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UP CNET practice questions

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Question 1Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A patient scheduled for surgery has a serum potassium of 2.8 mEq/L. Which action should the nurse take first?

  1. Encourage potassium-rich foods and proceed with preparation
  2. Document the value and recheck after surgery
  3. Administer the preoperative sedative as ordered
  4. Notify the surgeon and anticipate postponement of surgery Correct answer.

Explanation

Hypokalemia below 3.0 mEq/L predisposes to cardiac dysrhythmias and respiratory muscle weakness, so elective surgery is generally deferred until potassium is corrected. The nurse's priority is to inform the surgical team so the risk is addressed before anesthesia.

Question 2Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which finding in a newborn at 6 hours of life most strongly suggests respiratory distress?

  1. Nasal flaring with intercostal retractions Correct answer.
  2. Acrocyanosis of the hands and feet
  3. Passage of meconium stool
  4. Heart rate of 150 beats per minute

Explanation

Nasal flaring and intercostal retractions are accessory muscle signs of increased work of breathing and are reliable indicators of neonatal respiratory distress. The other findings listed are common and generally benign in the first day of life.

Question 3Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with major depressive disorder has been taking sertraline for two weeks. Which statement indicates the nurse should provide further teaching?

  1. I may notice some nausea during the first few weeks
  2. I should report any unusual agitation or restlessness
  3. I will avoid taking St John's wort while on this medication
  4. I will stop the drug if my mood has not improved by next week Correct answer.

Explanation

Antidepressant response typically requires four to six weeks, so premature discontinuation is a common and important error. Abrupt stopping also risks discontinuation symptoms, and the client must be taught to consult the prescriber before changing therapy.

Question 4Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which instruction is most important when teaching a patient about using a metered-dose inhaler with a spacer?

  1. Rinse the spacer with soap daily and let it dry completely
  2. Wait at least 30 seconds between puffs of the same drug
  3. Hold the breath for about 10 seconds after inhalation Correct answer.
  4. Inhale rapidly and forcefully during actuation

Explanation

A breath hold of roughly 10 seconds allows the aerosolized drug to deposit in the lower airways rather than being exhaled. Proper technique is central to therapeutic effect in asthma and COPD management.

Question 5Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A woman at 34 weeks' gestation presents with painless bright red vaginal bleeding. Which nursing action is appropriate?

  1. Obtain a urine specimen for culture and send the client home
  2. Perform a digital vaginal examination to assess dilation
  3. Place the client on bed rest and prepare for cesarean birth Correct answer.
  4. Ambulate the client to stimulate labor progression

Explanation

Painless bright red bleeding in late pregnancy suggests placenta previa, and digital examination can provoke catastrophic hemorrhage. The standard of care is to avoid vaginal examination, monitor maternal and fetal status, and prepare for cesarean birth.

Question 6Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which dietary instruction should the nurse give a client who has just started warfarin therapy?

  1. Eliminate all green leafy vegetables from the diet
  2. Double the warfarin dose on days when salad is eaten
  3. Increase vitamin K intake to strengthen clotting
  4. Keep vitamin K intake consistent from day to day Correct answer.

Explanation

Warfarin inhibits vitamin K-dependent clotting factors, so a stable intake of vitamin K keeps the INR predictable. Abrupt changes in intake, rather than vitamin K itself, cause dangerous fluctuations in anticoagulation.

Question 7Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with chronic kidney disease has a hemoglobin of 8.2 g/dL. Which finding is most consistent with the expected cause of this anemia?

  1. Low serum erythropoietin production Correct answer.
  2. Increased red cell survival time
  3. Elevated serum iron stores
  4. Elevated reticulocyte count

Explanation

Failing kidneys produce inadequate erythropoietin, which is the principal cause of anemia of chronic kidney disease. Iron deficiency may coexist, but the characteristic mechanism is reduced erythropoietin stimulation of the marrow.

Question 8Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which position should the nurse use for a client immediately after a lumbar puncture?

