NATIONAL AND STATE NURSING EXAM- MCQ _MG_00 180
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1. Pre-procedural preparation before taking oral temperature includes:
a. All of the above
b. Make sure that patient has not taken anything cold or hot 10-20 min before the procedure
c. Make sure that patient performed oral hygiene before the procedure
d. Make sure that patient is not wearing any denture while performing the procedure.
Answer: b. Make sure that patient has not taken anything cold or hot 10-20 min before the procedure
Description:a. Make sure that patient performed oral hygiene before the procedure: This is important to ensure that the patient's mouth is clean and free from any debris that could affect the accuracy of the temperature reading. b. Make sure that patient has not taken anything cold or hot 10-20 min before the procedure: Consuming hot or cold substances shortly before taking an oral temperature can affect the accuracy of the reading. This step helps to ensure that the patient's oral cavity temperature is not influenced by recent consumption of hot or cold items.
2. A patient in the unit has a 103.7℉ temperature. Which intervention would be most effective in restoring normal body temperature?
a. Provide increased fluids and have the UAP give sponges baths.
b. Administer antipyretics on an around-the clock schedule.
c. Give prescribed antibiotics and provide warm blankets for comfort.
d. Use a cooling blanket white the patient is febrile
Answer: b. Administer antipyretics on an around-the clock schedule.
Description:Preparation before taking oral temperature involves ensuring the patient hasn't consumed hot or cold items 10-20 minutes prior, as it can affect accuracy.
3. The patient has voided only 50-100 mL of urine after the removal of Foley’s catheter. What is the priority nursing action?
a. Check for bladder distention
b. Re-catheterize the client
c. Monitor I/O chart
d. Encourage fluid intake
Answer: a. Check for bladder distention
Description:Given that the patient has voided only a small amount of urine after the removal of Foley's catheter, the priority nursing action would be to check for bladder distention. This could indicate that the bladder hasn't emptied properly and may require intervention to prevent discomfort and potential complications.
4. What is the important nursing intervention while assigning for peritoneal dialysis catheter insertion
a. Check the renal function of the patient
b. Arrange emergency trolley near to bedside.
c. Ask the patient to empty the bladder
d. Explain the procedure and get consent form the patient
Answer: c. Ask the patient to empty the bladder
Description:To avoid injury to the bladder, option a is the physician’s responsibility.
5. Which of the following nursing interventions can prevent increase of intracranial pressure (ICP) in an unconscious child?
a. Avoid activities that cause pain or crying
b. Lower the position of head (Trendelenburg position)
c. Provide environment stimulation
d. Turn head side to side every hour.
Answer: a. Avoid activities that cause pain or crying
Description:In an unconscious child, activities that cause pain or crying can lead to increased intracranial pressure (ICP). This is because crying and pain can lead to increased pressure within the head. Therefore, avoiding such activities is an important nursing intervention to prevent further increase in ICP.
6. When the patient vomits, the most important nursing objective is to prevent:
a. Dehydration
b. Metabolic alkalosis
c. Rupture of suture line
d. Aspiration
Answer: d. Aspiration
Description:When a patient vomits, the most important nursing objective is to prevent aspiration. Aspiration occurs when stomach contents enter the airway, which can lead to serious respiratory complications and potentially compromise the patient's breathing and oxygenation. Preventing aspiration is a critical concern in such situations.
7. Physician ordered oral as well as nasal suction to a client. You will do suction first is:
a. Mouth
b. Where the secretion is more.
c. Where the secretion is less.
d. Nose
Answer: a. Mouth
Description:Always do first suction in the mouth, then the nose because doing suction first in the nose will stimulate pharynx and cause aspiration. To avoid this, always do suction first in the mouth.
8. Methods used to reconfirm the position of NG tube each time before administering a feeding is/are:
a. pH testing if the aspirated fluid
b. By dipping tip of the tube in bowel of water r
c. Pushing some all aspirated fluid
d. All of the above.
Answer: d. All of the above.
