1.

Using the principles of standard precautions, the nurse would wear gloves in what nursing

interventions?

a. Providing a back massage

b. Feeding a client

c. Providing hair care

d. Providing oral hygiene

2. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration

secondary to vomiting and diarrhea. What is the best method used to assess the client’s

temperature?

a. Oral

b. Axillary

c. Radial

d. Heat sensitive tape

3. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document this

findings as:

a. Tachypnea

b. Hyper pyrexia

c. Arrythmia

d. Tachycardia

4. Which of the following actions should the nurse take to use a wide base support when assisting a

client to get up in a chair?

a. Bend at the waist and place arms under the client’s arms and lift

b. Face the client, bend knees and place hands on client’s forearm and lift

c. Spread his or her feet apart

d. Tighten his or her pelvic muscles

5. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the

skin flushed and warm. Which of the following would be the best method to take the client’s body

temperature?

a. Oral

b. Axillary

c. Arterial line

d. Rectal

6. A client who is unconscious needs frequent mouth care. When performing a mouth care, the best

position of a client is:

a. Fowler’s position

b. Side lying
 c. Supine

d. Trendelenburg

7. A client is hospitalized for the first time, which of the following actions ensure the safety of the

client?

a. Keep unnecessary furniture out of the way

b. Keep the lights on at all time

c. Keep side rails up at all time

d. Keep all equipment out of view

8. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The

nurse takes the client’s vital sign hereafter. What phrase of nursing process is being implemented

here by the nurse?

a. Assessment

b. Diagnosis

c. Planning

d. Implementation

9. It is best describe as a systematic, rational method of planning and providing nursing care for

individual, families, group and community

a. Assessment

b. Nursing Process

c. Diagnosis

d. Implementation

10. Exchange of gases takes place in which of the following organ?

a. Kidney

b. Lungs

c. Liver

d. Heart

11. The Chamber of the heart that receives oxygenated blood from the lungs is the?

a. Left atrium

b. Right atrium

c. Left ventricle

d. Right ventricle

12. A muscular enlarge pouch or sac that lies slightly to the left which is used for temporary storage of

food…

a. Gallbladder

b. Urinary bladder

c. Stomach
 d. Lungs

13. The ability of the body to defend itself against scientific invading agent such as baceria, toxin,

viruses and foreign body

a. Hormones

b. Secretion

c. Immunity

d. Glands

14. Hormones secreted by Islets of Langerhans

a. Progesterone

b. Testosterone

c. Insulin

d. Hemoglobin

15. It is a transparent membrane that focuses the light that enters the eyes to the retina.

a. Lens

b. Sclera

c. Cornea

d. Pupils

16. Which of the following is included in Orem’s theory?

a. Maintenance of a sufficient intake of air

b. Self perception

c. Love and belonging

d. Physiologic needs

17. Which of the following cluster of data belong to Maslow’s hierarchy of needs

a. Love and belonging

b. Physiologic needs

c. Self actualization

d. All of the above

18. This is characterized by severe symptoms relatively of short duration.

a. Chronic Illness

b. Acute Illness

c. Pain

d. Syndrome

19. Which of the following is the nurse’s role in the health promotion

a. Health risk appraisal

b. Teach client to be effective health consumer

c. Worksite wellness
 d. None of the above

20. It is describe as a collection of people who share some attributes of their lives.

a. Family

b. Illness

c. Community

d. Nursing

21. Five teaspoon is equivalent to how many milliliters (ml)?

a. 30 ml

b. 25 ml

c. 12 ml

d. 22 ml

22. 1800 ml is equal to how many liters?

a. 1.8

b. 18000

c. 180

d. 2800

23. Which of the following is the abbreviation of drops?

a. Gtt.

b. Gtts.

c. Dp.

d. Dr.

24. The abbreviation for micro drop is…

a. µgtt

b. gtt

c. mdr

d. mgts

25. Which of the following is the meaning of PRN?

a. When advice

b. Immediately

c. When necessary

d. Now

26. Which of the following is the appropriate meaning of CBR?

a. Cardiac Board Room

b. Complete Bathroom

c. Complete Bed Rest

d. Complete Board Room

27. 1 tsp is equals to how many drops?

a. 15

b. 60

c. 10

d. 30

28. 20 cc is equal to how many ml?

a. 2

b. 20

c. 2000

d. 20000

29. 1 cup is equals to how many ounces?

a. 8

b. 80

c. 800

d. 8000

30. The nurse must verify the client’s identity before administration of medication. Which of the

following is the safest way to identify the client?

a. Ask the client his name

b. Check the client’s identification band

c. State the client’s name aloud and have the client repeat it

d. Check the room number

31. The nurse prepares to administer buccal medication. The medicine should be placed…

a. On the client’s skin

b. Between the client’s cheeks and gums

c. Under the client’s tongue

d. On the client’s conjuctiva

32. The nurse administers cleansing enema. The common position for this procedure is…

a. Sims left lateral

b. Dorsal Recumbent

c. Supine

d. Prone

33. A client complains of difficulty of swallowing, when the nurse try to administer capsule medication.

Which of the following measures the nurse should do?

a. Dissolve the capsule in a glass of water

b. Break the capsule and give the content with an applesauce

c. Check the availability of a liquid preparation

 d. Crash the capsule and place it under the tongue

34. Which of the following is the appropriate route of administration for insulin?

a. Intramuscular

b. Intradermal

c. Subcutaneous

d. Intravenous

35. The nurse is ordered to administer ampicillin capsule TIP p.o. The nurse shoud give the medication…

a. Three times a day orally

b. Three times a day after meals

c. Two time a day by mouth

d. Two times a day before meals

36. Back Care is best describe as:

a. Caring for the back by means of massage

b. Washing of the back

c. Application of cold compress at the back

d. Application of hot compress at the back

37. It refers to the preparation of the bed with a new set of linens

a. Bed bath

b. Bed making

c. Bed shampoo

d. Bed lining

38. Which of the following is the most important purpose of handwashing

a. To promote hand circulation

b. To prevent the transfer of microorganism

c. To avoid touching the client with a dirty hand

d. To provide comfort

39. What should be done in order to prevent contaminating of the environment in bed making?

a. Avoid funning soiled linens

b. Strip all linens at the same time

c. Finished both sides at the time

d. Embrace soiled linen

40. The most important purpose of cleansing bed bath is:

a. To cleanse, refresh and give comfort to the client who must remain in bed

b. To expose the necessary parts of the body

c. To develop skills in bed bath

d. To check the body temperature of the client in bed

41. Which of the following technique involves the sense of sight?

a. Inspection

b. Palpation

c. Percussion

d. Auscultation

42. The first techniques used examining the abdomen of a client is:

a. Palpation

b. Auscultation

c. Percussion

d. Inspection

43. A technique in physical examination that is use to assess the movement of air through the

tracheobronchial tree:

a. Palpation

b. Auscultation

c. Inspection

d. Percussion

44. An instrument used for auscultation is:

a. Percussion-hammer

b. Audiometer

c. Stethoscope

d. Sphygmomanometer

45. Resonance is best describe as:

a. Sounds created by air filled lungs

b. Short, high pitch and thudding

c. Moderately loud with musical quality

d. Drum-like

46. The best position for examining the rectum is:

a. Prone

b. Sim’s

c. Knee-chest

d. Lithotomy

47. It refers to the manner of walking

a. Gait

b. Range of motion

c. Flexion and extension

d. Hopping
 48. The nurse asked the client to read the Snellen chart. Which of the following is tested:

a. Optic

b. Olfactory

c. Oculomotor

d. Troclear

49. Another name for knee-chest position is:

a. Genu-dorsal

b. Genu-pectoral

c. Lithotomy

d. Sim’s

50. The nurse prepare IM injection that is irritating to the subcutaneous tissue. Which of the following is

the best action in order to prevent tracking of the medication

a. Use a small gauge needle

b. Apply ice on the injection site

c. Administer at a 45° angle

d. Use the Z-track technique

Answer Key

d 11.a 21.b 31.b 41.a

2.b 12.c 22.a 32.a 42.d
3.d 13.c 23.b 33.c 43.b
4b 14.c 24.a 34.c 44.c
5.b 15.c 25.c 35.a 45.a
6.b 16.a 26.c 36.a 46.vc
7.c 17.d 27.b 37.b 47.a
8.a 18.b 28.b 38.b 48.a
9.b 19.b 29.a 39.a 49.b
10.b 20.c 30.a 40.a 50.d
1. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath

would be…

a. Maintain the patient on strict bed rest at all times

b. Maintain the patient in an orthopneic position as needed

c. Administer oxygen by Venturi mask at 24%, as needed

d. Allow a 1 hour rest period between activities

2. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the

head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse

documents this breathing as:

a. Tachypnea

b. Eupnca

c. Orthopnea

d. Hyperventilation

3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is

responsible for:

a. Instructing the patient about this diagnostic test

b. Writing the order for this test

c. Giving the patient breakfast

d. All of the above

4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg

low sodium diet. These include:

a. A ham and Swiss cheese sandwich on whole wheat bread

b. Mashed potatoes and broiled chicken

c. A tossed salad with oil and vinegar and olives

d. Chicken bouillon

5. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant)

daily. Nursing responsibilities for Mrs. Mitchell now include:

a. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.

b. Reporting an APTT above 45 seconds to the physician

c. Assessing the patient for signs and symptoms of frank and occult bleeding

d. All of the above

6. The four main concepts common to nursing that appear in each of the current conceptual models

are:

a. Person, nursing, environment, medicine

b. Person, health, nursing, support systems

c. Person, health, psychology, nursing

 d. Person, environment, health, nursing

7. In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is:

a. Love

b. Elimination

c. Nutrition

d. Oxygen

8. The family of an accident victim who has been declared brain-dead seems amenable to organ

donation. What should the nurse do?

a. Discourage them from making a decision until their grief has eased

b. Listen to their concerns and answer their questions honestly

c. Encourage them to sign the consent form right away

d. Tell them the body will not be available for a wake or funeral

9. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift.

What should she do?

a. Complain to her fellow nurses

b. Wait until she knows more about the unit

c. Discuss the problem with her supervisor

d. Inform the staff that they must volunteer to rotate

10. Which of the following principles of primary nursing has proven the most satisfying to the patient

and nurse?

a. Continuity of patient care promotes efficient, cost-effective nursing care

b. Autonomy and authority for planning are best delegated to a nurse who knows the patient well

c. Accountability is clearest when one nurse is responsible for the overall plan and its

implementation.

d. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing

care.

11. If nurse administers an injection to a patient who refuses that injection, she has committed:

a. Assault and battery

b. Negligence

c. Malpractice

d. None of the above

12. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the

physician is incompetent, the nurse could be held liable for:

a. Slander

b. Libel

c. Assault
 d. Respondent superior

13. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning

away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a

skull fracture. The nurse could be charged with:

a. Defamation

b. Assault

c. Battery

d. Malpractice

14. Which of the following is an example of nursing malpractice?

a. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The

patient experiences an allergic reaction and has cerebral damage resulting from anoxia.

b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal

cramping.

c. The nurse assists a patient out of bed with the bed locked in position; the patient slips and

fractures his right humerus.

d. The nurse administers the wrong medication to a patient and the patient vomits. This information

is documented and reported to the physician and the nursing supervisor.

15. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian

patient for postoperative pain following abdominal surgery?

a. Decreased blood pressure and heart rate and shallow respirations

b. Quiet crying

c. Immobility, diaphoresis, and avoidance of deep breathing or coughing

d. Changing position every 2 hours

16. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe

abdominal pain. Which of the following would immediately alert the nurse that the patient has

bleeding from the GI tract?

a. Complete blood count

b. Guaiac test

c. Vital signs

d. Abdominal girth

17. The correct sequence for assessing the abdomen is:

a. Tympanic percussion, measurement of abdominal girth, and inspection

b. Assessment for distention, tenderness, and discoloration around the umbilicus.

c. Percussions, palpation, and auscultation

d. Auscultation, percussion, and palpation

18. High-pitched gurgles head over the right lower quadrant are:
 a. A sign of increased bowel motility

b. A sign of decreased bowel motility

c. Normal bowel sounds

d. A sign of abdominal cramping

19. A patient about to undergo abdominal inspection is best placed in which of the following positions?

a. Prone

b. Trendelenburg

c. Supine

d. Side-lying

20. For a rectal examination, the patient can be directed to assume which of the following positions?

a. Genupecterol

b. Sims

c. Horizontal recumbent

d. All of the above

21. During a Romberg test, the nurse asks the patient to assume which position?

a. Sitting

b. Standing

c. Genupectoral

d. Trendelenburg

22. If a patient’s blood pressure is 150/96, his pulse pressure is:

a. 54

b. 96

c. 150

d. 246

23. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is

99.8 F (37.7 C) This temperature reading probably indicates:

a. Infection

b. Hypothermia

c. Anxiety

d. Dehydration

24. Which of the following parameters should be checked when assessing respirations?

a. Rate

b. Rhythm

c. Symmetry

d. All of the above

25. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate,

88; respiratory rate, 30. Which findings should be reported?

a. Respiratory rate only

b. Temperature only

c. Pulse rate and temperature

d. Temperature and respiratory rate

26. All of the following can cause tachycardia except:

a. Fever

b. Exercise

c. Sympathetic nervous system stimulation

d. Parasympathetic nervous system stimulation

27. Palpating the midclavicular line is the correct technique for assessing

a. Baseline vital signs

b. Systolic blood pressure

c. Respiratory rate

d. Apical pulse

28. The absence of which pulse may not be a significant finding when a patient is admitted to the

hospital?

a. Apical

b. Radial

c. Pedal

d. Femoral

29. Which of the following patients is at greatest risk for developing pressure ulcers?

a. An alert, chronic arthritic patient treated with steroids and aspirin

b. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home

c. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula

d. A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get

out of bed.

30. The physician orders the administration of high-humidity oxygen by face mask and placement of the

patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing

diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing

interventions has the greatest potential for improving this situation?

a. Encourage the patient to increase her fluid intake to 200 ml every 2 hours

b. Place a humidifier in the patient’s room.

c. Continue administering oxygen by high humidity face mask

d. Perform chest physiotheraphy on a regular schedule

31. The most common deficiency seen in alcoholics is:

a. Thiamine

b. Riboflavin

c. Pyridoxine

d. Pantothenic acid

32. Which of the following statement is incorrect about a patient with dysphagia?

a. The patient will find pureed or soft foods, such as custards, easier to swallow than water

b. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing

c. The patient should always feed himself

d. The nurse should perform oral hygiene before assisting with feeding.

33. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse

measures his hourly urine output. She should notify the physician if the urine output is:

a. Less than 30 ml/hour

b. 64 ml in 2 hours

c. 90 ml in 3 hours

d. 125 ml in 4 hours

34. Certain substances increase the amount of urine produced. These include:

a. Caffeine-containing drinks, such as coffee and cola.

b. Beets

c. Urinary analgesics

d. Kaolin with pectin (Kaopectate)

35. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first

attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his

vision was unaffected by the surgery. Which of the following nursing interventions would be

appropriate?

a. Encourage the patient to walk in the hall alone

b. Discourage the patient from walking in the hall for a few more days

c. Accompany the patient for his walk.

d. Consuit a physical therapist before allowing the patient to ambulate

36. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by

shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An

appropriate nursing diagnosis would be:

a. Ineffective airway clearance related to thick, tenacious secretions.

b. Ineffective airway clearance related to dry, hacking cough.

c. Ineffective individual coping to COPD.

d. Pain related to immobilization of affected leg.

37. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be:

a. “Don’t worry. It’s only temporary”

b. “Why are you crying? I didn’t get to the bad news yet”

c. “Your hair is really pretty”

d. “I know this will be difficult for you, but your hair will grow back after the completion of

chemotheraphy”

38. An additional Vitamin C is required during all of the following periods except:

a. Infancy

b. Young adulthood

c. Childhood

d. Pregnancy

39. A prescribed amount of oxygen s needed for a patient with COPD to prevent:

a. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)

b. Circulatory overload due to hypervolemia

c. Respiratory excitement

d. Inhibition of the respiratory hypoxic stimulus

40. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most

significant symptom of his disorder?

a. Lethargy

b. Increased pulse rate and blood pressure

c. Muscle weakness

d. Muscle irritability

41. Which of the following nursing interventions promotes patient safety?

a. Asses the patient’s ability to ambulate and transfer from a bed to a chair

b. Demonstrate the signal system to the patient

c. Check to see that the patient is wearing his identification band

d. All of the above

42. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has

led to which of the following conclusions?

a. Side rails are ineffective

b. Side rails should not be used

c. Side rails are a deterrent that prevent a patient from falling out of bed.

d. Side rails are a reminder to a patient not to get out of bed

43. Examples of patients suffering from impaired awareness include all of the following except:

a. A semiconscious or over fatigued patient

b. A disoriented or confused patient

 c. A patient who cannot care for himself at home

d. A patient demonstrating symptoms of drugs or alcohol withdrawal

44. The most common injury among elderly persons is:

a. Atheroscleotic changes in the blood vessels

b. Increased incidence of gallbladder disease

c. Urinary Tract Infection

d. Hip fracture

45. The most common psychogenic disorder among elderly person is:

a. Depression

b. Sleep disturbances (such as bizarre dreams)

c. Inability to concentrate

d. Decreased appetite

46. Which of the following vascular system changes results from aging?

a. Increased peripheral resistance of the blood vessels

b. Decreased blood flow

c. Increased work load of the left ventricle

d. All of the above

47. Which of the following is the most common cause of dementia among elderly persons?

a. Parkinson’s disease

b. Multiple sclerosis

c. Amyotrophic lateral sclerosis (Lou Gerhig’s disease)

d. Alzheimer’s disease

48. The nurse’s most important legal responsibility after a patient’s death in a hospital is:

a. Obtaining a consent of an autopsy

b. Notifying the coroner or medical examiner

c. Labeling the corpse appropriately

d. Ensuring that the attending physician issues the death certification

49. Before rigor mortis occurs, the nurse is responsible for:

a. Providing a complete bath and dressing change

b. Placing one pillow under the body’s head and shoulders

c. Removing the body’s clothing and wrapping the body in a shroud

d. Allowing the body to relax normally

50. When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a

major nursing priority is to:

a. Protect the patient from injury

b. Insert an airway
 c. Elevate the head of the bed

d. Withdraw all pain medications

1. B. When a patient develops dyspnea and shortness of breath, the orthopneic position encourages

maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm,

thus improving ventilation. Bed rest and oxygen by Venturi mask at 24% would improve

oxygenation of the tissues and cells but must be ordered by a physician. Allowing for rest periods

decreases the possibility of hypoxia.

2. C. Orthopnea is difficulty of breathing except in the upright position. Tachypnea is rapid respiration

characterized by quick, shallow breaths. Eupnea is normal respiration – quiet, rhythmic, and without

effort.

3. C. A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is

responsible for giving the patient breakfast at the scheduled time. The physician is responsible for

instructing the patient about the test and for writing the order for the test.

4. B. Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham, olives, and

chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet.

5. D. All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The

normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time

is 12 to 15 seconds; these levels must remain within two to two and one half the normal levels. All

patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and

occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor,

cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and

the patient should be instructed to report promptly any bleeding that occurs with tooth brushing,

bowel movements, urination or heavy prolonged menstruation.

6. D. The focus concepts that have been accepted by all theorists as the focus of nursing practice from

the time of Florence Nightingale include the person receiving nursing care, his environment, his

health on the health illness continuum, and the nursing actions necessary to meet his needs.

7. D. Maslow, who defined a need as a satisfaction whose absence causes illness, considered oxygen

to be the most important physiologic need; without it, human life could not exist. According to this

theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity

and temperature regulation) must be met before proceeding to the next hierarchical levels on

psychosocial needs.

8. B. The brain-dead patient’s family needs support and reassurance in making a decision about organ

donation. Because transplants are done within hours of death, decisions about organ donation must

be made as soon as possible. However, the family’s concerns must be addressed before members

are asked to sign a consent form. The body of an organ donor is available for burial.
9. C. Although a new head nurse should initially spend time observing the unit for its strengths and

weakness, she should take action if a problem threatens patient safety. In this case, the supervisor

is the resource person to approach.

10. D. Studies have shown that patients and nurses both respond well to primary nursing care units.

Patients feel less anxious and isolated and more secure because they are allowed to participate in

planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback

from the patients. They also seem to gain a greater sense of achievement and esprit de corps.

11. A. Assault is the unjustifiable attempt or threat to touch or injure another person. Battery is the

unlawful touching of another person or the carrying out of threatened physical harm. Thus, any act

that a nurse performs on the patient against his will is considered assault and battery.

12. A. Oral communication that injures an individual’s reputation is considered slander. Written

communication that does the same is considered libel.

13. D. Malpractice is defined as injurious or unprofessional actions that harm another. It involves

professional misconduct, such as omission or commission of an act that a reasonable and prudent

nurse would or would not do. In this example, the standard of care was breached; a 3-month-old

infant should never be left unattended on a scale.

14. A. The three elements necessary to establish a nursing malpractice are nursing error (administering

penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and

proximal cause (administering the penicillin caused the cerebral damage). Applying a hot water

bottle or heating pad to a patient without a physician’s order does not include the three required

components. Assisting a patient out of bed with the bed locked in position is the correct nursing

practice; therefore, the fracture was not the result of malpractice. Administering an incorrect

medication is a nursing error; however, if such action resulted in a serious illness or chronic

problem, the nurse could be sued for malpractice.

15. C. An Asian patient is likely to hide his pain. Consequently, the nurse must observe for objective

signs. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance

of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from

pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the

abdominal wall. Such a patient is unlikely to display emotion, such as crying.

16. B. To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can

test for occult blood in vomitus, if present, or in stool – through guaiac (Hemoccult) test. A

complete blood count does not provide immediate results and does not always immediately reflect

blood loss. Changes in vital signs may be cause by factors other than blood loss. Abdominal girth is

unrelated to blood loss.

17. D. Because percussion and palpation can affect bowel motility and thus bowel sounds, they should

follow auscultation in abdominal assessment. Tympanic percussion, measurement of abdominal

 girth, and inspection are methods of assessing the abdomen. Assessing for distention, tenderness

and discoloration around the umbilicus can indicate various bowel-related conditions, such as

cholecystitis, appendicitis and peritonitis.

18. C. Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate

decreased bowel motility. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds

can indicate a bowel obstruction.

19. C. The supine position (also called the dorsal position), in which the patient lies on his back with his

face upward, allows for easy access to the abdomen. In the prone position, the patient lies on his

abdomen with his face turned to the side. In the Trendelenburg position, the head of the bed is

tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. In the lateral

position, the patient lies on his side.

20. D. All of these positions are appropriate for a rectal examination. In the genupectoral (knee-chest)

position, the patient kneels and rests his chest on the table, forming a 90 degree angle between the

torso and upper legs. In Sims’ position, the patient lies on his left side with the left arm behind the

body and his right leg flexed. In the horizontal recumbent position, the patient lies on his back with

legs extended and hips rotated outward.

21. B. During a Romberg test, which evaluates for sensory or cerebellar ataxia, the patient must stand

with feet together and arms resting at the sides—first with eyes open, then with eyes closed. The

need to move the feet apart to maintain this stance is an abnormal finding.

22. A. The pulse pressure is the difference between the systolic and diastolic blood pressure readings –

in this case, 54.

23. D. A slightly elevated temperature in the immediate preoperative or post operative period may

result from the lack of fluids before surgery rather than from infection. Anxiety will not cause an

elevated temperature. Hypothermia is an abnormally low body temperature.

24. D. The quality and efficiency of the respiratory process can be determined by appraising the rate,

rhythm, depth, ease, sound, and symmetry of respirations.

25. D. Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20

times a minute. Thus, a respiratory rate of 30 would be abnormal. A normal adult body

temperature, as measured on an oral thermometer, ranges between 97° and 100°F (36.1° and

37.8°C); an axillary temperature is approximately one degree lower and a rectal temperature, one

degree higher. Thus, an axillary temperature of 99.6°F (37.6°C) would be considered abnormal. The

resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal.

26. D. Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the

force of contraction, rate of impulse conduction and blood flow through the coronary vessels. Fever,

exercise, and sympathetic stimulation all increase the heart rate.

27. D. The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the

fourth, fifth, or sixth intercostal space. Base line vital signs include pulse rate, temperature,

respiratory rate, and blood pressure. Blood pressure is typically assessed at the antecubital fossa,

and respiratory rate is assessed best by observing chest movement with each inspiration and

expiration.

28. C. Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not

necessarily a significant finding. However, the presence or absence of the pedal pulse should be

documented upon admission so that changes can be identified during the hospital stay. Absence of

the apical, radial, or femoral pulse is abnormal and should be investigated.

29. B. Pressure ulcers are most likely to develop in patients with impaired mental status, mobility,

activity level, nutrition, circulation and bladder or bowel control. Age is also a factor. Thus, the 88-

year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed

is at greater risk.

30. A. Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost

from elevated temperature, diaphoresis, dehydration and dyspnea. High- humidity air and chest

physiotherapy help liquefy and mobilize secretions.

31. A. Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition.

32. C. A patient with dysphagia (difficulty swallowing) requires assistance with feeding. Feeding himself

is a long-range expected outcome. Soft foods, Fowler’s or semi-Fowler’s position, and oral hygiene

before eating should be part of the feeding regimen.

33. A. A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to

kidney function and inadequate fluid intake.

34. A. Fluids containing caffeine have a diuretic effect. Beets and urinary analgesics, such as pyridium,

can color urine red. Kaopectate is an anti diarrheal medication.

35. C. A hospitalized surgical patient leaving his room for the first time fears rejection and others

staring at him, so he should not walk alone. Accompanying him will offer moral support, enabling

him to face the rest of the world. Patients should begin ambulation as soon as possible after surgery

to decrease complications and to regain strength and confidence. Waiting to consult a physical

therapist is unnecessary.

36. A. Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs

of ineffective airway clearance. Ineffective airway clearance related to dry, hacking cough is

incorrect because the cough is not the reason for the ineffective airway clearance. Ineffective

individual coping related to COPD is wrong because the etiology for a nursing diagnosis should not

be a medical diagnosis (COPD) and because no data indicate that the patient is coping ineffectively.

Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient

with a leg fracture.

37. D. “I know this will be difficult” acknowledges the problem and suggests a resolution to it. “Don’t

worry..” offers some relief but doesn’t recognize the patient’s feelings. “..I didn’t get to the bad

news yet” would be inappropriate at any time. “Your hair is really pretty” offers no consolation or

alternatives to the patient.

38. B. Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during

pregnancy to supply demands for fetal growth and maternal tissues. Other conditions requiring

extra vitamin C include wound healing, fever, infection and stress.

39. D. Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive

pulmonary disease (COPD), who is usually in a state of compensated respiratory acidosis (retaining

carbon dioxide (CO2)), can inhibit the hypoxic stimulus for respiration. An increased partial pressure

of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Circulatory

overload and respiratory excitement have no relevance to the question.

40. C. Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include

muscle weakness, chronic fatigue, and cardiac dysrhythmias. The combined effects of inadequate

food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems.

41. D. Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to

evaluate the patient’s ability to carry out these functions safely. Demonstrating the signal system

and providing an opportunity for a return demonstration ensures that the patient knows how to

operate the equipment and encourages him to call for assistance when needed. Checking the

patient’s identification band verifies the patient’s identity and prevents identification mistakes in

drug administration.

42. D. Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said

to prevent falls; however, they do serve as a reminder that the patient should not get out of bed.

The other answers are incorrect interpretations of the statistical data.

43. C. A patient who cannot care for himself at home does not necessarily have impaired awareness; he

may simply have some degree of immobility.

44. D. Hip fracture, the most common injury among elderly persons, usually results from osteoporosis.

The other answers are diseases that can occur in the elderly from physiologic changes.

45. A. Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression,

the most common psychogenic disorder among elderly persons. Other symptoms include diminished

memory, apathy, disinterest in appearance, withdrawal, and irritability. Depression typically begins

before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors

46. D. Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance

and decreased blood flow. These changes, in turn, increase the work load of the left ventricle.

