SCFHS Saudi Nursing Licensing Exam (SNLE) — Questions and Answers

Question 1: A nurse is teaching a new mother about the 'danger signs' of postpartum depression versus 'baby blues.' Which symptom indicates postpartum depression requiring referral?

Occasional anxiety about being a new parent
Fatigue and emotional sensitivity in the first week
Mild mood swings and tearfulness on day 3
Persistent sadness and inability to care for self or baby lasting more than 2 weeks (Correct answer)

Correct answer: Persistent sadness and inability to care for self or baby lasting more than 2 weeks

Baby blues (tearfulness, mood swings) typically resolve within 2 weeks and require support only. Postpartum depression is characterized by persistent low mood, inability to care for the infant or self, feelings of hopelessness, and symptoms lasting more than 2 weeks — requiring professional evaluation and treatment.

Question 2: What is the therapeutic INR range for a patient on warfarin therapy for atrial fibrillation?

0.5-1.0
1.0-1.5
2.0-3.0 (Correct answer)
4.0-5.0

Correct answer: 2.0-3.0

The therapeutic INR range for warfarin in atrial fibrillation is 2.0-3.0. Below 2.0 increases thromboembolic risk; above 3.0 increases bleeding risk. Higher ranges (2.5-3.5) are used for mechanical heart valves. Regular INR monitoring is essential.

Question 3: A community nurse is using the PRECEDE-PROCEED model for health program planning. What does the PRECEDE phase involve?

Implementing the intervention
Assessing needs — identifying factors predisposing, enabling, and reinforcing health behaviors (Correct answer)
Allocating resources and training staff
Evaluating outcomes after implementation

Correct answer: Assessing needs — identifying factors predisposing, enabling, and reinforcing health behaviors

PRECEDE (Predisposing, Reinforcing, Enabling Constructs in Educational/Ecological Diagnosis and Evaluation) is the assessment phase that identifies why people behave as they do, including predisposing factors (knowledge, beliefs), enabling factors (resources, skills), and reinforcing factors (social support).

Question 4: A patient post-cardiac surgery develops hypotension, tachycardia, cool extremities, decreased urine output, and an elevated pulmonary capillary wedge pressure (PCWP) of 22 mmHg. These findings are consistent with:

Hypovolemic shock
Obstructive shock
Distributive shock
Cardiogenic shock (Correct answer)

Correct answer: Cardiogenic shock

Cardiogenic shock is characterized by decreased cardiac output (poor peripheral perfusion) and elevated filling pressures (high PCWP) due to failure of the heart as a pump.

Question 5: What are the principles of de-escalation when dealing with an agitated patient?

Maintain safe distance, use calm voice, offer choices, set clear limits, acknowledge feelings, and avoid threatening body language (Correct answer)
Use physical force immediately
Match the patient's aggressive tone
Ignore the patient until they calm down

Correct answer: Maintain safe distance, use calm voice, offer choices, set clear limits, acknowledge feelings, and avoid threatening body language

De-escalation principles: maintain safe distance (arm's length), calm low tone of voice, non-threatening body language, acknowledge the patient's feelings, offer limited choices (empowerment), set clear limits, remove audience, and offer medication or a quieter space.

Question 6: A 34-year-old male patient in a Saudi psychiatric facility is prescribed clozapine for treatment-resistant schizophrenia. On day 18 of therapy, his absolute neutrophil count (ANC) drops to 1,200 cells/mm³. According to SCFHS and NCBE monitoring protocols aligned with the Clozapine REMS program, what is the MOST appropriate immediate nursing action?

Continue clozapine and repeat the ANC in 48 hours as a single drop is not clinically significant
Administer a granulocyte colony-stimulating factor (G-CSF) injection and continue clozapine
Reduce the clozapine dose by 50% and increase monitoring frequency to twice weekly
Withhold clozapine and notify the physician immediately, as this meets criteria for mandatory interruption (Correct answer)

Correct answer: Withhold clozapine and notify the physician immediately, as this meets criteria for mandatory interruption

An ANC of 1,200–1,499 cells/mm³ constitutes 'mild neutropenia' under clozapine monitoring guidelines. However, in the first 18 days (early treatment phase), any ANC below 1,500 cells/mm³ requires immediate withholding of the drug and urgent physician notification, as early-onset neutropenia carries a higher risk of progression to life-threatening agranulocytosis. SCFHS psychiatric nursing standards mandate that nurses recognize this threshold and act without delay. Self-initiating a dose reduction or administering G-CSF are physician-ordered interventions and are not within independent nursing scope at this stage.

Question 7: A nurse is inserting a peripheral IV catheter. Which vein is preferred for the initial attempt in an adult?

Internal jugular vein
Distal veins of the forearm or dorsum of the hand (Correct answer)
Antecubital fossa (AC) vein
Femoral vein

Correct answer: Distal veins of the forearm or dorsum of the hand

Peripheral IV cannulation should start distally (forearm/dorsum of hand) and proceed proximally if needed. Starting distally preserves more proximal options if the distal site fails. The AC is avoided for routine access as it limits arm movement.

Question 8: A nursing student asks why personal protective equipment (PPE) must be removed in a specific order. What is the most important reason?

To prevent self-contamination — the outside of PPE is contaminated and must not touch the face or mucous membranes (Correct answer)
To comply with hospital policy regardless of rationale
To save PPE supplies by careful removal
To model correct behavior for other staff

Correct answer: To prevent self-contamination — the outside of PPE is contaminated and must not touch the face or mucous membranes

PPE removal (doffing) sequence prevents self-contamination by ensuring the most contaminated surfaces (outside of gloves, outside of gown) are removed first without touching the face. The sequence: gloves off first, then gown, then eye protection, then mask — hands cleaned after each step.

Question 9: A neonate born at 34 weeks gestation is admitted to the NICU in a Saudi tertiary hospital. On day 2 of life, the nurse notes abdominal distension, bloody stools, and absent bowel sounds. An abdominal X-ray reveals pneumatosis intestinalis. Which action should the nurse prioritize FIRST?

Administer an enema to relieve the distension and stimulate bowel motility
Discontinue all enteral feedings immediately and insert an orogastric tube for decompression (Correct answer)
Obtain a stool culture and begin empirical oral vancomycin per SCFHS neonatal guidelines
Increase the rate of enteral feeding to provide adequate caloric support for the preterm gut

Correct answer: Discontinue all enteral feedings immediately and insert an orogastric tube for decompression

The clinical and radiological findings describe necrotizing enterocolitis (NEC), a neonatal emergency. The first nursing priority is to make the infant nil by mouth (NPO) and insert an orogastric tube for gastric decompression to prevent further bowel distension and perforation risk. Continuing feeds would worsen NEC. Enemas are absolutely contraindicated as they can perforate the already-compromised bowel. Antibiotic therapy (typically IV, not oral) is initiated after cultures, but the immediate physical intervention of bowel rest and decompression comes first.

Question 10: Under Saudi MOH regulations, a healthcare facility identifies a cluster of 3 postoperative surgical site infections (SSIs) with the same organism within 30 days. Which body is the facility legally obligated to notify FIRST, and within what timeframe?

The local MOH Directorate of Health Affairs and the National IPC Program within 24 hours
The Saudi Food and Drug Authority (SFDA) within 24 hours
The facility's infection control committee within 48 hours before any external reporting
The Saudi Center for Disease Prevention and Control (Weqaya) within 72 hours (Correct answer)

Correct answer: The Saudi Center for Disease Prevention and Control (Weqaya) within 72 hours

Saudi Arabia established the Saudi Center for Disease Prevention and Control (Weqaya/CDC) as the national body for communicable disease surveillance. A cluster of healthcare-associated infections constitutes a reportable event to Weqaya within 72 hours under the National Communicable Disease Reporting System. While internal notification to the IPC committee is also required, the mandated external regulatory reporting goes to Weqaya, not SFDA (which oversees drugs/devices) and not just the local Directorate.

Question 11: What are the signs of respiratory distress in a newborn?

Only crying loudly
Nasal flaring, grunting, intercostal retractions, tachypnea (>60/min), and cyanosis (Correct answer)
Sleeping peacefully
Normal breathing rate

Correct answer: Nasal flaring, grunting, intercostal retractions, tachypnea (>60/min), and cyanosis

Neonatal respiratory distress signs: nasal flaring (widening nostrils with breathing), expiratory grunting, intercostal/subcostal/sternal retractions, tachypnea (>60 breaths/min), central cyanosis, and poor feeding. These require immediate medical intervention and possible NICU admission.

Question 12: Which action by a nurse BEST demonstrates the ethical principle of justice in patient care?

Giving preferential treatment to patients referred by senior physicians
Spending extra time with patients who are most cooperative
Allocating care based on severity of need regardless of social status (Correct answer)
Prioritizing patients who have private insurance

Correct answer: Allocating care based on severity of need regardless of social status

Justice requires fair distribution of care based on clinical need, not social or financial factors.

Question 13: A nurse is assessing a child with suspected appendicitis. Which assessment finding is most specific for appendicitis?

High fever of 40°C at onset
Periumbilical pain that does not migrate
Diffuse abdominal pain relieved by eating
Rebound tenderness at McBurney's point (Correct answer)

Correct answer: Rebound tenderness at McBurney's point

Rebound tenderness (pain worsening upon sudden release of pressure) at McBurney's point (one-third of the way from the right anterior superior iliac spine to the umbilicus) is the classic sign of appendiceal inflammation and peritoneal irritation.

Question 14: During a medication reconciliation at admission, a Saudi hospital nurse notes that a 68-year-old patient with chronic kidney disease (CKD stage 4) has been taking metformin 1000 mg twice daily prescribed by a private clinic. The admitting physician has not yet reviewed the medications. Which action reflects the highest standard of patient safety practice in this situation?

Withhold all home medications until the physician completes a full review at the next scheduled rounds
Continue administering metformin as prescribed, since it was already ordered by a licensed physician
Hold metformin and immediately flag the discrepancy to the admitting physician, documenting the CKD stage and the contraindication risk for urgent review (Correct answer)
Reduce the metformin dose by half as a precautionary measure pending physician review

Correct answer: Hold metformin and immediately flag the discrepancy to the admitting physician, documenting the CKD stage and the contraindication risk for urgent review

Metformin is contraindicated in CKD stage 4 (eGFR < 30 mL/min/1.73m²) due to the risk of lactic acidosis — a potentially fatal complication. The nurse's role in medication reconciliation includes identifying clinically significant discrepancies and escalating them urgently rather than autonomously modifying doses or passively withholding all medications. Flagging the specific, time-sensitive safety risk to the admitting physician immediately is the correct action. Continuing metformin without review is unsafe; unilaterally halving the dose falls outside nursing scope.

Question 15: The nurse is assessing a patient for lithium toxicity. Which early sign should be monitored?

Coarse tremor, nausea, diarrhea, and confusion at levels >1.5 mEq/L (Correct answer)
Polyuria and polydipsia as signs of toxicity
Fine tremor at therapeutic levels (0.6–1.2 mEq/L)
Hyperreflexia only at levels >3.0 mEq/L

Correct answer: Coarse tremor, nausea, diarrhea, and confusion at levels >1.5 mEq/L

Lithium toxicity occurs when levels exceed 1.5 mEq/L. Early signs include coarse tremors (vs. fine tremors at therapeutic levels), GI upset, drowsiness, and confusion. Levels >2.5 mEq/L cause seizures, cardiac arrhythmias, and coma. Therapeutic range is 0.6–1.2 mEq/L.

Question 16: Under Saudi MOH guidelines, a nurse administers methotrexate 15 mg/m² orally to a 45-year-old oncology patient with a BSA of 1.7 m². The patient is also taking ibuprofen 400 mg TID for arthritis pain, which was prescribed by another provider. Which pharmacokinetic interaction represents the PRIMARY concern requiring urgent escalation to the physician?

Ibuprofen chelates methotrexate in the GI tract, reducing oral bioavailability
Ibuprofen induces CYP3A4, accelerating methotrexate metabolism and reducing efficacy
Concurrent NSAIDs shift methotrexate protein binding, increasing free fraction transiently
NSAIDs reduce renal tubular secretion of methotrexate, causing toxic accumulation (Correct answer)

Correct answer: NSAIDs reduce renal tubular secretion of methotrexate, causing toxic accumulation

The primary and most dangerous interaction is that NSAIDs (including ibuprofen) competitively inhibit renal organic anion transporters (OATs) responsible for methotrexate tubular secretion. This reduces MTX clearance, leading to accumulation and severe toxicity (mucositis, myelosuppression, nephrotoxicity). Saudi oncology pharmacy guidelines explicitly list NSAIDs as a contraindicated concurrent medication with methotrexate. This requires immediate physician notification and NSAID discontinuation.

Question 17: Which acid-base disturbance is most commonly seen in a patient with prolonged nasogastric suctioning?

Respiratory alkalosis
Metabolic alkalosis (Correct answer)
Metabolic acidosis
Respiratory acidosis

Correct answer: Metabolic alkalosis

Loss of hydrochloric acid through NG suctioning causes metabolic alkalosis due to excess bicarbonate relative to acid.

Question 18: Which mechanism explains why proton pump inhibitors (PPIs) are more effective than H2 blockers in treating GERD?

PPIs irreversibly block the final step of acid secretion (Correct answer)
PPIs stimulate mucus production
PPIs increase gastric motility
PPIs neutralize gastric acid directly

Correct answer: PPIs irreversibly block the final step of acid secretion

PPIs irreversibly inhibit the H+/K+-ATPase pump (the final common pathway), suppressing acid from all stimuli more completely than H2 blockers.

Question 19: Which arterial blood gas result indicates uncompensated metabolic acidosis?

pH 7.48, PaCO2 40 mmHg, HCO3 30 mEq/L
pH 7.30, PaCO2 38 mmHg, HCO3 16 mEq/L (Correct answer)
pH 7.30, PaCO2 55 mmHg, HCO3 24 mEq/L
pH 7.50, PaCO2 30 mmHg, HCO3 22 mEq/L

Correct answer: pH 7.30, PaCO2 38 mmHg, HCO3 16 mEq/L

Uncompensated metabolic acidosis is characterized by a low pH and low HCO3 with a normal PaCO2, indicating a primary metabolic problem without respiratory compensation.

Question 20: The nurse is preparing to give a subcutaneous injection of insulin. At what angle should the needle be inserted?

45–90 degrees depending on body fat (Correct answer)
90 degrees always
15–20 degrees
30 degrees always

Correct answer: 45–90 degrees depending on body fat

Subcutaneous injections are given at 45–90 degrees. The angle depends on the patient's body fat: 90 degrees for patients with adequate subcutaneous tissue, 45 degrees for thin patients to avoid injecting into muscle.

Question 21: A 58-year-old male patient in the ICU at King Abdulaziz Medical City is on mechanical ventilation with the following ABG results: pH 7.22, PaCO₂ 38 mmHg, HCO₃⁻ 15 mEq/L, PaO₂ 88 mmHg, SaO₂ 94%. He has a serum lactate of 6.8 mmol/L and BP 78/50 mmHg despite 2L of crystalloid. Which intervention takes highest priority according to the Surviving Sepsis Campaign guidelines adopted by MOH Saudi Arabia?

Initiate norepinephrine infusion targeting MAP ≥65 mmHg (Correct answer)
Administer sodium bicarbonate 50 mEq IV bolus to correct acidosis
Obtain repeat blood cultures before initiating vasopressors
Increase PEEP from 5 to 10 cmH₂O to improve oxygenation

Correct answer: Initiate norepinephrine infusion targeting MAP ≥65 mmHg

The ABG shows high anion gap metabolic acidosis with a lactate of 6.8 mmol/L and refractory hypotension (MAP ~59 mmHg) despite fluid resuscitation — this is septic shock. Per Surviving Sepsis Campaign (SSC) 2021 guidelines adopted by MOH Saudi Arabia, norepinephrine is the first-line vasopressor to target MAP ≥65 mmHg. Sodium bicarbonate is not recommended for lactic acidosis until pH <7.15. Increasing PEEP addresses oxygenation, not the hemodynamic crisis. Blood cultures should ideally precede antibiotics but should not delay vasopressor initiation.

Question 22: The nurse is preparing to give IV morphine for severe pain. Which side effect must the nurse have equipment ready to manage?

Respiratory depression — have naloxone (Narcan) at bedside (Correct answer)
Hypertension — have antihypertensives ready
Hyperglycemia — have insulin available
Tachycardia — have beta-blockers available

Correct answer: Respiratory depression — have naloxone (Narcan) at bedside

The most dangerous side effect of opioids is respiratory depression, which can be fatal. Naloxone (Narcan) is the opioid antagonist used to reverse respiratory depression. Resuscitation equipment should also be available when administering IV opioids.

Question 23: The nurse is cleaning and disinfecting a blood spill on the floor. What is the correct sequence?

Remove blood with bare hands first, then apply alcohol hand rub
Clean with water first, then apply bleach, then remove residue
Apply disinfectant first, then remove the blood
Put on PPE, remove gross contamination with absorbent material, then disinfect with appropriate agent (e.g., 0.5% sodium hypochlorite) (Correct answer)

Correct answer: Put on PPE, remove gross contamination with absorbent material, then disinfect with appropriate agent (e.g., 0.5% sodium hypochlorite)

Blood spill management: PPE first (protect self), then remove gross soiling using paper towels/absorbent material (never bare hands), then apply approved disinfectant (0.5% sodium hypochlorite/bleach), allow contact time, and dispose of waste as clinical waste.

Question 24: Which behavior by a nurse BEST demonstrates professional accountability?

Documenting the error only if the patient asks about it
Asking a colleague to co-sign an incident report to share responsibility
Blaming equipment malfunction for a medication error
Acknowledging a mistake, reporting it, and implementing corrective measures (Correct answer)

Correct answer: Acknowledging a mistake, reporting it, and implementing corrective measures

Accountability means taking ownership of errors, disclosing them appropriately, and actively participating in prevention strategies.

Question 25: The nurse is caring for a patient with anorexia nervosa. Which physical complication is most life-threatening?

Cardiac arrhythmias from electrolyte imbalances (Correct answer)
Parotid gland enlargement
Lanugo hair growth
Amenorrhea

Correct answer: Cardiac arrhythmias from electrolyte imbalances

Hypokalemia and other electrolyte imbalances from starvation and purging can cause fatal cardiac arrhythmias in anorexia nervosa. Malnutrition also causes cardiomyopathy. Cardiac complications are the leading cause of death in anorexia nervosa.

Question 26: A 68 kg patient in a Saudi hospital ICU is prescribed dopamine at 7 mcg/kg/min. The available solution is dopamine 400 mg in 250 mL NS. What is the correct infusion rate in mL/hr?

23.6 mL/hr
14.9 mL/hr
29.8 mL/hr
17.9 mL/hr (Correct answer)

Correct answer: 17.9 mL/hr

First calculate the concentration: 400 mg/250 mL = 1.6 mg/mL = 1600 mcg/mL. Dose required = 7 mcg/kg/min × 68 kg = 476 mcg/min. Convert to mcg/hr: 476 × 60 = 28,560 mcg/hr. Rate = 28,560 ÷ 1600 = 17.85 mL/hr ≈ 17.9 mL/hr. This is a weight-based vasopressor calculation commonly tested at the advanced level.

Question 27: A patient receiving aminoglycoside therapy should be monitored most closely for which adverse effects?

Thrombocytopenia and fever
Nephrotoxicity and ototoxicity (Correct answer)
Peripheral neuropathy and hypotension
Hepatotoxicity and rash

Correct answer: Nephrotoxicity and ototoxicity

Aminoglycosides accumulate in renal tubular cells and cochlear hair cells, causing nephrotoxicity and ototoxicity as primary adverse effects.