Description:X-rays are currently the gold standard for NGT placement confirmation because they can visualize the course of the NGT tube. However, dipping tip of the tube in bowl of water to observe for air bubbles, pushing some air and auscultating, or pH testing of the aspirated fluid are the methods used to reconfirm NG tube position each time before administering feeding because the tube can become displaced later.
9. Length of insertion of NG is measured from:
a. Tip of nose to earlobe then to xiphoid process
b. Tip of nose to xiphoid process
c. Tip of nose to forehead and to xiphoid
d. Tip of nose to stomach.
Answer: a. Tip of nose to earlobe then to xiphoid process
Description:NG tube insertion length is measured from tip of nose to ear lobe then to xiphoid process.
10. While cleaning eye, it has to be cleaned from:
a. Inner canthus to outer canthus
b. Middle of the eye to inner canthus
c. Outer canthus to inner canthus
d. Middle of the eye to outer canthus
Answer: a. Inner canthus to outer canthus
Description:Cleaning has to done from more clean to less clean area, so inner canthus to outer canthus.
11. Mr. Alex was receiving transfusion of packed RBC’s. he suddenly developed difficulty in breathing, chills and flushing. Which of the following nursing intervention should take priority?
a. Check the client’s temperature
b. Administers oxygen
c. Stop the transfusion
d. Place the client on semi-fowler position:
Answer: c. Stop the transfusion
Description:The patient is experiencing blood transfusion reaction. The priority action of the nurse is to stop the transfusion immediately before initiating other inventions.
12. Find out the true statement regarding eye irrigation:
a. Irrigate from outer canthus to inner canthus
b. Most commonly using solution for eye irrigation is mannitol
c. Irrigate right eye first then left eye
d. Irrigation least infected eye firs then more infected eye.
Answer: d. Irrigation least infected eye firs then more infected eye.
Description:The only correct statement regarding eye, irrigation. Whild irrigation eye, least infected eye is irrigated first not the right eye. Irrigation has to be done from inner canthus to outer canthus, most commonly used solutions for eye irrigation are normal saline, 2% boric acid and 1% silver nitrate.
13. Find out the incorrect statement regarding colostomy irrigation:
a. NS and water can be used to irrigate the stoma
b. As the fluid moves in cramps can happen
c. It is a clean procedure
d. Irrigation is recommended for patient with stomal prolapse.
Answer: d. Irrigation is recommended for patient with stomal prolapse.
Description:Colostomy irrigation of patient with stomal prolapsed can increase the risk of further prolapse. Option a, b, c are correct statement regarding colostomy irrigation.
14. Frequent swallowing in patient following tonsillectomy indicate:
a. Hemorrhage
b. Active gag reflex
c. Thirst in patient
d. None of these
Answer: a. Hemorrhage
Description:Frequent swallowing following tonsillectomy suggestive of hemorrhage in the patient.
15. Chest drain should not be clamped. Why?
a. It leads to accumulation of more blood
b. It leads to tension pneumothorax
c. Patient will complain pain
d. None of the above.
Answer: b. It leads to tension pneumothorax
Description:There is a risk of the patient developing a tension pneumothorax if chest drainage is clamped.
16. What of the following statements is not TRUE regarding paracentesis?
a. Empty the bladder to avoid injury to bladder before the procedure
b. It can be done at 2 cm below the umbilicus in the midline
c. It can be done at 5 cm superior and medial to the anterior superior iliac spines on either side.
d. Paracentesis is usually performed with the patient in side lying position.
Answer: d. Paracentesis is usually performed with the patient in side lying position.
Description:Paracentesis is typically performed with the patient in a sitting or semi-Fowler's position, not in a side-lying position. This position helps to promote better access to the abdominal area and aids in the removal of ascitic fluid with minimal risk to the patient.
17. Milking of drainage tube will create:
a. Negative pressure
b. Positive pressure
c. Occlude the tube
d. None of these.
Answer: a. Negative pressure
Description: Milking of chest drain is only to be done with written orders form medical staff. Milking drain creates a high negative pressure that can cause pain, tissue trauma and bleeding.
