Final Subject Assessment Test

Nursing Foundations

1. Nurse Anita understands that the informed consent is based on _____ ethical
principle?
a. Justice b. Veracity
c. Fidelity d. Autonomy

Ans. d. Autonomy
• Option d: Informed consent is based on an individual’s right to make decisions
about his or her own health care, with adequate information to make that decision.
Principle of autonomy means respect for an individual’s right to self-determination,
independence and ability to self-direct. It is an ethical action on the part of nurse to
allow the patient to make decisions.
• Option a: Principle of Justice: The equitable distribution of potential benefits and tasks
determining the order in which clients should be cared and treated equally and fairly.
• Option b: Principle of veracity is defined as telling the truth. Telling the truth is basic
to communication and social relationship. Health care provider should give accurate,
reality-based information about health status and treatment prospective.
• Option c: Principle of Fidelity refers to the concept of keeping a commitment and is
based upon the virtue of caring. This principle hold that a person should be faithful
and truthful for his/her duties and obligations.

2. A nurse identifies a client’s responses to actual or potential health problems

during which step of the nursing process?
a. Assessment b. Diagnosis
c. Planning d. Evaluation

Ans. b. Diagnosis
• Option b: The nurse identifies human responses to actual or potential health problems
during the diagnosis step of the nursing process, which encompasses the nurse’s ability
to formulate a nursing diagnosis.
• Option a: During the assessment step, the nurse systematically collects data about the
client or his family.
• Option c: During the planning step, she develops strategies to resolve or decrease the
client’s problem.
2 Final Subject Assessment Test (Nursing Foundations)
• Option d: During the evaluation step, the nurse determines the effectiveness of the
care plan.

3. Identify the 3 components of problem-focused nursing diagnosis statement?

a. Problem, etiology and characteristics
b. Diagnostic label, risk factors, sign and symptoms
c. Potential problem, related to and evidenced
d. Both a and b

Ans. d. Both a and b

Rationale:
• Three Components of Nursing Diagnosis.

• Example: Impaired gas exchange related to altered oxygen supply as evidenced by

thick mucous secretion, dypnea, tachypnea.
• The PES format of nusing diagnosis is:
Ĕ The problem/Diagnositivc Label (P) = Impaired gas exchnage
Ĕ Etiology/related factors/risk factors (E) = Altered oxygen supply
Ĕ Characteristics/sign and symptoms (S) = Thick mucus secretion, dypnea,
tachypneaComponent of Risk Diagnosis
Ĕ Risk diagnostic label,
Ĕ Risk factors
ƒ Example: Risk for Injury related to altered mobility.
Ĕ Where risk for injury is the risk diagnosis and altered mobility is the risk factor.
• Components of a health promotion diagnosis generally include only the diagnostic
label or a one-part-statement.
Ĕ Example: Readiness for Enhanced Spiritual Well Being.

4. You are taking handover of your assigned patient, at the patient’s bedside you
noticed that the patient’s IV site is cool, pale, and swollen, and the solution is
not infusing. Which of the following complication you will document in your
handover report?
a. Phlebitis b. Infiltration
c. Extravasation d. Hypersensitivity

Ans. b. Infiltration
• Infiltration occurs when IV fluid or medications leak into the surrounding tissue.
Infiltration can be caused by improper placement or dislodgment of the catheter.
Patient movement can cause the catheter to slip out or through the blood vessel lumen.
It is characterized by:
Ĕ Swelling, discomfort, burning, and/or tightness
Ĕ Cool skin and blanching
 Final Subject Assessment Test (Nursing Foundations) 3

Ĕ Decreased or stopped flow rate

• Extravasation is the leaking of vesicant drugs into surrounding tissue. Extravasation can
cause severe local tissue damage, possibly leading to delayed healing, infection, tissue
necrosis, disfigurement, loss of function, and even amputation. It is characterized by:
Ĕ Blanching, burning, or discomfort at the IV site
Ĕ Cool skin around the IV site
Ĕ Swelling at or above the IV site
Ĕ Blistering and/or skin sloughing
• Phlebitis is defined as the inflammation of a vein which is characterized by
Ĕ Redness or tenderness at the site of the tip of the catheter or along the path of the
vein.
Ĕ Swelling area over the vein.
Ĕ Warmth around the insertion site.
• Local or systemic infection is another potential complication of IV therapy.
Ĕ Redness and discharge at the IV site
Ĕ Elevated pulse

Figure 1: Phlebitis

Figure 2: Infiltration
4 Final Subject Assessment Test (Nursing Foundations)

Figure 3: Extravasation

5. Which among the following intravenous (IV) cannula is correctly matched

according to their gauze size and color?
a. 18–gauge IV Cannula = Pink b. 26– gauge IV Cannula = Purple
c. 16– gauge IV Cannula = Green d. 14– gauge IV Cannula = Grey

Ans. b. 26– gauge IV Cannula = Purple

• The correct answer is 26-gauge IV cannula is Purple in color.

Figure: Different sizes of IV cannula (please note the flow rate can differ as it depend upon the
manufacturer)
Note: Gauze 17 cannula is white in color.
 Final Subject Assessment Test (Nursing Foundations) 5

6. The patient is receiving transfusion of PRBC & as an assigned nurse which of

the following IV fluid you should keep at the patient bedside?
a. 0.9% NS b. 0.45% NS
c. RL d. Any isotonic solution

Ans. a. 0.9% NS
The most commonly used crystalloid fluid is 0.9% sodium chloride (Normal Saline) close
to the concentration in the blood (isotonic). Saline solution is administered intravenously
(IV drips) and increases both intravascular and interstitial volume. They decrease osmotic
pressure by diluting the blood which makes it more compatible with red blood cells.
• Colloids are derived as plasma and responsible for maintaining and preserving a high-
colloid osmotic pressure (protein-exerted pressure) in the blood.

7. The nurse receives 450 ml of whole blood bag with CPDA-1 anticoagulant from
the blood bank. The nurse understands that the shelf life of blood bag with
CPDA-1 anticoagulant will be?

a. 21 days b. 35 days
c. 42 days d. 51 days

Ans. b. 35 days
• Anticoagulant and Shelf Life:
Ĕ CPD/CP2D: 21 days
Ĕ CPDA-1: 35 days
Ĕ Additive (AS1, AS3, AS5): 42 days

8. After the consultant round the attending doctor changes the patient’s current
oxygen therapy and orders to start oxygen with high flow oxygen device. The
nurse will select which of the following oxygen devices as per the doctor’s order?
a. Non Rebreathing Mask b. Nasal Prong
c. Simple face mask d. Venturi Mask

Ans. d. Venturi Mask

6 Final Subject Assessment Test (Nursing Foundations)
The oxygen delivery devices can be divided into two types:
• Variable performance devices/low flow devices
Ĕ Simple face mask
Ĕ NRM (non rebreather mask)
Ĕ Partial rebreather mask
Ĕ Nasal prong
• Fixed performance devices/high flow devices
Ĕ Venturi mask
Ĕ High flow nasal cannula

9. Match the following items as per their disposal in respective color coded bin?

1. 2.

3. 4.
a. 1-Red bin, 2-Red bin, 3-Blue cardboard box, 4-Puncture proof container
b. 1-yellow bin, 2-red bin, 3-puncture proof container, 4-red bin
c. 1-Red bin, 2-red bin, 3-puncture proof container, 4- blue cardboard box
d. 1-yellow bin, 2-red bin, 3-blue cardboard box, 4-puncture proof container

Ans. a.  Used gloves are discarded in red biomedical waste bin.

Used syringe without needle should be discarded in red

biomedical waste bin.
 Final Subject Assessment Test (Nursing Foundations) 7

Broken ampule should be discarded in blue cardboard box.

Insulin syringe (syringe with attached needle) should be

discarded in puncture proof container.

10. The patient with O+ blood group is in need of an emergency blood transfusion
but the blood bank does not have any O+ blood available. Which potential unit
of blood could be given to the patient?
a. O-ve unit b. A+ unit
c. B+ unit d. AB+

Ans. a. O-ve unit

• O negative blood is considered as the universal donor because it does not contain the
antigens A, B, or Rh. (AB+ is considered the universal recipient because it has all the
antigens on the blood).
• Other options are distracters.

11. You are assigned to provide care to an unconscious patient. The nurse is aware
about the early indicator of hypoxia in the unconscious client which is:
a. Cyanosis b. Increased respirations
c. Hypertension d. Restlessness

Ans. d. Restlessness
• Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in an
unconscious client who suddenly becomes restless. When oxygen delivery is severely
compromised, organ function will start to deteriorate. Neurologic manifestations
include restlessness, headache, and confusion with moderate hypoxia. In severe cases,
altered mentation and coma can occur, and if not corrected quickly may lead to death.
• Option a: Cyanosis is the bluish discoloration of the tissues. This may be a late
indication of hypoxia.
8 Final Subject Assessment Test (Nursing Foundations)
• Option b: Hypoxia induces a breathing pattern of rapid and shallow breaths with a
relatively higher increase in respiratory rate than tidal volume. This is more noticeable
in conscious patients.
• Option c: Pulmonary hypoxic hypertension is associated with high pressure in the
blood vessels of the lungs, caused by a shortage of oxygen in the body. This is a late
sign of hypoxia.

12. You are an operation theatre (OT) nursing officer. Today you are assigned in the
laparoscopic OT to function as a scrub nurse. The patient has taken inside the
OT and the entire operative team verified the patient, site of the operation, and
procedure before the incision. Which of the following surgical safety checklist
point is being performed in the given scenario?
a. Sign in b. Sign out
c. Time out d. All of the above

Ans. c. Time Out.

• Option a: Sign In is performed in the OT before the start of anaesthesia.
• Option b: Sign Out is performed before the patient leaves the operating theatre.
• Option c: Time out is held immediately before the incision involving the entire
operative team to verify correct patient, site and procedure.
• Option d: As we are having one separate answer of this question, so this option is not
correct.

13. Which of the following will provide high concentration of oxygen to a patient?
a. Non rebreather mask b. Patient rebreather mask
c. Venturi mask d. Nasal prongs

Ans. a. Non rebreather mask

• Non rebreather mask deliver high concentration of oxygen. FiO2, of 95% can be
achieved with an oxygen flow rate of 10-15 L/min whereas venture mask uses high
flow rate.
• Other options are distracters.

