Fundamentals of Nursing NCLEX Practice Questions Quiz #7 | 70 Questions

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Fundamentals of Nursing NCLEX Practice Questions Quiz #7 | 70 Questions

Questions related to Patient Tubes: NGT, Chest, and Tracheostomy

FNDNRS-07–001

Which of the following is not true regarding the types of a nasogastric tube?

• A. Cantor tube is a single-lumen long tube with a small inflatable bag at the distal end.
• B. Miller-Abbott tube is a long double-lumen used to drain and decompress the small intestine.
• C. Levin tube is a double-lumen nasogastric tube with an air vent.
• D. Sengstaken-Blakemore tube is a three-lumen tube.

Correct Answer: C. Levin tube is a double-lumen nasogastric tube with an air vent.

A Levin tube is a single lumen nasogastric tube while a Salem sump tube is a double-lumen nasogastric tube with an air vent. The Levin tube is used primarily for long-continued gastric drainage and for gavage feeding. It is also used for diagnostic purposes. Its advantages are that it can be inserted either nasally or orally and that it is firm enough to be passed into an unconscious patient but flexible enough so there is little danger of producing injury.

• Option A: The Cantor Tub is a 10-foot long, single-lumen tube used for intestinal decompression. The Cantor tube has a mercury-weighted rubber tab attached to its perforated tip to help carry the tube through the stomach and intestine. The mercury is placed in the bag with a syringe and needle before the tube is inserted nasally by the doctor.
• Option B: The Miller-Abbott tube is a 10-foot long double-lumen tube that is equipped with a small balloon near the metal tip at the distal end of the tube. One lumen is used for aspiration and irrigation; the other is used for inflating the balloon. Air, water, or mercury (4 to 5 ml) accomplishes inflation. This intestinal tube is used for small bowel suction. The two openings are independent of each other and are clearly marked.
• Option D: Also referred to as a Blakemore tube, this tube is a three-lumen, esophageal-gastric balloon tube that is used in the treatment of bleeding esophageal varices. One lumen is used to inflate the esophageal balloon, one lumen is used to inflate the gastric balloon, and the third lumen is used for decompression and irrigation of the stomach.

FNDNRS-07–002

A new RN nurse is about to insert a nasogastric tube into a client with Guillain-Barre Syndrome. To determine the accurate measurement of the length of the tube to be inserted, the nurse should:

• A. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the top of the sternum.
• B. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.
• C. Place the tube at the tip of the nose, and measure by extending the tube down to the chin and then down to the top of the xiphoid process.
• D. Place the tube at the base of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.

Correct Answer: B. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the xiphoid process.

Estimate the length of insertion by measuring the distance from the tip of the nose, around the ear, and down to just below the left costal margin. This point can be marked with a piece of tape on the tube. When using the Salem sump NG tube (Kendall, Mansfield, MA) in adults, the estimated length usually falls between the second and third preprinted black lines on the tube.

• Option A: Apart from the nose-to-ear-to-xiphisternum (NEX) method, several other methods for determining the length of the tube have been described. Among the various options, a formula based on gender, weight, and nose-to-umbilicus measurement while lying flat was found to be safer and more accurate in a study by Santos et al.
• Option C: While the stomach is a highly distensible structure and therefore, can vary in length, the empty stomach is generally around 25 cm long. Thus if one intended to place a tube through the nares and place it in the middle of the stomach, then approximately 55 cm of the tube should be inserted.
• Option D: There are several methods to estimate the depth that an NG should be placed. All methods for estimation will have some margin of error. A common pre-procedure maneuver is to loop the tube over one of the patient’s ears and place the tip at the patient’s xiphoid process and use this as an estimate for the length of the tube that should be inserted.

FNDNRS-07–003

A stroke client who was initially on NGT feeding was able to tolerate a soft diet so the physician ordered the removal of it. The nurse would instruct the client to do which of the following before he removes the tube?

• A. Inhale and exhale simultaneously.
• B. Take a long breath and hold it.
• C. Do a Valsalva maneuver.
• D. Blow the nose.

Correct Answer: B. Take a long breath and hold it.

Holding the breath closes the glottis hence it will be easier to withdraw the tube through the esophagus into the nose, and this method will also prevent aspiration. An NG tube should be removed if it is no longer required. The process of removal is usually very quick. Prior to removing an NG tube, verify physician orders. If the NG tube was ordered to remove gastric content, the physician’s order may state to “trial” clamping the tube for a number of hours to see if the patient tolerates its removal. During the trial, the patient should not experience any nausea, vomiting, or abdominal distension.

• Option A: Instruct the patient to take a deep breath and hold it. This prevents aspiration; holding the breath closes the glottis. Kink the NG tube near the naris and gently pull out the tube in a swift, steady motion, wrapping it in your hand as it is being pulled out. Dispose of tube in garbage bag.
• Option C: The Valsalva maneuver is a breathing technique that can be used to unclog ears, restore heart rhythm or diagnose an autonomic nervous system (ANS). To perform the Valsalva maneuver, the patient should close his mouth, pinch the nose shut and press the air out like blowing up a balloon.
• Option D: Blowing the nose is a way of clearing out mucus that has collected debris and pollutants from the atmosphere. Most of the time, people blow their nose because of excess mucus production — a cold, nasal allergy, hay fever, or other conditions.

FNDNRS-07–004

The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a comatose client. Which of the following actions is an inappropriate practice by the nurse?

• A. If bowel sounds are absent, hold the feeding and notify the physician.
• B. Assess tube placement by aspirating gastric content and check the PH level.
• C. Warm the feeding to room temperature to prevent the occurrence of diarrhea and cramps.
• D. Elevate the head of the bed to 45 degrees and maintain for 30 minutes after installation of feeding.

Correct Answer: D. Elevate the head of the bed to 45 degrees and maintain for 30 minutes after instillation of feeding.

If the client is comatose, place in a high-Fowler’s which is at a 90-degree level. Position client upright or in full Fowler’s position if possible. Place a clean towel over the client’s chest. Full Fowler’s position assists the client to swallow, for optimal neck-stomach alignment and promotes peristalsis.

• Option A: Inject 30 mL of air into the stomach and listen with the stethoscope for the “whoosh” of air into the stomach. The small diameter of some NG tubes may make it difficult to hear air entering the stomach. It is very important to ensure that the NG tube is in its correct place within the stomach because, if by accident the NG is within the trachea, serious complications in relation to the lungs would appear.
• Option B: Stomach aspirate will appear cloudy, green, tan, off-white, bloody, or brown. It is not always visually possible to distinguish between the stomach and respiratory aspirates. Measuring the pH of stomach aspirate is considered more accurate than visual inspection. Stomach aspirate generally has a pH range of 0 to 4, commonly less than 4.
• Option C: For powdered formula, mix according to the instructions on the package. Prepare just enough for the next 24 hours and refrigerate unused formula. Allow the formula to reach room temperature before using. Formula loses its nutritional value and can be contaminated if kept for more than 24 hours. Cold formulas can cause abdominal discomfort.

FNDNRS-07–005

A nurse is checking the nasogastric tube position of a client receiving a long-term therapy of Omeprazole (Prilosec) by aspirating the stomach contents to check for the PH level. The nurse proves the correct tube placement if the PH level is?

• A. 7.75.
• B. 7.5.
• C. 6.5.
• D. 5.5.

Correct Answer: D. 5.5.

Gastric placement is indicated by a pH of less than 4 but may increase to between pH 4–6 if the patient is receiving acid-inhibiting drugs. Measuring the pH of stomach aspirate is considered more accurate than visual inspection. Stomach aspirate generally has a pH range of 0 to 4, commonly less than 4.

• Option A: The aspirate of respiratory contents is generally more alkaline, with a pH of 7 or more. Testing the pH of gastric aspirate to show pH ≤5.5 is recommended first-line test to confirm correct placement of nasogastric tubes and reduce the risk of potentially fatal aspiration.
• Option B: The pH readings between 4.5 and 6.0 provided the greatest overall accuracy, however, there was only moderate agreement between observers at pH readings ≥5.0. Compared with studies that have taken aspirate directly from the nasogastric tube, patients undergoing scope procedures had a lower sensitivity at the pH cut-off ≤5.5 for identifying gastric aspirates for the whole group and in the presence and absence of antacid medications.
• Option C: Current healthcare guidelines recommend that the first-line test to confirm correct NGT placement prior to giving food or medications must be that the pH of an NGT aspirate is ≤5.5 (acidic). Nevertheless, false-positive readings might occur if the tube is misplaced in the esophagus or false-negative readings (pH >5.5) may occur in patients who secrete less gastric acid, because of antacid medications, achlorhydria, or buffering by NGT feeds.

FNDNRS-07–006

Before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of 90ml. What is the appropriate action for the nurse to take?

• A. Discard the residual amount.
• B. Hold the due feeding.
• C. Skip the feeding and administer the next feeding due in 4 hours.
• D. Reinstill the amount and continue with administering the feeding.

Correct Answer: D. Reinstill the amount and continue with administering the feeding.

If the residual feeding is less than 100ml, feeding is administered. Fasting volume of the normal stomach ranged from 0 to 98 mL in the study group. The researchers defined high as 100 mL for nasogastric (NG) tubes and 200 mL for gastrostomy (G) tubes and concluded that EN feedings should not be stopped for a single high GRV if there are no other physical examination or radiography findings to show actual gastrointestinal dysfunction.

• Option A: When interpreting Gastric Residual Volume (GRV), clinicians must keep in mind that the stomach has reservoir function and that the stomach fluid is a mixture of both the infused EN formula and normal gastric secretions. Chang and colleagues explained this concept in the article “Monitoring Bolus Nasogastric Tube Feeding by the Brix Value Determination and Residual Volume Measurement of Gastric Contents” published in the Journal of Parenteral and Enteral Nutrition (JPEN) in 2004.
• Option B: In a review article, “Measurement of Gastric Residual Volume: State of the Science,” published in 2000 in MEDSURG Nursing, Edwards and Metheny reported that the literature contained a variety of recommendations for what is considered a high GRV, ranging from 100 to 500 mL. Some sources have even (incorrectly) suggested holding tube feedings for a GRV of greater than 30 mL, or 1.5 times the flow rate, or even one-half of the hourly flow rate.
• Option C: Normal gastric emptying occurs within three hours and after a lag time of approximately one hour for a meal of solid foods. The process is slower for high-fat meals. Liquids empty more quickly (within one hour for a glucose solution and two hours for a protein solution).3 During fasting, the stomach secretes approximately 500 to 1,500 mL2; in the fed state, it secretes approximately 2,500 mL per day.

FNDNRS-07–007

Continuous type of feedings is administered over a __ hour period?

• A. 4.
• B. 12.
• C. 24.
• D. 36.

Correct Answer: C. 24.

Continuous feeding is administered for 24 hours. An infusion pump regulates the flow. Continuous drip feeding is delivered by either gravity drip or infusion pump. The infusion pump is a better method of delivery than gravity drip. The flow rate of gravity drip may be inconsistent and, therefore, needs to be checked frequently.

• Option A: When feedings are delivered continuously, stool output is reduced, a consideration for the child with chronic diarrhea. Continuous infusions of elemental formula have been successful in managing infants with short bowel syndrome, intractable diarrhea, necrotizing enterocolitis, and Crohn’s disease.
• Option B: Commonly, it is used for 8 to 10 hours during the night for volume-sensitive patients so that smaller bolus feedings or oral feeding may be used during the day. Continuous feeding can be administered at night, so it will not interfere with daytime activities. Continuous feeding increases energy efficiency, allowing more calories to be used for growth. This can be important for severely malnourished children.
• Option D: Continuous drip-feeding may be delivered without interruption for an unlimited period of time each day. Feeding around the clock is not recommended as this limits a child’s mobility and may elevate insulin levels contributing to hypoglycemia.

FNDNRS-07–008

A client is subjected to undergo a chest x-ray to confirm the endotracheal tube placement. The tube should be how many centimeters above the carina?

• A. 2–4 cm.
• B. 1.5–3 cm.
• C. 1–2 cm.
• D. 0.5–1 cm.

Correct Answer: C. 1–2 cm.

Placement of an endotracheal tube is confirmed by a chest x-ray and the correct placement is 1 to 2 cm above the carina. Check patient’s chest x-ray for tube placement and presence of C02 per ET C02 detector after any new intubation; auscultate chest for equal breath sounds bilaterally, and adjust E.T. tube for proper placement.

• Option A: Check tube placement with each ventilator assessment. The optimal placement for the endotracheal tube is 2–3cm above the carina in adults. If repositioning of the endotracheal tube is warranted, suction the tube and then suction the oropharynx.
• Option B: Positioning the ET tip 4 cm above carina as recommended will result in placement of tube cuff inside cricoid ring with currently available tubes. Optimal depth of ET placement can be estimated by the formula “(Height in cm/7)-2.5.”
• Option D: It is suggested that the tip of ET should be at least 4 cm from the carina, or the proximal part of the cuff should be 1.5 to 2.5 cm from the vocal cords. Considering that the length of trachea, as well as the distance from teeth to vocal cords, is variable, securing ET at a fixed length will result in endobronchial intubation or endolaryngeal placement of the ET cuff in some patients.

FNDNRS-07–009

After the client had tolerated the weaning process, the physician ordered the removal of the endotracheal tube and it will be shifted into a nasal cannula. Which of the following findings after the removal requires immediate intervention by the physician?

• A. Sore throat.
• B. Hoarseness of the voice.
• C. Coughing out blood.
• D. Neck discomfort.

Correct Answer: C. Coughing out blood.

A sign of a tracheal or esophageal perforation that prevents oxygen from reaching the lungs and can result in internal bleeding. This life-threatening side effect of being intubated requires immediate medical intervention. When hemoptysis begins after endotracheal intubation, upper airway trauma caused by the intubation procedure, endotracheal tube, or endotracheal suction catheters must be considered. If hemoptysis begins after a latent period of 1 or more weeks after intubation, a tracheo-artery fistula may be the source of hemorrhage.

• Option A: Endotracheal tube (ETT) is often necessary to achieve airway control during general anesthesia. However, postoperative sore throat (POST) is considered as a common adverse event after general anesthesia with ETTs. POST continues to be reported with a high frequency and can sometimes persist for several days
• Option B: The incidence of hoarseness after endotracheal intubation varies widely from 14% to 50% but is mostly temporary. In a retrospective study of 3093 patients who had endotracheal intubation during anesthesia, the incidence of hoarseness was 49% in the immediate postoperative period.
• Option D: Neck discomfort is normal and the client should limit talking if it occurs. Many people will experience a sore throat and difficulty swallowing immediately after intubation, but recovery is usually quick, taking several hours to several days depending on the time spent intubated. In most cases, a person will fully recover from intubation within a few hours to days and will have no long-term complications.

FNDNRS-07–010

The nurse is assessing a client with an endotracheal tube and observes that the client can make verbal sounds. What is the most likely cause of this?

• A. This is a normal finding.
• B. There is a leak.
• C. There is an occlusion.
• D. The endotracheal tube is displaced.

Correct Answer: B. There is a leak.

When conducting the minimal leak technique the client should not be able to make verbal sounds or no air should be felt coming out of the client’s mouth. Because the cuff blocks the flow of air around the tube, speech is not possible. Once the tube is removed (called extubation), the patient will be able to speak. The voice may sound hoarse and the patient may have some throat discomfort for the first few days.

• Option A: Verbal sounds in an intubated patient is not a normal finding. As long as the patient has an endotracheal tube in place, the cuff will need to be inflated. An inflated cuff will prevent the patient from being able to speak. Speech is produced when we exhale air through the vocal cords, causing them to vibrate.
• Option C: Without a gag reflex, saliva would enter the windpipe. This is called aspiration. It was hypothesized that the high minute volume of patients contributes to the inspissation of secretions. It is also possible that some characteristic of the Pneumocystis organism in secretions causes altered adherence characteristics of the sputum, resulting in this problem.
• Option D: If the patient has complete obstruction of the upper airway, a displaced tracheostomy tube will result in immediate respiratory distress and can lead to respiratory arrest. If the patient has an intact or at least a partially open upper airway, the displaced tube may not cause an immediate problem. Therefore, displacement of the tracheostomy tube may not be obvious in the patient with a partial airway.

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FNDNRS-07–011

While changing the tapes on a tracheostomy tube, the client coughs, and the tube is dislodged. Which is the initial nursing action?

• A. Call a respiratory therapist to reinsert the tracheotomy.
• B. Cover the tracheostomy site with a sterile dressing.
• C. Call the physician to reinsert the tracheotomy.
• D. Grasp the retention sutures to spread the opening.

Correct Answer: D. Grasp the retention sutures to spread the opening.

If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if necessary. Once replaced, tie the tube securely, leaving one finger space between ties and the patient’s neck.

• Option A: Ask the patient to breathe normally via their stoma while waiting for the doctor. Check tube position by (a) asking the patient to inhale deeply — they should be able to do so easily and comfortably, and (b) hold a piece of tissue in front of the opening — it should be “blown” during the patient’s exhalation.
• Option B: Covering the tracheostomy site will block the airway. Use tracheostomy covers to protect the airway from outside elements (such as dust, cold air, etc.). All trach tubes have an outer cannula (main shaft) and a neck plate (flange). The flange rests on the neck over the stoma (opening). Holes on each side of the neck plate allow you to insert trach tube ties to secure the trach tube in place.
• Option C: Calling a respiratory therapist or the physician will delay treatment in this emergency situation. Accidental dislodgement of the tracheostomy tube during the first several days is not uncommon and can be life-threatening, particularly in patients with severe oxygenation problems and/or high demands for pressure and volume from the ventilator.

FNDNRS-07–012

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate for the nurse?

• A. Increase the suction pressure so that the bubbling becomes vigorous.
• B. Do nothing since this is an expected finding.
• C. Immediately clamp the chest tube and notify the physician.
• D. Check for an air leak because the bubbling should be intermittent.

Correct Answer: B. Do nothing since this is an expected finding.

Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent. The water level in the suction chamber should be at the prescribed level and gentle bubbling should be observed. The level may drop due to evaporation or over-vigorous bubbling, if this occurs top fluid level up as per manufacturer’s instructions.

• Option A: Increasing the suction pressure only increases the rate of evaporation of water in the drainage system. and this is not done without any prescription of the physician. Suction is not always required and may lead to tissue trauma and prolongation of an air leak in some patients.
• Option C: Clamping should be done if there is accidental disconnection of the system. Clamp the drain tubing at the patient end. Clean ends of the drain and reconnect. Ensure all connections are cable tied. If a new drainage system is needed, cover the exposed patient end of the drain with sterile dressing while a new drain is set up. Ensure clamp is removed when the problem is resolved.
• Option D: Chest tubes should only be clamped to check for an air leak or when changing drainage devices. An air leak will be characterized by intermittent bubbling in the water seal chamber when the patient with a pneumothorax exhales or coughs. Continuous bubbling of this chamber indicates large air leak between the drain and the patient. Check drain for disconnection, dislodgement, and loose connection, and assess patient condition. Notify medical staff immediately if a problem cannot be remedied.

FNDNRS-07–013

The nurse is assessing the functioning of a chest tube drainage system in a client with hemothorax. Which of the following findings should prompt the nurse to notify the physician?

• A. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.
• B. Drainage system maintained below the client’s chest.
• C. Drainage amount of 100ml in the drainage collection chamber.
• D. Occlusive dressing in place over the chest tube insertion site.

Correct Answer: C. Drainage amount of 100ml in the drainage collection chamber.

Drainage of more than 70 to 100 mL/hour is not normal and requires the immediate notification of the physician. Measure date and time, and the amount of drainage, and mark on the outside of the chamber. Record amount and characteristics of the drainage on the fluid balance sheet and patient chart. Drainage that is red and free-flowing indicates a hemorrhage. A large amount of drainage, or drainage that changes in color, should be recorded and reported to the primary health care provider.

• Option A: The water in the water seal chamber will rise and fall (swing) with respirations. This will diminish as the pneumothorax resolves. Watch for unexpected cessation of swing as this may indicate the tube is blocked or kinked. Cardiac surgical patients may have some of their drains in the mediastinum in which case there will be no swing in the water seal chamber.
• Option B: Collection chamber (drainage system) is below the level of the chest and secured to prevent it from being accidentally knocked over. The drainage system must remain upright for the water-seal chamber to function correctly. The chest drainage system must be lower than the chest to facilitate drainage and prevent backflow.
• Option D: The classic dressing for chest thoracostomy tube (CTT) insertion sites is petroleum gauze held in place by a secondary dressing of sterile, 4″ x 4″ sponge gauze secured with tape. Studies suggest that petroleum gauze macerates skin over time.

FNDNRS-07–014

A nurse is supervising a student nurse who is performing tracheostomy care for a client. Which of the following actions by the student should the nurse intervene?

• A. Removing the inner cannula and cleaning using universal precaution.
• B. Suctioning the tracheostomy tube before performing tracheostomy care.
• C. Changing the old tracheostomy ties and securing the tube in place.
• D. Replacing the inner cannula and cleaning the site of the stoma.

Correct Answer: A. Removing the inner cannula and cleaning using universal precaution.

When performing tracheostomy care, a sterile field is set up and sterile technique is required. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of the tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection.

• Option B: Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages. The frequency of suctioning varies and is based on individual patient assessment. The depth of insertion of the suction catheter needs to be determined prior to suctioning. Using a spare tracheostomy tube of the same type and size and a suction catheter insert the suction catheter to measure the distance from the length of the tracheostomy tube 15mm connector to the end of the tracheostomy tube. Ensure the tip of the suction catheter remains within the tracheostomy tube.
• Option C: If tie changes are required before the first tube change — it is imperative that the procedure must be undertaken with both medical and nursing staff present who are able to reinsert the tracheostomy tube in case of accidental decannulation and the appropriate equipment is available at the bedside. Tracheostomy tie changes are performed daily in conjunction with stoma care, or as required if they become wet or soiled to maintain skin integrity.
• Option D: Care of the stoma is commenced in the immediate postoperative period, and is ongoing. Inspect the stoma area at least daily to ensure the skin is clean and dry to maintain skin integrity and avoid breakdown. Daily cleaning of the stoma is recommended using 0.9% sterile saline solution.

FNDNRS-07–015

The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally disconnected. What is the most appropriate action for the nurse to take?

• A. Secure the chest tube using tape.
• B. Clamp the chest tube immediately.
• C. Place the end of the chest tube in a container of normal sterile saline.
• D. Apply an occlusive dressing and notify the physician.

Correct Answer: C. Place the end of the chest tube in a container of normal sterile saline.

If a chest drainage system is disconnected, the nurse can place the end of the chest tube in a container of normal sterile saline to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. A chest tube drainage system disconnecting from the chest tube inside the patient is an emergency. Immediately place the end of the chest tube in sterile water or NS. The two ends will need to be swabbed with alcohol and reconnected. Bleeding may occur after insertion of the chest tube.

• Option A: The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected. Keep the system closed and below chest level. Make sure all connections are taped and the chest tube is secured to the chest wall.
• Option B: The nurse should not clamp the chest tube because doing so increases the risk of tension pneumothorax. Never clamp a chest tube without a doctor’s order or valid reason. The tube must remain unobscured and unclamped to drain air or fluid from the pleural space. There are a few exceptions where a chest tube may be clamped.
• Option D: The nurse should apply an occlusive dressing if the chest tube is pulled out and not if the system is disconnected. Dress the site with a dry occlusive dressing and discard the chest tube and drainage device in the hazardous waste bag. Obtain a post-removal chest X-ray if the physician has ordered it or facility protocol requires it.

Questions related to Laboratory Values

FNDNRS-07–016

A client with Congestive heart failure is about to take a dose of furosemide (Lasix). Which of the following potassium levels, if noted in the client’s record, should be reported before giving the due medication?

• A. 5.1 mEq/L.
• B. 4.9 mEq/L.
• C. 3.9 mEq/L.
• D. 3.3 mEq/L.

Correct Answer: D. 3.3 mEq/L.

The normal potassium level is 3.5 to 5.5 mEq/L. Low potassium levels can be dangerous, especially for people with CHF. Low potassium can cause fatal heart arrhythmias. An abnormal serum K+ level is associated with an increased risk of ventricular arrhythmia and sudden cardiac death (SCD) and these patients are generally prescribed furosemide and potassium chloride (KCl).

• Option A: Furosemide, a short-acting diuretic is commonly recommended as an essential drug in patients with heart failure and fluid retention. A recent study has shown that furosemide administration increases mortality in heart failure rat models. The commonly used drugs, furosemide, and KCl in the treatment of various diseases render the differential expression of proteins in the LV tissue, which is involved in the cardiac conductivity.
• Option B: The risk of hypokalemia increases with the use of a high dose of furosemide, decreased oral intake of potassium in patients with hyperaldosteronism states (liver abnormalities or licorice ingestion), or concomitant use of corticosteroid, ACTH, and laxatives.
• Option C: Careful monitoring of the patient’s clinical condition, daily weight, fluids intake, and urine output, electrolytes, i.e., potassium and magnesium, kidney function monitoring with serum creatinine and serum blood urea nitrogen level is vital to monitor the response to furosemide. If indicated as diuresis with furosemide, replete electrolytes lead to electrolyte depletion and adjust the dose or even hold off on furosemide if laboratory work shows signs of kidney dysfunction.

FNDNRS-07–017

A client went to the emergency room with a sudden onset of high fever and diaphoresis. Serum sodium was one of the laboratory tests taken. Which of the following values would you expect to see?

• A. 130 mEq/L.
• B. 148 mEq/L.
• C. 143 mEq/L.
• D. 139 mEq/L.

Correct Answer: B. 148 mEq/L.

The normal sodium level is 135–145 mEq/L. Diaphoresis and a high fever can lead to free water loss through the skin, resulting in increased sodium level (hypernatremia). Hypernatremia is defined as a serum sodium concentration of greater than 145 meq/l. The human body maintains sodium and water homeostasis by concentrating the urine secondary to the action of antidiuretic hormone (ADH) and increased fluid intake by a powerful thirst response.

• Option A: The basic mechanisms of hypernatremia are water deficit and excess solute. Total body water loss relative to solute loss is the most common reason for developing hypernatremia. Hypernatremia is usually associated with hypovolemia, which can occur in conditions that cause combined water and solute loss, where water loss is greater than sodium loss, or free water loss.
• Option C: Excessive sweating can occur due to exercise, fever, or high heat exposure. Renal losses can be seen in intrinsic renal disease, post-obstructive diuresis, and with the use of osmotic or loop diuretics. Hyperglycemia and mannitol are common causes of osmotic diuresis. Free water loss is seen with central or nephrogenic diabetes insipidus (DI) and also in conditions with increased insensible loss.
• Option D: Sodium excretion also involves regulatory mechanisms such as the renin-angiotensin-aldosterone systems. When serum sodium increases, the plasma osmolality increases which triggers the thirst response and ADH secretion, leading to renal water conservation and concentrated urine.

FNDNRS-07–018

A client is brought to the emergency department and states that he has accidentally been taking two times his prescribed dose of Warfarin (Coumadin). After observing that the client has no evidence of any obvious bleeding, the nurse should do which of the following?

• A. Draw a sample for activated partial thromboplastin time (aPTT) level.
• B. Draw a sample for prothrombin time (PT) level and international normalized ratio (INR).
• C. Prepare to administer Vitamin K.
• D. Prepare to administer Protamine sulfate.

Correct Answer: B. Draw a sample for prothrombin time (PT) level and international normalized ratio (INR).

