Question 1

The client is admitted to the ER with multiple rib fractures on the right side. The nurse's assessment reveals an area over the right clavicle that is puffy and produces a "crackling" noise on palpation. The nurse should further assess the client for which of the following problems?

Accepted Answer

Answer reason: Puffy area with palpable crackling (crepitus) indicates air in subcutaneous tissue—subcutaneous emphysema—often seen after chest trauma and rib fractures.

Question 2

In a head injury patient, which alarming event does a soft surface show?

Accepted Answer

Answer reason: Bleeding from the ear after head injury suggests a basilar skull fracture/otorrhagia, an urgent and specific warning sign. Other options are nonspecific; head injury classically shows hypertension and bradycardia rather than hypotension.

Question 3

What is a common site for recording pulse rate?

Accepted Answer

Answer reason: The radial artery at the wrist is the most commonly used site to measure pulse in adults because it is superficial, easily accessible, and allows for accurate rate assessment.

Question 4

What is the difference between oral and axillary temperature?

Accepted Answer

Answer reason: Axillary temperature typically reads about 1°F (≈0.6°C) lower than oral; thus the difference between oral and axillary temperatures is about 0.6°C.

Question 5

Which of the following would indicate that an infant with a tracheoesophageal fistula (TEF) needs suctioning?

Accepted Answer

Answer reason: Retractions indicate increased work of breathing due to airway obstruction from secretions and signal the need for immediate suctioning. A brassy cough is characteristic but not a specific cue to suction; decreased activity is nonspecific; tachypnea can have many causes.

Question 6

The difference between oral and axillary temperature is?

Accepted Answer

Answer reason: Axillary temperature readings are typically about 0.5–0.6°C lower than oral readings; thus the difference is approximately 0.6°C.

Question 7

Temperature recording is lowest when it is taken from?

Accepted Answer

Answer reason: Axillary temperatures are typically the lowest, about 0.5°C lower than oral and around 1°C lower than rectal/vaginal core measurements.

Question 8

According to IMNCI, fast breathing in a 5-month-old child is defined as?

Accepted Answer

Answer reason: IMNCI/WHO defines fast breathing as ≥50 breaths/min for infants aged 2–12 months; a 5‑month-old falls in this group.

Question 9

Fever is defined as a temperature greater than?

Accepted Answer

Answer reason: Fever is typically defined as a body temperature of 38°C (100.4°F) or higher; 37°C is normal, and 35–36°C are low/normal.

Question 10

When assessing a child with chronic hypoxia, the nurse should monitor for?

Accepted Answer

Answer reason: Chronic tissue hypoxemia leads to digital clubbing. Chronic hypoxia usually causes tachypnea and secondary polycythemia (increased RBCs), not slow respirations or decreased RBCs; subcutaneous hemorrhage is unrelated.

Question 11

A non-ventilated preterm baby in an incubator is under observation. Which is the best way to monitor the baby's breathing and detect apnea?

Accepted Answer

Answer reason: Transthoracic impedance pneumography detects changes in chest wall impedance with respiration and is the standard method for continuous monitoring of breathing and apnea in non-intubated neonates. Capnography requires an airway gas stream and nasal temperature or infrared motion methods are less reliable.

Question 12

The thumb is not used for taking a pulse because?

Accepted Answer

Answer reason: The thumb has its own strong arterial pulse, which can be mistaken for the patient’s pulse, so it should not be used to palpate a pulse.

Question 13

You identify that a polytrauma patient has developed acute respiratory distress syndrome when?

Accepted Answer

Answer reason: Early ARDS presents with acute dyspnea and tachypnea; a marked increase in respiratory rate is an early indicator of respiratory distress. Cyanosis is a late sign, crackles are nonspecific, and hypotension reflects hemodynamic instability rather than ARDS itself.

Question 14

Which of the following is NOT a sign of respiratory distress in a newborn?

Accepted Answer

Answer reason: Cyanosis, expiratory grunting, and sternal retractions are classic signs of neonatal respiratory distress. Variation in respiratory rate according to age is normal and not a distress sign.

Question 15

After chest tube placement, it started to drain dark red secretions. It suggests...?

Accepted Answer

Answer reason: Dark red drainage from a chest tube indicates blood in the pleural space, consistent with hemothorax. Pneumothorax is air, pyothorax is pus, and emphysema is air trapping in lung tissue.

Question 16

The most reliable method of taking temperature?

Accepted Answer

Answer reason: Rectal temperature best reflects core body temperature and is more accurate and reliable than oral or axillary measurements.

Question 17

An infant with HPS is admitted to the podiatric unit; what does the nurse look for when palpating the infant's abdomen?

Accepted Answer

Answer reason: Hypertrophic pyloric stenosis classically presents with a palpable olive-sized mass in the right upper quadrant/epigastrium from the hypertrophied pylorus. Visible peristaltic waves are an inspection finding (usually upper abdomen), not palpation; distended colon or umbilical tenderness are not typical.

