea, and crackles. What should the nurse do first?
A. Call the physician
B. Slow the IV infusion
C. Remove the IV catheter
D. Place the client in high Fowler’s position

Answer: B
Rationale: Signs indicate circulatory overload. The immediate nursing action is to slow the infusion to prevent further overload.

Q3.
A nurse is inserting a peripheral IV line. Which finding indicates correct placement?
A. The vein is distended under the needle
B. The catheter advances easily without resistance
C. Blood return is seen in the flashback chamber
D. The client reports no pain

Answer: C
Rationale: Blood return confirms the catheter is in the vein. Ease of advancement and absence of pain help, but blood return is the best confirmation.

Q4.
A patient with a history of severe anemia is scheduled for a blood transfusion. Which IV cannula size is most appropriate?
A. 24G Yellow
B. 20G Pink
C. 18G Green
D. 22G Blue

Answer: C
Rationale: 18G Green allows rapid transfusion of blood and prevents hemolysis. Smaller gauges may delay transfusion.

Q5.
The nurse is caring for a patient with hypoglycemia (blood glucose 60 mg/dL) in the hospital. What is the best initial intervention?
A. Give orange juice
B. Administer skimmed milk
C. Infuse 50/50 Lactated Ringer’s solution
D. Notify the physician

Answer: C
Rationale: In a hospital, IV glucose (50/50 LR or D50) is the fastest and safest method. At home/oral settings, juice or milk may be given.

Q6.
During a blood transfusion, the client suddenly develops fever, flank pain, and reddish urine. What is the nurse’s immediate action?
A. Slow the infusion rate
B. Administer acetaminophen
C. Stop the transfusion immediately
D. Notify the physician

Answer: C
Rationale: These are signs of hemolytic transfusion reaction. The transfusion must be stopped immediately before any further intervention.

Q7.
The nurse is about to insert a Foley catheter in a male client. The patient reports pain and resistance when the catheter meets the sphincter. What should the nurse instruct the patient to do?
A. Hold their breath
B. Take slow, deep breaths
C. Cough forcefully
D. Contract abdominal muscles

Answer: B
Rationale: Deep breathing relaxes the sphincter and eases insertion. Forcing the catheter against resistance may cause trauma.

Q8.
The nurse is preparing to administer an enema to an adult. Which position is best for the client?
A. Supine with knees bent
B. Left Sims’ position
C. Right lateral recumbent
D. Prone with pillow under the abdomen

Answer: B
Rationale: Left Sims’ position allows the enema solution to flow into the rectum and sigmoid colon following the natural curve of the intestine.

Q9.
The nurse is preparing to insert a nasogastric tube (NGT). To determine the correct length, the nurse should measure from:
A. Nose → Earlobe → Umbilicus
B. Nose → Earlobe → Xiphoid process
C. Nose → Chin → Sternum
D. Nose → Mouth → Clavicle

Answer: B
Rationale: The correct measurement is nose → earlobe → xiphoid process to ensure the tube reaches the stomach.

Q10.
A nurse is caring for a patient with a new colostomy. On assessment, the stoma appears dusky purple. What is the priority action?
A. Apply a warm compress
B. Notify the physician immediately
C. Document the finding
D. Clean with soap and water

Answer: B
Rationale: A dusky, blackish, or purple stoma indicates impaired circulation/necrosis. This is a surgical emergency.

Q11.
A client is prescribed 0.9% Normal Saline IV for fluid replacement. What is the primary action of this solution?
A. Causes cells to swell and burst
B. Keeps fluid in the intravascular compartment without shifting
C. Pulls fluid out of the cells, making them shrink
D. Provides free water to hydrate cells

Answer: B
Rationale: Isotonic solutions (0.9% NS, LR) maintain equal concentration with body fluids, keeping fluid in the vascular space with no fluid shifts.

Q12.
A nurse is monitoring a client receiving hypertonic saline (3%). Which finding requires immediate intervention?
A. Dry mouth
B. Increased urine output
C. Pulmonary crackles and dyspnea
D. Thirst

Answer: C
Rationale: Hypertonic solutions draw fluid into the vascular space, risking fluid overload and pulmonary edema. Crackles and dyspnea are warning signs.

Q13.
A patient receiving IV therapy complains of pain, swelling, and coolness at the insertion site. The IV flow has stopped. What should the nurse do first?
A. Slow the infusion rate
B. Remove the IV and elevate the extremity
C. Apply warm compress and restart infusion at the same site
D. Call the physician

Answer: B
Rationale: These are signs of infiltration. The IV should be removed, extremity elevated, and compress applied. Restart IV at another site.