The next action for the nurse to take is to draw a sample for INR and PT level to check the client’s anticoagulation status and risk for bleeding. These results will provide information on how to manage the client by either giving an antidote such as Vitamin K or administering a blood transfusion. Specific evaluation of warfarin toxicity should involve evaluation of the patient’s PT, INR, CBC, and BMP with hepatic function, in addition to the standard co-ingestions and a focused evaluation surrounding their symptoms.

• Option A: The aPTT determines the effects of heparin therapy. It is recommended that patients undergo measurement of PT/INR and PTT during the initial presentation. For acute exposures, patients should receive serial INR assessments every 12–24 hours. If INR remains normalized at 36 hours and there are no signs of bleeding, no further testing is generally necessary.
• Option C: The results of the INR and PT level will be needed first. For these recommendations, coagulopathy is defined as INR > 1.4. Warfarin toxicity is defined as INR > 3.0 or >3.5 in a patient with a mechanical heart valve. Unintentional toxicity in patients who are treated with warfarin for an underlying condition (most common presentation).
• Option D: Protamine sulfate is the antidote for heparin overdose. Patients with elevated INR displaying evidence of coagulopathy during evaluation, do not need to be started on vitamin K unless the INR is greater than 10 or they have evidence of bleeding.

FNDNRS-07–019

A male client with atrial fibrillation who is receiving maintenance therapy of warfarin (Coumadin) has a prothrombin time of 37 seconds. Based on the result, the nurse will follow which of the following doctor’s orders?

• A. Administering the next dose of warfarin.
• B. Increasing the next dose of warfarin.
• C. Decreasing the next dose of warfarin.
• D. Withholding the next dose of warfarin.

Correct Answer: D. Withholding the next dose of warfarin.

The normal prothrombin time is 9.6 to 11.8 seconds (male adult). A therapeutic level PT level is 1.5 to 2 times higher than the normal level. Since the value of 37 seconds is high, the nurse should expect that the client’s next dose of warfarin will be withheld. Patients receiving treatment with warfarin should have close monitoring to ensure the safety and efficacy of the medication. Periodic blood testing is recommended to assess the patient’s prothrombin time (PT) and the international normalized ratio (INR).

• Option A: The laboratory parameter utilized to monitor warfarin therapy is the PT/INR. The PT is the number of seconds it takes the blood to clot, and the INR allows for the standardization of the PT measurement depending on the thromboplastin reagent used by a laboratory. Therefore, monitoring a patient’s INR while on warfarin is strongly preferable over PT because it allows for a standardized measurement without variations due to different laboratory sites.
• Option B: Routine assessment of INR is essential in the management of patients receiving warfarin therapy. The INR of a patient who is not on anticoagulation therapy is approximately 1.0. If a patient has an INR of 2.0 or 3.0, that would indicate that it takes two or three times longer for that individual’s blood to clot than someone who does not take any anticoagulants.
• Option C: The therapeutic INR goal for patients on warfarin therapy is dependent on the indication but may vary based on the patient’s clinical presentation and provider preference. Most patients on warfarin have an INR goal of 2 to 3. However, specific indications, such as a mechanical mitral valve, require an INR goal of 2.5 to 3.5.

FNDNRS-07–020

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin time is 77 seconds. Based on this result, the nurse anticipated which of the following prescriptions?

• A. Maintain the rate of the heparin infusion.
• B. Decrease the rate of the heparin infusion.
• C. Increase the rate of the heparin infusion.
• D. Discontinue the heparin infusion.

Correct Answer: A. Maintain the rate of the heparin infusion.

The normal activated partial thromboplastin time is between 20 to 36 seconds. In the treatment of deep vein thrombosis, the therapeutic range is to maintain the aPTT level between 1.5 and 2.5 times the normal. This means that the client’s aPTT level should not be less than 30 seconds or greater than 90 seconds. Thus the client’s aPTT of 77 seconds is within the normal therapeutic range, and the dose/rate should not be changed.

• Option B: Therapeutic monitoring for heparin includes activated partial thromboplastin time (aPTT) and activated clotting time (ACT). Both of these are aspects of clotting time, which are prolonged by therapeutic heparin doses. Activated partial thromboplastin time is performed at baseline and every 6 hours until 2 or more therapeutic values are obtained, then aPTT can be assessed every 24 hours.
• Option C: Dose titrations are made based on the results of the aPTT. Hospitals have dosing nomograms specific to their target aPTT, which may vary depending upon the laboratory reagent used for their test. Therapeutic aPTT is considered therapeutic at 1.5 to 2 times control, which also varies from facility to facility based on controls.
• Option D: ACT is less sensitive than aPTT. ACT will only detect abnormalities when there is 95% abnormality rate in the factors, whereas aPTT can detect when there is 70% abnormality. ACT may also be affected when platelets are abnormal, which can result from the administration of heparin.

FNDNRS-07–021

A nurse is handling a pregnant client who was prescribed to have an Alpha Fetoprotein level. The nurse should explain to the client that this blood test:

• A. Can indicate lung disorders and neural tube defects.
• B. Abnormal levels are associated with an increased risk for chromosome abnormality.
• C. Once the Alpha-Fetoprotein levels are abnormal, amniocentesis will be ordered.
• D. An Alpha-Fetoprotein is a definitive test for neural tube defects.

Correct Answer: C. Once the Alpha-Fetoprotein levels are abnormal, amniocentesis will be ordered.

If the Alpha-Fetoprotein levels are abnormal, the physician will prescribe amniocentesis to confirm or eliminate the diagnosis of a neural tube defect. Alpha-fetoprotein (AFP) is a plasma protein produced by the embryonic yolk sac and the fetal liver. AFP levels in serum, amniotic fluid, and urine function as a screening test for congenital disabilities, chromosomal abnormalities, as well as some other adult occurring tumors and pathologies.

• Option A: Option A is incorrect since Alpha Fetoprotein does not indicate lung disorders. It is pertinent to explain that this is a screening test. Depending on the outcome, more tests may be ordered for the purpose of establishing a diagnosis. A negative test does not necessarily indicate no risk as very low maternal blood alpha-fetoprotein is associated with an increased incidence of Down syndrome.
• Option B: Option B is incorrect because an increase of human chorionic gonadotropin instead is associated with an increased risk for chromosome abnormality. This tumor marker is a glycoprotein encoded by the AFP gene on chromosome 4q25. Prenatal levels in developing human embryos rise from the end of the first trimester and begin to fall after 32 weeks of gestation. Maternal serum AFP forms part of the triple or quadruple screening tests for fetal anomaly.
• Option D: Option D is incorrect because an Alpha Fetoprotein level is a screening test and is not a definitive test. This tumor marker is a glycoprotein encoded by the AFP gene on chromosome 4q25. Prenatal levels in developing human embryos rise from the end of the first trimester and begin to fall after 32 weeks of gestation. Maternal serum AFP forms part of the triple or quadruple screening tests for fetal anomaly.

FNDNRS-07–022

Which of the following laboratory results indicates hypoparathyroidism?

• A. Serum potassium of 3.6 mEq/L.
• B. Serum calcium level of 4.3 mEq/L.
• C. Serum phosphorus level of 5.7 mg/dL.
• D. Serum magnesium level of 1.7 mg/dL.

Correct Answer: C. Serum phosphorus level of 5.7 mg/dL.

The parathyroid is responsible for the absorption of calcium and phosphorus. When a client has hypoparathyroidism, the serum calcium levels are low and the serum phosphorus levels are high. The normal phosphorus level is 2.7 to 4.5 mg/dL. Parathyroid hormone deficiency, also called hypoparathyroidism, results in hypocalcemia, hyperphosphatemia, and increased neuromuscular irritability. Patients may present with myalgias, muscle spasms, and in extreme cases tetany.

• Option A: Calcium is maintained within a fairly narrow range from 8.5 to 10.5 mg/dl (4.3 to 5.3 mEq/L or 2.2 to 2.7 mmol/L). Normal values and reference ranges may vary among laboratories as much as 0.5 mg/dl. Aldinger KA, et al., studied a large group of patients of normal renal function with hypercalcemia to determine the prevalence of hypokalemia and reported that 16.9% had hyperparathyroidism, and the degree and frequency of hypokalemia were greatest at the higher serum calcium levels.
• Option B: Parathyroid hormone activates the PTH receptor, another G-protein coupled receptor, increasing resorption of calcium and phosphorus from bone, enhancing the distal tubular reabsorption of calcium, and decreasing the renal tubular reabsorption of phosphorus. Deficient PTH results in hypocalcemia, hyperphosphatemia, while alkaline phosphatase, a marker of bone formation, is normal.
• Option D: The normal range for blood magnesium level is 1.7 to 2.2 mg/dL (0.85 to 1.10 mmol/L). Another common cause of hypoparathyroidism is abnormally low levels of magnesium (hypomagnesemia) in the blood. This is often called functional hypoparathyroidism because it resolves when magnesium is restored. Magnesium is a mineral that is very important in the function of the parathyroid glands.

FNDNRS-07–023

An adult male client has a hemoglobin count of 12.5 g/dL. Based on the result, the client is most likely having this due to which of the following notes in the client’s record?

• A. Emphysema.
• B. Client living at a high altitude.
• C. Dehydration.
• D. History of an enlarged spleen.

Correct Answer: D. History of splenomegaly.

The normal hemoglobin level for an adult male is 14–16.5 g/dL. An enlarged spleen may cause anemia (low hemoglobin count) in clients. The spleen normally removes old and/or damaged red blood cells from the bloodstream. However, when the spleen enlarges, it traps and stores an excessive number of red blood cells, causing anemia. Sometimes, the spleen also destroys white blood cells and/or platelets causing a low white blood cell count (leukopenia) and a low platelet count (thrombocytopenia).

• Option A: Anemia of chronic disease (ACD) is probably the most common type of anemia associated with COPD. ACD is driven by COPD-mediated systemic inflammation. Anemia in COPD is associated with greater healthcare resource utilization, impaired quality of life, decreased survival, and a greater likelihood of hospitalization.
• Option B: Living at higher altitudes causes red blood cell production to naturally increase to compensate for the lower oxygen supply. The amount of hemoglobin in blood increases at high altitude. This is one of the best-known features of acclimatization (acclimation) to high altitude. Increasing the amount of hemoglobin in the blood increases the amount of oxygen that can be carried.
• Option C: Dehydration may increase the hemoglobin level by hemoconcentration. Both the hemoglobin and the hematocrit are based on whole blood and are therefore dependent on plasma volume. If a patient is severely dehydrated, the hemoglobin and hematocrit will appear higher than if the patient were normovolemic; if the patient is fluid overloaded, they will be lower than their actual level.

FNDNRS-07–024

A screen test for the detection of human immunodeficiency virus (HIV) reveals a positive ELISA exam. Which of the following tests will be used to confirm the diagnosis of HIV?

• A. Indirect immunofluorescence assay (IFA).
• B. CD4-to-CD8 ratio.
• C. Radioimmunoprecipitation assay (RIPA) test.
• D. p24 antigen assay.

Correct Answer: A. Indirect immunofluorescence assay (IFA)

The indirect immunofluorescence assay (IFA) test and Western Blot test result are considered as confirmatory for HIV. An initial HIV test usually will either be an antigen/antibody test or an antibody test. If the initial HIV test is a rapid test or a self-test and it is positive, the individual should go to a health care provider to get follow-up testing. If the initial HIV test is a laboratory test and it is positive, the laboratory will usually conduct follow-up testing on the same blood sample as the initial test. Although HIV tests are generally very accurate, follow-up testing allows the health care provider to be sure the diagnosis is right.

• Option B: CD4-to-CD8 ratio monitors the progression of HIV. A normal CD4/CD8 ratio is greater than 1.0, with CD4 lymphocytes ranging from 500 to 1200/mm 3 and CD8 lymphocytes ranging from 150 to 1000/mm 3. If the ratio is higher than 1, it means the immune system is strong and the client may not have HIV. If the ratio is less than 1, the client may have HIV.
• Option C: Radioimmunoprecipitation assay (RIPA) test detects HIV protein rather than showing antibodies. Radioimmunoprecipitation assay buffer (RIPA buffer) is a lysis buffer used for rapid, efficient cell lysis and solubilization of proteins from both adherent and suspension-cultured mammalian cells.
• Option D: p24 antigen assay quantifies the amount of HIV viral core protein. One distinctive HIV antigen is a viral protein called p24, a structural protein that makes up most of the HIV viral core, or ‘capsid’. High levels of p24 are present in the blood serum of newly infected individuals during the short period between infection and seroconversion, making p24 antigen assays useful in diagnosing primary HIV infection.

FNDNRS-07–025

The client went to the emergency room with a sudden onset of chest pain and difficulty of breathing. Which of the following results is indicative that the client is experiencing a myocardial infarction?

• A. Myoglobin level of 98 mcg/L.
• B. Troponin T of 0.09 ng/mL.
• C. Troponin I 0.5 ng/mL.
• D. Creatine kinase (CK-MB) 155 units/L.

Correct Answer: A. Myoglobin level of 98 mcg/L.

The normal value of myoglobin is lower than 90 mcg/L; An elevation could indicate a myocardial infarction. Myoglobin, an oxygen-carrying protein found in cardiac muscle and striated skeletal muscle, presents an attractive alternative to CPK and LDH in the emergency department setting for identification of acute myocardial infarction. Myoglobin levels may be elevated in the serum within one hour after myocardial cell death with peak levels reached within four to six hours.

