1. The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incident, what should be the initial action?
A) Order a chest X-ray
B) Reinsert the tube
C) Cover the insertion site with a Vaseline gauze
D) Call the doctor
✅ Correct Answer: C) Cover the insertion site with a Vaseline gauze
Rationale: Immediate action is to prevent air entry into the pleural space, reducing the risk of tension pneumothorax.
2. A patient with TB can transmit the disease to another individual through?
A) Air droplets
B) Physical contact
C) Hand to mouth exchange
D) Blood and body fluids
✅ Correct Answer: A) Air droplets
Rationale: TB spreads through airborne droplets expelled during coughing or sneezing.
3. A patient is recently diagnosed with Herpes Zoster. Which nursing diagnosis is the priority?
A) Anxiety
B) Social isolation
C) Peripheral neurovascular dysfunction
D) Acute pain
✅ Correct Answer: D) Acute pain
Rationale: Pain is the most immediate and distressing symptom in shingles.
4. A patient is admitted with fluid volume deficit. What IV fluid is expected?
A) 0.9% sodium chloride
B) 0.45% sodium chloride
C) Dextran in normal saline
D) 5% sodium chloride
✅ Correct Answer: A) 0.9% sodium chloride
Rationale: Normal saline is isotonic and used to quickly restore fluid volume.
5. Why is the dorsogluteal site avoided in children for IM injections?
A) Vagus
B) Sciatic
C) Ilioinguinal
D) Lumbar plexus
✅ Correct Answer: B) Sciatic
Rationale: This site risks injuring the sciatic nerve, causing serious complications.
6. What precaution is used for a patient with Rubella?
A) Standard precaution
B) Airborne precaution
C) Droplet precaution
D) Contact precaution
✅ Correct Answer: C) Droplet precaution
Rationale: Rubella spreads through respiratory droplets, needing droplet precautions.
7. Which finding shows DDAVP is effective in diabetes insipidus?
A) Appetite improves
B) Blood sugar is 120mg/dL
C) Urinary output decreases
D) Activity level increases
✅ Correct Answer: C) Urinary output decreases
Rationale: DDAVP reduces excessive urination, a key symptom in diabetes insipidus.
8. Best nursing action for a client with impaired swallowing?
A) Supine during meals
B) Head elevated 90°
C) Remove dentures
D) Encourage thin liquids
✅ Correct Answer: B) Head elevated 90°
Rationale: Upright posture aids safe swallowing and prevents aspiration.
9. Most critical post-op complication after tonsillectomy/adenoidectomy?
A) Pulmonary HTN
B) Hemorrhage
C) Hearing loss
D) Cor pulmonale
✅ Correct Answer: B) Hemorrhage
Rationale: Bleeding is the most serious risk and must be monitored closely.
10. Which is NOT a sign of extravasation?
A) Local infection
B) Tissue breakdown
C) Redness and heat
D) Pain at IV site
✅ Correct Answer: A) Local infection
Rationale: Infection may occur later, but is not an immediate sign of extravasation.
11. Which test confirms TB diagnosis?
A) Chest X-ray
B) Bronchoscopy
C) Sputum culture
D) Tuberculin skin test
✅ Correct Answer: C) Sputum culture
Rationale: Sputum culture confirms presence of Mycobacterium tuberculosis.
12. Questions with fixed response options are called?
A) Survey
B) Close-ended
C) Questionnaire
D) Demographic
✅ Correct Answer: B) Close-ended
Rationale: These questions restrict answers to predefined options.
13. Who coined the term “nursing process”?
A) Nightingale
B) Johnson
C) Rogers
D) Lydia Hall
✅ Correct Answer: D) Lydia Hall
Rationale: Lydia Hall introduced the nursing process with 3 steps: Observation, Ministration, Validation.
14. Best site for Vitamin K injection in neonates?
A) Deltoid
B) Anterior femoris
C) Vastus lateralis
D) Gluteus maximus
✅ Correct Answer: C) Vastus lateralis
Rationale: Safest and most accessible muscle for neonate IM injections.
15. Which cell secretes mucus in the respiratory tract?
A) Type 1 pneumocytes
B) Type 2 pneumocytes
C) Goblet cells
D) Adipose cells
✅ Correct Answer: C) Goblet cells
Rationale: Goblet cells produce mucus to trap debris and protect airways.
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