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PGIMER Nursing Officer practice questions

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Question 1Medical-Surgical Nursing

A patient with a new ileostomy has liquid stool output of about 1,500 mL per day. Which electrolyte disturbance should the nurse anticipate on the metabolic panel?

  1. Hyperkalemia with metabolic acidosis
  2. Hypernatremia with metabolic alkalosis
  3. Hypocalcemia with respiratory alkalosis
  4. Hypokalemia with metabolic acidosis Correct answer.

Explanation

Ileostomy effluent is rich in sodium, potassium and bicarbonate, so large ileal losses typically produce hypokalemia, hyponatremia and a non-anion-gap metabolic acidosis from bicarbonate wasting. Recognizing this pattern guides replacement therapy and fluid monitoring.

Question 2Medical-Surgical Nursing

A patient is admitted with diabetic ketoacidosis. Which set of arterial blood gas findings is most consistent with this diagnosis?

  1. pH 7.50, PaCO2 48 mmHg, HCO3 30 mEq/L
  2. pH 7.48, PaCO2 30 mmHg, HCO3 24 mEq/L
  3. pH 7.30, PaCO2 30 mmHg, HCO3 12 mEq/L Correct answer.
  4. pH 7.32, PaCO2 55 mmHg, HCO3 26 mEq/L

Explanation

DKA produces a primary metabolic acidosis with a low bicarbonate and a compensatory respiratory alkalosis that lowers PaCO2. A pH below 7.35 with low HCO3 and low PaCO2 fits this compensated anion-gap acidosis.

Question 3Medical-Surgical Nursing

Which early clinical sign should the nurse monitor for in a patient receiving a rapid infusion of 0.45% sodium chloride?

  1. Bounding pulse and hypertension
  2. Pulmonary crackles and jugular venous distension
  3. Muscle weakness and confusion Correct answer.
  4. Warm flushed skin and thirst

Explanation

Hypotonic fluids shift water into cells and can dilute serum sodium, producing hyponatremia with headache, confusion, lethargy and muscle weakness. These neurologic signs reflect cerebral edema risk and require prompt reassessment.

Question 4Medical-Surgical Nursing

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

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

Explanation

Intravenous calcium stabilizes the cardiac membrane within minutes and is the immediate priority when hyperkalemia produces ECG changes. Potassium-lowering therapies are given afterward but act too slowly to prevent arrhythmia.

Question 5Medical-Surgical Nursing

A patient with heart failure is prescribed furosemide. Which instruction is most important for the nurse to include in discharge teaching?

  1. Report a weight gain of more than 1 kg in a day Correct answer.
  2. Increase potassium-rich foods without laboratory monitoring
  3. Stop the drug when ankle swelling resolves
  4. Take the dose at bedtime to improve absorption

Explanation

Daily weights are the most sensitive home indicator of fluid retention in heart failure, and a gain of about 1 kg in a day signals decompensation requiring contact with the provider. This teaching supports early intervention before overt symptoms develop.

Question 6Medical-Surgical Nursing

Which finding should the nurse report immediately in a patient who has just returned from a cardiac catheterization via the femoral artery?

  1. Mild back discomfort when lying flat
  2. Absent pedal pulse on the affected leg Correct answer.
  3. A small bruise at the puncture site
  4. Serum creatinine of 0.9 mg/dL

Explanation

Loss of the distal pulse suggests arterial occlusion or a developing hematoma compressing the vessel, which threatens limb viability and requires urgent assessment. Pulses, color, warmth and sensation are checked frequently after femoral access.

Question 7Medical-Surgical Nursing

A patient with an acute exacerbation of asthma has a silent chest on auscultation and rising PaCO2. How should the nurse interpret these findings?

  1. The exacerbation is resolving and wheezing has cleared
  2. Airflow is so poor that breath sounds are inaudible, indicating impending respiratory failure Correct answer.
  3. Mucus has plugged the airways and suctioning will fully restore airflow
  4. The patient is hyperventilating and needs a sedative

Explanation

A silent chest means airflow is too low to generate wheeze, and a rising PaCO2 in asthma signals fatigue and impending respiratory failure. These are ominous signs requiring immediate escalation rather than reassurance.

Question 8Medical-Surgical Nursing

Which assessment finding is most characteristic of a tension pneumothorax?

  1. Fine crackles at both lung bases
  2. Dull percussion note over the affected hemithorax
  3. Tracheal deviation toward the affected side
  4. Tracheal deviation away from the affected side with hypotension Correct answer.

Explanation

In tension pneumothorax, rising intrathoracic pressure pushes mediastinal structures away from the affected side and impairs venous return, producing hypotension. This combination is a life-threatening emergency requiring immediate decompression.

Question 9Medical-Surgical Nursing

A patient is receiving a blood transfusion. Fifteen minutes after starting, the patient reports chills, low back pain and dark urine. What is the nurse's first action?

  1. Slow the transfusion and reassess in 15 minutes
  2. Stop the transfusion and maintain intravenous access with normal saline Correct answer.
  3. Obtain a urine sample before stopping the infusion
  4. Give the prescribed antihistamine and continue the transfusion

Explanation

Fever, back pain and hemoglobinuria suggest an acute hemolytic reaction, which demands immediate cessation of the transfusion while venous access is preserved with saline. The blood bank and provider are notified and the unit is returned for investigation.

Question 10Medical-Surgical Nursing

A patient with a permanent pacemaker is scheduled for magnetic resonance imaging. Which action is most appropriate?

  1. Cancel the scan permanently because pacemakers are absolute contraindications
  2. Place a magnet over the generator during the scan
  3. Remove the pacemaker before the scan
  4. Verify that the device is MRI-conditional and arrange reprogramming before the scan Correct answer.

Explanation

Many modern pacemakers are MRI-conditional, but safe scanning requires confirming device and lead compatibility and reprogramming to an appropriate mode with monitoring. Non-conditional devices may need alternative imaging.

Question 11Medical-Surgical Nursing

Which ECG change should the nurse expect in a patient with hypokalemia?

  1. Shortened QT interval
  2. Flat or inverted T waves with prominent U waves Correct answer.
  3. First-degree heart block
  4. Peaked T waves and widened QRS

Explanation

Low potassium delays ventricular repolarization, producing flattened or inverted T waves, ST depression and prominent U waves. These changes predispose to ventricular arrhythmias and warrant potassium replacement.

Question 12Medical-Surgical Nursing

A patient is admitted with a suspected acute myocardial infarction. Which laboratory marker rises earliest after symptom onset?

  1. Myoglobin Correct answer.
  2. Troponin I
  3. Creatine kinase-MB
  4. Lactate dehydrogenase

Explanation

Myoglobin rises within one to four hours of myocardial injury but is nonspecific, so it is not used alone for diagnosis. Troponin remains the preferred marker because of its specificity and duration of elevation.

Question 13Medical-Surgical Nursing

A patient with an acute upper gastrointestinal bleed has a hemoglobin of 7.2 g/dL and is hypotensive. Which nursing action takes priority?

  1. Insert a nasogastric tube for lavage
  2. Administer oral iron supplements
  3. Establish two large-bore intravenous lines and begin fluid resuscitation Correct answer.
  4. Encourage oral fluids to maintain hydration

Explanation

Hemorrhagic shock requires rapid restoration of circulating volume through large-bore access while blood products are arranged. Diagnostic procedures follow only after airway, breathing and circulation are stabilized.

Question 14Medical-Surgical Nursing

Which position should the nurse use to promote comfort and reduce aspiration risk in a patient with acute pancreatitis?

  1. Trendelenburg position
  2. Supine with legs extended
  3. Prone with head turned to the side
  4. Sitting upright and leaning forward Correct answer.

Explanation

Sitting upright with a forward lean reduces pressure on the inflamed pancreas and diaphragm, easing pain and lowering aspiration risk. Supine positioning tends to worsen abdominal pain in pancreatitis.

Question 15Medical-Surgical Nursing

A patient with cirrhosis has ascites and is prescribed spironolactone. Which parameter best indicates the desired therapeutic response?

  1. Increased serum potassium
  2. Increased urine specific gravity
  3. Decreased serum albumin
  4. Reduction in abdominal girth and daily weight Correct answer.

Explanation

Abdominal girth and daily weight directly reflect the mobilization of ascitic fluid, which is the therapeutic goal of diuretic therapy. Serum electrolytes and renal function are monitored to detect adverse effects rather than to confirm benefit.

Question 16Medical-Surgical Nursing

A patient has a serum calcium of 6.8 mg/dL after a thyroidectomy. Which early sign should the nurse monitor for?