14. A 58-year-old female patient has deep partial-thickness burns to the anterior
head and neck, front and back of the left arm, front of the right arm, posterior
trunk, front, and back of the right leg, and back of the left leg. Using the rule of
Nines, calculate the total body surface area percentage that is burned?
a. 63% b. 81%
c. 72% d. 54%

Ans. a. 63%
 Final Subject Assessment Test (Nursing Foundations) 9

• Anterior head and neck = 4.5%

• Front and back of the left arm = 9%
• Front of the right arm = 4.5%
• Posterior trunk = 18%
• Front and back of the right leg = 18%
• Back of the left leg = 9%

TBSA = 63%

15. A 49-year-old male patient has full thickness burns on posterior of both the
legs, complete trunk and both the arms entirely. The patient weighs 110 Ibs.
Use the parkland Burn Formula: You’ve already infused fluids during the first
8 hours. For administering the fluid for the next 16 hours the nurse will set flow
rate at how many ml/hr?
a. 160mL/h b. 281 mL/h
c. 337 mL/h d. 450 mL/h

Ans. d. 450 mL/h

10 Final Subject Assessment Test (Nursing Foundations)
Step 1: Identify the total body surface area (TBSA) of burn first:
According to the Lund-Browder Chart,

Figure: Lund-Browder chart TBSA

Posterior side of both legs = 9% + 9%
Complete trunk = 18%+ 18%
Both entire arm = 9%+9%
TBSA= 9%+9%+18%+18%+9%+9%

TBSA=72%
Step 2: Convert the weight from lbs to kg
Patient weight = 110 lb
Patient weight in kg = 110 lb ÷ 2.2 kg/lb
Child weight in kg = 50 kg

Step 3:
Place the values in the parkland formula:
Parkland formula = 4 mL/kg × TBSA × Weight in kg
Total volume of fluid administered = 4 mL/kg × 72 × 50 kg
Total volume of fluid administered in 24 hours to the victim as per the burn area= 14,400
According to parkland formula, 50% given in first eight hours; 50% given in next 16 hours.
Now, we will need to determine how much to administer in the first 8 hours.
Step 4: During the 1st 8 hours ½ of the fluid should be administered
Volume of fluid administered in first 8 hours = Total volume of fluid ÷ 2
 Final Subject Assessment Test (Nursing Foundations) 11

Volume of fluid administered in first 8 hours = 14,400 mL ÷ 2

Volume of fluid administered in first 8 hours = 7200 mL
Step 5: During the next 16 hours the 2nd half of volume is to be administered.
Fluid administered in next 16 hours = Total Volume Required – Volume Administered 1st
8 hours
Volume of fluid administered in next 16 hours = 14,400-7200 ml
Volume of fluid administered in next 16 hours = 7200 mL

Step 6:
According to the question, we have to calculate the flow rate of fluid requirement over next
16 hours.
To calculate the flow rate in ml/hr, we will use this given below formula
Flow rate ml/hr = total volume in ml ÷ time in hours
So, according to formula we have
Time which is 16 hours and
The volume of fluid needs to be administered in next 16 hours= 7200ml
Now, put the values in the formula
Flow rate ml/hrs = 7200ml/ 16 hours
Flow rate ml/hrs=450ml/hrs

16. The emotional response to a death is called______

a. Depression b. Grieving
c. Bereavement d. Mourning

Ans. b. Grieving
• Grieving: Grieving is the normal process of reacting to the loss. It is defined as internal
emotional response to loss. Loss could include anything like death of loved one, loss of
body part (amputation), loss of job etc.
• Depression: It is a part of grieving explained by Kubler-Ross.
• Bereavement: Bereavement is the period after a loss during which grief is experienced
and mourning occurs.
Example: Husband died due to cancer. His wife (bereaved: the person who is
experiencing the grief) will experience the grief starting from his husband’s death till
she accept the reality that now her husband is no longer physically available with her.
• Mourning is the process by which people adapt to a loss. Mourning is also influenced
by cultural customs, rituals, and society’s rules for coping with loss. Example: Funeral.

17. For performing the ETT suctioning of an adult patient the nurse uses the wall
mounted suction at_____ pressure for effective suctioning procedure?
a. 150-200 mm Hg b. 100-120 mm Hg
c. 90-110 mm Hg d. 55-90 mm Hg

Ans. b. 100 – 120 mmHg

12 Final Subject Assessment Test (Nursing Foundations)

Rationale:
• Recommended suction pressure wall mounted
Ĕ Infants: 50 – 90 mmHg
Ĕ Children: 90-110 mmHg
Ĕ Adults: 100 – 120 mmHg
• Negative suction pressures should not exceed 150 mmHg as higher pressures have
been shown to cause trauma, hypoxemia and atelectasis.
• Other options are distractors.

18. The nurse has inserted the thumb pressure control suction catheter ETT until
she felt the resistance. After that she pulled back the suction catheter at 1-2 cm
above the resistance tin in order to avoid which complication?

a. Bradycardia b. Tachycardia
c. Infection d. Hypotension

Ans. a.Bradycardia
Rationale:
• Once resistance is met, then pull back the suction catheter 1-2 cm above the carina in
order to prevent complications like tracheo-mucosal injury as well as if you will apply
the negative suction pressure from the point of carina then it will stimulate the vagal
response and can lead to bradycardia.
• Other options are distractors.

19. Identify the pulse site?

 Final Subject Assessment Test (Nursing Foundations) 13

a. Dorsalis pedis b. Posterior tibial

c. Popliteal pulse d. None of the above

Ans. b. Posterior tibial

Pulse site Location

Carotid Pulse Located in the groove between the trachea and
sternocleidomastoid muscle, medial to and
alongside the muscle.
Apical Pulse • Adult: Left mid-clavicle, fifth intercostal
(Point of maximum impulse) space (ICS)
• Children/infant: 4th ICS, Left mid-clavicular
line
Brachial Pulse The brachial pulse can be located by feeling
the bicep tendon in the area of the antecubital
fossa above the elbow.
Femoral Pulse Located below the inguinal ligament, midway
between the symphysis pubis and the
anterosuperior iliac spine.
Posterior Tibial Pulse Located on the inner side of the ankle, behind
and below the medial malleolus (ankle bone).
Popliteal Pulse Located behind the knee within the popliteal
fossa
Dorsalis Pedis Pulse Located on the top of the foot, between the
extensor tendons of the great and first toes.
Temporal Pulse Palpated anterior to or in the front of the ear.
Radial Pulse The radial pulse is palpated immediately above
the wrist joint near the base of the thumb (i.e.,
common site), or in the anatomical snuff box
(i.e., alternative site), by gently pressing the
radial artery against the underlying bone with
the middle and index fingers.

20. The nurse understands that the width of the Sphygmomanometer be used for
blood pressure monitoring should be _____ of the upper arm circumference?
a. 80%
b. 50%
c. 40%
d. 20%

ans. c. 40%
• The recommended bladder length is 80 percent of the patient’s arm circumference,
and the ideal width is at least 40 percent.
14 Final Subject Assessment Test (Nursing Foundations)

21. While performing Heimlich maneuver, the volume of air used to expel the
foreign obstructed object is?

a. Tidal volume b. Residual volume

c. Vital capacity d. Inspiratory reserve

Ans. b. Residual volume

Lung Volumes (mL)

Measurement Typical Value Definition
Tidal volume (TV) 500 - 750 Amount of air that enters or leaves
lungs during one inspiration or
expiration (respiratory cycle).
Inspiratory reserve volume (IRV) 3000 (2000 - 3200) Maximum volume of air that can be
inspired over the normal TV.
Expiratory reserve volume (ERV) 1200 Extra volume of air expired by forceful
expiration after the end of normal tidal
expiration.
Residual volume (RV) 1300 Amount of air left in lungs after forced
exhalation.
 Final Subject Assessment Test (Nursing Foundations) 15

Closing volume (CV) Close to RV It is Lung volume above the residual

volume at which the alveoli of lung bases
begin to close off.
Lung Capacity (mL)
Vital capacity (VC) 3500 IRV + TV + ERV, Maximum amount of air
that can be exhaled after a maximum
inspiration.
Inspiratory capacity (IC) 2500 TV + IRV, Maximum amount of air that
can be inhaled after a normal expiration.
Expiratory Capacity (EC) 1500 TV + ERV
Functional residual capacity (FRC) 2500 RV + ERV, Amount of air remaining in the
lungs after a normal tidal expiration.
Total lung capacity (TLC) 5900 RV + VC, Maximum volume to which the
lungs can be expanded.

Closing capacity RV + The volume expired between the

beginning of airway closure and the RV.

22. The nurse is instructing the assigned patient about the use of Metered-dose
inhalers (MDI). Select which among the following indicates her poor
knowledge related to the use of MDI?
a. Use three-point position to hold the MDI
b. Never shake the inhaler medication before use
c. Have the patient hold breath for 10 seconds after pressing the canister
d. Remove the MDI and exhale through pursed lips

Ans. b Never shake the inhaler medication before use

• The correct answer is, never shake the inhaler medication before use as it shows poor
understanding of the nurse related to the use of MDI.
• The MDI is a pressurized canister of medicine in a plastic holder with a mouthpiece.

Figure: MDI parts

16 Final Subject Assessment Test (Nursing Foundations)
• Shake the inhaler vigorously five to six times to make sure that fine particles are
aerosolized.
• Instruct the patient to position the inhaler by holding it with the thumb at mouth piece
and index and middle fingers at the top.

Figure: The tree point or lateral hand position for holding MDI
• Instruct the patient to tilt head back slightly and inhale slowly and deeply through
mouth for 3 to 5 seconds while dressing canister fully.
• Ask the patient to hold breath for 10 seconds to allow the medication to reach the
airways of the lung.
• Remove the MDI and exhale through pursed lip to keep the small airway open during
expiration.

23. Select the additive present in the vacutainer given below?

a. 3.2% Sodium citrate

b. Sodium polyethanol sulfonate (SPS)
c. Ethylene diamine tetra-acetic acid
d. No additive

Ans. a. 3.2% Sodium citrate

 Final Subject Assessment Test (Nursing Foundations) 17

Additive: Liquid 3.2% tri-sodium citrate anticoagulant

24. Identify the surgical blade number as shown in the given image?

a. Surgical blade number 10

b. Surgical blade number 11
c. Surgical blade number 12
d. Surgical blade number 15

Ans. d. Surgical blade number 15

18 Final Subject Assessment Test (Nursing Foundations)

• Surgical blade number 10

• has a large curved cutting
edge which is one of the more
traditional blade shapes and is
used for making large incisions
and cutting soft tissue.

