DHA DHA Nursing Practice & Standards 2 — Questions and Answers
Question 1: A patient's urine output is 20 mL/hour for two consecutive hours. This finding is classified as:
- Normal output
- Oliguria (Correct answer)
- Polyuria
- Anuria
Correct answer: Oliguria
Oliguria is defined as urine output less than 30 mL/hour in adults, indicating inadequate renal perfusion.
Question 2: Which assessment finding is MOST indicative of deep vein thrombosis (DVT)?
- Bilateral leg oedema
- Unilateral calf pain, warmth, and swelling (Correct answer)
- Diffuse petechiae on lower limbs
- Bradycardia with leg fatigue
Correct answer: Unilateral calf pain, warmth, and swelling
DVT classically presents with unilateral calf pain, warmth, redness, and swelling due to thrombus formation in the deep venous system.
Question 3: The Braden Scale is used in nursing practice to assess:
- Fall risk
- Pain intensity
- Pressure injury risk (Correct answer)
- Delirium severity
Correct answer: Pressure injury risk
The Braden Scale evaluates six subscales — sensory perception, moisture, activity, mobility, nutrition, and friction/shear — to predict pressure injury risk.
Question 4: A nurse is verifying placement of a newly inserted nasogastric (NG) tube. Which method is considered MOST reliable?
- Injecting air and auscultating over the stomach
- pH testing of aspirate (≤5.5) confirmed by chest X-ray (Correct answer)
- Observing the patient for coughing
- Measuring the external tube length
Correct answer: pH testing of aspirate (≤5.5) confirmed by chest X-ray
Current evidence supports pH testing of gastric aspirate (≤5.5) combined with radiographic confirmation as the most reliable NG tube placement verification.
Question 5: A bedridden patient develops non-blanching erythema over the sacrum. This finding MOST likely represents:
- Stage 1 pressure injury (Correct answer)
- Cellulitis
- Dependent oedema
- Contact dermatitis
Correct answer: Stage 1 pressure injury
Non-blanching erythema over a bony prominence is the hallmark of a Stage 1 pressure injury, indicating compromised tissue perfusion.
Question 6: A nurse notes swelling, pallor, and coolness at a peripheral IV insertion site during infusion. This MOST likely indicates:
- Phlebitis
- Infiltration (Correct answer)
- Air embolism
- Catheter-related bloodstream infection
Correct answer: Infiltration
Infiltration occurs when IV fluid or medication leaks into surrounding tissue, causing coolness, pallor, and swelling at the site.
DHA DHA Nursing Practice & Standards 2
A patient's urine output is 20 mL/hour for two consecutive hours.
This finding is classified as: