MOHAP Nursing Evaluation Exam

A nurse is preparing to perform hand hygiene before an aseptic procedure. According to WHO 'Five Moments for Hand Hygiene', which moment does this represent?

• AMoment 2: Before a clean/aseptic procedure
• BMoment 1: Before touching a patient
• CMoment 3: After body fluid exposure risk
• DMoment 5: After touching patient surroundings

A nurse must administer 500 mL of normal saline over 4 hours using an infusion set with a drop factor of 15 gtt/mL. What is the correct flow rate in drops per minute?

• A21 gtt/min
• B42 gtt/min
• C31 gtt/min
• D63 gtt/min

A nurse is caring for several patients. Using the ABC (Airway, Breathing, Circulation) priority framework, which patient should be assessed FIRST?

• AA patient reporting pain at the surgical site rated 6/10
• BA patient requesting assistance to the bathroom
• CA patient whose IV fluid bag is nearly empty
• DA patient with an oxygen saturation of 86% and audible wheezing

Which sequence correctly describes the steps of the nursing process?

• ADiagnosis, Assessment, Planning, Implementation, Evaluation
• BAssessment, Diagnosis, Planning, Implementation, Evaluation
• CAssessment, Planning, Diagnosis, Evaluation, Implementation
• DPlanning, Assessment, Implementation, Diagnosis, Evaluation

A nurse measures an adult patient's blood pressure as 148/92 mmHg on two separate readings. According to common clinical classification, this most closely corresponds to which category?

• AStage 2 hypertension
• BNormal blood pressure
• CElevated blood pressure
• DStage 1 hypertension

A nurse is about to perform tracheal suctioning on a patient with an artificial airway. Which type of personal protective equipment and technique is required?

• AClean gloves and clean technique
• BNo gloves but a surgical mask only
• CSterile gloves and sterile technique
• DDouble gloving with clean technique

A nurse identifies a stage 2 pressure injury on a patient's sacrum. Which description matches a stage 2 pressure injury?

• AIntact skin with non-blanchable erythema
• BFull-thickness skin loss with visible subcutaneous fat
• CFull-thickness loss with exposed bone, tendon, or muscle
• DPartial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer or in…

A patient's laboratory results show a serum potassium of 6.2 mEq/L. Which finding should the nurse monitor for most urgently?

• AMuscle weakness and constipation
• BPeaked T waves and cardiac dysrhythmias on the ECG
• CIncreased deep tendon reflexes and tetany
• DPolyuria and increased thirst

The physician orders 750 mg of an antibiotic. The medication is available as 250 mg per 5 mL oral suspension. How many milliliters should the nurse administer?

• A15 mL
• B10 mL
• C20 mL
• D7.5 mL

Before administering any medication, the nurse verifies the 'rights' of medication administration. Which of the following is one of the recognized rights?

• ARight physician
• BRight pharmacy
• CRight documentation
• DRight insurance

A nurse is teaching a patient deep breathing and coughing exercises before abdominal surgery. What is the primary purpose of these exercises postoperatively?

• ATo prevent deep vein thrombosis
• BTo promote wound healing
• CTo reduce postoperative pain
• DTo prevent atelectasis and pneumonia

A nurse must move an immobile patient up in bed. Which action best protects the nurse from back injury when performing this task?

• ABending at the waist to reach the patient
• BKeeping the back straight, bending the knees, and using leg muscles
• CTwisting at the trunk while lifting
• DHolding the patient as far from the body as possible

A patient is at risk for falls. Which intervention is the most appropriate nursing action to reduce fall risk?

• AKeep the bed in the lowest position with the call bell within reach
• BKeep all four side rails up at all times
• CRestrain the patient to prevent movement
• DEncourage the patient to get up unassisted to build strength

A nurse notes a patient's intake and output over 8 hours: oral fluids 600 mL, IV fluids 800 mL, urine output 900 mL, and emesis 200 mL. What is the patient's fluid balance for this period?

• APositive 1100 mL
• BNegative 300 mL
• CPositive 300 mL
• DNegative 1100 mL

A nurse finds an unresponsive adult patient who is not breathing and has no pulse. After calling for help and starting CPR, what is the recommended chest compression rate and depth for an adult?

