GMCH CHANDIGARH Question Paper with Answer Key

1. An emergency room nurse is assessing a 22 year old male who has been using opioids. What
symptoms indicate that the client has overdosed?
a. Constricted pupils and hypotension
b. Vomiting and tachypnoea
c. Pupillary dilatation and hypertensive crisis
d. Tremors and ataxia
ANS- A-Pinpoint pupil (constricted pupil),hypotension ,bradycardia most commonly
seen in opioids overdose

2. Which of the following pairs is not the negative symptom of Schizophrenia?
a. Emotional flattening and Asociality
b. Anhedonia and amotivation
c. Poverty of speech and apathy
d. Hallucinations and Bizarre behaviour
ANS- D –option a,b,c comes in negative symptoms

3. The nurse is providing a teaching session to a client who has ulcerative colitis. The nurse will
instruct the client for which diet?
a. Carbohydrate-consistent diet
b. High-calorie, high-protein diet*
c. High-calcium and high potassium diet
d. Low-residue, low-fiber diet
ANS- D –patients has ulcerative colitis which indicates bloody diarrhoea ,low
,residue,lowfibre should be prescribed

4. Which of the following categories would a 70 year old adult be placed in?
a. Intimacy vs. Isolation
b. Generativity vs. Stagnation
c. Integrity vs. Despair
d. Longevity vs. Guilt
ANS-C-OPTION (A)-21-39YRS,(B)-45-66YRS,(D)-3-5YRS

5. Furosemide acts on which part of the nephron?
a. Proximal tubule
b. Descending limb of the loop of Henle
c. Ascending limp
d. Distal tubule
ANS-C –ascending limp as it inhibits reabsorbtion of Na,cl so that it will excreated in
urine
6. A person with schizophrenia was found to repeat whatever words the psychiatric nurse was
speaking. This behaviour can be labelled as:
a. Echopraxia
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b. Neologism
c. Word Salad
d. Echolalia
ANS-d imitation of language is echolalia
7. After falling from a 10 feet ladder, a patient is brought to the emergency department.
The patient is alert, reports back pain, and difficulty moving the lower extremities. Which
additional observation is an indication the patient may be experiencing neurogenic shock?
a. Cool and pale skin
b. Bradycardia
c. Poor skin turgor
d. Increased systolic blood pressure
ANS-B-warm dry ,flushed skin ,bradycardia one of the important sign in neurogenic
shock
8. The nurse should instruct a patient who is to receive digoxin (Lanoxin) to report
development of which of the following side effects?
a. Ringing in the ears
b. Alopecia
c. Signs of bruising
d. Sensitivity to sunlight
ANS-D-Sensitivity of light most common as it causes flashes ,yellow hallo vision
9. Match List – I with List – II and indicate your answer with the help of the codes given below:
List – I List – II
p) Number of new cases that occur over a given period of time. 1. Epidemiology
q) Study of the distribution of diseases or health related behaviours in a given population 2. Syndrome
r) Number of cases in a population in a given period of time 3. Incidence
s) A group or cluster of symptoms that occur together 4. Prevelance
Codes
p q r s
A 2 1 3 4
B 4 2 1 3
C 3 1 4 2
D 1 4 3- 2
ANS-C
10. Which of the following does not describe an obsession?
a. Continually reliving a traumatic event.
b. An unwanted thought that a person finds intrusive and distressing.
c. A behaviour that a person feels compelled to perform.
d. Something a person enjoys doing and talking about constantly.
A) 1,2 and 4
B) 2 and 4
C) 2, 3 and 4
D) 1, 3 and 4
ANS-D- 1,3,4
11. Arrange the following five events in correct order of occurrence:
I. Stimulation of anterior pituitary
II. Stimulation of ovaries
III. Stimulation of neurosecretory cells
IV. Release of Gonadotropic hormone
V. Release of Gonadotropin releasing hormone
Codes
A) III, V, I, IV, II
B) II, IV, I, V, III
C) I, V, III, II, IV
D) IV, V, III, II, I
ANS –A-
12. Arrange the following events in the order of their occurrence in Panic circle
I. Apprehension or worry
II. Body sensations
III. Perceived threat
IV. Interpretation of sensations as catastrophic
V. Trigger stimulus
Codes
A) I, III, II, V, IV
B) II, IV, I, V, III
C) I, V, III, II, IV
D) III, V, I, II, IV
ANS-C
13. While receiving blood transfusion the patient develops chills and headache. What should be
the nurses initial action?
a. Notify the physician STAT
b. Stop the transfusion immediately
c. Cover the patient with a blanket and administer ordered acetaminophen.
d. Slow the blood flow to keep vein open
ANS-B-
14. Choose the most therapeutic response to Mr. Shyam’s question: “Am I going to die?”
a. “We all are going to die one day.”
b. “What has your doctor told you?”
c. “You really don’t want to talk about death, do you?”
d. “Would you like to talk about your condition and prognosis?”
ANS-D-therapeutic response is to provide comfort to patient specific suggestions
15. Which of the following would be a common indication of infiltration of a peripheral
intravenous infusion?
a. Redness and swelling around the insertion site
b. Blood return in the cannula
c. Difficulty regulating the flow with gravity
d. Cool skin distal to the insertion site
ANS-D-COOL OEDEMA SWELLING is important sign of infiltration
16. Ms. Babita is in the emergency room after being involved in a traffic accident. What would
be an early sign of hemorrhagic shock?
a. Increased blood pressure.
b. Pallor
c. Increased pulse
d. Deep breathing
ANS-C-Always early sign of shock is rapid heart rate
17. Ms. Anita asks the nurse when she can start eating after surgery. What is the most
appropriate response by the nurse?
a. "You’ll have to ask the doctor."
b. "Tell me about your appetite."
c. "You'll likely start on clear fluids once bowel sounds can be heard.".
d. "I'll have the dietitician consult with you about the most nutritious post surgery
menus."
ANS- C-most important priority bowel sounds after surgery to start oral
18. When caring for an infant during cardiac arrest, which pulse must be palpated to determine
cardiac function?
a. Carotid
b. Brachial
c. Pedal
d. Radial
ANS-BRACHIAL
19. The evidence to assert, whether or not, experimental treatment/condition has made the
difference refers to:
a. External validity
b. Internal Validity
c. Criterion validity
d. Construct validity
ANS –B
c. The prodromal, primary infection , secondary infection and tertiary infection
d. The inflammation, infection and disease
ANS-B-
26. Match List – I with List – II and give your answer with the help of the codes given below:
List – I (Neuron systems) List – II (Areas of Brain)
p) The acetylcholinergic system 1. Raphe nucler
q) The noradrenergic system 2. Lateral hyporthalamus
r) The serotonergic system 3. Pons and basal forebrain
s) The hypocretinergic system 4. Locus coeruleaus
Codes
p Q r S
A 1 2 3 4
B 3 1 4 2
C 4 3 1 2
D 3 4 1 2
ANS
(D)
27. Which of the following is the best method to relieve constipation during pregnancy?
a. Lying flat on the bank while sleeping
b. Increasing the intake of vegetables and fruits
c. Reduction of iron intake by half
d. Taking a mild over-the-counter laxative
ANS-B-
28. Of the following, which disease causes most death worldwide?
a. Cardiovascular disease
b. HIV/AIDS
c. Malaria
d. Tuberculosis
ANS –A-
29. Which of the following is a vector of infection?
a. An infectious fly
b. A contaminated thermometer
c. A contaminated ball
d. An infected person
ANS –A-
30. An infant born with non-communicating hydrocephalus has just had a ventro peritoneal
shunt inserted. In addition to neuromuscular assessments what measures should the nurse
use in child’s care plan?
a. Reinforce wet dressings every 2 hourly
b. Position the infant on operative side
c. Place infant in semi fowler position
d. Measure head and abdominal circumfere
ANS-D- since there is chance of shunt malfunction watch for early sign of icp and
abdominal distension
31. Select the anatomic malformations associated with the Tetralogy of Fallot.
a. Ventricular septal defect, an overriding aorta, right ventricular hypertrophy,
pulmonay stenosis.
b. Atrial septal defect, an overriding aorta, right ventricular hypertrophy, pulmonary
stenosis.
c. Ventricular septal defect, an overriding aorta, left ventricular hypertrophy, and right
ventricular outflow.
