NATIONAL AND STATE NURSING EXAM- MCQ _MG_00 135
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1. An adult client with HIV infections as been given a treatment with efavirenz. The nurse expects this drug to be given along with emtricitabine and tenofovir as a combination (Atripla). The reason for administering this combination is to:
a. Prevent development of psychiatric comorbidities
b. Avoid dizziness, sedation, and nightmares.
c. Reduce viral resistance
d. Control sever rash and hepatotoxicity.
Answer: c. Reduce viral resistance
Description:ATRIPLA is a fixed-dose combination table containing efavirenz, emtricitabines, and tenofovir. The actual reason for using combination products is to reduce viral resistance. Atripla is NOT approved for the treatment of chronic hepatitis B virus (HBV) infection.
2. A 35-year-old male patient complains of abdominal discomfort and bloating. On examination, the nurse found leakage of watery stool from his rectum. The nurse is aware that this could be a possible sign of:
a. Intussusception
b. Bowel incontinence
c. Fecal impaction
d. Constipation
Answer: c. Fecal impaction
Description:Fecal impaction is a severe bowel condition in which a hard, dry mass of stool gets stuck in the colon or rectum. Fecal impaction can be serious. Fecal impaction can cause a range of symptoms, which include liquid stool leaking from the rectum, pain or discomfort in the abdomen, nausea or vomiting, abdominal bloating and feeling of a need to push.
3. A patient is diagnosed with Crohn’s daises and colostomy was performed as an intervention. While assessing the new stoma, the nurse suspects that the stoma has retracted. Which of the following findings by the nurse would suggest that the stoma has retracted?
a. Narrowed and flattened stoma
b. Stoma appears pinkish red and moist
c. Concave and bowl-shaped stoma
d. Stoma appears reddish purple and dry
Answer: c. Concave and bowl-shaped stoma
Description:A retracted stoma has a concave, bowl-shaped appearance. Retraction cause a poor pouching surface, leading to frequent peristomal skin complication. A healthy stoma is pinkish- red and moist. A narrowed or constricted or flattened stoma is a sign of stenosis. Narrowing of the stoma is a late complication of a stoma. A dry and reddish-purple stoma indicates ischemia.
4. Nurse is preparing a 45-year-old male client for gastrectomy surgery. The patient apprehensively asked the nurse about the possible complication of gastrectomy. Which of the following response by the nurse is appropriate?
a. Dumping syndrome
b. Clay colored stool
c. Ribbon like stool
d. Jaundice
Answer: a. Dumping syndrome
Description:In dumping syndrome, the stomach empties its contents into the small intestine (duodenum) faster than normal. Dumping syndrome is also known as rapid gastric emptying. The sudden influx of food into the intestine causes a lot of fluid to move from bloodstream into intestine. This extra fluid causes diarrhea and bloating.
5. A 45-year-old patient with frequent GI disturbances is apprehensive about developing a colorectal cancer. He approached a nurse regarding dietary recommendation. Which of the following dietary recommendations is recommended to reduce the risk of developing colon cancer.
a. Take low-fiber and low-residual foods regularly
b. Avoid whole grain in the diet.
c. Add more green vegetables such as broccoli and cauliflower in the diet.
d. Take diet which is high in red meat.
Answer: c. Add more green vegetables such as broccoli and cauliflower in the diet.
Description:High-fiber diets that include lots of vegetables, fruits, and whole grains have been lined with a decreased risk of colon or rectal cancer. Increased consumption of red meat (lamb, beef and pork) is associated with risk of colorectal cancer.
6. Mr. X is a chronic alcoholic who comes to the outpatient department with complaints of weakness and anorexia. His physical assessment shows abdominal distention, dull pain in the right upper quadrant, pale conjunctiva, and hepatomegaly. The nurse understands which of the following.
a. Ultrasonography
b. Biopsy
c. Blood biochemistry
d. Colonoscopy
Answer: d. Colonoscopy
Description:The patient shows the clinical features related to liver disease, hence to confirm the condition USG, Biopsy and blood testing are relevant, whereas the colonoscopy is not relevant to diagnose the liver condition rather it is used to rule out the problems related to the large intestine.