  1. Polyuria and excessive thirst
  2. Perioral tingling and carpopedal spasm Correct answer.
  3. Flushing and hyperthermia
  4. Bradycardia and hypertension

Explanation

Hypocalcemia after thyroidectomy increases neuromuscular excitability, producing perioral numbness, tingling of the extremities and carpopedal spasm. A positive Trousseau or Chvostek sign supports the finding and prompts calcium replacement.

Question 17Medical-Surgical Nursing

A patient with type 1 diabetes has a blood glucose of 48 mg/dL and is conscious and able to swallow. What should the nurse give first?

  1. A dose of long-acting insulin
  2. A high-protein snack without carbohydrate
  3. 15 g of fast-acting carbohydrate such as glucose tablets Correct answer.
  4. Intravenous 50% dextrose

Explanation

For a conscious patient who can swallow, the first step is 15 g of rapidly absorbed carbohydrate followed by rechecking glucose in about 15 minutes. Intravenous dextrose is reserved for patients who cannot take oral intake safely.

Question 18Medical-Surgical Nursing

Which finding in a patient with diabetic ketoacidosis indicates that treatment is progressing appropriately?

  1. Falling serum potassium with widening QRS
  2. Increasing serum osmolality and worsening confusion
  3. Increasing serum bicarbonate and falling anion gap Correct answer.
  4. Rising serum ketones with persistent Kussmaul breathing

Explanation

Resolution of ketoacidosis is shown by rising bicarbonate, closing of the anion gap and clearance of ketones as insulin takes effect. Electrolytes and neurologic status are watched closely for complications during treatment.

Question 19Medical-Surgical Nursing

A patient with chronic obstructive pulmonary disease has an oxygen saturation of 85% on room air. What is the appropriate oxygen therapy approach?

  1. Withhold oxygen entirely to avoid suppressing the respiratory drive
  2. Administer 100% oxygen by nonrebreather mask
  3. Titrate oxygen to a target saturation of about 88% to 92% Correct answer.
  4. Use only a nasal cannula at 10 L/min

Explanation

Controlled oxygen titrated to roughly 88% to 92% corrects hypoxemia while limiting the risk of hypercapnia in patients with chronic hypercapnic COPD. Oxygen is never withheld from a hypoxemic patient.

Question 20Medical-Surgical Nursing

Which assessment finding most strongly suggests increased intracranial pressure in a patient after a traumatic brain injury?

  1. Improved Glasgow Coma Scale score
  2. Bilateral pinpoint pupils with hyperreflexia
  3. Fixed dilated pupil with decreasing level of consciousness Correct answer.
  4. Increased urinary output with low urine specific gravity

Explanation

A fixed dilated pupil with declining consciousness reflects cranial nerve compression and herniation risk from rising intracranial pressure. Neurologic checks must be escalated immediately for medical and surgical intervention.

Question 21Medical-Surgical Nursing

A patient who had a stroke two days ago is being evaluated for swallowing. Which action is most appropriate before oral intake?

  1. Give thin liquids first to test tolerance
  2. Perform a bedside swallow screen and keep the patient NPO until it is passed Correct answer.
  3. Place the patient supine for feeding
  4. Encourage a full meal to assess fatigue

Explanation

Stroke commonly impairs swallowing, and aspiration risk is reduced by screening before any oral intake. Patients who fail the screen need formal evaluation and alternative nutrition.

Question 22Medical-Surgical Nursing

A patient with acute spinal cord injury at T4 develops severe hypertension, bradycardia and a pounding headache. What is the nurse's priority action?

  1. Administer a prescribed antipyretic
  2. Encourage the patient to bear down
  3. Place the patient flat and restrict fluids
  4. Sit the patient upright and check for bladder distension or fecal impaction Correct answer.

Explanation

These findings indicate autonomic dysreflexia, triggered by noxious stimuli below the injury level such as a distended bladder. Sitting the patient up lowers blood pressure while the cause is identified and removed.

Question 23Medical-Surgical Nursing

A patient is in the oliguric phase of acute kidney injury. Which nursing intervention is most important?

  1. Withhold all prescribed medications
  2. Encourage a high-protein diet
  3. Restrict potassium and monitor serum levels and ECG Correct answer.
  4. Maintain a high fluid intake to flush the kidneys

Explanation

Oliguric acute kidney injury impairs potassium excretion, so dietary restriction and monitoring for hyperkalemia are essential to prevent arrhythmia. Fluid balance and medication dosing are also adjusted to renal function.