47. D. Alzheimer;s disease, sometimes known as senile dementia of the Alzheimer’s type or primary

degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the

 brain whose etiology is still unknown. Parkinson’s disease is a neurologic disorder caused by lesions

in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia,

and dysphonia. Multiple sclerosis, a progressive, degenerative disease involving demyelination of

the nerve fibers, usually begins in young adulthood and is marked by periods of remission and

exacerbation. Amyotrophic lateral sclerosis, a disease marked by progressive degeneration of the

neurons, eventually results in atrophy of all the muscles; including those necessary for respiration.

48. C. The nurse is legally responsible for labeling the corpse when death occurs in the hospital. She

may be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of

a patient’s death; however, she is not legally responsible for performing these functions. The

attending physician may need information from the nurse to complete the death certificate, but he

is responsible for issuing it.

49. B. The nurse must place a pillow under the decreased person’s head and shoulders to prevent blood

from settling in the face and discoloring it. She is required to bathe only soiled areas of the body

since the mortician will wash the entire body. Before wrapping the body in a shroud, the nurse

places a clean gown on the body and closes the eyes and mouth.

50. A. Ensuring the patient’s safety is the most essential action at this time. The other nursing actions

may be necessary but are not a major priority.

51. Which element in the circular chain of infection can be eliminated by preserving skin integrity?

a. Host

b. Reservoir

c. Mode of transmission

d. Portal of entry

52. Which of the following will probably result in a break in sterile technique for respiratory isolation?

a. Opening the patient’s window to the outside environment

b. Turning on the patient’s room ventilator

c. Opening the door of the patient’s room leading into the hospital corridor

d. Failing to wear gloves when administering a bed bath

53. Which of the following patients is at greater risk for contracting an infection?

a. A patient with leukopenia

b. A patient receiving broad-spectrum antibiotics

c. A postoperative patient who has undergone orthopedic surgery

d. A newly diagnosed diabetic patient

54. Effective hand washing requires the use of:

a. Soap or detergent to promote emulsification

b. Hot water to destroy bacteria

c. A disinfectant to increase surface tension

 d. All of the above

55. After routine patient contact, hand washing should last at least:

a. 30 seconds

b. 1 minute

c. 2 minute

d. 3 minutes

56. Which of the following procedures always requires surgical asepsis?

a. Vaginal instillation of conjugated estrogen

b. Urinary catheterization

c. Nasogastric tube insertion

d. Colostomy irrigation

57. Sterile technique is used whenever:

a. Strict isolation is required

b. Terminal disinfection is performed

c. Invasive procedures are performed

d. Protective isolation is necessary

58. Which of the following constitutes a break in sterile technique while preparing a sterile field for a

dressing change?

a. Using sterile forceps, rather than sterile gloves, to handle a sterile item

b. Touching the outside wrapper of sterilized material without sterile gloves

c. Placing a sterile object on the edge of the sterile field

d. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile

container

59. A natural body defense that plays an active role in preventing infection is:

a. Yawning

b. Body hair

c. Hiccupping

d. Rapid eye movements

60. All of the following statement are true about donning sterile gloves except:

a. The first glove should be picked up by grasping the inside of the cuff.

b. The second glove should be picked up by inserting the gloved fingers under the cuff outside the

glove.

c. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the

glove over the wrist

d. The inside of the glove is considered sterile

61. When removing a contaminated gown, the nurse should be careful that the first thing she touches is

the:

a. Waist tie and neck tie at the back of the gown

b. Waist tie in front of the gown

c. Cuffs of the gown

d. Inside of the gown

62. Which of the following nursing interventions is considered the most effective form or universal

precautions?

a. Cap all used needles before removing them from their syringes

b. Discard all used uncapped needles and syringes in an impenetrable protective container

c. Wear gloves when administering IM injections

d. Follow enteric precautions

63. All of the following measures are recommended to prevent pressure ulcers except:

a. Massaging the reddened are with lotion

b. Using a water or air mattress

c. Adhering to a schedule for positioning and turning

d. Providing meticulous skin care

64. Which of the following blood tests should be performed before a blood transfusion?

a. Prothrombin and coagulation time

b. Blood typing and cross-matching

c. Bleeding and clotting time

d. Complete blood count (CBC) and electrolyte levels.

65. The primary purpose of a platelet count is to evaluate the:

a. Potential for clot formation

b. Potential for bleeding

c. Presence of an antigen-antibody response

d. Presence of cardiac enzymes

66. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?

a. 4,500/mm³

b. 7,000/mm³

c. 10,000/mm³

d. 25,000/mm³

67. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit

fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient

is experiencing:

a. Hypokalemia
 b. Hyperkalemia

c. Anorexia

d. Dysphagia

68. Which of the following statements about chest X-ray is false?

a. No contradictions exist for this test

b. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above

the waist

c. A signed consent is not required

d. Eating, drinking, and medications are allowed before this test

69. The most appropriate time for the nurse to obtain a sputum specimen for culture is:

a. Early in the morning

b. After the patient eats a light breakfast

c. After aerosol therapy

d. After chest physiotherapy

70. A patient with no known allergies is to receive penicillin every 6 hours. When administering the

medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing

action would be to:

a. Withhold the moderation and notify the physician

b. Administer the medication and notify the physician

c. Administer the medication with an antihistamine

d. Apply corn starch soaks to the rash

71. All of the following nursing interventions are correct when using the Z-track method of drug

injection except:

a. Prepare the injection site with alcohol

b. Use a needle that’s a least 1” long

c. Aspirate for blood before injection

d. Rub the site vigorously after the injection to promote absorption

72. The correct method for determining the vastus lateralis site for I.M. injection is to:

a. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the

iliac crest

b. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm

c. Palpate a 1” circular area anterior to the umbilicus

d. Divide the area between the greater femoral trochanter and the lateral femoral condyle into

thirds, and select the middle third on the anterior of the thigh

73. The mid-deltoid injection site is seldom used for I.M. injections because it:

a. Can accommodate only 1 ml or less of medication

 b. Bruises too easily

c. Can be used only when the patient is lying down

d. Does not readily parenteral medication

74. The appropriate needle size for insulin injection is:

a. 18G, 1 ½” long

b. 22G, 1” long

c. 22G, 1 ½” long

d. 25G, 5/8” long

75. The appropriate needle gauge for intradermal injection is:

a. 20G

b. 22G

c. 25G

d. 26G

76. Parenteral penicillin can be administered as an:

a. IM injection or an IV solution

b. IV or an intradermal injection

c. Intradermal or subcutaneous injection

d. IM or a subcutaneous injection

77. The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:

a. 0.6 mg

b. 10 mg

c. 60 mg

d. 600 mg

78. The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow

rate be if the drop factor is 15 gtt = 1 ml?

a. 5 gtt/minute

b. 13 gtt/minute

c. 25 gtt/minute

d. 50 gtt/minute

79. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?

a. Hemoglobinuria

b. Chest pain

c. Urticaria

d. Distended neck veins

80. Which of the following conditions may require fluid restriction?

a. Fever
 b. Chronic Obstructive Pulmonary Disease

c. Renal Failure

d. Dehydration

81. All of the following are common signs and symptoms of phlebitis except:

a. Pain or discomfort at the IV insertion site

b. Edema and warmth at the IV insertion site

c. A red streak exiting the IV insertion site

d. Frank bleeding at the insertion site

82. The best way of determining whether a patient has learned to instill ear medication properly is for

the nurse to:

a. Ask the patient if he/she has used ear drops before

b. Have the patient repeat the nurse’s instructions using her own words

c. Demonstrate the procedure to the patient and encourage to ask questions

d. Ask the patient to demonstrate the procedure

83. Which of the following types of medications can be administered via gastrostomy tube?

a. Any oral medications

b. Capsules whole contents are dissolve in water

c. Enteric-coated tablets that are thoroughly dissolved in water

d. Most tablets designed for oral use, except for extended-duration compounds

84. A patient who develops hives after receiving an antibiotic is exhibiting drug:

a. Tolerance

b. Idiosyncrasy

c. Synergism

d. Allergy

85. A patient has returned to his room after femoral arteriography. All of the following are appropriate

nursing interventions except:

a. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours

b. Check the pressure dressing for sanguineous drainage

c. Assess a vital signs every 15 minutes for 2 hours

d. Order a hemoglobin and hematocrit count 1 hour after the arteriography

86. The nurse explains to a patient that a cough:

a. Is a protective response to clear the respiratory tract of irritants

b. Is primarily a voluntary action

c. Is induced by the administration of an antitussive drug

d. Can be inhibited by “splinting” the abdomen

87. An infected patient has chills and begins shivering. The best nursing intervention is to:
 a. Apply iced alcohol sponges

b. Provide increased cool liquids

c. Provide additional bedclothes

d. Provide increased ventilation

88. A clinical nurse specialist is a nurse who has:

a. Been certified by the National League for Nursing

b. Received credentials from the Philippine Nurses’ Association

c. Graduated from an associate degree program and is a registered professional nurse

d. Completed a master’s degree in the prescribed clinical area and is a registered professional

nurse.

89. The purpose of increasing urine acidity through dietary means is to:

a. Decrease burning sensations

b. Change the urine’s color

c. Change the urine’s concentration

d. Inhibit the growth of microorganisms

90. Clay colored stools indicate:

a. Upper GI bleeding

b. Impending constipation

c. An effect of medication

d. Bile obstruction

91. In which step of the nursing process would the nurse ask a patient if the medication she

administered relieved his pain?

a. Assessment

b. Analysis

c. Planning

d. Evaluation

92. All of the following are good sources of vitamin A except:

a. White potatoes

b. Carrots

c. Apricots

d. Egg yolks

93. Which of the following is a primary nursing intervention necessary for all patients with a Foley

Catheter in place?

a. Maintain the drainage tubing and collection bag level with the patient’s bladder

b. Irrigate the patient with 1% Neosporin solution three times a daily

c. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
 d. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by

gravity

94. The ELISA test is used to:

a. Screen blood donors for antibodies to human immunodeficiency virus (HIV)

b. Test blood to be used for transfusion for HIV antibodies

c. Aid in diagnosing a patient with AIDS

d. All of the above

95. The two blood vessels most commonly used for TPN infusion are the:

a. Subclavian and jugular veins

b. Brachial and subclavian veins

c. Femoral and subclavian veins

d. Brachial and femoral veins

96. Effective skin disinfection before a surgical procedure includes which of the following methods?

a. Shaving the site on the day before surgery

b. Applying a topical antiseptic to the skin on the evening before surgery

c. Having the patient take a tub bath on the morning of surgery

d. Having the patient shower with an antiseptic soap on the evening v=before and the morning of

surgery

97. When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid

back injury?

a. Abdominal muscles

b. Back muscles

c. Leg muscles

d. Upper arm muscles

98. Thrombophlebitis typically develops in patients with which of the following conditions?

a. Increases partial thromboplastin time

b. Acute pulsus paradoxus

c. An impaired or traumatized blood vessel wall

d. Chronic Obstructive Pulmonary Disease (COPD)

99. In a recumbent, immobilized patient, lung ventilation can become altered, leading to such

respiratory complications as:

a. Respiratory acidosis, ateclectasis, and hypostatic pneumonia

b. Appneustic breathing, atypical pneumonia and respiratory alkalosis

c. Cheyne-Strokes respirations and spontaneous pneumothorax

d. Kussmail’s respirations and hypoventilation

100. Immobility impairs bladder elimination, resulting in such disorders as

 a. Increased urine acidity and relaxation of the perineal muscles, causing incontinence

b. Urine retention, bladder distention, and infection

c. Diuresis, natriuresis, and decreased urine specific gravity

d. Decreased calcium and phosphate levels in the urine

1. D. In the circular chain of infection, pathogens must be able to leave their reservoir and be

transmitted to a susceptible host through a portal of entry, such as broken skin.

2. C. Respiratory isolation, like strict isolation, requires that the door to the door patient’s room remain

closed. However, the patient’s room should be well ventilated, so opening the window or turning on

the ventricular is desirable. The nurse does not need to wear gloves for respiratory isolation, but

good hand washing is important for all types of isolation.

3. A. Leukopenia is a decreased number of leukocytes (white blood cells), which are important in

resisting infection. None of the other situations would put the patient at risk for contracting an

infection; taking broad-spectrum antibiotics might actually reduce the infection risk.

4. A. Soaps and detergents are used to help remove bacteria because of their ability to lower the

surface tension of water and act as emulsifying agents. Hot water may lead to skin irritation or

burns.

5. A. Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4

minutes. After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of

pathogen transmission.

6. B. The urinary system is normally free of microorganisms except at the urinary meatus. Any

procedure that involves entering this system must use surgically aseptic measures to maintain a

bacteria-free state.

7. C. All invasive procedures, including surgery, catheter insertion, and administration of parenteral

therapy, require sterile technique to maintain a sterile environment. All equipment must be sterile,

and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. In the

operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair

covers, and shoe covers for all invasive procedures. Strict isolation requires the use of clean gloves,

masks, gowns and equipment to prevent the transmission of highly communicable diseases by

contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies

and equipment after a patient has been discharged to prepare them for reuse by another patient.

The purpose of protective (reverse) isolation is to prevent a person with seriously impaired

resistance from coming into contact who potentially pathogenic organisms.

8. C. The edges of a sterile field are considered contaminated. When sterile items are allowed to come

in contact with the edges of the field, the sterile items also become contaminated.

9. B. Hair on or within body areas, such as the nose, traps and holds particles that contain

microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving

the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.

10. D. The inside of the glove is always considered to be clean, but not sterile.

11. A. The back of the gown is considered clean, the front is contaminated. So, after removing gloves

and washing hands, the nurse should untie the back of the gown; slowly move backward away from

the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the

gown inside out; discard it in a contaminated linen container; then wash her hands again.

12. B. According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most

commonly when a health care worker attempts to cap a used needle. Therefore, used needles

should never be recapped; instead they should be inserted in a specially designed puncture

resistant, labeled container. Wearing gloves is not always necessary when administering an I.M.

injection. Enteric precautions prevent the transfer of pathogens via feces.

13. A. Nurses and other health care professionals previously believed that massaging a reddened area

with lotion would promote venous return and reduce edema to the area. However, research has

shown that massage only increases the likelihood of cellular ischemia and necrosis to the area.

14. B. Before a blood transfusion is performed, the blood of the donor and recipient must be checked

for compatibility. This is done by blood typing (a test that determines a person’s blood type) and

cross-matching (a procedure that determines the compatibility of the donor’s and recipient’s blood

after the blood types has been matched). If the blood specimens are incompatible, hemolysis and

antigen-antibody reactions will occur.

15. A. Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count

determines the number of thrombocytes in blood available for promoting hemostasis and assisting

with blood coagulation after injury. It also is used to evaluate the patient’s potential for bleeding;

however, this is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A

count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is

associated with spontaneous bleeding.

16. D. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the

blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3

indicates leukocytosis.

17. A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate

potassium level), which is a potential side effect of diuretic therapy. The physician usually orders

supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another

symptom of hypokalemia. Dysphagia means difficulty swallowing.

18. A. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a

chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from

radiation. Jewelry, metallic objects, and buttons would interfere with the X-ray and thus should not

be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive

examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not

the abdominal region.

19. A. Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for

culturing and decreases the risk of contamination from food or medication.

20. A. Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who

have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse

should withhold the drug and notify the physician, who may choose to substitute another drug.

Administering an antihistamine is a dependent nursing intervention that requires a written

physician’s order. Although applying corn starch to the rash may relieve discomfort, it is not the

nurse’s top priority in such a potentially life-threatening situation.

21. D. The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a

way that the needle track is sealed off after the injection. This procedure seals medication deep into

the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is

contraindicated because it may cause the medication to extravasate into the skin.

22. D. The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by

many clinicians as the site of choice for I.M. injections because it has relatively few major nerves

and blood vessels. The middle third of the muscle is recommended as the injection site. The patient

can be in a supine or sitting position for an injection into this site.

23. A. The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its

size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve).

24. D. A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered

by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. injections in children,

typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for adult I.M. injections, which

are typically administered in the vastus lateralis or ventrogluteal site.

25. D. Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G

needle is recommended. This type of injection is used primarily to administer antigens to evaluate

reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oil-

based medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a

25G needle, for subcutaneous insulin injections.

26. A. Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be

administered subcutaneously or intradermally.

27. D. gr 10 x 60mg/gr 1 = 600 mg

28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute

29. A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic

reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the

recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or

reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh

incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended

neck veins are an indication of hypervolemia.

30. C. In real failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of

this, limiting the patient’s intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive

pulmonary disease, and dehydration are conditions for which fluids should be encouraged.

31. D. Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or

medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation),

or a localized allergic reaction to the needle or catheter. Signs and symptoms of phlebitis include

pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or

leg from the I.V. insertion site.

32. D. Return demonstration provides the most certain evidence for evaluating the effectiveness of

patient teaching.

33. D. Capsules, enteric-coated tablets, and most extended duration or sustained release products

should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in

these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an

alternate physician’s order when an ordered medication is inappropriate for delivery by tube.

34. D. A drug-allergy is an adverse reaction resulting from an immunologic response following a

previous sensitizing exposure to the drug. The reaction can range from a rash or hives to

anaphylactic shock. Tolerance to a drug means that the patient experiences a decreasing

physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an

individual’s unique hypersensitivity to a drug, food, or other substance; it appears to be genetically

determined. Synergism, is a drug interaction in which the sum of the drug’s combined effects is

greater than that of their separate effects.

35. D. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were

suspected. The other answers are appropriate nursing interventions for a patient who has

undergone femoral arteriography.

36. A. Coughing, a protective response that clears the respiratory tract of irritants, usually is

involuntary; however it can be voluntary, as when a patient is taught to perform coughing

exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal

muscles when a patient coughs.

37. C. In an infected patient, shivering results from the body’s attempt to increase heat production and

the production of neutrophils and phagocytotic action through increased skeletal muscle tension and

contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional

bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body

result in further shivering, increased metabloism, and thus increased heat production.

38. D. A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a

registered professional nurse. The National League of Nursing accredits educational programs in

nursing and provides a testing service to evaluate student nursing competence but it does not

certify nurses. The American Nurses Association identifies requirements for certification and offers

examinations for certification in many areas of nursing., such as medical surgical nursing. These

certification (credentialing) demonstrates that the nurse has the knowledge and the ability to

provide high quality nursing care in the area of her certification. A graduate of an associate degree

program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with

a high degree of knowledge and skill. She must successfully complete the licensing examination to

become a registered professional nurse.

39. D. Microorganisms usually do not grow in an acidic environment.

40. D. Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the

stool pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or tarry stool.

Constipation is characterized by small, hard masses. Many medications and foods will discolor stool

– for example, drugs containing iron turn stool black.; beets turn stool red.

41. D. In the evaluation step of the nursing process, the nurse must decide whether the patient has

achieved the expected outcome that was identified in the planning phase.

42. A. The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes,

squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and

cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.

43. D. Maintaing the drainage tubing and collection bag level with the patient’s bladder could result in

reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1

hour every 4 hours must be prescribed by a physician.

44. D. The ELISA test of venous blood is used to assess blood and potential blood donors to human

immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms

helps to diagnose acquired immunodeficiency syndrome (AIDS)

45. D. Tachypnea (an abnormally rapid rate of breathing) would indicate that the patient was still

hypoxic (deficient in oxygen).The partial pressures of arterial oxygen and carbon dioxide listed are

within the normal range. Eupnea refers to normal respiration.

46. D. Studies have shown that showering with an antiseptic soap before surgery is the most effective

method of removing microorganisms from the skin. Shaving the site of the intended surgery might
 cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving,

should be done immediately before surgery, not the day before. A topical antiseptic would not

remove microorganisms and would be beneficial only after proper cleaning and rinsing. Tub bathing

might transfer organisms to another body site rather than rinse them away.

47. C. The leg muscles are the strongest muscles in the body and should bear the greatest stress when

lifting. Muscles of the abdomen, back, and upper arms may be easily injured.

48. C. The factors, known as Virchow’s triad, collectively predispose a patient to thromboplebitis;

impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall.

Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot

formation, commonly the result of anticoagulant (heparin) therapy. Arterial blood disorders (such as

pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of

injure vessel walls.

49. A. Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk

for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and

accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by

stasis of mucus secretions.

50. B. The immobilized patient commonly suffers from urine retention caused by decreased muscle tone

in the perineum. This leads to bladder distention and urine stagnation, which provide an excellent

medium for bacterial growth leading to infection. Immobility also results in more alkaline urine with

excessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and

an increased specific gravity.

100 item Comprehensive Exam with Answers and Rationale
1. The nurse enters the room as a 3 year-old is having a generalized seizure. Which
intervention should the nurse do first?
A) Clear the area of any hazards
B) Place the child on the side
C) Restrain the child
D) Give the prescribed anticonvulsant

The correct answer is B: Place the child on the side

Protecting the airway is the top priority in a seizure. If a child is actively convulsing, a
patent airway and oxygenation must be assured.

2. A client has just returned to the medical-surgical unit following a segmental lung
resection. After assessing the client, the first nursing action would be to
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breathe and cought
D) Monitor oxygen saturation

The correct answer is B: Suction excessive tracheobronchial secretions

Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients
maintains an open airway which is always the priority nursing intervention.

3. A nurse from the surgical department is reassigned to the pediatric unit. The charge
nurse should recognize that the child at highest risk for cardiac arrest and is the least likely
to be assiged to this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple trauma

The correct answer is C: Prolonged hypoxemia

Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia.
Children usually have both cardiac and respiratory arrest.

4. Which of the following would be the best strategy for the nurse to use when teaching
insulin injection techniques to a newly diagnosed client with diabetes?
A) Give written pre and post tests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration

The correct answer is D: Observe a return demonstration

Since this is a psychomotor skill, this is the best way to know if the client has learned the
proper technique.

5. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart
disease. Which of these is most likely to be seen with this diagnosis?
A) Several otitis media episodes in the last year
B) Weight and height in 10th percentile since birth
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikes

The correct answer is C: Takes frequent rest periods while playing

Children with heart disease tend to have exercise intolerance. The child self-limits activity,
which is consistent with manifestations of congenital heart disease in children.

6. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which
of these cases of childhood poisoning would the nurse suggest that parents have the child
drink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of
diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid

The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain
cleaner. Drain cleaner is very alkaline. The orange juice is acidic and will help to neutralize
this substance.

7. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse
that she has everything ready for the baby and has made plans for the first weeks together
at home. Which normal emotional reaction does the nurse recognize?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy

The correct answer is C: Anticipation of the birth

Directing activities toward preparation for the newborn''s needs and personal adjustment
are indicators of appropriate emotional response in the third trimester.

8. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have
chalky white-to-yellowish staining with pitting of the enamel. Which of the following
conditions would most likely explain these findings?
A) Ingestion of tetracycline
B) Excessive fluoride intake
C) Oral iron therapy
D) Poor dental hygiene

The correct answer is B: Excessive fluoride intake

The described findings are indicative of fluorosis, a condition characterized by an increase in
the extent and degree of the enamel''s porosity. This problem can be associated with
repeated swallowing of toothpaste with fluoride or drinking water with high levels of
fluoride.

9. Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks

The correct answer is A: Avoid direct sunlight

Phenothiazine increases sensitivity to the sun, making clients especially susceptible to
sunburn.

10. The nurse is discussing dietary intake with an adolescent who has acne. The most
appropriate statement for the nurse is
A) "Eat a balanced diet for your age."
B) "Increase your intake of protein and Vitamin A."
C) "Decrease fatty foods from your diet."
D) "Do not use caffeine in any form, including chocolate."

The correct answer is A: "Eat a balanced diet for your age."

A diet for a teenager with acne should be a well balanced diet for their age. There are no
recommended additions and subtractions from the diet.
11. The nurse is caring for a child who has just returned from surgery following a
tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
A) Offer ice cream every 2 hours
B) Place the child in a supine position
C) Allow the child to drink through a straw
D) Observe swallowing patterns

The correct answer is D: Observe swallowing patterns

The nurse should observe for increased swallowing frequency to check for hemorrhage.

12. The nurse is caring for a client with acute pancreatitis. After pain management, which
intervention should be included in the plan of care?
A) Cough and deep breathe every 2 hours
B) Place the client in contact isolation
C) Provide a diet high in protein
D) Institute seizure precautions

The correct answer is A: Cough and deep breathe every 2 hours

Respiratory infections are common because of fluid in the retro peritoneum pushing up
against the diaphragm causing shallow respirations. Encouraging the client to cough and
deep breathe every 2 hours will diminish the occurrence of this complication.

13. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the
client with nutrition needs, the nurse should
A) Offer small meals of high calorie soft food
B) Assist the client to sit in a chair for meals
C) Provide additional servings of fruits and raw vegetables
D) Encourage the client to eat fish, liver and chicken

The correct answer is A: Offer small meals of high calorie soft food
If the client is losing weight because of poor appetite due to the pain, assist in selecting
foods that are high in calories and nutrients, to provide more nourishment with less
chewing. Suggest that frequent, small meals be eaten instead of three large ones. To
minimize jaw movements when eating, suggest that foods be pureed.

14. A client treated for depression tells the nurse at the mental health clinic that he recently
purchased a handgun because he is thinking about suicide. The first nursing action should
be to
A) Notify the health care provider immediately
B) Suggest in-patient psychiatric care
C) Respect the client's confidential disclosure
D) Phone the family to warn them of the risk

The correct answer is A: Notify the health care provider immediately

The health care provider must be contacted immediately as the client is a danger to self and
others. Hospitalization is indicated.

15. The initial response by the nurse to a delusional client who refuses to eat because of a
belief that the food is poisoned is
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness."
D) "You’re safe here. I won’t let anyone poison you."

The correct answer is A: "You think that someone wants to poison you?"
This response acknowledges perception through a reflective question which presents
opportunity for discussion, clarification of meaning, and expressing doubt.
16. A client has just been admitted with portal hypertension. Which nursing diagnosis would
be a priority in planning care?
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage
C) Ineffective individual coping
D) Fluid volume excess

The correct answer is B: Potential complication hemorrhage

Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk
for rupture if portal circulation pressures rise.

17. The nurse in a well-child clinic examines many children on a daily basis. Which of the
following toddlers requires further follow up?
A) A 13 month-old unable to walk
B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination
D) A 30 month-old only drinking from a sippy cup

The correct answer is D: A 30 month-old only drinking from a sippy cup

A 30 month-old should be able to drink from a cup without a cover.

18. Which of the following conditions assessed by the nurse would contraindicate the use of
benztropine (Cogentin)?
A) Neuromalignant syndrome
B) Acute extrapyramidal syndrome
C) Glaucoma, prostatic hypertrophy
D) Parkinson's disease, atypical tremors

The correct answer is C: Glaucoma, prostatic hypertrophy

Glaucoma and prostatic hypertrophy are contraindications to the use of benztropine
(Cogentin) as the drug is an anticholinergic agent.

19. A 15 year-old client with a lengthy confining illness is at risk for altered growth and
development of which task?
A) Loss of control
B) Insecurity
C) Dependence
D) Lack of trust

The correct answer is C: Dependence

The client role fosters dependency. Adolescents may react to dependency with rejection,
uncooperativeness, or withdrawal.

20. The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing
nursing assistants in the care of the client, the nurse should emphasize that
A) The client should remain on bed rest in a semi-Fowler's position
B) The client should alternate ambulation with bed rest with legs elevated
C) The client may ambulate and sit in chair as tolerated
D) The client may ambulate as tolerated and remain in semi-Fowlers position in bed

The correct answer is B: The client should alternate ambulation with bed rest with legs
elevated. Encourage alternating periods ambulation and bed rest with legs elevated to
mobilize edema and ascites. Encourage and assist the client with gradually increasing
periods of ambulation.

21. In providing care to a 14 year-old adolescent with scoliosis, which of the following will
be most difficult for this client?
A) Compliance with treatment regimens
B) Looking different from their peers
C) Lacking independence in activities
D) Reliance on family for their social support

The correct answer is B: Looking different from their peers

Conformity to peer influences peaks at around age 14. Since many persons view any
disability as deviant, the client will need help in learning how to deal with reactions of
others. Treatment of scoliosis is long-term and involves bracing and/or surgery.