  1. Side-lying with the head of bed elevated 45 degrees
  2. Prone with the head elevated
  3. Flat supine for several hours as ordered Correct answer.
  4. High Fowler position for one hour

Explanation

Lying flat after lumbar puncture reduces the incidence of postdural puncture headache by limiting cerebrospinal fluid leakage. The nurse should also encourage hydration and monitor for headache and neurologic changes.

Question 9Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client receiving intravenous gentamicin reports new ringing in the ears. Which action should the nurse take?

  1. Document the finding and continue the scheduled dose
  2. Hold the dose and notify the prescriber promptly Correct answer.
  3. Reassure the client that tinnitus is expected and harmless
  4. Increase the infusion rate to finish the dose sooner

Explanation

Tinnitus is an early sign of aminoglycoside ototoxicity, which can become irreversible. The nurse must stop the dose and notify the prescriber so levels and therapy can be reviewed.

Question 10Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which client is at highest risk for developing pressure injury on the sacrum?

  1. A client who had cataract surgery and is alert
  2. A client with a fractured wrist who is ambulatory
  3. A client with mild hypertension who walks with a cane
  4. An obese client with fecal incontinence who is sedated Correct answer.

Explanation

Pressure injury risk rises with immobility, moisture from incontinence, and impaired sensation or consciousness. The sedated, incontinent client combines all of these factors at the sacral site.

Question 11Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client in active labor has a fetal heart rate pattern showing late decelerations. Which action should the nurse take first?

  1. Increase the oxytocin infusion rate
  2. Perform a sterile vaginal examination
  3. Encourage the client to push with contractions
  4. Reposition the client to a lateral position Correct answer.

Explanation

Late decelerations reflect uteroplacental insufficiency and fetal hypoxemia. Lateral repositioning improves uterine blood flow and is the first step, followed by oxygen, fluid bolus, and stopping oxytocin if it is infusing.

Question 12Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which manifestation indicates that a client with a spinal cord injury at T6 has autonomic dysreflexia?

  1. Loss of pain sensation below the level of injury
  2. Flaccid paralysis of the lower extremities
  3. Severe pounding headache with a blood pressure of 210/110 mmHg Correct answer.
  4. Bradycardia with warm dry skin and hypotension

Explanation

Autonomic dysreflexia produces extreme hypertension, pounding headache, and often bradycardia and diaphoresis in response to a noxious stimulus below the injury. Immediate action includes sitting the client upright and identifying the trigger, commonly a distended bladder.

Question 13Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A nurse is calculating the dose for a child weighing 22 kg who is prescribed 15 mg/kg/day divided every 8 hours. How many milligrams should each dose contain?

  1. 110 mg Correct answer.
  2. 165 mg
  3. 220 mg
  4. 330 mg

Explanation

The total daily dose is 22 kg times 15 mg/kg, or 330 mg per day. Dividing 330 mg by three doses gives 110 mg per dose.

Question 14Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which assessment finding should the nurse report immediately in a client 24 hours after thyroidectomy?

  1. Mild incisional pain rated 3 out of 10
  2. Stridor with swelling at the incision site Correct answer.
  3. Voice hoarseness that is improving
  4. Serum calcium of 9.0 mg/dL

Explanation

Stridor and neck swelling after thyroidectomy suggest airway obstruction from hematoma or laryngeal edema, which is a surgical emergency. The nurse should stay with the client, open the airway, and call for immediate help.

Question 15Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which statement best describes the purpose of the Nursing Process standard within professional nursing practice?

  1. It is used only for documenting medication administration
  2. It guarantees that all client outcomes will be achieved
  3. It provides a systematic framework of assessment, diagnosis, planning, implementation, and evaluation Correct answer.
  4. It replaces the need for clinical judgment in routine care

Explanation

The nursing process organizes clinical reasoning into five cyclical phases that guide individualized, evidence-informed care. It structures rather than replaces judgment and does not guarantee outcomes.