Question 28: A child is admitted with suspected epiglottitis. Which nursing action is the highest priority?

Administer oral antibiotics and reassess
Prepare for lumbar puncture
Do not attempt to visualize the throat or obtain a throat swab (Correct answer)
Obtain a throat culture before starting treatment

Correct answer: Do not attempt to visualize the throat or obtain a throat swab

In suspected epiglottitis, examining the throat or causing distress can precipitate complete airway obstruction. The priority is airway management in a controlled setting. Diagnosis is made cautiously; immediate airway protection takes precedence.

Question 29: In a Saudi MOH ICU, a nurse is caring for a patient receiving continuous renal replacement therapy (CRRT) via CVVHDF mode. The blood flow rate is 200 mL/min, effluent rate is 35 mL/kg/hr, and the patient's serum phosphate is 0.45 mmol/L (normal: 0.87–1.45 mmol/L). The patient is hemodynamically stable. What is the MOST appropriate nursing intervention?

Notify the physician and anticipate phosphate supplementation to the replacement fluid or IV (Correct answer)
Increase the effluent rate to correct the electrolyte imbalance
Discontinue CRRT for 2 hours to allow phosphate levels to normalize
Administer oral phosphate binders as per hospital protocol

Correct answer: Notify the physician and anticipate phosphate supplementation to the replacement fluid or IV

Hypophosphatemia is a well-recognized complication of CRRT, particularly at high effluent rates, as phosphate is freely filtered. A serum phosphate of 0.45 mmol/L represents severe hypophosphatemia (normal lower limit ~0.87 mmol/L in Saudi/SI units), which can cause respiratory muscle weakness, cardiac dysfunction, and impaired weaning from ventilation. The correct action is to notify the physician and anticipate phosphate replacement — either added to the replacement/dialysate fluid or given IV. Increasing the effluent rate would worsen phosphate loss. Oral phosphate binders are used to reduce phosphate in hyperphosphatemia, not treat hypophosphatemia. Discontinuing CRRT is not clinically justified.

Question 30: A nurse is administering olanzapine to a patient with schizophrenia. Which metabolic side effects should be monitored?

Hypotension and bradycardia
Renal failure and electrolyte imbalances
Hypothyroidism and hair loss
Weight gain, hyperglycemia, and dyslipidemia (metabolic syndrome) (Correct answer)

Correct answer: Weight gain, hyperglycemia, and dyslipidemia (metabolic syndrome)

Second-generation (atypical) antipsychotics, especially olanzapine and clozapine, are associated with metabolic syndrome: significant weight gain, diabetes (hyperglycemia), and dyslipidemia. Regular monitoring of weight, glucose, and lipids is essential.

Question 31: A patient taking warfarin is prescribed ciprofloxacin. What INR change should the nurse anticipate?

INR will increase — bleeding risk rises due to CYP2C9 inhibition (Correct answer)
INR will remain stable — no significant interaction
INR will decrease — antibiotics reduce warfarin effect
INR may fluctuate unpredictably in the first 24 hours only

Correct answer: INR will increase — bleeding risk rises due to CYP2C9 inhibition

Fluoroquinolones (e.g., ciprofloxacin) inhibit CYP2C9, which metabolizes warfarin. Reduced warfarin clearance leads to increased serum warfarin levels and elevated INR. Additionally, broad-spectrum antibiotics reduce gut flora that produces vitamin K, further elevating INR.

Question 32: The nurse is preparing to perform a sterile dressing change. Which action breaks sterile technique?

Opening sterile packages away from the sterile field
Reaching across the sterile field (Correct answer)
Keeping sterile items above waist level
Wearing sterile gloves

Correct answer: Reaching across the sterile field

Reaching across a sterile field introduces contamination because the arm (non-sterile) passes over sterile items. Items must always be passed around, never over, a sterile field.

Question 33: The nurse is conducting a home visit to a patient with tuberculosis who is non-adherent with medications. The most appropriate intervention is:

Directly observed therapy (DOT) (Correct answer)
Education about the importance of completing treatment
Increased telephone follow-up only
Hospitalization for the full treatment course

Correct answer: Directly observed therapy (DOT)

Directly Observed Therapy (DOT) is the standard of care for TB when non-adherence is a concern. A healthcare worker directly watches the patient take each dose. DOT has significantly reduced TB treatment failure and drug resistance.

Question 34: A Saudi nurse is performing urinary catheterisation on a male patient using an indwelling Foley catheter. After inserting the catheter approximately 17–20 cm and observing urine return, the nurse inflates the balloon with 10 mL of sterile water. The patient immediately reports severe suprapubic pain. What is the most likely cause and correct immediate action?

The catheter tip is still in the urethra; deflate the balloon immediately and advance the catheter a further 5 cm before re-inflating (Correct answer)
The catheter has kinked; gently rotate the catheter 90 degrees and check for urine flow
The patient has bladder spasm from the saline; administer an antispasmodic and reassure the patient
The balloon has been over-inflated; withdraw 5 mL of sterile water and reassess

Correct answer: The catheter tip is still in the urethra; deflate the balloon immediately and advance the catheter a further 5 cm before re-inflating

Severe suprapubic pain immediately upon balloon inflation strongly indicates the balloon is being inflated within the urethra rather than the bladder. This can cause urethral rupture. The immediate action is to deflate the balloon completely, advance the catheter further (ensuring urine drains freely from the catheter lumen before re-inflating), and then reinflate. In male patients, the catheter is typically advanced to the bifurcation/hub (or at least 5 cm beyond the point of urine return) before balloon inflation to ensure placement in the bladder. Over-inflation with only 10 mL (standard for a Foley balloon rated for 10 mL) would not present this way.

Question 35: The nurse is caring for a patient with a spinal cord injury at T4. Which complication should the nurse monitor for most closely?

Autonomic dysreflexia (Correct answer)
Coagulopathy
Pulmonary fibrosis
Hypoglycemia

Correct answer: Autonomic dysreflexia

Autonomic dysreflexia is a life-threatening complication in spinal cord injury at T6 or above, caused by uncontrolled sympathetic response to stimuli below the injury level (e.g., full bladder). It causes severe hypertension, bradycardia, and can lead to stroke or death.

Question 36: Which epidemiological measure would a public health nurse use to compare the risk of disease in an exposed group versus an unexposed group?

Incidence rate difference
Attributable risk
Odds ratio
Relative risk (risk ratio) (Correct answer)

Correct answer: Relative risk (risk ratio)

Relative risk (RR) is the ratio of disease incidence in the exposed group to incidence in the unexposed group. RR >1 indicates increased risk with exposure. It is used in cohort studies to measure the strength of association between exposure and disease.

Question 37: A patient on a surgical ward develops fever, chills, and hypotension 48 hours after placement of a urinary catheter. The nurse suspects CAUTI. What is the most important immediate nursing action?

Administer antipyretics and reassess in 4 hours
Obtain urine culture and blood cultures, notify physician, and monitor vital signs (Correct answer)
Irrigate the bladder with normal saline
Change the urinary catheter immediately

Correct answer: Obtain urine culture and blood cultures, notify physician, and monitor vital signs

Suspected CAUTI with systemic signs (fever, chills, hypotension) may indicate urosepsis — a medical emergency. Obtaining cultures (urine and blood) before antibiotics are started provides diagnostic information. Immediate physician notification and hemodynamic monitoring are critical.

Question 38: A nurse in Saudi Arabia is preparing to administer the MERS-CoV (Middle East Respiratory Syndrome Coronavirus) precaution guidelines to a newly suspected case. Which precautions are required?

Droplet precautions with surgical mask only
Contact precautions with surgical mask
Standard precautions are sufficient for suspected cases
Airborne + Contact + standard precautions; N95 respirator for aerosol-generating procedures (Correct answer)

Correct answer: Airborne + Contact + standard precautions; N95 respirator for aerosol-generating procedures

Saudi MOH and WHO guidelines for MERS-CoV require contact and droplet precautions routinely, with additional airborne precautions (N95) for aerosol-generating procedures. Given the severe outcomes and limited treatment, many Saudi facilities apply full airborne precautions for all MERS-CoV cases.

Question 39: According to Saudi MOH Circular No. 9/B/4908 on healthcare-associated infections (HAIs), which organism has a mandated contact isolation threshold of a single positive culture result, regardless of clinical signs, in Saudi Arabian acute-care facilities?

Extended-spectrum beta-lactamase (ESBL)-producing organisms
Carbapenem-resistant Enterobacteriaceae (CRE) (Correct answer)
Vancomycin-resistant Enterococcus (VRE)
Methicillin-resistant Staphylococcus aureus (MRSA)

Correct answer: Carbapenem-resistant Enterobacteriaceae (CRE)

Saudi MOH mandates immediate contact precautions upon a single positive culture for CRE due to its extremely limited treatment options and high mortality rate in Saudi hospitals. Unlike MRSA or VRE, which may require confirmatory cultures or clinical correlation in some protocols, CRE triggers automatic isolation at first detection per Saudi infection prevention and control (IPC) national guidelines.

Question 40: A patient with chronic renal failure has a serum potassium of 6.2 mEq/L. Which ECG change should the nurse monitor for?

ST depression
Tall peaked T waves (Correct answer)
Prolonged PR interval
Widened QRS only

Correct answer: Tall peaked T waves

Hyperkalemia first manifests on ECG as tall, peaked (tent-shaped) T waves. As potassium rises further, PR interval prolongation, widened QRS, and eventually ventricular fibrillation can occur. Tall T waves are the earliest ECG sign.

Question 41: A 58-year-old male patient in a Riyadh tertiary hospital is post-operative day 2 following an open abdominal aortic aneurysm repair. His urine output drops to 18 mL/hour over 3 consecutive hours. Serum creatinine rises from 88 to 210 µmol/L. Which assessment finding would MOST specifically indicate acute tubular necrosis rather than prerenal azotemia?

Central venous pressure of 3 mmHg with skin turgor decreased
Urine sodium of 45 mEq/L with fractional excretion of sodium (FeNa) of 3.2% (Correct answer)
Urine sodium of 8 mEq/L with urine osmolality of 520 mOsm/kg
Blood pressure of 88/50 mmHg with heart rate of 118 beats per minute

Correct answer: Urine sodium of 45 mEq/L with fractional excretion of sodium (FeNa) of 3.2%

Acute tubular necrosis (ATN) is characterized by tubular dysfunction, evidenced by a high urine sodium (>40 mEq/L) and FeNa >2%, because damaged tubules cannot reabsorb sodium. In prerenal azotemia, kidneys are functionally intact and avidly retain sodium (urine Na <20 mEq/L, FeNa <1%). Options C and D suggest hypovolemia (prerenal cause), while option A (low urine Na, high osmolality) indicates prerenal state with concentrated urine. The FeNa of 3.2% in option B confirms intrinsic renal injury consistent with ATN.

Question 42: A patient on lithium therapy has a serum lithium level of 2.5 mEq/L. The nurse anticipates which clinical finding?

Increased urinary output only
Coarse tremor, confusion, and seizures (Correct answer)
Mild polyuria and fine hand tremor
Slight nausea and mild thirst

Correct answer: Coarse tremor, confusion, and seizures

A lithium level >2.0 mEq/L indicates severe toxicity, presenting with coarse tremors, confusion, seizures, and cardiovascular collapse.

Question 43: During a home visit in Riyadh, a Saudi public health nurse assesses a 3-year-old child whose mother reports he rarely speaks in sentences, cannot identify colors, and has frequent temper tantrums lasting over 30 minutes. The nurse plots his weight at the 5th percentile and height at the 10th percentile. Per SCFHS and Saudi Child Protection standards, what is the nurse's MOST appropriate next step?

Initiate a dietary supplementation program through the PHC and re-evaluate developmental milestones in 3 months
Reassure the mother that speech delays in bilingual Saudi households are normal and schedule a routine follow-up in 6 months
Refer to a multidisciplinary team including a developmental pediatrician and report concerns to the National Family Safety Program (NFSP) if neglect is suspected (Correct answer)
Refer only to a speech-language therapist, as language delay is the primary concern identified

Correct answer: Refer to a multidisciplinary team including a developmental pediatrician and report concerns to the National Family Safety Program (NFSP) if neglect is suspected

This child presents with multiple red flags: speech delay (should have 3-word sentences by age 3), behavioral dysregulation (temper tantrums > 30 minutes), and growth faltering (weight 5th percentile, height 10th percentile). The combination of developmental delay across multiple domains AND growth faltering raises concern for neglect or a complex medical etiology requiring multidisciplinary assessment. Under Saudi Child Protection regulations and NFSP protocols (affiliated with MOH), nurses are mandated reporters. A unidisciplinary referral (speech only, diet only) is insufficient. Reassurance and 6-month delay are inappropriate given the severity. The NFSP coordinates child protection services across Saudi Arabia.

Question 44: A G3P2 patient presents at 39 weeks in active labor. Suddenly the nurse notes a loop of umbilical cord protruding from the vagina. The priority nursing action is:

Manually hold the presenting part off the cord and call for emergency assistance (Correct answer)
Document the finding and await physician arrival
Attempt to push the cord back into the uterus
Place the patient in high Fowler's position

Correct answer: Manually hold the presenting part off the cord and call for emergency assistance

Umbilical cord prolapse is an obstetric emergency causing fetal hypoxia from cord compression. The nurse must manually elevate the presenting part off the cord (not push the cord back), position the patient in Trendelenburg or knee-chest, apply moist warm saline gauze to the cord, and call for emergency cesarean section.

Question 45: What is the APGAR score used for in newborn assessment?

Rapid assessment of newborn condition at 1 and 5 minutes after birth, evaluating 5 criteria (Correct answer)
Determining blood type
Measuring head circumference
Measuring birth weight

Correct answer: Rapid assessment of newborn condition at 1 and 5 minutes after birth, evaluating 5 criteria

APGAR assesses: Appearance (skin color), Pulse (heart rate), Grimace (reflex response), Activity (muscle tone), Respiration (breathing). Each scored 0-2, total 0-10. Assessed at 1 and 5 minutes. Score 7-10 is normal; below 7 needs intervention.

Question 46: A psychiatric nurse has been assigned to a male patient admitted for major depressive disorder. Over several weeks, she notices she becomes distressed when he misses sessions, brings him personal items 'to cheer him up,' stays late on her shifts specifically to be available to him, and realizes he resembles her younger brother who died by suicide. This clinical phenomenon is BEST described as:

Therapeutic use of self — the nurse is appropriately leveraging personal experience to build rapport
Transference — the patient is projecting his unresolved feelings onto the nurse
Professional boundary violation only, with no underlying psychological mechanism
Countertransference — the nurse is experiencing an unconscious emotional response rooted in her own personal history (Correct answer)

Correct answer: Countertransference — the nurse is experiencing an unconscious emotional response rooted in her own personal history

Countertransference refers to the nurse's (or clinician's) unconscious emotional reactions toward a patient, driven by the nurse's own unresolved conflicts, experiences, or needs — in this case, her unresolved grief over her brother's suicide. It differs from transference (which is the patient projecting feelings onto the clinician). While the behaviors described also constitute boundary violations, the root mechanism is countertransference. Recognizing it is essential; the nurse must bring this to clinical supervision immediately. Unexamined countertransference can severely compromise therapeutic integrity and patient safety, particularly with suicidal patients.

Question 47: A patient refuses a blood transfusion on religious grounds despite a life-threatening hemorrhage. What is the nurse's primary ethical obligation?

Respect the patient's autonomy and document the refusal (Correct answer)
Sedate the patient and proceed with the transfusion
Consult the family to override the patient's decision
Administer the transfusion to save the patient's life

Correct answer: Respect the patient's autonomy and document the refusal

Respecting autonomy means honoring a competent adult's informed refusal even when the nurse disagrees with the choice.

Question 48: A community nurse is managing a tuberculosis contact investigation following a confirmed smear-positive pulmonary TB case in a Riyadh compound housing 200 expatriate workers. Under the Saudi Communicable Disease Prevention and Control Law (Royal Decree No. M/27), which action is LEGALLY MANDATED within 24 hours of case confirmation?

Isolate the entire compound and restrict movement pending epidemiological clearance
Notify the regional health directorate through the official Saudi Communicable Disease Reporting System (CDRS) (Correct answer)
Submit a report to the General Directorate of Infection Prevention and Control within 72 hours
Initiate directly observed therapy (DOT) for all close contacts regardless of TST results

Correct answer: Notify the regional health directorate through the official Saudi Communicable Disease Reporting System (CDRS)

Under Saudi Arabia's Communicable Disease Prevention and Control Law and its implementing regulations, tuberculosis is a Group A notifiable disease requiring mandatory notification to the regional health directorate via the Saudi Communicable Disease Reporting System (CDRS) within 24 hours of laboratory confirmation. This is a legal — not merely procedural — obligation. DOT for contacts is initiated only after TST/IGRA screening and risk stratification, not universally. Mass compound isolation is not mandated by law for a single case. The 72-hour timeline applies to certain Group B diseases, not Group A like TB.

Question 49: A public health nurse is working on a food safety inspection following a Salmonella outbreak linked to a restaurant. Which food handling practice most likely caused the outbreak?

Inadequate refrigerator temperature (5°C vs. recommended ≤4°C)
Cross-contamination between raw poultry and ready-to-eat foods (Correct answer)
Using commercial rather than homemade mayonnaise
Failure to label food with expiration dates

Correct answer: Cross-contamination between raw poultry and ready-to-eat foods

Cross-contamination between raw poultry (a major Salmonella reservoir) and ready-to-eat foods (salads, bread, cooked foods) is the most common cause of Salmonella outbreaks. This occurs through shared cutting boards, utensils, or poor hand hygiene.

Question 50: The nurse is performing hand hygiene. What is the minimum recommended duration for rubbing hands with alcohol-based hand rub?

60 seconds
5–10 seconds
20–30 seconds (Correct answer)
15 seconds

Correct answer: 20–30 seconds

WHO guidelines recommend rubbing hands with alcohol-based hand rub for 20–30 seconds, covering all surfaces, until hands are dry. This duration ensures effective reduction of microbial load.

Question 51: A nurse is caring for a post-operative Saudi patient who is receiving a blood transfusion. Fifteen minutes into the transfusion of packed red blood cells, the patient develops back pain, haematuria, and a sudden drop in blood pressure. The nurse correctly identifies this as an acute haemolytic transfusion reaction. Placing the actions in correct priority order, which sequence is MOST appropriate?

Stop the transfusion → maintain IV access with normal saline → notify the physician and blood bank → send urine and blood samples (Correct answer)
Slow the transfusion rate → notify the physician → obtain vital signs → send the blood bag to the laboratory
Stop the transfusion → remove the IV line entirely → call a code blue → prepare epinephrine 1:1000
Notify the blood bank first → stop the transfusion → administer antihistamines IV → monitor vital signs

Correct answer: Stop the transfusion → maintain IV access with normal saline → notify the physician and blood bank → send urine and blood samples

In an acute haemolytic transfusion reaction (ABO incompatibility), the priority sequence is: (1) Stop the transfusion immediately to limit the volume of incompatible blood infused. (2) Maintain IV access with normal saline using new IV tubing to prevent further exposure to residual blood in the line. (3) Notify the physician and blood bank simultaneously. (4) Send required samples (urine for haemoglobinuria, blood for repeat crossmatch) and return the blood bag and tubing to the blood bank. Removing the IV line is incorrect — access is needed for fluid resuscitation. Antihistamines are for allergic/urticarial reactions, not haemolytic ones.

Question 52: A nurse in a Riyadh tertiary hospital is preparing to perform a central line dressing change on a patient placed under droplet precautions for influenza. Which PPE combination is correct per Saudi MOH/CDC-aligned IPC standards when simultaneously managing the dressing change?

