🩺 100 Nursing MCQs Quiz – Test Your Knowledge!
Want to sharpen your nursing skills? Here-under are 100 interactive nursing MCQs with answers and quiz scores. Perfect for NCLEX, Nursing Officer, NORCET, CBT, RN, PN, and other nursing exams.
These 100 nursing MCQs with answers may be helpful for students preparing for major nursing exams such as NCLEX-RN, NCLEX-PN, AIIMS NORCET, ESIC Nursing Officer, DHA Prometric and other staff nurse recruitment tests. The questions cover important subjects including Fundamentals of Nursing, Pharmacology, Community Health Nursing, Medical-Surgical Nursing, Pediatric Nursing, Obstetric Nursing & other remaining subjects. Practice these nursing objective questions to test your knowledge and improve exam preparation.
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📋 Quiz Details
- Questions: 100
- Difficulty: Mixed (Moderate)
- Subjects Covered: Fundamentals, Pharmacology, Medical-Surgical Nursing + 7 others
- Best For: NCLEX, NORCET, Staff Nurse Exams and others
Note: We add new questions randomly on Daily/Weekly basis, so come back to check.
Q1. When caring for an infant during cardiac arrest, which pulse must be palpated to determine cardiac function?
✓ Correct Answer Rationale:
The brachial pulse is palpated in an infant during cardiac arrest because it is a central pulse that can be reliably assessed in young infants to determine cardiac function.
The brachial pulse is palpated in an infant during cardiac arrest because it is a central pulse that can be reliably assessed in young infants to determine cardiac function.
✕ Why Other Options Are Incorrect:
A. Carotid:
Commonly used to assess the pulse in adults and older children, but it is not the preferred pulse site for infants.
C. Pedal:
A peripheral pulse site and less reliable for assessing cardiac function during infant cardiac arrest.
D. Radial:
Commonly used for routine pulse assessment in older children and adults, but it is not the preferred site during infant cardiac arrest.
Q2. Which intervention is the priority for a patient with a GCS score of 7?
✓ Correct Answer Rationale:
A GCS score of 7 indicates severe impairment of consciousness and an inability to reliably protect the airway. Preparing for endotracheal intubation is the priority to maintain airway patency and support ventilation.
A GCS score of 7 indicates severe impairment of consciousness and an inability to reliably protect the airway. Preparing for endotracheal intubation is the priority to maintain airway patency and support ventilation.
✕ Why Other Options Are Incorrect:
A. Insert a nasogastric tube:
May be considered later for gastric decompression or feeding, but airway protection takes priority.
B. Administer IV fluids:
IV fluids may be necessary depending on the patient’s condition, but they do not address the immediate risk of airway compromise.
D. Provide family counseling:
Family support is important but is not the priority during an immediate airway emergency.
Q3. The Heimlich manoeuvre (abdominal thrust) is used for a client who has:
✓ Correct Answer Rationale:
The Heimlich manoeuvre, also called abdominal thrusts, is used to relieve a severe airway obstruction caused by a foreign object in a conscious person.
The Heimlich manoeuvre, also called abdominal thrusts, is used to relieve a severe airway obstruction caused by a foreign object in a conscious person.
✕ Why Other Options Are Incorrect:
A. A bloody nose:
Epistaxis is managed with appropriate positioning and direct pressure, not abdominal thrusts.
C. Fall from bed:
A fall requires assessment for possible injury, but abdominal thrusts are not indicated unless there is airway obstruction.
D. Impaired eyesight:
Visual impairment does not cause an acute airway obstruction and is not treated with abdominal thrusts.
Q4. In a patient with Diabetic Ketoacidosis, which laboratory value requires the most immediate intervention?
✓ Correct Answer Rationale:
A serum potassium of 2.8 mEq/L indicates significant hypokalemia and requires immediate attention because severe potassium depletion can cause life-threatening cardiac dysrhythmias. In DKA, insulin therapy can further lower serum potassium by shifting potassium into cells.
A serum potassium of 2.8 mEq/L indicates significant hypokalemia and requires immediate attention because severe potassium depletion can cause life-threatening cardiac dysrhythmias. In DKA, insulin therapy can further lower serum potassium by shifting potassium into cells.
✕ Why Other Options Are Incorrect:
A. Blood glucose of 490 mg/dL:
Severe hyperglycemia is expected in DKA and requires treatment, but the markedly low potassium poses a more immediate risk of cardiac complications.
C. Serum bicarbonate of 12 mEq/L:
Low bicarbonate reflects metabolic acidosis associated with DKA, but it is not as immediately life-threatening as severe hypokalemia.
D. Arterial pH of 7.25:
This indicates metabolic acidosis, which is consistent with DKA, but the potassium level requires more immediate attention because of the risk of dangerous dysrhythmias.
Q5. During an Intravenous (IV) infusion of saline, you observe that the infusion has stopped and there is mild swelling around the IV site. The skin is cool and puffy. This suggests:
✓ Correct Answer Rationale:
Infiltration occurs when a non-vesicant IV solution, such as normal saline, leaks into the surrounding tissue. The IV infusion may stop, and the site typically becomes cool, swollen, and puffy.
Infiltration occurs when a non-vesicant IV solution, such as normal saline, leaks into the surrounding tissue. The IV infusion may stop, and the site typically becomes cool, swollen, and puffy.
✕ Why Other Options Are Incorrect:
B. Phlebitis:
Inflammation of the vein usually causes pain, warmth, redness, and tenderness along the vein rather than a cool, puffy IV site.
C. Air Embolism:
An air embolism occurs when air enters the bloodstream and may cause respiratory distress, chest pain, or neurological symptoms; it does not typically cause localized cool swelling at the IV site.
D. Atherosclerosis:
Atherosclerosis is the buildup of plaque within arteries and is unrelated to acute IV-site swelling or infiltration.
Q6. You observe that a patient of head injury opens his eyes on painful stimuli but not on command; he localizes the site of the painful stimulus; and mutters incomprehensible sounds. His Glasgow Coma Scale Score is in the range of:
✓ Correct Answer Rationale:
The Glasgow Coma Scale score is calculated as Eye opening to pain = 2, Motor response localizes pain = 5, and Verbal response with incomprehensible sounds = 2. The total score is 2 + 5 + 2 = 9, which falls within the 9–10 range.
The Glasgow Coma Scale score is calculated as Eye opening to pain = 2, Motor response localizes pain = 5, and Verbal response with incomprehensible sounds = 2. The total score is 2 + 5 + 2 = 9, which falls within the 9–10 range.
✕ Why Other Options Are Incorrect:
A. 5-6:
This range would indicate a much more severely impaired level of consciousness than the responses described.
C. 12-13:
This would require better eye, motor, or verbal responses than those described in the question.
D. 14-15:
This range indicates mild or minimal impairment and is inconsistent with eye opening only to pain and incomprehensible sounds.
Q7. While checking the blood pressure in the upper limb of a patient with a sphygmomanometer, you observe that she has developed carpal spasm. The most likely cause is:
✓ Correct Answer Rationale:
Carpal spasm during blood pressure measurement is known as Trousseau’s sign. It is a classic sign of hypocalcemia, caused by increased neuromuscular excitability. Inflation of the blood pressure cuff can provoke the characteristic carpal spasm.
Carpal spasm during blood pressure measurement is known as Trousseau’s sign. It is a classic sign of hypocalcemia, caused by increased neuromuscular excitability. Inflation of the blood pressure cuff can provoke the characteristic carpal spasm.
✕ Why Other Options Are Incorrect:
A. Hypokalemia:
Low potassium can cause muscle weakness, cramps, and cardiac dysrhythmias, but carpal spasm with BP cuff inflation is classically associated with hypocalcemia.
B. Hyponatremia:
Low sodium may cause neurological symptoms such as confusion or seizures when severe, but it does not typically cause Trousseau’s sign.
D. Hyperphosphatemia:
High phosphate levels can contribute to hypocalcemia, but the direct abnormality responsible for the carpal spasm is low serum calcium.
Q8. The nurse is teaching the client taking cyclosporine after renal transplantation about key medication information. The nurse tells the client to be especially alert for:
✓ Correct Answer Rationale:
Cyclosporine is an immunosuppressant used to prevent organ rejection after transplantation. Because it suppresses the immune response, the client is at increased risk of infection and should promptly report signs such as fever, chills, sore throat, or unusual weakness.
Cyclosporine is an immunosuppressant used to prevent organ rejection after transplantation. Because it suppresses the immune response, the client is at increased risk of infection and should promptly report signs such as fever, chills, sore throat, or unusual weakness.
✕ Why Other Options Are Incorrect:
B. Hypotension:
Cyclosporine is more commonly associated with hypertension rather than hypotension.
C. GI disturbances:
Gastrointestinal effects can occur with cyclosporine, but infection is a more important complication requiring close monitoring in an immunosuppressed transplant recipient.
D. Hair loss:
Hair changes can occur with some medications, but they are not the priority concern compared with the increased risk of serious infection.
Q9. There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor?
✓ Correct Answer Rationale:
Obesity is a modifiable risk factor for coronary artery disease because body weight can be reduced through lifestyle changes such as a healthy diet, regular physical activity, and appropriate weight management.