• Surgical blade number 11

• is an elongated triangular blade
sharpened along the hypotenuse
edge with a strong pointed tip
making it ideal for stab incisions
needed when lancing an abscess
or inserting a chest drain

• Surgical blade number 12

• Is a small, pointed, crescent-
shaped blade sharpened on the
inside edge of the curve.
• It is sometimes used as a suture
cutter.

• Surgical blade number 15

• has a small curved cutting edge
and is the most popular blade
shape ideal for making short and
precise incisions. It is utilized in
a variety of surgical procedures
including the excision of a skin
lesion or recurrent sebaceous cyst
and for opening coronary arteries.
 Final Subject Assessment Test (Nursing Foundations) 19

25. Identify the given image?

a. Prolene mesh b. Lica clip 300

c. Paraffin Gauze d. Absorbable Gelatin Sponge

Ans. a. Prolene mesh

RATIONALE:
• Prolene Mesh is a non-absorbable mesh indicated for the repair of abdominal wall
hernias and other fascial defects.

Figure: Prolene Mesh

20 Final Subject Assessment Test (Nursing Foundations)
• Option b: Clips designed for secure fixation on the structure and increased resistance
to dislodgement of a formed clip. Clips are compatible with both open and endoscopic
single clip appliers. Commonly used in Laparoscopic cholecystectiomy to ligate the
cystic artery.

Figure A: Liga clip 300

Figure B: Liga clip 400

• Option c: Bone wax is a non-absorbable product used for providing hemostasis in
bleeding bone.
 Final Subject Assessment Test (Nursing Foundations) 21

Figure: Bone wax

• Option 4: Abgel AbGel –Absorbable Gelatin Sponge used to control bleeding. AbGel
can be left in situ and is fully absorbed.

Figure: AbGel -Absorbable Gelatin Sponge

22 Final Subject Assessment Test (Nursing Foundations)

26. Aditya, an evening ICU nursing officer taking handover of his assigned patient
with central venous line. He asked to the morning staff about the transparent
dressing over the CVP line when the dressing needs to the changed. Select the
appropriate answer given by the morning staff?

a. Every 7 days or when it gets soiled

b. Every 10 days
c. Every day
d. Every 12 days
Ans. a. Every 7 days or when it gets soiled
Rationale:
• According to the centre for disease control and prevention (CDC), in order to prevent
CLABSI, it is recommended to provide CVP line care. Dressing of central lines should
be changed every 5 to 7 days with a transparent dressing material or every two days
with a gauze dressing.

27. Aleena, an assigned nurse is preparing the tray to give the IV bolus to patient.
Accidently Aleena has administered double dose of medications due to which
the patient is reflecting serious adverse effects. Identify the name of event
occurred in the given scenario?
a. Sentinel event b. Near miss
c. Harmful event d. All the above

Ans. b. Near miss

• The correct answer is option a which is sentinel event.
• Joint Commission International (JCI) defines a sentinel event as an unanticipated death
or loss of function unrelated to the natural course of the patient’s illness or underlying
condition or wrong-site, wrong-procedure, wrong-patient surgery. Such an event is
called sentinel because it signals a need for an immediate investigation and response.
• Option b: Near miss “any event that could have had adverse consequences but did not
and was indistinguishable from fully fledged adverse events in all but outcome.”
• Option c: The terms “sentinel event” and “medical error” are not synonymous; a patient
safety event that results in death, permanent harm, or severe temporary harm, not all
sentinel events occur because of an error and not all errors result in sentinel events.
 Final Subject Assessment Test (Nursing Foundations) 23

28. A patient with CVP triple lumen line in place admitted in ICU with the diagnosis
of right side heart failure. Doctor order to monitor the CVP by using the CVP
manometer. As an assigned nurse which lumen you will use to measure the
central venous pressure?

a. Proximal lumen b. Median lumen

c. Distal lumen d. Lateral lumen

Ans. c. Distal lumen

• Proximal lumen for blood sampling, medications and blood administration.
• Distal lumen for CVP monitoring, blood administration, medications.
• Medial lumen exclusively for total parenteral nutrition.

29. Select the non-shockable rhythm of cardiac arrest?

a. Asystole
b. Ventricular fibrillation
c. Pulseless ventricular tachycardia
d. All of the above

Ans. a. Asystole
• Shockable rhythm is: Pulseless Ventricular tachycardia and Ventricular fibrillation
• Asystole is a non-shockable rhythm.

30. Identify the marked part of ETT?

a. Cuff b. Pilot opening

c. Murphy’s eye d. Bevel

Ans. c. Murphy’s eye

24 Final Subject Assessment Test (Nursing Foundations)

Rationale:

Figure: Parts of Endotracheal Tube

• Other options are distractors.

31. You are posted in the ECG unit and received a patient for 12 unit ECG
procedure. As a nurse you are well aware that to obtain 12 lead how many leads
should be applied over the patient’s body?
a. 6 b. 10
c. 12 d. 16

Ans. b. 10
There are a total of 10 leads (4 limb leads & 6 chest/precordial leads). Certain electrodes are
part of two pairs and thus provide two leads.

32. Select the incorrect placement of chest electrode for an ECG?

a. V1: Placed in the second intercostal space to the right of the sternum
b. V4: Placed in the fifth intercostal space in the mid-clavicular line
c. V3: Placed directly between leads V2 and V4
d. V5: Placed level with V4 at the left anterior mid-axillary line

Ans. a. V1: Placed in the second intercostal space to the right of the sternum
Location of EKG 12 Lead Placement
• RA: Placed on the right arm or right below the right clavicle.
• LA: Placed on the left arm or right below the left clavicle.
• RL: Placed on the right leg or upper right quadrant.
• LL: Placed on the left leg or upper left quadrant.
• V1: Placed in the fourth intercostal space to the right of the sternum.
• V2: Placed in the fourth intercostal space to the left of the sternum.
• V3: Placed directly between leads V2 and V4.
 Final Subject Assessment Test (Nursing Foundations) 25

• V4: Placed in the fifth intercostal space in the mid-clavicular line.

• V5: Placed in level with V4 at the left anterior mid-axillary line.
• V6: Placed in level with V5 at the mid-axillary line.

33. Select which of the following is not a cardinal sign of adult cardiac arrest?
a. Unresponsiveness b. No pulse
c. Gasping d. No Bowel sound

Ans. d. No Bowel sound

• Vital parameters for cardiac arrest assessment includes:
Ĕ Unresponsiveness
Ĕ No pulse
Ĕ No respiration or gasping or agonal breathing.

34. Select the pulse site to assess cardiac arrest in adult victim?
a. Carotid pulse b. Brachial pulse
c. Femoral pulse d. Apical pulse

Ans. a. Carotid pulse

The preferred pulse site for cardiac arrest assessment:
• Adult= Carotid
• Child: Carotid/Femoral (But first preference is carotid pulse)
• Infant: Brachial
26 Final Subject Assessment Test (Nursing Foundations)

35. Select the correct sequence of providing chest compression and ventilation to
a cardiac arrest victim?
a. ABC b. BCA
c. CAB d. CBACorrect answer = option b

Ans. b. BCA
• In 2010, AHA changes their guidelines of providing CPR from ABC to CAB which is
the rescuer should first focus on compression ---airway and then breathing.

36. To provide chest compression the rescuer should select which of the following
landmark in adult victim?
a. Between the nipple line b. Upper part of sternum
c. Lower half of sternum d. None of the above
Ans c. Lower half of sternum

Figure 1: Location of Sternum

 Final Subject Assessment Test (Nursing Foundations) 27

• In children and adults, chest compressions are performed by locating the xiphoid
process and placing the heel of the hand over the lower half of the sternum. The
other hand is placed over the hand on the sternum with the fingers either interlaced
or extended and elbow extended so that the weight of the upper body is used for
compression.

Figure 2: Position of Hands over Sternum

• In infants, the chest compression can either delivered by using finger technique or by
using thumb encircling method.
28 Final Subject Assessment Test (Nursing Foundations)

37. Maximum depth of chest compression in adult victim to prevent the

complication of rib fracture?
a. 6.5 cm b. 6 cm
c. 5 cm d. 5.5 cm

Ans. b. 6 cm
Depth of chest compression
• Adult: 2 inches (5 cm) and maximum depth should be 2.4 inches (6 cm)
• Child: 2 inches (5 cm)
• Infant: 1.5 inches (4 cm)

38. A first aid provider found an adult victim who is unresponsive with pulse and
respiration. The single rescuer has activated the EMS. After starting the chest
compression how frequently the rescuer need to assess the patient for the sign
of pulse?
a. After 5 cycle of CPR b. After 10 cycle of CPR
c. After 2 minutes d. Both a & c

Ans. d. Both a & c

• After providing 5 cycles of CPR (2 minutes’ duration) the rescuer should check for
return of spontaneous circulation which is palpable pulse.

39. Select the pulse site to assess cardiac arrest in an adult victim?
a. Carotid Pulse b. Brachial pulse
c. Femoral Pulse d. Apical Pulse

Ans. a. Carotid Pulse

The preferred pulse site for cardiac arrest assessment:
• Adult= Carotid
• Child: Carotid/Femoral (But first preference is carotid pulse)
• Infant: Brachial

40. A nurse has received 34-year-old male patient from the Out-Patient Department
(OPD) with the chief complaints of allergic rhinitis, including episodic cough,
wheeze, itchy red watery eyes and a stuffy, runny, itchy nose. Patient had a
history of Asthma since 2008. After performing the initial assessment which
type of health assessment the nurse will perform?
a. Comprehensive Health Assessment
b. Focused Health Assessment
c. Episodic Health Assessment
d. Emergency Health Assessment

Ans. b. Focused Health Assessment

 Final Subject Assessment Test (Nursing Foundations) 29

Rationale:
• The correct answer is Focused Health Assessment.
• Comprehensive/Complete/Initial health assessment includes a complete health history
and physical examination and forms a baseline database. This type of assessment is
usually performed upon admission.
• Focused assessment is performed after the comprehensive assessment and it mainly
focuses on the present chief complaints of patients. As in the given question the patient
is admitted with the impairment in the respiratory system which indicates that the
nurse will perform focused respiratory assessment, which includes vital sign, lung
sounds, skin color to check cyanosis, etc.
• Episodic or follow up assessment focuses on evaluating a client’s progress.
• For example, after performing the focused respiratory system assessment the nurse
recorded that the patient SpO2 is 94 for which she placed her patient in Fowler’s
position to aid in better thoracic expansion. After some time, the nurse will perform
the follow up assessment by checking the SpO2 level of the patient to identify the need
of further interventions required for improving the patient’s SpO2 level.
• This can’t be considered a correct answer because the nurse hasn’t provided any
intervention yet (which can be evaluated) to the patient in the given scenario.
• Emergency assessment involves the rapid collection of data, often during the provision
of life-saving measures or conditions. It is also known by the name of primary survey
which includes the quick assessment of :
Ĕ A = AIRWAY
Ĕ B = BREATHING
Ĕ C = CIRCULATION
Ĕ D = DISABILITY
Ĕ E = EXPOSURE
• This can’t be the correct answer as the patient is in stable condition.

41. Identify the marked area of a surgical suture needle?

a. 1 = Tail, 2 = Body, 3 = Eye

b. 1 = Swaged end, 2 = Body, 3 = Needle point
c. 1 = Eye, 2 = Curve, 3 = Sharp edge
d. 1 = Holding point, 2 = Body, 3 = Pointed end

Ans. b. 1=swaged end, 2=body, 3=needle point

30 Final Subject Assessment Test (Nursing Foundations)

Rationale:

Figure: Parts of a suture needle

• A surgical needle has three sections which is the point, the body, and the swage. The
point is the sharpest portion and is used to penetrate the tissue. The body represents
the mid-portion of the needle. The swage is the thickest portion of the needle and the
portion to which the suture material is attached.

42. Identify the correct statement related to the image shown below?

Kindly add a clear image as Image is not that clear, so it will be difficult to identify.
a. Round body needle b. Cutting body needle
c. Reverse cutting needle d. a&c

Ans. a. Round body needle

 Final Subject Assessment Test (Nursing Foundations) 31

Rationale:
• The given image is of suture 2-0 vicryl which is a synthetic absorbable suture and
pronounced as two zero vicryl.

This round symbol here

indicate that it is round
body needle type.

• Round bodied needles are used in friable tissues such as liver and kidney.
• Cutting needles are triangular in shape, and have 3 cutting edges to penetrate tough
tissue such as the skin and sternum, and have a cutting surface on the concave edge.

Cutting body needle

• Reverse cutting needles have a cutting surface on the convex edge, and are ideal for
tough tissue such as tendon or subcuticular sutures, and have reduced risk of cutting
through tissue.

Reverse cutting needle

43. The nurse will set the suction chamber of underwater seal drainage system at
what pressure in adult patient with chest tube?
a. -20 cm H20 b. -5 cm H20
c. -2 cm H20 d. 0 cm H20

Ans. a. -20 cm H20

32 Final Subject Assessment Test (Nursing Foundations)
• Suction on the Drainage unit should be set to the prescribed level.
• -5 cmH20 is commonly used for neonates.
• -10 cmH20 to -20 cmH20 is usually used for adult.
• Other options are distracters.

44. While taking the nursing round you have noticed that one of the patient’s
chest tube drainage system has disconnected from the chest tube catheter and
fallen onto the floor. While the chest tube catheter is secured with sutures and
hanging in the air. What is your priority nursing action?
a. Inform the team leader immediately
b. Insert the chest tube catheter tubing I inch into a bottle of sterile water and obtain a new
system
c. Clamp the chest tube catheter and inform the doctor
d. Remove the chest tube catheter from the insertion site to reduce the risk of infection

Ans. b. Insert the chest tube catheter tubing I inch into a bottle of sterile water and obtain a new
system
• Insert or dip the chest tube catheter tubing 1 inch into a bottle of sterile water in
order to prevent the entry of atmospheric air into the chest cavity thereby preventing
negative respiratory pressure.
• Option a: Is not an immediate measure to be applied in this case.
• Option c: Clamping and informing the doctor is not an immediate measure in this case
because the chest tube catheter can’t be clamped for too long as it may cause building
up of a negative pressure inside the chest cavity.
• Option d: It is a distracter. The nurse should not remove the chest tube catheter out as
in the given scenario, it is mentioned only the chest tube drainage is disconnected from
the chest tube catheter while the catheter is secured in place with the sutures.

45. Name the instrument in the following image

a. Patient sling
b. Patient hoist
c. Recline lift
d. Patient walker

Ans. b. Patient hoist

 Final Subject Assessment Test (Nursing Foundations) 33

Patient hoist
Uses: It is an assistive device used to transfer the patient
between a bed and a chair or other similar resting
places.

Patient sling
Uses: They support and wrap around part of the
patient’s body, and attach to patient thereby lifts the
patient by the use of multiple straps. Some slings feature
soft linings to help cushion and protect a patient’s body.

Recline lift/ lift chair

Uses: It is used for those patients who have stiff and sore
joints, back pain, arthritis and difficulty in standing after
sitting position.

Patient Walker
Uses: It is used for disabled or elderly people who need
additional support to maintain balance or stability while
walking.
34 Final Subject Assessment Test (Nursing Foundations)

46. Identify the symbol shown in photograph

a. Radiation Hazard b. Biohazard waste

c. Cytotoxic waste d. Biodegradable waste

Ans. b. Biohazard waste

Figure: Cytotoxic waste symbol

Figure: Radiation hazard symbol

Figure: Biodegradable waste symbol

 Final Subject Assessment Test (Nursing Foundations) 35

47. Identify the image:

a. Ligating cutting stapler

b. Visistat skin stapler
c. Endoscopic ligaclip hemostatic clip applier
d. Ligaclip Multiple clip applier

Ans. d. Ligaclip Multiple clip applier.

Ligating cutting stapler

A. Ligating cutting stapler

B. cartridge for reloadable

Contd…
36 Final Subject Assessment Test (Nursing Foundations)

Visistat skin stapler

Endoscopic ligaclip hemostatic

clip applier

48. You have received a victim with a history of fall from 3rd floor and on
examination the victim is unresponsive. Which method the nurse will use to
assess the airway in this victim?
a. Jaw thrust maneuver
b. Head-tilt-chin lift maneuver
c. Heimlich maneuver
d. 5 back slap followed by chest compression

Ans. a. Jaw thrust maneuver

Rationale:
• As in the given scenario, victim came with a history of fall from 3rd floor, which expose
the victim for a higher risk of cervical fracture due to which the jaw thrust is most ideal
method of opening the airway in this case instead of head-tilt-chin method.
• Jaw thrust is an airway opening maneuver, used during resuscitative efforts when there
is suspicion of cervical injury. The head is maintained in neutral alignment while the
jaw is displaced forward at the mandibular angle: the rescuer places the tips of the
fingers behind the angle of the jaw and, without moving the patient’s neck, thrusts the
jaw upward/forward, moving the jaw away from the back of the patient’s head.

Figure: Jaw thrust

 Final Subject Assessment Test (Nursing Foundations) 37

• Head-tilt-chin lift maneuver: Place one hand on the victim’s forehead, and two fingers
on the bony part of the jaw. Gently tilt the head backward. This will open the airway
and lift the tongue off the back of the throat.

Figure 2: Head-tilt-chin lift

• Heimlich maneuver also known as abdominal thrusts is a first aid procedure used to
treat upper airway obstructions by foreign objects.

Figure 3: Heimlich maneuver

49. Which of the following statement best describe the term decannulation?
a. Removal of IV cannula b. Removal of ETT
c. Removal of TT d. Removal of PICC line

Ans. c. Removal of TT
• Removal of tracheostomy tube is called decannulation.
• Removal of endotracheal tube is called as extubation while insertion of a tube is called
as intubation.
38 Final Subject Assessment Test (Nursing Foundations)

50. Select the incorrect statement regarding the Hand hygiene Moments laid down
by WHO?
a. Before touching the patient
b. Before any aseptic procedure
c. Before touching the patient surrounding
d. After body fluid exposure

Ans. c. Before touching the patient surrounding

• As per the WHO (World Health Organization), recommended guidelines: all health
care workers should follow 5 moments of hand hygiene in order to prevent the risk of
transmission of infection in hospital setting.
• 5 moments of hand hygiene:
Ĕ Before touching a patient,
Ĕ Before clean/aseptic procedures,
Ĕ After body fluid exposure/risk,
Ĕ After touching a patient, and
Ĕ After touching patient surroundings.

Figure: WHO recommended 5 moments of Hand hygiene

51. N-95 masks, the N stands for which of the following?

 Final Subject Assessment Test (Nursing Foundations) 39

a. Non-resistance to oil and aerosol particles

b. Non-resistance to droplet particle
c. Non aerosol generating particle
d. None of the above

Ans. a. Non-resistance to oil and aerosol particles

• N-Nonresistance to oil and aerosol particles. Respirators that filter out 95 percent
of airborne particles are given a 95 rating, so N95 respirator filters out 95 percent of
airborne particles but is not resistant to oil.

52. World stroke day observed on which of the following date?

a. 17th September b. 28th July
c. 1st December d. 29th October

Ans. d. 29th October

Rationale:
2022: the World Stroke Day Theme is «#Precious time»,

53. For receiving the telephonic orders which of the following statement is related
to the “Joint commission International read-back requirement” policies?
a. Repeat and confirm
b. Write, read back and confirm
c. Listen, repeat and confirm
d. Document and proceed with the orders

Ans. b. Write, read back and confirm

Rationale:
• No verbal order by the doctors to nurses is allowed except in sterile condition, cardiac
arrest or other life-threatening situations.
• In order to reduce the errors, the “Joint Commission read-back requirement” policies
are best used for verbal or telephonic orders. The steps involve:
Ĕ First, note the date and time.
Ĕ Record the order word-for-word on the record sheet.
Ĕ On the next line, write “telephone order”.
Ĕ Then write the health care provider’s name, and along with your initials.
• Read back the order and get confirmation from the person who gave the order. (This
step is called the “Joint Commission read-back requirement” and applies to all verbal
and telephone orders.) The read-back requirement also applies to critical test results
reported verbally or by telephone.In case you are having any trouble in understanding
the verbal order always ask another nurse to take the order and she will also follow the
same principle of read back and sign the order too.
• After this as per the hospital protocol, it is recommended that the doctor who has given
the verbal order has to countersign the order. Without doctor signature the nurse may
be held liable for practicing the clinical care without license.
40 Final Subject Assessment Test (Nursing Foundations)

54. Identify the method of charting?

a. Charting by exception b. Patient critical notes

c. Progress report d. Care bundle checklist

Ans. a. Charting by exception

• Charting by exception (CBE) method of charting focuses on documenting deviations
from the established norm or abnormal findings. This approach reduces documentation
time and highlights trends (changes in patient health status).
• Other options of charting includes detailed information regarding the health status or
any procedure being performed.