Question 24Medical-Surgical Nursing

A patient with a chest tube after lobectomy has continuous bubbling in the water-seal chamber. How should the nurse interpret this?

  1. An air leak that requires assessment of the tubing and insertion site Correct answer.
  2. Normal bubbling that requires no action
  3. Ongoing drainage that should be measured hourly
  4. A sign that suction should be increased

Explanation

Continuous bubbling in the water-seal chamber indicates air escaping into the system, suggesting a leak at the insertion site, tubing or lung. The nurse assesses the system from patient to drainage unit and notifies the provider if it persists.

Question 25Medical-Surgical Nursing

Which instruction should the nurse give a patient about to start chemotherapy with a vesicant agent?

  1. Apply heat to the site if redness appears
  2. Expect the infusion to cause no local effects
  3. Delay reporting symptoms until the next visit
  4. Report pain or burning at the infusion site immediately Correct answer.

Explanation

Vesicants can cause severe tissue necrosis if extravasation occurs, so pain, burning or swelling at the site must be reported at once to stop the infusion. Early recognition limits tissue damage.

Question 26Medical-Surgical Nursing

A patient with an acute exacerbation of heart failure is prescribed furosemide 40 mg IV. Which assessment finding should the nurse document as the most direct evidence that the drug is producing the intended effect?

  1. Increase in serum potassium from 3.6 to 4.9 mEq/L
  2. Reduction in serum creatinine from 1.9 to 1.4 mg/dL
  3. Fall in heart rate from 118 to 96 beats per minute
  4. Reduction in bilateral lung crackles and a fall in body weight Correct answer.

Explanation

Loop diuretics such as furosemide relieve pulmonary congestion by promoting diuresis, so clearing of crackles and measurable weight loss from fluid removal are the direct markers of effect. Heart rate and creatinine may improve secondarily but do not confirm diuresis. A rising potassium is the opposite of the expected hypokalemic effect.

Question 27Medical-Surgical Nursing

A patient is started on isoniazid, rifampicin, pyrazinamide and ethambutol for pulmonary tuberculosis. Which instruction is most important for the nurse to give at discharge?

  1. Take the drugs only until fever and cough resolve
  2. Expect orange discolouration of urine and tears as a harmless effect Correct answer.
  3. Report yellowing of the eyes or dark urine promptly
  4. Avoid all dairy products for the entire course

Explanation

Rifampicin harmlessly stains urine, sweat, tears and soft contact lenses orange-red, and patients who are not warned may stop treatment out of alarm. Adherence to the full multi-drug course is essential to prevent resistance and relapse. Hepatotoxicity is also a concern, but the colour change is the predictable effect needing explanation.

Question 28Medical-Surgical Nursing

A patient is admitted with a suspected acute myocardial infarction. Which laboratory marker rises earliest after the onset of chest pain?

  1. Creatine kinase-MB
  2. Myoglobin Correct answer.
  3. Lactate dehydrogenase
  4. Troponin I

Explanation

Myoglobin is released from damaged muscle within one to two hours of infarction and is the earliest marker to rise, although it is nonspecific. Troponin is more specific and becomes positive within about three to four hours. CK-MB rises at roughly four to six hours and LDH peaks over several days.

Question 29Medical-Surgical Nursing

A patient has a serum potassium of 6.9 mEq/L with peaked T waves on the ECG. Which prescribed action should the nurse anticipate first?

  1. Administer oral sodium polystyrene sulfonate
  2. Start an insulin infusion with dextrose
  3. Give intravenous calcium gluconate Correct answer.
  4. Obtain a repeat potassium level in four hours

Explanation

Hyperkalemia with ECG changes threatens fatal arrhythmia, so the immediate priority is membrane stabilisation with intravenous calcium, which acts within minutes and does not lower the potassium itself. Insulin with dextrose and potassium binders lower the level but take longer. Waiting four hours risks cardiac arrest.

Question 30Medical-Surgical Nursing

A patient with chronic obstructive pulmonary disease has an oxygen saturation of 85% on room air. What is the appropriate initial oxygen therapy?