Obesity is a modifiable risk factor for coronary artery disease because body weight can be reduced through lifestyle changes such as a healthy diet, regular physical activity, and appropriate weight management.
✕ Why Other Options Are Incorrect:
B. Heredity:
Family history and genetic predisposition cannot be changed, making heredity a non-modifiable risk factor.
C. Gender:
Biological sex is a non-modifiable risk factor for coronary artery disease.
D. Age:
Age is a non-modifiable risk factor because it naturally increases over time and cannot be altered.
Q10. A nurse receives report on four clients admitted to the emergency room. Who should she assess first?
✓ Correct Answer Rationale:
The client vomiting after a heroin overdose should be assessed first because opioid overdose can cause severe respiratory depression and decreased level of consciousness. Vomiting further increases the risk of aspiration and airway compromise. Airway and breathing take priority in emergency assessment.
The client vomiting after a heroin overdose should be assessed first because opioid overdose can cause severe respiratory depression and decreased level of consciousness. Vomiting further increases the risk of aspiration and airway compromise. Airway and breathing take priority in emergency assessment.
✕ Why Other Options Are Incorrect:
A. Client with cherry red skin who has been waiting 15 minutes:
Cherry-red skin can occur with carbon monoxide poisoning and requires urgent evaluation, but the vomiting client with a heroin overdose has an immediate airway and respiratory risk.
B. Client with a blood pressure of 180/76 on 2L of oxygen via NC:
The elevated blood pressure requires assessment, but there is no indication of an immediate airway or breathing emergency from the information given.
D. Client with asthma receiving treatment from respiratory therapy:
This client is already receiving active respiratory treatment, whereas the heroin overdose client may have an unrecognized airway or breathing emergency.
Q11. A patient presents to the emergency department with a blood pressure of 180/130 mmHg, headache, and confusion. Which additional finding is consistent with a diagnosis of hypertensive emergency?
✓ Correct Answer Rationale:
Retinopathy can occur in severe hypertension because markedly elevated blood pressure can cause acute damage to the retinal blood vessels. Hypertensive emergency is characterized by severely elevated blood pressure accompanied by acute target-organ damage, which may involve the eyes, brain, heart, or kidneys.
Retinopathy can occur in severe hypertension because markedly elevated blood pressure can cause acute damage to the retinal blood vessels. Hypertensive emergency is characterized by severely elevated blood pressure accompanied by acute target-organ damage, which may involve the eyes, brain, heart, or kidneys.
✕ Why Other Options Are Incorrect:
B. Bradycardia:
Bradycardia is not a typical finding indicating hypertensive emergency and does not specifically demonstrate acute target-organ damage.
C. Jaundice:
Jaundice indicates increased bilirubin or hepatobiliary dysfunction and is not a characteristic finding of hypertensive emergency.
D. Urinary retention:
Urinary retention is usually related to bladder or urinary outflow problems and is not a typical manifestation of hypertensive emergency.
Q12. Which of the following would be a common indication of infiltration of a peripheral intravenous infusion?
✓ Correct Answer Rationale:
Infiltration occurs when a non-vesicant IV solution leaks from the vein into surrounding tissue. The affected area commonly becomes cool, pale, swollen, and puffy. Coolness distal to the insertion site is therefore a common indication of infiltration.
Infiltration occurs when a non-vesicant IV solution leaks from the vein into surrounding tissue. The affected area commonly becomes cool, pale, swollen, and puffy. Coolness distal to the insertion site is therefore a common indication of infiltration.
✕ Why Other Options Are Incorrect:
A. Redness and swelling around the insertion site:
Redness, warmth, pain, and swelling are more characteristic of phlebitis or inflammation of the vein.
B. Blood return in the cannula:
Blood return generally indicates that the catheter remains within the vascular system and is not a typical sign of infiltration.
C. Difficulty regulating the flow with gravity:
Sluggish or irregular flow can occur for several reasons, such as catheter position or mechanical obstruction, but it is not as characteristic of infiltration as cool, swollen tissue.
Q13. Which among the following is an inappropriate management for Mr. Y with serum potassium 6.2 mEq/L?
✓ Correct Answer Rationale:
Spironolactone is a potassium-sparing diuretic and can increase serum potassium levels. It is therefore inappropriate in a patient with significant hyperkalemia (serum potassium 6.2 mEq/L) because it may worsen the condition and increase the risk of life-threatening cardiac dysrhythmias.
Spironolactone is a potassium-sparing diuretic and can increase serum potassium levels. It is therefore inappropriate in a patient with significant hyperkalemia (serum potassium 6.2 mEq/L) because it may worsen the condition and increase the risk of life-threatening cardiac dysrhythmias.
✕ Why Other Options Are Incorrect:
B. Calcium gluconate infusion:
IV calcium gluconate helps stabilize the cardiac membrane during significant hyperkalemia and reduces the risk of dangerous dysrhythmias.
C. 5% dextrose with insulin:
Insulin promotes the movement of potassium from the extracellular space into cells. Dextrose is given to reduce the risk of hypoglycemia.
D. Infusion of sodium bicarbonate:
Sodium bicarbonate may be used in selected cases, particularly when significant metabolic acidosis accompanies hyperkalemia, although its effectiveness for potassium lowering depends on the clinical situation.
Q14. A nurse is caring for a patient with limited mobility who is at risk for skin breakdown. Which action best applies the principle of evidence-based nursing practice?
✓ Correct Answer Rationale:
Regular repositioning helps reduce prolonged pressure on bony prominences and is an important part of preventing pressure injuries in patients with limited mobility. The patient’s position and skin condition should be assessed regularly, with repositioning individualized according to the patient’s condition and risk level.
Regular repositioning helps reduce prolonged pressure on bony prominences and is an important part of preventing pressure injuries in patients with limited mobility. The patient’s position and skin condition should be assessed regularly, with repositioning individualized according to the patient’s condition and risk level.
✕ Why Other Options Are Incorrect:
B. Apply lotion to the patient’s skin every morning:
Moisturizing can help maintain skin condition, but lotion alone does not relieve prolonged pressure.
C. Offer the patient fluids at regular intervals:
Adequate hydration supports skin health but does not directly prevent pressure from remaining on the same area.
D. Encourage the patient to perform deep breathing exercises:
Deep breathing supports respiratory function but does not directly address pressure injury prevention.
Q15. Which finding should the nurse expect during assessment of a client with Ménière’s disease experiencing an acute episode?
✓ Correct Answer Rationale:
An acute episode of Ménière’s disease typically causes sudden or recurrent vertigo accompanied by tinnitus and fluctuating sensorineural hearing loss. The patient may also describe a feeling of pressure or fullness in the affected ear.
An acute episode of Ménière’s disease typically causes sudden or recurrent vertigo accompanied by tinnitus and fluctuating sensorineural hearing loss. The patient may also describe a feeling of pressure or fullness in the affected ear.
✕ Why Other Options Are Incorrect:
A. Gradual vision changes and ear fullness:
Vision changes are not a typical feature of Ménière’s disease, although ear fullness may occur.
B. Sudden onset of ear drainage:
Ear drainage is not a characteristic finding of an acute Ménière’s episode.
D. Mild pain without dizziness:
Vertigo is a major feature of Ménière’s disease, while significant ear pain is not typical.
Q16. The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child?
✓ Correct Answer Rationale:
Hemophilia is caused by a deficiency of a clotting factor, most commonly factor VIII in hemophilia A or factor IX in hemophilia B. Because these factors are part of the intrinsic coagulation pathway, the partial thromboplastin time (PTT) is typically prolonged. Platelet count, hemoglobin, and hematocrit are generally normal unless significant bleeding has occurred.
Hemophilia is caused by a deficiency of a clotting factor, most commonly factor VIII in hemophilia A or factor IX in hemophilia B. Because these factors are part of the intrinsic coagulation pathway, the partial thromboplastin time (PTT) is typically prolonged. Platelet count, hemoglobin, and hematocrit are generally normal unless significant bleeding has occurred.
✕ Why Other Options Are Incorrect:
A. Platelet count:
Platelet numbers are usually normal in hemophilia because the disorder involves clotting factors rather than platelet production.
B. Hematocrit level:
It is generally normal unless substantial blood loss has occurred.
C. Hemoglobin level:
Hemoglobin is usually normal unless repeated or significant bleeding causes anemia.
Q17. HIV contaminated waste products can be de-contaminated by the following agents except:
✓ Correct Answer Rationale:
Methanol is not a standard disinfectant used for decontaminating HIV-contaminated waste. Appropriate chemical disinfectants, such as sodium hypochlorite and certain aldehydes, can be used according to the type of material and applicable infection-control procedures.
Methanol is not a standard disinfectant used for decontaminating HIV-contaminated waste. Appropriate chemical disinfectants, such as sodium hypochlorite and certain aldehydes, can be used according to the type of material and applicable infection-control procedures.
✕ Why Other Options Are Incorrect:
A. Sodium hypochlorite:
Is an effective chlorine-based disinfectant commonly used for appropriate contaminated materials.
B. Formaldehyde:
Has disinfectant properties and has been used for decontamination in appropriate settings.
C. Glutaraldehyde:
Is a high-level disinfectant used for certain medical equipment and materials.