• Option B: The troponin T level is normal. Cardiac troponin T is measured in nanograms per milliliter (ng/mL). If the client’s troponin T level is above the 99th percentile for the test being used, the doctor will likely diagnose a heart attack. Levels that start high and fall suggest a recent injury to the heart. It could be a mild heart attack.
• Option C: The troponin I level is normal. High levels of troponin are an immediate red flag. The higher the number, the more troponin — specifically troponin T and I — has been released into the bloodstream, and the higher the likelihood of heart damage. Troponin levels can elevate within 3–4 hours after the heart has been damaged and can remain high for up to 14 days.
• Option D: Creatine kinase level has a normal value. The ECG and the determination of serum enzymes creatine phosphokinase (CPK) and lactate dehydrogenase (LDH) may be falsely normal early in acute myocardial infarction.

FNDNRS-07–026

A nurse is caring for a client with diarrhea and dehydration. The nurse determines that the client has received adequate fluid replacement if the blood urea nitrogen decreases to:

• A. 36 mg/dL.
• B. 27 mg/dL.
• C. 18 mg/dL.
• D. 6 mg/dL.

Correct Answer: C. 18 mg/dL.

The normal value of blood urea nitrogen is 8 to 25 mg/dL. Fluid status absolutely affects the levels of BUN and creatinine in the blood, but volume depletion or dehydration tends to affect BUN more so that we see a BUN: creatinine ratio of 20:1 or more in people who are very dry.

• Option A: 36 mg/dl indicates a high level of BUN. Dehydration generally causes BUN levels to rise more than creatinine levels. This causes a high BUN-to-creatinine ratio. Kidney disease or blockage of the flow of urine from the kidney causes both BUN and creatinine levels to go up.
• Option B: 27 mg/dl still indicates dehydration. A patient who is severely dehydrated may also have a high BUN due to the lack of fluid volume to excrete waste products. Because urea is an end product of protein metabolism, a diet high in protein, such as high-protein tube feeding, may also cause the BUN to increase.
• Option D: A low BUN occurs with conditions such as fluid volume overload, malnutrition, etc. Because urea is synthesized by the liver, severe liver failure causes a reduction of urea in the blood. Just as dehydration may cause an elevated BUN, overhydration causes a decreased BUN. When a person has “syndrome of inappropriate antidiuretic secretion” (SIADH), the antidiuretic hormone responsible for stimulating the kidney to conserve water causes excess water to be retained in the bloodstream rather than being excreted into the urine.

FNDNRS-07–027

A client with liver cirrhosis has been advised to follow a high-protein diet. The nurse evaluates the effectiveness of the diet if the total protein level is which of the following values?

• A. 6.9 g/dL.
• B. 4.9 g/dL.
• C. 2.9 g/dL.
• D. 0.9 g/dL.

Correct Answer: A. 6.9 g/dL.

The normal value for total serum protein is 6 to 8 g/dL. The client with liver cirrhosis has low total protein levels secondary to inadequate nutrition. Protein deficiency is often associated with liver disease. The principal cause of protein deficiency is decreased dietary intake. Deficiencies in digestion and absorption that are common in alcoholics contribute to protein deficiency in alcoholic liver disease.

• Option B: 4.9 mg/dl is a low value for total serum protein. The protein requirements in most patients with compensated chronic liver disease are not different from normal but increase during episodes of hepatocellular deterioration. An increased demand for protein after liver injury drains nitrogen from other organs such as muscle.
• Option C: 2.9 mg/dl is a very low total serum protein level. Circulating proteins synthesized by the liver, such as albumin and clotting factors, are frequently decreased in chronic liver disease. Vitamin deficiencies that are common in liver disease contribute to abnormalities of protein metabolism. Hepatic regeneration following hepatic resection or injury is adversely affected by protein and vitamin deficiencies and by alcohol ingestion.
• Option D: 0.9 mg/dl is an abnormally low total serum protein value. This is because some conditions affect the amounts of albumin or globulin in the blood. A low A/G ratio may be due to an overproduction of globulin, underproduction of albumin, or loss of albumin, which may indicate the following: an autoimmune disease. cirrhosis, involving inflammation and scarring of the liver.

FNDNRS-07–028

The nurse is handling a client with chronic pancreatitis. Upon reviewing the client’s record, which of the following serum amylase levels is to be expected?

• A. 50 units/L.
• B. 150 units/L.
• C. 350 units/L.
• D. 650 units/L.

Correct Answer: C. 350 units/L.

The normal serum amylase level is 25 to 151 unit/L. Clients with chronic pancreatitis have an increased level of serum amylase which does not exceed three times the normal value. Serum amylase and lipase levels may be slightly elevated in chronic pancreatitis; high levels are found only during acute attacks of pancreatitis.

• Option A: 50 units/L is a low serum amylase level. Low serum amylase (hypoamylasemia) has been reported in certain common cardiometabolic conditions such as obesity, diabetes (regardless of type), and metabolic syndrome, all of which appear to have a common etiology of insufficient insulin action due to insulin resistance and/or diminished insulin secretion.
• Option B: 150 units/L is within the normal values. However, in the later stages of chronic pancreatitis, atrophy of the pancreatic parenchyma can result in normal serum enzyme levels because of significant fibrosis of the pancreas, resulting in decreased concentrations of these enzymes within the pancreas.
• Option D: 650 units/L is seen with acute pancreatitis since the value may exceed five times the normal value. The sensitivity and specificity of amylase as a diagnostic test for acute pancreatitis depends on the chosen threshold value. By raising the cut-off level to 1000 IU/l (more than three times the upper limit of normal), amylase has a specificity approaching 95%, but sensitivity as low as 61% in some studies.

FNDNRS-07–029

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 10%. Based on the result, the nurse plans to teach the client about the importance of:

• A. Maintaining the result.
• B. Preventing hypoglycemia.
• C. Preventing hyperglycemia.
• D. Avoiding infection.

Correct Answer: C. Preventing hyperglycemia.

Glycosylated hemoglobin A1c level of 8% higher indicates poor diabetic control. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes. The test shows an average of the blood sugar level over the past 90 days and represents a percentage. The test can also be used to diagnose diabetes.

• Option A: For an A1c test to classify as normal, or in the non-diabetic range the value must be below 5.7 %. Anyone with an A1c value of 5.7 % to 6.4 % is considered to be prediabetic, while diabetes can be diagnosed with an A1c of 6.5% or higher. Hemoglobin A1c serves as an indicator of overall glycemic control and a reflection of the average blood sugar over the past three months.
• Option B: A falsely low A1c value can result from several conditions including high altitude, pregnancy, hemorrhages, blood transfusions, erythropoietin administration, iron supplementation, hemolytic anemia, chronic kidney failure, liver cirrhosis, alcoholism, folic acid deficiency, sickle cell anemia, and spherocytosis.
• Option D: A1c provides a measure of the glucose concentration over three months. Hemoglobin A1c is often used as an outcome measure to determine if an intervention in a population is successful by showing a decrease in A1c by a certain percentage. Levels of A1c should be measured twice a year in stable patients and at least four times in patients who have glucose fluctuations or those who have had a change in their diabetic treatment.

FNDNRS-07–030

The nurse is reviewing the laboratory result of a client receiving digoxin (Lanoxin) and notes that the result is 2.5 ng/mL. The nurse plans to do which of the following?

• A. Give the next dose.
• B. Notify the physician.
• C. Check the client’s pulse rate.
• D. Increase the next dose as ordered.

Correct Answer: B. Notify the physician.

The normal value therapeutic range for digoxin is 0.5 to 2 ng/mL. A level of 2.5 ng/mL indicates toxicity. The nurse should immediately inform the physician, who may give further instructions about holding the next doses of digoxin. Digoxin toxicity can present acutely after an overdose or chronically, as is often seen in patients on digoxin that develop acute kidney injury. Approximately 1% of CHF patients treated with digoxin develop toxicity. Additionally, 1% of adverse drug effects in patients greater than age 40 are due to digoxin toxicity; the incidence rises to greater than 3% in patients over age 85.

• Option A: Clinical staff should monitor the plasma digoxin level at least 6 hours or 12 hours post-administration of the last loading dose as this is the time to achieve steady-state levels. Recommended thresholds of therapeutic serum digoxin levels are between 0.5 to 2 ng/dl.
• Option C: The physician must request regular electrocardiograms and bloodwork to assess for renal function, and electrolytes require close monitoring. No more than 2 ml of the drug should be injected at the same site. The injection should be made deep into the muscle, and the overlying area massaged post-injection. Intravenous injections are metabolized more efficiently than intramuscular injections and are the preferred route, as only about 80% of the drug is absorbed in intramuscular injections as compared to intravenous dosing.
• Option D: Digoxin has a narrow therapeutic index. The recommended serum levels stand between 0.8 to 2 ng/mL. When measuring a digoxin serum level, it is essential to draw blood at least 6 to 8 hours after the last dose. The toxicity increases as the serum drug levels increase above 2.0 ng/mL.

FNDNRS-07–031

The nurse caring for a client with a serum calcium of 6.8 mg/dL. What would the nurse expect the change on the electrocardiogram (ECG)?

• A. None. This is a normal calcium level.
• B. Prolonged QT interval.
• C. Shortened ST segment.
• D. Widened T wave.

Correct Answer: B. Prolonged QT interval.

The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. The ECG hallmark of hypocalcemia remains the prolongation of the QTc interval because of lengthening of the ST segment, which is directly proportional to the degree of hypocalcemia or, as otherwise stated, inversely proportional to the serum calcium level. The exact opposite holds true for hypercalcemia.

• Option A: High and low levels of ionized serum calcium concentration can produce characteristic changes on the electrocardiogram. These changes are almost entirely limited to the duration of the ST segment, with no change in the QRS complexes or T waves.
• Option C: The ST segment on an electrocardiogram (ECG) normally represents an electrically neutral area of the complex between ventricular depolarization (QRS complex) and repolarization (T wave). However, it can take on various waveform morphologies that may indicate benign or clinically significant injury or insult to the myocardium.
• Option D: A widened T wave occurs with hypercalcemia. On electrocardiography (ECG), characteristic changes in patients with hypercalcemia include shortening of the QT interval. ECG changes in patients with very high serum calcium levels include the following: slight prolongation of the PR and QRS intervals; and T wave flattening or inversion.

FNDNRS-07–032

When providing care for a female client with Addison disease, the nurse should be alert for which of the following laboratory values?

• A. Potassium level of 3.2 mEq/L.
• B. Calcium level of 3.3 mEq/L.
• C. Sodium level of 150 mg/dL.
• D. Hematocrit level of 25%.

Correct Answer: D. Hematocrit level of 25%.

A client with Addison’s disease is at risk for anemia. The normal hematocrit level of a female adult is 35% to 45%. A client with anemia has a low hematocrit level. Addison anemia, better known today as pernicious anemia (PA), is characterized by the presence in the blood of large, immature, nucleated cells (megaloblasts) that are forerunners of red blood cells. (Red blood cells, when mature, have no nucleus). It is thus a type of megaloblastic anemia.

• Option A: The client with Addison’s disease has increased potassium. A deficiency of aldosterone, in particular, causes the body to excrete large amounts of sodium and retain potassium, leading to low levels of sodium and high levels of potassium in the blood.
• Option B: The client with Addison’s disease has an increased calcium level. As not all cases of adrenal insufficiency present with hypercalcemia, adrenal insufficiency is not easily considered an etiology of hypercalcemia. The prevalence of hypercalcemia at the time of diagnosis of Addison’s disease is reported to be ~5.5%–6.0%.
• Option C: The client with Addison’s disease has a low sodium level. The kidneys are not able to retain sodium easily, so when a person with Addison disease loses too much sodium, the level of sodium in the blood falls, and the person becomes dehydrated. Severe dehydration and a low sodium level reduce blood volume and can lead to shock.

FNDNRS-07–033

A client has been undergoing radiotherapy for the treatment of mandibular cancer. After a few sessions, the client is diagnosed with Tumor Lysis Syndrome (TLS). Which of the following findings correlates with TLS?

• A. Phosphorus level of 6 mg/dL.
• B. Phosphorus level of 3 mg/dL.
• C. Phosphorus level of 4 mg/dL.
• D. Phosphorus level of 2 mg/dL.

Correct Answer: A. Phosphorus level of 6 mg/dL.

Tumor lysis syndrome (TLS) is a potentially life-threatening metabolic disorder characterized by elevated phosphorus levels. The normal phosphorus is 2.5 to 4.5 mg/dL. When cancer cells break down quickly in the body, levels of uric acid, potassium, and phosphorus rise faster than the kidneys can remove them. This causes TLS. Excess phosphorus can “sop up” calcium, leading to low levels of calcium in the blood.

• Option B: 3 mg/dL is a normal phosphorus level. Changes in blood levels of uric acid, potassium, phosphorus, and calcium can affect the functioning of several organs, especially the kidneys, and also the heart, brain, muscles, and gastrointestinal tract.
• Option C: 4 mg/dL is a normal phosphorus level. Not all cancer patients are at equal risk of developing TLS. Patients with a large “tumor burden” of cancer cells and/or tumors that typically have rapidly dividing cells, such as acute leukemia or high-grade lymphoma, as well as tumors that are highly responsive to therapy, are at greatest risk of developing TLS.
• Option D: 2 mg/dL is a normal phosphorus level. TLS is not limited to patients receiving traditional chemotherapy; it can also occur in patients receiving steroids, hormonal therapy, targeted therapy, or radiation therapy. Patients who are dehydrated and those with existing kidney dysfunction are at higher risk of developing TLS.

FNDNRS-07–034

A female client went to the clinic with a creatinine clearance of 200 mL/min. Which of the following conditions of the client can cause the increased level of this test?

• A. Renal disease.
• B. Dehydration.
• C. Congestive heart failure.
• D. History of high dietary protein intake.

Correct Answer: D. History of high dietary protein intake.

The normal creatinine clearance for a female is 88 to 128 ml/min. An increased creatinine clearance is often referred to as hyperfiltration and is most commonly seen during pregnancy or in clients with a large dietary protein intake. Dietary protein consumption increases serum creatinine level through protein catabolism rather than decreased clearance. Hence, serum creatinine may be less reliable for estimating GFR or estimating a glomerular hyperfiltration response in studies that manipulate dietary protein.

