Question 1

A client with head injury, first investigation is ?

Accepted Answer

Answer reason: A CT scan is the first-line investigation in a head injury because it quickly detects life-threatening conditions such as intracranial bleeding, skull fractures, and brain swelling. It is fast, widely available, and can be performed even in unstable patients.

Question 2

ECG is used for the examination of which organ?

Accepted Answer

Answer reason: ECG records the heart’s electrical activity, showing rhythm, rate, conduction abnormalities, and ischemic changes, so it is specifically used to examine the heart.

Question 3

A client is admitted for a CAT scan. The nurse should question the client regarding?

Accepted Answer

Answer reason:CT scans use ionizing radiation, which poses a significant risk to a developing fetus. Because of potential teratogenic effects, pregnancy must always be assessed before performing a CT scan.

Question 4

What does an intraocular pressure of 16 mm Hg in the right eye and 18 mm Hg in the left eye indicate?

Accepted Answer

Answer reason:Normal intraocular pressure ranges from approximately 10–21 mm Hg. Values of 16 mm Hg and 18 mm Hg fall within this range, indicating no elevation or concern for glaucoma.

Question 5

What is the maximum score on the GCS?

Accepted Answer

Answer reason:The maximum Glasgow Coma Scale score is 15, representing full consciousness with the highest levels of eye opening, verbal response, and motor response.

Question 6

BNP can be elevated in several conditions other than heart failure. Which of the following is not associated with elevated BNP?

Accepted Answer

Answer reason: BNP rises in conditions that cause myocardial stretch or ventricular strain, such as pulmonary embolism, myocardial infarction, and ventricular hypertrophy. Acute pancreatitis does not typically cause BNP elevation.

Question 7

What is the priority nursing intervention for a patient with malaria presenting with fever, chills, and sweating?

Accepted Answer

Answer reason: Confirm the diagnosis first by obtaining a malaria blood smear; treatment and other interventions should follow the results unless the patient is unstable or severe malaria is suspected.

Question 8

Placing the patient's arm in a downward position during venipuncture helps to—?

Accepted Answer

Answer reason: Keeping the arm dependent keeps the tube below the venipuncture site, reducing the risk that blood mixed with tube additives will reflux into the patient.

Question 9

Assessment of the patient's gag response is a priority nursing intervention following which procedure?

Accepted Answer

Answer reason: After bronchoscopy, topical anesthesia of the oropharynx suppresses the gag reflex; assessing its return before oral intake prevents aspiration.

Question 10

The nurse is reviewing the lab reports for a client who is HIV-positive. Which lab report provides information about the effectiveness of the client's medication regimen?

Accepted Answer

Answer reason: Viral load directly measures the amount of HIV RNA in the blood, so a decreasing or undetectable viral load indicates that antiretroviral therapy is effective. ELISA and Western blot are diagnostic tests, and CD4 count reflects immune status rather than treatment efficacy.

Question 11

Precautions apply during the measurement of blood pressure?

Accepted Answer

Answer reason: During blood pressure measurement, the manometer should be positioned at eye level for an accurate reading, with the patient seated and the arm at heart level.

Question 12

A community health nurse should be resourceful and meet the needs of the client. A villager asks him, "Can you test my urine for glucose?" Which of the following techniques allows the nurse to test a client’s urine for glucose without the need for intricate instruments?

Accepted Answer

Answer reason: Benedict's test detects reducing sugars, like glucose, in urine using Benedict's reagent and heat. Acetic acid testing is for protein, and nitrazine or litmus papers assess pH, not glucose.

Question 13

The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be performed if the client has?

Accepted Answer

Answer reason: The MRI's strong magnetic field can disrupt or damage a permanent pacemaker; claustrophobia can be managed with sedation; oxygen therapy can be provided with MRI-compatible equipment; and deafness is not a contraindication.

Question 14

When preparing a client for magnetic resonance imaging, which of the following should the nurse implement?

Accepted Answer

Answer reason: MRI uses a strong magnet; all metal must be removed, and clients must be screened for metal implants or devices. The other options are not standard MRI preparation steps.