7. The patient was diagnosed with stage II liver cancer. The priority nursing diagnosis for this patient is:
a. Fluid volume excess.
b. Imbalanced nutrition
c. Impaired skin integrity
d. Disturbed body image
Answer: b. Imbalanced nutrition
Description:A client with this condition is not able to digest and process the food materials and absorb the nutrient, hence he/she experiences weight loss and poor muscle tone. Thus, the priority nursing care plan should be focused on imbalanced nutrition which is less than the body requirements.
8. Mr. X, 27-year-old has fever and pain in the right upper quadrants that increases on eating fatty food and anorexia. She is recently diagnosed with cholelithiasis on abdominal ultrasound. The nurse explains to the patient food which she should avoid taking, is:
a. Potato
b. Rice
c. Bread
d. Cheese
Answer: d. Cheese
Description:The patients with cholelithiasis are advised not to take food with high fat content such as dairy products like butter, cheese and ghee and should avoid fried foods. Because these fatty foods will further worsen the condition and result in sever pain to the patient. Other listed food items are appropriate for the client to consume.
9. A male patient is admitted with Addison’s diseases. Laboratory test report reveal low aldosterone. The patient is on high doses of corticosteroids. The nurse is planning for a health teaching of corticosteroids. The nurse is planning for a health teaching on dietary modifications. The nurse is aware that following dietary modifications is NOT recommended for this patients.
a. High carbohydrate diet
b. Calcium rich food
c. Food rich in vitamin – D
d. Sodium restricted diet.
Answer: d. Sodium restricted diet.
Description:Sodium should not be restricted in patient with low aldosterone levels. A patient with Addison’s disease (adrenal insufficiency) needs to take adequate sodium to prevent excess fluid loss and to maintain electrolyte balance. High doses of corticosteroids are linked to a higher risk of osteoporosis, so calcium and vitamin D rich diet is recommended. The patient should be instructed to have diet rich in complex carbohydrates and protein.
10. A 58-year-old male patient with Chronic renal failure (CRF) is on hemodialysis. He is advised to do peritoneal dialysis at home. While teaching the patient about how to perform peritoneal dialysis, the nurse instructs to warm the dialyzing solution to 37℃. The primary reason behind warming the dialyzing solutions is to:
a. Remove the waste materials from body cells.
b. Relax the abdominal muscles.
c. Dilate peritoneal blood vessels.
d. Maintain a constant body temperature
Answer: c. Dilate peritoneal blood vessels.
Description:Warming the dialyzing solution to 37℃ helps in the dilation of peritoneal blood vessels, which improves the rate of urea clearance. Warmed solution also helps in prevention of cold sensations and maintains body temperature, however, the primary reasons is to dilated peritoneal blood vessels.
11. A 60-year-old female patient who is admitted for more than two weeks in intensive care unit has developed a pressure ulcer on the sacral region. The nurse assessed the site of pressure ulcer and observed that the would extends through the dermis into fatty subcutaneous tissue but the bone and tendons are not visible. Which of the following stages will the nurse assign this pressure ulcer?
a. Stage-I
b. Stage-II
c. Stage-III
d. Stage-IV
Answer: c. Stage-III
Description:Signs of stage-III wound: The wound extends through the dermis (second layer of skin) into the fatty subcutaneous (below the skin) tissue. Bone, tendon and muscle are not visible. Possible signs of infection include redness around the edge of the sore, pus, odor, fever, or greenish drainage from the sore and possible necrosis (black, dead tissue).
12. X, 30-year-old female, suffered with deep partial thickness burns on the front and back of both legs, and anterior trunk. Calculate the burn area using the ‘rule of nine’
a. 27%
b. 36%
c. 45%
d. 54%
Answer: d. 54%
Description:In the given patient, the burns had occurred over the front and back of the both legs, according to the Rule of nine, each completed leg occupies 18%, hence for the both legs it would be 36% and for the anterior trunk it covers 18%, hence the total burned area would be 36+18=54%
13. Which type of fluid should the nurse except to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?
a. Colloids
b. Crystalloids
c. Fresh-frozen plasma
d. Packed red blood cells
Answer: b. Crystalloids
Description:The person undergone burn injury needs a priority action of fluid resuscitation rather than providing blood products, hence the crystalloids such as Ringer’s lactate and NS should be administered for fluid resuscitation and the blood products like colloid are not appropriate for the fluid management.