• Option A: Creatinine clearance has been used for many decades to estimate GFR. It involves a 24-hour urine collection to measure creatinine excretion. As the same sample can be used to measure the protein excretion rate, creatinine clearance is often used for the initial evaluation of renal diseases, such as glomerulonephritis.
• Option B: Dehydration generally causes BUN levels to rise more than creatinine levels. This causes a high BUN-to-creatinine ratio. Kidney disease or blocked urine flow from the kidney causes both BUN and creatinine levels to rise.
• Option C: Congestive heart failure is seen with a decreased creatinine clearance. Low creatinine clearance levels can mean the client has chronic kidney disease or serious kidney damage. Kidney damage can be from conditions such as a life-threatening infection, shock, cancer, low blood flow to the kidneys, or urinary tract blockage. Other conditions, such as heart failure and dehydration, can also cause low clearance levels.

FNDNRS-07–035

A nurse is reviewing the complete blood count (CBC) of a child who has been diagnosed with idiopathic thrombocytopenic purpura. Which of the following laboratory results should the nurse report immediately to the physician?

• A. Platelet count of 30,000/mm3.
• B. Hemoglobin level of 7.5 g/dL.
• C. Reticulocyte count of 6.5%.
• D. Eosinophil count of 700 cells/mm3.

Correct Answer: B. Hemoglobin level of 7.5 g/dL.

The low hemoglobin level indicates that the client has active bleeding, and immediate actions such as additional diagnostic exams and blood transfusions can be suggested. An initial impression of the severity of ITP is formed by examining the skin and mucous membranes. Widespread petechiae and ecchymoses, oozing from a venipuncture site, gingival bleeding, and hemorrhagic bullae indicate that the patient is at risk for a serious bleeding complication.

• Option A: Decreased platelet count is expected in a child with idiopathic thrombocytopenic purpura. Immune thrombocytopenia (ITP) is a syndrome in which platelets become coated with autoantibodies to platelet membrane antigens, resulting in splenic sequestration and phagocytosis by mononuclear macrophages. The resulting shortened life span of platelets in the circulation, together with incomplete compensation by increased platelet production by bone marrow megakaryocytes, results in a decreased number of circulating platelets.
• Option C: Increased reticulocyte is expected in a child with idiopathic thrombocytopenic purpura. The measurement of the content of hemoglobin of reticulocytes (CHr or Ret-He) reflects the synthesis of hemoglobin in marrow precursors and allows the detection of early stages of iron deficiency.
• Option D: An increased eosinophil count is expected in a child with idiopathic thrombocytopenic purpura. Many authors have reported associations between the increased numbers of eosinophils with platelet dysfunctions, such as increased bleeding time, reduction in platelet aggregation induced by various agonists, among other disorders.

Questions related to Parenteral Nutrition

FNDNRS-07–036

A patient receiving parenteral nutrition is administered via the following routes except:

• A. Subclavian line.
• B. Central Venous Catheter.
• C. PICC (Peripherally inserted central catheter) line.
• D. PEG tube.

Correct Answer: D. PEG tube.

Percutaneous endoscopic gastrostomy (PEG tube) is inserted into a person’s stomach through the abdominal wall that is used to provide a means of feeding when oral intake is not adequate. While parenteral nutrition bypasses the digestive system by the administration to the bloodstream.

• Option A: TPN may be administered as peripheral parenteral nutrition (PPN) or via a central line, depending on the components and osmolality. Central veins are usually the veins of choice because there is less risk of thrombophlebitis and vessel damage (Chowdary & Reddy, 2010).
• Option B: Parenteral nutrition may be delivered via femoral lines, internal jugular lines, and subclavian vein catheters in the hospital setting. Central access is required for infusions that are toxic to small veins due to medication pH, osmolarity, and volume.
• Option C: PICC lines may be used in ambulatory settings or for long-term therapy. It is inserted in the cephalic, basilic, median basilic, or median cephalic veins and threaded into the superior vena cava. It can remain in place for up to 1 year with proper maintenance and without complications.

FNDNRS-07–037

A nurse is monitoring the status of a client’s fat emulsion (lipid) infusion and notes that the infusion is 2 hours delay. The nurse should do which of the following actions?

• A. Adjust the infusion rate to catch up over the next hour.
• B. Make sure the infusion rate is infusing at the ordered rate.
• C. Increase the infusion rate to catch up over the next few hours.
• D. Adjust the infusion rate to full blast until the solution is back on time.

Correct Answer: B. Make sure the infusion rate is infusing at the ordered rate.

The nurse should maintain the prescribed rate of a fat emulsion even if the infusion’s time consumed is behind. The infusion of lipid emulsions allows a high energy supply, facilitates the prevention of high glucose infusion rates, and is indispensable for the supply with essential fatty acids. The administration of lipid emulsions is recommended within ≤7 days after starting PN (parenteral nutrition) to avoid deficiency of essential fatty acids.

• Option A: This intervention may cause hyperglycemia. Low-fat PN with a high glucose intake increases the risk of hyperglycemia. In parenterally fed patients with a tendency to hyperglycemia, an increase in the lipid-glucose ratio should be considered. In critically ill patients the glucose infusion should not exceed 50% of energy intake.
• Option C: C is incorrect since increasing the rate will potentially cause a fluid overload. The risk of PN complications (e.g. refeeding syndrome, hyperglycemia, bone demineralization, catheter infections) can be minimized by carefully monitoring patients and the use of nutrition support teams particularly during long-term PN.
• Option D: If the infusion rate is adjusted to full blast, the patient might undergo fluid overload and other complications. Occurring complications are e.g. the refeeding syndrome in patients suffering from severe malnutrition with the initiation of refeeding or metabolic, hypertriglyceridemia, hyperglycemia, osteomalacia and osteoporosis, and hepatic complications including fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, and cholelithiasis.

FNDNRS-07–038

A nurse is preparing to hang the initial bag of the parenteral nutrition (PN) solution via the central line of a malnourished client. The nurse ensures the availability of which medical equipment before hanging the solution?

• A. Glucometer.
• B. Dressing tray.
• C. Nebulizer.
• D. Infusion pump.

Correct Answer: D. Infusion pump.

The nurse should prepare an infusion pump prior to hanging a parenteral solution. The use of an infusion pump is important to make sure that the solution does not infuse too quickly or delayed since the parenteral nutrition has a high glucose content. An infusion pump controls the rate at which the TPN solution is given so that the concentrated food does not overload other digestive organs. For many patients receiving TPN, the pump is portable.

• Option A: A glucometer is also needed since the client’s glucose level is monitored every 4 to 6 hours, but it is not an essential item needed. Hyperglycemia is associated with increased hospital complications and mortality in patients receiving TPN. TPN-induced hyperglycemia is associated with increased length of hospital stay, increased risk of complications, and higher mortality in hospitalized patients.
• Option B: A dressing tray is not used before hanging a PN solution. With total parenteral nutrition, a solution of essential nutrients (including proteins, fluids, electrolytes, and fat-soluble vitamins) is given into the veins (intravenously). Because TPN solutions are highly concentrated and thick, the solutions must be given through catheters that are placed in large central veins in the neck, chest, or groin.
• Option C: A nebulizer is not used before hanging a PN solution. Total parenteral nutrition (TPN) is the standard therapy for people who have this problem. TPN can be used to treat a severe disorder that is expected to last for a relatively short time, such as intractable vomiting during pregnancy. It is also used as a long-term therapy.

FNDNRS-07–039

A nurse is conducting a follow-up home visit to a client who has been discharged with parenteral nutrition(PN). Which of the following should the nurse most closely monitor in this kind of therapy?

• A. Blood pressure and temperature.
• B. Blood pressure and pulse rate.
• C. Height and weight.
• D. Temperature and weight.

Correct Answer: D. Temperature and weight.

The client’s temperature is monitored to identify signs of infection which is one of the complications of this therapy. While the weight is monitored to detect hypervolemia and to determine the effectiveness of this nutritional therapy. Monitoring patients on parenteral nutrition (PN) requires a multidisciplinary approach with effective communication throughout the team. This will help to minimize potential complications and will aid safe, effective, and appropriate use of PN.

• Option A: Temperature should be monitored to watch for infection, however, blood pressure is not as important during total parenteral nutrition. But blood pressure should still be monitored routinely. The risk of infectious complications is increased due to venous access for PN. The likelihood of hyperglycemia-induced complications may depend on concomitant diseases, duration of PN, and life expectancy.
• Option B: Blood pressure and pulse rate may be checked routinely in a patient with TPN. Efficient monitoring in all types of PN can result in reduced PN-associated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should regularly be monitored during PN.
• Option C: Monitoring the patient’s height is not necessary during TPN administration. Nutritional status is most effectively assessed and monitored through a combination of anthropometric data, biochemical and clinical measures. A stand-alone measure e.g. weight can rarely provide adequate information.

FNDNRS-07–040

A nurse is preparing to hang a fat emulsion (lipids) and observes some visible fat globules at the top of the solution. The nurse ensures to do which of the following actions?

• A. Take another bottle of solution.
• B. Run the bottle solution under warm water.
• C. Roll the bottle solution gently.
• D. Shake the bottle solution vigorously.

Correct Answer: A. Take another bottle of solution.

Fat emulsions are used as dietary supplements for patients who are unable to get enough fat in their diet, usually because of certain illnesses or recent surgery. The nurse should examine the bottle of fat emulsion for separation of emulsion into layers or fat globules or the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy.

• Option B: Continuous fat infusion over 24 hours is the preferred method in neonates. For this reason, commercial lipid emulsions are repacked to a polypropylene syringe from original commercial bags and administered intravenously to neonates at neonates wards with a higher temperature. The higher temperature in neonatal wards could be an additional factor negatively affecting the stability of lipid emulsion.
• Option C: Storage of lipid emulsion in plastic containers is controversial. It was shown that patients who received lipids delivered in plastic bags are more likely to have hypertriglyceridemia than those who received lipids from glass bottles. This is possible because of a higher proportion of large-diameter fat globules in plastic bags.
• Option D: An increase in the droplet size is the first indication of formulation stability issues. Moreover, droplets greater than 5 μm can be trapped in the lungs and cause pulmonary embolism. Pulmonary embolism may develop and is associated with a high risk of morbidity and mortality.

FNDNRS-07–041

A client is receiving nutrition via parenteral nutrition (PN). A nurse assesses the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia?

• A. High-grade fever, chills, and decreased urination.
• B. Fatigue, increased sweating, and heat intolerance.
• C. Coarse dry hair, weakness, and fatigue.
• D. Thirst, blurred vision, and diuresis.

Correct Answer: D. Thirst, blurred vision, and diuresis.

Signs of hyperglycemia include excessive thirst, fatigue, restlessness, blurred vision, confusion, weakness, Kussmaul’s respirations, diuresis, and coma when hyperglycemia is severe. Hyperglycaemia is found in up to 50% of PN patients. Important predictors are insulin resistance or diabetes mellitus, severity of the underlying illness, concomitant steroid therapy, and the amount of glucose provided.

• Option A: High-grade fever, chills, and decreased urination are signs of infection. The risk of infectious complications is increased due to venous access for PN. The likelihood of hyperglycemia-induced complications may depend on concomitant diseases, duration of PN, and life expectancy.
• Option B: Fatigue, increased sweating, and heat intolerance are signs of hyperthyroidism. Hyperthyroidism may manifest as weight loss despite an increased appetite, palpitation, nervousness, tremors, dyspnea, fatigability, diarrhea or increased GI motility, muscle weakness, heat intolerance, and diaphoresis.
• Option C: Coarse dry hair, weakness, and fatigue are signs of hypothyroidism. Inquire about dry skin, voice changes, hair loss, constipation, fatigue, muscle cramps, cold intolerance, sleep disturbances, menstrual cycle abnormalities, weight gain, and galactorrhea. Also obtain a complete medical, surgical, medication, and family history.

FNDNRS-07–042

A nurse is caring for a client who disconnected the tubing of the parenteral nutrition from the central line catheter. A nurse suspects an occurrence of an air embolism. Which of the following is an appropriate position for the client in this kind of situation?

• A. On the right side, with head higher than the feet.
• B. On the right side, with head lower than the feet.
• C. On the left side, with the head higher than the feet.
• D. On the left side, with head lower than the feet.

Correct Answer: D. On the left side, with head lower than the feet.

Air embolism happens because of the entry of air into the catheter system. If it occurs, the client should be placed in a left-side-lying position with the head be lower than the feet. This position will lessen the effect of the air traveling as a bolus to the lungs by trapping it on the right side of the heart. It occurs as a result of a pressure gradient that allows air to enter the bloodstream, which can subsequently occlude blood flow.

• Option A: When removing catheters, it is also recommended to raise CVP by keeping the patient in a supine position or with their head down or Trendelenburg position. Ideally, the venotomy site should be below the level of the heart to ensure adequate central venous pressure at the time of removal.
• Option B: Patients should be instructed to perform a Valsalva maneuver during catheter removal, if possible. If this is not possible, removing the catheter during active expiration is recommended. It should be ensured that the exit site is covered with impermeable dressing and that pressure is applied afterward for 5–10 min, for hemostasis and prevention of bubble entry. It is recommended that the patient remains supine for 30 min after central venous access removal
• Option C: In cases of venous air embolism, Durant’s maneuver is performed, by placing the patient in the left lateral decubitus and Trendelenburg position. This serves to encourage the air bubble to move out of the right ventricular outflow tract (RVOT) and into the right atrium, thereby relieving the “air-lock” effect responsible for potentially catastrophic cardiopulmonary collapse.

FNDNRS-07–043

A client is being weaned off from parenteral nutrition (PN) and is given a go-signal to take a regular diet. The ongoing solution rate has been 120ml/hr. A nurse expects that which of the following prescriptions regarding the PN solution will accompany the diet order?