  1. Oxygen only if the patient becomes drowsy
  2. No oxygen, because it will abolish the hypoxic drive
  3. High-flow oxygen at 10 to 15 L/min by mask
  4. Controlled oxygen titrated to a saturation of 88 to 92% Correct answer.

Explanation

In COPD, oxygen is titrated to a target saturation of about 88 to 92% to correct hypoxaemia while avoiding hypercapnia and oxygen toxicity. Uncontrolled high-flow oxygen can worsen carbon dioxide retention in patients with chronic hypercapnia. Withholding oxygen is dangerous because hypoxaemia is more immediately life-threatening.

Question 31Medical-Surgical Nursing

A patient with type 1 diabetes is drowsy, has a blood glucose of 620 mg/dL, pH 7.12 and deep rapid respirations. Which finding best indicates that treatment is working?

  1. Increasing urine ketones on dipstick
  2. Narrowing of the anion gap with a rising pH Correct answer.
  3. Development of a bounding pulse and flushed skin
  4. Rising serum potassium with a falling pH

Explanation

Resolution of diabetic ketoacidosis is shown by closure of the anion gap and correction of the acidosis as insulin drives ketone production down and bicarbonate rises. Potassium shifts back into cells during treatment, so serum potassium usually falls rather than rises. Urine ketones can remain positive for hours after clinical recovery.

Question 32Medical-Surgical Nursing

A patient who had a stroke two days ago is being assessed before oral feeding. Which action is most appropriate first?

  1. Insert a nasogastric tube for routine feeding
  2. Give a small sip of water and observe for coughing
  3. Start a soft diet and sit the patient upright
  4. Perform a bedside swallowing screen and keep the patient nil by mouth until it is passed Correct answer.

Explanation

After stroke, dysphagia must be screened before any oral intake because aspiration can cause pneumonia. Until the screen is passed, the patient stays nil by mouth, with intravenous or tube support as needed. Trials of water or food before screening expose the patient to avoidable aspiration.

Question 33Medical-Surgical Nursing

A patient with a chest drain after lobectomy has continuous bubbling in the water-seal chamber. How should the nurse interpret this?

  1. A blocked drain requiring milking
  2. Normal bubbling caused by the patient's breathing
  3. Evidence that the lung has fully re-expanded
  4. An air leak in the system that should be located and assessed Correct answer.

Explanation

The water-seal chamber should bubble only briefly on coughing or on insertion; continuous bubbling indicates air entering the system, either from a leak around the insertion site or in the tubing connections. The nurse should check the connections and insertion site and report persistent leakage. Bubbling does not indicate re-expansion, which is shown by tidalling.

Question 34Medical-Surgical Nursing

A patient with acute kidney injury is in the oliguric phase with a potassium of 6.1 mEq/L. Which dietary instruction is most important?

  1. Increase intake of bananas and oranges for energy
  2. Increase protein to 2 g per kilogram per day
  3. Restrict all fluids to less than 200 mL per day
  4. Avoid potassium-rich foods such as bananas, oranges and potatoes Correct answer.

Explanation

In oliguric acute kidney injury, potassium excretion falls, so potassium-rich foods must be limited to prevent dangerous hyperkalaemia. Fluid restriction is individualized, usually based on urine output plus insensible losses, and 200 mL per day is far too severe. High protein intake is not appropriate in unresolved renal failure.

Question 35Medical-Surgical Nursing

A patient with cirrhosis has ascites and is prescribed spironolactone. Which parameter best indicates the desired therapeutic effect?

  1. Rising serum potassium
  2. Reduction in serum albumin
  3. Weight loss with stable renal function Correct answer.
  4. Increasing abdominal girth

Explanation

Spironolactone is a potassium-sparing aldosterone antagonist used to mobilise ascites; a gradual weight loss with preserved renal function shows effective diuresis without over-diuresis. Serum potassium may rise and needs monitoring, but that is an adverse effect rather than a therapeutic marker. Increasing girth or falling albumin indicates worsening disease.

Question 36Medical-Surgical Nursing

A patient with an acute upper gastrointestinal bleed has a haemoglobin of 7.2 g/dL and a blood pressure of 84/50 mmHg. Which action should the nurse take first?

