26Question
A nurse finds a heart rate of 108 beats/min in a client whose usual rate is 74. Which factors might explain the rise?
Select all that apply.
- Fever
- A dose of albuterol by inhaler an hour ago
- Dehydration
- Metoprolol therapy
- Anxiety about the procedure
- Deep sleep
Show the answers and explanation
Answers: A, B, C and E.
- A – Fever
- B – A dose of albuterol by inhaler an hour ago
- C – Dehydration
- E – Anxiety about the procedure
Topic: factors raising heart rate
Fever, beta-agonist bronchodilators, volume loss, and anxiety all increase heart rate. Beta-blockers and sleep lower it. Interpreting a pulse requires knowledge of medicines, hydration, and emotional state.
Why the others are wrong
- D – Metoprolol is a beta-blocker that slows the heart rate and would work against the rise.
- F – Rest and sleep slow the pulse.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
27Question
After inspecting the noses of four clients, a nurse must report one finding at once. Which finding requires immediate reporting?
- Pale, swollen mucosa with clear mucus during allergy season
- Dry, crusted mucosa in a client using oxygen by nasal cannula
- A mild septal deviation in a client with no breathing difficulty
- Clear, watery fluid draining from one nostril after a blow to the head
Show the answer and explanation
Answer: D. Clear, watery fluid draining from one nostril after a blow to the head
Topic: nasal drainage after head trauma
Clear watery drainage after head trauma may be cerebrospinal fluid leaking through a skull base fracture. The nurse reports at once, does not suction or pack the nose, and monitors neurologic status, since the leak opens a route for meningitis.
Why the others are wrong
- A – These are typical findings of allergic rhinitis and are not an emergency.
- B – Drying is a common effect of oxygen therapy and is managed with humidification and comfort measures.
- C – A mild deviation is a common variant that does not need urgent action.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
28Question
A nurse prepares to examine a client's right eye with an ophthalmoscope. Which technique is correct?
- Use the dominant hand and dominant eye for both of the client's eyes so the technique stays consistent and practiced.
- Ask the client to stare into the light so the eye stays still.
- Hold the instrument in your right hand and use your right eye, while the client looks at a distant point.
- Keep the room fully lit so the retina is clearly seen.
Show the answer and explanation
Answer: C. Hold the instrument in your right hand and use your right eye, while the client looks at a distant point.
Topic: ophthalmoscope technique
Matching hand and eye to the side being examined keeps the examiner out of the client's face, and a distant fixation point keeps the eye still while the room is dimmed to widen the pupil.
Why the others are wrong
- A – The instrument is held in the hand and eye on the same side as the client's eye being examined, to keep the examiner's head from crowding the client.
- B – The bright beam constricts the pupil and cannot be tolerated; the client fixes on a distant target.
- D – A dim room lets the pupil dilate and gives a better view.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
29Question
A nurse asks a client to say 'ah' and notes that the soft palate rises poorly on the left and the uvula pulls toward the right. Which cranial nerve is most likely impaired?
- CN V (trigeminal)
- CN X (vagus)
- CN VII (facial)
- CN XII (hypoglossal)
Show the answer and explanation
Answer: B. CN X (vagus)
Topic: vagus nerve assessment
The vagus nerve lifts the soft palate and pulls the uvula toward the intact side, so poor elevation on one side with deviation away from it points to impairment of that side. The vagus nerve also affects swallowing and voice.
Why the others are wrong
- A – This nerve provides facial sensation and chewing muscle control.
- C – This nerve controls facial expression and taste on the front of the tongue.
- D – This nerve controls tongue movement, and a lesion pushes the protruded tongue toward the weak side.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
30Question
A client is 6 hours after abdominal surgery. Which findings require the nurse to act immediately?
Select all that apply.
- Oxygen saturation 86% on room air
- New confusion in a previously oriented client
- Blood pressure 84/50 mm Hg with a heart rate of 124
- Pain of 3 out of 10 at the incision
- Ate half of the dinner tray
- Spouse asks about visiting hours
Show the answers and explanation
Answers: A, B and C.
- A – Oxygen saturation 86% on room air
- B – New confusion in a previously oriented client
- C – Blood pressure 84/50 mm Hg with a heart rate of 124
Topic: recognizing urgent cues
Hypoxemia, new confusion, and hypotension with tachycardia may signal respiratory failure, bleeding, or sepsis and must be acted on at once. Mild pain, a reduced meal, and a visitor question do not threaten life.