Q18. The most essential fatty acid that serves as a basis for production of other fatty acids is:
✓ Correct Answer Rationale:
Linoleic acid is an essential fatty acid because the human body cannot synthesize it and must obtain it from the diet. It also serves as a precursor for other important fatty acids, including arachidonic acid, making it an important component of normal lipid metabolism.
Linoleic acid is an essential fatty acid because the human body cannot synthesize it and must obtain it from the diet. It also serves as a precursor for other important fatty acids, including arachidonic acid, making it an important component of normal lipid metabolism.
✕ Why Other Options Are Incorrect:
B. Trans fatty acid:
Trans fatty acids are not considered essential fatty acids and are not required as a dietary precursor.
C. Butyric acid:
Is a short-chain fatty acid and is not classified as an essential fatty acid.
D. Caproic acid:
Is a short- to medium-chain fatty acid and is not an essential fatty acid.
Q19. A 35-year-old woman has an abnormal Pap smear and is found to have cervical intraepithelial neoplasia grade III. What is the most important next step in her management?
✓ Correct Answer Rationale:
CIN III represents a high-grade cervical precancerous lesion and requires careful evaluation to confirm the diagnosis and determine appropriate treatment. Colposcopy with directed biopsy allows the clinician to examine abnormal areas closely and obtain tissue for histopathological assessment.
CIN III represents a high-grade cervical precancerous lesion and requires careful evaluation to confirm the diagnosis and determine appropriate treatment. Colposcopy with directed biopsy allows the clinician to examine abnormal areas closely and obtain tissue for histopathological assessment.
✕ Why Other Options Are Incorrect:
A. Initiation of chemotherapy:
Chemotherapy is not the routine initial management for cervical intraepithelial neoplasia.
B. Observation and repeat Pap smear in one year:
CIN III is a high-grade lesion and generally requires further evaluation rather than simple observation.
D. Total abdominal hysterectomy:
Hysterectomy is not routinely the first step solely on the basis of CIN III and depends on the clinical situation and treatment plan.
Q20. Which assessment finding indicates progression from the latent to the active phase of the first stage of labour?
✓ Correct Answer Rationale:
Increasing cervical dilation is the clearest indicator that labour is progressing into the active phase. As active labour develops, cervical dilation becomes more rapid and contractions generally become stronger, longer, and more frequent. An urge to push is more characteristic of the second stage of labour.
Increasing cervical dilation is the clearest indicator that labour is progressing into the active phase. As active labour develops, cervical dilation becomes more rapid and contractions generally become stronger, longer, and more frequent. An urge to push is more characteristic of the second stage of labour.
✕ Why Other Options Are Incorrect:
B. Maternal urge to push intensifies:
A strong urge to push is usually associated with the second stage of labour when the cervix is fully dilated.
C. Regular contractions at 10-minute intervals:
Contractions at this frequency are more consistent with earlier labour and do not by themselves establish active-phase progression.
D. Presence of bloody show and backache:
These can occur during early labour but do not specifically indicate transition to the active phase.
Q21. A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should alert the nurse to intervene?
✓ Correct Answer Rationale:
Loss of deep tendon reflexes, particularly the patellar or knee-jerk reflex, is an important early warning sign of magnesium sulfate toxicity. If magnesium levels continue to rise, respiratory depression and serious cardiac complications can develop, so the nurse should respond promptly to absent reflexes.
Loss of deep tendon reflexes, particularly the patellar or knee-jerk reflex, is an important early warning sign of magnesium sulfate toxicity. If magnesium levels continue to rise, respiratory depression and serious cardiac complications can develop, so the nurse should respond promptly to absent reflexes.
✕ Why Other Options Are Incorrect:
A. Hyperactive sensorium:
Increased alertness or hyperactivity is not a typical early sign of magnesium toxicity.
B. Increase in respiratory rate:
Magnesium toxicity is more likely to cause respiratory depression and a decreasing respiratory rate.
D. Development of a cardiac dysrhythmia:
Cardiac complications can occur with severe toxicity but are later and more serious manifestations.
Q22. Type of family which consists blood relations together with their mates and their children is:
✓ Correct Answer Rationale:
A consanguineous family is based primarily on relationships by blood and may include blood relatives together with their spouses and children. The term distinguishes this family structure from arrangements defined mainly by the marital relationship or place of residence.
A consanguineous family is based primarily on relationships by blood and may include blood relatives together with their spouses and children. The term distinguishes this family structure from arrangements defined mainly by the marital relationship or place of residence.
✕ Why Other Options Are Incorrect:
A. Conjugal family:
Primarily consists of a married couple and their children.
B. Neolocal family:
Describes a couple establishing a new residence separate from both families.
D. Avunculocal family:
Refers to a residence pattern in which a married couple lives with or near the mother’s brother or maternal uncle.
Q23. Which of the following types of shock will usually have warm peripheral extremities?
✓ Correct Answer Rationale:
Neurogenic shock causes loss of sympathetic vascular tone, resulting in widespread vasodilation. Because peripheral blood vessels remain dilated, the skin may feel warm and dry. Bradycardia can also occur, which helps distinguish neurogenic shock from many other forms of shock.
Neurogenic shock causes loss of sympathetic vascular tone, resulting in widespread vasodilation. Because peripheral blood vessels remain dilated, the skin may feel warm and dry. Bradycardia can also occur, which helps distinguish neurogenic shock from many other forms of shock.
✕ Why Other Options Are Incorrect:
A. Hypovolemic:
Reduced circulating volume causes peripheral vasoconstriction, commonly producing cool or clammy skin.
C. Cardiogenic:
Reduced cardiac output usually triggers peripheral vasoconstriction, resulting in cool, pale, or clammy extremities.
D. Anaphylactic:
Although vasodilation occurs, the typical shock presentation can include hypotension, flushing, and other allergic manifestations rather than the characteristic warm, dry extremities associated with neurogenic shock.
Q24. A 39-year-old mother with OCD has become immobilized by her elaborate hand washing & walking rituals. The basis of OCD is often:
✓ Correct Answer Rationale:
In the traditional psychodynamic understanding of OCD, excessive guilt, doubt, and feelings of inadequacy may contribute to the development of obsessive thoughts and compulsive behaviors. The rituals can temporarily reduce the anxiety associated with these distressing thoughts.
In the traditional psychodynamic understanding of OCD, excessive guilt, doubt, and feelings of inadequacy may contribute to the development of obsessive thoughts and compulsive behaviors. The rituals can temporarily reduce the anxiety associated with these distressing thoughts.
✕ Why Other Options Are Incorrect:
A. Problems with being too conscientious:
Excessive conscientiousness may be associated with obsessive traits, but it does not fully explain the underlying anxiety and guilt described in the traditional formulation.
B. Problems with anger and remorse:
These are not considered the central basis of OCD in this formulation.
D. Feeling of unworthiness and hopelessness:
These feelings are more commonly associated with depressive disorders than with the core formulation of OCD.
Q25. A nurse is monitoring a patient with genetic alterations affecting enzyme production. What is the most plausible result of such alterations?
✓ Correct Answer Rationale:
Enzymes control and regulate many biochemical reactions in the body. A genetic alteration that changes enzyme production or function can disrupt a metabolic pathway, causing substances to accumulate or essential products to become deficient. The resulting metabolic imbalance depends on which enzyme is affected.
Enzymes control and regulate many biochemical reactions in the body. A genetic alteration that changes enzyme production or function can disrupt a metabolic pathway, causing substances to accumulate or essential products to become deficient. The resulting metabolic imbalance depends on which enzyme is affected.
✕ Why Other Options Are Incorrect:
A. Improved cellular energy efficiency:
Enzyme abnormalities are more likely to disrupt normal biochemical reactions than improve cellular efficiency.
B. Enhanced immune response activity:
An alteration in enzyme production does not inherently result in an enhanced immune response.
D. Reduced hormone receptor sensitivity:
Hormone receptor sensitivity is not the direct or most expected consequence of an enzyme-production defect.
Q26. Which of the following is an essential principle in the therapeutic relationship to ensure effective patient teaching?
✓ Correct Answer Rationale:
Establishing trust and rapport creates an environment in which patients feel comfortable asking questions, expressing concerns, and participating in their care. Good therapeutic communication also helps the nurse adapt teaching to the patient’s level of understanding and individual needs.
Establishing trust and rapport creates an environment in which patients feel comfortable asking questions, expressing concerns, and participating in their care. Good therapeutic communication also helps the nurse adapt teaching to the patient’s level of understanding and individual needs.
✕ Why Other Options Are Incorrect:
A. Using medical jargon to show expertise:
Complex medical terminology can confuse patients and interfere with understanding.
B. Speaking in a loud voice:
Speaking loudly is unnecessary unless the patient has a hearing difficulty that requires it.
D. Providing all information in a single, lengthy session:
Giving too much information at once can overwhelm the patient and reduce retention.
Q27. Psychotherapy groups in which all members of the group join at the same time and have a defined membership is called:
✓ Correct Answer Rationale:
A closed psychotherapy group has a defined membership, with members entering the group at the beginning and remaining together for the planned period of therapy. This stable membership can help the group develop trust, cohesion, and continuity.
A closed psychotherapy group has a defined membership, with members entering the group at the beginning and remaining together for the planned period of therapy. This stable membership can help the group develop trust, cohesion, and continuity.
✕ Why Other Options Are Incorrect:
B. Open:
An open group allows new members to join and existing members to leave during the course of the group.
C. Homogenous:
Refers to a group whose members share important characteristics, rather than describing when members join.
D. Heterogeneous:
Refers to a group composed of members with different characteristics or backgrounds.
Q28. A nurse is assessing a stroke patient’s ability to bathe, dress, and eat independently. These functions are referred to as:
✓ Correct Answer Rationale:
Bathing, dressing, eating, toileting, grooming, and transferring are examples of basic activities of daily living (ADLs). Assessing these functions helps the nurse determine how independently a patient can perform essential self-care activities.
Bathing, dressing, eating, toileting, grooming, and transferring are examples of basic activities of daily living (ADLs). Assessing these functions helps the nurse determine how independently a patient can perform essential self-care activities.
✕ Why Other Options Are Incorrect:
B. Performing medical procedures:
Medical procedures are clinical interventions and are not classified as basic ADLs.
C. Determine the condition of internal organs:
This describes diagnostic assessment rather than a patient’s ability to perform daily self-care.
D. Interaction and involvement of society and community:
These relate more to social participation and instrumental or community-level functioning than basic self-care.
Q29. Pancreatic enzyme replacement therapy is indicated in which of the following conditions?
✓ Correct Answer Rationale:
Pancreatic enzyme replacement therapy is used when the pancreas does not produce enough digestive enzymes. Chronic pancreatitis and cystic fibrosis can cause exocrine pancreatic insufficiency, leading to poor digestion and malabsorption of fats, proteins, and carbohydrates. Enzyme replacement helps improve nutrient absorption and reduce symptoms such as steatorrhea.
Pancreatic enzyme replacement therapy is used when the pancreas does not produce enough digestive enzymes. Chronic pancreatitis and cystic fibrosis can cause exocrine pancreatic insufficiency, leading to poor digestion and malabsorption of fats, proteins, and carbohydrates. Enzyme replacement helps improve nutrient absorption and reduce symptoms such as steatorrhea.
✕ Why Other Options Are Incorrect:
A. Ulcerative colitis:
Is an inflammatory bowel disease and is not routinely treated with pancreatic enzyme replacement.
B. Appendicitis:
Requires assessment and treatment of the inflamed appendix rather than pancreatic enzyme replacement.
D. Peptic ulcer disease:
Is generally managed with measures such as acid suppression and treatment of Helicobacter pylori when present, not pancreatic enzymes.
Q30. Which of the following diseases is characterised by bone decalcification and the development of renal calculi containing calcium?
✓ Correct Answer Rationale:
Hyperparathyroidism causes excessive secretion of parathyroid hormone (PTH), which increases calcium release from bones and raises blood calcium levels. The excess calcium can contribute to the formation of calcium-containing renal calculi.
Hyperparathyroidism causes excessive secretion of parathyroid hormone (PTH), which increases calcium release from bones and raises blood calcium levels. The excess calcium can contribute to the formation of calcium-containing renal calculi.
✕ Why Other Options Are Incorrect:
A. Grave’s disease:
This is a form of hyperthyroidism and is not primarily characterised by bone decalcification with calcium renal calculi.
B. Hypo-parathyroidism:
Low PTH levels generally decrease blood calcium levels and do not typically cause this combination of bone decalcification and calcium stones.
D. Myxedema:
Myxedema results from severe hypothyroidism and is not characterised by hypercalcemia with calcium renal calculi.
Q31. Which substance mainly accumulates in the alveolar spaces during the exudative phase of ARDS?
✓ Correct Answer Rationale:
During the exudative phase of ARDS, increased alveolar-capillary permeability allows protein-rich fluid and cellular debris to enter the alveolar spaces. This interferes with normal gas exchange.
During the exudative phase of ARDS, increased alveolar-capillary permeability allows protein-rich fluid and cellular debris to enter the alveolar spaces. This interferes with normal gas exchange.
✕ Why Other Options Are Incorrect:
A. Epithelial cells form a regenerative layer:
Regeneration is associated with later repair phases rather than the initial exudative phase.
B. Air, causing barotrauma and alveolar rupture:
Air trapping and barotrauma are complications of ventilation, not the characteristic alveolar accumulation in early ARDS.
C. White blood cells, forming microabscesses:
WBCs participate in the inflammatory response, but microabscess formation is not the defining alveolar finding in ARDS.
Q32. A patient presents with gastrointestinal symptoms. Stool culture reveals comma-shaped bacteria. Which morphological classification should be considered when assessing the causative agent?
✓ Correct Answer Rationale:
Vibrios are curved, comma-shaped bacteria. Vibrio cholerae is the classic example and causes cholera with prominent gastrointestinal symptoms.
Vibrios are curved, comma-shaped bacteria. Vibrio cholerae is the classic example and causes cholera with prominent gastrointestinal symptoms.
✕ Why Other Options Are Incorrect:
A. Cocci:
Cocci are spherical or round bacteria rather than comma-shaped organisms.
B. Spirilla:
Spirilla have a rigid spiral or helical shape and are not typically described as comma-shaped.
C. Bacilli:
Bacilli are rod-shaped bacteria, generally appearing as straight or slightly curved rods.
Q33. A 24-year-old college student presents with sudden onset fever, headache, and a petechial rash. Cerebrospinal fluid shows gram-negative diplococci. Which organism is most likely responsible for his condition?
✓ Correct Answer Rationale:
Neisseria meningitidis is a gram-negative diplococcus that can cause meningococcal meningitis. Fever, headache, and a petechial rash are characteristic clinical features.
Neisseria meningitidis is a gram-negative diplococcus that can cause meningococcal meningitis. Fever, headache, and a petechial rash are characteristic clinical features.
✕ Why Other Options Are Incorrect:
B. Acinetobacter baumannii:
This is a gram-negative coccobacillus associated mainly with healthcare-associated infections, not the classic meningococcal presentation.
C. Moraxella catarrhalis:
Although it is a gram-negative diplococcus, it is primarily associated with respiratory infections rather than meningococcal meningitis.
D. Escherichia coli:
E. coli is a gram-negative bacillus and does not have the diplococcal morphology described here.
Q34. A persistent craving to eat non-nutritive, non-edible items is known as:
✓ Correct Answer Rationale:
Pica is characterized by persistent eating of substances that have little or no nutritional value, such as soil, chalk, or paper. It can occur in children and during pregnancy.
Pica is characterized by persistent eating of substances that have little or no nutritional value, such as soil, chalk, or paper. It can occur in children and during pregnancy.
✕ Why Other Options Are Incorrect:
B. Enuresis:
Enuresis refers to involuntary urination, usually during sleep in children.
C. Encopresis:
Encopresis is the repeated passage of stool in inappropriate places, often in a child beyond the expected age for bowel control.
D. Somnambulism:
Somnambulism is sleepwalking, in which a person performs activities while partially aroused from sleep.
Q35. First heart sound (S1) is due to closure of:
✓ Correct Answer Rationale:
S1, the first heart sound or “lub,” occurs when the atrioventricular valves—the mitral and tricuspid valves—close at the beginning of ventricular systole.
S1, the first heart sound or “lub,” occurs when the atrioventricular valves—the mitral and tricuspid valves—close at the beginning of ventricular systole.
✕ Why Other Options Are Incorrect:
A. Aortic & Pulmonic valves:
These semilunar valves close at the end of systole and contribute to S2, not S1.
C. Pulmonic & Mitral valves:
This combination includes one semilunar and one atrioventricular valve and does not produce S1.
D. Aortic & Tricuspid valves:
The aortic valve contributes to S2, while tricuspid valve closure contributes to S1.
Q36. Which antiplatelet agent is preferred for stroke prevention in patients with aspirin intolerance?
✓ Correct Answer Rationale:
Clopidogrel inhibits ADP-mediated platelet aggregation and is commonly used as an alternative antiplatelet agent when aspirin cannot be tolerated.
Clopidogrel inhibits ADP-mediated platelet aggregation and is commonly used as an alternative antiplatelet agent when aspirin cannot be tolerated.
✕ Why Other Options Are Incorrect:
A. Tirofiban:
Tirofiban is a glycoprotein IIb/IIIa inhibitor primarily used in acute coronary syndromes rather than routine secondary stroke prevention.
B. Abciximab:
Abciximab is another glycoprotein IIb/IIIa inhibitor mainly used in selected acute coronary interventions.
C. Ticlopidine:
Ticlopidine is a thienopyridine antiplatelet drug, but its use has largely been replaced by clopidogrel because of safety and tolerability concerns.
Q37. A child born to an HBsAg positive mother should receive the first dose of hepatitis B vaccine:
✓ Correct Answer Rationale:
A newborn of an HBsAg-positive mother should receive hepatitis B vaccine promptly at birth, along with hepatitis B immune globulin when indicated, to reduce the risk of perinatal transmission.
A newborn of an HBsAg-positive mother should receive hepatitis B vaccine promptly at birth, along with hepatitis B immune globulin when indicated, to reduce the risk of perinatal transmission.
✕ Why Other Options Are Incorrect:
B. Within 1–2 months after birth:
Waiting this long would miss the important window for preventing perinatal hepatitis B transmission.
C. Between ages of 1 and 4 months:
This is too late for the initial birth prophylaxis required for an infant exposed to maternal hepatitis B infection.
D. Between 6 and 18 months:
Delaying the first dose until this age would leave the newborn unprotected during the period of greatest concern for perinatal transmission.
Q38. A nurse is preparing to feed a patient who has difficulty swallowing. Which approach is most appropriate to promote safety and adequate nutrition?
✓ Correct Answer Rationale:
A patient with dysphagia should be fed slowly with small bites, allowing adequate time to chew and swallow. This approach helps reduce choking and aspiration risk.
A patient with dysphagia should be fed slowly with small bites, allowing adequate time to chew and swallow. This approach helps reduce choking and aspiration risk.
✕ Why Other Options Are Incorrect:
B. Serve all food together and feed rapidly:
Rapid feeding can overwhelm a patient with dysphagia and increase the risk of choking or aspiration.
C. Provide only liquid foods to speed up feeding:
Thin liquids may be difficult for some patients with dysphagia and can increase aspiration risk.
D. Encourage talking during swallowing:
Talking while swallowing can interfere with coordinated swallowing and increase the risk of aspiration.
Q39. A patient undergoing warfarin therapy is monitored using prothrombin time because warfarin affects which part of the coagulation cascade?
✓ Correct Answer Rationale:
Warfarin reduces the synthesis of vitamin K-dependent clotting factors, including factor VII. Because factor VII is part of the extrinsic pathway, PT and INR are used to monitor warfarin therapy.
Warfarin reduces the synthesis of vitamin K-dependent clotting factors, including factor VII. Because factor VII is part of the extrinsic pathway, PT and INR are used to monitor warfarin therapy.
✕ Why Other Options Are Incorrect:
A. Common pathway:
The common pathway is shared by both intrinsic and extrinsic pathways and is not the primary reason PT is used for warfarin monitoring.
C. Fibrinolytic pathway:
Fibrinolysis involves breakdown of established clots through plasmin rather than the clotting cascade monitored by PT.
D. Intrinsic pathway:
The intrinsic pathway is more directly assessed by aPTT, which is commonly used to monitor unfractionated heparin.
Q40. What is generally indicated by a MUAC measurement of less than 115 mm in a child?
✓ Correct Answer Rationale:
In children aged 6–59 months, a MUAC below 115 mm indicates severe acute malnutrition and requires prompt nutritional assessment and appropriate management.
In children aged 6–59 months, a MUAC below 115 mm indicates severe acute malnutrition and requires prompt nutritional assessment and appropriate management.
✕ Why Other Options Are Incorrect:
B. Moderate malnutrition:
Moderate acute malnutrition is generally associated with a higher MUAC range than the severe malnutrition threshold.
C. Normal nutritional status:
A MUAC below 115 mm is well below the threshold used to identify severe acute malnutrition in this age group.
D. Overweight or obesity:
A very low MUAC reflects inadequate nutritional reserves rather than excess body weight.
Q41. In patients with diabetes mellitus, which complication is most closely linked to long-term poor glycemic control?
✓ Correct Answer Rationale:
Chronic hyperglycemia can progressively damage the renal glomerular microvasculature, leading to diabetic nephropathy and potentially chronic kidney disease.
Chronic hyperglycemia can progressively damage the renal glomerular microvasculature, leading to diabetic nephropathy and potentially chronic kidney disease.
✕ Why Other Options Are Incorrect:
A. Pulmonary fibrosis:
Pulmonary fibrosis is not a typical microvascular complication directly associated with long-term diabetes.
C. Gastric ulcer:
Gastric ulcers have several causes, particularly Helicobacter pylori infection and NSAID use, rather than being a classic diabetic complication.
D. Asthma:
Asthma is a chronic airway disorder and is not a characteristic complication of poor glycemic control.
Q42. A pediatric nurse is assessing a 3-year-old child who is starting to express a sense of independence and self-control, insists on feeding herself, and shows curiosity about new objects. Which psychosocial developmental stage is most relevant in this situation?
✓ Correct Answer Rationale:
Erikson’s autonomy vs. shame and doubt stage occurs approximately from 1–3 years. Children develop independence through activities such as self-feeding, dressing, and toilet training.
Erikson’s autonomy vs. shame and doubt stage occurs approximately from 1–3 years. Children develop independence through activities such as self-feeding, dressing, and toilet training.
✕ Why Other Options Are Incorrect:
A. Intimacy vs. Isolation:
This stage occurs during young adulthood and focuses on forming close relationships.
B. Generativity vs. Stagnation:
This stage occurs during middle adulthood and involves productivity, caregiving, and contributing to society.
C. Integrity vs. Despair:
This is associated with later adulthood, when individuals reflect on their life experiences.
Q43. The nurse health educates middle-aged women to undergo which of the following test for screening of cervical cancer?
✓ Correct Answer Rationale:
A Pap smear is a cervical screening test used to identify precancerous and cancerous cellular changes, allowing abnormal findings to be evaluated and managed appropriately.
A Pap smear is a cervical screening test used to identify precancerous and cancerous cellular changes, allowing abnormal findings to be evaluated and managed appropriately.
✕ Why Other Options Are Incorrect:
A. Mantoux test:
The Mantoux test is used to assess exposure or infection with Mycobacterium tuberculosis.
B. Ultrasonography:
Ultrasound is useful for imaging pelvic organs and many other structures but is not the standard cytologic screening test for cervical cancer.
C. Fine needle aspiration cytology:
FNAC is primarily used to evaluate accessible masses or lesions and is not the routine cervical cancer screening method.
Q44. A nurse educator evaluates students’ performance in a skills laboratory. Which assessment method would best measure students’ ability to apply learned concepts to real patient care situations?
✓ Correct Answer Rationale:
Objective structured clinical examinations (OSCEs) use standardized clinical stations to assess practical skills and the student’s ability to apply knowledge in simulated patient-care situations.
Objective structured clinical examinations (OSCEs) use standardized clinical stations to assess practical skills and the student’s ability to apply knowledge in simulated patient-care situations.
✕ Why Other Options Are Incorrect:
A. Assigning written quizzes after each laboratory session:
Written quizzes mainly assess knowledge and recall rather than direct clinical performance.
C. Collecting feedback from students about their experience:
Student feedback provides information about learning experiences but does not directly measure clinical skill performance.
D. Observing students during traditional role play activities:
Role play can be useful for learning, but it may lack the standardized structure and objective scoring of an OSCE.
Q45. Rechanneling of socially unacceptable drives into constructive activities is called:
✓ Correct Answer Rationale:
Sublimation is a mature defense mechanism in which unacceptable impulses or drives are redirected into socially acceptable and constructive activities, such as channeling aggression into sports.
Sublimation is a mature defense mechanism in which unacceptable impulses or drives are redirected into socially acceptable and constructive activities, such as channeling aggression into sports.
✕ Why Other Options Are Incorrect:
A. Projection:
Projection involves attributing one’s own unacceptable thoughts or feelings to another person.
C. Hallucination:
A hallucination is a sensory perception occurring without an external stimulus and is not a defense mechanism.
D. Displacement:
Displacement involves redirecting an emotional response from its original target toward a safer or less threatening target.
Q46. The most common cause of diarrhea in hospitalized patients receiving antibiotics is:
✓ Correct Answer Rationale:
Clostridioides difficile infection can occur after antibiotic-associated disruption of normal intestinal flora. It may cause significant diarrhea and colitis.
Clostridioides difficile infection can occur after antibiotic-associated disruption of normal intestinal flora. It may cause significant diarrhea and colitis.
✕ Why Other Options Are Incorrect:
A. Salmonella:
Salmonella commonly causes foodborne gastroenteritis but is not the classic cause of antibiotic-associated diarrhea.
C. E. coli:
Certain strains of E. coli cause infectious diarrhea, but it is not the characteristic antibiotic-associated pathogen in hospitalized patients.
D. Giardia lamblia:
Giardia causes intestinal infection and malabsorption, but it is not the usual cause of diarrhea following antibiotic exposure.
Q47. A 58-year-old male with a history of smoking presents with chronic cough producing sputum for more than 3 months in 2 consecutive years. What is the most likely diagnosis?
✓ Correct Answer Rationale:
Chronic bronchitis is classically defined by a productive cough occurring for at least 3 months in each of two consecutive years. It is a form of COPD and is strongly associated with smoking.
Chronic bronchitis is classically defined by a productive cough occurring for at least 3 months in each of two consecutive years. It is a form of COPD and is strongly associated with smoking.
✕ Why Other Options Are Incorrect:
A. Bronchial asthma:
Asthma is characterized by variable and reversible airflow obstruction rather than the chronic productive cough definition given here.
C. Pulmonary embolism:
Pulmonary embolism typically presents with acute dyspnea, chest pain, and sometimes hemoptysis rather than a two-year pattern of productive cough.
D. Pneumothorax:
Pneumothorax usually produces sudden chest pain and dyspnea due to air entering the pleural space.