18. For managing hemothorax. ICD is inserted in a patient continuous bubbling in the water seal indicates:
a. It is a normal finding
b. Air leakage
c. Time to remove the ICD
d. Fully expanded chest.
Answer: b. Air leakage
Description:In a person with hemothorax, bubbling in the water seal indicates air leakage. In pneumothorax it is normal finding.
19. Go through the following statements regarding swing of fluids in ICD and identify the correct statement:
a. The water in the water seal chamber will rise and fall with respirations
b. The swing will diminish as the pneumothorax resolves.
c. Unexpected cessation of swing may indicate the tube is blocked or kinked.
d. All of the above.
Answer: d. All of the above.
Description:All of the above statements are correct in relation to swing of fluid in ICD drainage.
20. While shifting the patient from stretcher to bed, accidental dislodging of ICD occurred. Which is the most appropriate nursing action?
a. Apply pressure to the exist site and seal
b. Call the doctor immediately
c. Try to reinsert the tube
d. None of the above.
Answer: a. Apply pressure to the exist site and seal
Description:Apply pressure to the exit site and seal with steri-strips. Placing an occlusive dressing over the top is the most appropriate nursing action.
21. Which of the following need to be performed before radial arterial cannulation to evaluate radial and ulnar arterial patency?
a. Allen’s test
b. Capillary refill test
c. Angiography
d. Buerger’s test
Answer: a. Allen’s test
Description: Before radial arterial cannulation, it is important to perform the Allen's test to evaluate the patency of the radial and ulnar arteries. The Allen's test assesses the collateral circulation between these arteries by occluding both arteries and then releasing pressure on one of them to see if the hand regains its color in a reasonable amount of time. This helps ensure that there is adequate blood flow to the hand and fingers after cannulation of the radial artery
22. Whild instilling ear drops, the ear canal of an adult is straightened by pulling the pinna:
a. Straight down
b. Up and back
c. Straight back
d. Down and back
Answer: b. Up and back
Description:For adults, gently pull the upper ear up and back. For children, gently pull the lower ear down and back.
23. All of the following instruction are given to a patient before computed tomography (CT) scan; EXCEPT:
a. Wear comfortable, loose-fitting clothing
b. Remove all metallic objects such as hairpin, dentures, jewelry, etc
c. It will not affect the outcome of pregnancy in case of female patient
d. Nil per oral several hours before the scan.
Answer: c. It will not affect the outcome of pregnancy in case of female patient
Description:When preparing a patient for a computed tomography (CT) scan, all of the mentioned instructions are typically given except for option c. Pregnancy can be a contraindication or require special precautions before undergoing certain imaging procedures, including CT scans, due to potential risks to the developing fetus. Pregnant patients or those who might be pregnant should inform the medical staff before the procedure to ensure appropriate measures are taken to minimize any potential risks.
24. Insertion of a needle into the pleural cavity is:
a. Endoscopy
b. Paracentesis
c. Thoracentesis
d. Evisceration
Answer: c. Thoracentesis
Description:Insertion of a needle into the pleural cavity is called thoracentesis. This procedure is performed to remove excess fluid or air from the pleural space, which is the area between the lungs and the chest wall. It is commonly used to diagnose and treat conditions such as pleural effusion (accumulation of fluid) or pneumothorax (accumulation of air) in the pleural cavity.
25. Which of the following nursing measure should be avoided in a patient with increased intracranial pressure?
a. Suctioning of prolonged time
b. NG tube feeding
c. Fowler’s position
d. Catheterization
Answer: a. Suctioning of prolonged time
Description:In a patient with increased intracranial pressure (ICP), suctioning for a prolonged time should be avoided. Suctioning can stimulate the gag reflex and cause an increase in ICP due to the changes in intrathoracic pressure during the procedure. It's important to minimize any activities that could potentially elevate intracranial pressure. Other options (b, c, and d) do not directly involve actions that can significantly increase ICP.
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