Why the others are wrong
- D – Mild incisional pain is expected after surgery and can be treated without emergency action.
- E – A partial meal is not an immediate threat to life.
- F – A visiting-hours question is a non-urgent social matter.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
31Question
When a nurse tests visual acuity with a wall chart, which cranial nerve is mainly being evaluated?
- CN III (oculomotor)
- CN IV (trochlear)
- CN II (optic)
- CN VI (abducens)
Show the answer and explanation
Answer: C. CN II (optic)
Topic: optic nerve
Visual acuity depends on the optic nerve, which carries signals from the retina to the brain. The other nerves listed control eye movement and pupil size.
Why the others are wrong
- A – This nerve moves most eye muscles and constricts the pupil.
- B – This nerve moves the superior oblique muscle, directing the eye downward and inward.
- D – This nerve moves the eye outward.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
32Question
A mechanically ventilated, sedated client cannot report pain. At the start of the shift the nurse needs a pain assessment tool. Which tool is most appropriate?
- Critical-Care Pain Observation Tool
- Numeric Rating Scale, scored from zero to ten by the client
- Wong-Baker FACES scale, in which the client points to a face
- Brief Pain Inventory, a questionnaire completed by the client
Show the answer and explanation
Answer: A. Critical-Care Pain Observation Tool
Topic: pain tool selection
When self-report is impossible, observation-based tools that score facial expression, body movement, muscle tension, and ventilator compliance are used. The Critical-Care Pain Observation Tool is validated for ventilated, sedated adults.
Why the others are wrong
- B – This tool requires the client to give a number, which a sedated ventilated client cannot do.
- C – This scale requires the client to point to a face and is designed for children and those who can self-report.
- D – This is a questionnaire the client completes about pain history and function.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
33Question
A client with an aching hip after a fall takes an oral analgesic tablet at 1400. When should the nurse plan to reassess the client's pain?
- At 1405, as soon as the client swallows the tablet
- At the next scheduled dose, about four hours later
- Between 30 and 60 minutes after the dose
- When the family visits in the evening
Show the answer and explanation
Answer: C. Between 30 and 60 minutes after the dose
Topic: timing of pain reassessment
Oral analgesics reach peak effect in roughly half an hour to an hour, so pain is reassessed in that window to judge effectiveness and decide whether additional measures are needed.
Why the others are wrong
- A – The tablet has not been absorbed and has had no chance to work.
- B – Reassessment is too late to catch ineffective relief.
- D – Reassessment must be timed to the peak effect of the drug, not to a visitor schedule.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
34Question
A nurse is about to assess a client with a weeping rash with open areas on the forearm. What should the nurse do before palpating the rash?
- Palpate with bare hands so texture and temperature are felt accurately.
- Cover the area with a dressing and skip palpation.
- Defer palpation until the provider has seen the rash.
- Perform hand hygiene and put on clean gloves.
Show the answer and explanation
Answer: D. Perform hand hygiene and put on clean gloves.
Topic: standard precautions for skin assessment
Standard precautions require gloves when touching non-intact skin or body fluids. Hand hygiene before and after protects both the nurse and the client.
Why the others are wrong
- A – Contact with non-intact skin requires gloves under standard precautions.
- B – Palpation is an essential part of the skin assessment.
- C – Palpation is a nursing skill and can be done safely with gloves.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
35Question
A client had axillary lymph nodes removed during breast cancer surgery and asks why arm swelling is a risk. Which explanation by the nurse is most accurate?
- The surgery permanently damaged the arteries that supply the whole arm.
- Red blood cells can no longer travel out of the arm into the chest.
- Fat from the diet is no longer able to be absorbed into the arm tissue.
- Fluid that lymph channels normally return to the bloodstream can collect in the arm.
Show the answer and explanation
Answer: D. Fluid that lymph channels normally return to the bloodstream can collect in the arm.
Topic: lymphatic function and lymphedema
The lymphatic system drains excess interstitial fluid back to the circulation and filters it through the nodes. When nodes are removed, fluid may build up, causing lymphedema, so clients protect the affected arm from injury and infection.
Why the others are wrong
- A – Arterial supply is not the issue; swelling results from impaired fluid return.
- B – Red blood cells travel in blood vessels, not lymphatic channels.
- C – Fat absorption occurs in the intestine, not the arm.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
36Question
With the client's eyes closed, the nurse holds the sides of the great toe and moves it up and down. The client cannot tell which direction the toe was moved. What should the nurse document?