N95 respirator, sterile gloves, sterile gown — eye protection only if splash risk is anticipated
Surgical mask, sterile gloves, sterile drape — no gown required since droplets do not contaminate sterile fields
N95 respirator, sterile gloves, sterile gown, and eye protection
Surgical mask, sterile gloves, sterile gown, and eye protection (Correct answer)

Correct answer: Surgical mask, sterile gloves, sterile gown, and eye protection

When performing an aseptic procedure (central line dressing) on a droplet-precaution patient, Saudi MOH IPC protocols require a surgical mask (adequate for droplet isolation unless aerosol-generating), sterile gloves and sterile gown (required for aseptic technique), and eye protection (standard precaution for any splash-risk procedure). An N95 is not indicated for influenza under droplet precautions unless an aerosol-generating procedure is performed concurrently — a central line dressing change is not aerosol-generating.

Question 53: A nurse caring for a mechanically ventilated patient notices the high-pressure alarm is triggering repeatedly. What is the FIRST action?

Increase the sedation dose
Manually ventilate the patient with a bag-valve mask (Correct answer)
Silence the alarm and continue monitoring
Increase the pressure limit on the ventilator

Correct answer: Manually ventilate the patient with a bag-valve mask

Manual ventilation ensures the patient receives adequate breaths while the cause of the high-pressure alarm is investigated.

Question 54: The nurse is assessing a child for signs of increased intracranial pressure (ICP). Which finding is most specific to increased ICP in a 9-month-old infant?

Bulging anterior fontanelle (Correct answer)
Bradycardia and hypertension
Papilledema
Altered level of consciousness

Correct answer: Bulging anterior fontanelle

In infants with open fontanelles, bulging or tenseness of the anterior fontanelle is the most specific sign of increased ICP. In older children and adults where fontanelles are closed, papilledema and Cushing's triad are used.

Question 55: The nurse is assessing a 2-year-old child's developmental milestones. Which finding is a concern?

No two-word phrases by 24 months (Correct answer)
Runs with frequent falls
Uses a spoon with some spilling
Can stack 4–6 blocks

Correct answer: No two-word phrases by 24 months

By 24 months, children should use at least two-word phrases. Failure to achieve this is a developmental red flag for speech/language delay or autism spectrum disorder and warrants referral. The other findings are normal for a 2-year-old.

Question 56: A nurse observes that a patient's urine is dark amber in color. This finding is most consistent with:

Renal failure
Dehydration (Correct answer)
Hematuria
Urinary tract infection

Correct answer: Dehydration

Dark amber urine indicates concentrated urine, which is a classic sign of dehydration. When fluid intake is insufficient, the kidneys conserve water by producing more concentrated urine.

Question 57: Which nursing intervention is most important when caring for a patient with increased intracranial pressure (ICP)?

Encourage vigorous coughing to clear secretions
Apply heat packs to the head to reduce swelling
Position the patient flat to promote cerebral perfusion
Elevate the head of the bed to 30 degrees and maintain neutral head alignment (Correct answer)

Correct answer: Elevate the head of the bed to 30 degrees and maintain neutral head alignment

Elevating the head of the bed to 30 degrees and keeping the head in neutral alignment facilitates venous drainage from the brain, helping to reduce ICP. Flat positioning increases ICP by impeding venous outflow.

Question 58: A Saudi PHC community health nurse is reviewing meningococcal vaccination records for an incoming group of Hajj pilgrims from abroad. According to Saudi MOH Hajj health requirements, which statement about meningococcal vaccination is CORRECT?

Vaccination is waived for pilgrims from countries with documented herd immunity above 85% coverage
The MenACWY polysaccharide vaccine is preferred over the conjugate form for all pilgrims above age 55
The MenC monovalent vaccine is acceptable if administered within 3 years, covering the dominant circulating serogroup
The MenACWY quadrivalent conjugate vaccine must be administered at least 10 days before arrival and is valid for 5 years (Correct answer)

Correct answer: The MenACWY quadrivalent conjugate vaccine must be administered at least 10 days before arrival and is valid for 5 years

Saudi MOH mandates the quadrivalent MenACWY vaccine for all Hajj pilgrims without exception, covering serogroups A, C, W, and Y — all implicated in Hajj-associated outbreaks. The conjugate formulation is preferred for its longer protection (valid up to 5 years) and superior immunogenicity, especially in younger pilgrims and those at risk of asymptomatic carriage. Vaccination must occur at least 10 days before arrival to allow protective antibody levels to develop. MenC alone does not fulfill requirements, and no national herd immunity waiver exists for this requirement.

Question 59: A postoperative patient in a Saudi hospital's PACU develops laryngospasm 15 minutes after extubation. Which is the nurse's PRIORITY intervention?

Apply jaw thrust, administer 100% oxygen via tight-fitting mask, and call the anesthesiologist immediately (Correct answer)
Administer IV morphine for pain as agitation may be triggering the spasm
Suction the oropharynx vigorously with a Yankauer catheter
Position the patient supine and monitor SpO2

Correct answer: Apply jaw thrust, administer 100% oxygen via tight-fitting mask, and call the anesthesiologist immediately

Laryngospasm is a life-threatening closure of the vocal cords causing airway obstruction. The immediate priorities are: apply a jaw thrust to open the airway, provide 100% oxygen with positive pressure via a tightly fitting mask, and immediately summon the anesthesiologist. Vigorous suctioning can worsen laryngospasm by stimulating the larynx. Opioids are contraindicated as they depress respiration. Supine positioning without airway management does not address the obstruction.

Question 60: A patient with type 2 diabetes managed with metformin 1000 mg twice daily is scheduled for a contrast CT scan at a Saudi radiology center. Which nursing action regarding metformin is correct according to clinical pharmacology guidelines?

Hold metformin 5 days before the procedure regardless of renal function
Switch to insulin on the day of the scan and resume metformin immediately post-procedure
Continue metformin as usual since contrast media does not interact with biguanides
Hold metformin on the day of the procedure and for 48 hours post-contrast, then check renal function before resuming (Correct answer)

Correct answer: Hold metformin on the day of the procedure and for 48 hours post-contrast, then check renal function before resuming

Iodinated contrast media can cause acute kidney injury, which reduces metformin clearance and raises plasma lactate, leading to potentially fatal lactic acidosis. Current guidelines recommend holding metformin on the day of contrast administration and for 48 hours post-procedure. Renal function (eGFR) must be reassessed before resuming. This is particularly relevant in Saudi tertiary hospitals where contrast CT is common. Continuing without interruption is dangerous; 5-day pre-hold is excessive and not evidence-based.

Question 61: A nurse is caring for a patient with acute pancreatitis. Which position provides the most comfort?

Supine with legs extended
High Fowler's position
Left lateral decubitus
Fetal position (knees drawn to chest) (Correct answer)

Correct answer: Fetal position (knees drawn to chest)

The fetal position (knees drawn to chest, leaning forward) reduces tension on the retroperitoneal space and alleviates pain from pancreatic inflammation. This position is a characteristic finding in acute pancreatitis history.

Question 62: A psychiatric nurse in Jeddah is caring for a patient with Bipolar I Disorder who is 7 months pregnant and experiencing a severe manic episode with psychotic features. The team is considering pharmacological intervention. Which of the following medication choices presents the GREATEST teratogenic risk that the nurse must prioritize flagging to the treating team?

Lorazepam for short-term agitation management
Valproate sodium at mood-stabilizing doses (Correct answer)
Quetiapine at low therapeutic doses
Haloperidol at the minimum effective dose

Correct answer: Valproate sodium at mood-stabilizing doses

Valproate (sodium valproate) carries a Category X-equivalent teratogenic profile and is explicitly contraindicated in pregnancy due to a high risk of neural tube defects (spina bifida), fetal valproate syndrome, and long-term neurodevelopmental impairment in the child. At 7 months gestation, the CNS is still maturing, and valproate remains harmful throughout pregnancy. The SCFHS maternal-psychiatric nursing guidelines and WHO recommendations strongly advise against valproate in pregnant women. While quetiapine, haloperidol, and lorazepam each carry their own perinatal risks, valproate represents the highest absolute teratogenic risk among these options and requires urgent flagging.

Question 63: A psychiatric nurse is conducting a risk assessment on a 34-year-old Saudi male admitted after a suicide attempt by medication overdose. Which finding from the assessment MOST significantly increases his risk for a completed suicide attempt compared to all other findings listed?

He has a concrete, high-lethality plan and has taken preparatory actions, including giving away personal belongings (Correct answer)
He discloses a previous low-lethality suicide attempt 5 years ago with rapid help-seeking behavior afterward
He expresses passive suicidal ideation with no current plan and states he does not want to die
He reports moderate depression with a PHQ-9 score of 14 and disturbed sleep for 3 weeks

Correct answer: He has a concrete, high-lethality plan and has taken preparatory actions, including giving away personal belongings

The combination of a concrete, high-lethality plan with preparatory behaviors (giving away belongings) is the single strongest predictor of imminent completed suicide. Preparatory actions indicate the patient has moved beyond ideation into the planning and intention stage, which dramatically elevates risk. Passive ideation without a plan, a moderate PHQ-9 score, or a prior low-lethality attempt with subsequent help-seeking are all concerning but do not carry the same immediacy and specificity of imminent lethal intent as the presence of an active, detailed, high-lethality plan combined with preparatory actions.

Question 64: A nurse is caring for a patient with obsessive-compulsive disorder (OCD) who performs handwashing rituals for 3 hours daily. What is the most appropriate initial nursing intervention?

Set strict time limits on handwashing immediately
Administer a sedative to interrupt the compulsive behavior
Allow the rituals while establishing a therapeutic relationship (Correct answer)
Distract the patient with group activities during rituals

Correct answer: Allow the rituals while establishing a therapeutic relationship

Initially allowing rituals while building trust prevents increased anxiety; reduction of rituals is a gradual process.

Question 65: A patient is prescribed dopamine 400 mg in 250 mL D5W to infuse at 5 mcg/kg/min. The patient weighs 80 kg. What is the infusion rate in mL/hr?

7.5 mL/hr
30 mL/hr
60 mL/hr
15 mL/hr (Correct answer)

Correct answer: 15 mL/hr

Step 1: Dose in mcg/min = 5 × 80 = 400 mcg/min. Step 2: Convert to mg/min: 400/1,000 = 0.4 mg/min. Step 3: Concentration = 400 mg/250 mL = 1.6 mg/mL. Step 4: mL/min = 0.4/1.6 = 0.25 mL/min. Step 5: mL/hr = 0.25 × 60 = 15 mL/hr.

Question 66: A 6-week-old infant is brought to a Saudi PHC center for the first scheduled vaccination visit. The mother reports the infant had a generalized tonic-clonic seizure lasting 3 minutes at 2 weeks of age, evaluated and attributed to neonatal hypocalcemia, with no recurrence since. The infant appears well today. According to the Saudi Expanded Program on Immunization (EPI) schedule and contraindication guidelines, which vaccine decision is CORRECT?

Administer all due vaccines (DTP-HepB-Hib-IPV, PCV, and Rotavirus) as a resolved metabolic cause of seizure is not a contraindication to any scheduled vaccine (Correct answer)
Administer all vaccines except DTP; substitute with DTaP to reduce the risk of febrile seizure recurrence
Defer all vaccines for 3 months and refer to pediatric neurology for EEG clearance before proceeding
Administer only IPV and PCV today; defer DTP-containing and Rotavirus vaccines until a seizure-free period of 6 months is confirmed

Correct answer: Administer all due vaccines (DTP-HepB-Hib-IPV, PCV, and Rotavirus) as a resolved metabolic cause of seizure is not a contraindication to any scheduled vaccine

Per the Saudi MOH EPI guidelines and WHO contraindication criteria, a past seizure with an identified and resolved metabolic cause (neonatal hypocalcemia) is NOT a contraindication to any routine vaccine, including DTP-containing vaccines. Contraindications to pertussis-containing vaccines include encephalopathy within 7 days of a prior dose or progressive neurological disorder — neither applies here. The infant is clinically well, seizure-free, and has a clear metabolic etiology. Deferral or substitution with DTaP is not warranted. All 6-week vaccines should proceed on schedule to protect the infant during the vulnerable early months.

Question 67: In a Saudi ICU, a mechanically ventilated patient with ARDS (P/F ratio 95) is being managed with lung-protective ventilation per the ARDSNet protocol. Despite optimizing PEEP to 14 cmH₂O and prone positioning for 18 hours, the patient's plateau pressure is 32 cmH₂O and driving pressure is 18 cmH₂O. The ICU consultant orders neuromuscular blockade. Which agent is the SCFHS/Saudi MOH-preferred first-line neuromuscular blocking agent for early moderate-to-severe ARDS, and what monitoring parameter is MANDATORY during its use?

Cisatracurium infusion; Train-of-Four (TOF) monitoring with target of 1–2 twitches (Correct answer)
Rocuronium infusion; Bispectral Index (BIS) monitoring only
Succinylcholine bolus; continuous SpO₂ and ETCO₂ monitoring
Vecuronium bolus PRN; daily spontaneous breathing trials

Correct answer: Cisatracurium infusion; Train-of-Four (TOF) monitoring with target of 1–2 twitches

Cisatracurium is the preferred NMBA for early moderate-to-severe ARDS (P/F <150) based on the ACURASYS trial and international critical care guidelines adopted by SCFHS. Its organ-independent Hofmann elimination makes it safe in hepatic and renal failure, which is common in ICU patients. The mandatory monitoring parameter is Train-of-Four (TOF) stimulation, targeting 1–2 twitches out of 4 to ensure adequate blockade without overdose and cumulative paralysis. Succinylcholine is an ultra-short depolarizing agent used only for intubation, not infusion. Rocuronium requires TOF monitoring but is second-line. Vecuronium PRN dosing without TOF is unsafe and non-standard.

Question 68: A nurse is assessing a patient with suspected ADHD in a school-age child. Which finding is most consistent with inattentive-type ADHD?

Runs and climbs excessively, cannot sit still
Frequently loses items, forgetful, easily distracted, fails to finish tasks (Correct answer)
Impulsive risk-taking and difficulty waiting in turn
Interrupts others constantly, blurts out answers

Correct answer: Frequently loses items, forgetful, easily distracted, fails to finish tasks

Inattentive-type ADHD presents with poor attention to detail, losing items, forgetfulness, distractibility, and failure to complete tasks — without hyperactivity/impulsivity. Hyperactive-impulsive type presents with the motor and impulse control symptoms.

Question 69: The nurse notes a patient's urine output has been 200 mL over the past 8 hours. This finding is best described as:

Anuria
Dysuria
Oliguria (Correct answer)
Polyuria

Correct answer: Oliguria

Oliguria is defined as urine output less than 400 mL/day (or 0.5 mL/kg/hr). 200 mL over 8 hours equals 25 mL/hr, which is significantly below the normal minimum of 30 mL/hr, indicating oliguria.

Question 70: A nurse in a Saudi MOH hospital discovers that a senior physician has been repeatedly performing a procedure without obtaining informed consent, citing patient family approval as sufficient. Under the Saudi Patient Rights Charter (1436H) and SCFHS ethical standards, what is the nurse's MOST appropriate course of action?

Accept the family-consent model as culturally appropriate in the Saudi context and continue assisting
Report directly to the Saudi Commission for Health Specialties without first using internal channels
Document the pattern and escalate through the hospital's Patient Rights Committee or formal incident reporting system (Correct answer)
Confront the physician publicly during rounds to protect future patients

Correct answer: Document the pattern and escalate through the hospital's Patient Rights Committee or formal incident reporting system

The Saudi Patient Rights Charter mandates individual informed consent from competent adult patients; family consent alone does not substitute unless the patient lacks capacity. The nurse is ethically and professionally obligated to document the pattern and escalate through established internal channels — the Patient Rights Committee or incident reporting system — before external escalation. Skipping internal channels (option D) violates institutional protocol, while accepting the practice (option A) violates the charter, and public confrontation (option C) is unprofessional and counterproductive.

Question 71: A nurse is preparing to give IV potassium chloride. Which action is most important?

Administer as an IV bolus for rapid effect
Mix the KCl in a lipid emulsion
Dilute and infuse at no more than 10–20 mEq/hour (Correct answer)
Give undiluted via peripheral IV push

Correct answer: Dilute and infuse at no more than 10–20 mEq/hour

Rapid IV potassium administration causes fatal cardiac arrhythmias; it must always be diluted and infused slowly (≤10–20 mEq/hr peripherally).

Question 72: A Saudi tertiary hospital nurse discovers that concentrated potassium chloride (KCl) ampoules are stored in the ward medication refrigerator for 'emergency use.' According to the Saudi Patient Safety Center (SPSC) high-alert medication guidelines aligned with ISMP standards, what is the nurse's most appropriate immediate action?

Ensure concentrated KCl is removed from the ward and that only pharmacy-prepared diluted solutions are stocked on general units (Correct answer)
Keep the ampoules but implement a double-check policy requiring two nurses to verify before any administration
Leave the ampoules in place but add a bright red warning label to the refrigerator
Relocate the ampoules to the locked controlled-substance cabinet on the unit

Correct answer: Ensure concentrated KCl is removed from the ward and that only pharmacy-prepared diluted solutions are stocked on general units

Concentrated KCl is a SPSC-designated Never-Stock high-alert medication on general patient care wards. ISMP and Saudi MOH/SPSC guidelines mandate its complete removal from floor stock — relabeling, double-checks, or moving to a locked cabinet on the unit are all insufficient. Only pharmacy-prepared, appropriately diluted solutions may be stocked at the bedside. IV push of concentrated KCl can be rapidly fatal.

Question 73: The nurse is preparing the patient's room after discharge for terminal cleaning. Which surfaces are highest priority?

Patient's personal belongings
High-touch surfaces: bed rails, call button, IV pole, light switches, door handles (Correct answer)
Floors and walls in the hallway
Window sills and ceiling tiles

Correct answer: High-touch surfaces: bed rails, call button, IV pole, light switches, door handles

High-touch surfaces in the patient environment harbor the most pathogens and are highest priority for terminal (discharge) cleaning. These include bed rails, call buttons, IV poles, light switches, door handles, faucets, and tray tables. Thorough cleaning of these surfaces significantly reduces pathogen transmission.

Question 74: A Saudi child aged 6 months is brought to a primary health care center and the mother reports exclusive breastfeeding. According to WHO and Saudi MOH infant feeding guidelines, what is the recommended approach at this age?

Switch entirely to commercial infant formula to meet increased caloric demands
Continue exclusive breastfeeding until 12 months with no complementary foods
Introduce cow's milk to supplement breast milk
Begin introducing complementary foods (pureed fruits, vegetables, iron-rich cereals) while continuing breastfeeding (Correct answer)

Correct answer: Begin introducing complementary foods (pureed fruits, vegetables, iron-rich cereals) while continuing breastfeeding

WHO and Saudi MOH Maternal and Child Health guidelines recommend exclusive breastfeeding for the first 6 months, followed by the introduction of complementary foods (starting with iron-rich foods, pureed vegetables and fruits) at 6 months while continuing breastfeeding until 2 years of age. Switching entirely to formula at 6 months is unnecessary. Exclusive breastfeeding beyond 6 months without complementary foods is inadequate for nutritional needs. Cow's milk is not recommended before 12 months of age.

Question 75: Which antidote is administered for acetaminophen (paracetamol) overdose?

Flumazenil
Atropine
Naloxone
N-acetylcysteine (Correct answer)

Correct answer: N-acetylcysteine

N-acetylcysteine replenishes glutathione stores, preventing toxic accumulation of NAPQI that causes hepatic necrosis.

Question 76: A mechanically ventilated patient develops sudden hypotension, absent breath sounds on the left side, and tracheal deviation to the right. The nurse should first suspect:

Pulmonary embolism
Pleural effusion
Hemothorax
Tension pneumothorax (Correct answer)

Correct answer: Tension pneumothorax

Tension pneumothorax presents with tracheal deviation away from the affected side, unilateral absent breath sounds, and hemodynamic instability requiring immediate needle decompression.

Question 77: A patient in a Saudi hospital ICU is receiving IV vancomycin 1g every 12 hours for MRSA bacteremia. The pharmacist reports a trough level of 22 mg/L (target: 10–20 mg/L). The patient's serum creatinine has risen from 62 to 104 µmol/L over 48 hours. Which is the MOST appropriate nursing action?

Switch to oral vancomycin as directed by the standing medication protocol
Hold the next dose and notify the physician immediately, documenting signs of nephrotoxicity (Correct answer)
Administer the next dose as scheduled and recheck trough in 24 hours
Reduce the infusion rate and continue monitoring without notifying the physician

Correct answer: Hold the next dose and notify the physician immediately, documenting signs of nephrotoxicity

A supratherapeutic vancomycin trough (>20 mg/L) combined with a rising serum creatinine (≥1.5× baseline, per KDIGO criteria) indicates vancomycin-induced nephrotoxicity. The next dose must be held and the prescribing physician notified immediately so dose adjustment or drug discontinuation can be ordered. Continuing the infusion at any rate without medical review is unsafe. Oral vancomycin has negligible systemic absorption and is only used for Clostridioides difficile colitis — not systemic MRSA infections.

Question 78: A nurse in a psychiatric unit in Saudi Arabia is caring for a patient with treatment-resistant schizophrenia who has been prescribed clozapine. According to SCFHS and Saudi MOH guidelines, which absolute contraindication must be confirmed BEFORE initiating clozapine therapy?

Concurrent use of carbamazepine due to the compounded risk of agranulocytosis (Correct answer)
A family history of neuroleptic malignant syndrome in a first-degree relative
Baseline fasting blood glucose of 6.8 mmol/L indicating pre-diabetes
History of a single episode of neutropenia with ANC nadir of 1,200 cells/mm³

Correct answer: Concurrent use of carbamazepine due to the compounded risk of agranulocytosis

Concurrent use of carbamazepine with clozapine is an absolute contraindication because both agents independently suppress bone marrow function, and their combination dramatically increases the risk of life-threatening agranulocytosis. Saudi MOH clozapine monitoring protocols strictly prohibit this combination. A single prior episode of mild neutropenia is a relative contraindication requiring careful monitoring, not an absolute one. Pre-diabetes warrants metabolic monitoring but does not contraindicate initiation. Family history of NMS is a risk factor requiring caution but is not an absolute contraindication.

Question 79: The Saudi MOH regulations require healthcare workers to report occupational blood or body fluid exposures within what time frame?

Within 1 week
Immediately or as soon as possible — within hours, not days (Correct answer)
Within 72 hours, before starting PEP
Within 48 hours

Correct answer: Immediately or as soon as possible — within hours, not days

Occupational exposure to blood/body fluids requires immediate reporting to the occupational health department because post-exposure prophylaxis (PEP) for HIV must begin within 2 hours (maximum 72 hours) to be effective. Immediate reporting enables timely decision-making.

Question 80: A nurse is teaching a patient about metformin. Which condition is an absolute contraindication?

Mild hypertension
Euthyroid goiter
Obesity
Renal impairment (eGFR < 30 mL/min) (Correct answer)

Correct answer: Renal impairment (eGFR < 30 mL/min)

Severe renal impairment causes metformin accumulation, dramatically increasing risk of life-threatening lactic acidosis.

Question 81: In a Saudi Arabian primary health care setting, a community health nurse is using the PRECEDE-PROCEED model to plan a health promotion intervention targeting type 2 diabetes prevention among Saudi women aged 35–55. During the PRECEDE phase, the nurse identifies 'fatalistic beliefs about disease as God's will' as a barrier to preventive behavior. Within the PRECEDE-PROCEED framework, this cultural factor is correctly classified as:

An epidemiological factor requiring quantitative measurement before intervention
A reinforcing factor that sustains existing health behaviors
An enabling factor that facilitates or impedes action
A predisposing factor influencing motivation and perception (Correct answer)

Correct answer: A predisposing factor influencing motivation and perception

In the PRECEDE-PROCEED model, predisposing factors are antecedents to behavior that provide the motivation or rationale for the behavior — including knowledge, attitudes, beliefs, values, and perceptions. Fatalistic beliefs ('this is God's will / qadar') are culturally embedded cognitive and attitudinal factors that predispose individuals toward or away from preventive health actions by shaping their perceived susceptibility and sense of control. They are predisposing, not reinforcing (which involves rewards/feedback from others post-behavior) or enabling (which involves skills, resources, or structural access). Correctly classifying this factor determines which type of educational or behavioral intervention is appropriate.

Question 82: What is the primary nursing intervention for a neonate with jaundice?

Administer antibiotics
Keep the baby in a dark room
Ensure adequate hydration, frequent feeding, monitor bilirubin levels, and prepare for phototherapy if levels are elevated (Correct answer)
Restrict feeding

Correct answer: Ensure adequate hydration, frequent feeding, monitor bilirubin levels, and prepare for phototherapy if levels are elevated

Neonatal jaundice management: frequent feeding (promotes bilirubin excretion through stool), adequate hydration, monitor serum bilirubin levels, phototherapy (blue light breaks down bilirubin) if levels exceed threshold, protect eyes during phototherapy, and assess skin/sclera color.

Question 83: The nurse is caring for a patient after a right-sided stroke. Where should the nurse expect motor deficits?

Left side of the body (Correct answer)
Both sides equally
Right side of the body
Face only

Correct answer: Left side of the body

The brain controls the contralateral (opposite) side of the body due to decussation of motor fibers in the medulla. A right-sided stroke causes left-sided (contralateral) hemiplegia or hemiparesis.

Question 84: A 32-year-old primigravida at 36 weeks gestation in a Saudi hospital is diagnosed with HELLP syndrome. Her lab results show: platelets 68,000/μL, LDH 820 U/L, AST 112 U/L, and serum creatinine 1.4 mg/dL. The physician plans delivery. Which nursing intervention takes HIGHEST priority in the immediate predelivery period?

Administer IV magnesium sulfate 4–6 g loading dose over 15–20 minutes to prevent seizures (Correct answer)
Obtain crossmatch for 4 units packed red blood cells and have FFP readily available
Position the patient in left lateral decubitus and apply continuous fetal monitoring
Insert a Foley catheter and begin strict hourly urine output monitoring targeting ≥30 mL/hr

Correct answer: Administer IV magnesium sulfate 4–6 g loading dose over 15–20 minutes to prevent seizures

In HELLP syndrome, the risk of eclamptic seizures is significant and magnesium sulfate is the first-line prophylactic agent per SCFHS/MOH obstetric protocols. A loading dose of 4–6 g IV over 15–20 minutes followed by a maintenance infusion is administered prior to delivery. While urine output monitoring, blood product preparation, and fetal positioning are all important concurrent measures, seizure prophylaxis with MgSO4 is the highest-priority nursing action because an uncontrolled seizure can precipitate abruption, fetal distress, and maternal hemorrhage.

Question 85: A 44-year-old female patient post-liver transplant at King Faisal Specialist Hospital is on tacrolimus, mycophenolate, and methylprednisolone. On day 7, she develops: temperature 39.2°C, new-onset confusion, right-sided weakness, and a CD4 count of 68 cells/µL. MRI brain shows ring-enhancing lesions with surrounding edema in the basal ganglia. Which opportunistic infection is MOST likely and requires immediate isolation precautions per Saudi infection control guidelines?

Progressive multifocal leukoencephalopathy (PML) — airborne isolation required
Cryptococcus neoformans meningoencephalitis — place in negative pressure room
Toxoplasma gondii encephalitis — no special isolation beyond standard precautions (Correct answer)
CMV encephalitis — initiate contact-plus precautions

Correct answer: Toxoplasma gondii encephalitis — no special isolation beyond standard precautions

Ring-enhancing lesions in the basal ganglia of a severely immunocompromised post-transplant patient (CD4 68) are classic for Toxoplasma gondii encephalitis. Toxoplasmosis is not transmitted person-to-person in immunocompetent contacts; it requires reactivation of latent T. gondii. Therefore, per Saudi MOH and CDC infection control guidelines, standard precautions are sufficient — no special isolation is needed. Cryptococcus presents with meningeal signs and CSF findings, not ring-enhancing lesions, and does not require negative pressure isolation. CMV encephalitis is rare and would not show ring-enhancing lesions; contact-plus is not the standard. PML (JC virus) also does not require airborne isolation and typically shows non-enhancing white matter lesions.

Question 86: A patient with major depressive disorder is started on fluoxetine. What must the nurse monitor for in the first 2 weeks?

Increased risk of suicidal ideation, especially in patients under 25 (Correct answer)
Agranulocytosis and bone marrow suppression
Serotonin syndrome from the first dose
Severe hypertension and tachycardia

Correct answer: Increased risk of suicidal ideation, especially in patients under 25

SSRIs, including fluoxetine, carry a black-box warning for increased suicidal thoughts particularly in children, adolescents, and young adults (under 25) during the first few weeks of treatment. Close monitoring for mood changes and emergent suicidality is essential.

Question 87: A nurse is performing wound care for a patient with a Stage III pressure injury over the sacrum. The wound bed shows 70% yellow slough and 30% granulation tissue. There is no clinical sign of infection. The physician orders wet-to-dry dressing changes three times daily. Based on current evidence-based wound care principles aligned with Saudi SCFHS competency standards, what should the nurse do?

Proceed with wet-to-dry dressings as ordered because mechanical debridement is the gold standard for slough removal in Stage III injuries
Apply wet-to-dry dressings but soak the gauze in povidone-iodine to reduce biofilm formation
Clarify the order with the physician and advocate for moist wound healing dressings such as hydrocolloid or foam, as wet-to-dry dressings are non-selective and damage granulation tissue (Correct answer)
Perform sharp debridement at the bedside before applying the wet-to-dry dressing to accelerate healing

Correct answer: Clarify the order with the physician and advocate for moist wound healing dressings such as hydrocolloid or foam, as wet-to-dry dressings are non-selective and damage granulation tissue

Evidence-based practice — endorsed by SCFHS and aligned with international wound care guidelines adopted in Saudi MOH facilities — indicates that wet-to-dry dressings are non-selective debridement methods that remove viable granulation tissue along with slough, causing pain and impairing healing. For Stage III pressure injuries with slough, moist wound healing using autolytic debridement agents (hydrocolloid, foam, or alginate dressings) is preferred. The nurse has both a professional and ethical obligation under SCFHS Code of Ethics to advocate for evidence-based care and clarify orders that may cause patient harm. Povidone-iodine is cytotoxic to granulation tissue; bedside sharp debridement requires specific credentialing beyond standard nursing scope.

Question 88: A 44-year-old female patient in a SCFHS-accredited ICU is receiving continuous renal replacement therapy (CRRT) for acute kidney injury secondary to septic shock. Her ionized calcium is 0.88 mmol/L (normal 1.15–1.35 mmol/L). She is on regional citrate anticoagulation for the CRRT circuit. Which finding would indicate systemic citrate toxicity rather than simple hypocalcemia from the sepsis itself?

QTc prolongation greater than 500 ms on ECG
Chvostek's sign and carpopedal spasm
Ionized calcium less than 1.0 mmol/L with normal total calcium
Total calcium to ionized calcium ratio greater than 2.5 with metabolic alkalosis (Correct answer)

Correct answer: Total calcium to ionized calcium ratio greater than 2.5 with metabolic alkalosis

Systemic citrate toxicity occurs when the liver cannot metabolize citrate rapidly enough (e.g., in severe hepatic dysfunction), leading to citrate accumulation. Citrate chelates calcium, so both total and ionized calcium fall. The hallmark finding is a total calcium to ionized calcium ratio >2.5 (or sometimes cited as >2.1), because total calcium (which includes calcium bound to citrate complexes) rises relative to free ionized calcium. This ratio, combined with metabolic alkalosis (citrate is metabolized to bicarbonate), distinguishes systemic citrate accumulation from simple hypocalcemia. Options B, C, and D represent general hypocalcemia signs that could occur from any cause, not specifically citrate toxicity.

Question 89: The nurse is educating a patient with peptic ulcer disease about diet. Which food should the patient avoid?

Bananas
Coffee and alcohol (Correct answer)
Cooked vegetables
Low-fat milk

Correct answer: Coffee and alcohol

Coffee (even decaffeinated) and alcohol stimulate gastric acid secretion and damage the gastric mucosal barrier, worsening peptic ulcer disease. Patients should avoid these along with spicy foods, NSAIDs, and smoking.

Question 90: A patient with paranoid schizophrenia refuses to eat, stating 'the food is poisoned.' Which nursing intervention is most appropriate?

Offer sealed, commercially packaged food the patient can open themselves (Correct answer)
Skip meals until the patient consents to eat normally
Force the patient to eat using the nasogastric route
Assure the patient the food is safe and insist they eat

Correct answer: Offer sealed, commercially packaged food the patient can open themselves

Offering sealed, unopened commercially packaged food allows the patient with paranoid delusions to verify the food has not been tampered with, thereby improving safety and nutritional intake. This respects the patient's paranoid belief while meeting a physiological need.

Question 91: A ward manager wants to improve hand hygiene compliance from 55% to the WHO target. Which quality improvement model is most commonly applied in Saudi MOH hospitals for such initiatives?

PDCA (Plan-Do-Check-Act) cycle (Correct answer)
SWOT Analysis
Root Cause Analysis (RCA)
FMEA (Failure Mode and Effects Analysis)

Correct answer: PDCA (Plan-Do-Check-Act) cycle

The PDCA (Plan-Do-Check-Act) cycle is the standard continuous quality improvement model used in Saudi MOH hospitals for process improvement initiatives such as hand hygiene campaigns. FMEA and RCA are used reactively to analyze potential or actual failures, while SWOT is a strategic planning tool, not a QI cycle.

Question 92: The nurse is caring for a patient with cirrhosis who develops asterixis (liver flap). This finding indicates:

Spontaneous bacterial peritonitis
Bleeding esophageal varices
Hepatic encephalopathy (Correct answer)
Hepatorenal syndrome

Correct answer: Hepatic encephalopathy

Asterixis (flapping tremor of the hands) is a classic sign of hepatic encephalopathy caused by accumulation of ammonia and other toxins that the failing liver cannot clear. It indicates significant neurological impairment from hepatocellular failure.

Question 93: The nurse is assessing an isolation room for a patient with chickenpox (varicella). The room must have:

Negative pressure with at least 6–12 air changes per hour and exhaust to outside or HEPA filtration (Correct answer)
Any available private room with the door closed
Standard pressure with door kept open
Positive pressure to protect the immunocompromised patient

Correct answer: Negative pressure with at least 6–12 air changes per hour and exhaust to outside or HEPA filtration

Varicella (chickenpox) is an airborne infection transmitted via airborne droplet nuclei. Airborne precautions require a negative-pressure isolation room with at least 6–12 air changes per hour and exhaust vented directly outside or through HEPA filtration to prevent recirculation.

Question 94: A patient is receiving IV insulin infusion for DKA. The blood glucose is now 250 mg/dL and the protocol states: 'When glucose reaches 250 mg/dL, add dextrose to IV fluids.' Why is dextrose added at this point?

To prevent hypoglycemia while continuing insulin to close the anion gap (Correct answer)
To provide calories for energy metabolism only
To increase the blood glucose back to 300 mg/dL
To stop insulin therapy immediately

Correct answer: To prevent hypoglycemia while continuing insulin to close the anion gap

In DKA management, insulin must continue until the anion gap closes and acidosis resolves (not just until glucose normalizes). Dextrose is added to prevent hypoglycemia while continuing insulin to complete acidosis correction — the glucose normalizes before the ketosis resolves.

Question 95: The nurse is assessing skin turgor. Where is the best site to assess skin turgor in an adult?

Forehead
Abdomen
Forearm or sternum (Correct answer)
Back of the hand

Correct answer: Forearm or sternum

In adults, skin turgor is best assessed on the forearm or sternum because the skin in these areas is less affected by aging. The back of the hand is less reliable in elderly patients due to normal age-related skin changes.

Question 96: A patient is placed on contact precautions. Which personal protective equipment (PPE) is required upon entering the room?

Gloves and gown (Correct answer)
Mask and gloves
Gown and mask
N95 respirator and gloves

Correct answer: Gloves and gown

Contact precautions require gloves and a gown to be worn when entering the patient's room, as they prevent transmission of pathogens through direct or indirect contact with the patient or their environment.

Question 97: A nurse is preparing a Saudi patient with bipolar I disorder and stage 3 chronic kidney disease (CKD) for discharge on a mood stabilizer regimen. The psychiatrist has prescribed lithium. Which nursing action reflects the HIGHEST level of patient safety advocacy in this specific clinical context?

Administer the prescribed lithium and document the prescription as ordered
Immediately clarify the prescription with the psychiatrist and flag the renal contraindication, recommending consideration of valproate or lamotrigine (Correct answer)
Substitute lithium with an atypical antipsychotic without notifying the psychiatrist
Educate the patient on lithium toxicity signs and schedule monthly lithium levels

Correct answer: Immediately clarify the prescription with the psychiatrist and flag the renal contraindication, recommending consideration of valproate or lamotrigine

Lithium is primarily renally excreted and is relatively contraindicated in stage 3+ CKD due to the high risk of accumulation and toxicity. The nurse's highest advocacy role is to proactively flag this pharmacological risk to the prescribing psychiatrist before the medication is dispensed—not after. While lithium can occasionally be used with extreme caution and adjusted dosing in mild-moderate CKD under specialist oversight, the nurse must initiate the safety conversation. Alternatives such as valproate (with liver monitoring) or lamotrigine are commonly preferred in renal impairment. Substituting medications independently without physician order would exceed the nurse's scope of practice.

Question 98: A nurse is documenting patient care. Which entry is most appropriate?

Patient appears to be in pain. Treated accordingly.
Patient states 'I have pain in my left knee.' Pain rated 6/10. Ice pack applied. (Correct answer)
Left knee pain treated per standard protocol.
Patient complained about knee. Nurse took appropriate action.

Correct answer: Patient states 'I have pain in my left knee.' Pain rated 6/10. Ice pack applied.

Good nursing documentation uses objective, specific language, includes direct patient quotes, and describes exactly what was done. Vague entries like 'treated accordingly' do not meet documentation standards.

Question 99: A Saudi mother brings her 6-week-old male infant to the emergency department. She reports the baby has had forceful, non-bilious projectile vomiting after every feed for the past 5 days and now appears lethargic with dry mucous membranes. Blood gas shows pH 7.51, HCO₃ 34 mEq/L, pCO₂ 48 mmHg, and serum Cl⁻ 88 mEq/L. Which metabolic disturbance is present, and what is the underlying surgical condition?

Metabolic acidosis with hyperchloremia due to Hirschsprung disease
Metabolic alkalosis with hypochloremia due to hypertrophic pyloric stenosis (Correct answer)
Mixed alkalosis due to gastroesophageal reflux disease with vagal hypertonicity
Respiratory alkalosis with compensatory metabolic acidosis due to intestinal malrotation

Correct answer: Metabolic alkalosis with hypochloremia due to hypertrophic pyloric stenosis

The classic metabolic picture of hypertrophic pyloric stenosis (HPS) is hypochloremic, hypokalemic metabolic alkalosis caused by loss of HCl through repeated vomiting. The blood gas confirms metabolic alkalosis (pH 7.51, elevated HCO₃ 34 mEq/L) with respiratory compensation (elevated pCO₂). Low Cl⁻ (88 mEq/L, normal 98–106) confirms hypochloremia. HPS typically presents at 3–6 weeks in first-born males with projectile non-bilious vomiting. The Ramstedt pyloromyotomy is the definitive surgical treatment, after metabolic correction and fluid resuscitation.

Question 100: A patient is diagnosed with acute respiratory distress syndrome (ARDS). Which ventilator strategy is supported by the strongest evidence?

Non-invasive BiPAP ventilation as sole support
High tidal volumes (12–15 mL/kg) to maximize alveolar recruitment
High FiO2 (100%) without PEEP to avoid barotrauma
Low tidal volume ventilation (6 mL/kg ideal body weight) with appropriate PEEP (Correct answer)

Correct answer: Low tidal volume ventilation (6 mL/kg ideal body weight) with appropriate PEEP

Lung-protective ventilation using low tidal volumes (6 mL/kg ideal body weight) with PEEP is the evidence-based strategy for ARDS, reducing ventilator-induced lung injury.

Question 101: A nurse administers IV magnesium sulfate 4g over 20 minutes as a loading dose to a preeclamptic patient in a Saudi maternity hospital. Thirty minutes later, the patient's respiratory rate is 10 breaths/min, deep tendon reflexes are absent, and urine output is 15 mL over the past hour. What is the nurse's PRIORITY intervention, in the correct sequence?

Stop the MgSO₄ infusion → administer oxygen → prepare calcium chloride 1g IV for immediate administration
Reduce the MgSO₄ infusion rate by 50% → increase IV fluid rate → recheck reflexes in 30 minutes
Administer calcium gluconate 1g IV push immediately, then stop the infusion and notify the physician
Stop the MgSO₄ infusion → call the physician → prepare calcium gluconate 1g IV for immediate administration (Correct answer)

Correct answer: Stop the MgSO₄ infusion → call the physician → prepare calcium gluconate 1g IV for immediate administration

The clinical picture — RR <12, absent DTRs, and oliguria — represents magnesium toxicity. The correct sequence per Saudi MOH obstetric emergency protocols is: (1) STOP the magnesium infusion immediately; (2) notify the physician urgently; (3) prepare calcium gluconate 1g (10 mL of 10% solution) IV for administration as directed by the physician. Calcium gluconate — NOT calcium chloride — is the preferred antidote in obstetrics because calcium chloride is caustic if it extravasates and is reserved for cardiac arrest contexts. Administering the antidote before physician notification or before stopping the causative agent violates the correct management sequence. Merely reducing the infusion rate is inadequate for overt toxicity.

Question 102: During handover in a Saudi tertiary hospital using the SBAR communication tool, a night nurse reports a patient has a urine output of 25 mL/hour for the past 3 hours. The patient weighs 80 kg and received 500 mL IV bolus 2 hours ago without improvement. Which component of the SBAR should include the nurse's clinical judgment that this likely represents oliguria requiring urgent medical review?

Recommendation (R) — because the nurse is proposing a course of action for the physician
Assessment (A) — because this is the nurse's interpretation and clinical synthesis of the data (Correct answer)
Background (B) — because the IV bolus response contextualizes the degree of compromise
Situation (S) — because it is the immediate clinical problem being reported

Correct answer: Assessment (A) — because this is the nurse's interpretation and clinical synthesis of the data

In the SBAR framework: Situation = the current presenting problem (e.g., 'patient has low urine output'); Background = relevant history and context (e.g., the IV bolus given without improvement); Assessment = the nurse's clinical interpretation and synthesis — 'I believe this represents oliguria and potentially developing acute kidney injury'; Recommendation = the specific action requested (e.g., 'Please review the patient and consider urinalysis and nephrology consult'). Clinical judgment — the interpretation of what the data means — belongs in Assessment. Confusion between Assessment and Recommendation is a common error; Assessment is 'what I think is happening,' Recommendation is 'what I think should be done.'

Question 103: A patient on warfarin therapy is admitted to a Saudi hospital with an INR of 8.2 and active bleeding. According to SCFHS nursing standards, which intervention takes priority?

Apply direct pressure only and monitor INR hourly
Administer protamine sulfate IV immediately
Administer vitamin K 10 mg IV slowly and prepare fresh frozen plasma (Correct answer)
Hold the next warfarin dose and repeat INR in 24 hours

Correct answer: Administer vitamin K 10 mg IV slowly and prepare fresh frozen plasma

An INR of 8.2 with active bleeding is a pharmacological emergency. The priority is reversal of anticoagulation using IV vitamin K (which takes 6–12 hours to act) combined with fresh frozen plasma (FFP) for immediate factor replacement. Protamine sulfate reverses heparin, NOT warfarin. Simply withholding the dose is insufficient in the presence of active bleeding.

Question 104: What is the purpose of a nursing care plan?

To document billing information for insurance
To record physician orders for nursing staff
To schedule nursing staff assignments
To provide a individualized, coordinated plan of care based on patient needs (Correct answer)

Correct answer: To provide a individualized, coordinated plan of care based on patient needs

A nursing care plan provides an individualized, structured approach to patient care, outlining nursing diagnoses, expected outcomes, and specific interventions tailored to each patient's needs and goals.

Question 105: During a psychiatric home visit supervised by a Saudi community mental health team, a patient with bipolar I disorder on lithium carbonate 900 mg/day reports tremors, polyuria, and mild confusion. His serum lithium level drawn 12 hours post-dose is 1.6 mEq/L. Which nursing intervention is the PRIORITY?

Administer the next lithium dose as scheduled and notify the psychiatrist at the next clinic visit
Encourage oral fluid intake of 3 liters per day and reassess in 24 hours
Withhold the next lithium dose immediately and arrange urgent transfer to an emergency department (Correct answer)
Reduce the lithium dose by half and recheck serum level after 5 days

Correct answer: Withhold the next lithium dose immediately and arrange urgent transfer to an emergency department

A lithium level of 1.6 mEq/L combined with neurological symptoms (confusion, tremor) and renal symptoms (polyuria) represents early-to-moderate lithium toxicity. The therapeutic range is 0.6–1.2 mEq/L for maintenance. At this level with symptom burden, the priority is to withhold the dose immediately and transfer the patient urgently for IV fluids, cardiac monitoring, and possible hemodialysis if levels rise. Encouraging oral fluids alone is insufficient for a symptomatic patient at this level. Continuing the dose is dangerous. Independently halving the dose without medical assessment is outside nursing scope.

Question 106: A community health nurse in Saudi Arabia is calculating the attack rate during a suspected foodborne outbreak at a wedding celebration. Of 240 guests who attended, 180 ate the kabsa dish, and 60 did not. Among those who ate kabsa, 72 developed gastroenteritis. Among those who did not eat kabsa, 6 developed gastroenteritis. What is the food-specific attack rate for kabsa?

30%
32.5%
40% (Correct answer)
10%

Correct answer: 40%

The food-specific attack rate is calculated as (number ill among those who ate the food ÷ total who ate the food) × 100. Here: 72 ÷ 180 × 100 = 40%. This is distinct from the overall attack rate (78/240 = 32.5%) or the rate among non-exposed (6/60 = 10%). The food-specific attack rate is used in outbreak investigations to implicate specific food vehicles.

Question 107: During the second stage of labor, a multigravida patient's cardiotocograph (CTG) shows a baseline fetal heart rate of 155 bpm, absence of accelerations for 50 minutes, late decelerations with every contraction, and reduced baseline variability of 3 bpm. The cervix is fully dilated and the fetal head is at +2 station. The attending physician is in another delivery. What is the CORRECT sequence of nursing actions per Saudi MOH obstetric emergency protocols?

Perform an amnioinfusion to dilute meconium and relieve cord compression before escalating
Position patient in left lateral, apply high-flow oxygen via face mask, discontinue oxytocin if infusing, insert IV access, call the obstetrician STAT and activate the emergency response team (Correct answer)
Continue monitoring and document findings; late decelerations in the second stage are expected and do not require intervention until delivery is complete
Encourage the patient to push with the next contraction to expedite delivery, then reassess CTG

Correct answer: Position patient in left lateral, apply high-flow oxygen via face mask, discontinue oxytocin if infusing, insert IV access, call the obstetrician STAT and activate the emergency response team

This CTG shows a Category III (non-reassuring/ominous) pattern: late decelerations (uteroplacental insufficiency), absent accelerations, and minimal variability — indicating fetal hypoxia requiring immediate intervention. The nurse's emergency sequence follows the ABCDE obstetric emergency framework: (1) Left lateral position to relieve aortocaval compression, (2) high-flow O₂ to maximize maternal oxygenation, (3) discontinue oxytocin to reduce uterine hyperstimulation, (4) IV access for emergency medications, (5) immediate physician notification and team activation. Pushing with decelerations worsens fetal hypoxia. Amnioinfusion is not a first-line emergency measure. Late decelerations at any stage are never 'expected.'

Question 108: A nurse in a Saudi MOH hospital is managing a patient with diabetic ketoacidosis (DKA). The patient's serum potassium on admission is 5.8 mEq/L. After 3 hours of IV insulin infusion at 0.1 units/kg/hr and normal saline resuscitation, the repeat potassium level is 3.2 mEq/L. Blood glucose has decreased from 28 mmol/L to 14 mmol/L. Which action is MOST appropriate at this point?

Continue the insulin infusion and add IV potassium chloride replacement to the fluid (Correct answer)
Stop the insulin infusion immediately until potassium normalizes above 3.5 mEq/L
Switch IV fluid from normal saline to 5% dextrose in 0.45% saline and continue insulin
Reduce the insulin infusion rate to 0.05 units/kg/hr only and hold potassium replacement

Correct answer: Continue the insulin infusion and add IV potassium chloride replacement to the fluid

At a serum K⁺ of 3.2 mEq/L, the protocol requires continuing insulin (to resolve ketoacidosis) while initiating potassium replacement — typically 20–40 mEq/hr IV KCl. Insulin must NOT be stopped unless K⁺ falls below 3.0 mEq/L (per Saudi/international DKA protocols). Switching to dextrose-containing fluid is indicated when glucose approaches 11 mmol/L (250 mg/dL) to prevent hypoglycemia but does not address the hypokalemia. Simply reducing the insulin rate without replacing potassium would allow ketoacidosis to persist while hypokalemia remains uncorrected.

Question 109: The nurse is reviewing reportable diseases in Saudi Arabia. Tuberculosis, cholera, and measles are examples of which category?

Notifiable communicable diseases requiring mandatory reporting to MOH (Correct answer)
Non-communicable diseases with special reporting requirements
Diseases requiring treatment authorization only
Occupational diseases requiring employer notification

Correct answer: Notifiable communicable diseases requiring mandatory reporting to MOH

Saudi Arabia's MOH requires mandatory reporting of notifiable communicable diseases including TB, cholera, measles, meningitis, and others. Reporting enables surveillance, outbreak detection, and control measures. Non-compliance is a regulatory violation.

Question 110: In a Saudi NICU, a 26-week preterm neonate (weight 780 g) on high-frequency oscillatory ventilation (HFOV) develops sudden oxygen desaturation from 95% to 65%, bradycardia (HR 82 bpm), and absent chest wiggle on the right side. Which diagnosis must be ruled out FIRST?

Intraventricular hemorrhage grade III
Endotracheal tube migration into the right mainstem bronchus
Right-sided tension pneumothorax (Correct answer)
Pulmonary hemorrhage

Correct answer: Right-sided tension pneumothorax

In a preterm neonate on HFOV, sudden deterioration with absent chest wiggle on one side (not absent breath sounds — wiggle is the HFOV-equivalent assessment sign), desaturation, and bradycardia is tension pneumothorax until proven otherwise. This is a life-threatening emergency requiring immediate needle decompression (2nd ICS, midclavicular line) without waiting for X-ray confirmation. ETT migration causes unilateral hyperinflation/decreased movement on the contralateral side and is managed differently. Pulmonary hemorrhage presents with blood-tinged secretions. IVH does not acutely affect ventilation parameters in this pattern.

Question 111: The nurse is preparing to administer IV amiodarone 150 mg over 10 minutes for acute ventricular tachycardia. Available: 450 mg in 9 mL (50 mg/mL). How many mL are needed for 150 mg?

6 mL
3 mL (Correct answer)
1.5 mL
9 mL

Correct answer: 3 mL

Volume = dose / concentration = 150 mg / 50 mg/mL = 3 mL. The drug is then diluted in D5W (amiodarone requires D5W, not saline) and administered via a filtered infusion set over 10 minutes.

Question 112: A nurse is preparing to administer heparin 5,000 units subcutaneously. The available vial contains 10,000 units/mL. How many mL should be administered?

2 mL
0.25 mL
0.5 mL (Correct answer)
1 mL

Correct answer: 0.5 mL

Volume = desired dose / available concentration = 5,000 units / 10,000 units per mL = 0.5 mL. This is a standard dosage calculation using the ratio method or the formula D/H × V.

Question 113: Which medication used to treat hypertension is classified as a calcium channel blocker and primarily affects cardiac conduction?

Nifedipine
Verapamil (Correct answer)
Hydralazine
Amlodipine

Correct answer: Verapamil

Verapamil is a non-dihydropyridine calcium channel blocker that slows SA node automaticity and AV conduction, making it useful for rate control.

Question 114: Following a wrong-site surgery at a JCI-accredited Saudi hospital, the patient safety officer initiates a Root Cause Analysis (RCA). According to JCI standards — the accreditation framework governing most Saudi tertiary facilities — within what maximum timeframe must the completed RCA be submitted to hospital leadership?

45 calendar days (Correct answer)
7 calendar days
90 calendar days
24 hours after the sentinel event is identified

Correct answer: 45 calendar days

JCI standards, which govern the majority of accredited Saudi hospitals, require that a Root Cause Analysis be completed and submitted to hospital leadership within 45 calendar days of a sentinel event being identified. Wrong-site surgery is a classic Never Event/Sentinel Event triggering mandatory RCA. The 24-hour window applies to initial incident reporting, not RCA completion; 90 days is outside JCI requirements.

Question 115: Under Saudi MOH's National IPC Program, a hospital's infection control committee reviews a cluster of three postoperative wound infections caused by the same MRSA strain within 72 hours. According to mandatory HAI surveillance reporting requirements, which action must occur FIRST?

Escalate to the Saudi Center for Disease Prevention and Control (Weqaytna/CDC-SA) within 48 hours while completing internal investigation
Complete internal root cause analysis before any external reporting to avoid premature disclosure
Notify the National IPC Department electronically through the Infection Reporting System (IRS) within 24 hours
Notify the regional MOH directorate within 24 hours and activate an outbreak investigation team (Correct answer)

Correct answer: Notify the regional MOH directorate within 24 hours and activate an outbreak investigation team

Saudi MOH mandates that a surgical site infection (SSI) cluster of ≥2 epidemiologically linked cases triggers immediate outbreak declaration and notification to the regional MOH Health Directorate within 24 hours, simultaneously activating an internal outbreak investigation team. While the Saudi CDC (previously called SCDC, now operating under the Public Health Authority) may be involved, the first mandatory reporting channel is the regional directorate. Internal root cause analysis runs in parallel, not as a prerequisite to reporting.

Question 116: Which antibiotic class is associated with photosensitivity and should be accompanied by sun-avoidance counseling?

Macrolides
Cephalosporins
Penicillins
Tetracyclines (Correct answer)

Correct answer: Tetracyclines

Tetracyclines (e.g., doxycycline) cause photosensitivity reactions; patients must avoid prolonged sun exposure and use sunscreen.

Question 117: A school nurse notes an outbreak of head lice (pediculosis capitis) in an elementary school. Which public health measure is most evidence-based?

Send all children home until all cases are treated
Screen all children daily for 4 weeks
Fumigate the school
Treat affected children with pediculicide; no-nit policies are not recommended (Correct answer)

Correct answer: Treat affected children with pediculicide; no-nit policies are not recommended

Current evidence-based guidelines (CDC, AAP) recommend treating affected children with pediculicide shampoo and do NOT support 'no-nit' policies (sending children home for nit presence), as nits alone do not indicate active infestation and cause unnecessary school absence.

Question 118: The nurse assesses a patient and finds pitting edema in both ankles rated 3+. What does this finding indicate?

The indentation is 1–2 mm deep and rebounds quickly
The indentation persists for more than 1 minute and is 5–6 mm deep (Correct answer)
The indentation disappears immediately
The indentation is >8 mm and does not rebound

Correct answer: The indentation persists for more than 1 minute and is 5–6 mm deep

Pitting edema is graded 1+ to 4+. 3+ edema produces a 5–6 mm pit that persists for more than 1 minute. 4+ edema produces an indentation >8 mm that does not rebound. This grading system helps track fluid overload.

Question 119: What are the developmental milestones a nurse should assess in a 6-month-old infant?

Speaking in sentences
Sitting with support, reaching and grasping objects, babbling, responding to name, and rolling over (Correct answer)
Walking independently
Running and jumping

Correct answer: Sitting with support, reaching and grasping objects, babbling, responding to name, and rolling over

At 6 months, infants should: sit with support (may sit briefly alone), reach and grasp objects (transferring hand to hand), babble consonant sounds ('ba-ba'), recognize familiar faces, respond to name, roll both ways, and show interest in solid foods.

Question 120: When performing nasopharyngeal suctioning, the nurse should apply suction:

Continuously throughout insertion and withdrawal
Before inserting the catheter
Only during insertion of the catheter
Only while withdrawing the catheter (Correct answer)

Correct answer: Only while withdrawing the catheter

Suction should only be applied while withdrawing the catheter to minimize mucosal trauma and hypoxia. Applying suction during insertion causes unnecessary tissue damage and depletes oxygen.

Question 121: A nurse working in a Saudi MOH general hospital is assigned to care for a patient under transmission-based contact precautions for carbapenem-resistant Enterobacteriaceae (CRE). The nurse must perform a head-to-toe assessment and wound dressing. Applying the correct donning sequence for PPE and considering SCFHS infection control standards, which order is correct?

Mask/respirator → gown → goggles/face shield → gloves
Gown → gloves → mask/respirator → goggles/face shield
Gown → mask/respirator → goggles/face shield → gloves (Correct answer)
Gloves → gown → mask/respirator → goggles/face shield

Correct answer: Gown → mask/respirator → goggles/face shield → gloves

The WHO and CDC donning sequence — adopted by SCFHS infection control guidelines — is: (1) Gown first, to protect clothing and skin; (2) Mask or respirator, to protect mucous membranes of the mouth and nose; (3) Goggles or face shield, to protect eyes (placed over the mask); (4) Gloves last, extending over the gown cuffs. Gloves are donned last because they are the outermost barrier and must cover the gown cuffs to prevent contamination of exposed wrists. For CRE (contact precautions), a surgical mask is sufficient (not an N95), unless aerosol-generating procedures are performed. Donning gloves before the gown leaves wrist skin exposed during gown tying.

Question 122: A 67-year-old male admitted to a Saudi MOH ICU following a massive ischemic stroke develops fever (39.8°C), hypertension (BP 195/110 mmHg), bradycardia (HR 44 bpm), and irregular respirations. CT head shows significant cerebral edema with midline shift of 8 mm. Intracranial pressure (ICP) monitoring shows ICP 32 mmHg and cerebral perfusion pressure (CPP) of 55 mmHg. Per SCFHS neurocritical care guidelines, which intervention should be PRIORITIZED FIRST?