Figure: Critical care observational sheet

 Final Subject Assessment Test (Nursing Foundations) 41

55. The new nursing staff has recorded the oral temperature of her patient
98.5-degree Fahrenheit without knowing that the documentation of patient’s
body temperature is to be made in degree Celsius as per the hospital protocols.
What reading the nurse will document in her patient’s vital sign clinical chart?
a. 36.0°C b. 36.9°C
c. 37.0°C d. 37.2°C

Ans. b. 36.9 °C
Here, we will use the formula for converting the body temperature reading from Fahrenheit
to Celsius:
• Celsius = (temperature in Fahrenheit -32) × 5/9
• Temperature in °C = (98.5 °F -32) × 5/9
• Temperature in °C =66.5 × 5/9
• Temperature in °C = 36.9

56. The gradual decrease in body’s temperature after death is called:

a. Liver mortis b. Algor mortis
c. Rigor mortis d. Stiff mortis

Ans. b. Algor mortis

• There are three main stages of decomposition of body after death over the first 24–48
hours. This helps the forensic specialist in determining the time of death.
Ĕ Livor mortis: It is the first stage and is characterized by discoloration of the skin in
the dependent parts of the body after death. This happens in the dependent parts
of the body and these parts become dark.
Ĕ Algor mortis means “coldness of death”. Once circulation stops, the body starts to
cool down. This starts 30–60 minutes after death and lasts for a few hours.
Ĕ Rigor mortis: It is the third stage, which means “stiffness of death”. In this stage,
the body becomes very stiff and starts after a few hours after death and lasts up to
24 hours.

57. _____ enema is also called antispasmodic enema:

a. Carminative b. Purgative
c. Anthelminthic d. Cold

Ans. a. Carminative
• Carminative enema is used to remove the abdominal gaseous distention (flatus) by
stimulating the peristaltic movement.
• Antihelminthic enema is used to destroy and expel the worms from the intestines.
Before the treatment is given, the bowel should be cleansed by a soap water enema
so that the drug may come in direct contact with the worms and the lining of the
intestines. The treatment is given until the worms are destroyed.
• Purgative enema is given to cause the bowel to contract actively and to evacuate its
contents.
• Cold enema is used to decrease the body temperature in hyperpyrexia and heat stroke.
42 Final Subject Assessment Test (Nursing Foundations)

58. Most preferred site for CVP insertion?

a. Left internal jugular
b. Right internal jugular
c. Subclavian
d. Femoral

Ans. b. Right internal jugular

Right internal jugular vein, left subclavian vein are the most direct paths to the right atrium
via the superior vena cava.

59. Surgical removal of infected or dead tissue from the wound is called______:
a. Dehiscence
b. Debridement
c. Evisceration
d. Exudate

Ans. b. Debridement
Rationale:
• Debridement is the removal of dead (necrotic) or infected skin tissue which is done as
an intervention to wound heal.
• An exudate is a collection of fluid that has a relatively high specific gravity and protein
concentration which usually occur as the result of an inflammatory process that either
increases the permeability of the surrounding membrane or disrupts the ability of
resorption of fluid.
• Dehiscence is a surgical complication where the edges/layer of a wound are separated.
It is also known as “wound separation.
• Evisceration is a rare but severe surgical complication where the surgical incision
opens (dehiscence) and the abdominal organs then protrude or come out of the
incision (evisceration).

60. Apical pulse is felt at:

a. Below jawbone
b. At wrist
c. Left side of the chest
d. Top of the foot

Ans. c. Left side of the chest

Auscultation Point Location

Aortic Right of the sternal border in 2nd ICS.
Erb’s Point Left of the sternal border in 3rd ICS.
Pulmonic Left of the sternal border in 2nd ICS.
Mitral (Apical) 5th Intercostal space (ICS) mid- clavicular line left side.
Tricuspid Right of the sternal border in 4th ICS.
 Final Subject Assessment Test (Nursing Foundations) 43

61. The type of assessment that includes data related to a patient’s biological,
cultural, spiritual and social needs is called:
a. Behavioral assessment
b. Screening assessment
c. Comprehensive assessment
d. Focused assessment

Ans. c. Comprehensive assessment

Rationale:
• Comprehensive/Complete/Initial health assessment includes a complete health history
and physical examination and forms a baseline database. This type of assessment is
usually performed upon admission and includes patient biological, cultural, social and
spiritual needs.
• Focused assessment is performed after the comprehensive assessment and it mainly
focused on the present chief complaints of patients. As in the given question, the
patient is admitted with the impairment in the respiratory system which indicates that
the nurse will perform focused respiratory assessment, which includes vital signs, lung
sounds, skin color to check cyanosis, etc.
• Episodic or follow up assessment focuses on evaluating a client’s progress.
• For example, after performing the focused respiratory system assessment the nurse
recorded that the patient SpO2 is 94 for which she placed her patient in Fowler’s
position to aid in better thoracic expansion. After some time, the nurse will perform
the follow up assessment by checking the SpO2 level of the patient to identify the need
of further interventions required for improving the patient’s SpO2 level.
• This can’t be considered a correct answer because the nurse hasn’t provided any
intervention yet (which can be evaluated) to the patient in the given scenario.
• Emergency assessment involves the rapid collection of data, often during the provision
of life-saving measures or conditions. It is also known by the name of primary survey
which includes the quick assessment of :
Ĕ A= AIRWAY
Ĕ B=BREATHING
Ĕ C=CIRCULATION
Ĕ D=DISABILITY
Ĕ E=EXPOSURE

62. Which of the following stage of anesthesia is characterized by stage of surgical

anesthesia where eyes roll, then become fixed and the corneal and laryngeal
reflexes are lost?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4

Ans. c. Stage 3Rationale:

• Stage 1, also known as induction stage or stage of analgesia or disorientation, is the
period between the administration of induction agents and loss of consciousness.
44 Final Subject Assessment Test (Nursing Foundations)
• Stage 2, also known as the excitement or delirium stage. During this stage, the
patient’s respiration and heart rate may become irregular. In addition, there may be
uncontrolled movements, vomiting, suspension of breathing, and pupillary dilation.
Because the combination of spastic movements, vomiting, and irregular respiration
may compromise the patient’s airway, rapidly acting drugs are used to minimize time
in this stage and reach Stage 3 as fast as possible.
• In Stage 3, also known as surgical anaesthesia, the skeletal muscles relax, vomiting
stops, respiratory depression occurs, and eye movements slow and then stops. The
patient is unconscious and ready for surgery. This stage is divided into four planes:
Ĕ Plane I - From onset of automatic respiration to cessation of eyeball movements.
The eyes roll, then become fixed.
Ĕ Plane II - From cessation of eyeball movements to beginning of paralysis of
intercostal muscles. Corneal and laryngeal reflexes are lost.
Ĕ Plane III - From beginning to completion of intercostal muscle paralysis. The
pupils dilate and light reflex is lost.
Ĕ Plane IV - From complete intercostal paralysis to diaphragmatic paralysis (Apnea).
• Stage 4 also known as overdose, occurs when too much anaesthetic medication
is given relative to the amount of surgical stimulation and the patient has severe
brainstem or medullary depression, resulting in a cessation of respiration and potential
cardiovascular collapse.

63. A clinical instructor is providing bedside teaching to the 2nd year BSc nursing
students about the whoosh test on a patient with NG tube. Select the most
appropriate statement related to the test?
a. It is used to assess the correct placement of NG tube
b. The examiner will place the diaphragm of the stethoscope over the left upper quadrant
of abdomen to listen to the bubbling air sound
c. The air is injected with the help of syringe through the NG tube while simultaneously
auscultating, a whoosh sound is heard which indicates the tube is in stomach
d. All of the above

Ans. d. All of the above

• Whoosh test is one of the methods to check NG tube placement. Use a syringe to push
10-30 mL of air into NG tube and listen over the left upper quadrant of stomach with
stethoscope for “whoosh “sound.
• Other methods to confirm the placement of NG tube are:
Ĕ Aspiration of gastric content and measuring the pH using pH indicator strips/
paper, the pH reading must be 5.5 or below to confirm the placement of NG tube.
Ĕ Radiography (e.g. chest X-ray)
Ĕ Measuring the length of the tube from the point it protrudes from the nose to the
remaining part of the tube.
• Other options are distractors.

64. Identify the image given below?

 Final Subject Assessment Test (Nursing Foundations) 45

a. CVP Manometer b. Burette set

c. Transducer set d. Plebostatic axis

Ans. a. CVP Manometer

Rationale:
• The CVP can be measured either manually using a manometer (Figure 1) or
electronically using a transducer (Figure 2).

Figure 1: CVP monitoring with manometer

Figure 2: CVP monitoring with transducer system

46 Final Subject Assessment Test (Nursing Foundations)
• Burette set is used to deliver a fixed volume of IV fluid at a fixed rate, usually with
added medication. A primary IV solution set is attached to the spike adaptor at the
distal end of the in-line burette set

Figure 3: Burette set

• Plebostatic axis: Phlebostatic axis is regarded as the anatomical point that corresponds
to the right atrium and most accurately reflects a patient’s hemodynamic status
• Phlebostatic axis is located at the fourth intercostal space at the mid-anterior- posterior
diameter of the chest wall. This is the location of the right atrium.

Figure 4: Phlebostatic axis

65. Identify the image given below?

a. Corrugated drain b. Silicon foley’s catheter

c. Chest tube catheter d. Suction tube

Ans. c. Chest tube catheter

 Final Subject Assessment Test (Nursing Foundations) 47

Chest tube catheter

Corrugated drain sheet

Silicon Foley’s Catheter

Suction tube with Yankauer tip

48 Final Subject Assessment Test (Nursing Foundations)

66. Using Abraham maslow’s hierarchy of human needs. A nurse assigns highest
priority to which client need?

a. Security b. Elimination
c. Safety d. Belonging

Ans. b. Elimination
• As per the Maslow’s hierarchy pyramid the needs of the individuals are categorized
into 5 main level. Started from the very basic and without which an individual cannot
survive is the physiological need like oxygen, water, food, elimination.
• Other options are distractors.