Question 16Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with type 1 diabetes has a blood glucose of 48 mg/dL and is alert but shaky. Which action should the nurse take?

  1. Administer the next scheduled insulin dose
  2. Provide a high-protein snack without carbohydrate
  3. Start an intravenous infusion of 0.9% sodium chloride
  4. Give 15 g of fast-acting oral carbohydrate Correct answer.

Explanation

For a conscious client with hypoglycemia, the rule of 15 applies: give about 15 g of fast-acting carbohydrate and recheck glucose in 15 minutes. Protein alone is inadequate because it does not raise glucose quickly.

Question 17Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which finding in a client with a chest tube for a pneumothorax requires immediate intervention?

  1. Fluctuation of the fluid level with respiration
  2. Tidaling in the suction control chamber
  3. Serosanguineous drainage of 20 mL in the first hour
  4. Continuous bubbling in the water-seal chamber Correct answer.

Explanation

Continuous bubbling in the water-seal chamber indicates an air leak in the system, which can prevent lung re-expansion. Intermittent bubbling is normal, but constant bubbling requires checking connections and notifying the provider.

Question 18Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with chronic obstructive pulmonary disease is receiving oxygen. Which goal is most appropriate?

  1. Keep the client sedated to reduce oxygen demand
  2. Maintain oxygen saturation between 88% and 92% Correct answer.
  3. Restrict fluids to reduce sputum production
  4. Maintain oxygen saturation at 100%

Explanation

In COPD with chronic carbon dioxide retention, target saturations of about 88% to 92% preserve hypoxic drive while correcting severe hypoxemia. Overoxygenation can worsen carbon dioxide retention and respiratory depression.

Question 19Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with a new ileostomy has liquid output of 1,800 mL per day. Which complication should the nurse monitor for most closely?

  1. Constipation with fecal impaction
  2. Fluid volume deficit with electrolyte imbalance Correct answer.
  3. Hyperkalemia with fluid overload
  4. Increased risk of urinary retention

Explanation

High-output ileostomies lose large volumes of water, sodium, and potassium, leading to dehydration and electrolyte disturbance. Monitoring intake, output, weight, and electrolytes guides replacement therapy.

Question 20Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which action is correct when a nurse receives a telephone order from a physician for a client?

  1. Ask the pharmacist to transcribe the order into the chart
  2. Accept the order and ask the charge nurse to sign it later
  3. Wait until the physician arrives to write the order in person
  4. Write the order, read it back to the prescriber, and document it Correct answer.

Explanation

Telephone orders must be documented immediately, read back to the prescriber to verify accuracy, and signed according to facility policy. Read-back communication prevents medication and treatment errors.

Question 21Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with schizophrenia has been taking haloperidol and now has a temperature of 39.5 degrees Celsius, muscle rigidity, and altered mental status. Which condition should the nurse suspect?

  1. Tardive dyskinesia
  2. Serotonin syndrome
  3. Neuroleptic malignant syndrome Correct answer.
  4. Acute dystonic reaction

Explanation

Neuroleptic malignant syndrome presents with hyperthermia, lead-pipe rigidity, autonomic instability, and altered consciousness after antipsychotic use. It is a medical emergency requiring drug discontinuation and supportive treatment.

Question 22Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which immunization is typically given at birth in the Indian national immunization schedule?

  1. Measles-rubella vaccine
  2. Bacille Calmette-Guerin vaccine Correct answer.
  3. Oral polio vaccine birth dose
  4. Diphtheria-tetanus-pertussis vaccine

Explanation

BCG is given as soon as possible after birth, along with the birth dose of oral polio vaccine and hepatitis B vaccine. BCG protects against severe forms of childhood tuberculosis.

Question 23Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client has a prescription for 1,000 mL of normal saline over 8 hours using tubing with a drop factor of 15 drops per mL. What should the flow rate be?