- Impaired position sense (proprioception)
- Absent vibration sense in the lower extremity
- Loss of light-touch sensation on the dorsum of the foot
- Impaired two-point discrimination on the skin of the foot
Show the answer and explanation
Answer: A. Impaired position sense (proprioception)
Topic: position sense testing
Moving a digit up or down with eyes closed tests the sense of limb position. Failure to identify the direction indicates impaired proprioception, which may occur in diabetic neuropathy or damage to the dorsal columns.
Why the others are wrong
- B – Vibration is tested with a tuning fork over a bony prominence, not by moving the toe.
- C – Light touch is tested with a wisp of cotton on the skin.
- D – This is tested with two simultaneous points on the skin.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
37Question
A nurse suspects an older adult has reduced hearing. Which observations support this concern?
Select all that apply.
- Turns one ear toward the speaker
- Gives answers that do not match the questions
- Says that other people mumble
- Squints at the clock across the room
- Asks for printed handouts in larger type
Show the answers and explanation
Answers: A, B and C.
- A – Turns one ear toward the speaker
- B – Gives answers that do not match the questions
- C – Says that other people mumble
Topic: signs of hearing loss
Turning an ear toward the speaker, giving mismatched answers, and blaming others for mumbling are typical behaviors of someone who is not hearing well. Squinting and requests for larger print point to impaired vision.
Why the others are wrong
- D – Squinting at distant objects suggests a vision problem.
- E – A request for larger print also suggests a vision problem.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
38Question
A client has abdominal pain and nausea. In which sequence should the nurse perform the abdominal assessment techniques?
- Inspection, palpation, percussion, auscultation
- Palpation, inspection, auscultation, percussion
- Inspection, auscultation, percussion, palpation
- Auscultation, inspection, palpation, percussion
Show the answer and explanation
Answer: C. Inspection, auscultation, percussion, palpation
Topic: abdominal assessment sequence
The abdomen is the exception to the usual order: inspect, auscultate, percuss, then palpate. Touching and tapping can change bowel motility and the sounds heard, so listening comes before them, and painful areas are palpated last.
Why the others are wrong
- A – Palpation and percussion before auscultation can change bowel sounds and give a false picture.
- B – Inspection is the first step, and touching before looking can miss visible findings.
- D – Looking comes before listening, and palpation should come last.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
39Question
A client with new right-leg weakness is allowed out of bed for the first time. Which nursing action best reduces the risk of a fall?
- Apply a gait belt and walk beside and slightly behind the client on the weaker side.
- Let the client walk alone to the doorway to test endurance and confidence.
- Hold the client's good arm and walk on the stronger side for balanced support.
- Keep the client in bed with all four side rails raised until the provider reassesses.
Show the answer and explanation
Answer: A. Apply a gait belt and walk beside and slightly behind the client on the weaker side.
Topic: fall prevention with weakness
A client with unilateral weakness is guarded on the weak side with a gait belt so the nurse can steady or lower the client if the leg gives way. Mobility is encouraged safely, not forbidden.
Why the others are wrong
- B – Unassisted ambulation of a client with new weakness invites a fall.
- C – Support belongs on the weaker side, where the client is most likely to buckle.
- D – This restricts movement, causes deconditioning, and full rails are a restraint concern.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
40Question
While deflating the cuff, the nurse hears the first clear tapping sound at 134 mm Hg, the sounds become muffled at 90 mm Hg, and they disappear at 82 mm Hg. Using the standard adult approach, how should the nurse record the blood pressure?
- 134/90 mm Hg
- 82/134 mm Hg
- 134/82 mm Hg
- 90/82 mm Hg
Show the answer and explanation
Answer: C. 134/82 mm Hg
Topic: recording Korotkoff sounds
Systolic pressure is the pressure at the first clear Korotkoff sound, and diastolic pressure in adults is recorded where the sounds disappear. The reading is written systolic over diastolic: 134/82 mm Hg.
Why the others are wrong
- A – The muffling point is not the standard diastolic value in adults; the point where sounds disappear is used.
- B – Systolic is written first, then diastolic, so the numbers are reversed.
- D – The muffling and disappearance points are not systolic; the first tapping sound is.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
41Question
With the head of the bed raised to 45 degrees, a nurse sees jugular vein pulsations well above the clavicle in a client who has leg edema and has gained 3 kg in four days. What does this finding most likely indicate?
