100 Questions Exam – Answers & Rationales
1. A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a
prescribed medication is higher than the normal dose. The nurse calls the physician's
answering service and is told that the physician is off for the night and will be available in the
morning. The nurse should:
Call the nursing supervisor
Correct Ask the answering service to contact the on-call physician
Withhold the medication until the physician can be reached in the morning
Administer the medication but consult the physician when he becomes available
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a
physician’s prescription may be in error is responsible for clarifying the prescription before
carrying it out. Therefore the nurse would not administer the medication; instead, the nurse
would withhold the medication until the dose can be clarified. The nurse would not wait until the
next morning to obtain clarification. It is premature to call the nursing supervisor.
Test-Taking Strategy: Use the process of elimination and your knowledge of the legal
responsibilities of the nurse in regard to medication administration and physician’s prescriptions.
Eliminate the options that are comparable or alike in that they avoid clarification of the
prescription (administering the medication and holding the medication). To select from the
remaining options, note that it is premature to call the nursing supervisor. Also note that the
correct option is the only one that clarifies the prescription. Review legal responsibilities in
regard to medication prescriptions if you had difficulty with this question.
2. A nurse has assisted a physician in inserting a central venous access device into a client with
a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After
insertion of the catheter, the nurse immediately plans to:
Correct Call the radiography department to obtain a chest x-ray
Check the client's blood glucose level to serve as a baseline measurement
Hang the prescribed bag of PN and start the infusion at the prescribed rate
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency
,Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter has
been placed but before it is used for infusions, its placement must be checked with an x-ray.
Hanging the prescribed bag of PN and starting the infusion at the prescribed rate and infusing
normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency are all
incorrect because they could result in the infusion of solution into a lung if a pneumothorax is
present. Although the nurse may obtain a blood glucose measurement to serve as a baseline, this
action is not the priority.
Test-Taking Strategy: Note the strategic word “immediately.” Use the ABCs — airway,
breathing, and circulation. Recalling that pneumothorax is a complication of the insertion of this
type of catheter will direct you to the correct option. Review care after central venous catheter
placement if you have difficulty with this question.
3. A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical
ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this
type of tube, does the nurse implement?
Frequent suctioning
Correct Maintaining cuff pressure
Maintaining mechanical ventilation settings
Alternating the use of a cuffed tube with a cuffless tube on a daily basis
Rationale: Necrosis of the tracheal wall caused by the cuff of an endotracheal tube can lead to
the development of an opening between the posterior trachea and esophagus, a complication
known as tracheoesophageal fistula. The fistula allows air to escape into the stomach, resulting in
abdominal distention. It also leads to the aspiration of gastric contents. To prevent this
complication, the nurse must maintain cuff pressure, monitor the amount of air needed for cuff
inflation, and help the client progress to a deflated cuff or cuffless tube as soon as possible as
prescribed by the physician. Suctioning should be performed only as needed; frequent suctioning
can cause mucosal damage. Maintenance of mechanical ventilation settings ensures that the
client is adequately oxygenated, but this intervention is not a measure for the prevention of
tracheoesophageal fistula. Alternating the use of a cuffed tube and a cuffless tube on a daily basis
is incorrect, because the endotracheal tube would not be removed and replaced on a daily basis.
Test-Taking Strategy: Use your knowledge of anatomy and medical terminology to answer this
question. A fistula is an artificial opening. The term "tracheoesophageal" indicates "trachea to
,esophagus." Next think about the intervention that will help prevent this complication. Note the
word “pressure” in the correct option. Review the measures for the prevention of
tracheoesophageal fistula if you had difficulty with this question.
4. A nurse is preparing to insert a nasogastric tube into a client. In which position does the
nurse place the client before inserting the tube?
Correct
, Rationale: A nasogastric tube is inserted through the nose and into the stomach for the purpose
of gastric decompression or feeding the client. The client is placed in the Fowler position before
insertion of the tube to promote comfort and easy insertion. A flat position may be used for
clients who are hypotensive. In the reverse Trendelenburg position, the entire bed frame is tilted
with the foot of the bed down and may be used to promote gastric emptying or prevent
esophageal reflux. A trendelenburg position is one in which the entire bed frame is tilted with the
head of the bed down and may be used for postural drainage or to facilitate venous return in
clients with poor peripheral perfusion.
Test-Taking Strategy: Use the process of elimination and focus on the subject, the position
for insertion of anasogastric tube. Visualizing this procedure will direct you to the correct
option. Review the procedure for inserting a nasogastric tube if you had difficulty with this
question.
5. A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and
the nurse suspects an air embolism. The nurse immediately places the client in a lateral
Trendelenburg position, on the left side. What action does the nurse take next?
Auscultating heart sounds
Correct Clamping the intravenous catheter
Checking the client's blood pressure
Obtaining an arterial blood gas specimen
Rationale: The signs of air embolism include chest pain, dyspnea, and hypoxia. Tachycardia and
hypotension will also be present, and the client will experience anxiety. The nurse will also hear
a loud churning sound on auscultation over the pericardium. The nurse immediately places the
client in a lateral Trendelenburg position, on the left side. This position prevents air from
flowing into the pulmonary veins. The nurse then clamps the intravenous catheter and notifies
the physician. Although auscultating heart sounds, checking the client’s blood pressure, and
obtaining an arterial blood gas specimen may be appropriate interventions, none is the next
action to take after positioning the client.
Test-Taking Strategy: Use the process of elimination and note the strategic word "next" in the
query of the question. Think about the consequences of an air embolism that travels to the
pulmonary vessels. This will direct you to the correct option. Review care for the client with an
air embolism if you had difficulty with this question.
