Question 1

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm?

Accepted Answer

Answer reason: Absence of P waves with irregular fibrillatory (f) waves and preserved QRS complexes is characteristic of atrial fibrillation. Sinus tachycardia has visible P waves; ventricular fibrillation lacks organized QRS; ventricular tachycardia shows wide QRS without fibrillatory baseline.

Question 2

A client with suspected bacterial meningitis has a lumbar puncture. Which cerebrospinal fluid (CSF) finding confirms bacterial meningitis?

Accepted Answer

Answer reason: Bacterial meningitis produces purulent CSF with high WBCs (neutrophils) and low glucose due to bacterial consumption; fluid appears cloudy.

Question 3

Tuberculin test is given on?

Accepted Answer

Answer reason: The Mantoux tuberculin skin test is administered intradermally on the volar aspect of the forearm.

Question 4

In collecting a routine specimen for fecalysis, Which of the following, if done by a nurse, indicates inadequate knowledge and skills about the procedure?

Accepted Answer

Answer reason: For stool collection, the client should be instructed not to contaminate the specimen with toilet tissue or other materials and to call before wiping, as tissue may be placed in the bedpan and contaminate the sample. Collect about 1 inch and include areas with blood or mucus; defecation in a clean bedpan with a specimen container is appropriate.

Question 5

David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health teaching is important to ensure accurate reading?

Accepted Answer

Answer reason: For accurate serum lipid levels, the client should fast for about 12 hours prior to testing to avoid postprandial triglyceride elevation. Drinking a specific glass of water is unnecessary, eating fatty meals would distort results, and lipase ranges are unrelated.

Question 6

In collecting a urine from a catheterized patient, Which of the following statement indicates an accurate performance of the procedure?

Accepted Answer

Answer reason: For a sterile specimen from an indwelling catheter, clamp the tubing below the sampling port to allow fresh urine to collect in the tubing before aspirating from the port. Clamping above the port or for only 5–10 minutes is incorrect; 30–60 minutes ensures an adequate fresh sample.

Question 7

Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a Correct preparation before the procedure?

Accepted Answer

Answer reason: For ophthalmoscopy, the room should be dark to allow maximal pupil dilation and enhance the red reflex, improving visualization. Opening windows increases ambient light; draping is not essential; warming the scope is unnecessary and unsafe.

Question 8

After gastroscopy, an adaptation that indicates major complication would be?

Accepted Answer

Answer reason: Post-gastroscopy, severe dysphagia can indicate esophageal or pharyngeal perforation/edema—an urgent complication. The other findings are more common or minor after the procedure.

Question 9

The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?

Accepted Answer

Answer reason: Normal ICP is 5–15 mmHg; a reading of 66 is critically elevated and indicates risk of brain herniation. The priority is to urgently notify the provider for immediate interventions. Documenting only is unsafe, turning or placing supine can increase ICP.

Question 10

The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?

Accepted Answer

Answer reason: Endoscopy (EGD) directly visualizes the mucosa and allows biopsy, making it the most accurate and reliable test for diagnosing peptic ulcers.

Question 11

What is the most appropriate initial action if a client treated for anaphylactic reaction who has diabetes mellitus begins to exhibit restlessness, irritability, diaphoresis, and tremors?

Accepted Answer

Answer reason: The symptoms listed are classic adrenergic signs of hypoglycemia. For a client with diabetes, the priority initial action is to assess by checking the blood glucose so that hypoglycemia can be confirmed and treated promptly. Other options address anxiety or safety but do not first assess the likely physiological cause.

Question 12

What is the most appropriate action if a client treated for anaphylaxis with epinephrine and who takes human regular insulin begins to exhibit restlessness, irritability, diaphoresis, and tremors?

Accepted Answer

Answer reason: Symptoms are adrenergic signs consistent with hypoglycemia, especially in a client on insulin; verify with a bedside blood glucose before other interventions.

Question 13

Which statement by the client about colonoscopy indicates a need for further teaching?

Accepted Answer

Answer reason: Clients receive sedation for colonoscopy and must not drive afterward; they need a responsible adult to accompany them. The other statements accurately reflect prep and purpose.