Q14.
A patient receiving IV antibiotics develops redness, heat, and tenderness along the vein. Which action is most appropriate?
A. Stop the IV and notify the physician
B. Continue the IV at a slower rate
C. Apply an ice pack to the site
D. Massage the vein to improve circulation

Answer: A
Rationale: Symptoms indicate phlebitis. IV must be stopped, the physician notified, and a new IV started at another site.

Q15.
The nurse is transfusing packed red blood cells. Which nursing intervention is most important in the first 15 minutes?
A. Take vital signs every hour
B. Stay with the client and monitor for reaction
C. Increase infusion rate if no reaction occurs
D. Administer diuretics to prevent overload

Answer: B
Rationale: Most transfusion reactions occur within the first 15 minutes. The nurse must remain with the patient and monitor closely.

Q16.
A nurse is preparing to insert a urinary catheter in a female client. What position is best for visualization of the urethral meatus?
A. Supine with legs extended
B. Left lateral with knees flexed
C. Dorsal recumbent or lithotomy
D. Prone with hips elevated

Answer: C
Rationale: Dorsal recumbent or lithotomy position exposes the vulva and allows correct catheter insertion.

Q17.
The nurse is caring for a patient with a tracheostomy. Which action should be included in routine care?
A. Suction the patient every 2 hours regardless of need
B. Place the client in semi-Fowler’s position
C. Clean stoma site with povidone-iodine
D. Deflate the cuff during feedings

Answer: B
Rationale: Semi-Fowler’s position promotes lung expansion and reduces aspiration risk. Suctioning is PRN, not routine.

Q18.
A nurse is preparing to administer an enema to a patient. The patient complains of cramping during the infusion. What is the correct response?
A. Stop the infusion and remove the tube immediately
B. Clamp the tubing for 30 seconds, then resume at a slower rate
C. Continue infusion quickly to finish the procedure
D. Lower the enema container to the level of the rectum

Answer: B
Rationale: Cramping indicates too rapid infusion. Pausing and then resuming more slowly reduces discomfort.

Q19.
A client is receiving oxygen via non-rebreather mask. Which finding indicates proper function of the mask?
A. The reservoir bag remains partially inflated during inspiration
B. The reservoir bag fully collapses with each breath
C. The one-way valves are taped open
D. The flow rate is set at 2 L/min

Answer: A
Rationale: The reservoir bag should not collapse completely, ensuring high oxygen delivery (60–100%). Flow must be 6–15 L/min.

Q20.
A nurse is caring for a patient with a new ileostomy. Which finding requires immediate attention?
A. Liquid effluent drainage
B. Minimal odor from stool
C. Skin irritation around the stoma
D. Stoma appears blackish purple

Answer: D
Rationale: A dark or purple stoma indicates ischemia/necrosis and requires immediate physician notification.

Q21.
A patient is ordered Lactated Ringer’s (LR) after surgery. What is the primary purpose of this solution?
A. To replace electrolytes and restore fluid balance
B. To provide free water for cellular hydration
C. To lower blood glucose levels
D. To increase osmotic pressure in the vascular space

Answer: A
Rationale: LR is isotonic and contains electrolytes, making it ideal for fluid replacement and correcting electrolyte imbalances.

Q22.
A patient develops wet cough, dyspnea, and distended neck veins while receiving IV fluids. What is the nurse’s first action?
A. Discontinue the IV immediately
B. Slow the IV to KVO (keep vein open) rate
C. Place the client in Trendelenburg position
D. Notify the physician

Answer: B
Rationale: These are signs of circulatory overload. The nurse must first slow the infusion, then notify the physician.

Q23.
A nurse is caring for a client receiving packed red blood cells. Fifteen minutes into the transfusion, the client complains of chills, flushing, and itching. What is the priority nursing action?
A. Stop the transfusion immediately
B. Administer diphenhydramine
C. Slow the transfusion and observe
D. Document the reaction and continue monitoring

Answer: A
Rationale: These are signs of a mild allergic reaction. The transfusion must be stopped first before any medication is given.

Q24.
A client with renal failure has a hemoglobin of 8 g/dL. Which hormone deficiency is most responsible for this condition?
A. Aldosterone
B. Antidiuretic hormone (ADH)
C. Erythropoietin
D. Cortisol

Answer: C
Rationale: Erythropoietin, produced by the kidneys, stimulates RBC production. Renal failure leads to anemia.

Q25.
The nurse is caring for a client with a Foley catheter. Which action helps prevent catheter-associated urinary tract infection (CAUTI)?
A. Use the largest size catheter possible
B. Disconnect the catheter to empty urine
C. Maintain a closed drainage system
D. Clamp the tubing to prevent backflow

Answer: C
Rationale: A closed drainage system reduces infection risk. Using smallest catheter size also helps. Disconnection increases risk of CAUTI.