22. The nurse is preparing to perform a physical examination on an 8 month-old who is

sitting contentedly on his mother's lap. Which of the following should the nurse do first?
A) Elicit reflexes
B) Measure height and weight
C) Auscultate heart and lungs
D) Examine the ears

The correct answer is C: Auscultate heart and lungs

The nurse should auscultate the heart and lungs during the first quiet moment with the
infant so as to be able to hear sounds clearly. Other assessments may follow in any order.

23. Which of these principles should the nurse apply when performing a nutritional
assessment on a 2 year-old client?
A) An accurate measurement of intake is not reliable
B) The food pyramid is not used in this age group
C) A serving size at this age is about 2 tablespoons
D) Total intake varies greatly each day

The correct answer is C: A serving size at this age is about 2 tablespoons

In children, a general guide to serving sizes is 1 tablespoon of solid food per year of age.
Understanding this, the nurse can assess adequacy of intake.

24. The nurse is assessing a client with delayed wound healing. Which of the following risk
factors is most important in this situation?
A) Glucose level of 120
B) History of myocardial infarction
C) Long term steroid usage
D) Diet high in carbohydrates

The correct answer is C: Long term steroid usage

Steroid dependency tends to delay wound healing. If the client also smokes, the risk is
increased.

25. Which of the following nursing assessments indicate immediate discontinuance of an

antipsychotic medication?
A) Involuntary rhythmic stereotypic movements and tongue protrusion
B) Cheek puffing, involuntary movements of extremities and trunk
C) Agitation, constant state of motion
D) Hyperpyrexia, severe muscle rigidity, malignant hypertension

The correct answer is D: Hyperpyrexia, severe muscle rigidity, malignant hypertension,

hyperpyrexia, sever muscle rigidity, and malignant hypertension are assessment signs
indicative of NMS (neuroleptic malignant syndrome).

26. A client with HIV infection has a secondary herpes simplex type 1 (HSV-1) infection. The
nurse knows that the most likely cause of the HSV-1 infection in this client is
A) Immunosuppression
B) Emotional stress
C) Unprotected sexual activities
D) Contact with saliva
The correct answer is A: Immunosuppression
The decreased immunity leads to frequent secondary infections. Herpes simplex virus type 1
is an opportunistic infection. The other options may result in HSV-1. However they are not
the most likely cause in clients with HIV.

27. The nurse measures the head and chest circumferences of a 20 month-old infant. After
comparing the measurements, the nurse finds that they are approximately the same. What
action should the nurse take?
A) Notify the health care provider
B) Palpate the anterior fontanel
C) Feel the posterior fontanel
D) Record these normal findings

The correct answer is D: Record these normal findings

The question is D. The rate of increase in head circumference slows by the end of infancy,
and the head circumference is usually equal to chest circumference at 1 to 2 years of age.

28. At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed
several times a month. What is the nurse's best response?
A) "This is normal at this time of day."
B) "How long has this been occurring?"
C) "Do you offer fluids at night?"
D) "Have you tried waking her to urinate?"

The correct answer is B: "How long has this been occurring?"

Nighttime control should be present by this age, but may not occur until age 5. Involuntary
voiding may occur due to infectious, anatomical and/or physiological reasons.

29. A client was admitted to the psychiatric unit after refusing to get out of bed. In the
hospital the client talks to unseen people and voids on the floor. The nurse could best
handle the problem of voiding on the floor by
A) Requiring the client to mop the floor
B) Restricting the client’s fluids throughout the day
C) Withholding privileges each time the voiding occurs
D) Toileting the client more frequently with supervision

The correct answer is D: Toileting the client more frequently with supervision
With altered thought processes the most appropriate nursing approach to alter the behavior
is by attending to the physical need.

30. The nurse is caring for a client with a sigmoid colostomy who requests assistance in
removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct
intervention?
A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus
B) Opening the bottom of the pouch, allowing the flatus to be expelled
C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
D) Assisting the client to ambulate to reduce the flatus in the pouch

The correct answer is B: Opening the bottom of the pouch, allowing the flatus to be
expelled. The only correct way to vent the flatus from a 1 piece drainable ostomy pouch is
to instruct the client to obtain privacy (the release of the flatus will cause odor), and to
open the bottom of the pouch, release the flatus and dose the bottom of the pouch.

31. The nurse is teaching parents of an infant about introduction of solid food to their baby.
What is the first food they can add to the diet?
A) Vegetables
B) Cereal
C) Fruit
D) Meats
The correct answer is B: Cereal
Cereal is usually introduced first because it is well tolerated, easy to digest, and contains
iron.

32. When counseling parents of a child who has recently been diagnosed with hemophilia,
what must the nurse know about the offspring of a normal father and a carrier mother?
A) It is likely that all sons are affected
B) There is a 50% probability that sons will have the disease
C) Every daughter is likely to be a carrier
D) There is a 25% chance a daughter will be a carrier

The correct answer is D: There is a 25% chance a daughter will be a carrier

Hemophilia A is a sex-linked recessive trait seen almost exclusively in males. With a normal
father and carrier mother, affected individuals are male. There is a 25% chance of having
an affected male, 25% chance of having a carrier female, 25% chance of having a normal
female and 25% chance of having a normal male.

33. When teaching a client with chronic obstructive pulmonary disease about oxygen by
cannula, the nurse should also instruct the client's family to
A) Avoid smoking near the client
B) Turn off oxygen during meals
C) Adjust the liter flow to 10 as needed
D) Remind the client to keep mouth closed

The correct answer is A: Avoid smoking near the client

Since oxygen supports combustion, there is a risk of fire if anyone smokes near the oxygen
equipment.

34. The nurse is caring for a post-op colostomy client. The client begins to cry saying, "I'll
never be attractive again with this ugly red thing." What should be the first action by the
nurse?
A) Arrange a consultation with a sex therapist
B) Suggest sexual positions that hide the colostomy
C) Invite the partner to participate in colostomy care
D) Determine the client's understanding of her colostomy

The correct answer is D: Determine the client''s understanding of her colostomy. One of the
greatest fears of colostomy clients is the fear that sexual intimacy is no longer possible.
However, the specific concern of the client needs to be assessed before specific suggestions
for dealing with the sexual concerns are given.

35. A schizophrenic client talks animatedly but the staff are unable to understand what the
client is communicating. The client is observed mumbling to herself and speaking to the
radio. A desirable outcome for this client’s care will be
A) Expresses feelings appropriately through verbal interactions
B) Accurately interprets events and behaviors of others
C) Demonstrates improved social relationships
D) Engages in meaningful and understandable verbal communication

The correct answer is D: Engages in meaningful and understandable verbal communication.

Data support impaired verbal communication deficit. The outcome must be related to the
diagnosis and supporting data. No data is presented related to feelings or to thinking
processes.

36. A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet
high in protein and carbohydrates is recommended. The nurse informs the child and family
that the most important reason for this diet is to
A) Promote healing and strengthen the immune system
B) Provide a well balanced nutritional intake
C) Stimulate increased peristalsis absorption
D) Spare protein catabolism to meet metabolic needs

The correct answer is D: Spare protein catabolism to meet metabolic needs

Because of the burn injury, the child has increased metabolism and catabolism. By
providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins
are then used to restore tissue.

37. The parents of a 7 year-old tell the nurse their child has started to "tattle" on siblings.
In interpreting this new behavior, how should the nurse explain the child's actions to the
parents?
A) The ethical sense and feelings of justice are developing
B) Attempts to control the family use new coping styles
C) Insecurity and attention getting are common motives
D) Complex thought processes help to resolve conflicts

The correct answer is A: The ethical sense and feelings of justice are developing. The child
is developing a sense of justice and a desire to do what is right. At seven, the child is
increasingly aware of family roles and responsibilities. They also do what is right because of
parental direction or to avoid punishment.

38. A school nurse is advising a class of unwed pregnant high school students. What is the
most important action they can perform to deliver a healthy child?
A) Maintain good nutrition
B) Stay in school
C) Keep in contact with the child's father
D) Get adequate sleep

The correct answer is A: Maintaining good nutrition

Nurses can serve a pivotal role in providing nutritional education and case management
interventions. Weight gain during pregnancy is one of the strongest predictors of infant birth
weight. Specifically, teens need to increase their intake of protein, vitamins, and minerals
including iron. Pregnant teens who gain between 26 and 35 pounds have the lowest
incidence of low-birth-weight babies.

39. A client continually repeats phrases that others have just said. The nurse recognizes this
behavior as
A) Autistic
B) Ecopraxic
C) Echolalic
D) Catatonic

The correct answer is C: Echolalic

Echolalic - repeating words heard.

40. A client is admitted for hemodialysis. Which abnormal lab value would the nurse
anticipate not being improved by hemodialysis?
A) Low hemoglobin
B) Hypernatremia
C) High serum creatinine
D) Hyperkalemia

The correct answer is A: Low hemoglobin

Although hemodialysis improves or corrects electrolyte imbalances it has not effect on
improving anemia.

41. The nurse is caring for a 7 year-old child who is being discharged following a
tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the
parents?
A) Report a persistent cough to the health care provider
B) The child can return to school in 4 days
C) Administer chewable aspirin for pain
D) The child may gargle with saline as necessary for discomfort

The correct answer is A: Report a persistent cough to the health care provider. Persistent
coughing should be reported to the health care provider as this may indicate bleeding.

42. The nurse is caring for a 14 month-old just diagnosed with Cystic Fibrosis. The parents
state this is the first child in either family with this disease, and ask about the risk to future
children. What is the best response by the nurse?
A) 1in 4 chance for each child to carry that trait
B) 1in 4 risk for each child to have the disease
C) 1in 2 chance of avoiding the trait and disease
D) 1in 2 chance that each child will have the disease

The correct answer is B: 1 in 4 risk for each child to have the disease
Cystic Fibrosis is an autosomal recessive transmission pattern. In this situation, both
parents must be carriers of the trait for the disease since neither one of them has the
disease. Therefore, for each pregnancy, there is a 25% chance of the child having the
disease, 50% chance of carrying the trait and a 25% chance of having neither the trait or
the disease.

43. The nurse is performing an assessment on a client with pneumococcal pneumonia.

Which finding would the nurse anticipate?
A) Bronchial breath sounds in outer lung fields
B) Decreased tactile fremitus
C) Hacking, nonproductive cough
D) Hyperresonance of areas of consolidation

The correct answer is A: Bronchial breath sounds in outer lung fields

Pneumonia causes a marked increase in interstitial and alveolar fluid. Consolidated lung
tissue transmits bronchial breath sounds to outer lung fields.

44. During seizure activity which observation is the priority to enhance further direction of
treatment?
A) Observe the sequence or types of movement
B) Note the time from beginning to end
C) Identify the pattern of breathing
D) Determine if loss of bowel or bladder control occurs

The correct answer is A: Protect the client from injury

It is a priority to note, and then record, what movements are seen during a seizure because
the diagnosis and subsequent treatment often rests solely on the seizure description.

45. Which of the following statements describes what the nurse must know in order to
provide anticipatory guidance to parents of a toddler about readiness for toilet training?
A) The child learns voluntary sphincter control through repetition
B) Myelination of the spinal cord is completed by this age
C) Neuronal impulses are interrupted at the base of the ganglia
D) The toddler can understand cause and effect

The correct answer is B: Myelination of the spinal cord is completed by this age. Voluntary
control of the sphincter muscles can be gradually achieved due to the complete myelination
of the spinal cord, sometime between the ages of 18 to 24 months of age.

46. A client complaining of severe shortness of breath is diagnosed with congestive heart
failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and
she expectorates large amounts of pink frothy sputum. The first action of the nurse would
be which of the following?
A) Call the health care provider
B) Check vital signs
C) Position in high Fowler's
D) Administer oxygen

The correct answer is D: Administer oxygen

When dealing with a medical emergency, the rule is airway first, then breathing, and then
circulation. Starting oxygen is a priority.

47. The nurse is caring for a client with benign prostatic hypertrophy. Which of the following
assessments would the nurse anticipate finding?
A) Large volume of urinary output with each voiding
B) Involuntary voiding with coughing and sneezing
C) Frequent urination
D) Urine is dark and concentrated

The correct answer is C: Frequent urination

Clients with Benign Prostatic Hypertrophy have overflow incontinence with frequent
urination in small amounts day and night.

48. An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the
child's question, "Where do babies come from?" What is the nurse's best response to the
parent?
A) "When a child asks a question, give a simple answer."
B) "Children ask many questions, but are not looking for answers."
C) "This question indicates interest in sex beyond this age."
D) "Full and detailed answers should be given to all questions."

The correct answer is A: "When a child asks a question, give a simple answer." During
discussions related to sexuality, honesty is very important. However, honesty does not
mean imparting every fact of life associated with the question. When children ask 1
question, they are looking for 1 answer. When they are ready, they will ask about the other
pieces.

49. A 3 year-old child is treated in the emergency department after ingestion of 1ounce of a
liquid narcotic. What action should the nurse do first?
A) Provide the ordered humidified oxygen via mask
B) Suction the mouth and the nose
C) Check the mouth and radial pulse
D) Start the ordered intravenous fluids

The correct answer is C: Check the mouth and radial pulse

The first step in treatment of a toxic exposure or ingestion is to assess the airway,
breathing and circulation; then stabilize the client. The other nursing actions will follow.

50. The charge nurse on the eating disorder unit instructs a new staff member to weigh
each client in his or her hospital gown only. What is the rationale for this nursing
intervention?
A) To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
B) To cover the bony prominence and areas where there is skin breakdown
C) So the client knows what type of clothing to wear when weighed
D) To reduce the tendency of the client to hide objects under his or her clothing

The correct answer is D: To reduce the tendency of the client to hide objects under his or
her clothing. The client may conceal weights on their body to increase weight gain.
51. In teaching parents to associate prevention with the lifestyle of their child with sickle
cell disease, the nurse should emphasize that a priority for their child is to
A) Avoid overheating during physical activities
B) Maintain normal activity with some restrictions
C) Be cautious of others with viruses or temperatures
D) Maintain routine immunizations

The correct answer is A: Avoid overheating

Fluid loss caused by overheating and dehydration can trigger a crisis.