Question 14

Which of the following nursing intervention is important for a client scheduled to have a Guaiac Test?

Accepted Answer

Answer reason: For guaiac-based fecal occult blood testing, clients should avoid peroxidase-containing vegetables such as turnips, radishes, and horseradish for about 3 days to prevent false-positive results. Red meat should be avoided for 3 days (not just 12 hours). Iron and caffeine/dark foods are not encouraged as they can interfere with interpretation.

Question 15

Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity?

Accepted Answer

Answer reason: For a clean-catch midstream urine culture, the initial stream is voided to flush urethral contaminants; the midstream portion is collected. Other choices are either incomplete (sterile—not just clean—container) or context dependent.

Question 16

Which of the following is incorrect with regards to proper urine testing using Benedict’s Solution?

Accepted Answer

Answer reason: Benedict’s test for reducing sugars turns from blue to green/yellow/orange/brick-red when positive; remaining blue indicates a negative result. The other steps describe correct procedure.

Question 17

Where should the nurse place lead V1 for proper ECG lead placement in a patient with significant ST elevation?

Accepted Answer

Answer reason: Precordial lead V1 is placed at the 4th intercostal space at the right sternal border. Other sites listed correspond to different leads (e.g., V4 at 5th ICS MCL, V2 at 4th ICS left sternal).

Question 18

What is an important nursing intervention immediately after a lumbar puncture (spinal tap)?

Accepted Answer

Answer reason: Following a lumbar puncture, keeping the client supine/flat for several hours helps prevent CSF leakage and post–dural puncture headache. Immediate ambulation or sitting increases risk, and fluids should be encouraged rather than restricted.

Question 19

What is an important consideration for the nurse when conducting a non-stress test on a patient with gestational diabetes?

Accepted Answer

Answer reason: Maternal glucose levels directly affect fetal well-being and NST reactivity; monitoring prevents hypo/hyperglycemia during the test. Extra food or insulin during the test is not routine, and fetal monitoring is essential.

Question 20

What information should the nurse include on the laboratory requisition when sending an arterial blood gas (ABG) specimen for analysis?

Accepted Answer

Answer reason: ABG interpretation depends on the fraction of inspired oxygen (FiO2)/supplemental oxygen the client is receiving; this information must be documented for accurate analysis.

Question 21

During a routine ECG, the nurse notes a baseline wandering pattern; what could be a potential reason for this finding?

Accepted Answer

Answer reason: Baseline wandering is an ECG artifact commonly caused by loose or poorly adhered electrodes, patient movement, or poor skin contact. Securing the electrodes corrects the issue.

Question 22

What is a key piece of information a nurse should include when teaching a patient how to prepare for an ECG?

Accepted Answer

Answer reason: Lotions and oils interfere with electrode adhesion and signal quality for ECGs. Fasting is not required, tight clothing is not recommended, and jewelry is typically removed.

Question 23

While placing electrodes for an ECG, which area should the nurse avoid for optimal lead placement?

Accepted Answer

Answer reason: Electrodes should not be placed on irritated, injured, or diseased skin because adhesion and signal quality are poor and it increases risk of skin injury. Hair can be shaved and muscles/bony areas may be used if necessary, but diseased skin should be avoided.

Question 24

An 18-year-old woman with a confirmed ectopic pregnancy treated with intramuscular methotrexate has a rising BhCG level 3 days after treatment; what is the most appropriate next management step?

Accepted Answer

Answer reason: With single-dose methotrexate for ectopic pregnancy, BhCG is checked on day 4 and day 7. A rise by day 3–4 can be expected; success is judged by a ≥15% decline from day 4 to day 7. Therefore, recheck BhCG in 72 hours (day 7).

Question 25

Specimens of urine that are not taken directly to the laboratory are usually?

Accepted Answer

Answer reason: If urine cannot be sent immediately, it should be refrigerated to inhibit bacterial growth and chemical changes. It should not be discarded, shaking is unnecessary, and while sterile containers are used, refrigeration is the key action when there is a delay.