Q48. A preterm neonate with muscle twitching, seizures, cyanosis, abnormal respirations, and shrill cry is suspected to have:
✓ Correct Answer Rationale:
Intracranial hemorrhage is an important complication in premature neonates. Neurological signs may include seizures, abnormal respirations, changes in muscle tone, and a high-pitched or shrill cry.
Intracranial hemorrhage is an important complication in premature neonates. Neurological signs may include seizures, abnormal respirations, changes in muscle tone, and a high-pitched or shrill cry.
✕ Why Other Options Are Incorrect:
A. Brachial palsy:
Brachial plexus injury primarily causes weakness or paralysis of the affected upper limb rather than seizures and abnormal respirations.
B. Dislocate hip:
Hip dislocation would mainly produce abnormal hip positioning or limited movement and would not explain the neurological symptoms described.
D. Fractured hip:
A hip fracture would cause localized pain and movement limitation rather than the generalized neurological findings described.
Q49. A nurse is caring for a child with nephrotic syndrome. Which of the following is the priority nursing intervention?
✓ Correct Answer Rationale:
Daily weight provides a sensitive way to monitor changes in fluid balance. Rapid increases in weight can indicate worsening fluid retention in a child with nephrotic syndrome.
Daily weight provides a sensitive way to monitor changes in fluid balance. Rapid increases in weight can indicate worsening fluid retention in a child with nephrotic syndrome.
✕ Why Other Options Are Incorrect:
A. Monitoring urine specific gravity:
Specific gravity can provide useful information but does not measure overall fluid gain or loss as directly as daily weight.
C. Restricting fluids:
Fluid restriction is not automatically required for every child with nephrotic syndrome and should depend on the child’s clinical condition and prescribed plan.
D. Encouraging high salt intake:
High sodium intake can worsen edema and fluid retention and is therefore generally avoided.
Q50. A patient with acute myocardial infarction complains of severe chest pain. Which drug is the first line of management?
✓ Correct Answer Rationale:
Morphine can be used for severe pain associated with acute myocardial infarction when appropriate, particularly when pain remains severe despite initial measures. It provides analgesia and may reduce sympathetic stress.
Morphine can be used for severe pain associated with acute myocardial infarction when appropriate, particularly when pain remains severe despite initial measures. It provides analgesia and may reduce sympathetic stress.
✕ Why Other Options Are Incorrect:
B. Digoxin:
Digoxin is used for selected heart failure and certain atrial arrhythmias, not as the routine first-line treatment for acute MI pain.
C. Furosemide:
Furosemide is a loop diuretic used primarily when fluid overload or pulmonary edema is present.
D. Atropine:
Atropine is used for symptomatic bradycardia and is not a routine analgesic treatment for acute MI.
Q51. Softening of the cervix during pregnancy is termed as:
✓ Correct Answer Rationale:
Goodell’s sign refers to softening of the cervix during early pregnancy due to increased vascularity and hormonal changes.
Goodell’s sign refers to softening of the cervix during early pregnancy due to increased vascularity and hormonal changes.
✕ Why Other Options Are Incorrect:
A. Jacquemier’s sign:
This refers to bluish or purplish discoloration of the vaginal mucosa associated with increased pelvic vascularity.
B. Osiander’s sign:
Osiander’s sign refers to increased pulsation felt in the lateral vaginal fornices during pregnancy.
D. Hegar’s sign:
Hegar’s sign is softening and compressibility of the lower uterine segment rather than the cervix itself.
Q52. A nurse notices that a patient receiving IV blood transfusion develops chills, fever, and back pain within 15 minutes. What should the nurse do first?
✓ Correct Answer Rationale:
Chills, fever, and back pain occurring shortly after starting a transfusion can indicate an acute hemolytic transfusion reaction. The transfusion should be stopped immediately to prevent further exposure.
Chills, fever, and back pain occurring shortly after starting a transfusion can indicate an acute hemolytic transfusion reaction. The transfusion should be stopped immediately to prevent further exposure.
✕ Why Other Options Are Incorrect:
A. Slow down the infusion:
Slowing the transfusion still exposes the patient to the suspected incompatible blood and is not appropriate.
C. Administer antihistamine:
Antihistamines may be used for certain mild allergic reactions but do not address a suspected hemolytic reaction.
D. Collect urine sample:
A urine sample may be collected later as part of the investigation, but stopping the transfusion is the immediate priority.
Q53. A patient is very restless while receiving IV fluids to treat dehydration. The IV catheter has slipped out of the vein and fluid is delivered to the surrounding tissues under the skin, causing swelling. Which term best describes this occurrence?
✓ Correct Answer Rationale:
Infiltration occurs when a non-vesicant IV solution escapes from the vein into the surrounding tissue. It commonly causes swelling, coolness, and discomfort around the IV site.
Infiltration occurs when a non-vesicant IV solution escapes from the vein into the surrounding tissue. It commonly causes swelling, coolness, and discomfort around the IV site.
✕ Why Other Options Are Incorrect:
A. Infection:
Infection involves microbial contamination and inflammation at the IV site rather than simple leakage of IV fluid into tissue.
B. Fluid overload:
Fluid overload is a systemic excess of fluid, not localized leakage around an IV catheter.
D. Extravasation:
Extravasation specifically refers to leakage of a vesicant or irritant medication into surrounding tissue, whereas ordinary IV fluid leakage is termed infiltration.
Q54. When caring for a patient with lower limb paralysis, which nursing intervention best prevents venous thromboembolism?
✓ Correct Answer Rationale:
Compression stockings can promote venous return and reduce venous stasis in the lower limbs, helping decrease the risk of venous thromboembolism in patients with limited mobility.
Compression stockings can promote venous return and reduce venous stasis in the lower limbs, helping decrease the risk of venous thromboembolism in patients with limited mobility.
✕ Why Other Options Are Incorrect:
B. Restricting the movement of the leg:
Further restriction of movement promotes venous stasis and can increase thromboembolic risk.
C. Encouraging oral fluid intake:
Adequate hydration may be helpful when appropriate, but it does not provide the same mechanical reduction in venous stasis as compression therapy.
D. Providing complete bed rest:
Prolonged immobility increases venous stasis and therefore increases the risk of DVT.
Q55. Temperature of 98.7°F is approximately equal to _____ degree Celsius:
✓ Correct Answer Rationale:
Using the formula °C = (°F − 32) × 5/9, 98.7°F converts to approximately 37.06°C.
Using the formula °C = (°F − 32) × 5/9, 98.7°F converts to approximately 37.06°C.
✕ Why Other Options Are Incorrect:
A. 38.16:
This value is higher than the Celsius equivalent of 98.7°F.
B. 37.56:
This is slightly higher than the calculated conversion of 98.7°F.
C. 36.52:
This value is lower than the correct Celsius conversion.
Q56. Which of the following is NOT a critical reason for the documentation of the medication administration in the drug chart?
✓ Correct Answer Rationale:
Medication documentation does not replace infection-control practices such as hand hygiene. Handwashing must still be performed before medication administration as required.
Medication documentation does not replace infection-control practices such as hand hygiene. Handwashing must still be performed before medication administration as required.
✕ Why Other Options Are Incorrect:
B. Reducing the potential for error and duplicate doses:
Accurate documentation helps the healthcare team determine what medication has already been administered.
C. Ensuring the most accurate record of care:
Medication records provide an important and accurate account of treatments given to the patient.
D. Alerting to changes in the patient’s condition:
Medication records and related observations can help identify responses or changes that require further assessment.
Q57. A patient admitted with atrial fibrillation is receiving anticoagulant therapy. Which primary nursing intervention should be implemented to minimize the risk of complications?
✓ Correct Answer Rationale:
Anticoagulants reduce clot formation but increase bleeding risk. The nurse should monitor for bleeding, assess vital signs, and watch for other signs of anticoagulant-related complications.
Anticoagulants reduce clot formation but increase bleeding risk. The nurse should monitor for bleeding, assess vital signs, and watch for other signs of anticoagulant-related complications.
✕ Why Other Options Are Incorrect:
A. Administer analgesics as prescribed and observe for pain relief:
Pain management may be appropriate but does not directly address the major complication of anticoagulant therapy.
B. Promote early ambulation and assess for muscle strength:
Mobility assessment can be useful, but it is not the primary intervention for preventing anticoagulant-related bleeding.
D. Encourage deep breathing exercises and monitor oxygen saturation:
These measures can support respiratory care but do not specifically monitor the principal complication of anticoagulation.
Q58. Which clinical feature is expected in a child with Kawasaki disease during the acute phase?
✓ Correct Answer Rationale:
Kawasaki disease commonly causes mucosal changes such as a strawberry tongue, along with prolonged fever, red cracked lips, conjunctival changes, rash, and lymphadenopathy.
Kawasaki disease commonly causes mucosal changes such as a strawberry tongue, along with prolonged fever, red cracked lips, conjunctival changes, rash, and lymphadenopathy.
✕ Why Other Options Are Incorrect:
B. Oliguria:
Oliguria is not a characteristic acute clinical feature of Kawasaki disease.
C. Koplik spots:
Koplik spots are classically associated with measles.
D. Vesicular rash:
A vesicular rash is more characteristic of infections such as varicella rather than Kawasaki disease.