Question 15

A client with diabetes shows signs of diaphoresis, tremors, and confusion. What should the nurse do first?

Accepted Answer

Answer reason: Diaphoresis, tremors, and confusion suggest hypoglycemia. The priority is to assess and verify with a bedside glucose check to guide treatment; giving insulin would worsen the condition.

Question 16

A client with cancer is to undergo an intravenous pyelogram. The nurse should?

Accepted Answer

Answer reason: For an IVP, the bladder should be emptied just before imaging to avoid obscuring urinary tract views. Fluids are encouraged after the study to flush the dye. CNS meds are not held, and pelvic shielding would obscure the area being imaged.

Question 17

The nurse caring for a client with a closed-head injury obtains an intracranial pressure (ICP) reading of 17 mm Hg. The nurse recognizes that?

Accepted Answer

Answer reason: Normal adult ICP is about 5–15 mmHg. A reading of 17 mmHg is elevated for a head-injured client and indicates a risk of increased ICP, so the provider should be notified.

Question 18

A patient is diagnosed with placenta previa. Which test is most often used to help diagnose placenta previa?

Accepted Answer

Answer reason: Placenta previa is primarily identified by obstetric ultrasound (transabdominal and/or transvaginal). It avoids ionizing radiation and is the standard first-line test.

Question 19

Which of the following cannot cause a low pulse oximetry reading in a patient with respiratory distress?

Accepted Answer

Answer reason: Hyperthermia tends to increase peripheral perfusion and does not cause falsely low SpO2. Inadequate circulation, edema, and nail polish can interfere with the sensor’s light transmission or perfusion and lead to low or inaccurate pulse oximetry readings.

Question 20

A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient?

Accepted Answer

Answer reason: MRI is contraindicated for patients with pacemakers or other ferromagnetic implants due to the strong magnetic field. Shellfish allergy pertains to iodinated contrast for CT. Claustrophobia can be managed with sedation, and antipsychotics are not a contraindication.

Question 21

In which conditions are opaque hemithorax X-ray findings seen?

Accepted Answer

Answer reason: An opaque hemithorax results when a lung becomes completely consolidated, such as with severe pneumonia. A diaphragmatic hernia typically produces a lucent hemithorax from bowel gas, and cancer or pulmonary hemorrhage do not usually cause total hemithorax opacification by themselves.

Question 22

A client scheduled for a carotid endarterectomy requires insertion of an intra-arterial blood-pressure monitoring device. The nurse plans to perform the Allen test. Which observation indicates patency of the ulnar artery?

Accepted Answer

Answer reason: A return of color after releasing the ulnar artery confirms adequate collateral blood flow, ensuring safe arterial cannulation.

Question 23

A client is admitted with suspected Guillain-Barré syndrome. Which of the following would the nurse expect the cerebrospinal fluid (CSF) analysis to reveal to confirm the diagnosis?

Accepted Answer

Answer reason: Guillain-Barré is characterized by albuminocytologic dissociation—high protein with normal WBC—confirming demyelination.

Question 24

A client with cancer is to undergo a bone scan. The nurse should?

Accepted Answer

Answer reason: Bone scans use a radiotracer excreted in the urine; the bladder should be emptied immediately before imaging to reduce pelvic artifact and radiation exposure and to improve visualization. Forcing fluids 24 hours beforehand is unnecessary, CNS medications are not routinely withheld, and shielding would interfere with nuclear imaging.

Question 25

A client with suspected leukemia is to undergo a bone marrow aspiration. Which statement does the nurse plan to include in the teaching session?

Accepted Answer

Answer reason: Bone marrow aspiration is performed with local anesthesia, and patients typically feel pressure and brief sharp pain during the procedure. Sedation causing amnesia and fluid restriction are not routine, and positioning can vary by site, so the most accurate teaching point is that some discomfort will occur.

Question 26

A client admitted with transient ischemic attacks has returned from a cerebral arteriogram. The nurse performs an assessment and finds a newly formed hematoma in the right groin area. What is the nurse's initial action?