Q26.
The nurse is inserting an indwelling urinary catheter in a male client. Which action promotes passage of the catheter if resistance is felt?
A. Withdraw the catheter immediately
B. Ask the client to cough
C. Instruct the client to take slow, deep breaths
D. Force the catheter gently past the resistance

Answer: C
Rationale: Deep breathing relaxes the urinary sphincter, making catheter passage easier. Forcing the catheter may cause trauma.

Q27.
A nurse is preparing to administer a cleansing enema to an adult. How far should the rectal tube be inserted?
A. 2–3 cm (1 inch)
B. 5–7.5 cm (2–3 inches)
C. 7.5–10 cm (3–4 inches)
D. 12–15 cm (5–6 inches)

Answer: C
Rationale: In adults, the rectal tube is inserted 7.5–10 cm (3–4 in). Deeper insertion may cause injury.

Q28.
A nurse is preparing an enema solution for an infant. Which solution is safest?
A. Tap water
B. Hypertonic solution
C. Normal saline
D. Soapsuds

Answer: C
Rationale: Physiological normal saline is safest for infants and children to prevent fluid and electrolyte imbalance.

Q29.
The nurse is assessing oxygen delivery with a nasal cannula at 4 L/min. What is the expected fraction of inspired oxygen (FiO₂)?
A. 24%
B. 28%
C. 36%
D. 45%

Answer: C
Rationale: A nasal cannula delivers 2–6 L/min (24–45% FiO₂). At 4 L/min, the FiO₂ is about 36%.

Q30.
A nurse is caring for a client with a tracheostomy. The obturator should always be kept at the bedside because it is used to:
A. Clear secretions from the airway
B. Assist in reinsertion of the tracheostomy tube if dislodged
C. Inflate the cuff to prevent aspiration
D. Maintain patency of the tracheostomy

Answer: B
Rationale: The obturator guides the outer cannula during reinsertion if the tracheostomy tube becomes dislodged.

Q31.
A nurse is caring for a client with a new colostomy. The stoma is red, moist, and protruding slightly from the abdomen. How should the nurse interpret this finding?
A. Normal and expected
B. Early sign of necrosis
C. Indication of infection
D. Abnormal and must be reported

Answer: A
Rationale: A healthy stoma should be red, moist, and slightly protruding. Dusky, black, or pale indicates poor circulation.

Q32.
A nurse is teaching a client with a colostomy about diet. Which food should the nurse advise the patient to avoid to reduce odor and gas?
A. Apples
B. Fish and cabbage
C. Rice and bananas
D. Chicken and potatoes

Answer: B
Rationale: Cabbage, eggs, fish, beans, and peanuts increase odor and gas. Rice, bananas, and potatoes reduce diarrhea.

Q33.
A client with a fractured femur is placed in Bryant’s traction. Which nursing action is essential?
A. Keep the buttocks resting on the bed
B. Elevate the buttocks slightly off the bed
C. Position the client in prone position
D. Ensure weights are touching the floor

Answer: B
Rationale: In Bryant’s traction, the buttocks are slightly elevated and not resting on the bed to maintain correct alignment.

Q34.
A client with a cervical spine fracture is placed in a halo vest. Which action by the nurse is appropriate?
A. Use the halo ring to reposition the patient
B. Turn the patient as a unit (logroll technique)
C. Apply talcum powder inside the vest
D. Loosen the pins for comfort

Answer: B
Rationale: Clients with halo vests should be turned with logrolling to prevent spinal misalignment. The vest must not be loosened.

Q35.
A patient with suspected poisoning is being transported to the ER. Which position is best during transport to minimize aspiration?
A. Supine with head elevated
B. Right lateral position
C. Left side-lying position
D. Trendelenburg position

Answer: C
Rationale: In poisoning cases, left side-lying prevents toxins from moving into other areas and reduces aspiration risk.

Q36.
A nurse is inserting a nasogastric tube into an adult client. The patient begins gagging and coughing. What should the nurse do first?
A. Continue inserting the tube quickly
B. Withdraw the tube slightly and pause
C. Remove the tube immediately and stop procedure
D. Ask the client to hold their breath

Answer: B
Rationale: If gagging occurs, the nurse should withdraw slightly and pause to allow the patient to recover, then continue with swallowing.

Q37.
A nurse is preparing to feed a client via gastrostomy tube. Which position is safest during feeding?
A. Supine with head flat
B. High Fowler’s position
C. Prone with head turned
D. Side-lying with head down

Answer: B
Rationale: High Fowler’s reduces aspiration risk during tube feeding.