d. Atrial septal defect, an overriding aorta, pulmonary atresia, and right ventricular
outflow
ANS –A-
32. Which of the following conditions is related to the development of renal calculi?
a. Pancreatitis
b. Fractured femur
c. Gout
d. Disc disease
ANS C-GOUT increased uric acid
33. Select the cranial nerve paired with its name correctly.
a. The twelfth cranial nerve: The hypoglossal nerve
b. The fifth cranial nerve: The auditory nerve
c. The second cranial nerve: The olfactory nerve
d. The tenth cranial nerve: The trigemminal nerve
ANS-A-
34. What could be the expected delivery date for the woman who got her last menstrual cycle
on 20th April, 2018?
a. January 27th 2019
b. February 20th 2019
c. January 31st 2019
d. February 27th 2019
ANS A-
35. A 4-year-old female child suffered severe bums in a house fire. How will you examine the
extent of her bums?
a. By using the Parkland Formula
b. By using the Lund and Browder chart
c. By using the Hartman’s formula
d. By using the Rule of Ten
ANS –B-
36. A female client who has just been diagnosed with hepatitis A asks, “How could I have got
this disease?” What is the nurse’s best response?
a. “You may have eaten contaminated restaurant food”
b. “You could have gotten it by using I.V. drugs”
c. “You must have received an infected blood transfusion"
d. “You probably got it by engaging in unprotected sex”
ANS –A-FAECORAL
37. Select the criterion that is coupled with its indication of gestational age or birth weight.
a. Small for gestational age: The neonate’s weight is less than 20th percentile
b. Large for gestational age: The infant’s weight is above 99lh percentile
c. Low birth weight: The infant’s weight is less than 1,500g at the time of delivery
d. Appropriate for gestational age: The neonate’s weight lies in the range of 10th to
90th percentile
ANS-D-
38. Which of the following is paired correctly with its description about skeletal fracture?
a. An avulsion fracture: A fracture that extracts a part of bone from the ligament or
tendon
b. A greenstick fracture: This bends the bone but does not lead to a fracture
c. A complete fracture: The fractured bone pierces to the skin surface through the skin
d. A pathological fracture: A fracture that occurs due to some physical trauma
ANS –A-
39. Which of the following signs and symptoms indicates salicylate toxicity?
a. Chest pain
b. Pink coloured urine
c. Slow pulse rate
d. Ringing in ears
ANS –D- tinitis –ringing in ear
40. Urinary bladders is lined with ___________?
a. Simple epithelium
b. Stratified epithelium
c. Transitional epithelium
d. Pseudostratified epithelium
ANS-C- transititional epithelium- pseudostratified columnar epithelium –
lungs,stratified –salivary glands,sweat glands
41. Given below are the three types psychological investigations: (1) Field experiments, (2)
Laboratory experiments, and (3) Ex post facto field studies. If the above investigations are
arranged in descending order in terms of researcher’s ability to control secondary variance,
the typical order would be:
a. 2, 1, 3
b. 3, 1, 2
c. 2, 3, 1
d. 3, 2, 1
ANS –A-
42. World Health Day is observed on
a. 7
th April
b. 8
th May
c. 9
th June
d. 10th July
ANS –A-
43. 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?
a. Retinopathy
b. Bradycardia
c. Jaundice
d. Urinary retention
ANS –A- HYPERTENSIVE EMERGENCY CAUSES TARGET ORGAN DAMAGE (TOD)
44. Which of these assessment findings should the nurse expect to identify as an early clinical
characteristic of multiple sclerosis (MS)?
a. Dementia
b. Muscle atrophy
c. Vision loss
d. Clonus
ANS C-Vision loss,diplopia earlest sign of multiple sclerosis
45. A patient who has a history of chronic bronchitis is admitted to the medical unit. The nurse
notes the red blood cell count is elevated. Which of these is likely contributing factor to this
lab result in this patient?
a. Chronic hypoxia
b. Hypercapnia
c. Decreased fluid intake
d. Insensible water loss
ANS- A-CHRONIC hypoxia will stimulate erythropoietin to produce more red blood cells
in bone marrow
46. A patient has recently been diagnosed with leukemia. Which of the following symptoms
would a nurse expect to see given this diagnosis?
a. Bruising, fatigue, and bone pain
b. Bradycardia, hypotension, and palpitations
c. Paresthesia, facial rash, and abdominal pain
d. Dyspnea, malaise, and hypotension
ANS-A-Most common symptoms of leukemia
47. A pediatric patient has been diagnosed with right lower lobe pneumonia. Upon auscultation
of this lung field, the nurse would expect to hear which breath sound?