14. The weight of Ms. X 63kg using Parkland Formula, the nurse calculates the total amount of Ringer’s lactate that will be given over the next 24 hours is:
a. 13, 608 mL
b. 12200 mL
c. 8635 mL
d. 6789 mL
Answer: a. 13, 608 mL
Description:Here the client’s weight is 63 kg, therefore, according to the parkland formula, 4 mL should be multiplied with the percentage of burned surface area (BSA) and the weight of the client, here the calculated BSA is 54% and the weight is 63 kg. therefore, it would be 4x54x63=13,608 mL fluid should be administered over next 24 hours. Out of this, half of the fluid needs to be administered in the first 8 hours and remaining half in the next 16 hours.
15. A 42-year-old woman with cancer of breast underwent mastectomy. A Jackson-Pratt drain is placed to help empty excess fluid from the wound site. After emptying a Jackson-Pratt bulb, the nurse needs to reestablish the negative pressure in the system. Which of the following actions is required to reestablish negative pressure?
a. Place the bulb lower the chest level
b. Fill the bulb with normal saline
c. Compress the bulb and open the valve.
d. Compress the bulb and close valve.
Answer: d. Compress the bulb and close valve.
Description:Jackson-Pratt drain is a type of surgical drain that is used to collect excess fluid from a wound site. The drain is made up of a tube that is inserted into the wound and a bulb that is attached to the tube. The bulb creates negative pressure in the system, which helps to draw fluid out of the wound. • After emptying a Jackson-Pratt bulb, it is important to reestablish the negative pressure in the system. This is done by compressing the bulb and closing the valve. Compressing the bulb forces air out of the system, creating negative pressure. Closing the valve prevents air from re-entering the system. • The other options are incorrect. Placing the bulb lower than the chest level will not create negative pressure. Filling the bulb with normal saline will not create negative pressure and may actually increase the risk of infection. Opening the valve will allow air to enter the system, which will negate the negative pressure. • It is important to note that the nurse should always follow the manufacturer's instructions when caring for a Jackson-Pratt drain
16. A 42 years-old women with cancer of breast underwent mastectomy. A Jackson-Pratt drain is placed to help empty excess fluid from the wound site. The nurse is aware that the Jackson-Pratt drain
a. 20 mL
b. 30 mL
c. 50 mL
d. 60 mL
Answer: b. 30 mL
Description:How long the Jackson-Pratt drain has to be inserted depends on the surgery and the amount of drainage. The Jackson-Pratt drain is usually removed when the drainage is 39 mL or less than 24 hours.
17. Nurse palliative care nurse, is providing nursing care to a terminally ill patient during the dying and grieving process. She is aware that the least important goal of nursing intervention in this client is:
a. Providing comfort measures.
b. Promotion of rest and sleep
c. Increase self-esteem through cosmetic improved
d. Pain management
Answer: c. Increase self-esteem through cosmetic improved
Description:The nursing interventions should target pain management through pain-reduction techniques and analgesia providing comfort measures, promotion of sleep and rest, and energy conservation for this patient. Through dying with dignity and self-esteem is important, increase of self-esteem through cosmetic improvement is not important for this client.
18. A 42-year-old woman is recovering from mastectomy. The patient has to be poisoned to promote the lymphatic fluid return. Which of the following position is inappropriate to promote lymphatic fluid return?
a. Semi-Fowler’s position.
b. Placing the affected arm on the pillow
c. Side-lying position on the unaffected side.
d. Turn the patient on the prone
Answer: c. Side-lying position on the unaffected side.
Description:Semi-Flower’s position (head of the bed 30 degrees) with the affected arm placed on the pillow promotes lymphatic fluid return. Side-lying position on the unaffected side will not promote lymphatic fluid return.
19. Nurse is taking care of a patient who has family history of colon cancer. The patient is anxious and afraid that she may develops a colon cancer. The patient states “My elder sister and father colon cancer. What would be chance that I will get colon cancer is near future? “Which of the following would be the best response by the nurse?
a. Take low-residual and low-fiber diet, then the chances will get decreased.
b. You don’t need to worry as this is an autosomal recessive disorder.
c. Prophylactic chemotherapy and surgery may be required in prevent you from developing colon cancer.
d. You should have colonoscopy done more frequently to find abnormal polys early.
Answer: d. You should have colonoscopy done more frequently to find abnormal polys early.