52. The nurse understands that during the "tension building" phase of a violent relationship,
when the batterer makes unreasonable demands, the battered victim may experience
feelings of
A) Anger
B) Helplessness
C) Calm
D) Explosive

The correct answer is B: Helplessness

The battered individual internalizes appropriate anger at the batterer’s unfairness and
instead feels depressed with a sense of helplessness, when the partner explodes in spite of
best efforts to please the batterer.

53. A parent has numerous questions regarding normal growth and development of a 10
month-old infant. Which of the following parameters is of most concern to the nurse?
A) 50% increase in birth weight
B) Head circumference greater than chest
C) Crying when the parents leave
D) Able to stand up briefly in play pen

The correct answer is A: 50% increase in birth weight

Birth weight should be doubled at 6 months of age, tripled at 1 year, and quadrupled by 18
months.

54. The nurse has been assigned to these clients in the emergency room. Which client
would the nurse go check first?
A) Viral pneumonia with atelectasis
B) Spontaneous pneumothorax with a respiratory rate of 38
C) Tension pneumothorax with slight tracheal deviation to the right
D) Acute asthma with episodes of bronchospasm

The correct answer is C: Tension pneumothorax with slight tracheal deviation to the right.
Tracheal deviation indicates a significant volume of air being trapped in the chest cavity
with a mediastinal shift. In tension pneumothorax the tracheal deviation is away from the
affected side. The affected side is the side where the air leak is in the lung. This situation
also results in sudden air hunger, agitation, hypotension, pain in the affected side, and
cyanosis with a high risk of cardiac tamponade and cardiac arrest.

55. The nurse is assessing a 4 year-old for possible developmental dysplasia of the right
hip. Which finding would the nurse expect?
A) Pelvic tip downward
B) Right leg lengthening
C) Ortolani sign
D) Characteristic limp

The correct answer is D: Characteristic limp

Developmental dysplasia produces a characteristic limp in children who are walking.

56. A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching
the parents about home care for the child. Which of the following information is appropriate
for the nurse to include?
A) Allow the child to continue normal activities
B) Schedule frequent rest periods
C) Limit exposure to other children
D) Restrict activities to inside the house

The correct answer is A: Allow the child to continue their normal activities Physical activity is
important in a two year-old who is developing autonomy. Physical activity is a valuable
adjunct to chest physical therapy. Exercise tends to stimulate mucous secretion and help
develop normal breathing patterns.

57. The nurses on a unit are planning for stoma care for clients who have a stoma for fecal
diversion. Which stomal diversion poses the highest risk for skin breakdown
A) Ileostomy
B) Transverse colostomy
C) Ileal conduit
D) Sigmoid colostomy

The correct answer is A: Ileostomy

Ileostomy output contains gastric and enzymatic agents that when present on skin can
denuded skin in several hours. Because of the caustic nature of this stoma output adequate
peristomal skin protection must be delivered to prevent skin breakdown.

58. A client is unconscious following a tonic-clonic seizure. What should the nurse do first?
A) Check the pulse
B) Administer Valium
C) Place the client in a side-lying position
D) Place a tongue blade in the mouth

The correct answer is C: Place the client in a side-lying position

Place the client in a side-lying position to maintain an open airway, drain secretions, and
prevent aspiration if vomiting occurs.

59. The nurse is teaching a client who has a hip prostheses following total hip replacement.
Which of the following should be included in the instructions for home care?
A) Avoid climbing stairs for 3 months
B) Ambulate using crutches only
C) Sleep only on your back
D) Do not cross legs

The correct answer is D: Do not cross legs

Hip flexion should not exceed 60 degrees.

60. A nurse who travels with an agency is uncertain about what tasks can be performed
when working in a different state. It would be best for the nurse to check which resource?
A) The state nurse practice act in which the assignment is made
B) With a nurse colleague who has worked in that state 2 years ago
D) The Nursing Social Policy Statement within the United States
C) The policies and procedures of the assigned agency in that state

The correct answer is A: The state nurse practice act in which the assignment is made. The
state nurse practice act is the governing document of what can be done in the assigned
state.

61. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home
from school because of a rash. The child had been seen the day before by the health care
provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most
appropriate action by the nurse?
A) Tell the parents to bring the child to the clinic for further evaluation
B) Refer the school officials to printed materials about this viral illness
C) Inform the teacher that the child is receiving antibiotics for the rash
D) Explain that this rash is not contagious and does not require isolation

The correct answer is D: Explain that this rash is not contagious and does not require
isolation. Fifth Disease is a viral illness with an uncertain period of communicability (perhaps
1 week prior to and 1 week after onset). Isolation of the child with Fifth Disease is not
necessary except in cases of hospitalized children who are immunosuppressed or having
aplastic crises. The parents may need written confirmation of this from the health care
provider.

62. What principle of HIV disease should the nurse keep in mind when planning care for a
newborn who was infected in utero?
A) The disease will incubate longer and progress more slowly in this infant
B) The infant is very susceptible to infections
C) Growth and development patterns will proceed at a normal rate
D) Careful monitoring of renal function is indicated

The correct answer is B: The infant is very susceptible to infections

HIV infected children are susceptible to opportunistic infections due to a compromised
immune system.

63. While teaching a client about their medications, the client asks how long it will take
before the effects of lithium take place. What is the best response of the nurse?
A) Immediately
B) Several days
C) 2 weeks
D) 1 month

The correct answer is C: 2 weeks

Lithium is started immediately to treat bipolar disorder because it is quite effective in
controlling mania. Lithium takes approximately 2 weeks to effect change in a client’s
symptoms.

64. The nurse is caring for a 12 year-old with an acute illness. Which of the following
indicates the nurse understands common sibling reactions to hospitalization?
A) Younger siblings adapt very well
B) Visitation is helpful for both
C) The siblings may enjoy privacy
D) Those cared for at home cope better

The correct answer is B: Visitation is helpful for both

Contact with the ill child helps siblings understand the reasons for hospitalization and
maintains the relationship.

65. Following a cocaine high, the user commonly experiences an extremely unpleasant
feeling called
A) Craving
B) Crashing
C) Outward bound
D) Nodding out

The correct answer is B: Crashing

Following cocaine use, the intense pleasure is replaced by an equally unpleasant feeling
referred to as crashing.

66. One reason that domestic violence remains extensively undetected is

A) Few battered victims seek medical care
B) There is typically a series of minor, vague complaints
C) Expenses due to police and court costs are prohibitive
D) Very little knowledge is currently known about batterers and battering relationships

The correct answer is B: There is typically a series of minor, vague complaints. Signs of
abuse may not be clearly manifested and a series a minor complaints such as headache,
abdominal pain, insomnia, back pain, and dizziness may be covert indications of abuse
undetected. Complaints may be vague.

67. When making a home visit to a client with chronic pyelonephritis, which nursing action
has the highest priority?
A) Follow-up on lab values before the visit
B) Observe client findings for the effectiveness of antibiotics
C) Ask for a log of urinary output
D) As for the log of the oral intake

The correct answer is C: Ask for a log of urinary output

The nurse must monitor the urine output as a priority because it is the best indictor of renal
function. The other options would be done after an evaluation of the urine output.

68. When a client is having a general tonic clonic seizure, the nurse should
A) Hold the client's arms at their side
B) Place the client on their side
C) Insert a padded tongue blade in client's mouth
D) Elevate the head of the bed

The correct answer is B: Place the client on their side

This position keeps the airway patent and prevents aspiration.

69. The nurse is teaching a client with dysrhythmia about the electrical pathway of an
impulse as it travels through the heart. Which of these demonstrates the normal pathway?
A) AV node, SA node, Bundle of His, Purkinje fibers
B) Purkinje fibers, SA node, AV node, Bundle of His
C) Bundle of His, Purkinje fibers, SA node , AV node
D) SA node, AV node, Bundle of His, Purkinje fibers

The correct answer is D: SA node, AV node, Bundle of His, Purkinje fibers

The pathway of a normal electrical impulse through the heart is: SA node, AV node, Bundle
of His, Purkinje fibers.

70. Clients with mitral stenosis would likely manifest findings associated with congestion in
the
A) Pulmonary circulation
B) Descending aorta
C) Superior vena cava
D) Bundle of His

The correct answer is A: Pulmonary circulation

Congestion occurs in the pulmonary circulation due to the inefficient emptying of the left
ventricle and the lack of a competent valve to prevent back flow into the pulmonary vein.

71. In assessing the healing of a client's wound during a home visit, which of the following
is the best indicator of good healing?
A) White patches
B) Green drainage
C) Reddened tissue
D) Eschar development

The correct answer is C: Reddened tissue

As the wound granulates, redness indicates healing.

72. The nursing intervention that best describes treatment to deal with the behaviors of
clients with personality disorders include
A) Pointing out inconsistencies in speech patterns to correct thought disorders
B) Accepting client and the client's behavior unconditionally
C) Encouraging dependency in order to develop ego controls
D) Consistent limit-setting enforced 24 hours per day

The correct answer is D: Consistent limit-setting enforced 24 hours per day

Treatment approaches that include restructuring the personality, assisting the person with
developmental level and setting limits for maladaptive behavior such as acting out.

73. A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly
experiences torticollis and involuntary spastic muscle movement. In addition to
administering the ordered anticholinergic drug, what other measure should the nurse
implement?
A) Have respiratory support equipment available
B) Immediately place her in the seclusion room
C) Assess the client for anxiety and agitation
D) Administer prn dose of IM antipsychotic medication

The correct answer is A: Have respiratory support equipment available

Persons receiving neuroleptic medication experiencing torticollis and involuntary muscle
movement are demonstrating side effects that could lead to respiratory failure.

74. The nurse asks a client with a history of alcoholism about the client’s drinking behavior.
The client states "I didn’t hurt anyone. I just like to have a good time, and drinking helps
me to relax." The client is using which defense mechanism?
A) Denial
B) Projection
C) Intellectualization
D) Rationalization

The correct answer is D: Rationalization

Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing
acceptable explanations that satisfies the teller as well as the listener.

75. The nurse is teaching a smoking cessation class and notices there are 2 pregnant
women in the group. Which information is a priority for these women?
A) Low tar cigarettes are less harmful during pregnancy
B) There is a relationship between smoking and low birth weight
C) The placenta serves as a barrier to nicotine
D) Moderate smoking is effective in weight control

The correct answer is B: There is a relationship between smoking and low birth weight.
Nicotine reduces placental blood flow, and may contribute to fetal hypoxia or placenta
previa, decreasing the growth potential of the fetus.

76. The nurse is caring for a client with end stage renal disease. What action should the
nurse take to assess for patency in a fistula used for hemodialysis?
A) Observe for edema proximal to the site
B) Irrigate with 5 mls of 0.9% Normal Saline
C) Palpate for a thrill over the fistula
D) Check color and warmth in the extremity

The correct answer is C: Palpate for a thrill over the fistula

To assess for patency in a fistula or graft, the nurse auscultates for a bruit and palpates for
a thrill. Other options are not related to evaluation for patency.
77. Which therapeutic communication skill is most likely to encourage a depressed client to
vent feelings?
A) Direct confrontation
B) Reality orientation
C) Projective identification
D) Active listening

The correct answer is D: Active listening

Use of therapeutic communication skills such as silence and active listening encourages
verbalization of feelings.

78. The nurse walks into a client's room and finds the client lying still and silent on the
floor. The nurse should first
A) Assess the client's airway
B) Call for help
C) Establish that the client is unresponsive
D) See if anyone saw the client fall

The correct answer is C: Establish that the client is unresponsive

The first step in CPR is to establish unresponsiveness. Second is to call for help. Third is
opening the airway.

79. What is the best way for the nurse to accomplish a health history on a 14 year-old
client?
A) Have the mother present to verify information
B) Allow an opportunity for the teen to express feelings
C) Use the same type of language as the adolescent
D) Focus the discussion of risk factors in the peer group

The correct answer is B: Allow an opportunity for the teen to express feelings
Adolescents need to express their feelings. Generally, they talk freely when given an
opportunity and some privacy to do so.

80. A new nurse on the unit notes that the nurse manager seems to be highly respected by
the nursing staff. The new nurse is surprised when one of the nurses states: "The manager
makes all decisions and rarely asks for our input." The best description of the nurse
manager's management style is
A) Participative or democratic
B) Ultraliberal or communicative
C) Autocratic or authoritarian
D) Laissez faire or permissive

The correct answer is C: Autocratic or authoritarian

Autocratic leadership style is suggested in this situation. It is appropriate for groups with
little education and experience and who need strong direction, while participative or
democratic style is usually more successful on nursing units.

81. A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose,
for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40
mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug
administration, what should the nurse do next?
A) Give the medication as ordered
B) Call the health care provider to clarify the dose
C) Recognize that antibiotics are over-prescribed
D) Hold the medication as the dosage is too low

The correct answer is A: Give the medication as ordered

Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The
dose range is 20-40 mg/kg/day divided every 8 hours. 15kg x 40mg = 600mg, divided by 3
= 200 mg per dose. The prescribed dose is correct and should be given as ordered.

82. The nurse is performing a developmental assessment on an 8 month-old. Which finding

should be reported to the health care provider?
A) Lifts head from the prone position
B) Rolls from abdomen to back
C) Responds to parents' voices
D) Falls forward when sitting

The correct answer is D: Falls forward when sitting

Sitting without support is expected at this age.

83. The nurse is participating in a community health fair. As part of the assessments, the
nurse should conduct a mental status examination when
A) An individual displays restlessness
B) There are obvious signs of depression
C) Conducting any health assessment
D) The resident reports memory lapses

The correct answer is C: Conducting any health assessment

A mental status assessment is a critical part of baseline information, and should be a part of
every examination.

84. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted
after a fall while playing basketball. In understanding his behavior and in planning care for
this client, what must the nurse understand about adolescents with hemophilia?
A) Must have structured activities
B) Often take part in active sports
C) Explain limitations to peer groups
D) Avoid risks after bleeding episodes

The correct answer is B: Often take part in active sports

Establish an age-appropriate safe environment. Adolescent hemophiliacs should be aware
that contact sports may trigger bleeding. However, developmental characteristics of this age
group such as impulsivity, inexperience and peer pressure, place adolescents in unsafe
environments.