Question 26

Which investigation should be done for a pregnant lady with jaundice?

Accepted Answer

Answer reason: Initial evaluation of jaundice in pregnancy includes liver function tests—transaminases (ALT, AST) and alkaline phosphatase—to help characterize hepatocellular versus cholestatic patterns.

Question 27

What is the significance of the D4 to D3 ratio in a clinical context?

Accepted Answer

Answer reason: The D4:D3 ratio is referenced as a parameter used to gauge fetal surfactant development, thus indicating fetal lung maturity.

Question 28

How should the nurse interpret a Tensilon (edrophonium) test result when a client with myasthenia gravis becomes weaker after administration?

Accepted Answer

Answer reason: Edrophonium increases acetylcholine. If weakness worsens after administration, it indicates excessive cholinergic stimulation (depolarization block), consistent with cholinergic crisis.

Question 29

Why should a lumbar puncture not be performed on a patient with increased intracranial pressure?

Accepted Answer

Answer reason: With elevated intracranial pressure, removing CSF via lumbar puncture can rapidly lower spinal CSF pressure relative to intracranial pressure and precipitate downward brain herniation.

Question 30

What is the best time for a nurse to collect a sputum specimen from a client?

Accepted Answer

Answer reason: Early-morning specimens are best because secretions pool overnight, producing the highest yield of sputum with minimal contamination from food or oral flora.

Question 31

What is the primary purpose of the rheumatoid factor (RF) test?

Accepted Answer

Answer reason: Rheumatoid factor is an autoantibody measured to support the diagnosis of rheumatoid arthritis; it is not a test for infections, liver integrity, or kidney function.

Question 32

After administering prescribed intravenous fluids to a client admitted with septic shock, which laboratory test should the nurse anticipate the physician will order to evaluate the efficacy of the fluids?

Accepted Answer

Answer reason: Lactate levels reflect tissue perfusion; decreasing serum lactic acid after fluids indicates improved oxygen delivery in septic shock. Troponin assesses myocardial injury, glucose reflects metabolic status, and WBC indicates infection/inflammation, not fluid resuscitation efficacy.

Question 33

Why should nurse Jamie explain to the male client that self-monitoring of blood glucose is preferred over urine glucose testing?

Accepted Answer

Answer reason: Blood glucose self-monitoring directly measures current blood glucose, unlike urine tests which reflect past levels and depend on renal threshold and hydration, making SMBG more accurate and reliable.

Question 34

What is the preferred site for bone marrow aspiration in an obese patient?

Accepted Answer

Answer reason: In adults, including obese patients, the posterior superior iliac crest provides a large marrow cavity, reliable landmarks, and a safe approach, making it the preferred site for bone marrow aspiration.

Question 35

After gastroscopy, which adaptation indicates a major complication?

Accepted Answer

Answer reason: Marked abdominal distention after EGD suggests serious complications such as perforation or bleeding leading to peritonitis. Nausea/vomiting and transient dysphagia can occur post-procedure and are less critical; increased GI motility is not a typical danger sign.

Question 36

A 46-year-old, non-pregnant, morbidly obese woman presents with irregular periods over the past 6 months; what is the most appropriate initial management?

Accepted Answer

Answer reason: Women age 45 or older and those with risk factors for endometrial hyperplasia (e.g., obesity) who have abnormal uterine bleeding require endometrial sampling as the initial step to rule out hyperplasia or cancer before initiating treatment.

Question 37

Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?

Accepted Answer

Answer reason: For a midstream clean-catch, the client performs perineal care, discards the initial urine, and collects a midstream sample (about 5–10 mL is adequate). Collecting the first voided specimen is not midstream and is therefore inappropriate.

Question 38

Before scheduling a patient for endoscopic retrograde cholangiopancreatography (ERCP), which client parameter should the nurse assess?

Accepted Answer

Answer reason: ERCP evaluates the biliary and pancreatic ducts, commonly for obstructive jaundice. Assessing bilirubin level helps confirm obstruction and provides a baseline relevant to the procedure.