• A. Decrease the PN rate to 60ml/hr.
• B. Start 0.9% normal saline at 30 ml/hr.
• C. Maintain the present infusion rate.
• D. Discontinue the PN.

Correct Answer: A. Decrease the PN rate to 60ml/hr.

When a client begins eating a regular diet after a period of receiving PN, the PN is decreased slowly. Gradually decreasing the infusion rate allows the client to remain sufficiently nourished during the transition to a normal diet and prevents an episode of hypoglycemia.

• Option B: Parenteral nutrition is the intravenous administration of nutrition outside of the gastrointestinal tract. Total parenteral nutrition (TPN) is when the IV administered nutrition is the only source of nutrition the patient is receiving. Total parenteral nutrition is indicated when there is an inadequate gastrointestinal function and contraindications to enteral nutrition.
• Option C: Patients who recently received TPN should be monitored daily until stable. They require more frequent monitoring if metabolic abnormalities are detected or if the patient has a risk of refeeding syndrome. Refeeding syndrome can occur in severely malnourished and cachectic individuals when feeding is reintroduced and can lead to severe electrolyte instabilities.
• Option D: PN that is terminated abruptly will cause hypoglycemia. Total parenteral nutrition administration is through a central venous catheter. A central venous catheter is an access device that terminates in the superior vena cava or the right atrium and is used to administer nutrition, medication, chemotherapy, etc. Establishing this access could be through a peripherally inserted central catheter (PICC), central venous catheter, or an implanted port.

FNDNRS-07–044

A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to identify the presence of which of the following?

• A. Hypotension.
• B. Crackles upon auscultation of the lungs.
• C. Thirst.
• D. Polyuria.

Correct Answer: B. Crackles upon auscultation of the lungs.

Normally, the weight gain of a client receiving PN is about 1–2 pounds a week. A weight gain of five (5) pounds over a week indicates a client is experiencing fluid retention that can result in hypervolemia. Signs of hypervolemia include weight gain more than desired, headache, jugular vein distention, bounding pulse, and crackles on lung auscultation.

• Option A: Hypertension, not hypotension is expected. Fluid overload can occur for the same reasons that fluid overload can occur with a regular peripheral intravenous flow. The rate is too fast and rapid for the client. The signs and symptoms of fluid overload include hypertension, edema, adventitious breath sounds like crackles and rales, shortness of breath, and bulging neck veins.
• Option C: Thirst is associated with hyperglycemia. Hyperglycemia can occur as the result of the high dextrose content of the total parenteral nutrition solution as well as the lack of a sufficient amount of administered. This total parenteral nutrition complication can be prevented with the continuous monitoring of the client’s blood glucose levels and the titration of insulin administration based on these levels of insulin.
• Option D: Polyuria is associated with hyperglycemia. The signs and symptoms of hyperglycemia secondary to total parenteral nutrition are the same as those associated with poorly managed diabetes and they include a high blood glucose level, thirst, excessive urinary output, headache, nausea, and fatigue.

FNDNRS-07–045

A nurse is making initial rounds at the beginning of the shift and notices that the parenteral nutrition (PN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit?

• A. 10% dextrose in water.
• B. 5% dextrose in water.
• C. 5% dextrose in normal saline.
• D. 5% dextrose in lactated Ringer solution.

Correct Answer: A. 10% dextrose in water.

The client is at risk of hypoglycemia. Hence the nurse will hang a solution that has the highest amount of glucose until the new parenteral nutrition solution becomes readily available. Crystalloid fluids are a subset of intravenous solutions that are frequently used in the clinical setting. Crystalloid fluids are the first choice for fluid resuscitation in the presence of hypovolemia, hemorrhage, sepsis, and dehydration.

• Option B: Option B is also a crystalloid fluid, but contains less glucose than option A. Other clinical applications include acting as a solution for intravenous medication delivery, to deliver maintenance fluid in patients with limited or no enteral nutrition, blood pressure management, and to increase diuresis to avoid nephrotoxic drug or toxin-mediated end-organ damage.
• Option C: Dextrose 5 in .9 Sodium Chloride is a prescription medicine used to treat the symptoms of hypoglycemia. Dextrose 5 in .9 Sodium Chloride may be used alone or with other medications. Dextrose 5 in .9 Sodium Chloride belongs to a class of drugs called Glucose-Elevating Agents; Metabolic and Endocrine, Other.
• Option D: 5% Dextrose in Lactated Ringer’s Injection provides electrolytes and calories, and is a source of water for hydration. It is capable of inducing diuresis depending on the clinical condition of the patient. This solution also contains lactate which produces a metabolic alkalinizing effect.

FNDNRS-07–046

A nurse is caring for a group of clients in a medical-surgical nursing unit. The nurse recognizes that which of the following clients would be the least likely candidate for parenteral nutrition?

• A. A 55-year-old with persistent nausea and vomiting from chemotherapy.
• B. A 44-year old client with ulcerative colitis.
• C. A 59-year old client who had an appendectomy.
• D. A 25-year old client with Hirschsprung‘s Disease.

Correct Answer: C. A 59-year old client who had an appendectomy.

The client with an appendectomy is not a candidate because this client would resume a regular diet within a few days following the surgery. The principal indication for TPN is a seriously ill patient where enteral feeding is not possible. It may also be used to supplement inadequate oral intake. The successful use of TPN requires proper selection of patients, adequate experience with the technique, and awareness of its complications.

• Option A: An indication of TPN are patients with malignancies in whom malnutrition may jeopardize successful delivery of a therapeutic option (surgery, chemo- or radiotherapy). While the indication for TPN may be self-evident in the majority of the patients, it is recommended to have some form of assessment of the nutritional status of the patient prior to institution of TPN in order to plan the treatment and to formulate clear-cut therapeutic goals
• Option B: Malabsorption secondary to sprue, enzyme & pancreatic deficiencies, regional enteritis, ulcerative colitis, granulomatous colitis, and tuberculous enteritis are indications for parenteral nutrition. The indications of TPN are now fairly well defined, as is the knowledge about its limitations, side effects, and complications. Advances in technology have now made it possible for TPN to be delivered at the patient’s own residence, thus reducing hospital costs.
• Option D: Option D is incorrect because parenteral nutrition is indicated in this client since their gastrointestinal tracts are not functional or cannot take in a diet enterally for extended periods. Newborns with gastrointestinal anomalies such as tracheoesophageal fistula, massive intestinal atresia, complicated meconium ileus, massive diaphragmatic hernia, gastroschisis, omphalocele or cloacal exstrophy, and neglected pyloric stenosis.

FNDNRS-07–047

A client is receiving parenteral nutrition (PN) and is suddenly having a fever. A nurse notifies the physician and the physician initially prescribes that the solution and tubing be changed. The nurse should do which of the following with the discontinued materials?

• A. Send them to the laboratory for culture.
• B. Save them for a return to the manufacturer.
• C. Return them to the hospital pharmacy.
• D. Discard them in the unit trash.

Correct Answer: A. Send them to the laboratory for culture.

When the client who is receiving PN has a high temperature, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for an infectious organism. Septic complications of central venous catheters (CVCs) remain a significant cause of patient morbidity and mortality both in the intensive care unit (ICU) and in general hospital wards. Approximately 25% of CVCs inserted have been reported to become colonized, with rates of catheter-related bloodstream infection (CRBSI) varying between 0% and 11%.

• Option B: The solution and tubing should be brought immediately to the laboratory to avoid the growth of other organisms. It has been proposed that TPN, being a potential culture medium, is an independent risk factor for CRBSI. However, there is a paucity of studies related to CVC colonization and CRBSI and in patients receiving TPN via short-term CVCs.
• Option C: Returning the solution to the pharmacy is not the appropriate action. Patients receiving total parenteral nutrition (TPN) are at high risk for bloodstream infections (BSI). The notion that intravenous calories and glucose lead to hyperglycemia, which in turn contributes to BSI risk, is widely held.
• Option D: Do not discard the solution and tubing immediately. Other studies have shown an increased infection risk without a survival benefit in patients receiving TPN. There is a reported sepsis incidence of between 20% and 30% in patients receiving parenteral nutrition. The high risk of sepsis is a major factor leading to an overall preference for enteral nutrition over parenteral nutrition.

FNDNRS-07–048

A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that there is redness and drainage at the insertion site. The nurse next assesses which of the following?

• A. Time of last dressing change.
• B. Allergy.
• C. Client’s temperature.
• D. Expiration date.

Correct Answer: C. Client’s temperature.

Redness at the catheter insertion site is a possible sign of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. TPN requires a chronic IV access for the solution to run through, and the most common complication is an infection of this catheter. Infection is a common cause of death in these patients, with a mortality rate of approximately 15% per infection, and death usually results from septic shock.

• Option A: Assess skin integrity and wound healing. Skin integrity changes and wound healing are used as parameters in monitoring the effectiveness of TPN feeding.
• Option B: TPN composition is based on the calculated nutritional needs of the client. Before the therapy is started, a thorough baseline assessment will be completed by health care members which include physicians, nurses, dieticians, and pharmacists. Changes in fluid balance, weight, and caloric intake are used to assess TPN effectiveness.
• Option D: Administer TPN at the ordered rate; if the infusion is interrupted, infuse 10% dextrose in water until the TPN infusion is restarted. This substitute infusion provides needed fluid in addition to protecting the client from sudden hypoglycemia; hypoglycemia can result when the high glucose concentration to which the client has metabolically adjusted is suddenly withdrawn.

FNDNRS-07–049

A client receiving parenteral nutrition (PN) complains of a headache. A nurse notes that the client has a bounding pulse, jugular distension, and weight gain greater than desired. The nurse determines that the client is experiencing which complication of PN therapy?

• A. Air embolism.
• B. Hypervolemia.
• C. Hyperglycemia.
• D. Sepsis.

Correct Answer: B. Hypervolemia.

The client’s signs and symptoms are consistent with hypervolemia. This happens when the client receives excessive fluid administration or administration of fluid too rapidly. Increased central venous pressure is noticed first as distention of the jugular veins. Maintaining the head of bed elevated will promote ease in breathing. This position also allows pooling of fluid in the bases and for gas exchange to be more available to the lung tissue.

• Option A: An air embolism may occur if IV tubing disconnects and is open to air, or if part of the catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.
• Option C: Hyperglycemia related to sudden increase in glucose after a recent malnourished state. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO2 production, hypercapnia, and respiratory failure.
• Option D: CR-BSI, which starts at the hub connection, is the spread of bacteria through the bloodstream. There’s an increased risk of CR-BSI with TPN, due to the high dextrose concentration of TPN. Symptoms include tachycardia, hypotension, elevated or decreased temperature, increased breathing, decreased urine output, and disorientation.

FNDNRS-07–050

A nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tube change?

• A. Turn the head to the right.
• B. Inhale deeply, hold it, and bear down.
• C. Breathe normally.
• D. Exhale slowly and evenly.

Correct Answer: B. Inhale deeply, hold it, and bear down.

The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tube changes. The nurse asks the client to take a deep breath, hold it, and bear down. Make sure all connections are clamped and closed. Clamp catheter, position patient in left Trendelenburg position, call health care provider, and administer oxygen as needed.

• Option A: Option A is incorrect because if the intravenous line is on the right, the client turns his or head to the left. This position increases intrathoracic pressure. Central line management is a crucial skill that is necessary on a routine basis to help lessen or prevent catheter-based infections and complications. Initial placement of central lines is typically by trained physicians, physician assistants, and nurse practitioners in a sterile fashion.
• Option C: An air embolism may occur if IV tubing disconnects and is open to air, or if part of the catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.
• Option D: Exhaling can cause the potential for an air embolism during the tube change. Routine evaluation by every team member will ensure that appropriate handling and care of the central line is being performed to help reduce the risk of catheter-associated complications.

FNDNRS-07–051

A nurse observes the client receiving fat emulsions is having hives. A nurse reviews the client’s history and notes which of the following may be caused by the complaint of the client?

• A. Allergy to an egg.
• B. Allergy to peanuts.
• C. Allergy to shellfish.
• D. Allergy to corn.

Correct Answer: A. Allergy to an egg.

Fat emulsions (lipids) contain egg yolk phospholipids and should not be given to clients with egg allergies. Intravenous fat emulsions (IFEs) are a vital component of total parenteral nutrition, because they provide essential fatty acids. IFE is a sterile fat emulsion that contains egg-yolk phospholipids. Although egg allergy is listed as a contraindication, adverse reactions are uncommon.

• Option B: Hypersensitivity reactions to TPN can be managed by withholding the TPN and treating with antihistamines if needed until the reaction resolves. Identification, possibly by epicutaneous allergy testing, and removal of the offending agent(s) from the TPN is necessary if TPN therapy must be restarted.
• Option C: Although ingestion of egg lecithin in cooked food is generally tolerated by egg-allergic people, administration of intravenous egg-containing lipid emulsions may cause significant adverse reactions.
• Option D: If the patient has an allergy to amino acids, dextrose, fat emulsion, or any other part of total parenteral nutrition, he should be referred to a doctor first. If the patient has an allergy to corn, corn products, eggs, peanuts, or soybeans, he should talk with a doctor.

FNDNRS-07–052

A client receiving parenteral nutrition (PN) complains of shortness of breath and shoulder pain. A nurse notes that the client has an increased pulse rate. The nurse determines that the client is experiencing which complication of PN therapy?

• A. Air embolism.
• B. Hypervolemia.
• C. Hyperglycemia.
• D. Pneumothorax.

Correct Answer: D. Pneumothorax.

Pneumothorax might happen during parenteral therapy due to inexact catheter placement. In order to prevent this, the nurse obtains a chest x-ray after insertion of the catheter to ensure proper catheter placement. A pneumothorax occurs when the tip of the catheter enters the pleural space during insertion, causing the lung to collapse. Symptoms include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, and tachycardia.