  1. 31 drops per minute Correct answer.
  2. 15 drops per minute
  3. 21 drops per minute
  4. 42 drops per minute

Explanation

The rate is calculated as 1,000 mL divided by 480 minutes, giving 2.08 mL per minute. Multiplying by 15 drops per mL yields about 31 drops per minute.

Question 24Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

Which client is at highest risk for aspiration during enteral feeding?

  1. A client with a healed leg fracture who is ambulatory
  2. A client with a colostomy who is feeding himself
  3. A client receiving a clear liquid diet who is alert
  4. A client with a decreased level of consciousness and a nasogastric tube Correct answer.

Explanation

Depressed consciousness and tube feeding together impair protective airway reflexes and increase aspiration risk. Elevating the head of the bed and checking residual volume reduce that risk.

Question 25Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A nurse is caring for a client in the fourth stage of labor. Which assessment is the priority?

  1. Uterine tone and amount of vaginal bleeding Correct answer.
  2. Urine specific gravity
  3. Return of bowel sounds
  4. Deep tendon reflexes

Explanation

The fourth stage of labor is the immediate postpartum period when postpartum hemorrhage is most likely. Assessing uterine firmness and blood loss allows early detection of uterine atony and prompt intervention.

Question 26Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A nurse is teaching a client about the correct technique for using a metered-dose inhaler with a spacer. Which instruction should the nurse include?

  1. Breathe in slowly and deeply after activating the device, then hold the breath for about 10 seconds Correct answer.
  2. Rinse the spacer with soap and water after every individual dose
  3. Inhale as rapidly as possible to drive the medication into the lungs
  4. Activate the inhaler twice in quick succession before the first inhalation

Explanation

Slow, deep inhalation followed by a breath-hold allows the aerosolized drug to deposit in the lower airways rather than impacting the oropharynx. The spacer reduces oropharyngeal deposition, so one actuation with a coordinated slow breath is the standard technique.

Question 27Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with a new colostomy asks the nurse how to care for the stoma and appliance. Which statement by the client indicates correct understanding?

  1. I should change the pouch every day regardless of leakage to prevent infection
  2. I will clean the stoma with alcohol and apply a tight belt to prevent prolapse
  3. I will restrict all fluids so the stool becomes firm and easier to manage
  4. I will cut the skin barrier opening about 2 mm larger than the stoma and change the pouch when it leaks Correct answer.

Explanation

The barrier opening should be sized just slightly larger than the stoma (about 1–2 mm) to protect peristomal skin without constricting the stoma. Pouches are changed on a scheduled basis or when leakage occurs, since leakage causes skin breakdown.

Question 28Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client is admitted with a suspected acute myocardial infarction. Which laboratory test should the nurse expect to be most specific for myocardial injury?

  1. Troponin I Correct answer.
  2. C-reactive protein
  3. Serum amylase
  4. Serum potassium

Explanation

Cardiac troponin I and T are highly specific markers of myocardial cell injury and rise within a few hours of infarction. Amylase, CRP, and potassium are not specific to myocardial damage.

Question 29Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A postoperative client is ordered to use an incentive spirometer. Which instruction should the nurse give to promote effective lung expansion?

  1. Sit upright, exhale normally, seal the lips around the mouthpiece, and inhale slowly to raise the marker Correct answer.
  2. Use the spirometer only when shortness of breath is present
  3. Inhale quickly and forcefully to raise the marker as high as possible
  4. Lie flat and breathe rapidly through the nose while watching the marker

Explanation

Incentive spirometry works by encouraging slow, sustained maximal inspiration from a functional residual capacity, which re-expands alveoli and prevents atelectasis. Upright positioning and a normal exhalation before the effort improve the result.

Question 30Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A nurse is preparing to administer a blood transfusion. Which action is essential before starting the transfusion?

  1. Begin the transfusion at the maximum rate to finish quickly
  2. Warm the blood in a microwave before administration
  3. Prime the tubing with dextrose 5% in water
  4. Verify the unit with a second nurse against the client's identification and blood bank form at the bedside Correct answer.

Explanation

Bedside two-person verification of client identity, blood group, unit number, and crossmatch compatibility is the key safeguard against a hemolytic transfusion reaction. Normal saline is the only compatible priming solution, and blood is started slowly.

Question 31Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client has an indwelling urinary catheter. Which nursing action best prevents catheter-associated urinary tract infection?

  1. Irrigating the catheter routinely every shift
  2. Maintaining a closed drainage system and keeping the bag below the level of the bladder Correct answer.
  3. Disconnecting the tubing daily to allow the bladder to rest
  4. Applying antiseptic ointment to the meatus each shift

Explanation

A closed system with dependent drainage prevents reflux of contaminated urine back into the bladder, which is the main route of catheter-associated infection. Routine irrigation and unnecessary disconnection break the closed system.

Question 32Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

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

  1. Assess the client's respiratory rate, oxygen saturation, and skin condition at the nares Correct answer.
  2. Keep the client in a supine position throughout therapy
  3. Increase the flow to 8 L/min if the saturation is 94%
  4. Apply petroleum jelly to the nares to prevent dryness

Explanation

Oxygen is a drug with prescribed flow rates, and the nurse must monitor response through respiratory assessment and saturation. Nasal mucosal assessment detects drying or pressure injury from the cannula.

Question 33Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A nurse is assessing a newborn at 1 minute after birth using the Apgar score. Which parameter is included in this assessment?

  1. Blood glucose
  2. Muscle tone Correct answer.
  3. Head circumference
  4. Urine output

Explanation

The Apgar score evaluates heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and 5 minutes after birth. Glucose, head circumference, and urine output are separate newborn assessments, not part of Apgar scoring.

Question 34Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with major depressive disorder is started on sertraline. Which instruction should the nurse include in client teaching?

  1. Stop the drug immediately if mood improves to avoid dependence
  2. Take the medication only on days when feeling low
  3. Therapeutic effects may take several weeks to appear, so continue the medication as prescribed Correct answer.
  4. Expect an immediate improvement in energy within 24 hours

Explanation

SSRIs such as sertraline typically require 2–4 weeks or more before full antidepressant effects emerge, so adherence must be emphasized. Abrupt discontinuation can cause withdrawal symptoms and relapse.

Question 35Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with a diagnosis of bipolar disorder in a manic phase is pacing, talking loudly, and refusing to sit for meals. Which nursing intervention is most appropriate initially?

  1. Provide a quiet environment and offer frequent high-calorie finger foods Correct answer.
  2. Confront the client about disruptive behavior in front of the group
  3. Restrict all physical activity until the client agrees to eat
  4. Initiate seclusion immediately to prevent exhaustion

Explanation

During mania, distractibility and hyperactivity make structured meals difficult, so frequent portable high-calorie foods and a low-stimulus environment support nutrition and safety. Confrontation escalates agitation, and seclusion is reserved for imminent danger after less restrictive measures.

Question 36Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate infusion. Which assessment is the priority?

  1. Blood glucose and skin turgor
  2. Visual acuity and hearing
  3. Deep tendon reflexes, respiratory rate, and urine output Correct answer.
  4. Appetite and bowel sounds

Explanation

Magnesium sulfate toxicity depresses the central nervous system and neuromuscular transmission, so reflexes, respirations, and renal excretion (urine output) are the essential monitoring parameters. Loss of reflexes and respiratory depression signal toxicity requiring immediate action.

Question 37Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with an acute exacerbation of asthma has a peak expiratory flow at 40% of personal best and is using accessory muscles. Which action should the nurse take first?

  1. Administer the prescribed short-acting beta-2 agonist and position the client upright Correct answer.
  2. Withhold bronchodilators until a chest radiograph is obtained
  3. Apply a tight abdominal binder to support breathing
  4. Encourage the client to lie flat and rest

Explanation

A peak flow at 40% of personal best with accessory muscle use indicates a severe exacerbation; a short-acting beta-2 agonist is the first-line rescue treatment, and upright positioning improves ventilation. Delaying bronchodilation worsens bronchospasm.

