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AIIMS M.Sc. Nursing study materials
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AIIMS M.Sc. Nursing practice questions

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Question 1Nursing Foundations and Fundamentals of Nursing

A postoperative patient has a physician's order for morphine 4 mg IV every 4 hours as needed for pain. Before administering the dose, the nurse verifies the patient's identity, checks the last dose time, and reviews the respiratory rate. Which step of the nursing process does this activity most directly represent?

  1. Planning
  2. Assessment
  3. Implementation Correct answer.
  4. Evaluation

Explanation

Carrying out a prescribed intervention and monitoring the patient before and after giving it is implementation, the phase in which the care plan is put into action. Assessment is the collection of data, planning is prioritising and setting goals, and evaluation judges whether outcomes were met.

Question 2Nursing Foundations and Fundamentals of Nursing

Which route of drug administration is correctly paired with its characteristic absorption pattern?

  1. Sublingual tablet: avoidance of first-pass hepatic metabolism Correct answer.
  2. Intradermal injection: rapid absorption from rich subcutaneous blood flow
  3. Intramuscular injection: absorption slower than subcutaneous injection
  4. Oral tablet: complete absorption before reaching the portal circulation

Explanation

Drugs absorbed under the tongue enter the systemic circulation directly, bypassing the portal vein and first-pass hepatic metabolism. Intradermal sites have poor absorption, intramuscular absorption is generally faster than subcutaneous because muscle is more vascular, and orally absorbed drugs reach the liver before the systemic circulation.

Question 3Nursing Foundations and Fundamentals of Nursing

A nurse is preparing to give an intramuscular injection into the ventrogluteal site. Which landmark correctly identifies this site?

  1. The lower third of the lateral thigh, one handbreadth above the knee
  2. The palm of the hand placed on the greater trochanter with the index finger on the anterior superior iliac spine Correct answer.
  3. Two fingerbreadths below the acromion process, on the deltoid muscle
  4. The midpoint of a line between the posterior superior iliac spine and the greater trochanter

Explanation

The ventrogluteal site is located by placing the palm on the greater trochanter and the index finger on the anterior superior iliac spine, then injecting into the centre of the V formed by the index and middle fingers. It is preferred because it is free of major nerves and blood vessels and has a thick muscle mass.

Question 4Nursing Foundations and Fundamentals of Nursing

During hand hygiene with soap and water, which action best reflects correct technique according to standard infection-control principles?

  1. Rubbing the hands together briskly for 5 seconds under running water
  2. Applying soap and scrubbing only the palms and backs of the hands
  3. Lathering all surfaces, including finger webs and thumbs, for at least 15 to 20 seconds Correct answer.
  4. Cleaning the hands with an alcohol-based rub when they are visibly soiled

Explanation

Effective handwashing requires lathering all surfaces, including the backs of the hands, finger webs, thumbs, and fingertips, and rubbing for a sufficient duration, generally 15 to 20 seconds. Friction and contact time are what remove and kill transient organisms.

Question 5Nursing Foundations and Fundamentals of Nursing

A patient is to receive 1,000 mL of normal saline over 8 hours by gravity infusion. The giving set delivers 15 drops per millilitre. What is the correct drip rate?

  1. 63 drops per minute
  2. 42 drops per minute
  3. 21 drops per minute
  4. 31 drops per minute Correct answer.

Explanation

The formula is (volume in mL × drop factor) ÷ time in minutes. Here (1000 × 15) ÷ 480 = 31.25, which rounds to 31 drops per minute.

Question 6Nursing Foundations and Fundamentals of Nursing

When measuring a patient's blood pressure by the auscultatory method, which finding indicates the systolic pressure?

  1. The point at which all sounds disappear
  2. The point at which the Korotkoff sounds become muffled
  3. The reading obtained when the cuff is fully inflated
  4. The first clear tapping sound heard as the cuff deflates Correct answer.

Explanation

The systolic pressure corresponds to the first appearance of clear tapping Korotkoff sounds as the cuff is deflated. The muffling and disappearance of sounds correspond to diastolic pressures, and the fully inflated reading reflects occlusion of the artery, not a pressure value.

Question 7Nursing Foundations and Fundamentals of Nursing

A patient with a nasogastric tube is to receive an enteral feed. Which action should the nurse take before each feed to verify tube placement?

  1. Place the tube tip in water and look for bubbling
  2. Auscultate the epigastrium while injecting 30 mL of air
  3. Ask the patient to speak and note any hoarseness
  4. Measure the pH of aspirated gastric contents Correct answer.

Explanation

Measuring the pH of aspirated fluid is a reliable bedside method, since gastric aspirate is typically acidic. Auscultation of injected air is no longer considered reliable, and the other measures do not confirm gastric placement.

Question 8Nursing Foundations and Fundamentals of Nursing

Which statement correctly describes the purpose of a sterile field during a dressing change?

  1. It provides a work surface on which ungloved hands may touch sterile items
  2. It sterilises the wound bed by releasing antimicrobial vapour
  3. It limits the growth of organisms already present on the patient's skin
  4. It prevents contamination of the wound by organisms from the environment and the nurse Correct answer.

Explanation

A sterile field is a barrier that keeps micro-organisms from the air, surfaces, and the nurse away from the wound and sterile supplies. The field does not sterilise the wound or the patient's skin, and sterile items must not be touched with ungloved hands.

Question 9Nursing Foundations and Fundamentals of Nursing

A patient is admitted with a stage 2 pressure injury over the sacrum. Which finding best characterises this stage?

  1. Intact skin with non-blanchable redness
  2. Partial-thickness loss of skin with a shallow open wound Correct answer.
  3. Full-thickness loss with slough obscuring the wound base
  4. Full-thickness loss with exposed bone or tendon

Explanation

A stage 2 pressure injury involves partial-thickness loss of the dermis, presenting as a shallow open ulcer or a blister. Intact skin with non-blanchable redness is stage 1, while exposed deep structures and slough-obscured wounds indicate deeper stages.

Question 10Nursing Foundations and Fundamentals of Nursing

A nurse is repositioning a hemiplegic patient in bed. Which action best protects the patient's skin and joints?

  1. Using a draw sheet and lifting rather than pulling the patient Correct answer.
  2. Keeping the head of the bed elevated at 60 degrees continuously
  3. Placing the patient directly on the trochanter for long periods
  4. Dragging the patient upward by the shoulders to reduce the number of staff needed

Explanation

Lifting with a draw sheet reduces friction and shear, which are major contributors to pressure injury and skin damage. Dragging creates shear, side-lying directly on the trochanter concentrates pressure, and high head elevation increases shear over the sacrum.

Question 11Nursing Foundations and Fundamentals of Nursing

Which instruction should the nurse give a patient who is learning to use a cane?

  1. Hold the cane on the stronger side and advance it after both legs
  2. Hold the cane on the weaker side and advance it before the strong leg
  3. Hold the cane on the weaker side and move it with the weak leg
  4. Hold the cane on the stronger side and advance it with the weaker leg Correct answer.

Explanation

The cane is held on the unaffected or stronger side to widen the base of support and shift weight away from the weak limb. The cane and the weaker leg advance together, then the stronger leg follows.

Question 12Nursing Foundations and Fundamentals of Nursing

A patient reports acute chest pain. Which action should the nurse take first?

  1. Obtain a 12-lead electrocardiogram and assess vital signs Correct answer.
  2. Administer the prescribed analgesic and reassess in 30 minutes
  3. Document the pain characteristics and continue routine care
  4. Ask the patient to walk to the treatment room for assessment

Explanation

Acute chest pain requires immediate assessment of airway, breathing, circulation, vital signs, and a 12-lead ECG to identify a life-threatening cause such as myocardial ischaemia. Analgesia and documentation follow this initial evaluation, and exertion should be avoided.

Question 13Nursing Foundations and Fundamentals of Nursing

Which technique correctly demonstrates the use of a metered-dose inhaler with a spacer?

  1. Holding the breath for 1 second after inhalation
  2. Inhaling through the nose while the spacer is in the mouth
  3. Activating the inhaler and then inhaling as quickly as possible
  4. Activating the inhaler immediately after beginning a slow, deep inhalation Correct answer.

Explanation

The canister is activated just after the patient begins a slow, deep inhalation, and the breath is then held for about 10 seconds to allow deposition in the airways. Rapid inhalation or nasal breathing reduces delivery of the drug to the lungs.

Question 14Nursing Foundations and Fundamentals of Nursing

A patient is prescribed oxygen at 2 L/min by nasal cannula. Which nursing action is most important during oxygen therapy?

  1. Keeping the cannula prongs free of moisture and the nares patent Correct answer.
  2. Restricting oral fluids to reduce the need for mouth care
  3. Applying petroleum jelly to the nares to prevent dryness
  4. Discontinuing the oxygen whenever the patient falls asleep

Explanation

Oxygen delivery requires clear, patent airways and clean, dry cannula prongs to maintain the prescribed flow and prevent skin breakdown. Petroleum-based products are flammable and should not be used near oxygen, and oxygen is never stopped simply because the patient sleeps.

Question 15Nursing Foundations and Fundamentals of Nursing

Which finding should the nurse report immediately in a patient receiving a blood transfusion?

  1. A temperature rise of 1 degree Celsius with chills and flank pain Correct answer.
  2. Mild itching at the venepuncture site
  3. Slight bruising around the cannula insertion point
  4. Gradual darkening of the urine over several days

Explanation

Fever with chills, flank pain, and a sense of unease suggests an acute haemolytic transfusion reaction, which requires stopping the transfusion at once and notifying the provider. Itching, delayed dark urine, and minor bruising do not carry the same immediate life-threatening significance.

Question 16Nursing Foundations and Fundamentals of Nursing

A patient is receiving a continuous intravenous infusion of potassium chloride. Which nursing action is essential?

  1. Withholding cardiac monitoring during the infusion
  2. Administering the solution by rapid IV push
  3. Using a controlled infusion device and verifying the concentration Correct answer.
  4. Adding potassium directly to a hanging bag without mixing

Explanation

Potassium chloride must be diluted and infused slowly using a controlled device, with the concentration and rate verified, because rapid delivery can cause fatal dysrhythmias. Cardiac monitoring is required during infusion.

Question 17Nursing Foundations and Fundamentals of Nursing

Which statement correctly describes the principle of surgical asepsis?

  1. It allows sterile items to touch unsterile surfaces if contact is brief
  2. It requires that objects be free of all micro-organisms, including spores Correct answer.
  3. It applies only to the operating theatre and not to ward procedures
  4. It is used to reduce the number of organisms on intact skin before an injection

Explanation

Surgical asepsis, or sterile technique, aims to eliminate all micro-organisms including spores from objects and areas. Medical asepsis reduces organisms on skin and in the environment but does not achieve sterility.

Question 18Nursing Foundations and Fundamentals of Nursing

A patient has been on bed rest for a week. Which nursing measure is most effective in preventing deep vein thrombosis?

  1. Keeping the legs dependent below heart level for long periods
  2. Encouraging early ambulation and leg exercises as tolerated Correct answer.
  3. Applying warm compresses to both legs continuously
  4. Massaging the calves vigorously several times a day

Explanation

Early mobilisation and active leg exercises promote venous return and prevent stasis, which is the main mechanism of deep vein thrombosis in immobile patients. Calf massage is unsafe when thrombosis is suspected, and dependent positioning promotes pooling.

Question 19Nursing Foundations and Fundamentals of Nursing

A nurse is teaching a patient about a low-sodium diet for hypertension. Which food choice best meets this instruction?

  1. Processed cheese and cured ham
  2. Pickled vegetables and soy sauce
  3. Fresh fruit and unsalted nuts Correct answer.
  4. Canned soup with crackers

Explanation

Fresh fruit and unsalted nuts are naturally low in sodium and are appropriate choices for sodium restriction. Canned, cured, pickled, and processed foods are typically high in sodium because salt is used in processing or preservation.