Question 18

The nurse is completing the admission assessment on a 13-year-old client diagnosed with asthma. Which signs and symptoms would the nurse expect to find?

Accepted Answer

Answer reason: Asthma causes airway inflammation and bronchospasm leading to expiratory wheezing and dyspnea. The other options are not typical findings in asthma or indicate normal findings.

Question 19

The nurse is caring for a client experiencing an acute asthma attack. The client has stopped wheezing and breath sounds are not audible. This change occurred because?

Accepted Answer

Answer reason: Loss of wheezing with inaudible breath sounds during an acute asthma attack indicates a "silent chest" from near-complete airway obstruction due to severe bronchospasm and swelling, not resolution of the attack.

Question 20

In a patient hospitalized with acute glomerulonephritis, nursing care includes all of the following EXCEPT?

Accepted Answer

Answer reason: Acute glomerulonephritis requires close monitoring for fluid overload and hypertension. Weights should be taken daily to track fluid status, not twice weekly. Frequent vital signs/BP checks and strict intake–output recording are appropriate.

Question 21

A loose cuff on the BP instrument gives?

Accepted Answer

Answer reason: A BP cuff that is loose (under-cuffing) requires greater pressure to occlude the artery, leading to an erroneously elevated reading.

Question 22

The nurse is assessing an infant with Hirschsprung's disease. The nurse can expect the infant to?

Accepted Answer

Answer reason: Hirschsprung disease (congenital aganglionosis) causes chronic constipation, abdominal distention, and failure to thrive, so weight may be below expected. Scaphoid abdomen is seen with diaphragmatic hernia; clubbing indicates chronic hypoxia; hyperactive DTRs are unrelated.

Question 23

A client is admitted with a thrombotic cerebrovascular accident (CVA). Which of the following is the priority nursing assessment within the first 24 hours after admission?

Accepted Answer

Answer reason: After a CVA, the priority is frequent neurological checks to detect increased intracranial pressure or deterioration. Monitoring pupil size and reactivity is a key early indicator. EEG/EMG are not priority assessments, and bowel sounds are lower priority.

Question 24

Right route to check the temperature in children?

Accepted Answer

Answer reason: For routine temperature measurement in children, the axillary route is preferred because it is safe and noninvasive. Oral is unreliable in young children and rectal is invasive with risk of injury, so not preferred.

Question 25

A newborn's failure to pass meconium within the first 24 hours after birth may indicate which of the following?

Accepted Answer

Answer reason: Absence of ganglion cells in the distal bowel causes functional obstruction, leading to delayed meconium passage. This clinical finding is a key assessment clue for Hirschsprung’s disease.

Question 26

Features of 'Kussmaul' respiration are?

Accepted Answer

Answer reason: Kussmaul respiration is a compensatory mechanism for metabolic acidosis (commonly diabetic ketoacidosis), characterized by deep, rapid, and regular breathing.

Question 27

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?

Accepted Answer

Answer reason: In frostbite, tissue freezing causes pallor or white discoloration with waxy appearance and loss of sensation. These are key signs of impaired perfusion and nerve function.

Question 28

How many times should the baby pass urine during phototherapy?

Accepted Answer

Answer reason: Adequate hydration during phototherapy increases urine output due to bilirubin excretion. Normal urine frequency ranges 6–9 times daily, indicating proper hydration and therapy tolerance.

Question 29

Which of these sign indicates tracheoesophagel fistula immediately after birth?

Accepted Answer

Answer reason: Newborns with tracheoesophageal fistula accumulate saliva and secretions due to esophageal atresia/abnormal connection, leading to continuous drooling immediately after birth, often with choking and coughing on feeds.

Question 30

A child has been brought to the emergency room with an asthma attack. What signs and symptoms would the nurse expect to see?

Accepted Answer

Answer reason: Asthma exacerbation features bronchial mucosal edema and bronchospasm causing expiratory wheezing that can become continuous. Other options contradict typical findings: asthma has air trapping with prolonged expiration (not inspiration), and cough is usually nonproductive or with thick mucus rather than clear frothy sputum; hypoinflation is incorrect.

Question 31

Number of pulse beats/minute is known as?

Accepted Answer

Answer reason: Pulse beats counted per minute define the pulse rate; volume refers to strength, tension to vessel wall pressure, and rhythm to regularity.

Question 32

Nurse Bhawana is evaluating a female child with acute post-streptococcal glomerulonephritis for signs of improvement. Which finding typically is the earliest sign of improvement?

Accepted Answer

Answer reason: In acute post-streptococcal glomerulonephritis, recovery begins with improved renal perfusion and GFR, leading to diuresis. Increased urine output and reduction of edema occur before appetite or energy return; diarrhoea is unrelated.

Question 33

A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client?

Accepted Answer

Answer reason: Wheezes progressing from end-expiratory and low-pitched to high-pitched throughout exhalation indicates worsening bronchospasm and narrowing of airways, i.e., increased obstruction. Hyperventilation or need for suction would not cause this pattern, and improvement would show decreased or later-occurring wheezes.