85. When assessing a client who has just undergone a cardioversion, the nurse finds the
respirations are 12. Which action should the nurse take first?
A) Try to vigorously stimulate normal breathing
B) Ask the RN to assess the vital signs
C) Measure the pulse oximetry
D) Continue to monitor respirations

The correct answer is D: 4. Continue to monitor respirations

12 respirations per minute is tolerated post-operatively. A range from 8 to 10 gives cause
for concern. At that point pulse oximetry is taken, as that rate could be tolerated. Vigorous
stimulation is not indicated beyond deep breathing and coughing. It is not necessary to ask
the RN to check findings.

86. In order to enhance a client's response to medication for chest pain from acute angina,
the nurse should emphasize
A) Learning relaxation techniques
B) Limiting alcohol use
C) Eating smaller meals
D) Avoiding passive smoke

The correct answer is A: Learning relaxation techniques

The only factor that can enhance the client''s response to pain medication for angina is
reducing anxiety through relaxation methods. Anxiety can be great enough to make the
pain medication totally ineffective.

87. The primary nursing diagnosis for a client with congestive heart failure with pulmonary
edema is
A) Pain
B) Impaired gas exchange
C) Cardiac output altered: decreased
D) Fluid volume excess

The correct answer is C: Cardiac output altered: decreased

All nursing interventions should be focused on improving cardiac output. Increasing cardiac
output is the primary goal of therapy. Comfort will improve as the client improves and the
respiratory status will improve as cardiac output increases.

88. After talking with her partner, a client voluntarily admitted herself to the substance
abuse unit. After the second day on the unit the client states to the nurse, "My husband told
me to get treatment or he would divorce me. I don’t believe I really need treatment but I
don’t want my husband to leave me." Which response by the nurse would assist the client?
A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people
can’t get well."
B) "In early recovery, it’s quite common to have mixed feelings, but I didn’t know you had
been pressured to come."
C) "In early recovery it’s quite common to have mixed feelings, perhaps it would be best to
seek treatment on an outclient bases."
D) "In early recovery, it’s quite common to have mixed feelings. Let’s discuss the
benefits of sobriety for you."

The correct answer is D: "In early recovery, it’s quite common to have mixed feelings. Let’s
discuss the benefits of sobriety for you." This response gives the client the opportunity to
decrease ambivalent feelings by focusing on the benefits of sobriety. Dependence issues are
great for the client fostering ambivalence.

89. Clients taking which of the following drugs are at risk for depression?
A) Steroids
B) Diuretics
C) Folic acid
D) Aspirin

The correct answer is A: Steroids

Adverse medication effects can cause a syndrome that may or may not remit when the
medication is discontinued. Examples include: phenothiazines, steroids, and reserpine.

90. The nurse is assessing a client on admission to a community mental health center. The
client discloses that she has been thinking about ending her life. The nurse's best response
would be
A) "Do you want to discuss this with your pastor?"
B) "We will help you deal with those thoughts."
C) "Is your life so terrible that you want to end it?"
D) "Have you thought about how you would do it?"

The correct answer is D: "Have you thought about how you would do it?"
This response provides an opening to discuss intent and means of committing suicide.

91. The nurse is caring for a client 2 hours after a right lower lobectomy. During the
evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles
constantly in the water seal chamber. On inspection of the chest dressing and tubing, the
nurse does not find any air leaks in the system. The next best action for the nurse is to
A) Check for subcutaneous emphysema in the upper torso
B) Reposition the client to a position of comfort
C) Call the health care provider as soon as possible
D) Check for any increase in the amount of thoracic drainage

The correct answer is A: Check for subcutaneous emphysema in the upper torso.
Continuous bubbling in the water seal chamber is an abnormal finding 2 hours after a
lobectomy. Further assessment of appropriate factors was done by the nurse to rule out an
air leak in the sytem. Thus the conclusion is that the problem is one of an air leak in the
lung. This client may need to be returned to surgery to deal with the sustained air leak.
Action by the health care provider is required to prevent further complications.

92. The nurse is caring for a newborn who has just been diagnosed with hypospadias. After
discussing the defect with the parents, the nurse should expect that
A) Circumcision can be performed at any time
B) Initial repair is delayed until ages 6-8
C) Post-operative appearance will be normal
D) Surgery will be performed in stages

The correct answer is D: Surgery will be performed in stages

Hypospadias, a condition in which the urethral opening is located on the ventral surface or
below the penis, is corrected in stages as soon as the infant can tolerate surgery.

93. A client has been receiving lithium (Lithane) for the past two weeks for the treatment of
bipolar illness. When planning client teaching, what is most important to emphasize to the
client?
A) Maintain a low sodium diet
B) Take a diuretic with lithium
C) Come in for evaluation of serum lithium levels every 1-3 months
D) Have blood lithium levels drawn during the summer months

The correct answer is D: Have blood lithium levels drawn during the summer months.
Clients taking lithium therapy need to be aware that hot weather may cause excessive
perspiration, a loss of sodium and consequently an increase in serum lithium concentration.

94. When an autistic client begins to eat with her hands, the nurse can best handle the
problem by
A) Placing the spoon in the client’s hand and stating, "Use the spoon to eat your
food."
B) Commenting "I believe you know better than to eat with your hand."
C) Jokingly stating, "Well I guess fingers sometimes work better than spoons."
D) Removing the food and stating "You can’t have anymore food until you use the spoon."

The correct answer is A: Placing the spoon in the client’s hand and stating "Use the spoon to
eat your food." This response identifies adaptive behavior with instruction and verbal
expectation.

95. A client develops volume overload from an IV that has infused too rapidly. What
assessment would the nurse expect to find?
A) S3 heart sound
B) Thready pulse
C) Flattened neck veins
D) Hypoventilation

The correct answer is A: Auscultation of an S3 heart sound

Auscultation of an S3 heart sound. This is an early sign of volume overload (or CHF)
because during the first phase of diastole, when blood enters the ventricles, an extra sound
is produced due to the presence of fluid left in the ventricles.
96. A neonate born 12 hours ago to a methadone maintained woman is exhibiting a
hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool.
Which of these is a nursing priority?
A) Hold the infant at frequent intervals.
B) Assess for neonatal withdrawl syndrome
C) Offer fluids to prevent dehydration
D) Administer paregoric to stop diarrhea

The correct answer is B: Assess for neonatal withdrawl syndrome

Neonatal withdrawl syndrome is a cluster of findings that signal the withdrawal of the infant
from the opiates. The findings seen in methadone withdrawal are often more severe than
for other substances. Initial signs are central nervous system hyper irritability and gastro-
intestinal symptoms. If withdrawal signs are severe, there is an increased mortality risk.
Scoring the infant ensures proper treatment during the period of withdrawal.

97. While planning care for a preschool aged child, the nurse understands developmental
needs. Which of the following would be of the most concern to the nurse?
A) Playing imaginatively
B) Expressing shame
C) Identifying with family
D) Exploring the playroom

The correct answer is B: Expressing shame

Erikson describes the stage of the preschool child as being the time when there is normally
an increase in initiative. The child should have resolved the sense of shame and doubt in the
toddler stage.

98. A depressed client who has recently been acting suicidal is now more social and
energetic than usual. Smilingly he tells the nurse "I’ve made some decisions about my life."
What should be the nurse’s initial response?
A) "You’ve made some decisions."
B) "Are you thinking about killing yourself?"
C) "I’m so glad to hear that you’ve made some decisions."
D) "You need to discuss your decisions with your therapist."

The correct answer is B: "Are you thinking about killing yourself?"

Sudden mood elevation and energy may signal increased risk of suicide. The nurse must
validate suicide ideation as a beginning step in evaluating seriousness of risk.

99. The nurse is caring for 2 children who have had surgical repair of congenital heart
defects. For which defect is it a priority to assess for findings of heart conduction
disturbance?
A) Artrial septal defect
B) Patent ductus arteriosus
C) Aortic stenosis
D) Ventricular septal defect

The correct answer is D: Ventricular septal defect

While assessments for conduction disturbance should be included following repair of any
defect, it is a priority for this condition. A ventricular septal defect is an abnormal opening
between the right and left ventricles. The atrioventricular bundle (bundle of His), a part of
the electrical conduction system of the heart, extends from the atrioventricular node along
each side of the interventricular septum and then divides into right and left bundle
branches. Surgical repair of a ventricular septal defect consists of a purse-string approach
or a patch sewn over the opening. Either method involves manipulation of the ventricular
septum, thereby increasing risk of interrupting the conduction pathway. Consequently,
postoperative complications include conduction disturbances.

100. The nurse is caring for a post myocardial infarction client in an intensive care unit. It is
noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This
change is most likely due to
A) Dehydration
B) Diminished blood volume
C) Decreased cardiac output
D) Renal failure

The correct answer is C: Decreased cardiac output

Cardiac output and urinary output are directly correlated. The nurse should suspect a drop
in cardiac output if the urinary output drops.
When a health care worker is washing his hands, which of the following observations
made by the nurse would indicate that the worker understands the principle of proper
hand washing?

a. Washes hands prior to removing gloves

b. Wash hands for 5 seconds
c. Rinses hands with fingers pointed up
d. Removes rings before washing

You are caring a client in isolation. After nursing care is done what will you remove first
after handling the patient?

a. Gown
b. Gloves
c. Bonnet
d. Mask

With color change sterilization indicators, the white stripes on the tape change to _____
when the appropriate conditions (temperature) have been met.

a. Red
b. Black
c. Blue
d. Green

The type of surgical scissor used to cut delicate and soft tissues.

a. Straight Mayo scissors

b. Kelly scissors
c. Curved Mayo scissors
d. Metzenbaum scissors

When the patient vomits, the most important nursing objective is to prevent:

a. Dehydration
b. Aspiration
c. Rupture of suture line
d. Met. Alkalosis

How frequent should the nurse monitor the VS of the patient in the recovery room?
a. Every 15 minutes
b. Every 30 mins
c. Every 45 mins
d. Every 60 mins

Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before
surgery?

a. To prevent malnutrition
b. To prevent electrolyte imbalance
c. To prevent aspiration pneumonia
d. To prevent intestinal obstruction

To prevent headache after spinal anesthesia the patient should be positioned:

a. Semi-fowler’s
b. Flat on bed for 6 to 8 hours
c. Prone position
d. Modified trendelenburg

Which of the following is most dangerous complication during induction of spinal

anesthesia?

a. Tachycardia
b. Hypotension
c. Hyperthermia
d. Bradypnea

The important nursing intervention prior to administration of pre-anesthetic medication

is:

a. Ask patient to empty the bladder

b. Do deep breathing and coughing exercises
c. Regulate IVF accurately
d. Shave the skin

The most important factor in the prevention of post op wound infection is:

a. Adequate fluid intake

b. Proper administration of antibiotics
c. Practice of strict aseptic technique
d. Frequent cleaning of the wound
FUNDAMENTALS OF NURSING client vomits and begins choking. Which of the following
actions is most appropriate for the nurse to take?
1. A facility has a system for transcribing medication orders to
a Kardex as well as a computerizedmedication administration a. Clear the client's airway.
record (MAR). A physician writes the following order for a b. Make the client comfortable.
client: "Prednisone 5 mg P.O. daily for 3 days." The order is c. Start cardiopulmonary resuscitation.
correctly transcribed on the Kardex. However, the nurse who d. Stop the feeding and remove the NG tube.
transcribes the order onto the MAR neglects to place the
limitation of 3 days on the prescription. On the 4th day after 8. The nurse is caring for a geriatric client with a pressure
the order was instituted, a nurse administers prednisone 5 ulcer on the sacrum. When teaching the client about
mg P.O. During an audit of the chart, the error is identified. fundamentals in nursing on dietary intake, which foods
The person most responsible for the error is the: should the nurse plan to emphasize?

a. nurse who transcribed the order incorrectly on the MAR a. Legumes and cheese
b. nurse who administered the erroneous dose. b. Whole grain products
c. pharmacist who filled the order and provided the c. Fruits and vegetables
erroneous dose. d. Lean meats and low-fat milk
d. facility because of its policy on transcription of
medications.
9. A client with chronic renal failure is admitted with a heart
rate of 122 beats/minute, a respiratory rate of 32
2. To evaluate a client's chief complaint, the nurse performs breaths/minute, a blood pressure of 190/110 mm Hg, neck
deep palpation. The purpose of deep palpation is to assess vein distention, and bibasilar crackles. Which nursing
which of the following? diagnosis takes highest priority for this client?

a. Skin turgor a. Fear

b. Hydration b. Urinary retention
c. Organs c. Excessive fluid volume
d. Temperature d. Self-care deficient: Toileting

3. One of the nursing fundamentals questions is about giving 10. A client's blood test results are as follows: white blood
an I.M. injection, the nurse should insert the needle into cell (WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl;
the muscle at an angle of: hematocrit (HCT), 42%. Which of the following goals would be
most important for this client?
a. 15 degrees.
b. 30 degrees. a. Promote fluid balance
c. 45 degrees. b. Prevent infection.
d. 90 degrees. c. Promote rest.
d. Prevent injury.
4. A client, age 43, has no family history of breast cancer or
other risk factors for this disease. The nurse should instruct
her to have a mammogram how often
Answers and Rationale
a. Once, to establish a baseline
b. Once per year 1) B
c. Every 2 years - The nurse administering the dose should have compared the
d. Twice per year MAR with the Kardex and noted the discrepancy. The
transcribing nurse and pharmacist aren't void of
5. When prioritizing a client's plan of care based on Maslow's responsibility; however, the nurse administering the dose is
hierarchy of needs, the nurse's first priority would be: most responsible. The facility's policy does provide for a
system of checks and balances. Therefore, the facility isn't
a. allowing the family to see a newly admitted client. responsible for the error.
b. ambulating the client in the hallway.
c. administering pain medication 2) C
d. placing wrist restraints on the client. - The purpose of deep palpation, in which the nurse indents
the client's skin approximately 1½" (3.8 cm), is to assess
6. A 49-year-old client with acute respiratory distress watches underlying organs and structures, such as the kidneys and
everything the staff does and demands full explanations for spleen. Skin turgor, hydration, and temperature can be
all procedures and medications. Which of the following assessed by using light touch or light palpation
actions would best indicate that the client has achieved an
increased level of psychological comfort? 3) D
Nursing Fundamentals Questions Rationale: When giving an
a. Making decreased eye contact I.M. injection, the nurse inserts the needle into the muscle at
b. Asking to see family members a 90-degree angle, using a quick, dartlike motion. A 15-degree
c. Joking about the present condition angle is appropriate when administering an intradermal
d. Sleeping undisturbed for 3 hours injection. A 30-degree angle isn't used for any type of
injection. A 45- or 90-degree angle can be used when giving a
7. A hospitalized client who has a living will is being fed subcutaneous injection
through a nasogastric (NG) tube. During a bolus feeding, the