- Hypovolemia from poor oral intake and recent vomiting
- A normal finding that is expected in a semi-upright position
- Raised right-sided heart pressure from fluid volume excess
- Unusually strong emptying of the left ventricle with each beat
Show the answer and explanation
Answer: C. Raised right-sided heart pressure from fluid volume excess
Topic: jugular venous distention
Jugular distention above the usual level at a 45-degree angle reflects raised pressure in the right atrium, which is often due to heart failure or fluid overload. Weight gain and edema support this.
Why the others are wrong
- A – Low volume flattens the neck veins.
- B – In a semi-upright position, normal pulsations are low, near the clavicle.
- D – Forceful left ventricular emptying does not distend the jugular veins.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
42Question
A client with long-standing emphysema is admitted. Which percussion note over the lung fields should the nurse expect?
- Dullness
- Resonance
- Flatness
- Hyperresonance
Show the answer and explanation
Answer: D. Hyperresonance
Topic: percussion in emphysema
Emphysema traps air in overinflated lungs, which produces a louder, lower, more booming percussion note than normal. This hyperresonance accompanies barrel chest and diminished breath sounds.
Why the others are wrong
- A – Dullness occurs over fluid or solid tissue such as pneumonia or effusion.
- B – Resonance is the expected note over normal lung tissue.
- C – Flatness is heard over dense tissue such as bone or a large effusion.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
43Question
A client who rated postoperative pain 9 out of 10 receives IV analgesia. Forty minutes later the client rates it 4 out of 10, rests comfortably, and says this level is acceptable and allows walking to the chair. How should the nurse evaluate this response?
- The goal is met because pain is at a level the client finds acceptable and function has improved.
- Pain remains inadequately controlled because the rating has not reached zero.
- The response cannot be judged until the provider confirms it.
- Effectiveness should be judged by vital signs rather than by the client's report.
Show the answer and explanation
Answer: A. The goal is met because pain is at a level the client finds acceptable and function has improved.
Topic: evaluating pain relief
Pain is a subjective experience, and effectiveness is judged by the client's report, comfort goal, and ability to function. The drop from 9 to 4 with improved mobility and acceptance means the intervention worked.
Why the others are wrong
- B – Pain management aims for comfort and function agreed with the client, not necessarily zero.
- C – Evaluating effectiveness is a nursing responsibility within the nursing process.
- D – Self-report is the most reliable indicator of pain; vital signs are unreliable.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
44Question
A client admitted with pneumonia has an oxygen saturation of 88% on room air, a respiratory rate of 28, and is using accessory muscles to breathe while lying flat. Which action should the nurse take first?
- Send blood for an arterial gas and wait for the result before acting.
- Encourage rest and recheck the saturation in an hour.
- Give the scheduled antibiotic early.
- Raise the head of the bed and apply oxygen per protocol.
Show the answer and explanation
Answer: D. Raise the head of the bed and apply oxygen per protocol.
Topic: symptomatic low oxygen saturation
A client with low saturation and signs of respiratory distress needs immediate support: sitting upright to improve lung expansion and oxygen to correct hypoxemia. Further diagnostics and treatment follow.
Why the others are wrong
- A – Treatment is not delayed while a symptomatic client waits for laboratory results.
- B – Symptomatic hypoxemia needs immediate intervention.
- C – Antibiotics will not correct hypoxemia in the next minutes; breathing comes first.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
45Question
During a sports physical, a 15-year-old reports light-headedness and a near-faint during practice. Which finding requires the nurse's immediate report?
- A pulse that speeds up on inhaling and slows on exhaling
- A respiratory rate of 16 breaths/min with easy breathing and clear lung sounds
- A blood pressure of 106/64 mm Hg while seated and relaxed
- A resting pulse of 44 beats/min together with the near-fainting episode
Show the answer and explanation
Answer: D. A resting pulse of 44 beats/min together with the near-fainting episode
Topic: bradycardia with symptoms in an adolescent
A very slow pulse with symptoms such as near-syncope suggests inadequate cardiac output and needs urgent evaluation. Sinus arrhythmia is a normal finding in the young, and the other values are expected.
Why the others are wrong
- A – This pattern, sinus arrhythmia, is normal in children and adolescents.
- B – This rate is within the expected range.
- C – This value is within the expected range for an adolescent.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
46Question
A provider orders metoprolol with instructions to hold for an apical pulse below 60 beats/min. Before the dose, the nurse auscultates the apical pulse for a full minute and counts 52, and the client reports feeling light-headed. What should the nurse do?