a. Rhonchi
b. Stridor
c. Crackles
d. Wheezes
ANS –RHONCHI or RALES most commonly seen in pneumonia on auscultation,stridor-
laryngeal spasm,crackles-pulmonary oedema,wheezes -asthma
48. The nurse anticipates the following laboratory study to assess the therapeutic effect in the
client taking heparin intravenously:
a. Prothrombin time
b. Activated partial thromooplastin time
c. Hematocrit
d. Hemoglobin
ANS –B- normal should be <90s if it >90s initiate bleeding precaution,PT-warfarin
therapy,
49. A nurse performs pre operative teaching for a client who is to have a cataract surgery. Which
is most important instruction for the client she should render?
a. Remain flat for 3 hours
b. Eat a soft diet for 2 days
c. Breathe and cough deeply
d. Avoid bending form the waist
ANS-D- avoid pain related activitis which causes iris prolapse after cataract surgery
50. Which of the following is not a potential source of acquired immunity?
a. Antibodies received in response to disease
b. Antibodies received from the mother
c. Prescribed multivitamins
d. Animal serum
ANS –C-
51. When teaching the care givers of a patient who has dementia of the Alzheimer type, a nurse
should stress the importance of
a. Increased stimuli
b. Predictable environment
c. Restricted activities
d. Independent decision making
ANS B- predicable ans safe environment should be given patient has cognitive
impairment become agitated,anxious quickly ,unable to do their own activity
52. Which of the following describes the cognitive triad of depression?
a. Helplessness, sleeplessness, worthlessness
b. Thoughtlessness, worthlessness, sleeplessness
c. Hopelessness, worthlessness, thoughtlessness
d. Hopelessness, worthlessness, helplessness
ANS –D-
53. A 65-year-old patient with pneumonia is receiving garamycin (Gentamicin). It would be
most important for a nurse to monitor which of the following laboratory values in this
patient?
a. Hemoglobin and hematocrit
b. Blood Urea Nitrogen and creatinine
c. Platelet count and clotting time
d. Sodium and potassium
ANS –B-gentamycin causes renal toxicity and decrease creatine clearance
54. A man is admitted to the Telemetry Unit for evaluation of complaints of chest pain. Eight
hours after admission, the patient goes into ventricular fibrillation. The physici defibrillates
the patient. The nurse understands that the purpose of defibrillation is to.
a. Increase cardiac contractility and cardiac output
b. Cause asystole so the normal pacemaker can recapture
c. Reduce cardiac ischemia and acidosis
d. Provide energy for depleted myocardial cells
ANS B-VF can go to asystole if not defribrilllation ,further it purpose to activate SA
NODE pacemaker to beat at normal rhythm ,option a- to decrese contractility,option
c,d -provide oxygen not realted to defibrillation
55. A perception that occurs when a sensory stimulus is present but is incorrectly percei and
misinterpreted is known as:
a. Hallucination
b. Delusion
c. Illusion
d. Neologism
ANS-C-imaginary perception with stimulus
56. What is the age limit approved in COTPA bill for the sale of tobacco products and cigarettes
in approved packaging?
a. 16 years
b. 18 years
c. 21 years
d. 25 years
ANS C- 21
57. A nurse is giving instructions to a client receiving lithium citrate. The nurse tells the client to
do which of the following to prevent lithium toxicity:
a. Avoid becoming dehydrated during exercise
b. Instruct the client to change positions slowly
c. Restrict salt intake in the diet
d. Limit fluid intake
ANS –A –HYPONATEREMIA precipates lithium toxicity, as exercise causes salt loses
58. DOTS stands for
a. Direct Observation Treatment Short course
b. Differential Observation Treatment Short course
c. Direct Observation Treatment Scheme
d. Direct Observation Treatment Survey
ANS -A
59. Which of the following is responsible for the spread of dengue?
a. Anopheles mosquito
b. Culex mosquito
c. Aedes mosquito
d. Housefly
ANS C
60. Which of the following is true about the aim of sustainable development goals : goal 1:
a. Cut poverty by half in 2030
b. Reduce poverty by 75% by 2030
c. End poverty in all its forms everywhere
d. Help each nation make progress on reducing poverty
ANS -C
61. What is the term used for normal respiratory rhythm and depth in a client?
a. Eupnea
b. Apnea
c. Bradypnea
d. Tachpnea
ANS A
62. Alarm, resistance, and exhaustion are concepts related to
a. Health belief model
b. Trans theoretical model
c. Health promotion model
d. General adaptation syndrome
ANS D
63. A client is in the late active phase of labour. Suddenly she tells the nurse she feels weak and
dizzy. The nurse notes the drop in maternal B.P. and late decelerations of fetal heart rate.