67. Identify the movement presented in the given image?

a. Adduction b. Abduction
c. Circumduction d. Extension

Ans. b. Abduction
 Final Subject Assessment Test (Nursing Foundations) 49

Rationale:
Abduction: Movement of the bone away
from the midline of the body.

Adduction Movement of the bone toward

the midline of the body.

Circumduction Movement of the distal part of

the bone in a circle while the
proximal end remains fixed.

Contd…
50 Final Subject Assessment Test (Nursing Foundations)

Extension Increasing the angle of the

joint. Example: straightening
the arm at the elbow.

68. How many links are in the chain of infection?

a. 4
b. 5
c. 6
d. 8

Ans. c. 6
Rationale:
• There are total 6 links present in the chain of infection:
Ĕ Infectious Agent----Reservoir-----Portal of exit-----Mode of transmission----
Portal of entry------Susceptible host.
Ĕ Infectious agent is the micro-organism or the pathogen which is responsible for
the diseases condition.
Ĕ Reservoir is the places where the infectious agent lives, reside, grow and multiply.
It could be people, animals and insects, medical equipment, and soil and water.
Ĕ The next link in the chain of infection is Portal of exit where the channel through
which the infectious agent makes an exit from the reservoir. It could be through
open wounds, aerosols, and splatter of body fluids including coughing, sneezing,
and saliva.
Ĕ Mode of transmission is the medium through which the infectious agents can be
transmitted to others. It includes through direct or indirect contact, ingestion, or
inhalation.
Ĕ Portal of entry considered as the path through which the infectious agent can enter
into a new host. It could be through broken skin, the respiratory tract, mucous
membranes, and catheters and tubes.
Ĕ Susceptible host are those individuals that are vulnerable or with
immunocompromised condition who are more at risk for getting the infection.

69. Identify the image given below?

 Final Subject Assessment Test (Nursing Foundations) 51

a. Veress needle b. Hasson Trocar

c. Fogarty catheter d. Luc’s Forceps

Ans. a . The Veress needle is designed to create pneumo-perritoneum prior to insertion of trocar
in a closed fashion.
• It consists of an outer sharp cutting needle and inner blunt spring-loaded obturator.
• As you have seen in the video the surgeon is inserting the Veress needle, later the
needle tip is then connected with the CO2 gas pipe to inflate the abdomen. Once the
abdomen is fully inflated the Veress needle is then removed and trochar cannula with
trochar is inserted to carry out the laparoscopic surgery.

Figure 1: Veress needle

Option a: Hasson Trocar with cannula used for gaining initial access to the abdominal cavity
with an open cut-down technique.

Figure 2: Laparoscopic Hasson Trocar with Cannula 10 mm

Option c: Fogarty arterial embolectomy catheter is a device developed by Dr. Thomas J.
Fogarty to remove fresh emboli in the arterial system.

Figure 3: Fogarty arterial embolectomy catheter

52 Final Subject Assessment Test (Nursing Foundations)
Option d: Luc’s forceps are used for grasping tissues during tonsillectomy or in case of
septoplasty for removal of cartilage and bone

Figure 4: Luc’s Forceps

70. The nurse during assisting the doctor in pleural tapping asked for the associated
complication, select the most suitable complication of pleural tapping?
a. Pneumothorax b. Hypotension
c. Infection d. All of the above

Ans. d. All of the above

• Pneumothorax= collection of air in the pleural space. It is one of the common
complication of pleural tapping procedure.
• Hypotension = Accidental removal of too much fluid from the pleural space can result
into decrease in circulatory volume and leading to hypotension and syncope.
• Thoracentesis should be performed under strict sterile technique and Infection can be
occur if aseptic technique is not followed throughout the procedure

71. Identify the image given below?

a. Glycerine syringe b. Toomey syringe

c. Asepto syringe d. Eccentric tip syringe

Ans. a. Glycerine syringe

 Final Subject Assessment Test (Nursing Foundations) 53

Glycerine Syringe
Available in 50 to 100 ml. Used for
administration of small volume
enema. Present with nozzle tip that
can easily be inserted into the rectum.

Asepto Syringe
Feeding and irrigation syringe pump.
Capacity 60ml
The bulb at the end of syringe creates
a vacuum for gentle suction of small
amounts of bodily drainage, such as
oral and nasal secretions.

Eccentric Tip syringe is different from

the regular syringe.
Eccentric tip syringes nozzle is present
on the edge of the syringe barrel
which allows an attached needle to be
closer in line with the syringe walls so
that the needle is nearly parallel with
the injection surface.

ECCENTRIC   
A Toomey syringe is used for irrigating
and evacuating during medical
procedures.
54 Final Subject Assessment Test (Nursing Foundations)

72. The “Science of Unitary Human nursing” was explained by which nursing
theorist?
a. Rogers b. Neuman
c. Virginia Henderson’s d. Imogene M. King

Ans. a. Rogers
• Martha Rogers’ theory is called as the Science of Unitary Human Beings (SUHB). It
contains two dimensions: the science of nursing and the art of nursing.
• In 1962, Ida Jean Orlando developed the Deliberative Nursing Process Theory. The
theory explains that the nurse’s role is to find out and meet the patient’s immediate
needs for help.
• In 1860, Florence Nightingale proposed Environmental Theory. In which she focused
on utilizing patient’s environment in his/her recovery
• In 1972, Betty Neuman proposed Neuman’s system model which is based on the
person’s relationship to stress, response, and reconstitution factors that are progressive
in nature.

73. Identify the type of crutch walking gait illustrated in the given image which
describes as the client move both the crutches along with the affected leg first
and then take the step forward from the unaffected leg.

a. 3-point gait b. 4-point gait

c. 2-point gait d. Swing through gait

Ans. a. 3-point gait

Rationale:
• Crutches are the ambulatory aids which is used by the person with lower limb disability.
There are several different walking patterns that an individual can have while using
crutches. It includes: 2 point, 3 point crutch gait, 4-point crutch gait and swing through
gait, swing to gait.
• 2-point gait: This type of gait with crutch used when the patient can bear some weight
on both lower extremities.
• Scenario: To explain the different walking pattern we will use an example of a patient
who is having left leg weakness.
 Final Subject Assessment Test (Nursing Foundations) 55

Ĕ Example: In 2 point gait according to the given scenario, the patient will move the
right leg and the left side crutch forward together and then the next step will be
taken by the left leg with right side crutch forward together and the same process
is repeated. One crutch and one leg moved at a time are considered as 2-point
contact with floor.

Figure 1: 2-point crutch gait walking

• 3 point crutch gait walking: This gait pattern is used when one side lower extremity (LE)
is unable to bear weight due to fracture, amputation or because of joint replacement.
• Scenario: To explain the different walking pattern we will use an example of a patient
who is having fracture in left leg.
Ĕ Example: According to the scenario in 3 point gait walking, the patient will move
both the crutches and the left leg (affected one) simultaneously and then move the
right leg (unaffected). Both crutches and the unaffected leg 3-point contact with
the floor.

Figure 2: 3-point gait walking

56 Final Subject Assessment Test (Nursing Foundations)
• 4 point gait walking: This gait pattern is used when there’s lack of coordination, poor
balance and muscle weakness in both lower extremities. It provides slow and stable gait
pattern with 4 point contact with the floor i.e. point one is the crutch on the affected
side of leg, point two is the unaffected leg, point three is the crutch of unaffected side
of leg, and point four is the affected leg.
• Scenario: To explain the different walking pattern we will use an example of a patient
who is having uncoordinated gait.
Ĕ Example: In this scenario, the patient will move the right crutch forward then move
the left foot forward then move the left crutch forward after that move the right
foot forward and will repeat this sequence of crutch-foot-crutch-foot for desired
ambulation.

Figure 3: 4-point gait crutch walking

Ĕ It might look similar to 2 point gait walking but there is a huge difference between
them, that is in 2 point gait, the person moves the crutch and the leg which is
opposite to the moved crutch together or at the same time but in 4 point gait, the
person will first move the crutch then move forward the leg which is opposite to
the moved crutch.
• Swing to gait: The person moves both the crutches together after that swings both the
legs together and place them at the same line on the floor where the crutches lies.

Figure 4: Swing to gait

• Swing through gait: The person moves both the crutches forward together after that
the patient moves and swings both the legs and pass the crutch line and place the foot
ahead of crutches.
 Final Subject Assessment Test (Nursing Foundations) 57

Figure 5: Swing through gait

74. While inserting the CVP line in internal jugular vein the preferred patient
position will be?
a. Trendelenburg position
b. High-fowlers position
c. Lateral position
d. Supine position

Ans. a. Trendelenburg position

• Right side approach Trendelenburg position: Head turned slightly away from the
puncture site in order to minimize the risk of pneumothorax.

75. Which biohazard bin is used to discard the item shown in the given image?

a. Red bin
b. Puncture proof container
c. Yellow bin
d. Blue cardboard box

Ans. d. Blue cardboard box

• As per the protocol and new BMWM rule 2016, all the metallic implants should be
discarded in a separate blue container.
58 Final Subject Assessment Test (Nursing Foundations)

76. Identify the symbol given below:

a. Corrosive b. Radioactive waste

c. Flammable d. Bio-hazard

Ans. a. Corrosive
Rationale:
• Option b: Oxidizer

Figure 1: Oxidizer symbol

• Option c: Flammable

Figure 2: Flammable symbol

• Option d: laser radiation

Figure 3: Laser radiation

 Final Subject Assessment Test (Nursing Foundations) 59

77. Which of the following best describe about common biomedical waste
treatment and disposal facility (CBWTF)?
a. Place where biomedical waste is generated
b. Place where biomedical waste undergoes pre-treatment
c. Place where final disposal of the waste takes place
d. Both a & b

Ans. d. Both a & b

• Common bio-medical waste treatment and disposal facility (CBWTF) is a set up where
biomedical waste generated from member health care facilities is imparted necessary
treatment to reduce adverse effects that this waste may pose on human health and
environment. The treated recyclable waste may finally be sent for disposal in a secured
landfill or for recycling.

