NATIONAL AND STATE NURSING EXAM- MCQ _MG_00 136
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1. Mr. X, 42-year—old male, is experiencing weakness in lower limbs, and bladder dysfunction due to prolapsed L1-L2 disc. The student nurse checks the doctor’s chart and found which surgery in planned to correct the prolapsed disc?
a. Burr hole
b. Laminectomy
c. Septoplasty
d. Decompressive hemicraniectomy.
Answer: b. Laminectomy
Description:The patient is diagnosed with prolapsed lumbar disc and the doctor has planned to have a surgical intervention to correct the prolapse. Laminectomy is the surgical method to remove a certain part or whole lamina (vertebral bone) to relieve the pressure on the spinal cord and to treat the client condition.
2. Which these intervention by the nurse is essential in management of this patient?
a. Insertion of Ryle’s tube to start feeding and maintain nutrition.
b. Arterial line insertion to assess arterial BP.
c. Foley’s catheter insertion
d. Central line insertion to guide IV fluids in view of cardiac problems.
Answer: c. Foley’s catheter insertion
Description:After laminectomy, the client should be placed in an appropriate position to restrict the common movements like bending or stopping or lifting anything that cause pressure to the back for several weeks. Hence, the HCP will plan to have Foley’s catheter to prevent the unwanted movements and protect the operated sites. Although other interventions are necessary, the nurse would give priority care to the Foley’s catheterization.
3. The nurse puts mechanical calf pumps to this patient. The rationale behind it is:
a. Prevention of deep vein thrombosis
b. To help stimulate neural recovery.
c. Mechanical calf pumps are not essential. Log rolling can be done.
d. To prevent spontaneous flexor spams.
Answer: a. Prevention of deep vein thrombosis
Description:The application of machinal pumps over the client’s calf muscles will pride regular interval of compression and prevent the clot formation. This will help the client from the development of DVT and the pulmonary embolism. Other statements are not relevant to the mechanism of action of artificial calf pump device.
4. A strong, healthy patient with a lower leg cast is learning to move and mobilize with axillary crutches. Which of the following gaits is most appropriate for this type of patient in this scenario?
a. Two-point gait
b. Three-point gait
c. Four-point gait
d. Any gait can be applied.
Answer: c. Four-point gait
Description:The four-point gait enables a normal step pattern and requires low energy expenditure. The patient must be able to bear weight on both feet. Patients are often taught the four-point gait as the first gait and the faster gaits are taught when this one is mastered.
5. A 35-year-old male patient recovering from an orthopedic surgery in lower leg and is practicing swing-to crutch gait. In this method, the patient needs to move both crutches forward this method, the patient needs to move both crutches forward lean on the crutches and then lift and swing both legs to place it.
a. Before reaching the crutch tips.
b. At the level with the crutch tips
c. Past the crutch tips
d. At either before or at the level of crutch tips
Answer: b. At the level with the crutch tips
Description:During the swing-to-gait, the patient advances both crutches, leans on the crutches, and then lift swing both legs to the same points as crutch tips. In swing-through crutch gait, the patient swings both legs past the crutch tips.
6. The nurse instructing a patient who has crutches how to sit down on a chair while holding the crutches. While doing this action, the patient should hold both crutches in the:
a. Dominant hand
b. Non-dominant hand
c. Hand on the affected side
d. Hand on the unaffected side.
Answer: c. Hand on the affected side
Description:Steps while sitting down on a chair with crutches. a. Back up until you feel the chair with the back of your leg. b. Hold both crutches in the hand on the affected side. c. Grab the armrest or the side of the chair with the free hand d. Lower yourself onto the front of the chair, then slide back e. To get up, reverse the 4 steps.
7. A 35-year-old male patient is brough to the emergency room after he sustained multiple injuries from a road traffic accident. Which of the following assessments should take the highest priority to take?
a. Grey Turner’s sign in the flank
b. Irregular pulse
c. Pupils unequal
d. A deviated trachea.
Answer: d. A deviated trachea.
Description:A deviated trachea is a sign of tension pneumothorax that indicates chest injury. If untreated, this will result in respiratory distress. NOTE: Use the ABC technique. Airway comes first while prioritizing intervention.
8. Nurse is working emergency room as a triage nurse. A 45-year-old male patient is brough to the emergency room with complains of dizziness, diaphoresis, and mid-sternal chest pain. Which of the following nursing interventions is the priority action for this client?
a. Notify the physician
b. Attach ECG leads and put on ECG monitoring
c. Collect complete history
d. Administer oxygen via nasal cannula
Answer: d. Administer oxygen via nasal cannula
Description:The priority action in this scenario is to start oxygen through nasal cannula to increase myocardial oxygenation. Other given interventions are also important but that can be given after starting oxygen therapy.