1. A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a
prescribed medication is higher than the normal dose. The nurse calls the physician's
answering service and is told that the physician is off for the night and will be available in the
morning. The nurse should:
Call the nursing supervisor
Correct Ask the answering service to contact the on-call physician
Withhold the medication until the physician can be reached in the morning
Administer the medication but consult the physician when he becomes available
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a
physician’s prescription may be in error is responsible for clarifying the prescription before
carrying it out. Therefore the nurse would not administer the medication; instead, the nurse
would withhold the medication until the dose can be clarified. The nurse would not wait until the
next morning to obtain clarification. It is premature to call the nursing supervisor.
Test-Taking Strategy: Use the process of elimination and your knowledge of the legal
responsibilities of the nurse in regard to medication administration and physician’s prescriptions.
Eliminate the options that are comparable or alike in that they avoid clarification of the
prescription (administering the medication and holding the medication). To select from the
remaining options, note that it is premature to call the nursing supervisor. Also note that the
correct option is the only one that clarifies the prescription. Review legal responsibilities in
regard to medication prescriptions if you had difficulty with this question.
2. A nurse has assisted a physician in inserting a central venous access device into a client with
a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After
insertion of the catheter, the nurse immediately plans to:
Correct Call the radiography department to obtain a chest x-ray
Check the client's blood glucose level to serve as a baseline measurement
Hang the prescribed bag of PN and start the infusion at the prescribed rate
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency
,Rationale: One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter has
been placed but before it is used for infusions, its placement must be checked with an x-ray.
Hanging the prescribed bag of PN and starting the infusion at the prescribed rate and infusing
normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency are all
incorrect because they could result in the infusion of solution into a lung if a pneumothorax is
present. Although the nurse may obtain a blood glucose measurement to serve as a baseline, this
action is not the priority.
Test-Taking Strategy: Note the strategic word “immediately.” Use the ABCs — airway,
breathing, and circulation. Recalling that pneumothorax is a complication of the insertion of this
type of catheter will direct you to the correct option. Review care after central venous catheter
placement if you have difficulty with this question.
3. A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical
ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this
type of tube, does the nurse implement?
Frequent suctioning
Correct Maintaining cuff pressure
Maintaining mechanical ventilation settings
Alternating the use of a cuffed tube with a cuffless tube on a daily basis
Rationale: Necrosis of the tracheal wall caused by the cuff of an endotracheal tube can lead to
the development of an opening between the posterior trachea and esophagus, a complication
known as tracheoesophageal fistula. The fistula allows air to escape into the stomach, resulting in
abdominal distention. It also leads to the aspiration of gastric contents. To prevent this
complication, the nurse must maintain cuff pressure, monitor the amount of air needed for cuff
inflation, and help the client progress to a deflated cuff or cuffless tube as soon as possible as
prescribed by the physician. Suctioning should be performed only as needed; frequent suctioning
can cause mucosal damage. Maintenance of mechanical ventilation settings ensures that the
client is adequately oxygenated, but this intervention is not a measure for the prevention of
tracheoesophageal fistula. Alternating the use of a cuffed tube and a cuffless tube on a daily basis
is incorrect, because the endotracheal tube would not be removed and replaced on a daily basis.
Test-Taking Strategy: Use your knowledge of anatomy and medical terminology to answer this
question. A fistula is an artificial opening. The term "tracheoesophageal" indicates "trachea to
,esophagus." Next think about the intervention that will help prevent this complication. Note the
word “pressure” in the correct option. Review the measures for the prevention of
tracheoesophageal fistula if you had difficulty with this question.
4. A nurse is preparing to insert a nasogastric tube into a client. In which position does the
nurse place the client before inserting the tube?
Correct
, Rationale: A nasogastric tube is inserted through the nose and into the stomach for the purpose
of gastric decompression or feeding the client. The client is placed in the Fowler position before
insertion of the tube to promote comfort and easy insertion. A flat position may be used for
clients who are hypotensive. In the reverse Trendelenburg position, the entire bed frame is tilted
with the foot of the bed down and may be used to promote gastric emptying or prevent
esophageal reflux. A trendelenburg position is one in which the entire bed frame is tilted with the
head of the bed down and may be used for postural drainage or to facilitate venous return in
clients with poor peripheral perfusion.
Test-Taking Strategy: Use the process of elimination and focus on the subject, the position
for insertion of anasogastric tube. Visualizing this procedure will direct you to the correct
option. Review the procedure for inserting a nasogastric tube if you had difficulty with this
question.
5. A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and
the nurse suspects an air embolism. The nurse immediately places the client in a lateral
Trendelenburg position, on the left side. What action does the nurse take next?
Auscultating heart sounds
Correct Clamping the intravenous catheter
Checking the client's blood pressure
Obtaining an arterial blood gas specimen
Rationale: The signs of air embolism include chest pain, dyspnea, and hypoxia. Tachycardia and
hypotension will also be present, and the client will experience anxiety. The nurse will also hear
a loud churning sound on auscultation over the pericardium. The nurse immediately places the
client in a lateral Trendelenburg position, on the left side. This position prevents air from
flowing into the pulmonary veins. The nurse then clamps the intravenous catheter and notifies
the physician. Although auscultating heart sounds, checking the client’s blood pressure, and
obtaining an arterial blood gas specimen may be appropriate interventions, none is the next
action to take after positioning the client.
Test-Taking Strategy: Use the process of elimination and note the strategic word "next" in the
query of the question. Think about the consequences of an air embolism that travels to the
pulmonary vessels. This will direct you to the correct option. Review care for the client with an
air embolism if you had difficulty with this question.