Perform immediate decompressive hemicraniectomy
Administer 23.4% hypertonic saline 30 mL IV bolus to acutely lower ICP (Correct answer)
Start labetalol IV infusion to lower MAP to less than 120 mmHg
Initiate therapeutic hypothermia to 33°C to reduce cerebral metabolic demand

Correct answer: Administer 23.4% hypertonic saline 30 mL IV bolus to acutely lower ICP

The patient has Cushing's triad (hypertension, bradycardia, irregular respirations) indicating critically elevated ICP with impending herniation, and ICP of 32 mmHg with CPP of only 55 mmHg (target is ≥60 mmHg). The immediate priority is to acutely reduce ICP. In refractory or acute ICP crisis, 23.4% hypertonic saline (30 mL bolus) provides rapid osmotic reduction of cerebral edema and is the most potent acute pharmacological ICP-lowering agent, superior to mannitol in this context. Therapeutic hypothermia (option B) is not first-line for ischemic stroke. Lowering MAP with labetalol (option C) would dangerously reduce CPP further (CPP = MAP − ICP). Hemicraniectomy (option D) is a surgical option but not the immediate first priority before medical management is maximized.

Question 123: A nurse working in a Saudi primary healthcare center is conducting a well-child visit for a 15-month-old child. The mother reports the child has not yet started walking and uses only 2-3 words. According to the Saudi Child Health and Development Surveillance Program (Seha), which response is MOST appropriate?

Reassure the mother that gross motor and language development vary widely up to 18 months
Document the findings and schedule a repeat surveillance visit at 18 months
Administer the Ages and Stages Questionnaire (ASQ) and refer only if the score is below the cutoff
Refer the child immediately to a developmental pediatrician for formal evaluation (Correct answer)

Correct answer: Refer the child immediately to a developmental pediatrician for formal evaluation

At 15 months, a child is expected to walk independently (milestone: 12–15 months) and use at least 3 meaningful words. Failing both gross motor and language milestones simultaneously is a significant developmental red flag. Saudi MOH and the Seha Child Development Program mandate immediate referral when two or more developmental domains are delayed at any surveillance visit, rather than watchful waiting until the next scheduled review.

Question 124: A neonate born at 34 weeks gestation is at highest risk for which complication related to surfactant deficiency?

Meconium aspiration syndrome
Transient tachypnea of the newborn
Respiratory distress syndrome (Correct answer)
Bronchopulmonary dysplasia

Correct answer: Respiratory distress syndrome

Surfactant deficiency in preterm infants leads to alveolar collapse and respiratory distress syndrome (RDS), most common in infants born before 36 weeks.

Question 125: The public health nurse is interpreting a sensitivity of 95% for a screening test. What does this mean?

The test has a 5% false positive rate
95% of people with the disease will test positive (true positive rate) (Correct answer)
95% of positive tests are truly positive
95% of people without the disease will test negative

Correct answer: 95% of people with the disease will test positive (true positive rate)

Sensitivity = true positives / (true positives + false negatives). A sensitivity of 95% means the test correctly identifies 95% of people who truly have the disease. High sensitivity = low false negative rate, making it good for ruling out disease (negative result = unlikely to have disease).

Question 126: A nurse is reviewing lab results for a pregnant woman at 28 weeks. Her serum ferritin is 8 ng/mL and hemoglobin is 9.5 g/dL. What should the nurse anticipate ordering?

IV iron infusion immediately
Blood transfusion
Oral iron supplementation and dietary iron counseling (Correct answer)
Vitamin B12 injections

Correct answer: Oral iron supplementation and dietary iron counseling

Low ferritin (depleted iron stores) and low hemoglobin indicate iron deficiency anemia in pregnancy. First-line treatment is oral iron supplementation (elemental iron 150–200 mg/day in divided doses) with dietary counseling. IV iron is reserved for cases of intolerance or non-response to oral therapy.

Question 127: A postpartum woman on day 3 develops a temperature of 38.5°C with uterine tenderness and foul-smelling lochia. The priority nursing action is to:

Encourage fluid intake and rest
Obtain a urinalysis before taking any action
Apply a warm compress to the abdomen
Notify the physician and administer prescribed antibiotics (Correct answer)

Correct answer: Notify the physician and administer prescribed antibiotics

Signs of endometritis (fever, uterine tenderness, foul lochia) require prompt notification of the physician and initiation of antibiotic therapy to prevent sepsis.

Question 128: Which layer of the skin contains the sebaceous glands and hair follicles?

Dermis (Correct answer)
Subcutaneous layer
Hypodermis
Epidermis

Correct answer: Dermis

The dermis is the second layer of skin and contains sebaceous (oil) glands, hair follicles, sweat glands, nerves, and blood vessels. It provides structural support and nourishment to the skin.

Question 129: A community health nurse is working with a low-income population with high rates of hypertension. According to the social determinants of health framework, which intervention addresses upstream factors?

Providing free blood pressure checks at community events
Advocating for affordable healthy food access and safe exercise spaces (Correct answer)
Educating patients about the DASH diet
Teaching patients how to take blood pressure medications

Correct answer: Advocating for affordable healthy food access and safe exercise spaces

Social determinants of health (SDH) are upstream factors — the conditions in which people live, work, and play. Addressing structural barriers (food insecurity, built environment, poverty) through advocacy is more impactful at the population level than individual-level education.

Question 130: A patient with a chest tube is being transported. Which action is correct?

Clamp the chest tube during transport
Disconnect the chest tube from the drainage system
Keep the drainage system below the level of the chest at all times (Correct answer)
Place the drainage system on the patient's lap

Correct answer: Keep the drainage system below the level of the chest at all times

The chest tube drainage system must always remain below the level of the chest to allow gravity drainage and prevent fluid from draining back into the pleural space. Clamping is only done per specific orders and briefly.

Question 131: The nurse is implementing a health promotion program based on the Health Belief Model. Which component of this model most strongly predicts whether an individual will take preventive action?

Perceived susceptibility to disease
Perceived severity of disease
Cues to action
Perceived barriers to taking action (Correct answer)

Correct answer: Perceived barriers to taking action

Research on the Health Belief Model shows perceived barriers are the strongest predictor of non-action — if the person perceives too many obstacles (cost, inconvenience, fear), they are unlikely to act regardless of how susceptible or severe they believe the disease to be.

Question 132: A nurse is caring for a patient who discloses suicidal ideation. Which action takes HIGHEST priority?

Document the disclosure and continue routine care
Reassure the patient that feelings will pass
Ask the family to stay with the patient and monitor remotely
Ensure the patient's immediate safety and notify the care team (Correct answer)

Correct answer: Ensure the patient's immediate safety and notify the care team

Immediate patient safety is the top priority; the nurse must stay with the patient and promptly alert the multidisciplinary team.

Question 133: A critically ill patient is receiving norepinephrine infusion. The nurse observes blanching and swelling at the IV site. What is the priority action?

Stop the infusion, discontinue the IV, and administer phentolamine subcutaneously to the site (Correct answer)
Flush the IV line with normal saline
Switch to dopamine via the same IV
Slow the infusion rate and apply warm compress

Correct answer: Stop the infusion, discontinue the IV, and administer phentolamine subcutaneously to the site

Norepinephrine extravasation causes tissue necrosis; the infusion must be stopped and phentolamine infiltrated to counteract vasoconstriction.

Question 134: A nurse working in a SCFHS-accredited psychiatric facility in Riyadh is caring for a patient on clozapine therapy for treatment-resistant schizophrenia. On day 18 of therapy, the patient's absolute neutrophil count (ANC) is reported as 1,200 cells/mm³. Per international clozapine monitoring protocols adopted in Saudi practice, what is the CORRECT immediate nursing action?

Reduce the clozapine dose by 50% and recheck ANC in 48 hours
Permanently discontinue clozapine, as any ANC below 1,500 mandates lifelong discontinuation
Withhold clozapine, notify the psychiatrist immediately, and increase ANC monitoring frequency to twice weekly (Correct answer)
Continue clozapine and repeat ANC in 7 days as this value is within normal limits

Correct answer: Withhold clozapine, notify the psychiatrist immediately, and increase ANC monitoring frequency to twice weekly

An ANC of 1,200–1,499 cells/mm³ represents mild neutropenia (Grade 2 alert). Per clozapine monitoring protocols, clozapine must be withheld and the prescribing psychiatrist notified immediately, with ANC rechecked twice weekly until it returns to ≥1,500. Permanent discontinuation is only mandated for severe agranulocytosis (ANC <500). Dose reduction is not a recognized protocol step.

Question 135: A nurse working in a SCFHS facility is preparing to administer a unit of packed red blood cells (PRBCs) to a 45-year-old female patient. Fifteen minutes into the transfusion, the patient complains of low back pain, the nurse notes dark reddish-brown urine in the catheter bag, and the patient's temperature rises from 37.0°C to 38.8°C. What is the nurse's PRIORITY action?

Stop the transfusion, send the remaining blood bag to the blood bank, and obtain a urine specimen for culture
Switch to the secondary IV line, increase IV fluid rate to force diuresis, and administer antipyretics
Slow the transfusion rate to 50 mL/hr, administer IV diphenhydramine, and continue monitoring
Stop the transfusion immediately, keep the IV line open with normal saline via new tubing, and notify the physician (Correct answer)

Correct answer: Stop the transfusion immediately, keep the IV line open with normal saline via new tubing, and notify the physician

The triad of low back pain, hemoglobinuria (dark reddish-brown urine), and fever during a blood transfusion is pathognomonic for an acute hemolytic transfusion reaction (AHTR) — a life-threatening ABO incompatibility. The nurse must STOP the transfusion IMMEDIATELY and keep the IV access patent with normal saline through NEW tubing (to avoid infusing any remaining incompatible blood from the existing tubing). The physician must be notified urgently. While sending the blood bag and obtaining specimens are correct subsequent steps, the immediate priority is stopping the transfusion and maintaining IV access. Slowing the rate (option A) is used for febrile non-hemolytic reactions and is dangerous in AHTR.

Question 136: Which situation requires a nurse to apply the principle of 'least restrictive intervention' in patient safety?

A confused patient at risk of falling who tries to get out of bed (Correct answer)
A patient who requests stronger pain medication
A patient who refuses oral medications
A patient with an infectious disease who needs isolation

Correct answer: A confused patient at risk of falling who tries to get out of bed

The least restrictive intervention principle requires trying alternatives like bed alarms and closer monitoring before resorting to physical restraints.

Question 137: A nurse is administering an intramuscular injection to an adult. Which site is preferred to avoid injury to the sciatic nerve?

Ventrogluteal site (Correct answer)
Dorsogluteal site
Vastus lateralis
Deltoid muscle

Correct answer: Ventrogluteal site

The ventrogluteal site is now preferred for IM injections in adults because it is free of major nerves and blood vessels. The dorsogluteal site is associated with risk of sciatic nerve injury and is no longer recommended.

Question 138: A nurse is reviewing the Saudi MOH 'zero tolerance' HAI targets. Which infection has a zero-tolerance target in Saudi accredited hospitals?

Surgical site infection after elective surgery
Catheter-associated UTI in all wards
Community-acquired urinary tract infection
Central line-associated bloodstream infection (CLABSI) in ICUs (Correct answer)

Correct answer: Central line-associated bloodstream infection (CLABSI) in ICUs

Saudi MOH and accreditation bodies (e.g., CBAHI) set zero-tolerance (zero preventable infections) targets specifically for CLABSI in ICU settings, as evidence shows most CLABSIs are preventable with proper bundle compliance. This drives bundle implementation and surveillance.

Question 139: A school nurse is implementing a program to prevent teen pregnancy in a Saudi secondary school. Which approach is most culturally appropriate and effective?

Comprehensive reproductive health education aligned with Saudi cultural and religious values, involving family (Correct answer)
Focusing only on abstinence without discussing reproductive health concepts
Importing a Western sexual education curriculum directly
Distributing contraceptives at the school health clinic

Correct answer: Comprehensive reproductive health education aligned with Saudi cultural and religious values, involving family

Effective health education in Saudi Arabia must be culturally and religiously contextual. Programs that involve family, align with Islamic values, and address reproductive health within appropriate cultural frameworks are more accepted and effective than direct adoption of Western models.

Question 140: A nurse is administering IV potassium chloride (KCl) to correct hypokalemia. What is the maximum safe rate for IV KCl administration in a peripheral line?

40 mEq/hour
10 mEq/hour (Correct answer)
20 mEq/hour
5 mEq/hour

Correct answer: 10 mEq/hour

The maximum safe rate for peripheral IV KCl administration is 10 mEq/hour in a concentration of no more than 40 mEq/L. Faster rates can cause cardiac arrhythmias. Central line administration allows higher rates with continuous cardiac monitoring.

Question 141: The nurse is performing a physical assessment and notices the patient has clubbing of the fingers. This finding is most commonly associated with:

Liver disease
Chronic hypoxia (Correct answer)
Anemia
Hypertension

Correct answer: Chronic hypoxia

Digital clubbing is associated with chronic hypoxia, most commonly due to chronic lung diseases (e.g., COPD, cystic fibrosis) or cyanotic heart disease. The mechanism involves chronic tissue hypoxia causing soft tissue proliferation.

Question 142: During Hajj season, a public health nurse is assigned to a medical station in Mina. A pilgrim is brought in with confusion, agitated behavior, absence of sweating, flushed dry skin, and a measured tympanic temperature of 41.2°C. A companion reports the patient had been walking outdoors for six hours in 44°C heat. Which nursing intervention takes HIGHEST priority?

Administer 1 g paracetamol suppository to reduce core temperature and monitor response for 15 minutes
Initiate rapid evaporative cooling — wet the skin and apply fans — while arranging immediate emergency transfer (Correct answer)
Establish IV access and infuse 1 L of normal saline over 20 minutes to correct dehydration
Provide chilled oral rehydration fluid and place the patient in a shaded recovery position

Correct answer: Initiate rapid evaporative cooling — wet the skin and apply fans — while arranging immediate emergency transfer

This presentation — hyperthermia above 40°C, anhidrosis (absence of sweating), and CNS dysfunction (confusion, agitation) — constitutes classic exertional heat stroke, a life-threatening emergency. Per Saudi MOH Hajj mass-gathering protocols, rapid core temperature reduction is the immediate priority. Evaporative cooling (misting with fans) is first-line in field settings. Oral fluids are contraindicated with altered consciousness. Paracetamol is ineffective in heat stroke as the hyperthermia is not cytokine-mediated. IV fluids are secondary to cooling and must not delay it.

Question 143: What are the nursing considerations for electroconvulsive therapy (ECT)?

Only available for schizophrenia
No nursing preparation is needed
ECT is no longer used
Pre-procedure fasting, informed consent, pre/post vital signs, airway management, post-procedure orientation assessment and safety monitoring (Correct answer)

Correct answer: Pre-procedure fasting, informed consent, pre/post vital signs, airway management, post-procedure orientation assessment and safety monitoring

ECT nursing care: pre-procedure (NPO 6-8 hours, informed consent, remove dentures/jewelry, baseline vitals), during (assist anesthesia team, airway management), post-procedure (monitor vital signs, airway, orientation, confusion level, nausea, headache, memory assessment).

Question 144: A 24-year-old primigravida at 41+3 weeks gestation undergoes an oxytocin induction of labor in a Saudi tertiary hospital. The electronic fetal monitoring (EFM) shows a baseline FHR of 145 bpm, with repeated late decelerations after every contraction, and minimal variability (amplitude 2–5 bpm) over 40 minutes. The cervix is 5 cm dilated. The attending nurse should FIRST:

Prepare for immediate operative vaginal delivery as the cervix is sufficiently dilated
Place the mother in a left lateral position, discontinue oxytocin, administer O₂ via face mask at 8–10 L/min, and call the obstetrician immediately (Correct answer)
Perform amnioinfusion to relieve variable decelerations and re-evaluate the FHR pattern
Increase IV fluid rate to 500 mL normal saline over 30 minutes and continue monitoring for another 20 minutes

Correct answer: Place the mother in a left lateral position, discontinue oxytocin, administer O₂ via face mask at 8–10 L/min, and call the obstetrician immediately

Repeated late decelerations with minimal variability constitute a Category III (ominous) fetal heart rate pattern per ACOG/SCFHS intrapartum guidelines, indicating uteroplacental insufficiency and possible fetal acidemia. The priority nursing actions are: position change to lateral decubitus (improve uteroplacental blood flow), immediate oxytocin discontinuation (remove uterotonic stimulus), supplemental oxygen, IV fluid bolus, and urgent physician notification for possible emergency cesarean delivery. Amnioinfusion addresses variable decelerations (cord compression), not late decelerations.

Question 145: A nurse is caring for a patient in the ICU who develops ICU psychosis. Which intervention is most effective?

Reorient the patient frequently, maintain day-night cycles, and reduce sleep disruptions (Correct answer)
Administer high-dose antipsychotics immediately
Place the patient in isolation to reduce stimulation
Restrain the patient to prevent self-harm

Correct answer: Reorient the patient frequently, maintain day-night cycles, and reduce sleep disruptions

ICU psychosis (delirium) is best managed non-pharmacologically: frequent reorientation, maintaining circadian rhythms (lights on during day, dim at night), minimizing sleep disruption, early mobility, removing unnecessary catheters/lines, and involving family. This is evidence-based through ABCDEF bundle.

Question 146: A Saudi MOH community health nurse discovers that a Hajj season worker has active pulmonary tuberculosis confirmed by sputum smear positivity. The worker is currently asymptomatic for fever but has a productive cough. Under the Saudi MOH Hajj Health Regulations and the Communicable Disease Control Law, which statement BEST describes the nurse's legal obligations?

Report to Weqaya within 72 hours; the patient may continue duties with surgical mask use and directly observed therapy (DOT)
Initiate immediate isolation, report to the local MOH Directorate and Weqaya within 24 hours, and the patient may not be permitted to continue Hajj duties until deemed non-infectious (Correct answer)
Initiate DOT and report to the facility infection control officer; external reporting is only required if transmission is confirmed
Report to the Hajj Ministry within 48 hours; isolation is voluntary unless the patient refuses treatment

Correct answer: Initiate immediate isolation, report to the local MOH Directorate and Weqaya within 24 hours, and the patient may not be permitted to continue Hajj duties until deemed non-infectious

Saudi Arabia's Communicable Disease Prevention Law grants the MOH authority to mandate isolation for smear-positive TB, which is a notifiable disease requiring immediate action. During Hajj, where mass gathering amplifies transmission risk, Saudi MOH Hajj Health Regulations apply stricter controls: the worker must be immediately isolated, the case reported to both the local Directorate of Health Affairs and Weqaya within 24 hours, and the worker is prohibited from resuming public-facing Hajj duties until smear conversion (non-infectious status) is confirmed. Voluntary isolation or masking alone does not satisfy the legal standard for smear-positive cases in this high-risk context.

Question 147: A patient develops a stage 2 pressure injury. Which description best matches this stage?

Intact skin with non-blanchable erythema
Full-thickness skin loss with visible subcutaneous fat
Partial-thickness skin loss with exposed dermis (Correct answer)
Full-thickness tissue loss with exposed bone

Correct answer: Partial-thickness skin loss with exposed dermis

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable and may appear as a shallow open ulcer or intact/ruptured seroma. Stage 1 shows intact skin with non-blanchable redness.

Question 148: Under the Saudi Mental Health Law (Royal Decree No. M/63, 1435H), which combination of criteria is REQUIRED to justify involuntary psychiatric hospitalization?

The patient poses a danger to self or others AND voluntary treatment is not achievable (Correct answer)
A first-degree family member requests admission AND the treating psychiatrist agrees
The patient has a documented history of prior involuntary admissions AND current psychosis
Two independent psychiatrists certify the need for inpatient care within 48 hours

Correct answer: The patient poses a danger to self or others AND voluntary treatment is not achievable

Under Saudi Mental Health Law (Royal Decree M/63, 1435H), involuntary (compulsory) admission requires both conditions: (1) the patient presents a clear danger to themselves or others due to a mental disorder, AND (2) voluntary treatment cannot be achieved. Family consent or request alone does not satisfy the legal threshold; the law protects patient autonomy and requires the dual criteria to be met. This aligns with international human rights frameworks adopted by the Kingdom.