The initial action the nurse should be to:
a. Increase the I.V. drip rate and notify the provider
b. Turn the client on side and administer oxygen
c. Assess for cord prolapse or vaginal bleeding
d. Prepare for immediate delivery
ANS C –LATE deceleration cause cord compression
64. During which war did the United States ask for Florence Nightingale’s assistance in setting up
military hospitals?
a. Crimean war
b. World war I
c. World war II
d. Civil war
Ans A
65. Birth rate is:
a. Live birth/1000 mid-year population
b. Birth/1000 mid-year population
c. Live birth/10000mid-year population
d. Live birth/1000 population of reproductive age Group (15-45 year)
ANS –A-
66. As per latest census sex ratio (the number of females per 1000 of males) of Chandigarh is
reported to be…..
a. 718
b. 818
c. 918
d. 1000
ANS B
67. This step of the nursing process includes the systematiabc collection of all subjective and
objective data about the client in which the nurse focuses holistically on the client physical,
psychological, emotional, sociocultural, and spiritual aspect.
a. Assessment
b. Planning
c. Implementation
d. Diagnosis
ANS A
68. There are a number of risk factors associated with coronary artery disease. Which of the
following is a modifiable risk factor?
a. Obesity
b. Heredity
c. Gender
d. Age
ANS A
69. When administering single rescuer adult CPR, what is breaths-to-compressions ratio?
a. 2 breaths every 30 compressions
b. 1 breath every 30 compressions
c. 1 breath every 15 compressions
d. 2 breaths every 5 compressions
ANS –A-
70. Rashtriya Bal Swasthya Karyakram (RBSK) is a new initiative aiming at early identification and
early intervention for children from birth to 18 years to cover 4 ‘D’s viz
a. Defects at birth, Deficiencies, Diseases, Development delays including disability.
b. Drug Abuse, Deficiencies, Development delays including disability and Defects at
birth
c. Deformities, Development delays including disability, deficiencies and drug abuse
d. Diseases, Development delays including disability, defects at birth and diarrhoeal
disease
ANS A
PART – II
71. Which of the following are correct techniques while checking the blood pressure of a patent:
I. Before the measurement patient must remain in a sitting position
for about 5 minutes.
II. The cuff must be at the level of the heart.
III. The arm must be freely hanging without any firm support
IV. The stethoscope must be placed a little above than the cuff
a. I, II, IV
b. I, III, IV
c. I & II
d. II & IV
ANS -C
72. Which of the following actions should the nurse take to use a wide base support when
assisting a client to get up in a chair?
a. Bend at the waist and place arms under the client’s arms and lift
b. Face the client, bend knees and place hands on client’s forearm and lift
c. Spread his or her feet apart
d. Stand at the back of patient and lift him/ her
ANS B- ERGONOMICS PRINCIPAL
73. During an arteriogram (angiogram), the patient suddenly says, "I m feeling really hot." Which
is the best response?
a. "You are having an allergic reaction to the dye. I will get an order for Benadry!"
b. "The heat indicates that the clots in the coronary vessels are dissolving"
c. “Let me check the room temperature”
d. “That feeling of warmth is normal when the dye is injected. It will last up to 20
seconds.”