• A60-80 compressions per minute, depth 3-4 cm
• B120-140 compressions per minute, depth 2-3 cm
• C80-100 compressions per minute, depth 6-7 cm
• D100-120 compressions per minute, depth at least 5 cm

A nurse is assigned a patient with active pulmonary tuberculosis. Which type of isolation precaution and respiratory protection is required?

• AContact precautions with clean gloves and gown
• BAirborne precautions with an N95 respirator and negative-pressure room
• CDroplet precautions with a surgical mask
• DStandard precautions only

When documenting in the patient's medical record, which entry best reflects accurate and professional nursing documentation?

• APatient rates incisional pain 7/10, grimacing, requesting analgesia
• BPatient appears to be in a bad mood today
• CPatient seems fine, no problems
• DPatient is being difficult and uncooperative

A patient receiving an intravenous infusion develops redness, warmth, and a palpable cord along the vein at the IV site. Which complication does the nurse suspect?

• AInfiltration
• BAir embolism
• CPhlebitis
• DSpeed shock

A nurse is calculating a pediatric medication dose. The order is 20 mg/kg/day divided into two equal doses for a child weighing 15 kg. How many milligrams should each individual dose contain?

• A100 mg
• B300 mg
• C75 mg
• D150 mg

A nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale. The patient opens eyes to speech, is confused in conversation, and localizes to pain. What is the total GCS score?

• A10
• B12
• C11
• D15

A nurse is caring for a patient with newly diagnosed type 2 diabetes mellitus. The patient asks why metformin was prescribed. Which response best explains the primary action of metformin?

• AIt decreases glucose production by the liver and improves insulin sensitivity
• BIt stimulates the pancreas to release more insulin
• CIt blocks carbohydrate absorption in the intestine
• DIt increases the kidney's excretion of glucose in the urine

A patient with type 1 diabetes is found drowsy, with fruity-smelling breath, deep rapid respirations, and a blood glucose of 480 mg/dL. Which condition does the nurse suspect, and what is the priority intervention?

• AHypoglycemia; give 15 g of fast-acting oral carbohydrate
• BHyperosmolar hyperglycemic state; give oral hypoglycemics
• CDiabetic ketoacidosis; initiate IV fluids and IV insulin per protocol
• DSomogyi effect; reduce the evening insulin dose

A patient is admitted with acute chest pain. Which laboratory marker is the most specific indicator of myocardial injury?

• ATotal creatine kinase (CK)
• BLactate dehydrogenase (LDH)
• CC-reactive protein (CRP)
• DCardiac troponin I or T

A patient with chronic heart failure is prescribed furosemide. Which laboratory value should the nurse monitor most closely because of this drug?

• ASerum calcium and phosphate
• BSerum sodium and potassium
• CWhite blood cell count
• DSerum amylase and lipase

A patient is receiving warfarin therapy. Which laboratory test is used to monitor the therapeutic effect of warfarin?

• AInternational normalized ratio (INR)
• BActivated partial thromboplastin time (aPTT)
• CPlatelet count
• DBleeding time

A patient with chronic obstructive pulmonary disease (COPD) has chronic carbon dioxide retention. Why must the nurse administer oxygen cautiously at a low flow rate?

• AHigh oxygen can cause oxygen toxicity within minutes
• BLow oxygen prevents fluid overload
• CHigh oxygen may reduce the hypoxic respiratory drive and worsen CO2 retention
• DHigh oxygen increases the risk of pneumothorax

A patient is admitted with an acute asthma exacerbation. Which medication provides the most rapid relief of bronchospasm?

• AOral montelukast
• BInhaled fluticasone
• COral theophylline
• DInhaled salbutamol (albuterol)

A nurse is caring for a patient after a total hip replacement. Which position should be avoided to prevent dislocation of the prosthesis in the early postoperative period?

• AKeeping the legs abducted with a pillow
• BFlexing the hip more than 90 degrees
• CLying supine with the head slightly elevated
• DMaintaining neutral rotation of the affected leg

A patient with cirrhosis develops confusion, asterixis (flapping tremor), and an elevated blood ammonia level. Which medication is commonly prescribed to reduce ammonia levels?