  1. Give oral iron supplements with vitamin C
  2. Obtain a stool sample for occult blood
  3. Establish large-bore intravenous access and begin fluid resuscitation Correct answer.
  4. Send the patient for an urgent endoscopy without further preparation

Explanation

The priority in a bleeding patient with hypotension is haemodynamic resuscitation: large-bore access, crystalloid and blood products, and monitoring, while arranging endoscopy. Sending an unstable patient to endoscopy without resuscitation risks collapse. Oral iron and stool testing are irrelevant in acute haemorrhage.

Question 37Medical-Surgical Nursing

A patient with a T4 spinal cord injury develops severe hypertension, bradycardia and a pounding headache. What is the nurse's priority action?

  1. Administer a prescribed intravenous beta-blocker immediately
  2. Lay the patient flat to improve cerebral perfusion
  3. Sit the patient upright and check for bladder distension Correct answer.
  4. Give a prescribed antipyretic and recheck the temperature

Explanation

This is autonomic dysreflexia, triggered by a noxious stimulus below the injury, most often a distended bladder or impacted bowel. The immediate response is to sit the patient up to reduce blood pressure and find and remove the trigger. Drugs are used if the pressure remains high after these measures.

Question 38Medical-Surgical Nursing

A patient is receiving a blood transfusion. Fifteen minutes after starting, the patient reports chills, low back pain and dark urine. Which action should the nurse take?

  1. Stop the transfusion, keep the line patent with normal saline and notify the provider Correct answer.
  2. Give the prescribed antihistamine and continue the transfusion
  3. Slow the transfusion and reassess in 15 minutes
  4. Check the vital signs and document the findings

Explanation

Fever, chills, back pain and haemoglobinuria suggest an acute haemolytic transfusion reaction, usually from ABO incompatibility. The transfusion must be stopped at once, the line maintained with normal saline through new tubing, and the provider notified while the patient is supported. Continuing or merely slowing the transfusion allows further haemolysis.

Question 39Medical-Surgical Nursing

A patient with acute pancreatitis is prescribed enteral nutrition. Which route and rationale should the nurse expect?

  1. Total parenteral nutrition, because the gut must be rested completely
  2. Oral clear fluids only, because any feeding worsens pain
  3. Nasojejunal feeding, because it bypasses pancreatic stimulation Correct answer.
  4. Nasogastric feeding, because gastric acid inactivates pancreatic enzymes

Explanation

Enteral feeding is preferred in acute pancreatitis to maintain gut mucosal integrity, and nasojejunal delivery bypasses the stomach and duodenum so pancreatic stimulation is reduced. Prolonged bowel rest and total parenteral nutrition are avoided where possible because of infection risk. Nasogastric feeding may stimulate pancreatic secretion more than jejunal feeding.

Question 40Medical-Surgical Nursing

Which finding should the nurse report immediately in a patient who has just returned from a cardiac catheterisation via the femoral artery?

  1. A small bruise at the puncture site
  2. Absent pedal pulse in the affected leg with cool, pale skin Correct answer.
  3. Serum potassium of 4.2 mEq/L
  4. Complaint of mild back discomfort when lying flat

Explanation

Loss of the pedal pulse with a cool, pale limb suggests arterial occlusion or a haematoma compressing the vessel, which threatens limb viability and needs urgent assessment. A small bruise is common and expected. Mild back discomfort from lying flat and a normal potassium do not require immediate escalation.

Question 41Fundamentals of Nursing

A patient is receiving a continuous nasogastric tube feeding. Which nursing action best prevents aspiration during the feeding?

  1. Flush the tube with 10 mL of water before starting the feed
  2. Elevate the head of the bed to 30–45 degrees during and for 30–60 minutes after feeding Correct answer.
  3. Change the feeding container every 48 hours
  4. Check the gastric residual volume every 8 hours

Explanation

Semi-recumbent positioning uses gravity to keep formula in the stomach and reduces reflux into the pharynx, so it is the single most effective aspiration-prevention measure during enteral feeding. Flushing, residual checks and set changes address tube patency and infection control rather than aspiration risk directly.

Question 42Fundamentals of Nursing

Which route is used to administer the BCG vaccine to a newborn under the national immunisation schedule?

  1. Subcutaneous
  2. Intravenous
  3. Intradermal Correct answer.
  4. Intramuscular

Explanation

BCG is given intradermally, usually over the left deltoid, because the vaccine must be deposited in the dermis to produce the characteristic local reaction and scar. Intramuscular or subcutaneous placement alters absorption and is not the recommended route.