- Give the dose, because the client's other vital signs are stable.
- Hold the dose and notify the provider.
- Give half of the dose to limit the effect on the heart rate.
- Recheck the pulse at the wrist in 30 minutes, then give the full dose.
Show the answer and explanation
Answer: B. Hold the dose and notify the provider.
Topic: hold parameters for beta-blocker
A beta-blocker slows the heart, so the apical pulse is measured for one full minute beforehand. When the value falls below the ordered parameter, especially with symptoms, the nurse holds the medication and notifies the provider.
Why the others are wrong
- A – The stated hold parameter has been met, so the drug must be held.
- C – Changing the dose is outside the nurse's scope without an order.
- D – The apical pulse is the accurate site, and the parameter is already met.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
47Question
A nurse must perform an intimate examination on a client who has disclosed a history of sexual abuse. Which approach best reflects trauma-informed care?
- Work quickly and quietly so the examination is over sooner.
- Use the usual position without discussion to save time.
- Ask the client to describe the abuse to judge how upsetting the examination will be.
- Explain each step, ask permission before touching, and agree on a signal to pause.
Show the answer and explanation
Answer: D. Explain each step, ask permission before touching, and agree on a signal to pause.
Topic: trauma-informed examination
Trauma-informed care emphasizes safety, choice, collaboration, and control. Telling the client what will happen, gaining consent at each step, and providing a stop signal give back the control the trauma took.
Why the others are wrong
- A – Silence and haste remove the client's sense of control.
- B – Position should be a shared decision, not assumed.
- C – Trauma-informed care does not require retelling the trauma, which can retraumatize.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
48Question
A client recovering from knee replacement surgery is being screened for fall risk. Which questions should the nurse ask?
Select all that apply.
- Have you fallen or nearly fallen in recent months?
- Do you feel dizzy or light-headed when you stand up?
- Are you taking any medicines that make you drowsy?
- Which foods do you enjoy most at holiday meals?
- Has anyone in your family had a heart attack?
Show the answers and explanation
Answers: A, B and C.
- A – Have you fallen or nearly fallen in recent months?
- B – Do you feel dizzy or light-headed when you stand up?
- C – Are you taking any medicines that make you drowsy?
Topic: fall risk screening questions
Past falls, orthostatic dizziness, and sedating medicines are strong predictors of falls. Questions about food preferences or distant family history do not identify modifiable fall risks.
Why the others are wrong
- D – Food preferences do not bear on the risk of falling.
- E – Family cardiac history is not a direct fall-risk factor for this client.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
49Question
On the first morning after laparoscopic gallbladder surgery, a client reports aching pain in the right shoulder but denies incisional pain. Vital signs are stable. What is the most likely explanation?
- A shoulder dislocation from arm positioning during surgery
- Diaphragm irritation from leftover carbon dioxide gas, felt as shoulder pain
- An early sign of a heart attack
- Nerve damage at the incision site
Show the answer and explanation
Answer: B. Diaphragm irritation from leftover carbon dioxide gas, felt as shoulder pain
Topic: referred pain after laparoscopy
Gas used to inflate the abdomen during laparoscopy can remain under the diaphragm, irritating the phrenic nerve and causing pain referred to the shoulder. Walking, repositioning, and heat usually ease it.
Why the others are wrong
- A – A dislocation causes pain with movement and visible deformity, not an aching pain with stable findings.
- C – A cardiac event would be accompanied by other signs and changes in vital signs.
- D – Nerve damage would cause numbness or pain at the incision, not at the shoulder.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
50Question
A nurse needs to listen to the lungs of a fearful 4-year-old. Which approach is most developmentally appropriate?
- Explain the physiology of breathing in detail so the child understands.
- Let the child handle the stethoscope and listen to a doll first.
- Say that it will not hurt and start without any preparation.
- Ask whether the child agrees and proceed only if the answer is yes.
Show the answer and explanation
Answer: B. Let the child handle the stethoscope and listen to a doll first.
Topic: approach to a preschooler
Preschoolers learn through play and concrete experience. Letting them handle equipment and watch it used on a doll reduces fear and increases cooperation.
Why the others are wrong
- A – Preschoolers think concretely, and long explanations are lost on them.
- C – Reassurance without involvement does not reduce fear and may erode trust.
- D – A preschooler cannot decide on necessary care; offer limited choices about how, not whether.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
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