Question 34

During assessment the nurse notes symptoms positively correlated with ARDS that include?

Accepted Answer

Answer reason: ARDS commonly manifests with increased work of breathing including accessory muscle use, tachypnea and tachycardia from hypoxemia, and may cause hypotension and dysrhythmias; therefore all listed findings are consistent.

Question 35

A client with cancer of the prostate requests the urinal at frequent intervals but either does not void or voids in very small amounts. What does the nurse conclude is most likely the causative factor?

Accepted Answer

Answer reason: Prostate pathology can obstruct bladder outflow, causing urinary retention characterized by frequent urge with little or no urine. Dysuria is painful urination, suppression is failure of urine formation, and edema is unrelated.

Question 36

A newborn is suspected to have respiratory distress if there is ______?

Accepted Answer

Answer reason: Nasal flaring is a classic sign of increased work of breathing in neonates. Acrocyanosis and irregular respirations are common normal findings in newborns, and breath-holding spells are not typical for newborns.

Question 37

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client’s neurovascular status?

Accepted Answer

Answer reason: Warmth, redness, and edema with a palpable pedal pulse after arterial bypass indicate improved arterial perfusion and are expected findings from increased blood flow, not impairment or venous complication.

Question 38

A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder?

Accepted Answer

Answer reason: Acute bacterial prostatitis typically presents on digital rectal exam as an enlarged, very tender, boggy prostate. The term boggy is characteristic of prostatitis, distinguishing it from indurated (hard) lesions.

Question 39

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia?

Accepted Answer

Answer reason: A regular rhythm with no P waves and wide QRS complexes at a rate >140 bpm is characteristic of ventricular tachycardia. Sinus tachycardia has P waves and narrow QRS; ventricular fibrillation is chaotic and irregular; PVCs are isolated ectopic beats, not a sustained regular tachycardia.

Question 40

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm?

Accepted Answer

Answer reason: Chaotic rhythm with no P waves or identifiable QRS and coarse, irregular baseline describes ventricular fibrillation, often precipitated by an R-on-T PVC.

Question 41

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?

Accepted Answer

Answer reason: Frothy pink-tinged sputum and air hunger indicate acute pulmonary edema from left ventricular failure post-MI. Pulmonary edema produces crackles due to fluid in the alveoli; stridor is upper-airway obstruction, rhonchi reflect large-airway secretions, and diminished sounds occur with effusion or pneumothorax.

Question 42

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

Accepted Answer

Answer reason: Snellen visual acuity is assessed with each eye separately first (right then left) and then both together. Options 3 and 4 use an incorrect testing distance, and option 2 uses the wrong order.

Question 43

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?

Accepted Answer

Answer reason: Air in the pleural space with pneumothorax reduces or abolishes breath sounds on the affected side. Tachypnea, not a low respiratory rate, is typical; barrel chest suggests chronic COPD; a sucking sound indicates an open chest wound from penetrating trauma, not blunt injury.

Question 44

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

Accepted Answer

Answer reason: Rib fractures cause sharp pleuritic pain that worsens with inspiration, leading to splinting and shallow breaths. Paradoxical respirations occur with flail chest, and deep respirations are not expected.

Question 45

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

Accepted Answer

Answer reason: Mastoiditis usually results from acute otitis media, producing a middle-ear effusion. The tympanic membrane becomes erythematous, dull, thickened, and immobile on otoscopic exam.

Question 46

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client’s peripheral response to pain?

Accepted Answer

Answer reason: Peripheral pain response is best assessed with distal stimulation such as nail bed pressure. Sternal rub, supraorbital (orbital rim) pressure, and squeezing neck muscles are central stimuli and do not specifically test peripheral response.

Question 47

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

Accepted Answer

Answer reason: Rising ICP produces Cushing response: hypertension (widened pulse pressure), bradycardia, and decreased/irregular respirations; temperature may rise with hypothalamic involvement. Option 2 matches this trend.

Question 48

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?

Accepted Answer

Answer reason: Acoustic neuroma arises from CN VIII in the cerebellopontine angle; surgical removal commonly endangers the adjacent facial nerve (CN VII), leading to facial weakness. Thus CN VII assessment best detects a surgery-related complication.

Question 49

Suitable site to check pulse in newborns?

Accepted Answer

Answer reason: In newborns, a central palpable pulse is most reliably obtained at the femoral artery; pedal pulses are often difficult to feel, carotid is not typically used in infants, and the apical site is for auscultating heart rate rather than palpating a pulse.

Question 50

When assessing cranial nerve XII in a client who has experienced a stroke, which task should the nurse ask the client to perform?

Accepted Answer

Answer reason: Cranial nerve XII (hypoglossal) controls tongue movement; it is assessed by asking the client to protrude the tongue and observe for deviation or weakness.

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