Question 20Nursing Foundations and Fundamentals of Nursing

Which action demonstrates correct technique when collecting a midstream urine specimen from a female patient?

  1. Collecting the first portion of the voided stream
  2. Cleaning the labia from front to back and collecting the middle portion of the stream Correct answer.
  3. Collecting the specimen after a 24-hour collection period
  4. Cleansing the perineum from back to front before voiding

Explanation

A clean-catch midstream specimen requires front-to-back cleansing of the labia and collection of the middle portion of the stream, so that flushing removes contaminants from the distal urethra. Collecting the first portion or cleansing back to front increases contamination.

Question 21Nursing Foundations and Fundamentals of Nursing

Which statement best explains why the nurse documents care promptly after it is given?

  1. Documentation replaces the need for verbal handover between staff
  2. Documentation is required only for procedures that carry risk
  3. Documentation may be completed at the end of the shift from memory
  4. Documentation serves as a legal record and supports continuity of care Correct answer.

Explanation

The clinical record is a legal document that provides evidence of care and communicates information to the team, supporting continuity and safety. It does not replace verbal handover, is required for all care, and should be completed promptly rather than reconstructed from memory.

Question 22Nursing Foundations and Fundamentals of Nursing

A patient with a new colostomy asks how to care for the stoma. Which instruction is correct?

  1. Cleanse the stoma with alcohol before applying the pouch
  2. Cut the skin barrier opening to fit the stoma size and check for leakage Correct answer.
  3. Scrub the stoma vigorously to remove mucus
  4. Apply the pouch only when the stoma is actively discharging stool

Explanation

The skin barrier must be cut to fit the stoma, leaving a small margin, so that effluent does not contact and damage the peristomal skin. Gentle washing with water is sufficient; alcohol and vigorous scrubbing injure the stoma mucosa.

Question 23Nursing Foundations and Fundamentals of Nursing

A nurse is caring for a patient with an indwelling urinary catheter. Which measure best reduces the risk of catheter-associated urinary tract infection?

  1. Routine clamping of the catheter to test bladder tone
  2. Disconnecting the tubing daily to obtain urine samples
  3. Irrigating the catheter routinely every shift
  4. Keeping the drainage bag below the level of the bladder Correct answer.

Explanation

Keeping the drainage bag below bladder level prevents backflow of urine into the bladder, a key source of infection. Routine irrigation, frequent disconnection, and unnecessary clamping all increase contamination risk.

Question 24Nursing Foundations and Fundamentals of Nursing

A patient is receiving nasogastric suction and has developed muscle weakness, a low serum potassium, and an irregular pulse. Which interpretation is most appropriate?

  1. The findings reflect expected effects of bed rest
  2. The findings indicate fluid overload from sodium retention
  3. The findings suggest hypokalaemia from gastrointestinal losses requiring prompt reporting Correct answer.
  4. The findings are unrelated to the suction therapy

Explanation

Nasogastric suction removes potassium-rich gastrointestinal secretions, and hypokalaemia can cause muscle weakness and cardiac dysrhythmias. The nurse should report these findings promptly and anticipate potassium replacement and cardiac monitoring.

Question 25Nursing Foundations and Fundamentals of Nursing

A patient is admitted with severe vomiting and dehydration. Which assessment finding would most strongly support a diagnosis of hypovolaemia?

  1. Bounding pulses and neck vein distension
  2. Crackles at the lung bases and weight gain
  3. Postural hypotension with tachycardia and decreased urine output Correct answer.
  4. Warm, flushed skin with a full pulse

Explanation

Hypovolaemia reduces circulating volume, producing postural hypotension, compensatory tachycardia, and oliguria as the kidneys conserve water and sodium. Bounding pulses, distended neck veins, crackles, and weight gain indicate the opposite problem, fluid overload.

Question 26Nursing Foundations and Fundamentals of Nursing

A patient is unable to bear weight after hip surgery and must be transferred from bed to a chair. Which action should the nurse take first to ensure a safe transfer?

  1. Apply a gait belt around the patient's waist and lock the chair wheels Correct answer.
  2. Delegate the transfer to a single unlicensed assistant to save time
  3. Ask the patient to place both arms around the nurse's neck for support
  4. Raise the bed to the highest position to reduce the distance to the chair

Explanation

A gait belt provides a secure handhold and protects both patient and nurse from injury, while locking the chair wheels prevents the chair from sliding during the transfer. The bed should be at a height that allows the patient's feet to rest flat on the floor, not at its highest position. Safe transfer of a weight-bearing-restricted patient requires at least two trained caregivers and never relies on the patient gripping the nurse's neck.

Question 27Nursing Foundations and Fundamentals of Nursing

A nurse is preparing to perform a bed bath for a dependent patient. Which action best maintains the patient's privacy and dignity?

  1. Wash the genital area first to reduce the total bath time
  2. Keep the room door open so other staff can monitor the patient
  3. Expose only the body part being washed and cover the rest with a bath blanket Correct answer.
  4. Ask the patient to remove all clothing before starting the bath

Explanation

Exposing only the area being washed and keeping the rest covered preserves warmth, privacy, and dignity, which are core principles of fundamental nursing care. The door should be closed or a privacy screen used, and the genital area is washed last, after the cleaner areas, to prevent contamination. Removing all clothing at once increases heat loss and embarrassment.

Question 28Nursing Foundations and Fundamentals of Nursing

A patient has been prescribed a clear liquid diet. Which selection by the patient indicates correct understanding of the diet?

  1. Plain gelatin dessert Correct answer.
  2. Milk
  3. Vanilla ice cream
  4. Strained orange juice

Explanation

A clear liquid diet includes items that are transparent or translucent at room temperature, such as water, broth, tea, clear juices, and plain gelatin. Milk, ice cream, and pulpy juices are not clear liquids because they contain fat, protein, or pulp that leave residue in the gastrointestinal tract. These items are withheld until the patient advances to a full liquid diet.

Question 29Nursing Foundations and Fundamentals of Nursing

A nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale. The patient opens the eyes only to painful stimulation, gives confused verbal responses, and withdraws from pain. Which score should the nurse record?

  1. 11
  2. 10
  3. 8
  4. 9 Correct answer.

Explanation

The Glasgow Coma Scale assigns eye opening to pain a score of 2, confused conversation a verbal score of 4, and withdrawal from pain a motor score of 4. Adding these gives 2 + 4 + 4 = 10, which is the correct total. Scores are summed across the three components, so each subscore must be identified accurately before adding.

Question 30Nursing Foundations and Fundamentals of Nursing

A patient is to receive a subcutaneous injection of insulin. Which technique should the nurse use?

  1. Aspirate before injecting to check for blood return
  2. Insert the needle at a 90-degree angle into the deltoid muscle
  3. Massage the site vigorously after withdrawing the needle
  4. Pinch the skin fold and insert the needle at a 45- to 90-degree angle into the fatty tissue Correct answer.

Explanation

Subcutaneous tissue lies beneath the dermis, so the nurse lifts a skin fold and inserts the needle at 45 to 90 degrees, depending on the patient's adipose thickness, to reach fatty tissue. The deltoid is a site for intramuscular, not subcutaneous, injection. Aspiration is not recommended for insulin, and vigorous massage can alter absorption and cause bruising.

Question 31Nursing Foundations and Fundamentals of Nursing

A nurse is caring for a patient with an order for strict intake and output monitoring. Which entry should the nurse include in the output record?

  1. The amount of water used for mouth care
  2. The volume of urine emptied from the urinary drainage bag Correct answer.
  3. The volume of ice chips swallowed by the patient
  4. The volume of intravenous fluid infused

Explanation

Output includes measurable losses from the body, such as urine, vomitus, wound drainage, and liquid stool. Intravenous fluid, water used for mouth care, and melted ice chips are intake, not output. Accurate intake and output records require consistent classification of each measured volume.

Question 32Nursing Foundations and Fundamentals of Nursing

A patient is ordered to receive a cleansing enema. Which position should the nurse place the patient in for administration?

  1. Sims' position lying on the left side Correct answer.
  2. Supine position with the head elevated 30 degrees
  3. Prone position
  4. High Fowler's position

Explanation

Sims' position on the left side allows the enema solution to flow by gravity along the natural curve of the sigmoid colon and rectum, improving retention and cleansing. High Fowler's, prone, and supine positions do not align the rectum with the descending colon and may cause immediate expulsion of the solution. The left lateral position is therefore standard for administering an enema.

Question 33Nursing Foundations and Fundamentals of Nursing

A nurse is preparing to administer a medication through a nasogastric tube. Which action should the nurse take first?

  1. Crush all medications together and dissolve them in water
  2. Verify tube placement and check for residual volume Correct answer.
  3. Flush the tube with 30 mL of air before giving the medication
  4. Place the patient in a supine position

Explanation

Before any medication is given through a nasogastric tube, the nurse must confirm that the tube is in the stomach and assess residual volume, because misplacement or delayed emptying can cause aspiration or ineffective drug delivery. Medications should be given separately, with flushing between doses, rather than crushed together. The patient is positioned upright, not supine, during administration.

Question 34Nursing Foundations and Fundamentals of Nursing

A patient is admitted with a suspected fracture of the right femur. Which action should the nurse take to immobilize the limb before transfer?

  1. Ask the patient to move the leg to test the range of motion
  2. Apply traction by pulling the limb straight
  3. Support the limb above and below the fracture site and splint it in the position found Correct answer.
  4. Bind the injured leg to the uninjured leg

Explanation

A suspected fracture should be immobilized in the position found by supporting the joints above and below the injury and applying a splint, which prevents further displacement and tissue damage. Pulling on the limb or testing range of motion can worsen the fracture and injure nerves and vessels. Binding the injured leg to the uninjured leg is not a safe substitute for proper splinting.

Question 35Nursing Foundations and Fundamentals of Nursing

A nurse is teaching a patient how to perform a breast self-examination. Which instruction should the nurse include?

  1. Perform the examination at the same time each month, about 7 to 10 days after the start of menstruation Correct answer.
  2. Use the fingertips to press deeply into the breast tissue
  3. Examine only the breast tissue around the nipple
  4. Skip the examination during pregnancy because it is not useful

Explanation

Breast self-examination is best performed about 7 to 10 days after menstruation begins, when hormonal swelling has subsided and the tissue is least tender, and doing it at the same time each month improves consistency. The entire breast, including the axillary tail and nipple, should be examined using the pads of the fingers. Pregnancy does not eliminate the need for breast awareness and examination.

Question 36Nursing Foundations and Fundamentals of Nursing

A patient has a new order for a 24-hour urine collection. Which instruction is essential for the nurse to give the patient?

  1. Discard the first voided specimen and collect all urine thereafter until the 24-hour period ends Correct answer.
  2. Keep the collection container at room temperature
  3. Collect the first voided specimen of the period and discard all later specimens
  4. Stop collecting urine during the night to avoid errors

Explanation

A 24-hour urine collection begins by discarding the first voided specimen, because it represents urine formed before the start time, and then includes all urine voided until the end of the 24-hour period. The container should be kept cool and may need to be refrigerated or placed on ice. Night-time urine must be collected to ensure the full 24-hour volume is captured.

Question 37Nursing Foundations and Fundamentals of Nursing

A nurse is preparing to give a patient a bed bath. Which action should the nurse take to prevent infection?

  1. Wash from the perineal area toward the head
  2. Reuse the bath water for the next patient
  3. Wash the cleanest areas first and the perineal area last Correct answer.
  4. Use the same washcloth for the face and the perineal area

Explanation

Washing from the cleanest areas to the dirtiest, with the perineal area last, prevents microorganisms from the perineum from being transferred to the face, eyes, and skin breaks. Each patient must have fresh bath water and a clean washcloth. Washing from the perineum toward the head or reusing water spreads contamination.