Question 39

What is the correct placement for ECG lead V4?

Accepted Answer

Answer reason: V4 is placed in the 5th intercostal space at the left midclavicular line. (V1 4th ICS right sternal border; V2 4th ICS left sternal border; V5-V6 at 5th ICS anterior/midaxillary.).

Question 40

Which of the following is a contraindication for lumbar puncture?

Accepted Answer

Answer reason: Lumbar puncture is contraindicated when increased ICP is suspected due to risk of brain herniation. Meningitis and Guillain-Barré syndrome are indications for LP, not contraindications.

Question 41

If a PAP smear shows carcinoma in situ, what is the best next logical procedure?

Accepted Answer

Answer reason: A cytologic finding of carcinoma in situ on Pap requires confirmation and assessment of lesion extent. The next step is colposcopy with directed biopsy. Conization or hysterectomy are treatments considered after histologic confirmation; HPV DNA testing is for screening/triage, not after CIS cytology.

Question 42

What is the best position for a client undergoing a renal biopsy?

Accepted Answer

Answer reason: For a native kidney biopsy, the client is positioned prone with a pillow under the abdomen to elevate the flank, stabilize the kidney, and optimize access while reducing bleeding risk.

Question 43

For a lumbar puncture in an infant, what position is best to expose the spine?

Accepted Answer

Answer reason: For lumbar puncture, flexing the infant in a side-lying fetal position widens the intervertebral spaces and exposes the lumbar area. Other positions do not open the spine adequately.

Question 44

Which factor could potentially interfere with the accuracy of a TSH test in a patient with thyroid disease?

Accepted Answer

Answer reason: Certain anticoagulants (e.g., heparin) can interfere with immunoassays for thyroid tests and alter results, potentially affecting TSH accuracy. Fasting is not required for TSH, recent thyroid surgery does not interfere with the assay itself, and vitamin D has no known effect on TSH assay accuracy.

Question 45

A patient presents with frequent atrial premature complexes; which laboratory test should the physician anticipate ordering?

Accepted Answer

Answer reason: PACs are often precipitated by electrolyte disturbances (e.g., K+, Mg2+). An electrolyte panel is the most relevant lab; CBC or urinalysis would not evaluate this cause.

Question 46

In hypothyroid patients well controlled on thyroid hormone replacement, how often should thyroid function tests be performed during pregnancy?

Accepted Answer

Answer reason: During pregnancy, TSH/thyroid function should be monitored about every 4–6 weeks (especially early), which corresponds to every 1–2 months; more frequent than once per trimester.

Question 47

Which test should the nurse describe that will evaluate the woman's organs of reproduction to determine the cause of infertility?

Accepted Answer

Answer reason: A hysterosalpingogram is an X-ray with contrast that outlines the uterine cavity and fallopian tube patency, used to evaluate causes of female infertility. A cystogram assesses the bladder, culdoscopy visualizes the pelvic cavity but not tubal patency, and biopsy samples tissue rather than evaluating reproductive tract patency.

Question 48

Which type of cell in the spinal fluid suggests that a client with meningitis has become infected with viral meningitis?

Accepted Answer

Answer reason: Viral meningitis typically produces a lymphocytic pleocytosis in cerebrospinal fluid, whereas bacterial meningitis shows neutrophil predominance. Platelets and red blood cells are not indicators of viral meningitis.

Question 49

A 26-year-old pregnant woman at 34 weeks’ gestation with a blood pressure of 142/94 mmHg presents to the clinic; what test should be checked next?

Accepted Answer

Answer reason: Hypertension at 34 weeks raises concern for preeclampsia; the immediate next test is a urine dip to screen for proteinuria. Other labs (CBC, LFTs, uric acid) are secondary evaluations.

Question 50

A college student comes to the college health services with complaints of a severe headache, nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumbar puncture (LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis were made?

Accepted Answer

Answer reason: Bacterial meningitis typically shows cloudy CSF due to high neutrophils and a systemic leukocytosis. Option 1 matches these expected findings; other options show clear CSF, normal WBC, or RBCs from a traumatic tap.

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