Question 149: Which nursing intervention is most appropriate for a patient with increased intracranial pressure (ICP)?

Place patient in prone position
Elevate head of bed to 30–45 degrees (Correct answer)
Position patient in Trendelenburg (head-down)
Keep patient supine with head flat

Correct answer: Elevate head of bed to 30–45 degrees

Elevating the head of the bed 30–45 degrees promotes cerebral venous drainage, which reduces intracranial pressure.

Question 150: A primigravida at 37 weeks presents with sudden onset severe headache, visual disturbances, and BP of 162/110 mmHg. The nurse should prepare for which condition?

Hypertensive urgency unrelated to pregnancy
Chronic hypertension exacerbation
Gestational hypertension
Severe preeclampsia (Correct answer)

Correct answer: Severe preeclampsia

Severe headache, visual disturbances, and BP ≥160/110 mmHg in a pregnant woman meet criteria for severe preeclampsia, requiring immediate antihypertensive and magnesium sulfate therapy.

Question 151: A patient on a medical ward in a Saudi hospital has a nasogastric tube in situ for enteral feeding. Before administering the 08:00 feeding, the nurse aspirates 280 mL of gastric residual volume (GRV). According to evidence-based practice guidelines endorsed by SCFHS, what is the most appropriate nursing action?

Discard the aspirate, administer a prokinetic agent, and proceed with feeding at half the prescribed rate
Hold the feeding, discard the aspirate, and notify the physician immediately
Return the aspirate, hold the feeding, place the patient in the right lateral decubitus position, and reassess after two hours
Return the aspirate, hold the feeding, reassess GRV after one hour, and notify the physician if it remains elevated (Correct answer)

Correct answer: Return the aspirate, hold the feeding, reassess GRV after one hour, and notify the physician if it remains elevated

Current evidence-based guidelines (reflected in SCFHS Prometric content) recommend returning the gastric aspirate to prevent electrolyte loss, temporarily holding the feeding, reassessing GRV after approximately one hour, and notifying the physician if the GRV remains ≥250–500 mL on repeat measurement. Discarding the aspirate risks fluid and electrolyte imbalance. Proceeding with feeding when GRV is this high risks aspiration. A GRV of 280 mL alone is not an emergency requiring immediate physician notification before reassessment.

Question 152: A community health nurse in Riyadh is conducting a windshield survey and notices a high prevalence of obesity-related signage at local clinics. According to the Saudi National Plan for Prevention and Control of Overweight and Obesity, which PRIMARY determinant classification should the nurse document as the leading modifiable risk factor driving Saudi Arabia's obesity epidemic?

Sedentary lifestyle combined with excessive consumption of high-calorie traditional foods (Correct answer)
Hormonal dysregulation secondary to extreme heat exposure
Over-reliance on domestic workers reducing physical household activity
Genetic predisposition unique to the Arabian Peninsula population

Correct answer: Sedentary lifestyle combined with excessive consumption of high-calorie traditional foods

The Saudi National Plan for Prevention and Control of Overweight and Obesity identifies physical inactivity and high-calorie dietary patterns (including traditional Saudi foods high in saturated fats and refined carbohydrates) as the primary modifiable determinants. Saudi Arabia has one of the highest obesity rates in the GCC region, with the Ministry of Health attributing it predominantly to lifestyle factors. While cultural practices involving domestic workers contribute marginally, the dual combination of sedentary behavior and caloric excess is documented as the primary driver.

Question 153: When administering medications to elderly patients in a Saudi long-term care setting, the nurse should be aware that age-related changes in renal function primarily affect which pharmacokinetic parameter?

Drug absorption
Drug metabolism in the liver
Drug excretion (Correct answer)
Drug distribution

Correct answer: Drug excretion

Aging causes a progressive decline in glomerular filtration rate (GFR), reducing renal drug excretion. This leads to drug accumulation and toxicity risk, especially with renally cleared drugs (e.g., digoxin, aminoglycosides, metformin). Absorption changes are minor; distribution is affected by body composition changes; hepatic metabolism declines but less predictably than renal excretion.

Question 154: A 3-year-old child is brought in with a barking cough, inspiratory stridor, and low-grade fever. Which condition is most likely?

Croup (laryngotracheobronchitis) (Correct answer)
Epiglottitis
Foreign body aspiration
Bronchiolitis

Correct answer: Croup (laryngotracheobronchitis)

The classic triad of barking cough, inspiratory stridor, and low-grade fever in a toddler is characteristic of croup, caused most often by parainfluenza virus.

Question 155: Which early sign of septic shock differentiates it from other forms of shock?

Markedly elevated central venous pressure
Warm, flushed skin with high cardiac output (hyperdynamic state) (Correct answer)
Severe bradycardia
Cool, clammy skin with low cardiac output

Correct answer: Warm, flushed skin with high cardiac output (hyperdynamic state)

Early septic shock is characterized by a hyperdynamic state with vasodilation, warm skin, and elevated cardiac output.

Question 156: An 80-year-old male patient admitted to a Saudi hospital is found confused at night, agitated, and pulling at his IV line. He was alert on admission 2 days ago. Which condition should the nurse suspect FIRST?

Depression
Delirium (Correct answer)
Dementia
Normal aging

Correct answer: Delirium

The acute onset of confusion in a previously alert elderly patient is characteristic of delirium, not dementia (which has a gradual onset) or depression. Night-time worsening (sundowning pattern) is common in delirium. Immediate assessment for underlying causes — infection, medication toxicity, electrolyte imbalance, and hypoxia — is required. This is never 'normal aging.'

Question 157: A 55 kg female patient with CrCl of 28 mL/min (moderate renal impairment) is prescribed metformin 1,000 mg twice daily for Type 2 diabetes. According to Saudi clinical pharmacy guidelines aligned with SFDA labeling, what is the MOST appropriate nursing response?

Administer with a dose reduction to 500 mg twice daily based on renal function
Hold only if the patient develops lactic acidosis symptoms first
Question the order and withhold the medication pending physician review, as metformin is contraindicated below CrCl 30 mL/min (Correct answer)
Administer as ordered since 28 mL/min is close to the threshold and acceptable

Correct answer: Question the order and withhold the medication pending physician review, as metformin is contraindicated below CrCl 30 mL/min

Metformin is contraindicated when CrCl falls below 30 mL/min due to the risk of lactic acidosis from drug accumulation. A CrCl of 28 mL/min is below this threshold. The nurse should withhold the dose and contact the prescribing physician for order clarification or an alternative agent. This aligns with SFDA-approved metformin prescribing information and Saudi MOH formulary guidance. Self-adjusting the dose (option C) is outside nursing scope and still dangerous at this CrCl.

Question 158: Per the Saudi MOH IPC Manual aligned with CBAHI Patient Safety Standards, a sharps container in a clinical area should be sealed and sent for disposal when it reaches which fill level?

Two-thirds (67%) full
Three-quarters (75%) full (Correct answer)
Completely full (100%)
One-half (50%) full

Correct answer: Three-quarters (75%) full

Saudi MOH IPC guidelines and CBAHI standards specify that sharps containers must be sealed and removed from clinical areas when they reach three-quarters (75%) full. Filling beyond this level significantly increases the risk of needlestick injury during closure. Allowing containers to reach 100% capacity violates both MOH healthcare waste regulations and CBAHI accreditation standards, and can result in a non-conformity finding during audit.

Question 159: A nurse is using the Braden Scale to assess pressure injury risk for a bedridden patient in a Saudi hospital. The patient scores: Sensory Perception 3, Moisture 2, Activity 1, Mobility 2, Nutrition 2, Friction and Shear 2. What is the correct total score interpretation?

Total score 12 — High Risk, requiring a specialty mattress and 2-hourly repositioning (Correct answer)
Total score 10 — Very High Risk, requiring an air-fluidized mattress and 1-hourly repositioning
Total score 12 — Moderate Risk, requiring repositioning every 4 hours and nutritional support
Total score 14 — Mild Risk, requiring a turning schedule and skin assessment every shift

Correct answer: Total score 12 — High Risk, requiring a specialty mattress and 2-hourly repositioning

Adding the subscores: 3+2+1+2+2+2 = 12. A Braden Scale total score of 13–14 indicates Mild Risk, 10–12 indicates High Risk, and ≤9 indicates Very High Risk. A score of 12 places this patient in the High Risk category. High-risk interventions include use of a pressure-redistributing specialty mattress and repositioning at minimum every 2 hours. Score 14 would be Mild Risk with less intensive intervention, and score 10 would require more aggressive intervention.

Question 160: In a patient with increased intracranial pressure (ICP), which nursing position is most appropriate?

Flat supine with no head elevation
Trendelenburg position
Prone position
Head of bed elevated 30–45 degrees with head midline (Correct answer)

Correct answer: Head of bed elevated 30–45 degrees with head midline

Elevating the head of bed 30–45 degrees with the head in midline promotes venous drainage and reduces ICP.

Question 161: A patient is prescribed digoxin. Which assessment finding requires the nurse to withhold the medication and notify the physician?

Serum sodium of 138 mEq/L
Apical pulse of 52 beats per minute (Correct answer)
Blood pressure of 130/82 mmHg
Serum potassium of 3.8 mEq/L

Correct answer: Apical pulse of 52 beats per minute

Digoxin should be withheld if the apical pulse is below 60 beats per minute. Bradycardia is a sign of digoxin toxicity. Hypokalemia also increases digoxin toxicity risk, but the potassium level here is normal.

Question 162: When teaching a patient with limited health literacy, the nurse should:

Limit teaching to one session
Use plain language and teach-back method (Correct answer)
Provide detailed written pamphlets
Use medical terminology for accuracy

Correct answer: Use plain language and teach-back method

The teach-back method (asking patients to repeat information in their own words) is the most effective strategy for verifying understanding, especially with patients with limited health literacy. Plain language removes barriers.

Question 163: A patient receiving total parenteral nutrition (TPN) via central line develops fever, chills, and hypotension. The nurse suspects catheter-related bloodstream infection (CRBSI). What should be done FIRST?

Change the TPN bag and tubing
Remove the central line immediately
Obtain blood cultures from the central line and a peripheral site (Correct answer)
Start broad-spectrum antibiotics without cultures

Correct answer: Obtain blood cultures from the central line and a peripheral site

Blood cultures from both the central line and a peripheral vein are essential to confirm CRBSI before initiating treatment.

Question 164: A surgical nurse is reviewing a postoperative patient who had a Whipple procedure (pancreaticoduodenectomy) 5 days ago. The patient develops a sudden high-volume output from the Jackson-Pratt drain — 350 mL of clear watery fluid in 4 hours. Drain fluid amylase is sent and returns at 4,200 U/L (serum amylase 180 U/L). Which nursing action is MOST appropriate FIRST?

Increase IV fluid rate to replace drain losses milliliter-for-milliliter and monitor electrolytes
Notify the surgical team immediately — this drain amylase:serum amylase ratio indicates a postoperative pancreatic fistula (Correct answer)
Clamp the drain for 2 hours to allow the fluid to reabsorb into the peritoneal cavity
Remove the JP drain to prevent ascending infection from prolonged drainage

Correct answer: Notify the surgical team immediately — this drain amylase:serum amylase ratio indicates a postoperative pancreatic fistula

A drain amylase level more than 3× the upper limit of normal serum amylase on postoperative day 3 or beyond — or a drain:serum amylase ratio >3 — defines a Postoperative Pancreatic Fistula (POPF) per the International Study Group on Pancreatic Fistula (ISGPF) criteria, endorsed in Saudi hepatopancreaticobiliary surgery guidelines. This is a major complication of the Whipple procedure, carrying risks of delayed hemorrhage, abscess, and sepsis. The nurse must immediately notify the surgical team for assessment. Drain removal (A) is contraindicated — it can trap bile/pancreatic juice and cause peritonitis. Clamping (C) is dangerous. Fluid replacement (D) is supportive and may be needed, but the FIRST priority is escalation to the physician for urgent assessment of fistula severity grading.

Question 165: A patient with acute kidney injury (AKI) has a potassium level of 6.8 mEq/L and an ECG showing peaked T-waves. What is the nurse's PRIORITY intervention?

Administer sodium polystyrene sulfonate (Kayexalate) orally
Restrict dietary potassium intake
Administer calcium gluconate IV immediately (Correct answer)
Initiate emergent hemodialysis

Correct answer: Administer calcium gluconate IV immediately

Calcium gluconate stabilizes the cardiac membrane against the arrhythmogenic effects of hyperkalemia and acts within minutes; it is the immediate priority when ECG changes are present.

Question 166: Which of the following is an example of a tertiary prevention intervention?

Mammography screening
Rehabilitation after a stroke (Correct answer)
Childhood immunization
Health education on smoking cessation

Correct answer: Rehabilitation after a stroke

Tertiary prevention aims to reduce the impact of an established disease by restoring function and preventing complications. Rehabilitation after stroke is a classic example. Primary prevention prevents disease; secondary prevention detects it early.

Question 167: A 58-year-old male patient in a Riyadh tertiary care hospital is post-operative day 2 following an open cholecystectomy. He develops sudden onset of dyspnea, pleuritic chest pain, and his SpO₂ drops to 89% on room air. His HR is 118 bpm and BP is 100/70 mmHg. The Wells score is calculated at 7. According to SCFHS nursing standards, which immediate nursing action takes priority BEFORE the physician's order is received?

Administer supplemental oxygen via non-rebreather mask at 10–15 L/min (Correct answer)
Prepare the patient for immediate surgical embolectomy
Obtain a 12-lead ECG and draw arterial blood gases simultaneously
Position the patient supine with legs elevated to improve venous return

Correct answer: Administer supplemental oxygen via non-rebreather mask at 10–15 L/min

In a suspected massive or submassive pulmonary embolism with hypoxemia (SpO₂ 89%), the nurse's first independent action is to restore oxygenation — administering high-flow O₂ via non-rebreather mask at 10–15 L/min is within nursing scope and is the most life-saving immediate step. Positioning supine with legs elevated is contraindicated as it worsens RV strain and can increase thrombus propagation. ECG and ABGs are important but are concurrent physician-driven orders, not the first independent nursing priority. Surgical embolectomy is a physician/surgical decision.

Question 168: The nurse is conducting a windshield survey of a community. What is a windshield survey?

A statistical analysis of community health data
An observational assessment of community characteristics conducted by driving through the community (Correct answer)
An interview-based assessment of community leaders
A review of hospital admission records

Correct answer: An observational assessment of community characteristics conducted by driving through the community

A windshield survey is an observational community assessment tool where the nurse systematically observes community characteristics (housing, businesses, transportation, green spaces, safety, demographics) while driving or walking through the area. It provides qualitative community data.

Question 169: The nurse is preparing to insert a urinary catheter in a female patient. In what order should anatomical structures be cleaned?

Labia majora, labia minora, urethral meatus (Correct answer)
Urethral meatus, labia minora, labia majora
Labia minora, labia majora, urethral meatus
Urethral meatus, labia majora, labia minora

Correct answer: Labia majora, labia minora, urethral meatus

Perineal cleaning for catheter insertion follows an outward-to-inward, clean-to-less-clean principle — outer to inner. Clean from outer (labia majora) inward to the meatus to prevent introducing microorganisms into the urethra.

Question 170: A Saudi hospital pharmacist contacts the nurse regarding a potential drug interaction for a patient receiving warfarin (INR currently 2.4, target 2–3). The physician has now prescribed fluconazole 200 mg daily for 7 days for an oral candidiasis. What is the PRIMARY pharmacokinetic mechanism behind this interaction, and what nursing action is most appropriate?

Fluconazole inhibits CYP2C9, decreasing warfarin metabolism and raising bleeding risk — monitor INR more frequently and notify the prescriber (Correct answer)
Fluconazole induces CYP2C9, increasing warfarin clearance — reduce the warfarin dose preemptively
Fluconazole displaces warfarin from plasma proteins, temporarily lowering the free drug level — no dose adjustment needed
Fluconazole accelerates Vitamin K absorption, antagonizing warfarin — supplement Vitamin K to restore anticoagulation

Correct answer: Fluconazole inhibits CYP2C9, decreasing warfarin metabolism and raising bleeding risk — monitor INR more frequently and notify the prescriber

Fluconazole is a potent inhibitor of CYP2C9, the primary enzyme responsible for warfarin (S-enantiomer) metabolism. Inhibition leads to elevated warfarin plasma levels and a significantly increased INR, raising the risk of serious bleeding. The nurse's priority action is to flag the interaction, notify the prescriber for INR monitoring frequency adjustment (e.g., checking INR within 2–3 days of starting fluconazole), and document the safety alert. In Saudi CBAHI-accredited facilities, nurses are within scope to initiate medication reconciliation alerts. Warfarin dose adjustment decisions rest with the physician or clinical pharmacist.

Question 171: A nurse is preparing a critically ill patient for nasogastric tube (NGT) insertion. After insertion, which combination of confirmation methods is considered the gold standard per evidence-based nursing practice guidelines endorsed by SCFHS?

Radiographic confirmation (X-ray) combined with pH testing of aspirate (pH ≤ 5.5) (Correct answer)
Auscultation of air insufflation over the epigastrium combined with aspiration of gastric contents
Capnography to rule out tracheal placement combined with epigastric auscultation
pH testing of aspirate alone (pH ≤ 5.5) is sufficient for initial placement confirmation

Correct answer: Radiographic confirmation (X-ray) combined with pH testing of aspirate (pH ≤ 5.5)

SCFHS and international evidence-based guidelines (including NICE and NPSA) identify radiographic (X-ray) confirmation as the definitive gold standard for NGT placement verification, particularly before first use in high-risk patients. pH testing of aspirate (pH ≤ 5.5 confirms gastric placement) is a validated bedside adjunct. The combination of both provides the highest accuracy. Auscultation of air insufflation alone is no longer considered reliable and has been associated with fatal misplacements. Capnography detects tracheal placement but cannot confirm correct gastric positioning. pH testing alone, while useful, is not considered the gold standard.

Question 172: A patient develops hypotension, tachycardia, warm flushed skin, and a widened pulse pressure following a severe anaphylactic reaction. This presentation is most characteristic of:

Distributive shock (Correct answer)
Obstructive shock
Cardiogenic shock
Hypovolemic shock

Correct answer: Distributive shock

Distributive shock, as seen in anaphylaxis, is caused by massive vasodilation leading to a relative hypovolemia with warm skin and widened pulse pressure.

Question 173: A 58-year-old male in the ICU is on mechanical ventilation with the following ABG results: pH 7.22, PaCO₂ 38 mmHg, HCO₃⁻ 15 mEq/L, PaO₂ 88 mmHg, SaO₂ 94%. His anion gap is 24 mEq/L (Na⁺ 138, Cl⁻ 99, HCO₃⁻ 15). Which condition is MOST consistent with this presentation?

Mixed respiratory alkalosis and metabolic acidosis
Hyperchloremic non-anion gap metabolic acidosis
Diabetic ketoacidosis with compensatory hyperventilation masked by ventilator settings (Correct answer)
Respiratory acidosis with metabolic compensation

Correct answer: Diabetic ketoacidosis with compensatory hyperventilation masked by ventilator settings

The ABG shows metabolic acidosis (low pH, low HCO₃⁻) with a normal PaCO₂, indicating the ventilator is not allowing appropriate compensatory hyperventilation (expected PaCO₂ via Winter's formula = 1.5×15 + 8 ± 2 = 29–31 mmHg). The elevated anion gap of 24 mEq/L points to an anion-gap metabolic acidosis such as DKA. In Saudi ICU practice, DKA is among the leading causes of high anion gap metabolic acidosis; the ventilator settings must be adjusted to permit adequate CO₂ clearance to avoid worsening acidemia.