ANS –D-
74. A nurse receives report on four clients admitted to the emergency room. Who should she
assess first?
a. Client with cherry red skin who has been waiting 15 minutes
b. Client with a blood pressure of 180/76 on 2L of oxygen via NC
c. Client vomiting from a heroine overdose
d. Client with asthma receiving treatment from respiratory therapy
ANS C-
75. The healthcare provide is caring for a patient on a ventilator with an endotracheal tube in
place. What assessment data indicate the tube has migrated too far down the trachea?
a. Decreased breath sounds on the left side of the chest
b. A high pressure alarm sounds
c. Increased crackles auscultation bilaterally
d. Low pressure alarm sounds
ANS A- IF ET is migrated it always goes to right bronchus as it is little straight compare
to left
76. The doctor orders Zofran (ondesteron HCI) 8 mg PO t.i.d. The pharmacy sends a 100 ml
bottle, labelled 4 mg/teaspoon. How many ml should be given for each dose?
a. 2 ml
b. 8 ml
c. 5 ml
d. 10 ml
ANS-D as 1teaspoon containg 5ml =4mg,we need 8mg -5x2 10ml
77. A patient who has experienced a stroke is being monitored during the acute management
phase. The clinician notes that the patient’s intracranial pressure (ICP) is 30 mm Hg. Which
of the following interventions should be taken first?
a. Give Trendelenburg position to the patient
b. Obtain vital signs and measure urine output
c. Assess level of consciousness
d. Raise the head of the bed to 30⁰
ANS D
78. A patient with a history of atrial fibrillation is scheduled for a left hip hemiarthroplasty at
09:00 AM. The health professional is administering 08:00 AM medications. Which of these
medication orders should the nurse be concerned about?
a. Opioid analgesic intravenously
b. Low molecular weight heparin anticoagulant subcutaneously
c. Beta blocker orally
d. Cephalosporin antibiotic intravenously
ANS –B lmwh should be withheld 24hrs before
79. The nurse is assisting a doctor with the removal of a central venous catheter. To prevent
complications, the patient should be instructed to
a. Perform the Adsons maneuver while removing catheter.
b. Perform the Valsalva maneuver as the catheter is pulled.
c. Turn his head to the right while grasping the siderails.
d. Turn his head to the left side and hyperextend the neck while looking up.
ANS B adsons maneuver is comes in thoracic outlet syndrome
80. During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the
nurse. Which of the following should be the nurse's next action?
a. Ask the patient to perform a Valsalva maneuver
b. Obtain an order for a bladder scan
c. Assess femoral pulses
d. Measure the abdominal circumference
ANS C as it causes abdominal aorta aneurysm
81. When examining a patient with abdominal pain the nurse in charge should assess:
a. Any quardent first
b. The symptomatic quardrant first
c. The symptomatic quardrant last
d. The symptomatic quardrant either second or third
 ANS C
82. The nurse is caring for a patient with cervical cancer. The nurse notes that the cervical
implant has become dislodged. Which of the following actions should the nurse take first?
a. Stay with the patient and contact radiology
b. Wrap the implant in a blanket and place it behind the lead shield
c. Obtain a dosimeter reading on the patient and report it to the physician
d. Pick up the implant with long-handled forceps and place it in a lead container
ANS D
83. A 68 year old women diagnosed with thrombocytopenia due to acute lymphocytic leukemia
is admitted to the hospital. The nurse should assign the patient to:
a. To a private room so she will not infect other patients and health care workers
b. To private room so she will not be infected by other patients and health care
workers
c. To a semiprivate room so she will have stimulation during her hospitalization
d. To a semiprivate room so she will have the opportunity to express her feelings about
her illness
ANS B reverse isolation
84. Which nursing action is essential when providing continuous enteral feeding?
a. Elevating the head of the bed
b. Positioning the patient on left side
c. Warming the formula before administering it
d. Hanging the formula for 8 hrs in the beginning of morning shift
ANS A
85. Which one of the following is the correct formula for calculating a person's body mass index
(BMI)?
a. Weight in Kg x height in metres
b. Weight in Kg divided by height in metres squared
c. Weight in Kg divided by height in metres
d. None of the above
ANS B
86. Which action by the nurse in charge is essential when cleaning the area around a Jackson-
Pratt wound drain?
a. Cleaning from the center outward in a circular motion.
b. Cleaning from periphery towards centre in circular motion.
c. Cleaning briskly around the site from left to right
d. Cleaning briskly around the site from right to left
ANS A ,option b-cleaning from periphery towards centre is in bedsore
87. A patient is to receive 3,000 ml of 0.9% NaCl IV in 24 hours. The intravenous set delivers 15
drops per milliliter. The nurse should regulate the flow rate so that the patien receives how
many drops of fluid per minute?