• ALactulose
• BSpironolactone
• CPropranolol
• DOmeprazole

A patient with chronic kidney disease has a serum phosphate that is elevated. Which dietary instruction should the nurse provide?

• AIncrease intake of dairy products and nuts
• BEncourage a high-protein diet with red meat at every meal
• CLimit phosphorus-rich foods such as dairy, nuts, and cola beverages
• DIncrease intake of bananas and oranges

A nurse is caring for a patient receiving a unit of packed red blood cells. Fifteen minutes into the transfusion, the patient develops fever, chills, low back pain, and dark urine. What is the nurse's priority action?

• ASlow the transfusion and continue monitoring
• BAdminister an antipyretic and restart the transfusion
• CIncrease the transfusion rate to finish quickly
• DStop the transfusion immediately and keep the IV line open with normal saline

A patient is started on the aminoglycoside gentamicin. Which adverse effects require the nurse to monitor renal function and hearing?

• AHepatotoxicity and photosensitivity
• BNephrotoxicity and ototoxicity
• CCardiotoxicity and hyperkalemia
• DPulmonary fibrosis and bone marrow suppression

A patient who has had a cerebrovascular accident (stroke) has difficulty swallowing (dysphagia). Which nursing intervention reduces the risk of aspiration during meals?

• AHave the patient sit upright at 90 degrees and tuck the chin while swallowing
• BPosition the patient flat in bed during meals
• COffer thin liquids freely to ease swallowing
• DEncourage the patient to talk while eating to stay alert

A patient with a history of peptic ulcer disease tests positive for Helicobacter pylori. Which treatment approach is most appropriate?

• AA single proton pump inhibitor for two weeks
• BAn antacid taken as needed
• CTriple therapy with a proton pump inhibitor plus two antibiotics
• DLong-term corticosteroid therapy

A patient with hypothyroidism is started on levothyroxine. Which instruction should the nurse provide about taking this medication?

• ATake it with a large meal to avoid stomach upset
• BTake it at bedtime with an antacid
• CStop the medication once symptoms improve
• DTake it on an empty stomach in the morning, 30-60 minutes before breakfast

A patient receiving digoxin has a heart rate of 52 beats per minute and reports nausea, anorexia, and seeing yellow-green halos around lights. What should the nurse do first?

• AAdminister the next dose of digoxin as scheduled
• BWithhold the digoxin and notify the physician, anticipating a digoxin level
• CGive an additional dose to control the heart rate
• DEncourage the patient to rest and reassess in 4 hours

A nurse is teaching a patient about preventing deep vein thrombosis after surgery. Which intervention is most effective in promoting venous return in the legs?

• AEarly ambulation and leg exercises
• BCrossing the legs while sitting
• CProlonged bed rest
• DMassaging the calves vigorously

A nurse is caring for a patient diagnosed with major depressive disorder who has just been started on a selective serotonin reuptake inhibitor (SSRI). The patient asks how soon the medication will work. What is the most accurate response?

• AYou should feel completely better within 24 hours
• BSSRIs work immediately like a sedative
• CIt usually takes 2 to 4 weeks to feel the full antidepressant effect
• DThe medication will not help unless combined with electroconvulsive therapy

A patient in the emergency department expresses a clear plan and intent to harm themselves. What is the nurse's priority nursing action?

• AEncourage the patient to think positively and go home
• BLeave the patient alone to calm down
• CDocument the statement and address it at the next shift
• DEnsure constant observation and maintain a safe environment free of harmful objects

A patient with a chest tube connected to a closed water-seal drainage system has continuous bubbling in the water-seal chamber. What does this finding most likely indicate?

• ANormal functioning of the system
• BAn air leak in the system or from the patient
• CThe lung has fully re-expanded
• DThe drainage chamber is full

A patient with rheumatoid arthritis is prescribed methotrexate. Which instruction is essential for the nurse to include in patient teaching?

• AAvoid alcohol and report signs of infection, mouth sores, or unusual bleeding
• BTake an extra dose if you miss one to catch up
• CStop folic acid supplements while on this drug
• DTake the medication every day for best results