Accepted Answer

Answer reason: A new groin hematoma after femoral access indicates active bleeding. The priority is to stop the bleeding by applying firm, direct pressure to the puncture site; distal pulse checks and provider notification follow once bleeding is controlled.

Question 27

The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave before each QRS, a PR interval between 0.12 and 0.20 seconds, and a P:QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?

Accepted Answer

Answer reason: All parameters show normal sinus conduction with a rate > 100 bpm and a 1:1 P:QRS with a normal PR interval, which defines sinus tachycardia. PACs are premature beats; atrial flutter has sawtooth waves with non-1:1 conduction; and SVT often obscures P waves.

Question 28

When is the best time to collect a urine specimen for routine urinalysis and C/S?

Accepted Answer

Answer reason: First-morning urine is the most concentrated and provides the highest bacterial yield for culture and the most accurate urinalysis results.

Question 29

In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

Accepted Answer

Answer reason: Before collecting a routine sputum specimen, the nurse prepares the needed supplies by obtaining a clean container. Mouthwash, such as Listerine, should not be used (rinse with water before collection). Four tablespoons is excessive, and discarding a contaminated container relates to handling during or after collection, not before.

Question 30

This specimen is required to assess glucose levels and the presence of albumin in the urine?

Accepted Answer

Answer reason: For routine screening of urine glucose and albumin, the preferred specimen is the second voided urine to avoid an overly concentrated first-morning specimen and contaminants. Midstream clean-catch is mainly for culture; 24-hour urine is for quantitative measurements; and postprandial testing targets glucose only.

Question 31

A community health nurse is assessing a client's urine using an acetic acid solution. Which of the following, if done by a nurse, indicates a lack of correct knowledge of the procedure?

Accepted Answer

Answer reason: For the heat and acetic acid urine test, the nurse should first heat the urine sample, then add acetic acid to distinguish protein from phosphates. Heating after adding acetic acid reflects an incorrect procedure and unsafe practice.

Question 32

Clinitest is used to test a client's urine for glucose. Which of the following, if committed by a nurse, indicates an error?

Accepted Answer

Answer reason: Urine for Clinitest should be a fresh specimen collected before meals; postprandial samples can produce false positives due to transient glycosuria. The other steps and the result interpretation are correct.

Question 33

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before and 48 hours after the procedure?

Accepted Answer

Answer reason: Metformin should be held when iodinated contrast is used for cardiac catheterization to prevent lactic acidosis if renal function declines. It is withheld 24 hours before and for 48 hours after the procedure, until renal function is verified. Sulfonylureas and insulin do not carry this contrast-related restriction.

Question 34

Which of the following blood tests is most indicative of cardiac damage?

Accepted Answer

Answer reason: Troponin I is a cardiac-specific protein that rises with myocardial injury and is the most sensitive and specific marker of cardiac damage. CK and LDH are less specific; the CBC is unrelated.

Question 35

A client's admission history reveals complaints of fatigue, chronic sore throat, and enlarged lymph nodes in the axilla and neck. Which exam would assist the physician to make a tentative diagnosis of leukemia?

Accepted Answer

Answer reason: A CBC can quickly show abnormal white blood cell counts, anemia, and thrombocytopenia, supporting a tentative diagnosis of leukemia. Bone marrow aspiration is confirmatory rather than tentative.

Question 36

The physician suspects acute respiratory distress syndrome. A STAT chest X-ray is ordered. What finding on the chest X-ray is indicative of ARDS?

Accepted Answer

Answer reason: ARDS is characterized by diffuse alveolar damage and pulmonary edema, producing a “whiteout” appearance on chest X-ray due to widespread infiltrates.

Question 37

When should the client test his blood sugar levels for greater accuracy?

Accepted Answer

Answer reason: Preprandial testing provides a baseline not influenced by recent food intake and is the standard for accurate SMBG comparisons; during or after meals reflects postprandial fluctuations.

