1. Which of the following is the most appropriate nursing intervention for a patient experiencing hypoglycemia?
A) Administer intravenous insulin
B) Give a glass of fruit juice or glucose orally
C) Encourage the patient to exercise
D) Monitor blood glucose after 24 hours
Key: B) Give a glass of fruit juice or glucose orally
2. A patient with chronic obstructive pulmonary disease (COPD) is on oxygen therapy. What is the recommended oxygen flow rate to prevent oxygen toxicity?
A) 1-2 L/min
B) 4-6 L/min
C) 6-8 L/min
D) 10-12 L/min
Key: A) 1-2 L/min
3. Which of the following signs and symptoms are most commonly associated with right-sided heart failure?
A) Pulmonary congestion and dyspnea
B) Peripheral edema and jugular vein distension
C) Hypertension and headache
D) Chest pain and palpitations
Key: B) Peripheral edema and jugular vein distension
4. A nurse is assessing a patient with meningitis. Which of the following clinical signs is indicative of meningeal irritation?
A) Kernig’s sign
B) Trousseau’s sign
C) Chvostek’s sign
D) Babinski’s sign
Key: A) Kernig’s sign
5. The primary goal of nursing care for a patient in the immediate postoperative period is to:
A) Ensure the patient’s pain is completely eliminated
B) Monitor for complications and maintain airway patency
C) Encourage early ambulation to prevent bedsores
D) Administer IV fluids to prevent dehydration
Key: B) Monitor for complications and maintain airway patency
6. A patient receiving digoxin therapy is experiencing nausea, vomiting, and visual disturbances. What should the nurse do first?
A) Administer an antiemetic
B) Check the patient’s serum potassium level
C) Hold the medication and notify the physician
D) Encourage the patient to drink more water
Key: C) Hold the medication and notify the physician
7. Which of the following precautions should be followed while administering intramuscular injections in children under 2 years of age?
A) Use the dorsogluteal site
B) Use the deltoid muscle
C) Use the vastus lateralis muscle
D) Use a 3-inch needle
Key: C) Use the vastus lateralis muscle
8. A patient with tuberculosis is started on rifampicin therapy. Which of the following instructions should the nurse give?
A) Stop the medication if urine turns orange
B) Take the medication with milk
C) Avoid alcohol while on this medication
D) This medication is only needed for two weeks
Key: C) Avoid alcohol while on this medication
9. Which of the following is an early sign of increased intracranial pressure (ICP)?
A) Bradycardia
B) Hypertension
C) Altered level of consciousness
D) Fixed and dilated pupils
Key: C) Altered level of consciousness
10. A nurse is caring for a patient with a deep vein thrombosis (DVT) in the left leg. Which intervention should be avoided?
A) Elevating the affected leg
B) Applying warm compresses
C) Encouraging bed rest
D) Massaging the affected leg
Key: D) Massaging the affected leg
Explanation of NNC license model Questions
- Hypoglycemia Management
Rationale: Hypoglycemia (low blood sugar) is treated with quick-acting carbohydrates, such as fruit juice or glucose tablets, to rapidly raise blood sugar levels. Insulin administration (option A) would worsen the condition. - Oxygen Therapy in COPD
Rationale: In COPD patients, high oxygen levels can suppress the respiratory drive. A low-flow oxygen rate (1-2 L/min) is recommended to prevent carbon dioxide retention and respiratory failure. - Right-Sided Heart Failure
Rationale: Right-sided heart failure leads to fluid retention and systemic venous congestion, causing peripheral edema (swelling) and jugular vein distension (JVD) due to increased pressure in the venous system. - Meningitis Signs
Rationale: Kernig’s sign (pain and resistance with leg extension when the hip is flexed) is a classic indication of meningeal irritation seen in bacterial or viral meningitis. - Postoperative Nursing Priorities
Rationale: The most critical concern after surgery is maintaining airway patency and preventing complications such as respiratory distress, bleeding, or shock. Pain control is important but secondary to airway management. - Digoxin Toxicity
Rationale: Digoxin toxicity presents with nausea, vomiting, visual disturbances (yellow vision), and bradycardia. The nurse should hold the drug and notify the physician to prevent severe toxicity and cardiac complications. - IM Injection in Children
Rationale: The vastus lateralis muscle (thigh) is the safest site for intramuscular injections in infants and young children because it has a large muscle mass and fewer major nerves or blood vessels. - Rifampicin Therapy in Tuberculosis
Rationale: Rifampicin (used in TB treatment) can cause orange-colored urine (a harmless side effect), but alcohol should be avoided as it increases liver toxicity. - Increased Intracranial Pressure (ICP)
Rationale: The earliest sign of increased ICP is an altered level of consciousness, including confusion or drowsiness, due to brain pressure affecting neurological function. Late signs include bradycardia and dilated pupils. - Deep Vein Thrombosis (DVT) Precautions
Rationale: Massaging a DVT-affected leg can dislodge a clot, potentially leading to a pulmonary embolism, which can be life-threatening. Instead, elevating the leg and ensuring proper blood circulation is recommended.