Description:People with history of colorectal cancer in first degree relative (parent, siblings or child) are at higher risk of developing colorectal cancer. So it is recommended to have frequent colonoscopy to find any abnormal polyps. This will help in early diagnosis. Recommendation of low-fiber and low-residual diet will increase the risk of colorectal caner. False assurance such as “you don’t need to worry†should be avoided. Prophylactic surgery is not performed to prevent cancer. It is a curative intervention.
20. A nurse is providing health education to patient receiving external beam radiation. Which of the following is NOT included in the health teaching?
a. Protect the skin from direct sunlight, chlorine, and extreme temperature.
b. Shave with an electric razor only
c. Apply good, scented cream to moisturize the sin
d. Wear loose-fitting clothes.
Answer: c. Apply good, scented cream to moisturize the sin
Description:After external radiation therapy, patients are not allowed to have direct contact with UV light and to use any creams or lotion or liquid over their skin. Hence, the nurse should not educate applying of any manual cream over their skin. Other statements are appropriate for teaching this client.
21. A long-term hemodialysis is planned for a 60-year-old male patient with end stage renal disease. He opted for an arteriovenous fistula for hemodialysis. Following surgical creation of AV fistula, how long the patient has to wait to use it for hemodialysis?
a. 2-3 weeks
b. 3-4 weeks
c. 2-3 months
d. 4-6 months
Answer: c. 2-3 months
Description:The arteriovenous fistula (AVF) remains the ‘gold standard’ access to hemodialysis showing better survival and lower complication rates the graft and catheters. However, fistulae are not readily usable after creation. The current guidelines suggest a minimum of 1 month and preferably 2-3 months before utilization of an AV fistula.
22. A factory worker is admitted with a fractured femur after fall from first floor. A full leg plaster cast is applied. The nurse provides discharge instructions for the patient. All of the following instructions are appropriate for this patient; EXCEPT:
a. Keep the limb raised on a soft surface, such a pillow.
b. Put an ice pack over the cast to avoid itching
c. Walk around on your cast as soon as you get home
d. Call your doctor if toes becomes number or turn blue.
Answer: c. Walk around on your cast as soon as you get home
Description:A patient with a full leg plaster cast should not walk on the cast until the doctor has cleared them to do so. Walking on the cast can put pressure on the fracture and slow down the healing process. The other instructions are all appropriate for a patient with a full leg plaster cast. Keeping the limb raised on a soft surface, such as a pillow, will help to reduce swelling. Putting an ice pack over the cast can help to reduce pain and swelling. Calling the doctor if toes become numb or turn blue is important because this could be a sign of a circulation problem. It is important to follow the doctor's instructions carefully after having a cast applied. This will help to ensure that the fracture heals properly and that there are no complications.
23. A client reported that he had foul smell from the cast. Which of the following actions by the nurse is most appropriate?
a. Advise the client to elevate the casted limb on pillow
b. Check pulse on casted limb
c. Preform balancing test
d. Notify the physician
Answer: d. Notify the physician
Description:Strong or persistent unpleasant odor may be a sign of a skin infection. This must be notified to the physician to determine if the cast should be changed.
24. After arthroscopy procedures cline reports increased knee pain for more than 3 days. Which of the following actions by the nurse is most appropriate?
a. Notify the physician
b. Advise the client to elevate the legs
c. Apply ice package on the site of pain
d. Explain the client that it is normal finding
Answer: a. Notify the physician
Description:One complication that has been lined to knee arthroscopy is a condition called spontaneous osteonecrosis of the knee, or SONK. After their surgery, they develop persistent pain typically along the inner (medial) side of the knee. SONK is a condition that cause inflammation within the bone. This needs to be notified to the physician for further treatment.
25. A 54-year-old woman who is on treatment for her osteoporosis is prescribed alendronate. The nurse is providing health education regarding self-administration of alendronate for this client. Which of the following instruction has to be included in the health teaching of this client?
a. Take the drug on an empty stomach with full glass of milk.
b. Always take the drug with food.
c. Take the drug on an empty stomach with full glass of water and stay upright for 30 minutes
d. Take the drug after breakfast
Answer: c. Take the drug on an empty stomach with full glass of water and stay upright for 30 minutes
Description:The drug alendronate will cause GI upset, so always administer this medication with full glass of water. The patient should take this drug on empty stomach in the morning at least 30 minutes before any food and food and stay upright for 30 minutes that will help in absorption of alendronate.
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