a. 21
b. 28
c. 31
d. 42
ANS 31 – 3000x15/24x60=31
88. Nurse can minimize agitation in a disturbed client by:
a. Increasing stimulation
b. Limiting unnecessary interaction
c. Increasing appropriate sensory perception
d. Ensuring constant client and staff contact
ANS B
89. Physical assessment is being performed by a nurse. During the abdominal examination,
nurse should perform the four physical examination techniques in which sequence:
a. Auscultation immediately after inspection and then percussion and palpation
b. Percussion, followed by inspection, auscultation, and palpation
c. Palpation of tender areas first and then inspection, percussion, and auscultation
d. Inspection and then palpation, percussion and auscultation
ANS A
90. A client has just returned to a nursing unit after a cardiac catheterization performed using
the femoral artery. The nurse places the client in which position?
a. Bed rest with head elevation at 30°
b. Bed rest with head elevation at 45°
c. Bed rest with head elevation at 60°
d. Bed rest with head elevation at 90°
ANS A
91. A nurse auscultates the heart of Anu, a 21-year-old female. Anne seeks a consultation for
dizziness and easy fatigability. During assessment, the nurse identifies a mid-to-late systolic
click followed with mid-to-late systolic murmur at the cardiac apex. The murmur gets louder
when Anne stands up. Based on these findings, Anu is most likely considered for which of
the following cardiac problems?
a. Aortic stenosis
b. Mitral valve prolapsed
c. Pulmonic stenosis
d. Mitral regurgitation
ANS B
92. While doing the tracheal suctioning of a patient, the suction should be applied….
a. Only when withdrawing the suction catheter
b. Only when inserting the suction catheter
c. Either during insertion or withdrawal, depending on when the patient coughs
d. Only if the patient coughs
ANS A
93. A nurse gives a double dose of acetaminophen (Tylenol) to a client who only requires single
dose. What, if anything, must the nurse do?
a. Ask a colleague to help assess the client
b. Withhold the client’s next dose of Tylenol
c. Report the error as soon as possible
d. Nothing, because this is an over-the-counter medication
ANS C
94. Which of the following is a primary nursing intervention necessary for all patients with a
Foley Catheter in place?
a. Maintain the drainage tubing and collection bag level with the patient’s bladder
b. Irrigate the patient with 1% Neosporin solution three times a daily
c. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
d. Maintain the drainage tubing and collection bag below bladder level
ANS D
95. After assessing the client, the nurse formulates the following diagnoses Place them in order
of priority, with the most important (classified as high) listed first. 1. Constipation 2.
Anticipated grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion
a. 3, 4, 2, 1
b. 4, 3, 2, 1
c. 1, 3, 2, 4
d. 3, 4, 1, 2
ANS D
96. You come upon an unconscious victim with a palpable pulse. He does not appear to be
breathing. You are unable to deliver the first breath. What is the next step?
a. Begin CPR
b. Repeat the head tilt/chin maneuveur and attempt the breath again
c. Abdominal thrusts
d. Helminch maneuveur
ANS B –as there is respiratory arrest
97. A nurse is caring for a client who expresses active suicidal ideations. Which of the tollowing
should be the nurses’s action?
a. Engage patient actively in ward activities so that patient does not talk more about
suicide
b. Administer the anti depressant drugs to reduce suicidal thoughts.
c. Teach JPMR. exercises to patient to reduce suicidal thoughts via relaxation.
d. Indulge patient in interaction on suicide related thoughts and actions
ANS A
98. Where should you place the AED pads on an adult victim?
a. One under the left arm pit and one high on the right side of the chest
b. One under the right arm and one high on the left side of the chest
c. One under each arm pit
d. One in the centre of the back and one over the centre of the chest
ANS A
99. A nurse is assessing a pregnant client for the presence of ballotment. To make this
determination, the nurse does which of the following?
a. Ascultates for fetal heart sounds
b. Assesses the cervix for compressibility
c. Palpates the abdomen for fetal movement
d. Initiates a gentle upward tap on the cervix
ANS C
100. The nurse is caring for a 10-year-old on admission to the burn unit. One assessment
parameter that will indicate that the child has adequate fluid replacement is
a. Unnary output of 30 ml per hour
b. No complaints of thirst
c. Increased hematocrit
d. Good skin turgor around burn
ANS A- normal -0.5ml/kg/hr
x