Q38.
A nurse is providing care for a patient on a clear liquid diet. Which food is appropriate?
A. Yogurt
B. Apple juice
C. Oatmeal
D. Scrambled eggs

Answer: B
Rationale: Clear liquids include apple juice, tea, coffee, broth, popsicles. Yogurt, oatmeal, and eggs are full liquid/soft diet.

Q39.
A nurse is reviewing lab results. Which of the following potassium levels is abnormal?
A. 3.8 mEq/L
B. 4.2 mEq/L
C. 2.9 mEq/L
D. 3.6 mEq/L

Answer: C
Rationale: Normal potassium: 3.5–5.0 mEq/L. 2.9 mEq/L indicates hypokalemia, requiring intervention.

Q40.
A client’s hemoglobin is 7 g/dL. Which therapy should the nurse anticipate?
A. IV antibiotics
B. Packed red blood cell transfusion
C. Platelet transfusion
D. Fresh frozen plasma transfusion

Answer: B
Rationale: Packed RBCs are given for low hemoglobin/anemia to restore oxygen-carrying capacity.

Q41.
A nurse is reviewing a client’s lipid panel. Which result is concerning?
A. Triglycerides 120 mg/dL
B. HDL 30 mg/dL (male)
C. LDL 90 mg/dL
D. Total cholesterol 180 mg/dL

Answer: B
Rationale: Normal HDL: ≥40 mg/dL (men), ≥50 mg/dL (women). HDL 30 is too low, increasing cardiovascular risk.

Q42.
A nurse is reviewing a client’s CBC. Which finding requires immediate action?
A. WBC 8,000/mm³
B. Hematocrit 38%
C. Platelets 90,000/µL
D. Hemoglobin 14 g/dL

Answer: C
Rationale: Normal platelets: 150,000–350,000/µL. 90,000 increases bleeding risk and must be addressed.

Q43.
A patient receiving IV therapy develops a hard, painful lump with bruising at the site. What complication does this suggest?
A. Infiltration
B. Phlebitis
C. Hematoma
D. Air embolism

Answer: C
Rationale: Hematoma occurs when blood collects at the site, causing swelling and bruising.

Q44.
The nurse is assessing a client with hypomagnesemia. Which finding is consistent with this imbalance?
A. Hypoactive reflexes
B. Muscle cramps and tremors
C. Respiratory depression
D. Sedation

Answer: B
Rationale: Low magnesium causes neuromuscular excitability: tremors, cramps, and hyperactive reflexes.

Q45.
A client with a tracheostomy has thick secretions. What is the most appropriate intervention?
A. Encourage increased fluid intake if not contraindicated
B. Instill sterile water into the tracheostomy tube
C. Apply powder around the stoma
D. Reduce suctioning frequency

Answer: A
Rationale: Hydration thins secretions, making them easier to clear. Powder may cause infection.

Q46.
A client is scheduled for a blood transfusion. Which action by the nurse is most important before initiating the transfusion?
A. Warm the blood before administration
B. Verify client’s identity and blood compatibility with another nurse
C. Insert an IV with a 24G cannula
D. Document baseline vital signs after transfusion begins

Answer: B
Rationale: Verification of client identity and compatibility prevents transfusion reactions.

Q47.
A nurse is caring for a client with suspected circulatory overload from IV therapy. Which assessment is most important?
A. Peripheral pulses
B. Skin temperature
C. Breath sounds
D. Capillary refill

Answer: C
Rationale: Auscultating breath sounds helps detect crackles, a key sign of fluid overload.

Q48.
The nurse is caring for a client receiving oxygen therapy via Venturi mask. The oxygen adapter is set to deliver 28% oxygen. What flow rate should the nurse set?
A. 2 L/min
B. 4 L/min
C. 6 L/min
D. 8 L/min

Answer: B
Rationale: Venturi mask delivers precise FiO₂. For 28%, the flow rate is 4 L/min.

Q49.
The nurse is caring for a patient with an indwelling urinary catheter. Which finding requires immediate action?
A. 350 mL urine output in 6 hours
B. Amber-colored urine
C. Cloudy urine with foul odor
D. Catheter secured to the thigh

Answer: C
Rationale: Cloudy, foul-smelling urine suggests infection and requires intervention.

Q50.
A nurse is caring for a client after colostomy surgery. When teaching the patient about stoma care, the nurse should explain that the appliance opening should be:
A. The exact size of the stoma
B. Slightly smaller than the stoma
C. About 0.3 cm (1/8 in) larger than the stoma
D. At least 1 cm larger than the stoma

Answer: C
Rationale: The appliance should be slightly larger (0.3 cm) to prevent rubbing or trauma while protecting the ski