Question 38Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client is receiving total parenteral nutrition through a central line. Which nursing action is most important to prevent complications?

  1. Increase the infusion rate rapidly if the client reports hunger
  2. Flush the line with sterile water before each infusion
  3. Monitor blood glucose regularly and never abruptly stop the infusion Correct answer.
  4. Change the central line dressing only when it becomes soiled

Explanation

TPN contains high concentrations of dextrose, so hyperglycemia must be monitored, and abrupt cessation can cause rebound hypoglycemia. Dressing changes follow strict aseptic protocol on a scheduled basis, not just when soiled.

Question 39Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client has a stage 2 pressure injury over the sacrum with a shallow open ulcer and a red-pink wound bed. Which dressing approach is most appropriate?

  1. Cleaning the wound with hydrogen peroxide each shift
  2. Keeping the wound open to air to form a dry scab
  3. Applying a tight gauze wrap to compress the wound
  4. A moist wound-healing dressing such as a hydrocolloid or foam Correct answer.

Explanation

Stage 2 pressure injuries heal best in a moist environment, so hydrocolloid or foam dressings protect the wound bed and support epithelialization. Dry, caustic, or constricting treatments impair healing.

Question 40Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A nurse is caring for a client with cirrhosis who has ascites and is prescribed spironolactone. Which finding should the nurse monitor most closely?

  1. Serum potassium and renal function Correct answer.
  2. Serum calcium and magnesium
  3. Visual acuity and pupil size
  4. Platelet count and bleeding time

Explanation

Spironolactone is a potassium-sparing diuretic, so hyperkalemia is a key risk, particularly with impaired renal function. Monitoring potassium and renal status guides safe dosing and detects complications of cirrhosis and diuresis.

Question 41Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with an above-knee amputation has a rigid, tense, painful residual limb with wound drainage 48 hours postoperatively. Which complication should the nurse suspect?

  1. Hematoma or infection under the rigid dressing Correct answer.
  2. Muscle atrophy from disuse
  3. Normal postoperative edema requiring no action
  4. Phantom limb pain requiring no evaluation

Explanation

A rigid, tense, painful stump with drainage suggests bleeding or infection beneath the rigid dressing, which can compromise circulation and healing. This requires prompt evaluation and possible dressing revision.

Question 42Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A nurse is teaching a client with type 2 diabetes about foot care. Which instruction should the nurse include?

  1. Inspect feet daily and test bath water temperature with the hands or a thermometer Correct answer.
  2. Walk barefoot indoors to toughen the soles
  3. Soak feet in hot water for 30 minutes each evening
  4. Cut corns and calluses with a sharp blade at home

Explanation

Peripheral neuropathy reduces protective sensation, so daily inspection and safe water temperature testing prevent burns and unnoticed injuries. Self-cutting of corns and going barefoot increase the risk of ulceration and infection.

Question 43Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client is admitted with suspected pulmonary embolism. Which finding is most consistent with this diagnosis?

  1. Productive cough with rust-colored sputum and fever
  2. Sudden dyspnea with pleuritic chest pain and tachycardia Correct answer.
  3. Bradycardia with hypertension and flushed skin
  4. Gradual onset of bilateral leg edema over weeks

Explanation

Pulmonary embolism classically presents with sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxemia due to ventilation-perfusion mismatch. The other findings suggest different conditions and do not fit the acute presentation.

Question 44Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client is receiving intravenous morphine for severe pain after surgery. Which assessment is most important after administration?

  1. Deep tendon reflexes and gait
  2. Serum amylase and lipase levels
  3. Urine specific gravity and color
  4. Respiratory rate and depth, level of sedation, and oxygen saturation Correct answer.

Explanation

Opioids depress the central respiratory drive and cause sedation, so respiratory rate, depth, sedation level, and oxygen saturation are the essential monitoring parameters. These assessments detect early respiratory depression.