Question 43Fundamentals of Nursing

A nurse is preparing to insert a peripheral intravenous cannula. Which action follows standard aseptic technique?

  1. Palpating the cleaned site with a gloved finger before puncture
  2. Applying the tourniquet after skin antisepsis
  3. Wearing sterile gloves for the whole procedure
  4. Cleaning the skin with alcohol and fanning it dry before puncture Correct answer.

Explanation

Skin antisepsis must be allowed to dry so that the disinfectant acts and so that residual alcohol does not cause stinging or impair adhesion. Re-palpation after antisepsis contaminates the site and restarts the process.

Question 44Fundamentals of Nursing

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

  1. A rise in temperature of 1 °C with chills and flank pain Correct answer.
  2. Bruising near the venepuncture site
  3. A heart rate of 88 beats per minute
  4. Mild pruritus at the cannula site

Explanation

Fever with chills and flank or back pain suggests an acute haemolytic transfusion reaction, which requires stopping the transfusion and notifying the clinician at once. Pruritus, bruising and a normal heart rate do not carry the same urgency.

Question 45Fundamentals of Nursing

Which position is most appropriate for a patient with severe dyspnoea due to pulmonary oedema?

  1. Prone position
  2. Supine with legs elevated
  3. Trendelenburg position
  4. High Fowler's position Correct answer.

Explanation

High Fowler's position lowers the diaphragm and reduces venous return to the thorax, easing the work of breathing in pulmonary oedema. Supine and Trendelenburg positions increase venous return and worsen pulmonary congestion.

Question 46Fundamentals of Nursing

A nurse is assessing a patient's pain using a numerical rating scale. Which statement reflects correct pain assessment practice?

  1. Pain intensity should be documented using the patient's self-report Correct answer.
  2. Vital signs alone reliably indicate the presence of pain
  3. Pain should be reassessed only at the end of the shift
  4. Pain should be assessed only when the patient requests analgesia

Explanation

Pain is a subjective experience, and the patient's self-report is the most reliable indicator of its intensity. Objective signs such as vital signs are adjuncts, not substitutes, and reassessment should follow each intervention.

Question 47Fundamentals of Nursing

Which principle applies when a nurse calculates a paediatric drug dose?

  1. Use the dose based on the child's height in centimetres
  2. Use the adult dose adjusted by the child's weight in kilograms Correct answer.
  3. Use the adult dose unless the child is under one year
  4. Use the adult dose reduced by half for all children

Explanation

Paediatric doses are calculated from body weight, and sometimes body surface area, using a verified reference, because drug handling differs from adults. Age, height alone or a fixed fraction of the adult dose is not a safe basis.

Question 48Fundamentals of Nursing

A patient is prescribed oxygen at 2 L/min by nasal cannula. Which nursing action is correct?

  1. Set the flow rate before placing the cannula on the patient Correct answer.
  2. Fill the humidifier bottle to the top
  3. Use a non-rebreather mask for this flow rate
  4. Apply petroleum jelly to the nostrils to prevent dryness

Explanation

The flow rate must be set and checked before the device is applied so the patient receives the prescribed concentration. Petroleum-based lubricants are avoided near oxygen because they are flammable, and a nasal cannula is the appropriate device for low-flow oxygen.

Question 49Fundamentals of Nursing

When performing a surgical hand scrub, the nurse should keep the hands and forearms in which position?

  1. Below elbow level to allow water to drain from the fingers
  2. Above elbow level throughout the scrub and rinse Correct answer.
  3. Alternating above and below elbow level
  4. At the same level as the elbows

Explanation

Keeping the hands higher than the elbows allows water and contaminants to flow away from the hands toward the elbows, maintaining the cleanest area. Hands held below the elbows allow contaminated water to run back over the hands.

Question 50Fundamentals of Nursing

Which statement correctly describes the purpose of a pressure ulcer risk assessment tool such as the Braden Scale?

  1. It determines the need for surgical debridement
  2. It diagnoses the stage of an existing pressure ulcer
  3. It estimates the risk of developing a pressure ulcer so preventive measures can be planned Correct answer.
  4. It measures the depth of tissue damage in a wound

Explanation

The Braden Scale scores factors such as mobility, moisture, nutrition and friction to estimate a patient's likelihood of developing a pressure injury. It guides prevention planning and is not a diagnostic or wound-measurement tool.