Q59. What term describes a condition in which a patient perceives his/her face distorted and legs shortened?
✓ Correct Answer Rationale:
Depersonalization involves an altered or distorted perception of oneself or one’s body, sometimes producing feelings of detachment or unfamiliarity with one’s own body.
Depersonalization involves an altered or distorted perception of oneself or one’s body, sometimes producing feelings of detachment or unfamiliarity with one’s own body.
✕ Why Other Options Are Incorrect:
A. Illusion:
An illusion is a misinterpretation of an actual external sensory stimulus.
B. Hallucination:
A hallucination is a sensory perception that occurs without an appropriate external stimulus.
D. Denationalization:
This is not the psychiatric term used to describe an altered perception of one’s own body or self.
Q60. Blisters are mainly seen in:
✓ Correct Answer Rationale:
Second-degree, or partial-thickness, burns commonly produce fluid-filled blisters because the injury involves the epidermis and part of the dermis.
Second-degree, or partial-thickness, burns commonly produce fluid-filled blisters because the injury involves the epidermis and part of the dermis.
✕ Why Other Options Are Incorrect:
A. 1st degree burn:
First-degree burns primarily affect the epidermis and usually cause redness and pain without blisters.
C. 3rd degree burn:
Full-thickness burns destroy the epidermis and dermis and often have a dry, leathery appearance rather than typical intact blisters.
D. 4th degree burn:
Fourth-degree burns extend into deeper tissues such as muscle or bone and involve extensive tissue destruction.
Q61. A patient is taking cyclophosphamide for the treatment of lymphoma. The nurse is very cautious while administering the medication because this drug poses a fatal side effect of…..?
✓ Correct Answer Rationale:
Cyclophosphamide can cause hemorrhagic cystitis because its metabolite acrolein irritates the bladder lining. Adequate hydration and, in appropriate regimens, mesna can help reduce this risk.
Cyclophosphamide can cause hemorrhagic cystitis because its metabolite acrolein irritates the bladder lining. Adequate hydration and, in appropriate regimens, mesna can help reduce this risk.
✕ Why Other Options Are Incorrect:
A. Alopecia:
Hair loss is a recognized adverse effect of cyclophosphamide, but it is not the characteristic serious bladder toxicity described here.
B. Myeloma:
Myeloma is a malignancy, not an adverse effect caused by cyclophosphamide.
C. CNS toxicity:
CNS toxicity is not the characteristic dose-limiting adverse effect associated with cyclophosphamide in this context.
Q62. What is the therapeutic level of digoxin?
✓ Correct Answer Rationale:
The commonly cited therapeutic serum digoxin range is 0.5–2 ng/mL. Clinical interpretation should also consider the patient’s symptoms, renal function, age, and other factors because toxicity can occur even within a reported range.
The commonly cited therapeutic serum digoxin range is 0.5–2 ng/mL. Clinical interpretation should also consider the patient’s symptoms, renal function, age, and other factors because toxicity can occur even within a reported range.
✕ Why Other Options Are Incorrect:
B. 5–10 ng/mL:
These concentrations are well above the usual therapeutic range and are associated with a significant risk of toxicity.
C. 1.5–3.5 ng/mL:
This range extends above the commonly accepted therapeutic concentration for digoxin.
D. 2.5–5 ng/mL:
These concentrations are above the usual therapeutic range and may indicate potentially toxic exposure.
Q63. A probable sign of pregnancy in which there is bluish/violet blue or purplish discoloration of cervix and vaginal wall is known as:
✓ Correct Answer Rationale:
Chadwick’s sign is the bluish or purplish discoloration of the cervix and vaginal mucosa caused by increased pelvic vascularity during pregnancy.
Chadwick’s sign is the bluish or purplish discoloration of the cervix and vaginal mucosa caused by increased pelvic vascularity during pregnancy.
✕ Why Other Options Are Incorrect:
B. Goodell’s sign:
Goodell’s sign refers to softening of the cervix during early pregnancy.
C. Hegar’s sign:
Hegar’s sign describes softening and compressibility of the lower uterine segment.
D. Osiander’s sign:
Osiander’s sign refers to increased pulsation felt in the lateral vaginal fornices.
Q64. Which cardiac rhythm is a medical emergency requiring immediate defibrillation?
✓ Correct Answer Rationale:
Ventricular fibrillation is a pulseless, chaotic ventricular rhythm that prevents effective cardiac output. It is a shockable rhythm requiring immediate defibrillation along with CPR.
Ventricular fibrillation is a pulseless, chaotic ventricular rhythm that prevents effective cardiac output. It is a shockable rhythm requiring immediate defibrillation along with CPR.
✕ Why Other Options Are Incorrect:
B. Atrial flutter:
Atrial flutter is an atrial arrhythmia and is not treated with immediate defibrillation as the standard response to a pulseless shockable rhythm.
C. Sinus tachycardia:
Sinus tachycardia usually has an identifiable underlying cause and is managed by addressing that cause.
D. Premature atrial contraction:
An isolated PAC is generally not a shockable rhythm and usually does not require defibrillation.
Q65. How many drops per minute would you administer when the doctor’s order states that the client should receive 1000 cc of fluid for 8 hours and the IV set delivers 20 gtts per cc?
✓ Correct Answer Rationale:
Use the formula: IV rate = (Volume × Drop factor) ÷ Time in minutes. Therefore, (1000 × 20) ÷ (8 × 60) = 41.67, which is rounded to 42 gtts/min.
Use the formula: IV rate = (Volume × Drop factor) ÷ Time in minutes. Therefore, (1000 × 20) ÷ (8 × 60) = 41.67, which is rounded to 42 gtts/min.
✕ Why Other Options Are Incorrect:
A. 48 gtts:
This rate is higher than the calculated flow rate of approximately 42 gtts/min.
B. 51 gtts:
This value does not result from the given volume, time, and drop factor.
D. 31 gtts:
This rate is lower than the calculated requirement for the prescribed infusion.
Q66. What is the antidote for acetaminophen overdose?
✓ Correct Answer Rationale:
Acetylcysteine is the specific antidotal treatment for acetaminophen overdose. It helps restore glutathione availability and reduces the risk of serious hepatic injury.
Acetylcysteine is the specific antidotal treatment for acetaminophen overdose. It helps restore glutathione availability and reduces the risk of serious hepatic injury.
✕ Why Other Options Are Incorrect:
A. Flumazenil:
Flumazenil is used to reverse the effects of benzodiazepines in selected situations.
C. Naloxone:
Naloxone is an opioid antagonist used to reverse opioid-induced respiratory and central nervous system depression.
D. Atropine:
Atropine is an anticholinergic medication used in conditions such as symptomatic bradycardia and certain poisonings.
Q67. The cord that is inserted into the membranes some distance from the edge of placenta is:
✓ Correct Answer Rationale:
In velamentous cord insertion, the umbilical cord inserts into the fetal membranes rather than directly into the placental disc. The exposed vessels then travel through the membranes toward the placenta.
In velamentous cord insertion, the umbilical cord inserts into the fetal membranes rather than directly into the placental disc. The exposed vessels then travel through the membranes toward the placenta.
✕ Why Other Options Are Incorrect:
B. Battledore insertion of cord:
Battledore insertion refers to marginal insertion of the umbilical cord at or very near the placental edge.
C. Succenturiate placenta:
A succenturiate placenta has one or more accessory placental lobes separate from the main placental disc.
D. Circumvallate placenta:
Circumvallate placenta is a placental morphological abnormality involving the chorionic plate and surrounding membranes.
Q68. Normal level of fasting blood sugar:
✓ Correct Answer Rationale:
The provided reference range for this question is 70–110 mg/dL for fasting blood glucose. Fasting glucose is measured after an adequate period without food and is used to assess glucose regulation.
The provided reference range for this question is 70–110 mg/dL for fasting blood glucose. Fasting glucose is measured after an adequate period without food and is used to assess glucose regulation.
✕ Why Other Options Are Incorrect:
B. 100–120 mg/dl:
This range starts above the lower end of the reference range used in the question.
C. 60–180 mg/dl:
This range is too broad and includes values that may represent hypoglycemia or hyperglycemia.
D. 120–160 mg/dl:
These values are above the reference range given for normal fasting blood glucose.
Q69. Health education on lifestyle modification to prevent hypertension is an example of which level of prevention?
✓ Correct Answer Rationale:
Primary prevention aims to prevent a disease before it develops. Lifestyle education about healthy diet, physical activity, weight control, and smoking cessation can reduce the risk of hypertension.
Primary prevention aims to prevent a disease before it develops. Lifestyle education about healthy diet, physical activity, weight control, and smoking cessation can reduce the risk of hypertension.
✕ Why Other Options Are Incorrect:
A. Secondary:
Secondary prevention focuses on early detection and treatment of disease, such as screening and prompt management.
B. Quaternary:
Quaternary prevention focuses on protecting patients from unnecessary or potentially harmful medical interventions.
D. Tertiary:
Tertiary prevention aims to reduce complications and disability after a disease has already developed.
Q70. All of the following are included in DSM-5 diagnostic criteria for intellectual disabilities, EXCEPT:
✓ Correct Answer Rationale:
Physical abnormalities are not required for a diagnosis of intellectual disability. The core DSM-5 criteria involve deficits in intellectual functioning, deficits in adaptive functioning, and onset during the developmental period.