Question 45Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client is scheduled for electroconvulsive therapy. Which nursing action is essential before the procedure?

  1. Withhold all antihypertensive medications indefinitely
  2. Allow the client to eat a full breakfast to prevent hypoglycemia
  3. Administer a stimulant to increase alertness
  4. Ensure informed consent is documented and the client has fasted as prescribed Correct answer.

Explanation

ECT requires informed consent and adherence to anesthesia fasting guidelines to prevent aspiration during sedation. Antihypertensives are generally continued per anesthesia guidance rather than all withheld.

Question 46Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A nurse is caring for a client with a chest drain after lobectomy. The nurse observes continuous bubbling in the water-seal chamber. Which interpretation is correct?

  1. Continuous bubbling confirms that the lung has fully re-expanded
  2. Continuous bubbling suggests an air leak in the system and requires assessment of the tubing and insertion site Correct answer.
  3. Continuous bubbling indicates the suction is too low and should be increased
  4. Continuous bubbling is expected and requires no action

Explanation

The water-seal chamber should show only gentle tidaling with respiration; continuous bubbling indicates air entering the system, usually from a loose connection or leak at the insertion site. The nurse must locate and correct the leak.

Question 47Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with acute kidney injury has a serum potassium of 6.9 mEq/L and peaked T waves on the electrocardiogram. Which action should the nurse anticipate first?

  1. Encourage a high-potassium diet to maintain electrolyte balance
  2. Administer intravenous calcium gluconate as prescribed to stabilize the myocardium Correct answer.
  3. Administer a loop diuretic only after the next potassium result
  4. Give a potassium supplement to correct the imbalance

Explanation

Severe hyperkalemia with electrocardiographic changes is a cardiac emergency; intravenous calcium stabilizes the myocardium while measures to shift and remove potassium are initiated. Potassium supplementation is contraindicated, and delaying treatment risks dysrhythmia.

Question 48Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client with a head injury has a Glasgow Coma Scale score that has fallen from 13 to 9 over 2 hours, and the nurse notes a dilated pupil on the right. Which action should the nurse take?

  1. Administer a prescribed sedative to promote rest
  2. Notify the physician immediately and prepare for measures to reduce intracranial pressure Correct answer.
  3. Position the client flat and encourage coughing
  4. Document the findings and recheck in 4 hours

Explanation

A falling GCS with an ipsilateral dilated pupil suggests uncal herniation and rising intracranial pressure, which is a neurosurgical emergency. Prompt notification and interventions such as head elevation and osmotic therapy are required.

Question 49Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A nurse is reviewing the medication record of a client taking warfarin and notes a new prescription for aspirin. Which action is most appropriate?

  1. Recognize the increased bleeding risk and clarify the order with the prescriber before administration Correct answer.
  2. Withhold warfarin permanently and give aspirin alone
  3. Double the warfarin dose to compensate for the aspirin
  4. Administer both drugs together because they act on different pathways

Explanation

Aspirin inhibits platelet aggregation and displaces warfarin from plasma proteins, substantially increasing bleeding risk. The nurse should clarify the prescription with the prescriber and monitor for bleeding if both are indicated.

Question 50Nursing (B.Sc Nursing, Post Basic B.Sc Nursing, M.Sc Nursing)

A client has a new tracheostomy and is being suctioned. Which action indicates correct suction technique?

  1. Hyperventilate the client with 100% oxygen for 5 minutes after each pass
  2. Apply continuous suction for 30 seconds while inserting the catheter
  3. Apply suction intermittently for no more than 10–15 seconds while withdrawing the catheter Correct answer.
  4. Insert the catheter without lubrication and suction on insertion only

Explanation

Suction should be applied only during withdrawal, intermittently, for no more than 10–15 seconds to limit hypoxemia and mucosal trauma. Prolonged or insertion-phase suctioning increases hypoxia and injury.