Question 38

The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to?

Accepted Answer

Answer reason: Pinworms deposit eggs on the perianal skin at night. Applying clear tape to the perianal area around bedtime (or before the child awakens) captures eggs for microscopic evaluation. The other options do not collect appropriate specimens.

Question 39

A client with hepatitis C is scheduled for a liver biopsy. What would the nurse include in the teaching plan for this client?

Accepted Answer

Answer reason: Liver biopsy carries bleeding risk, especially with liver disease; pre-procedure PT/INR, PTT, and platelets are checked. Post-procedure the client lies on the right side; enemas are not indicated; the biopsy is invasive and can cause discomfort.

Question 40

A glucometer helps to see...?

Accepted Answer

Answer reason: A glucometer measures capillary blood glucose, used for random blood sugar (RBS) testing. Serum creatinine, blood urea, and CBC require laboratory analyzers and are not measured by a glucometer.

Question 41

Confirmatory test for pneumonia?

Accepted Answer

Answer reason: Pneumonia is confirmed by radiographic evidence of an infiltrate or consolidation on chest x-ray; cultures identify the pathogen but do not confirm the presence of pneumonia.

Question 42

Rubin's test is?

Accepted Answer

Answer reason: Rubin’s test evaluates fallopian tube patency by insufflating gas through the uterus and tubes. It is a diagnostic gynecologic procedure used in infertility evaluation.

Question 43

The physician orders an amniocentesis for a primigravida client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity?

Accepted Answer

Answer reason: Fetal lung maturity is assessed by the lecithin-to-sphingomyelin (L/S) ratio in amniotic fluid; a ratio ≥2 indicates mature surfactant production. Bilirubin, RBCs, and Barr bodies do not assess lung maturity.

Question 44

The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. Which laboratory value does the nurse determine is most significant to review?

Accepted Answer

Answer reason: Tonsillectomy carries high risk of bleeding; reviewing coagulation studies is most critical. Prothrombin time evaluates clotting function. Creatinine and BUN assess renal function, and ESR indicates inflammation—less relevant to perioperative bleeding risk.

Question 45

Which of the following diagnostic tests is typically used to diagnose pneumonia?

Accepted Answer

Answer reason: Pneumonia is confirmed by imaging that shows infiltrates or consolidation; the standard test is a chest X-ray. ABGs assess oxygenation, and cultures identify pathogens but do not by themselves establish the diagnosis.

Question 46

A newborn baby had a normal APGAR score at birth and developed excessive frothing and choking during attempted feeds. The investigation of choice is?

Accepted Answer

Answer reason: In suspected tracheoesophageal fistula, a radiograph with a red rubber catheter helps confirm esophageal atresia by showing the tube coiled in the upper pouch and air in the stomach. This test is simple, accurate, and first-line for diagnosis.

Question 47

Which of following test done to detect Rh incompatibility for baby?

Accepted Answer

Answer reason: Rh incompatibility in the newborn is detected with a direct antiglobulin (Direct Coombs) test, which identifies maternal anti-D antibodies bound to the infant’s RBCs. Indirect Coombs screens maternal serum; tTG and FTA-ABS are unrelated.

Question 48

You're educating a patient how to use a peak flow meter to help monitor the status of their asthma. Which statement by the patient demonstrates they understand how to use the device?

Accepted Answer

Answer reason: Peak flow meters are for monitoring, not strengthening. Correct technique includes daily use at a consistent time and comparing results to the patient's personal best; blowing out hard and fast is required (not inhaling). Values ≥90% are in the green zone and do not require notifying the provider.

Question 49

Mantoux test is to determine?

Accepted Answer

Answer reason: The Mantoux (tuberculin skin) test detects delayed hypersensitivity to Mycobacterium tuberculosis exposure, used to screen for TB infection.

Question 50

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?

Accepted Answer

Answer reason: During ERCP, clients receive IV sedation and topical throat anesthetic and must lie still while the endoscope is advanced; consent is also required. Saying they don’t need to lie still indicates misunderstanding.

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