Question 174: A patient admitted with suspected Ebola hemorrhagic fever requires which level of transmission-based precautions?

Standard precautions only
Contact precautions with N95 mask
Droplet precautions with surgical mask
Contact + Droplet + Airborne (full PPE including PAPR) (Correct answer)

Correct answer: Contact + Droplet + Airborne (full PPE including PAPR)

Ebola requires all three levels of transmission-based precautions plus enhanced PPE including a powered air-purifying respirator (PAPR) or equivalent, due to high lethality, contact with body fluids, and potential aerosol generation during procedures. Saudi MOH and CDC recommend this approach.

Question 175: Which beta-blocker property makes carvedilol different from metoprolol?

Carvedilol also blocks alpha-1 receptors (Correct answer)
Carvedilol is cardioselective
Carvedilol has intrinsic sympathomimetic activity
Carvedilol crosses the blood-brain barrier

Correct answer: Carvedilol also blocks alpha-1 receptors

Carvedilol is a non-selective beta-blocker with additional alpha-1 blocking activity, providing vasodilation along with beta blockade.

Question 176: A nurse is conducting a health assessment of a community. Which data source provides population-level mortality data?

Vital statistics records (death certificates) (Correct answer)
Behavioral risk factor surveys
Outpatient clinic encounter records
Hospital discharge summaries

Correct answer: Vital statistics records (death certificates)

Vital statistics (birth and death certificates) are the primary source of population-level mortality data, including cause of death, age, sex, and geography. They form the basis for calculating mortality rates and trends.

Question 177: Which of the following is a subjective finding during patient assessment?

Patient reports pain of 8/10 (Correct answer)
Blood pressure of 150/90 mmHg
Respiratory rate of 22 breaths per minute
Temperature of 38.5°C

Correct answer: Patient reports pain of 8/10

Subjective data is information reported by the patient that cannot be directly measured, such as pain, nausea, or dizziness. Objective data includes measurable vital signs and physical findings.

Question 178: A psychiatric nurse in a Saudi hospital is using the Columbia Suicide Severity Rating Scale (C-SSRS) — adopted by MOH mental health guidelines — to assess a 35-year-old male patient. The patient reports passive suicidal ideation without a specific plan but discloses he has access to a firearm at home and has researched methods online in the past week. Under C-SSRS risk stratification, this patient is BEST classified as:

Low risk — passive ideation without a concrete plan requires only outpatient safety planning
Moderate risk — ideation with preparatory behavior warrants urgent voluntary hospitalization discussion
Indeterminate risk — the absence of a specific plan means risk cannot be formally stratified
High risk — access to lethal means combined with preparatory behavior (online research) constitutes imminent risk requiring immediate inpatient admission (Correct answer)

Correct answer: High risk — access to lethal means combined with preparatory behavior (online research) constitutes imminent risk requiring immediate inpatient admission

Under C-SSRS guidelines, online research of methods combined with access to a lethal means (firearm) constitutes preparatory behavior — elevating this to HIGH risk regardless of whether a formal plan exists. Saudi MOH mental health protocols align with this: lethal means access + preparatory behavior = imminent risk requiring inpatient-level intervention. Passive ideation alone does not capture the full clinical picture here.

Question 179: A patient is scheduled for elective laparoscopic cholecystectomy at a Saudi hospital. She has been NPO (nil per os) since midnight. The anesthesiologist approves clear fluids up to 2 hours before surgery per current Saudi guidelines. At 06:00 for a 10:00 surgery, the nurse should:

Maintain strict NPO and offer nothing by mouth
Administer IV dextrose to maintain blood glucose
Offer the patient water or clear apple juice up to 250 mL since it is still 4 hours before surgery (Correct answer)
Offer a light meal since the patient complains of hunger

Correct answer: Offer the patient water or clear apple juice up to 250 mL since it is still 4 hours before surgery

Current enhanced recovery after surgery (ERAS) and anesthesia guidelines — adopted in Saudi MOH hospitals — permit clear fluids up to 2 hours before surgery (solids NPO for 6–8 hours). At 06:00 for a 10:00 surgery, the patient has 4 hours remaining, so offering up to 250 mL of clear fluid is appropriate and reduces preoperative thirst and insulin resistance. Strict midnight NPO for clear fluids is outdated practice.

Question 180: A public health nurse is reviewing data showing that cardiovascular disease rates are disproportionately higher in lower-income neighborhoods. This difference is an example of:

Expected biological variation across populations
Random variation in disease distribution
A health disparity related to social determinants of health (Correct answer)
A genetic difference in disease susceptibility

Correct answer: A health disparity related to social determinants of health

Health disparities are preventable differences in disease burden linked to social, economic, and environmental disadvantage. Income, education, neighborhood environment, and access to care are social determinants that drive disparities in cardiovascular disease and other conditions.

Question 181: A patient is taking St. John's Wort with their antiretroviral therapy. What is the most significant drug interaction concern?

No significant interaction exists
St. John's Wort causes serotonin syndrome with antiretrovirals
St. John's Wort induces CYP3A4 and reduces antiretroviral drug levels, risking treatment failure (Correct answer)
St. John's Wort enhances antiretroviral absorption

Correct answer: St. John's Wort induces CYP3A4 and reduces antiretroviral drug levels, risking treatment failure

St. John's Wort is a potent CYP3A4 inducer, significantly increasing the metabolism and clearance of many antiretroviral drugs (protease inhibitors, NNRTIs). This reduces drug levels below therapeutic range, causing treatment failure and potential development of HIV drug resistance.

Question 182: The community health nurse is investigating a cluster of gastrointestinal illness after a community dinner. This investigation process is called:

Epidemiological outbreak investigation (Correct answer)
Environmental health surveillance
Disease burden analysis
Health promotion assessment

Correct answer: Epidemiological outbreak investigation

Outbreak investigation is an epidemiological process that identifies the source of a disease cluster through case definition, case finding, descriptive epidemiology, hypothesis generation, and control measures. It is a core function of public health nursing.

Question 183: The nurse is preparing to administer insulin. The order reads: 'Regular insulin 10 units IV push.' The available vial is U-100 insulin. How many mL should be drawn up?

0.5 mL
0.01 mL
1 mL
0.1 mL (Correct answer)

Correct answer: 0.1 mL

U-100 insulin contains 100 units per mL. Volume = 10 units ÷ 100 units/mL = 0.1 mL. This small volume requires use of an insulin syringe for accuracy. Note: only regular insulin is used IV; NPH and long-acting insulins are not for IV use.

Question 184: A Saudi ICU patient has a creatinine clearance (CrCl) of 25 mL/min and weighs 70 kg. The standard gentamicin dose is 5 mg/kg/day for CrCl ≥ 60 mL/min. Using proportional dose reduction, what is the adjusted daily dose?

175 mg/day
350 mg/day
146 mg/day (Correct answer)
233 mg/day

Correct answer: 146 mg/day

Standard dose = 5 mg/kg × 70 kg = 350 mg/day. Adjustment factor = 25 ÷ 60 = 0.417. Adjusted dose = 350 × 0.417 ≈ 146 mg/day. In Saudi CBAHI-accredited facilities, therapeutic drug monitoring (TDM) of aminoglycosides is mandatory for renal-impaired patients; target peak 5–10 mcg/mL, trough < 2 mcg/mL to avoid nephrotoxicity and ototoxicity.

Question 185: A patient with traumatic brain injury is assessed and has a GCS score of 6. The nurse should interpret this score as indicating:

Vegetative state with no meaningful response
Severe brain injury requiring immediate airway management (Correct answer)
Moderate brain injury — patient responds to verbal stimuli only
Mild brain injury — patient is oriented and follows commands

Correct answer: Severe brain injury requiring immediate airway management

A GCS score of 8 or below indicates severe brain injury; these patients typically cannot protect their airway and require endotracheal intubation.

Question 186: A nurse preparing chemotherapy inadvertently spills the agent on their skin. What is the FIRST action to take?

Immediately flush the affected area with copious water and report the exposure (Correct answer)
Notify the pharmacist and wait for further instructions
Apply a topical antibiotic and continue working
Finish preparing the medication before addressing the spill

Correct answer: Immediately flush the affected area with copious water and report the exposure

Immediate flushing with copious water is the primary first-aid response for chemotherapy skin exposure, followed by formal incident reporting.

Question 187: Which class of drugs is contraindicated in patients with bilateral renal artery stenosis?

Beta-blockers
ACE inhibitors and ARBs (Correct answer)
Thiazide diuretics
Calcium channel blockers

Correct answer: ACE inhibitors and ARBs

ACE inhibitors and ARBs reduce glomerular filtration pressure by dilating the efferent arteriole. In bilateral renal artery stenosis, where perfusion pressure is maintained by angiotensin II, this effect causes acute renal failure. These drugs are contraindicated in this condition.

Question 188: A 7-year-old Saudi child is admitted with acute streptococcal pharyngitis. On day 14, the child presents with periorbital edema, tea-colored urine, hypertension (BP 130/88 mmHg), and oliguria. Urinalysis shows 3+ protein, RBC casts, and granular casts. Which nursing intervention is MOST appropriate to include in the immediate management plan?

Encourage oral fluid intake of ≥2 L/day to flush the renal tubules and prevent cast accumulation
Prepare the child for urgent hemodialysis as RBC casts indicate irreversible renal failure
Restrict sodium and fluid intake and monitor blood pressure every 2–4 hours (Correct answer)
Administer IM penicillin G benzathine immediately to eradicate the ongoing streptococcal infection

Correct answer: Restrict sodium and fluid intake and monitor blood pressure every 2–4 hours

This presentation is classic post-streptococcal glomerulonephritis (PSGN). The primary nursing concerns are hypertension and fluid overload. The immediate management includes sodium restriction (≤2 g/day), fluid restriction based on urine output plus insensible losses, and frequent blood pressure monitoring to guide antihypertensive therapy. Encouraging fluids would worsen hypertension and edema in an oliguric patient. Penicillin treats active infection but PSGN is immune-mediated and the acute phase does not respond to antibiotics (the throat infection is already resolving by this stage). RBC casts indicate glomerular inflammation, not permanent failure — PSGN in children typically resolves spontaneously; dialysis is rarely needed.

Question 189: A nurse is caring for a patient following a myocardial infarction. The patient develops new ST elevation in leads II, III, and aVF. Which area of the heart is most likely affected?

Inferior wall (Correct answer)
Posterior wall
Anterior wall
Lateral wall

Correct answer: Inferior wall

Leads II, III, and aVF view the inferior wall of the heart, which is supplied by the right coronary artery (RCA). ST elevation in these leads indicates an inferior MI, most commonly due to RCA occlusion.

Question 190: A 44-year-old Saudi female patient with type 2 diabetes and CKD Stage 3b (eGFR 32 mL/min/1.73m²) is admitted for elective coronary angiography. She takes metformin 1 g twice daily. Serum creatinine is 168 µmol/L. As the admitting nurse, which pre-procedural action regarding her metformin is CORRECT according to current clinical practice?

Administer sodium bicarbonate IV pre-hydration to neutralize metformin-associated lactic acid before contrast exposure
Switch metformin to insulin sliding scale 24 hours before the procedure and resume metformin the evening of the procedure
Hold metformin 48 hours before the procedure and restart only after confirming stable renal function post-contrast (Correct answer)
Continue metformin as usual since her eGFR is above 30 mL/min/1.73m², which is the absolute contraindication threshold

Correct answer: Hold metformin 48 hours before the procedure and restart only after confirming stable renal function post-contrast

Iodinated contrast media used in coronary angiography can cause contrast-induced nephropathy (CIN), which may transiently reduce renal function. Metformin is renally cleared and accumulates in renal impairment; if AKI occurs post-contrast and metformin continues, lactic acidosis risk increases significantly. Current SCFHS/Saudi clinical practice guidelines (aligned with ESC/ACC) recommend withholding metformin 48 hours before intravascular iodinated contrast in patients with eGFR <45 mL/min/1.73m² (CKD Stage 3b), and restarting only after re-checking renal function at 48 hours post-procedure if stable. Option A is incorrect — the threshold for extra caution is eGFR <45, not <30. Option C (bicarbonate for lactic acid neutralization) is not indicated prophylactically. Option D's restart timing is too early.

Question 191: A patient with diabetic ketoacidosis (DKA) has blood glucose 480 mg/dL, pH 7.18, HCO3 10 mEq/L, and urine ketones positive. After initial fluid resuscitation, the priority treatment is:

Infuse sodium bicarbonate
Administer oral metformin
Administer glucagon injection
Start a continuous regular insulin infusion (Correct answer)

Correct answer: Start a continuous regular insulin infusion

Continuous regular insulin infusion is the cornerstone of DKA treatment after adequate fluid resuscitation; it suppresses ketogenesis and gradually lowers blood glucose.

Question 192: A patient with acute MI is prescribed streptokinase. Which finding is an absolute contraindication to thrombolytic therapy?

Serum potassium of 4.2 mEq/L
Hypertension of 150/90 mmHg
Recent intracranial surgery within 3 months (Correct answer)
Age over 65 years

Correct answer: Recent intracranial surgery within 3 months

Recent intracranial surgery, stroke, or head trauma within 3 months is an absolute contraindication to thrombolytic therapy due to the high risk of intracranial hemorrhage. Other absolute contraindications include active internal bleeding and known intracranial neoplasm.

Question 193: A nurse notes that a patient's blood culture has grown MRSA. Which precautions should be implemented?

Droplet precautions with surgical mask
Airborne precautions only
Contact precautions (gown and gloves) for all patient care activities (Correct answer)
No additional precautions beyond standard precautions

Correct answer: Contact precautions (gown and gloves) for all patient care activities

MRSA (methicillin-resistant Staphylococcus aureus) is transmitted primarily through direct skin-to-skin contact and contact with contaminated surfaces. Contact precautions (gown and gloves for all patient contact) are required in addition to standard precautions.

Question 194: The nurse observes bradycardia, systolic hypertension with widened pulse pressure, and irregular respirations in a patient with a severe head injury. This clinical triad is known as:

Charcot's triad
Virchow's triad
Beck's triad
Cushing's triad (Correct answer)

Correct answer: Cushing's triad

Cushing's triad (bradycardia, hypertension with widened pulse pressure, and irregular respirations) is a late and ominous sign of brainstem herniation due to critically elevated ICP.

Question 195: A patient with myasthenia gravis is in crisis. What distinguishes a myasthenic crisis from a cholinergic crisis?

Myasthenic crisis worsens with edrophonium; cholinergic crisis improves
Neither crisis is affected by edrophonium
Both crises improve with edrophonium
Myasthenic crisis improves with edrophonium (Tensilon test); cholinergic crisis worsens (Correct answer)

Correct answer: Myasthenic crisis improves with edrophonium (Tensilon test); cholinergic crisis worsens

The Tensilon (edrophonium) test differentiates the two crises: myasthenic crisis (under-medication) improves with edrophonium because it increases acetylcholine. Cholinergic crisis (over-medication with anticholinesterases) worsens with edrophonium.

Question 196: Which blood pressure reading would be classified as hypertension stage 1 according to current guidelines?

120–129/<80 mmHg
130–139/80–89 mmHg (Correct answer)
<120/<80 mmHg
≥140/≥90 mmHg

Correct answer: 130–139/80–89 mmHg

According to updated cardiovascular guidelines, hypertension stage 1 is defined as systolic 130–139 mmHg or diastolic 80–89 mmHg. Elevated blood pressure is 120–129/<80, and stage 2 hypertension is ≥140/≥90.

Question 197: A nurse working in a general medical ward in Riyadh is caring for a 68-year-old male patient with chronic kidney disease (CKD) Stage 4. The physician prescribes enemas until clear for bowel preparation before a diagnostic procedure. After the third enema, the patient becomes increasingly lethargic and his serum sodium returns at 128 mEq/L. Which physiological mechanism best explains this complication?

Stimulation of ADH release secondary to rectal pressure causing free water retention
Suppression of aldosterone secretion due to bowel distension
Sodium loss through repeated stool evacuation causing true hyponatraemia
Absorption of hypotonic tap water through the colonic mucosa leading to dilutional hyponatraemia (Correct answer)

Correct answer: Absorption of hypotonic tap water through the colonic mucosa leading to dilutional hyponatraemia

In CKD patients, the kidneys cannot excrete free water efficiently. Repeated tap water enemas result in absorption of hypotonic fluid across the colonic mucosa, expanding intravascular volume and diluting serum sodium — producing dilutional (hypotonic) hyponatraemia. This is particularly dangerous in CKD Stage 4 where GFR is 15–29 mL/min/1.73m². SCFHS guidelines emphasise caution with volume-expanding procedures in renally impaired patients. Sodium is not lost in significant quantities through stool, and aldosterone/ADH mechanisms described in the other options do not account for the primary pathophysiology here.

Question 198: A patient on digoxin reports seeing yellow-green halos around lights. The nurse's priority action is to:

Reassure the patient this is a normal side effect
Check serum potassium and digoxin levels immediately (Correct answer)
Increase oral fluid intake
Administer the next scheduled dose as planned

Correct answer: Check serum potassium and digoxin levels immediately

Visual disturbances (yellow-green halos) are a classic sign of digoxin toxicity; serum digoxin and electrolyte levels must be checked immediately.

Question 199: A medical-surgical nurse in a Saudi hospital is caring for a patient on warfarin therapy for atrial fibrillation who undergoes an elective knee replacement. On post-op day 1, the patient's INR is 1.1. The orthopedic surgeon prescribes low molecular weight heparin (LMWH) for DVT prophylaxis. The patient's renal function shows a GFR of 22 mL/min/1.73m². Which action should the nurse take?

Restart warfarin immediately and hold LMWH until INR reaches therapeutic range of 2.0–3.0
Administer the LMWH and monitor anti-Xa levels 4 hours post-injection to guide therapy
Withhold the LMWH and contact the physician, as severe renal impairment (GFR <30) requires dose adjustment or alternative anticoagulation (Correct answer)
Administer the LMWH as prescribed, as LMWH is safe regardless of renal function when used for prophylaxis only

Correct answer: Withhold the LMWH and contact the physician, as severe renal impairment (GFR <30) requires dose adjustment or alternative anticoagulation

LMWH (e.g., enoxaparin) is predominantly renally cleared. In patients with GFR <30 mL/min, there is significant accumulation risk leading to over-anticoagulation and major bleeding. The Saudi Commission for Health Specialties (SCFHS) and international pharmacovigilance standards require dose reduction (e.g., enoxaparin 0.5 mg/kg once daily) or switching to unfractionated heparin, which is not renally cleared. The nurse's professional obligation is to withhold and clarify before administration — a critical patient safety act. Monitoring anti-Xa is appropriate if LMWH is continued after adjustment, not before addressing the contraindication. Restarting warfarin immediately post-operatively without bridging is inappropriate and not indicated here.

Question 200: A patient's Glasgow Coma Scale score is 8. How should the nurse interpret this finding?

Mild confusion with intact orientation
Severe brain injury requiring immediate intervention (Correct answer)
Normal neurological status
Moderate injury with expected full recovery

Correct answer: Severe brain injury requiring immediate intervention

The Glasgow Coma Scale ranges from 3 (deep coma/brain death) to 15 (fully alert). A score of 8 or below indicates severe brain injury and typically necessitates airway management and urgent medical intervention.

SCFHS Saudi Nursing Licensing Exam (SNLE)

The Saudi Nursing Licensing Exam (SNLE), administered by the Saudi Commission for Health Specialties (SCFHS) via Prometric, assesses the competency of nursing professionals seeking licensure to practice in Saudi Arabia.

200

Questions

270 min

Time Limit

63%

To Pass

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scfhs.org.sa — Test dates, test delivery, eligibility, exam format, passing score, retake policy, score release · verified Oct 2026