Question 38Nursing Foundations and Fundamentals of Nursing

A patient with a history of falls is being admitted to the unit. Which nursing action is most important to prevent falls?

  1. Keep the bed in the lowest position with the side rails raised as appropriate Correct answer.
  2. Place the call light out of reach to discourage the patient from getting up
  3. Apply physical restraints to all patients with a fall history
  4. Keep the room dark at night to promote sleep

Explanation

Keeping the bed low and the side rails raised when appropriate reduces the distance and impact of a fall and is a standard environmental safety measure. The call light must be within reach so the patient can call for help instead of attempting unsafe transfers. Physical restraints are not a routine fall-prevention measure and require a specific order and monitoring, and adequate lighting at night reduces falls.

Question 39Nursing Foundations and Fundamentals of Nursing

A nurse is caring for a patient who has just returned from surgery and is drowsy. Which action should the nurse take to maintain a patent airway?

  1. Give the patient oral fluids to stimulate swallowing
  2. Keep the head of the bed flat and the neck flexed
  3. Position the patient in a lateral or semi-prone position with the head turned to the side Correct answer.
  4. Place the patient in a supine position with a pillow under the head

Explanation

A drowsy postoperative patient is at risk for aspiration, so the lateral or semi-prone position with the head turned to the side allows secretions and vomitus to drain from the mouth. A supine position with the neck flexed can obstruct the airway, and oral fluids should be withheld until the patient is fully alert and protective reflexes have returned. Airway patency is the priority in the immediate postoperative period.

Question 40Nursing Foundations and Fundamentals of Nursing

A nurse is preparing to administer a medication by the intramuscular route to an adult. Which site is preferred for a large-volume injection?

  1. Dorsogluteal site
  2. Deltoid site
  3. Dorsal surface of the forearm
  4. Ventrogluteal site Correct answer.

Explanation

The ventrogluteal site has a thick muscle mass, is free of major nerves and blood vessels, and can accommodate larger volumes, making it the preferred intramuscular site for adults. The deltoid is small and suitable only for limited volumes, and the dorsogluteal site carries a risk of sciatic nerve injury. The dorsal forearm is not an intramuscular site at all.

Question 41Medical-Surgical Nursing

A patient with acute decompensated heart failure is receiving intravenous furosemide. Which laboratory parameter should the nurse monitor most closely to detect a common adverse effect of this therapy?

  1. Serum amylase
  2. Serum potassium Correct answer.
  3. Serum calcium
  4. Serum bilirubin

Explanation

Loop diuretics such as furosemide block sodium reabsorption in the thick ascending limb and increase urinary excretion of potassium, producing hypokalemia that can precipitate dysrhythmias. Serum potassium is therefore the key electrolyte to trend during therapy.

Question 42Medical-Surgical Nursing

A patient is admitted with an acute ST-elevation myocardial infarction. Which intervention has the greatest impact on limiting final infarct size when reperfusion is available?

  1. Oral aspirin continued for one year
  2. Bed rest with continuous cardiac monitoring
  3. Immediate primary percutaneous coronary intervention Correct answer.
  4. Sublingual nitroglycerin every five minutes

Explanation

Primary percutaneous coronary intervention restores coronary blood flow and the duration of ischemia is the strongest determinant of myocardial salvage. Reperfusion within the recommended time window limits infarct size and improves survival outcomes.

Question 43Medical-Surgical Nursing

A patient with chronic obstructive pulmonary disease has a respiratory rate of 28/min and oxygen saturation of 88% on room air. Which oxygen delivery approach is safest initially?

  1. High-flow oxygen titrated to 100% saturation
  2. Mouth-to-mask ventilation with 100% oxygen
  3. Non-rebreather mask at 15 L/min
  4. Controlled low-flow oxygen targeting 88–92% saturation Correct answer.

Explanation

In patients with chronic hypercapnia, over-oxygenation can worsen carbon dioxide retention and respiratory drive, so controlled oxygen targeting 88–92% is recommended. Oxygen is titrated to the target saturation rather than to maximum values.