Physical abnormalities are not required for a diagnosis of intellectual disability. The core DSM-5 criteria involve deficits in intellectual functioning, deficits in adaptive functioning, and onset during the developmental period.
✕ Why Other Options Are Incorrect:
A. The onset is during childhood:
Intellectual disability must have its onset during the developmental period, although the wording is broader than childhood alone.
C. Deficits in intellectual functioning:
Deficits in reasoning, problem-solving, learning, and related intellectual abilities are a core diagnostic criterion.
D. Deficits in adaptive functioning:
Impairment in adaptive functioning is a core part of the diagnosis and affects conceptual, social, or practical functioning.
Q91. What is the correct formula for converting Fahrenheit into centigrade?
✓ Correct Answer Rationale:
To convert Fahrenheit to Celsius, subtract 32 from the Fahrenheit value and then multiply the result by 5/9. The formula is C = (F − 32) × 5/9.
To convert Fahrenheit to Celsius, subtract 32 from the Fahrenheit value and then multiply the result by 5/9. The formula is C = (F − 32) × 5/9.
✕ Why Other Options Are Incorrect:
A. C × 9 / 5 + 32:
This is used to convert Celsius to Fahrenheit, not Fahrenheit to Celsius.
B. F + 32 × 5 / 9:
The formula incorrectly adds 32 instead of subtracting it.
D. F – 32 × 9 / 5:
The conversion factor should be 5/9, not 9/5.
Q92. Widal, a serological test, is used to detect the presence of which pathogenic microorganism?
✓ Correct Answer Rationale:
The Widal test detects antibodies against Salmonella antigens and has traditionally been used as a serological test in suspected enteric (typhoid) fever.
The Widal test detects antibodies against Salmonella antigens and has traditionally been used as a serological test in suspected enteric (typhoid) fever.
✕ Why Other Options Are Incorrect:
A. E. coli:
E. coli is associated with several intestinal and urinary infections but is not the target of the Widal test.
B. Mycobacterium tuberculosis:
This bacterium causes tuberculosis and is evaluated using tests such as sputum examination or molecular testing.
C. Haemophilus influenzae:
This organism can cause respiratory and invasive infections but is not detected by the Widal test.
Q93. Which of the following disorders affects the joints and is characterized by inflammation, pain, and stiffness?
✓ Correct Answer Rationale:
Arthritis refers to disorders involving the joints and commonly causes pain, inflammation, swelling, stiffness, and restricted movement.
Arthritis refers to disorders involving the joints and commonly causes pain, inflammation, swelling, stiffness, and restricted movement.
✕ Why Other Options Are Incorrect:
A. Osteoporosis:
Osteoporosis primarily causes reduced bone density and increased fracture risk rather than joint inflammation.
C. Muscular dystrophy:
Muscular dystrophy is a group of inherited disorders characterized mainly by progressive muscle weakness.
D. Multiple sclerosis:
Multiple sclerosis is a disease of the central nervous system that can affect movement, sensation, and coordination.
Q94. Reason to perform naloxone challenge test on a client with opioid abuse?
✓ Correct Answer Rationale:
A naloxone challenge can be used to assess physical opioid dependence because naloxone may rapidly precipitate withdrawal in a physically dependent person. This is particularly relevant before certain opioid-antagonist treatments.
A naloxone challenge can be used to assess physical opioid dependence because naloxone may rapidly precipitate withdrawal in a physically dependent person. This is particularly relevant before certain opioid-antagonist treatments.
✕ Why Other Options Are Incorrect:
A. To check reaction of drug:
The test is not simply a general medication-reaction test; its purpose relates to opioid dependence and withdrawal.
B. To check patient interest:
Patient motivation or interest in treatment cannot be determined through a naloxone challenge.
C. To treat opioid abuse:
Naloxone is used for opioid overdose reversal, but a naloxone challenge is not itself a treatment for opioid use disorder.
Q95. In which type of schizophrenia is the patient’s motor behavior greatly disturbed?
✓ Correct Answer Rationale:
Catatonic schizophrenia is an older classification associated with prominent psychomotor abnormalities, including stupor, rigidity, posturing, negativism, or excessive motor activity.
Catatonic schizophrenia is an older classification associated with prominent psychomotor abnormalities, including stupor, rigidity, posturing, negativism, or excessive motor activity.
✕ Why Other Options Are Incorrect:
B. Residual schizophrenia:
This older subtype described patients with persistent residual symptoms after prominent acute symptoms had subsided.
C. Hebephrenic schizophrenia:
This older subtype was characterized mainly by disorganized thinking, speech, and behavior.
D. Paranoid schizophrenia:
This older subtype was primarily associated with prominent delusions and hallucinations, rather than marked motor abnormalities.
Q96. Term ‘Gossypiboma’ means?
✓ Correct Answer Rationale:
Gossypiboma refers to a mass or foreign-body reaction caused by a retained surgical textile, most commonly a sponge, left inside the body after surgery.
Gossypiboma refers to a mass or foreign-body reaction caused by a retained surgical textile, most commonly a sponge, left inside the body after surgery.
✕ Why Other Options Are Incorrect:
A. Tumor in head:
Gossypiboma is not a type of head tumor.
B. Tumor in abdomen:
Although gossypiboma can occur in the abdomen, the term refers to retained surgical material rather than an abdominal tumor.
D. During surgery, accidentally body organ damage inside the body:
Organ injury is a different surgical complication and does not describe a retained surgical sponge.
Q97. A major risk with IV potassium chloride is:
✓ Correct Answer Rationale:
IV potassium chloride must be diluted and administered at a controlled rate. Rapid or excessive administration can cause severe hyperkalemia, dangerous cardiac dysrhythmias, and potentially cardiac arrest.
IV potassium chloride must be diluted and administered at a controlled rate. Rapid or excessive administration can cause severe hyperkalemia, dangerous cardiac dysrhythmias, and potentially cardiac arrest.
✕ Why Other Options Are Incorrect:
A. Constipation:
Constipation is not the major immediate danger associated with IV potassium administration.
B. Hypertension:
Hypertension is not the characteristic life-threatening complication of excessive IV potassium.
D. Hypoglycemia:
Potassium administration does not directly produce hypoglycemia as its major adverse effect.
Q98. A nurse encounters a situation where a colleague consistently administers medications without following the double-check protocol for high-alert drugs. According to nursing practice standards, which is the most appropriate immediate action the nurse should take?
✓ Correct Answer Rationale:
High-alert medications carry a significant risk of serious harm if administered incorrectly. Repeated failure to follow required safety checks should be addressed promptly through the organization’s reporting and escalation process.
High-alert medications carry a significant risk of serious harm if administered incorrectly. Repeated failure to follow required safety checks should be addressed promptly through the organization’s reporting and escalation process.
✕ Why Other Options Are Incorrect:
A. Directly confront the colleague without documentation:
Speaking with a colleague may be appropriate in some situations, but bypassing required reporting processes is not sufficient for a recurring high-risk safety issue.
C. Ignore the behavior as long as no error occurs:
A near miss or unsafe practice can still place patients at risk and should not be ignored.
D. Wait for a formal review before taking action:
Delaying action can allow an unsafe practice to continue and potentially harm a patient.
Q99. When is the best time to perform breast self-examination?
✓ Correct Answer Rationale:
Traditionally, breast self-examination was taught a few days after menstruation ends, when breast tenderness and swelling are usually reduced and the breast tissue is easier to examine.
Traditionally, breast self-examination was taught a few days after menstruation ends, when breast tenderness and swelling are usually reduced and the breast tissue is easier to examine.
✕ Why Other Options Are Incorrect:
A. During menstruation:
Breast tenderness and swelling may make examination less comfortable and more difficult.
C. Before menstruation:
Hormonal changes before menstruation can increase breast fullness and tenderness.
D. Anytime in the cycle:
Traditional teaching recommends examining a few days after menstruation rather than choosing a random time in the cycle.
Q100. What indicator confirms that sterilization has occurred in an autoclave cycle?
✓ Correct Answer Rationale:
A color change in autoclave indicator tape shows that the package has been exposed to the specified sterilization conditions. However, chemical tape alone does not prove sterility; proper cycle monitoring also uses physical and, when required, biological indicators.
A color change in autoclave indicator tape shows that the package has been exposed to the specified sterilization conditions. However, chemical tape alone does not prove sterility; proper cycle monitoring also uses physical and, when required, biological indicators.
✕ Why Other Options Are Incorrect:
A. Warm chamber after cycle:
A warm chamber only indicates residual heat and does not confirm that sterilization conditions were adequately achieved.
B. Sound of the autoclave buzzer:
The buzzer signals completion of the programmed cycle but does not independently confirm sterilization.
C. Moist items after completion:
Moisture may indicate inadequate drying and does not confirm that sterilization has occurred.
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i scored 83 its a good try
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I scored 82…
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I got 54 score
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i scored 66/100 very educative
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I got 74, very important questions for every nursing exams point of view
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I score 75
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excellent mscq. For nursing exams preparation
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92
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i score 73. the question are veryhelpful for examination
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