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Exam (elaborations)

Core Nursing Questions and Answers with Detailed Rationales

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This document is a comprehensive nursing revision guide containing 40 essential questions with clear answers and concise clinical explanations. It covers core nursing fundamentals such as vital signs, emergency care, infection control, medication administration, patient assessment, anatomy and physiology, and common clinical procedures. Each question is designed to reinforce critical thinking, patient safety, and early recognition of deterioration, making the document ideal for exam preparation, quick revision, and foundational nursing practice.

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Core Nursing Questions and Answers with Detailed Rationales
1. What is the normal adult respiratory rate?
Answer: 12–20 breaths per minute
Explanation:
A healthy adult at rest typically breathes between 12 and 20 times per minute. This range reflects
effective ventilation and oxygen exchange. Rates below 12 breaths per minute (bradypnea) may indicate
central nervous system depression, medication effects, or metabolic disturbances. Rates above 20
breaths per minute (tachypnea) can signal fever, anxiety, respiratory compromise, shock, or acidosis.
Because respiratory rate often changes before other vital signs, it is a critical early indicator of patient
deterioration and must be assessed promptly.



2. Which pulse site is preferred during adult CPR?
Answer: Carotid artery
Explanation:
The carotid artery, located alongside the trachea in the neck, is the most reliable site for checking a
pulse during CPR in adults. It remains palpable even when blood pressure is severely reduced. Peripheral
pulses often disappear during cardiac arrest or shock, making them unreliable. Absence of a carotid
pulse within 10 seconds confirms the need to begin chest compressions immediately.



3. What is the main purpose of the Glasgow Coma Scale (GCS)?
Answer: To evaluate a patient’s level of consciousness
Explanation:
The Glasgow Coma Scale is a standardized neurological assessment tool used to objectively measure
consciousness. It assesses eye opening, verbal response, and motor response, producing a score from 3
to 15. GCS is especially valuable in trauma, stroke, and neurological conditions, where even subtle
changes may indicate worsening brain function and require urgent intervention.



4. Which sign is commonly associated with dehydration?
Answer: Decreased skin turgor
Explanation:
Loss of skin elasticity is a common sign of dehydration due to reduced fluid volume. When the skin is
pinched, it returns slowly to its normal position. Other symptoms include dry mucous membranes, dark
urine, dizziness, and increased heart rate. While useful, skin turgor assessment may be less reliable in
older adults due to age-related changes.



5. At what angle should subcutaneous injections be administered?
Answer: 45° to 90°
Explanation:
Subcutaneous injections are delivered into fatty tissue beneath the skin. The angle depends on needle

, length and the patient’s body composition. A 45° angle is preferred for lean individuals, while a 90°
angle is suitable for patients with adequate subcutaneous tissue. Correct technique ensures proper
absorption and prevents muscle penetration or tissue injury.



6. Which electrolyte imbalance can cause cardiac arrhythmias?
Answer: Both hyperkalemia and hypokalemia
Explanation:
Potassium is essential for normal cardiac conduction. Elevated potassium levels can lead to life-
threatening arrhythmias such as widened QRS complexes and cardiac arrest, while low potassium levels
may cause ventricular dysrhythmias. Continuous ECG monitoring and laboratory evaluation are vital,
especially in patients taking diuretics or undergoing dialysis.



7. What is the nurse’s first action when a patient is found unresponsive?
Answer: Assess responsiveness and summon assistance
Explanation:
According to Basic Life Support guidelines, the nurse should first check for responsiveness by calling the
patient and gently stimulating them. If there is no response, emergency help must be activated
immediately before proceeding with airway, breathing, and circulation assessment. Early activation of
emergency response improves survival outcomes.



8. Which isolation precaution is required for tuberculosis?
Answer: Airborne precautions
Explanation:
Tuberculosis is transmitted via airborne droplets that remain suspended in the air. Patients require
placement in a negative-pressure room, and healthcare workers must use N95 respirators. Limiting
patient movement and strict adherence to airborne precautions are essential to prevent transmission
within healthcare facilities.



9. What is the normal adult systolic blood pressure range?
Answer: 90–120 mmHg
Explanation:
Systolic blood pressure reflects the force exerted on arterial walls during heart contraction. Readings
above this range may suggest hypertension, increasing cardiovascular risk, while readings below may
indicate hypotension and reduced tissue perfusion. Accurate measurement technique is essential to
ensure appropriate clinical decisions.



10. How is correct placement of a nasogastric (NG) tube best confirmed?
Answer: Radiographic (X-ray) verification
Explanation:
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