Question 44Medical-Surgical Nursing

A patient with diabetic ketoacidosis has a blood glucose of 480 mg/dL and a serum potassium of 3.1 mEq/L. What is the priority action before starting the insulin infusion?

  1. Withhold all fluids until glucose falls
  2. Give intravenous sodium bicarbonate
  3. Administer intravenous potassium replacement Correct answer.
  4. Start a rapid 0.9% saline bolus only

Explanation

Insulin drives potassium into cells and can precipitate dangerous hypokalemia, so potassium must be replaced when the serum level is below the threshold before insulin is given. Fluid resuscitation proceeds concurrently with electrolyte correction.

Question 45Medical-Surgical Nursing

A patient with a new ileostomy has a high-volume output. Which finding most directly indicates the need for urgent intervention?

  1. Stoma that is pink and moist
  2. Serum potassium of 3.0 mEq/L with orthostatic dizziness Correct answer.
  3. Mild peristomal skin irritation
  4. Stoma output of 250 mL in 24 hours

Explanation

High-output ileostomies cause loss of sodium, potassium, and water, and hypokalemia with orthostatic symptoms signals significant volume and electrolyte depletion requiring prompt replacement. A pink moist stoma and modest output are expected findings.

Question 46Medical-Surgical Nursing

A patient is receiving intravenous heparin for a pulmonary embolism. Which laboratory test is used to monitor the therapeutic effect?

  1. Activated partial thromboplastin time Correct answer.
  2. Platelet count
  3. International normalized ratio
  4. D-dimer

Explanation

Unfractionated heparin potentiates antithrombin and prolongs the activated partial thromboplastin time, which is used to titrate the infusion to a therapeutic range. The INR monitors warfarin, not heparin.

Question 47Medical-Surgical Nursing

A patient with a closed head injury has a Glasgow Coma Scale score of 13 and is becoming increasingly drowsy. Which nursing action takes priority?

  1. Perform a full neurological assessment every four hours
  2. Elevate the head of the bed and notify the provider immediately Correct answer.
  3. Administer a prescribed PRN analgesic for headache
  4. Encourage the patient to ambulate in the hallway

Explanation

A declining level of consciousness after head injury suggests rising intracranial pressure, so the nurse should position the head to promote venous drainage and escalate to the provider urgently. Frequent reassessment alone delays needed intervention.

Question 48Medical-Surgical Nursing

Which finding is most characteristic of acute respiratory distress syndrome in an adult patient?

  1. Hypercapnia with a normal chest radiograph
  2. Refractory hypoxemia with bilateral infiltrates and normal cardiac filling pressures Correct answer.
  3. Sudden pleuritic pain with a localized friction rub
  4. Unilateral wheezing that resolves with bronchodilators

Explanation

ARDS is defined by acute onset of hypoxemia that is refractory to supplemental oxygen, bilateral opacities not fully explained by cardiac failure, and a normal or low pulmonary capillary wedge pressure. The hallmark is non-cardiogenic permeability edema.

Question 49Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.8 mEq/L and peaked T waves on the electrocardiogram. Which medication should be given first to protect the myocardium?

  1. Intravenous regular insulin with dextrose
  2. Oral sodium polystyrene sulfonate
  3. Subcutaneous terbutaline
  4. Intravenous calcium gluconate Correct answer.

Explanation

Calcium stabilizes the myocardial cell membrane within minutes and prevents lethal dysrhythmias from hyperkalemia, so it is given first when ECG changes are present. Other measures shift or remove potassium but act more slowly.

Question 50Medical-Surgical Nursing

A patient with type 2 diabetes is prescribed metformin. Which instruction is essential to include in patient teaching?

  1. Report persistent nausea, abdominal pain, or rapid breathing promptly Correct answer.
  2. Take the medication on an empty stomach every morning
  3. Increase the dose whenever a meal is skipped
  4. Stop the drug whenever blood glucose is below 200 mg/dL

Explanation

Metformin can precipitate lactic acidosis, which presents with gastrointestinal symptoms, malaise, and hyperventilation, so these warning signs require urgent evaluation. The drug is taken with meals to reduce gastrointestinal upset.