• Option A: An air embolism may occur if IV tubing disconnects and is open to air, or if part of the catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.
• Option B: Signs and symptoms include fine crackles in lower lung fields or throughout lung fields, hypoxia (decreased O2 sats). Notify primary health care providers regarding change in condition. The patient may require IV medication, such as Lasix to remove excess fluids. A decrease or discontinuation of IV fluids may also occur. Raise head of bed to enhance breathing and apply O2 for oxygen saturation less than 92% or as per agency protocol. Monitor intake and output. Pulmonary edema may be more common in the elderly, young, and patients with renal or cardiac conditions.
• Option C: Hyperglycemia related to sudden increase in glucose after a recent malnourished state. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO2 production, hypercapnia, and respiratory failure.

FNDNRS-07–053

A nurse is caring for a combative client who is ordered to have a nutritional therapy using parenteral nutrition (PN). The nurse should plan which of the following measures to prevent the client from injury?

• A. Monitor blood glucose twice a day.
• B. Instruct the relative to stay with the nurse.
• C. Measure 24-hour intake and output.
• D. Secure all connections in the parenteral system.

Correct Answer: D. Secure all connections in the parenteral system.

The nurse should plan to secure all connections in the tubing. This will prevent the client from pulling the connections apart. An air embolism may occur if IV tubing disconnects and is open to air, or if part of the catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure.

• Option A: The nurse may monitor the blood glucose but it is unrelated to the situation. Many fatal instances of air emboli in patients with central venous catheters have been reported in the literature. They frequently occur when the tubing becomes tangled while a patient is getting out of bed, causing the catheter to disconnect. Although less common, cracks in the catheter hub can also allow air to enter the venous system.
• Option B: The relative may stay with the patient when necessary. Central venous catheters are also used in applications other than TPN. These include central venous pressure monitoring, rapid infusion of fluids, pulmonary arterial pressure monitoring using Swan-Ganz catheters, and hemodialysis. Also, a central venous catheter is often placed in the right atrium during surgery to remove air that might be introduced elsewhere in the venous system. It is possible for an air embolism to develop during all of these central venous applications.
• Option C: Measuring the I&O of the patient is not related to the situation. An air embolism can develop when the right side of the heart is open to outside air through a disconnected catheter and a negative intrathoracic pressure is present, such as during inspiration. The right side of the heart is open to outside air when the catheter is first inserted and during catheter changes.

FNDNRS-07–054

Nurse Spencer is caring for an anorexic client who is having a total parenteral nutrition solution for the first time. Which of the following assessments requires the most immediate attention?

• A. Dry sticky mouth.
• B. Temperature of 100° Fahrenheit.
• C. Blood glucose of 210 mg/dl.
• D. Fasting blood sugar of 98 mg/dl.

Correct Answer: C. Blood glucose of 210 mg/dl.

Total parenteral nutrition formula containing dextrose ranges from 5% to 70%. A blood glucose level of 210mg/dl is considered high. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO2 production, hypercapnia, and respiratory failure.

• Option A: Refeeding syndrome is caused by rapid refeeding after a period of malnutrition, which leads to metabolic and hormonal changes characterized by electrolyte shifts (decreased phosphate, magnesium, and potassium in serum levels) that may lead to widespread cellular dysfunction. Phosphorus, potassium, magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening. High-risk patients include the chronically undernourished and those with little intake for more than 10 days. Patients with dysphagia are at higher risk. The syndrome usually occurs 24 to 48 hours after refeeding has started. The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia.
• Option B: CR-BSI, which starts at the hub connection, is the spread of bacteria through the bloodstream. There’s an increased risk of CR-BSI with TPN, due to the high dextrose concentration of TPN. Symptoms include tachycardia, hypotension, elevated or decreased temperature, increased breathing, decreased urine output, and disorientation.
• Option D: Monitor blood sugar frequently QID (four times per day), then less frequently when blood sugars are stable. Follow agency policy for glucose monitoring with TPN. Be alert to changes in dextrose levels in amino acids and the addition/removal of insulin to TPN solution.

FNDNRS-07–055

Nurse Russell is preparing to give total parenteral nutrition using a central line. Place the following steps for administration in the correct order?

1. Check the solution for cloudiness, particles, or a change in color.

2. Select and flush the correct tubing and filter.

3. Prime the IV tubing through an infusion pump.

4. Maintain an aseptic technique when handling the injection cap.

5. Connect the tubing to the central line.

6. Regulate the electric infusion pump at the ordered rate.

The correct order is shown above.

Total Parenteral Nutrition (TPN), also known as intravenous or IV nutrition feeding, is a method of getting nutrition into the body through the veins. In other words, it provides nutrients for patients who do not have a functioning GI tract or who have disorders requiring complete bowel rest.

• Option A: Selecting the correcting tubing is the second step, not handling the injection cap. TPN is usually used for 10 to 12 hours a day, five to seven times a week. Most TPN patients administer the TPN infusion on a pump during the night for 12–14 hours so that they are free of administering pumps during the day. TPN can also be used in both the hospital or at home.
• Option B: Selecting the correct tubing is not the first step. External tubing should be changed every day and dressings should be kept sterile with replacement every two days.
• Option C: Review physician’s orders and compare to MAR and content label on TPN solution bag and for rate of infusion. Each component of the TPN solution must be verified with the physician’s orders. Complete all safety checks for CVC as per agency policy.
• Option D: Asepsis during handling of the injection cap is not the first step. TPN is administered through a needle or catheter that is placed in a large vein that goes directly to the heart called a central venous catheter. Since the central venous catheter needs to remain in place to prevent further complications, TPN must be administered in a clean and sterile environment.

Questions related to patient positioning

FNDNRS-07–056

Nurse Aaron is inserting a nasogastric tube to a stroke client. He understands that the best position for the insertion is?

• A. Low Fowler’s.
• B. Sims position.
• C. Trendelenburg.
• D. High Fowler’s.

Correct Answer: D. High Fowler’s.

The best position during a nasogastric tube insertion is sitting or High Fowler’s position in order to prevent the risk of aspiration. Position patient sitting up at 45 to 90 degrees (unless contraindicated by the patient’s condition), with a pillow under the head and shoulders. This allows the NG tube to pass more easily through the nasopharynx and into the stomach.

• Option A: Low fowler’s position is similar to the supine position, and is considered the best position for rest. In a low-Fowler’s position, the patient’s head is inclined at a 15- or 30-degree angle. Insertion of NGT could be particularly difficult in this position. Low Fowler’s position is typically used to reduce lower back pain, during administration of drugs, or during tube feeding.
• Option B: Insertion of NGT would be impossible in Sim’s position. The Sims position is a standard position in which the patient lies on their left side, with right hip and knees bent. The lower arm is behind the back, the thighs flexed. The left knee is slightly tilted. The right arm is positioned comfortably in front of the body, the right arm is rested behind the body. This is also known as “lateral” position. Sim’s position is often used for rectal examination and treatments.
• Option C: Placing the patient in Trendelenburg position for NGT insertion is highly inappropriate. In Trendelenburg position, the patient is supine on the table with their head declined below their feet at an angle of roughly 16°. Trendelenburg position is typically used for lower abdominal surgeries including colorectal, gynecological, and genitourinary procedures as well as central venous catheter placement.

Sources:

FNDNRS-07–057

Nurse Monica is handling a female client who had undergone a mastectomy. Which is the best position in which she should place the client?

• A. Head of bed elevated at least 30° with the affected arm elevated on a pillow.
• B. Forward side-lying position.
• C. Supine position with the affected arm remains flat.
• D. Head of bed elevated at least 30° with the unaffected arm elevated on a pillow.

Correct Answer: A. Head of bed elevated at least 30°.

Position a post-mastectomy client with the head of the bed elevated at least 30 degrees, with the affected arm elevated on a pillow to promote lymphatic fluid return after the removal of axillary lymph nodes. The patient is draped with the arm free to allow for movements during the procedure. It is important not to hyperextend the arm when positioning the patient; hyperextension may cause significant postoperative neurapraxia.

• Option B: Patient positioning is in a supine position in the operating room, and the breast, chest wall, axilla, and upper arm are exposed, after induction of anesthesia. Many surgeons may include the contralateral breast in the prepped operative field. There has been a growing trend toward breast conservation, and numerous studies have looked at the efficacy of breast-conserving surgery when compared to standard mastectomy techniques.
• Option C: The patient is kept in a supine position with a thin sandbag under the ipsilateral scapula to facilitate axillary dissection. The ipsilateral arm is draped separately and kept free for adduction during axillary dissection.
• Option D: The patient is placed supine with the ipsilateral arm stretched out level with the shoulder. The head end of the operating table is raised to 30º. The side being operated on is raised by 30º. Lymphedema is less commonly present since the advent of modified mastectomy techniques. Axillary lymph node dissection is the most significant risk factor for the development of lymphedema, with a reported incidence of greater than 20%.

FNDNRS-07–058

A nurse is caring for a client with severe burns of the face and head. The nurse will place the client in which position?

• A. Trendelenburg.
• B. Head of bed elevated.
• C. Supine position.
• D. Prone position.

Correct Answer: B. Head of bed elevated.

For clients with burns on the face and head, the best position is to elevate the head of the bed to reduce the occurence of facial edema. Elevation will encourage drainage of fluid and allow it to be reabsorbed by the body. The swollen part should be higher than the rest of the limb so that gravity can assist.

• Option A: Placing the patient in Trendelenburg position would aggravate the facial edema. Physiochemical changes in the extracellular spaces cause protein denaturation, increasing the oncotic pressures, increasing local edema. It is also important to be aware of the requirement for fluid resuscitation, which increases the hydrostatic gradient, ultimately pushing more fluid into the extracellular space, compounding the tissue edema from the initial insult.
• Option C: If the client has facial swelling it is extremely important to maintain an upright position. The client should avoid lying flat as this encourages fluid collection in the face and head which can lead to difficulty opening the eyes and may also affect breathing.
• Option D: If the patient is placed in a prone position, fluid would accumulate in the face. Burns cause a local cytokine-mediated inflammatory response, creating hyperpermeability of the microvasculature, leading to tissue swelling. For the patient who sustains any facial burns or inhalation injuries, local swelling can occur rapidly and immediately.

FNDNRS-07–059

Which of the following does not match with the appropriate position?

• A. Vaginal examination: Lithotomy position.
• B. Thyroidectomy: Fowler’s position.
• C. Hemorrhoidectomy: Lateral position.
• D. Hypophysectomy: Prone position.

Correct Answer: D. Hypophysectomy: Prone position.

Hypophysectomy is the surgical removal of the hypophysis (pituitary gland). After the surgery, the client’s head is elevated to prevent increased intracranial pressure. CSF fluid around the brain and spine leaks into the nervous system. This requires treatment with a procedure called a lumbar puncture, which involves inserting a needle into the spine to drain excess fluid.

• Option A: Lithotomy position is commonly used during gynecologic, rectal, and urologic surgeries with a patient lying supine with legs abducted 30 to 45 degrees from midline with knees flexed and legs held supported with the foot of the bed lowered or removed to facilitate the procedure.
• Option B: When a patient comes back from having their thyroidectomy surgery, place them in a semi-Fowler’s position. Sitting totally upright would put the patient at a 90-degree angle, but in a semi-Fowler’s position, they are angled between 15 and 45 degrees.
• Option C: In lateral position, the lower extremities are carefully padded between the knees and below the dependent knee to avoid excessive external pressure over bony prominences. The dependent lower extremity is somewhat flexed to avoid stretch or compression of the lower extremity nerves.

FNDNRS-07–060

Nurse Ian is handling a client with gastroesophageal reflux disease. Which of the following positions will best help the client in this case?

• A. Right Lateral Recumbent.
• B. Supine position.
• C. Reverse Trendelenburg position.
• D. Sims position.

Correct Answer: C. Reverse Trendelenburg position.

Reverse Trendelenburg position is advised to a client to promote gastric emptying and prevent gastroesophageal reflux. Studies that monitored esophageal acid exposure after elevation of the head of the bed showed a decrease in reflux activity in adults. Placing blocks under the head of the bed or placing a foam wedge under the patient’s mattress can accomplish this.

• Option A: In the right lateral recumbent position, the individual is lying on their right side. This position makes it easier to access a patient’s left side. The word “lateral” means “to the side,” while “recumbent” means “lying down.”
• Option B: Avoid placing the patient in supine position, have the patient sit upright after meals. Supine position after meals can increase regurgitation of acid. Elevate HOB while in bed to prevent aspiration by preventing the gastric acid to flow back into the esophagus.
• Option D: The Sims position is a standard position in which the patient lies on their left side, with right hip and knees bent. The lower arm is behind the back, the thighs flexed. The left knee is slightly tilted. The right arm is positioned comfortably in front of the body, the right arm is rested behind the body. This is also known as “lateral” position. This position is often used for rectal or vaginal examination, and treatments.

FNDNRS-07–061

A client with pleural effusion is scheduled to have a thoracentesis. The nurse on duty will assist the client to which position during the procedure?

A. Lying in bed on the unaffected side with the head of the bed elevated about 45°.

B. Forward side-lying position with head of bed flat.

C. Lying in bed on the affected side with the head of the bed elevated about 45°.

D. Supine position with both arms extended.

Correct Answer: A. Lying in bed on the unaffected side with head of bed elevated about 45°.

During thoracentesis, to facilitate removal of pleural fluid from the pleural space, position the client sitting on the edge of the bed, leaning over a bedside table with the feet supported on a stool, or lying in bed on the unaffected side with head of bed elevated about 45°.