9. Nurse is educating a patient allergic to pollen about signs and symptoms of anaphylactic shock. She is aware that all of the following signs and symptoms are associated with anaphylactic shock, except:
a. Feeling dizzy
b. Itching
c. Hypertension
d. Dyspnea
Answer: c. Hypertension
Description:In anaphylactic shock, the signs and symptoms are associated with the effects of histamine. Histamine affects, cardiac GI, respiratory system and skin. The patient in anaphylactic shock may have dyspnea, wheezing, swelling of upper airway, coughing, difficulty in speaking watery eyes, stuffy nose, tachycardia, hypotension, loss of consciousness, dizziness, nausea and vomiting itching, etc.
10. A patient admitted in the ward has developed a sudden anaphylactic reaction while administering and IV medication. The nurse responds by immediately stopping the medication. Assessment of vitals revelated blood pressure 80/50 heart rate 124, and SpO2 88%. Redness on face, swelling and wheezing is noted. The nurse is aware that the most appreciate initial treatment for this condition is:
a. IV chlorpheniramine
b. IV Normal saline Bolus
c. IM adrenaline
d. Budecort nebulization
Answer: c. IM adrenaline
Description:IM or subcutaneous adrenaline/epinephrine is the first-line treatment to treat anaphylactic reaction. Adrenaline/epinephrine will increase blood pressure (Vasoconstriction effect) and dilation of airways (bronchodilation effect). Hence IM adrenaline is the appropriate drug to administrate in the situation.
11. A student nurse is caring for a patient with DVT. Which action by the student nurse should be corrected by the duty nurse?
a. Elevating the legs of the patient
b. Applying warm pumps
c. Applying compression pumps
d. Applying pressure after IM injection
Answer: c. Applying compression pumps
Description:Compression devices are used to prevent the blood clot and thus prevent the occurrence of DVT, whereas in this case the client is already diagnosed with DVT, hence sequential compression pump or device is not appropriate or contraindicated to this client. Other interventions given in the options are relevant to the client with DVT.
12. Nurse is caring for a patient who is anaphylactic shock. While checking the prescription order before administering medication, she found a inappropriate drug is ordered and asked for an order clarification from the treating doctor. Which of the following drugs clarification from the treating doctor. Which of the following drugs is most likely the inappropriate drug for this patient?
a. Adrenaline
b. Corticosteroids
c. IV furosemide
d. Isotonic IV fluids
Answer: c. IV furosemide
Description:Furosemide, a loop-diuretic, removes extra fluid from the blood volume while the patient in anaphylactic shock need fluids because of shift of fluid from intravascular space to interstitial space. All other medications are appropriate to treat a patient in anaphylactic shock.
13. A 52-years-old postmenopausal woman presented to the emergency department with 24 hours history of right leg pain, redness, warmth and tenderness. Which of the following is the most likely diagnosis of this client?
a. Muscle strain
b. Deep vein thrombosis
c. Nephrotic syndrome
d. Chronic venous insufficiency
Answer: b. Deep vein thrombosis
Description:Swelling (edema) in the affected leg (rarely there is swelling in both legs), tenderness, redness, and a feeling of warmth in the affected leg are the manifestations of deep vein thrombosis.
14. A 30-year old laborer, X is admitted to hospital with high degree of fever, maculopapular rash and joint pain from last 4 days. The patient shows typical symptoms of:
a. Dengue shock syndrome
b. Dengue hemorrhagic fever
c. Classical dengue fever
d. Malaria
Answer: c. Classical dengue fever
Description:The major significant symptoms of the classical dengue fever are the high degree fever, frontal headache, measles like rashes especially over the chest and upper limbs, join pains and painful limbs. Hence, Ram Lal shows all the positive signs of classical dengue fever. The nurse would confirm the diagnosis as the other conditions are not relevant to the client’ symptoms.
15. Next day, the nurse assess increase in abdominal girth, distention and shifting dullness. The nurse suspects ascites in this patient because of:
a. Decrease platelet count
b. Increase in capillary permeability
c. Increase in hydrostatic pressure
d. Liver involvement
Answer: b. Increase in capillary permeability
Description:Decrease in the oncotic pressure or the increased capillary permeability will allow the excess of fluid movements into interstitial space. In this case, the fluid gets shifted the peritoneal space that results in the development of ascites.
16. Mr. X, 47 years old male, is admitted in orthro ward with a fracture of right leg, suddenly complaints of chest pain and dyspnea. His BP is 85/.50mm of Hg. PR-124 beast/min and RR-24 breaths/min. which of the following initial assessments should a nurse perform to diagnose the condition?
a. Take a sample for ABG analysis
b. Obtain in chest X-ray
c. Auscultate the lung and heart sound
d. Prepare the patient for pulmonary angiography
Answer: d. Prepare the patient for pulmonary angiography
Description:From the given clinical scenario and manifestations, client is experiencing pulmonary embolism as a complication of fracture. The best diagnostic test for pulmonary embolism is pulmonary angiography.
17. A 45 year old woman is admitted with generalized edema and suspected heart failure. The nurse expects which of the following diagnostic tests to be ordered by the physician in addition to standard blood tests?
a. D-dimer
b. Serum albumin
c. Serum albumin
d. Serum brain natriuretic peptide level.