78. Fluid build-up caused by tissue leakage due to inflammation or local cellular
damage is known as?
a. Transudate b. Exudate
c. Pleural effusion d. None of the above

Ans. b. Exudate
• Transudates are caused by disturbances of hydrostatic or colloid osmotic pressure, not
by inflammation.
• Exudate” is fluid buildup caused by tissue leakage due to inflammation or local cellular
damage.

79. Which among the following sequence the nurse should follow while measuring
the vital sign during newborn assessment?
a. Temperature, pulse, respirations b. Pulse, respirations, temperature
c. Respirations, temperature, pulse d. Respirations, pulse, temperature

Ans. d. Respirations, pulse, temperature

Rationale:
• The correct answer is option d, which is Respiration, pulse, temperature.
• This sequence is least disturbing. Touching with the stethoscope and use or inserting
of thermometer will increase anxiety level and may affect the vital sign reading due to
which it is recommended to measure the temperature in new born at last.

80. The nursing intern has provided the bolus NG tube feeding with the help of 60
mL syringe to the conscious bedridden patient. Which of the following action
by the nurse is recommended to prevent regurgitation after NG tube feeding?
60 Final Subject Assessment Test (Nursing Foundations)
a. Place the patient in left lateral position for 1 hour after feeding
b. Place the patient in fowlers position for 1–2 hours after feeding
c. Place the patient in fowler’s position for 30–60 minutes after feeding
d. Place the patient in supine position after NG tube feeding.

Ans. c. Place the patient in fowler’s position for 30–60 minutes after feeding
Rationale:
• The correct answer is option 3: After the NG tube feeding in order to prevent the risk of
regurgitation or backflow of gastric content it is recommended that the patient should
be placed in the fowler’s position for at least 30 minutes to maximum 60 minutes.
• Other options are distractors.

81. Match the following surgical retractor according to their respective name?
1. Deaver retractor

a.  
2. Langenbeck retractors

b.  
Contd…
 Final Subject Assessment Test (Nursing Foundations) 61

3. Czerny Retractor

c.  
4. Doyen

d.  
a. 1=b, 2=a, 3=d,4=c b. 1=d, 2=c, 3=a, 4=b
c. 1=c,2=a,3=d,4=b d. 1=b,2=a,3=c,4=d

Ans. b. 1=d, 2=c, 3=a, 4=b

Rationale:
The correct answer is option b.
62 Final Subject Assessment Test (Nursing Foundations)

Doyen Retractor The Doyen Retractor is a broad

based retractor used to pull back
soft tissues and widen the surgical
field. This is useful in laparotomies
and pelvic surgeries like abdominal
hysterectomy and caesarean section,
as well as retractions of the urinary
bladder.

Langenbeck Langenbeck retractors are used

retractors to retract soft tissues and wound
edges in order to visualize deeper
structures. They were designed
by the German surgeon, Bernhard
von Langenbeck, for urological
procedures, and are now used
for plastic, urological and general
surgical procedures.

Deaver retractor A Deaver retractor is a surgical

instrument used in thoracic and
abdominal surgery for holding back
muscle, tissue, and bone. It allows
the surgeon to be able to reach the
underlying organs. It is a thin, flat
instrument with curved ends.

Contd…
 Final Subject Assessment Test (Nursing Foundations) 63

Czerny Retractor Retractor with two spikes on one

end and a broad surface on the
other. Typically used during closure
of a midline laparotomy wound to
retract the superior or inferior edges
to facilitate insertion of the first
mass closure stitch.

82. A medical-surgical nurse has recorded the patient’s vital parameters as Pulse
79 bpm, respiration 18 breath/m, blood pressure is 100/ 66 mm Hg. Doctor
asked the nurse to calculate the mean arterial pressure?
a. 144 mm Hg b. 165 mm Hg
c. 100 mm Hg d. 77 mm Hg

Ans. d. 77 mm Hg
Rationale
• Mean arterial pressure (MAP) is defined as the presence of average pressure in arteries
during one cardiac cycle. It is considered a better indicator of perfusion to vital organs
than systolic blood pressure.
• MAP is calculated by double the diastolic blood pressure and add the sum to the
systolic blood pressure. Then divide by 3.

Where in the formula,

DBP = Diastolic blood pressure
SBP = Systolic blood pressure

83. A senior nurse is supervising a student nurse who is performing tracheostomy

care for a patient. Which of the following actions by the student should the
nurse intervene?
a. Pre-oxygenate the patient and perform suctioning before the tracheostomy dressing
change
b. Untie the old tracheostomy tie from the dressing
c. Removing the inner cannula and cleaning using standard precaution
d. Clean the stoma with gentle stroke
64 Final Subject Assessment Test (Nursing Foundations)
ans. c. Removing the inner cannula and cleaning using standard precaution

Rationale
• Removing the inner cannula and cleaning using standard precaution.
• Tracheostomy care is a sterile procedure. When performing tracheostomy care, a sterile
field is set up and sterile technique is required in order to prevent the risk of respiratory
infection. Standard precautions such as washing hands must also be maintained but are
not enough when performing tracheostomy care.

• Other options are distracters.

84. Doctor order to administer 500 mg of antibiotics added in 50 ml of 0.9%

normal saline IV four times a day. The antibiotic is supplied in single dose vial
of 1 gram. The direction advice that the instillation of 0.8 ml of NS will yield
1.2 ml of solution. How much (ml) of antibiotic solution should be added to
the 50 ml of NS.
a. 0.6ml b. 0.8ml
c. 1ml d. 5ml

Ans. a. 0.6 ml
• Antibiotic comes in powder form and to administer it we need to dissolve it by using
Normal saline
• In the given scenario,
• Doctor order = 500 mg of antibiotic added in 50 ml NS
• And we need to figure out how much ml of antibiotic (not mg) will the nurse add into
50 ml NS.
• Available in stock is 1 g antibiotic vial in powdered form in which nurse has added 0.8
ml of NS and the final solution in the vial becomes 1.2 ml which the nurse can add
into 50 ml of NS solution.
But, Here we need to give 500 mg.
• So, first we need to convert 500mg into g.
• Mg is the smaller unit and g is higher unit.
• To convert smaller unit into higher we need to divide by 1000.
 Final Subject Assessment Test (Nursing Foundations) 65

• Antibiotic dose in g= 500 mg X 1g

• 1000 mg
• Antibiotic dose in g= 0.5 g
• 1 gram powdered form antibiotic is = 1.2 ml of antibiotic solution
  So, 0.5 gram powdered form antibiotic = X (Find out)
• 0.5 gram Antibiotic in solution form = 0.5 X 1.2 ml
• If the nurse will add 0.8 ml of NS in 0.5 g of antibiotic then it will be 0.6 ml of solution
which will be added in 50 ml of NS for infusion

85. Name the blood borne pathogens that the health care personnel are most
commonly exposed due to needle stick injury?
a. Hepatitis B b. Hepatitis B and C
c. Hepatitis B and C, HIV d. HIV

Ans. c. Hepatitis B and C, HIV

Rationale:
• The pathogens that cause the most serious health risks due to needle stick injuries are:
Ĕ Hepatitis B virus (HBV): 21–22%
Ĕ Hepatitis C virus (HCV): 2–3%
Ĕ Human immunodeficiency virus (HIV), the virus that causes AIDS: 0.3%

86. The lumbar Puncture is contraindicated in which of the following condition?

a. Vomiting b. Patient with artificial respiratory support
c. Raised ICP d. Subarachnoid hematoma

Ans. c. Raised ICP

• Lumbar puncture is contraindicated in patient with increased intracranial pressure as
it can result into cerebral herniation.
• Sudden removal of CSF results in pressures lower in the lumbar area than the brain and
favours herniation of the brain.
• Lumbar Puncture is performed for diagnostic purpose to rule out subarachnoid
hematoma or meningitis (viral, bacterial) or for therapeutic purpose for administration
of medication into the subarachnoid space.

87. Identify the method illustrated in the given image:

66 Final Subject Assessment Test (Nursing Foundations)
a. Log roll technique b. C-spine control
c. Stand pivot d. Mechanical traction

Ans. a. Log roll technique

Rationale
• The correct answer is log roll technique.
• Log rolling is done to maintain alignment of the spine while turning and moving the
patient who has had spinal surgery or suspected or documented spinal injury.
• C-spine control requires the use of a cervical collar or sandbag or it can also be done
manually for the cervical spine stabilization to reduce or eliminate instability. Instability
can be caused by degenerative disc diseases, injury, trauma, herniated discs and more.

Figure 1: Manual C-spine control

Figure 2: C-Spine control with cervical collar

• Stand pivot is the type of transferring the patient from higher surface to lower surface.
Example, if the patient is transferring from the edge of his or her bed to his or her
wheelchair, raise the bed so that it’s somewhat higher than the wheelchair.
• Mechanical traction is a distractor used among other options.
 Final Subject Assessment Test (Nursing Foundations) 67

88. Match the correct entry with the appropriate SOAP category.
1. Repositioned patient on right side. Encouraged patient to use patient-controlled
analgesia device
2. The pain increases every time I try to turn on my left side
3. Acute pain related to tissue injury from surgical incision
4. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no
drainage. Pain noted on mild palpation
a. S-2, O-3, A-4, P-1 b. S-2, O-4, A-3, P-1
c. S-3, O-2, A-4, P-1 d. S-2, O-3, A- 1, P-4

Ans. b. S-2, O-4, A-3, P-1

• SOAP Acronym
S= Subjective
0= Objective
A= Assessment
P= Planning
• SOAP method of documentation is used as organized format for making the progress
notes in the patient chart.
• Other options are distractors.

89. You are assigned to provide care to a patient. The nurse will plan to inject
iron dextran by which technique?
a. Intramuscular (IM) injection using the Z-track method
b. Subcutaneous injection with a ½-inch, 25-gauge needle
c. IM injection with a ½-inch, 18-gauge needle
d. Intradermal injection with a sunburst technique of administration

Ans. a. Intramuscular (IM) injection using the Z-track method

• Iron dextran should be administered deep in a large muscle mass using the Z-track
method and a 23-gauge, 1½-inch needle to prevent skin irritation and potential
necrosis.
• The Z-tract injection technique is useful for medications that stain upper tissue such as
iron dextran or drugs that irritate tissues such as diazepam by preventing the leakage
of medication into the subcutaneous tissues.