• Option B: Patient lies between supine and prone with legs flexed in front of the patient. Arms should be comfortably placed beside the patient, not underneath. However, the head of the bed should be elevated to facilitate drainage of pleural fluid from the pleural space.
• Option C: The patient should lie on the unaffected side. The patient is moved to the extreme side of the bed, the ipsilateral hand is placed behind the head, and a towel roll is placed under the contralateral shoulder. This measure facilitates dependent drainage and provides good access to the posterior axillary space.
• Option D: Patients who are alert and cooperative are most comfortable in a seated position, leaning slightly forward and resting the head on the arms or hands or on a pillow, which is placed on an adjustable bedside table. This position facilitates access to the posterior axillary space, which is the most dependent part of the thorax. Unstable patients and those who are unable to sit up may be supine for the procedure.

FNDNRS-07–062

Nurse Maria is administering a cleansing enema to a client with severe constipation. She will place the client in which position?

• A. Low Fowler’s position.
• B. High Fowler’s position.
• C. Left Sim’s position.
• D. Right Sim’s position.

Correct Answer: C. Left Sim’s position.

During a cleansing enema, place the client in the left Sim’s position to allow the solution to flow by gravity in the natural direction of the colon. Position the patient on the left side, lying with the knees drawn to the abdomen. This eases the passage and flow of fluid into the rectum. Gravity and the anatomical structure of the sigmoid colon also suggest that this will aid enema distribution and retention.

• Option A: Position the patient on his left side in Sims’ position or left lateral position with the right knee flexed, which will adequately expose the anus. This position allows the solution to flow downward by gravity along the curve of the sigmoid colon and rectum, thus improving the effectiveness of the enema.
• Option B: The ideal positions for enema administration are the left-side position and the knee-chest position. It is advised that the patient remains in one of these positions to receive the enema for one-third of the time.
• Option D: The left lateral position is the most appropriate position for giving an enema because of the anatomical characteristics of the colon. Although the length of the tube to be inserted is designated as approximately 5–6 cm, do not try to force it but pull it back slightly if any resistance is felt.

FNDNRS-07–063

What type of client would benefit the most from an elevated head of the bed position?

• A. Patient who had a hemorrhoidectomy.
• B. Patient who had a laryngectomy.
• C. Patient who had a liver biopsy.
• D. Patient who had a lumbar puncture.

Correct Answer: B. Patient who had a laryngectomy.

Place a post-laryngectomy client with the head of bed elevated at 30–45 degrees to maintain a patent airway and reduce edema. Maintain an upright or sitting position during feedings (or place on the lap or in an infant seat); allow to remain in position for 30 minutes afterward. Promotes the flow of fluids and foods through gravity.

• Option A: Post-operative hemorrhoidectomy position is supine position. Supine position, also known as Dorsal Decubitus, is the most frequently used position for procedures. In this position, the patient is face-up. The patient’s arms should be tucked at the patient’s sides with a bedsheet, secured with arm guards to sleds.
• Option C: Liver biopsy patients should remain in a right side-lying position after the procedure. After the biopsy, the doctor will place a bandage over the cut on the abdomen. The client may be asked to lie on his right side after the biopsy, and he will need to remain lying down for a few hours. Health care professionals will typically check the vital signs regularly for 2 to 4 hours after the procedure.
• Option D: After lumbar puncture, place the client in a supine position for at least 4 hours. As blood will distribute into the epidural space through few spinal segments superiorly and inferiorly, it is not essential to introduce it into the exact place at which the dural puncture was performed. After the procedure, the patient is asked to lie still in a supine position and is then mobilized.

FNDNRS-07–064

Nurse Justin is taking care of a client with deep vein thrombosis. Which position should be provided to the client?

• A. Bed rest with the affected extremity remains flat at all times.
• B. Bed rest with the unaffected extremity on top of the affected extremity.
• C. Bed rest with the affected extremity in a dependent position.
• D. Bed rest with the affected extremity elevated.

Correct Answer: D. Bed rest with the affected extremity elevated.

Bed rest is indicated to prevent emboli while the elevation of the affected leg facilitates blood flow by the force of gravity and reduces pain and edema. Elevating the legs can help to instantly relieve pain. A doctor may also instruct a patient to elevate the legs above the heart three or four times a day for about 15 minutes at a time. This can help to reduce swelling. If prolonged standing or sitting is necessary, bending the legs several times will help promote blood circulation.

• Option A: DVT develops as a result of being in a continuous seated prone positioning for 6 hours. Deep vein thrombosis and its sequelae such as PE can be severe or fatal. However, these consequences are preventable. Deep vein thrombosis may arise spontaneously or may be caused by trauma, surgery, or prolonged bed rest.
• Option B: Deep vein thrombosis is a clinical challenge for doctors because it can develop in any section of the venous system; however, it arises most frequently in the deep veins of the leg. There are reports of DVT developing in a fiberglass mold maker after 6 weeks of working in a kneeling position, and in a patient maintaining a prone position after spine surgery with a central venous catheter in place.
• Option C: A surgical operation where the patient is asleep (under general anesthetic) is the most common cause of a DVT. The legs are still when the client is under anesthetic because the muscles in the body are temporarily paralyzed. Blood flow in the leg veins can become very slow, making a clot more likely to occur. Certain types of surgery (particularly operations on the pelvis or legs) increase the risk of DVT even more.

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FNDNRS-07–065

Nurse Sandra had just received a postoperative total hip replacement client from the recovery unit. Which is the best position in which she should place the client?

• A. Side-lying with the affected leg externally rotated.
• B. Side-lying with the affected leg internally rotated.
• C. On the nonoperative side with the legs abducted.
• D. On the nonoperative side with the legs adducted.

Correct Answer: C. On the nonoperative side with the legs abducted.

Abduction is maintained when the client is in a supine position or positioned on the non-operative side. The patient’s leg should be positioned in abduction. This is to prevent dislocation of the prosthesis. It is very crucial that the femoral head component of the acetabular cap is maintained in the correct position. Abduction splints, wedge pillows, and two or three pillows between the legs of the patient will keep the hip in abduction.

• Option A: In cases where the patient needs to be turned, the operative hip must be kept in abduction and the entire length of the leg supported by pillows. The hip of the patient should NOT be flexed more than 45 to 60 degrees.
• Option B: To prevent acute hip flexion, the head of the bed should not be elevated more than 45 degrees. Remind the patient not to sleep on the operated side until this position is cleared with the surgeon.
• Option D: An abduction splint or pillows should be kept between the legs. The patient is encouraged to keep the operative hip in extension when transferring or sitting. The patient is instructed to pivot in the unoperated leg while assisted by the nurse, who protects the operative leg from adduction, flexion, and excessive weight-bearing.

FNDNRS-07–066

A client has just returned to a nursing unit after a cardiac catheterization performed using the femoral artery. The nurse places the client in which position?

• A. Bed rest with head elevation at 30°.
• B. Bed rest with head elevation at 45°.
• C. Bed rest with head elevation at 60°.
• D. Bed rest with head elevation at 90°.

Correct Answer: A. Bed rest with head elevation at 30°.

During cardiac catheterization, if the femoral artery was accessed for the procedure, the client is maintained on bed rest for 4 to 6 hours and the affected extremity is maintained straight and the head is elevated to no more than 30°. Frequent assessment of the extremity for adequate perfusion enables prompt intervention as needed.

• Option B: Guidelines require patient puncture sites to be assessed every thirty minutes for four hours minimum before the patient is allowed off of bed rest. The patient is free to move side to side for their comfort. The head of the bed should be at a maximum thirty-degree tilt. The patient should be allowed to eat and drink right after the procedure if they wish to.
• Option C: Encourage bed rest and keep affected extremity straight or slight bend in the knee (10 degrees) for 6 hours. Bed rest and slight, or no flexion, provide improved circulation and minimizes the risk of further trauma which could promote the formation of a clot.
• Option D: Patients should be kept lying flat for several hours after the procedure so that any serious bleeding can be avoided and that the artery can heal. It is advised that diagnostic catheterization patients are kept on bed rest for four hours, and interventional catheterization patients stay on bed rest for six hours.

FNDNRS-07–067

A nurse is preparing to care for a client who had undergone an above-knee amputation of the right leg. The nurse plans to allow which position for the client in the first 24 hours?

• A. Supine position, with the affected limb flat on the bed.
• B. Supine position, with the affected limb supported with pillows.
• C. Prone position, with the affected limb in a dependent position.
• D. Trendelenburg’s position.

Correct Answer: B. Supine position, with the affected limb supported with pillows.

The amputated limb is usually supported with pillows on the first post-op day to promote venous return and reduce edema. Preventing contractures is very important. A contracture occurs when a joint becomes stuck in one position. If this happens, it may be hard or impossible to straighten the remaining limb and use an artificial leg.

• Option A: Make sure the client puts equal weight on both hips when he sits. Use firm chairs, and sit up straight. The client should keep the remaining limb flat with both legs together while lying on the back. The client should not sit for more than an hour or two. He must stand, or lie on his stomach now and then.
• Option C: If the affected limb is put in a dependent position, edema might occur. Edema in the residual limb is also a common complication after LLA surgery. Controlling the amount of edema post-surgically is vital for promoting wound-healing, pain control, protecting the incision during rehabilitation, and assisting in shaping the stump for prosthetic fitting
• Option D: The main goal of good positioning at any time is to prevent adjacent joint contractures. The patient should be advised on how to position themselves while sitting and lying in the hospital bed or standing to prevent contractures. Make sure you explain to the patient the dangers of the dependent position (residual limb hanging down) in the early post-op phase as this may increase edema, pain, and healing time.

FNDNRS-07–068

A client is to be on bed rest for 24 hours and the affected extremity is to be kept straight during this time. Which of the following procedures would require a client to do the above?

• A. Varicose vein surgery.
• B. Myelogram.
• C. Abdominal aneurysm resection.
• D. Arterial Vascular Grafting.

Correct Answer: D. Arterial Vascular Grafting.

To promote graft patency after the procedure, bedrest is maintained for the first 24 hours and the affected extremity is kept straight. The pathophysiology of vein graft failure has been attributed to acute thrombosis within the first month, intimal hyperplasia up to 1 year, and atherosclerosis beyond 1 year.

• Option A: After treatment of large varicose veins by any method, a 30- to 40-mm Hg gradient compression stocking is applied, and patients are instructed to maintain or increase their normal activity levels. Most practitioners also recommend the use of gradient compression stockings even after treatment of spider veins and smaller tributary veins.
• Option B: The client may need to sit or lay down for several hours after the procedure to reduce the risk of developing a CSF (cerebral spinal fluid) leak. Most patients are asked to lie down for two hours after the procedure. If the client needs to urinate, he may need to do so in a bedpan or urinal during the time that he needs to stay flat.
• Option C: Avoid strenuous activities that may put stress on the incision, such as bicycle riding, jogging, weight lifting, or aerobic exercise, for 6 weeks or until the doctor says it is okay. For 6 weeks, avoid lifting anything that would make a strain. This may include a child, heavy grocery bags and milk containers, a heavy briefcase or backpack, cat litter or dog food bags, or a vacuum cleaner.

FNDNRS-07–069

Which is the best position for a client with autonomic dysreflexia?

• A. Sim’s Position.
• B. Fowler’s Position.
• C. Semi-Fowler’s Position.
• D. High Fowler’s Position.

Correct Answer: D. High Fowler’s Position.

Autonomic dysreflexia is a condition in which there is a sudden onset of excessively high blood pressure. If it occurs, immediately place the client in a high Fowler’s position to promote adequate ventilation and assist in the prevention of a hypertensive stroke.

• Option A: The Sims position is a standard position in which the patient lies on their left side, with right hip and knees bent. The lower arm is behind the back, the thighs flexed. The left knee is slightly tilted. The right arm is positioned comfortably in front of the body, the right arm is rested behind the body. This is also known as “lateral” position. This position is often used for rectal or vaginal examination, and treatments.
• Option B: In Fowler’s position, the patient is at an increased risk for air embolism, skin injury from shearing and sliding, and DVT forming in the patient’s lower extremities. In this position, a patient has an increased pressure risk in their scapulae, sacrum, coccyx, ischium, back of knees, and heels.
• Option C: When positioning a patient in Fowler’s position, the surgical staff should minimize the degree of the patient’s head elevation as much as possible and always maintain the head in a neutral position. The patient’s arms should be flexed and secured across the body, the buttocks should be padded, and the knees flexed 30 degrees.

FNDNRS-07–070

A nurse is caring for a client who has returned to the recovery unit following a craniotomy. The nurse can safely place the client in which position?

• A. Trendelenburg position.
• B. Fowler’s position with the head leaning on the left side.
• C. Semi-fowler’s position with the head in a midline position.
• D. Supine position with the neck flexed.

Correct Answer: C. Semi-Fowler’s position with the head in a midline position.

Post-craniotomy clients should be placed in a semi-Fowler’s position and the head is in a midline position to facilitate venous drainage from the head. For nearly all types of craniotomy, the patient is observed for at least the first 24 hours in a neurological intensive care unit (NICU) or general surgical ICU. Basic laboratory tests are sent (complete blood cell count and basic metabolic panel). Neurological examinations are performed by the nursing staff every 1–2 hours and any changes in neurologic status.

• Option A: Placing the client in a Trendelenburg position may increase the swelling of the brain. Frequent neurological checks will be done by the nursing and medical staff to test the brain function and to make sure the body systems are functioning properly after the surgery. The client will be asked to follow a variety of basic commands, such as moving the arms and legs, to assess brain function.
• Option B: The client’s head must be placed in a midline position to facilitate venous drainage from the head and reduce the swelling. The recovery process will vary depending upon the type of procedure done and the type of anesthesia given. Once the client’s blood pressure, pulse, and breathing are stable and he is alert, he may be taken to the ICU or the hospital room.
• Option D: The head of the bed may be elevated to prevent swelling of the face and head. Some swelling is normal. The client will be encouraged to move around as tolerated while in bed and to get out of bed and walk around, with assistance at first, as his strength improves. A physical therapist (PT) may be asked to evaluate the client’s strength, balance, and mobility, and give him suggestions for exercises to do both in the hospital and at home.