Answer: d. Serum brain natriuretic peptide level.
Description:Brain natriuretic peptide (BNP) test measures levels of a protein called BNP that is made by the heart and blood vessels BNP levels are higher than normal in case of heart failure.
18. Nurse X is providing care to a patient who acutely experiences a cardiac arrest. As the nurse is in the emergency situation, which substance in the nurse’s body will be secreted in large among to help the nurse respond to this situation?
a. Aldosterone
b. Thyroid-stimulating hormone
c. Epinephrine
d. ACTH
Answer: c. Epinephrine
Description:Adrenaline or epinephrine hormone is known as the emergency hormone because it initiates a rapid reaction helps the persons think rapidly and respond to stress. It raises the rate of metabolism, dilating the blood vessels going into the heart and brain.
19. Mr. X, 40 year old male was brough to ER after a road traffic accident with a laceration on the forehead. Upon absent and capillary refill time >2 seconds, which triage category would this client be assigned to?
a. Black
b. Green
c. Red
d. Yellow
Answer: c. Red
Description:In the given scenario, the client had a head trauma with related signs and symptoms. Hence the patient needs an immediate intervention and resuscitation. In the triage category red on should be applied for the emergency condition, yellow should be applicable for urgent condition and green should be indicated in the standard to minimal condition.
20. The patient needs to be shifted for a CT scan. What mandatory precaution the duty nurse should take before shifting Mr. X
a. Philadelphia collar for neck stabilization
b. Insert a Ryle’s tube to decompress the stomach
c. Perform oral and nasal suctioning
d. Insert an arterial line to accurately measure BP.
Answer: a. Philadelphia collar for neck stabilization
Description:After head injury, the patient head movement should be restricted to prevent the further complications. Hence, attaching Philadelphia collar will prevent the head or neck movement while shifting the patient from one place to another.
21. The CT scan show a subdural hematoma with radiological signs of increased intracranial pressure. Which of the following actions by the nurse will be helpful in preventing further increase in intracranial pressure?
a. Placing the patient in lateral position
b. Raised head end of bed by 30 degrees
c. Keeping the neck flexed
d. Doing a lumbar puncture
Answer: b. Raised head end of bed by 30 degrees
Description:In semi-Flower’s position the gravity pulls and works against the circulation, hence the flow of blood the cranial region will be compromised and the raise of the intracranial pressure level can be prevented. But in the supine it will raise up the ICP level.
22. After about one hour of the injury, the nurse assess the patient again. Which of the following would alert her toward as worsening status of the patient?
a. Pupils reactive to light
b. Headache
c. Decrease in GCS score
d. Hypertension
Answer: c. Decrease in GCS score
Description:By measuring the Glasgow Come Scale(GCS), the nurse can find alertness and the level of consciousness of the patient. With the total score of 15, the highest range of score expresses the client’s good level of consciousness and the decreased range of (GSC) score show the deterioration of conscious level and the nurse needs to provide immediate intervention to the client.
23. Mr. X. 57-year old male, is admitted in emergency with complaints of chest pain, shortness of breath and dyspnea. The nurse administers oxygen and nitroglycerin to the patient as prescribed. She understand the rationale behind this intervention:
a. To decrease the workload of lung and heart
b. To prevent hypoxia of body tissue
c. To increase the cardiac output
d. To meet the oxygen demand of cardiac muscles.
Answer: d. To meet the oxygen demand of cardiac muscles.
Description:The main indication for giving nitroglycerin is to dilate the coronary bold vessels and relax the smooth muscles which will decrease the chest pain and improve the oxygen supply. Along with this drug the oxygen administration will help to manage the client with coronary artery disease.
24. A relative standing in the waiting room suddenly falls on the floor. List the order for the actions that duty nurse must perform. 1. Call for help and activate the code team 2. Start compressions 3. Give breaths. 4. Establish unresponsiveness
a. 4, 1, 2, 3
b. 3, 1, 2, 4
c. 1, 2, 3, 4
d. 4, 3, 2, 1
Answer: a. 4, 1, 2, 3
Description:According to the Baic Life Support (BLS) guidelines, if someone is found unresponsive, the rescuer should first look the scene safety and check the response of the victim. Then the compression call for help or activate the emergency response team. Then the compression and rescue breath should be followed. These are the orders to be followed by the rescuer during emergency condition.
25. Mr. X, carpenter by profession, has come to emergency 1 hour back with sever non-productive cough, difficulty breathing and shortness of breath. He has an allergic history in of wood dust. Which of the following lung sound a nurse may expect while auscultating the lungs of Mr. X?
a. Rhonchi
b. Wheezing
c. Pleural friction rub
d. Stridor
Answer: b. Wheezing
Description:In the given scenario, the client signs and symptoms show that the is experiencing occupational asthma, due to the inhalation of wood dust in his workplace. The clinical feature of occupational asthma would be same as asthma, hence the nurse would anticipate the sound of wheezing auscultating this lung.
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