Figure: Z track technique for IM injection

68 Final Subject Assessment Test (Nursing Foundations)
• The skin is laterally displaced prior to injection, the needle is inserted, and the injection
is administered. The needle then is withdrawn, and the skin released. This creates a
“Z” pattern that blocks infiltration of the drug into the muscle. These injections are
generally 2 - 3 inches deep.

90. You have received a RTA case with severe blood loss. Attending doctor
prescribed with multiple transfusion of blood. Which most essential piece of
equipment should the nurse use to prevent the risk of cardiac dysrhythmias?
a. Cardiac monitor b. Blood warmer
c. ECG machine d. Infusion pump

Ans. b. Blood warmer

• As in the given scenario, the patient is in hypovolemic shock and in need of rapid
transfusion of blood. The nurse has to make sure that the blood should be kept atleast
30 minutes at room temperature before transfusion as in emergency cases where we
need to give rapid blood transfusion it is must for the nurse to have a blood warmer
because cool blood transfusion can lead to the risk for cardiac dysrhythmias.
• Options a & c: Cardiac monitor and ECG will help to rule out any blood transfusion-
related complications, like cardiac arrythmias but they do not prevent the occurrence
of cardiac dysrhythmia.
• Option d is not beneficial in this case since the infusion must be given rapidly. It acts
as a distracter in this question.

91. The patient with O+ blood group is in need of an emergency blood transfusion
but the blood bank does not have any O+ blood available. Which potential unit
of blood could be given to the patient?
a. O –ve unit b. A+ unit
c. B+ unit d. AB +

Ans. a. O –ve unit

• O- negative blood is considered as the universal donor because it does not contain the
antigens A, B, or Rh. (AB+ is considered the universal recipient because it has all the
antigens on the blood).
• Other options are distracters.

92. What is the purpose of giving carminative enema?

a. Provides relief from gaseous distention
b. Contracts tissue to control bleeding
c. Lubricates the rectum and colon
d. To soften hard faecal matter

Ans. a. Provides relief from gaseous distention

• Carminative enema is administration of small volume enema to release flatus. The
enema stimulated peristalsis resulting in a bowel movement in which faeces and flatus
are expelled.
 Final Subject Assessment Test (Nursing Foundations) 69

• Oil-Retention Enema is used to lubricate the rectum and colon; the faeces absorb the
oil and become softer and easier to pass.
• Astringent Enema is to contract tissue to control bleeding.

93. Which of the following statement best describe about the respite care?
a. Care to terminally ill patient
b. Curative treatment of a hospitalized patient
c. Care provided to the family members of terminally ill patient
d. Short term relief to a primary caregiver

Ans. d. Short term relief to a primary caregiver

• Respite care is a short-term relief to enable a primary caregiver time away from the day
to day responsibilities of providing home care to sick and ill person.
• Hospice Care: End of life care for terminally ill patient with the prognosis of 6 months
or less.
• Palliative Care: Curative treatment to provide relief from a diseased condition.

94. The final treatment of waste collected in red color biomedical waste bin is:
a. Incineration and deep burial
b. Autoclaving followed by shredding
c. Disinfection then sent for recycling
d. Sterilize with non-chlorinated chemicals on-site

Ans. b. Autoclaving followed by shredding

Rationale
All the infected and non-infected plastics should be discarded in red biomedical waste bins
example: catheters, IV sets, IV bottles, gloves etc.
• Final treatment of waste collected in yellow bin: Incineration or plasma pyrolysis or
deep burial. All other discarded medicines shall be either sent back to manufacturer or
disposed by incineration.
• Final treatment of wastes collected in red bin: Autoclaving or micro-waving/
hydroclaving followed by shredding.
• Final treatment of blue bin disinfection by soaking the washed glass waste after
cleaning with detergent and sodium hypochlorite treatment or through autoclaving or
microwaving or hydroclaving and then sending for recycling.
• Puncture proof container: Autoclaving or dry heat sterilization followed by shredding
or mutilation or encapsulation in metal container or cement concrete (sharp pit);
combination of shredding cum autoclaving.

95. Doctor order to start the infusion of one-liter NS over 24 hours using a micro
drip set. Identify the flow rate?
a. 10.4 drops/minute b. 6.9 drops/minute
c. 32.5 drops/minute d. 41.6 drops/minute

Ans. d. 41.6 drops/minute

70 Final Subject Assessment Test (Nursing Foundations)

Rationale
The correct answer is option d, 41.6 drops/minute.
According to the scenario, the given values are:
Total volume= 1-liter NS (change this into mL)
Total volume in mL = 1liter × 1000 mL/liter
• Total volume in mL = 1000mL
Total time in minutes= 24 hours × 60minutes/hours
• Total time in minutes= 1440 minutes
Drop factor= Here in this question the nurse is using micro drip set to infuse the solution.
Drop factor= 60 drops/mL
Now, we will place all the given values into the flow rate (drops/minute) formula:
Flow rate (drops/minute) = Total volume (mL) × drop factor (drops/mL)
DROP FACTORS:
Total time in minute
• Micro drip set = 60drops/mL
• Macro drip set = 10-20 drops/mL (15
drops/mL)
• Gravity bag = 20 drops/ml

• Total volume = 1000mL

• Total time= 1440 minutes
• Drop factor= 60 drops/mL
Flow rate (drops/minute) = 1000mL× 60drops/mL
1440 minutes
Flow rate in drops/minute = 41.6 drops/minute
• Other options are distracters.

96. You are posted in the ENT OPD and doctor order to administer an eardrop to
a 2-year-old child. Which action the nurse will use to administer the ear drop?
a. Pull the auricle down and back
b. Pull the auricle upward and outward
c. Make the child sit and lean forward
d. Tilt the head to the affected side and administer the medication

Ans. a. Pull the auricle down and back

Rationale:
• Pull the auricle (pinna) down and back in case of children up to 3 year of age.
 Final Subject Assessment Test (Nursing Foundations) 71

• If your child is older than 3 years: Gently pull and hold the auricle (pinna) up and back.

• Other option are distracters.

97. Which of the following will provide high concentration of oxygen to a patient?
a. Non rebreather mask
b. Partial rebreather mask
c. Venturi mask
d. Nasal prongs

Ans. a. Non rebreather mask

• Non rebreather mask delivers high concentration of oxygen. FiO2, of 95% can be
achieved with an oxygen flow rate of 10-15 L/min whereas venturi mask uses high
flow rate.
• Other options are distracters.

98. A pressure ulcer that is superficial and presents as a blister with partial
thickness skin loss involving epidermis and dermis is graded as a:
a. Stage I
b. Stage II
c. Stage III
d. Stage IV

Ans. b. Stage II
• Pressure ulcer also known as bedsores or decubitus ulcer.
• Stage 1: Intact skin with non-blanchable redness of a localized area, usually over a bony
prominence.
• Stage 2: Pressure ulcer extend and involve epidermis and dermis. Partial thickness loss
of epidermis or dermis or both/serous filled blister. Presenting as Shallow open ulcer,
Red or pink wound bed and without slough.
• Stage 3: Ulcers are characterized by a lesion that extends well into the dermis and
begins to involve the hypodermis (also known as the subcutaneous layer).
• Stage 4: Pressure ulcers occur when the hypodermis and underlying fascia are breached,
exposing muscle and bone.
72 Final Subject Assessment Test (Nursing Foundations)

99. The Post-Operative nurse received an unconscious patient after commando

surgery under GA. While positioning the patient on bed the nurse will use
which of the following position?
a. Prone position
b. Supine position
c. Lateral position
d. Fowler’s position

Ans. c. Lateral position

• Unconscious patient Surgery under general anaesthesia means patient is at high risk
for aspiration due to which the Post-Operative nurse should keep the patient in lateral
of side lying position to prevent this complication.
• The lateral position facilitates the flow of secretions out of the mouth by gravity, keeps
the tongue to the side of the mouth maintaining the airway, and permits effective
assessment of the oropharynx and respiratory status.
• Other position is associated with risk of aspiration due to which all other options are
excluded.

100. You have measured the patient’s body temperature by using a disposable
thermometer. What temperature reading you will document in the patient’s
vital signs clinical chart on the basis of results shown in the given image?
a. 37 °C
b. 37.1 °C
c. 37.2 °C
d. 37.4 °C

Ans. a. 37°C
Rationale:
• Disposable Oral/axilla Thermometers are single-use instruments which provide
accurate temperature readings. They have dots on them that change color from brown
to blue, according to the patient’s body temperature.
• For oral: Place under the tongue for 60 seconds and after that remove it and wait for
10 seconds.
• For axillary: Place it parallel to the body for 3 minutes but not more than 5 minutes
then remove and wait for 10 seconds.
• If the disposable thermometer is in Celsius reading, then each digit on the disposable
thermometer will increase by 0.1 °C.
• For example, as you can see the given below image is of disposable thermometer in
Celsius. So, the digits will proceed in such manner as shown in figure:
 Final Subject Assessment Test (Nursing Foundations) 73

Figure: Disposable thermometer in Celsius

• To measure the reading one has to read the last blue dot which changed its color.
• So, here in the given example, the last blue dot is 37°C.

101. You are working in Neurological ICU and assigned to provide care to a patient
who is lightly sedated. You are doing the documentation into the electronic
medical system and notice that the patient is continuously doing a non-
purposeful action by tapping the side rails of the bed which is very disturbing
in work. You went to the patient bed side and threaten him that you will apply
the restraint if he doesn’t stop. Identify the most appropriate legal term for this
scenario.
a. Battery b. Assault
c. Liability d. Respondent superior

Ans. b. Assault
Rationale
• Assault: Assault, is threatening to touch a person without his/her consent. Here, in the
given scenario the assigned nurse is giving verbal threat to the patient that if he doesn’t
stop, she will apply the restraint.
• Battery: Battery means touching a person without his/her consent. This can’t be
considered as a correct answer because in the given scenario, the nurse hasn’t applied
the restraint but gave a warning or threat to the patient.
• Liability is vulnerability and legal responsibility of the nurse. For example, nurses
are liable when they fail to carry out doctor’s orders. This option doesn’t relate to the
scenario given in the question. So, this is a distractor.
• Respondent superior is the legal doctrine or principle that states that employers are
legally responsible for the acts and behaviors of their employees which again are
not related to the scenario discussed in the given question so we consider this as a
distractor.