#1
Which intervention is appropriate for a patient experiencing respiratory distress?
Administering bronchodilators
Providing a warm blanket
Applying cold packs
Offering a massage
#2
What precaution should be taken when caring for a patient with a nasogastric tube?
Keeping the head of the bed elevated
Encouraging the patient to lie flat
Taping the tube securely to the patient's cheek
Administering tube feedings at room temperature
#3
In caring for a patient with a chest tube, what action requires immediate intervention?
Clamping the chest tube during transport
Checking for fluctuation in the water seal chamber
Milking the chest tube to maintain patency
Emptying the drainage system as needed
#4
Which intervention should a nurse prioritize for a patient with a central venous catheter experiencing occlusion?
Applying warm compresses to the insertion site
Administering a thrombolytic agent
Encouraging increased oral fluid intake
Positioning the patient on the affected side
#5
What is a critical nursing action when caring for a patient with a urinary catheter?
Securing the catheter tubing to the bed frame
Emptying the drainage bag when it's half full
Encouraging the patient to drink caffeinated beverages
Performing perineal care every shift and as needed
#6
Which intervention should the nurse prioritize for a patient at risk for venous thromboembolism?
Encouraging ambulation as soon as possible
Administering anticoagulant therapy as ordered
Elevating the affected extremity
Applying cold compresses to the area
#7
Which action is essential when caring for a patient with a wound vacuum-assisted closure (VAC) device?
Applying pressure dressings directly over the wound
Changing the VAC dressing daily
Ensuring the device is powered on continuously
Assessing for signs of infection at the wound site
#8
Which precaution is essential when caring for a patient with a peripherally inserted central catheter (PICC)?
Changing the PICC dressing weekly
Administering vesicant medications through the PICC
Using the PICC for blood draws only
Assessing for signs of phlebitis or infection regularly
#9
Which intervention should the nurse prioritize for a patient undergoing continuous bladder irrigation (CBI)?
Irrigating with cold sterile solution
Monitoring urinary output hourly
Encouraging the patient to ambulate frequently
Administering opioids for pain management
#10
Which intervention should the nurse prioritize for a patient with a chest tube experiencing excessive bubbling in the water seal chamber?
Increasing the suction pressure
Checking for kinks or obstructions in the tubing
Removing the chest tube immediately
Emptying the water seal chamber
#11
Which precaution is essential when caring for a patient with a ventriculoperitoneal shunt?
Restricting the patient's fluid intake
Ensuring the patient remains in Trendelenburg position at all times
Regularly assessing for signs of infection at the insertion site
Encouraging the patient to perform Valsalva maneuver frequently
#12
Which intervention should the nurse prioritize for a patient with an external fixator device for fracture management?
Removing the pins and cleaning the insertion sites daily
Assessing for signs of infection at the pin sites regularly
Encouraging the patient to bear weight on the affected limb immediately
Applying tight dressings over the fixator to prevent movement
#13
Which intervention is essential when caring for a patient with an indwelling urinary catheter?
Securing the catheter tubing to the bed frame with tape
Irrigating the catheter with normal saline every shift
Maintaining a closed urinary drainage system
Emptying the urinary drainage bag every 24 hours
#14
What precaution should the nurse take when caring for a patient with an endotracheal tube?
Regularly suctioning the tube every 4 hours
Placing the patient in a supine position
Taping the tube loosely to prevent displacement
Assessing for air leakage around the tube cuff
#15
Which intervention is crucial when caring for a patient with a Jackson-Pratt drain?
Removing the drain to irrigate the wound
Emptying the drain when it is more than half full
Clamping the drain while ambulating the patient
Compressing the bulb to create negative pressure
#16
Which intervention is essential when caring for a patient with a Jackson-Pratt drain?
Securing the drain to the skin with a sterile dressing
Applying continuous suction to the drain
Compressing the bulb intermittently to facilitate drainage
Emptying the drain into a graduated container every 8 hours
#17
What is a priority nursing action when caring for a patient with an arterial line?
Monitoring for signs of infection at the insertion site
Ensuring the transducer is at the level of the phlebostatic axis
Administering anticoagulant therapy as ordered
Keeping the line and site clean and dry
#18
What is a primary precaution when administering intravenous potassium chloride?
Administering via rapid bolus
Diluting the medication in a large volume of IV fluid
Administering undiluted via IV push
Monitoring for signs of infiltration
#19
Which intervention is crucial when caring for a patient with a tracheostomy tube?
Changing the ties securing the tube every 24 hours
Maintaining strict NPO status to prevent aspiration
Assisting with regular tracheostomy tube cuff deflation
Suctioning the airway frequently to prevent secretions
#20
What is a priority intervention for a patient receiving total parenteral nutrition (TPN)?
Monitoring blood glucose levels frequently
Administering TPN via gravity infusion
Administering TPN through the same line as other IV medications
Changing the TPN bag every 48 hours
#21
What is a critical nursing action when caring for a patient with a gastrointestinal tube (e.g., Levin tube)?
Flushing the tube with carbonated beverages
Checking tube placement before each feeding or medication administration
Administering tube feedings at a rapid rate
Removing the tube during meals
#22
What is a critical nursing action when caring for a patient with a wound requiring a wet-to-dry dressing?
Leaving the dressing unchanged for several days
Ensuring the dressing remains dry between changes
Removing the dressing when it becomes dry
Irrigating the wound with sterile saline before dressing changes
#23
What is a priority nursing action when caring for a patient with an implanted intrathecal pump for pain management?
Administering oral pain medications on a fixed schedule
Encouraging the patient to engage in strenuous physical activity
Monitoring for signs of cerebrospinal fluid leakage
Refilling the pump reservoir only when it is completely empty
#24
What is a priority nursing action when caring for a patient with a tracheostomy tube?
Suctioning the airway frequently to remove secretions
Applying tight dressings over the tracheostomy site
Encouraging the patient to speak as much as possible
Securing the tube with cloth tape
#25
Which intervention should the nurse prioritize for a patient with an arterial line?
Regularly flushing the arterial line with normal saline
Ensuring the transducer is level with the phlebostatic axis
Removing the arterial line when not in use
Monitoring for signs of venous thrombosis