1
4) C tachypneic. The nurse understands that
- A client age 40 to 49 with no family history of breast tachypnea means:
cancer or other risk factors for this disease should have a
mammogram every 2 years. After age 50, the client should a. Pulse rate greater than 100 beats per minute
have a mammogram every year b. Blood pressure of 140/90
c. Respiratory rate greater than 20 breaths per
5) C minute
- In Maslow's hierarchy of needs, pain relief is on the d. Frequent bowel sounds
first layer. Activity (option B) is on the second layer. Safety
(option D) is on the third layer. Love and belonging (option A)
are on the fourth layer. 2. The nurse listens to Mrs. Sullen’s lungs and
notes a hissing sound or musical sound. The
6) D nurse documents this as:
- Sleeping undisturbed for a period of time would indicate
that the client feels more relaxed, comfortable, and trusting a. Wheezes
and is less anxious. Decreasing eye contact, asking to see b. Rhonchi
family, and joking may also indicate that the client is more c. Gurgles
relaxed. However, these also could be diversions. d. Vesicular

7) A
3. The nurse in charge measures a patient’s
- A living will states that no life-saving measures are to be
temperature at 101 degrees F. What is the
used in terminal conditions. There is no indication that the
equivalent centigrade temperature?
client is terminally ill. Furthermore, a living will doesn't apply
to nonterminal events such as choking on an enteral feeding
a. 36.3 degrees C
device. The nurse should clear the client's airway. Making the
b. 37.95 degrees C
client comfortable ignores the life-threatening event.
c. 40.03 degrees C
Cardiopulmonary resuscitation isn't indicated, and removing
d. 38.01 degrees C
the NG tube would exacerbate the situation

8) D 4. Which approach to problem solving tests any

- Although the client should eat a balanced diet with foods number of solutions until one is found that works
from all food groups, the diet should emphasize foods that for that particular problem?
supply complete protein, such as lean meats and low-fat milk,
because protein helps build and repair body tissue, which a. Intuition
promotes healing. Fundamentals in nursing teaches that b. Routine
legumes provide incomplete protein. Cheese contains c. Scientific method
complete protein, but also fat, which should be limited to d. Trial and error
30% or less of caloric intake. Whole grain products supply
incomplete proteins and carbohydrates. Fruits and vegetables
provide mainly carbohydrates. 5. What is the order of the nursing process?

9) C a. Assessing, diagnosing, implementing,

- A client with renal failure can't eliminate sufficient fluid, evaluating, planning
increasing the risk of fluid overload and consequent b. Diagnosing, assessing, planning,
respiratory and electrolyte problems. This client has signs of implementing, evaluating
excessive fluid volume and is acutely ill. Fear and a toileting c. Assessing, diagnosing, planning,
self-care deficit may be problems, but they take lower priority implementing, evaluating
because they aren't life-threatening. Urinary retention may d. Planning, evaluating, diagnosing, assessing,
cause renal failure but is a less urgent concern than fluid implementing
imbalance.

10) B 6. During the planning phase of the nursing

- The client is at risk for infection because the WBC count is process, which of the following is the outcome?
dangerously low. Hb level and HCT are within normal limits;
therefore, fluid balance, rest, and prevention of injury are a. Nursing history
inappropriate. b. Nursing notes
c. Nursing care plan
d. Nursing diagnosis

Nursing Board Review: Fundamentals of

Nursing Practice Test Part 1 7. What is an example of a subjective data?
http://www.rnpedia.com/home/exams/philippine-board-
exam-nle/nursing-board-review-fundamentals-of-nursing- a. Heart rate of 68 beats per minute
practice-test-part-1 b. Yellowish sputum
c. Client verbalized, “I feel pain when urinating.”
1. Jake is complaining of shortness of breath. The d. Noisy breathing
nurse assesses his respiratory rate to be 30
breaths per minute and documents that Jake is
8. Which expected outcome is correctly written?

2
a. “The patient will feel less nauseated in 24 15. What nursing action is appropriate when
hours.” obtaining a sterile urine specimen from an
b. “The patient will eat the right amount of food indwelling catheter to prevent infection?
daily.”
c. “The patient will identify all the high-salt food a. Use sterile gloves when obtaining urine.
from a prepared list by discharge.” b. Open the drainage bag and pour out the urine.
d. “The patient will have enough sleep.” c. Disconnect the catheter from the tubing and
get urine.
d. Aspirate urine from the tubing port using a
9. Which of the following behaviors by Nurse sterile syringe.
Jane Robles demonstrates that she understands
well th elements of effecting charting?
16. A client is receiving 115 ml/hr of continuous
a. She writes in the chart using a no. 2 pencil. IVF. The nurse notices that the venipuncture site
b. She noted: appetite is good this afternoon. is red and swollen. Which of the following
c. She signs on the medication sheet after interventions would the nurse perform first?
administering the medication.
d. She signs her charting as follow: J.R a. Stop the infusion
b. Call the attending physician
c. Slow that infusion to 20 ml/hr
10. What is the disadvantage of computerized d. Place a clod towel on the site
documentation of the nursing process?

a. Accuracy 17. The nurse enters the room to give a

b. Legibility prescribed medication but the patient is inside
c. Concern for privacy the bathroom. What should the nurse do?
d. Rapid communication
a. Leave the medication at the bedside and leave
the room.
11. The theorist who believes that adaptation and b. After few minutes, return to that patient’s
manipulation of stressors are related to foster room and do not leave until the patient takes the
change is: medication.
c. Instruct the patient to take the medication and
a. Dorothea Orem leave it at the bedside.
b. Sister Callista Roy d. Wait for the patient to return to bed and just
c. Imogene King leave the medication at the bedside.
d. Virginia Henderson

18. Which of the following is inappropriate

12. Formulating a nursing diagnosis is a joint nursing action when administering NGT feeding?
function of:
a. Place the feeding 20 inches above the pint if
a. Patient and relatives insertion of NGT.
b. Nurse and patient b. Introduce the feeding slowly.
c. Doctor and family c. Instill 60ml of water into the NGT after
d. Nurse and doctor feeding.
d. Assist the patient in fowler’s position.

13. Mrs. Caperlac has been diagnosed to have

hypertension since 10 years ago. Since then, she 19. A female patient is being discharged after
had maintained low sodium, low fat diet, to thyroidectomy. After providing the medication
control her blood pressure. This practice is teaching. The nurse asks the patient to repeat
viewed as: the instructions. The nurse is performing which
professional role?
a. Cultural belief
b. Personal belief a. Manager
c. Health belief b. Caregiver
d. Superstitious belief c. Patient advocate
d. Educator

14. Becky is on NPO since midnight as

preparation for blood test. Adreno-cortical 20. Which data would be of greatest concern to
response is activated. Which of the following is the nurse when completing the nursing
an expected response? assessment of a 68-year-old woman hospitalized
due to Pneumonia?
a. Low blood pressure
b. Warm, dry skin a. Oriented to date, time and place
c. Decreased serum sodium levels b. Clear breath sounds
d. Decreased urine output c. Capillary refill greater than 3 seconds and
buccal cyanosis
d. Hemoglobin of 13 g/dl

3
 A respiratory rate of greater than 20 breaths per
minute is tachypnea. A blood pressure of 140/90
21. During a change-of-shift report, it would be is considered hypertension. Pulse greater than
important for the nurse relinquishing 100 beats per minute is tachycardia. Frequent
responsibility for care of the patient to bowel sounds refer to hyper-active bowel
communicate. Which of the following facts to the sounds.
nurse assuming responsibility for care of the
patient? 2. (A) Wheezes
Wheezes are indicated by continuous, lengthy,
a. That the patient verbalized, “My headache is musical; heard during inspiration or expiration.
gone.” Rhonchi are usually coarse breath sounds.
b. That the patient’s barium enema performed 3 Gurgles are loud gurgling, bubbling sound.
days ago was negative Vesicular breath sounds are low pitch, soft
c. Patient’s NGT was removed 2 hours ago intensity on expiration.
d. Patient’s family came for a visit this morning.
3. (B) 37.95 degrees C
To convert °F to °C use this formula, ( °F – 32 )
22. Which statement is the most appropriate goal (0.55). While when converting °C to °F use this
for a nursing diagnosis of diarrhea? formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9
and 1.8 is 9/5.
a. “The patient will experience decreased
frequency of bowel elimination.” 4. (D) Trial and error
b. “The patient will take anti-diarrheal The trial and error method of problem solving
medication.” isn’t systematic (as in the scientific method of
c. “The patient will give a stool specimen for problem solving) routine, or based on inner
laboratory examinations.” prompting (as in the intuitive method of problem
d. “The patient will save urine for inspection by solving).
the nurse.
5. (C) Assessing, diagnosing, planning,
implementing, evaluating
23. Which of the following is the most important The correct order of the nursing process is
purpose of planning care with this patient? assessing, diagnosing, planning, implementing,
evaluating.
a. Development of a standardized NCP.
b. Expansion of the current taxonomy of nursing 6. (C) Nursing care plan
diagnosis The outcome, or the product of the planning
c. Making of individualized patient care phase of the nursing process is a Nursing care
d. Incorporation of both nursing and medical plan.
diagnoses in patient care
7. (C) Client verbalized, “I feel pain when
urinating.”
24. Using Maslow’s hierarchy of basic human Subjective data are those that can be described
needs, which of the following nursing diagnoses only by the person experiencing it. Therefore,
has the highest priority? only the patient can describe or verify whether he
is experiencing pain or not.
a. Ineffective breathing pattern related to pain,
as evidenced by shortness of breath. 8. (C) “The patient will identify all the high-
b. Anxiety related to impending surgery, as salt food from a prepared list by discharge.”
evidenced by insomnia. Expected outcomes are specific, measurable,
c. Risk of injury related to autoimmune realistic statements of goal attainment. The
dysfunction phrases “right amount”, “less nauseated” and
d. Impaired verbal communication related to “enough sleep” are vague and not measurable.
tracheostomy, as evidenced by inability to speak.
9. (C) She signs on the medication sheet
after administering the medication.
25. When performing an abdominal examination, A nurse should record a nursing intervention (ex.
the patient should be in a supine position with Giving medications) after performing the nursing
the head of the bed at what position? intervention (not before). Recording should also
be done using a pen, be complete, and signed
a. 30 degrees with the nurse’s full name and title.
b. 90 degrees
c. 45 degrees 10. (C) Concern for privacy
d. 0 degree A patient’s privacy may be violated if security
measures aren’t used properly or if policies and
procedures aren’t in place that determines what
Answer and Rationale : Fundamentals in type of information can be retrieved, by whom,
Nursing Practice Test Part 1 and for what purpose.

11. (B) Sister Callista Roy

1. (C) Respiratory rate greater than 20 Sister Roy’s theory is called the adaptation theory
breaths per minute and she viewed each person as a unified

4
biophysical system in constant interaction with a condition that the nurse assuming responsibility
changing environment. Orem’s theory is called for care of the patient will need to monitor. The
self-care deficit theory and is based on the belief other options are not critical enough to include in
that individual has a need for self-care actions. the report.
King’s theory is the Goal attainment theory and
described nursing as a helping profession that 22. (A) “The patient will experience
assists individuals and groups in society to attain, decreased frequency of bowel elimination.”
maintain, and restore health. Henderson The goal is the opposite, healthy response of the
introduced the nature of nursing model and problem statement of the nursing diagnosis. In
identified the 14 basic needs. this situation, the problem statement is diarrhea.

12. (B) Nurse and patient 23. (C) Making of individualized patient care
Although diagnosing is basically the nurse’s To be effective, the nursing care plan developed
responsibility, input from the patient is essential in the planning phase of the nursing process
to formulate the correct nursing diagnosis. must reflect the individualized needs of the
patient.
13. (C) Health belief
Health belief of an individual influences his/her 24. (A) Ineffective breathing pattern related
preventive health behavior. to pain, as evidenced by shortness of
breath.
14. (D) Decreased urine output Physiologic needs (ex. Oxygen, fluids, nutrition)
Adreno-cortical response involves release of must be met before lower needs (such as safety
aldosterone that leads to retention of sodium and and security, love and belongingness, self-
water. This results to decreased urine output. esteem and self-actualization) can be met.
Therefore, physiologic needs have the highest
15. (D) Aspirate urine from the tubing port priority.
using a sterile syringe.
The nurse should aspirate the urine from the port 25. (D) 0 degree
using a sterile syringe to obtain a urine The patient should be positioned with the head of
specimen. Opening a closed drainage system the bed completely flattened to perform an
increase the risk of urinary tract infection. abdominal examination. If the head of the bed is
elevated, the abdominal muscles and organs can
16. (A) Stop the infusion be bunched up, altering the findings
The sign and symptoms indicate extravasation so
the IVF should be stopped immediately and put
warm not cold towel on the affected site.
Practice Test I -Foundation of Nursing
17. (B) After few minutes, return to that
patient’s room and do not leave until the
patient takes the medication http://www.rnpedia.com/home/exams/philippine-board-
This is to verify or to make sure that the exam-nle/practice-test-i--foundation-of-nursing-1
medication was taken by the patient as directed.
1. Which element in the circular chain of infection
can be eliminated by preserving skin integrity?
18. (A) Place the feeding 20 inches above
the pint if insertion of NGT.
a. Host
The height of the feeding is above 12 inches
b. Reservoir
above the point of insertion, bot 20 inches. If the
c. Mode of transmission
height of feeding is too high, this results to very
d. Portal of entry
rapid introduction of feeding. This may trigger
nausea and vomiting.
2. Which of the following will probably result in a
19. (D) Educator
break in sterile technique for respiratory
When teaching a patient about medications
isolation?
before discharge, the nurse is acting as an
educator. A caregiver provides direct care to the
a. Opening the patient’s window to the outside
patient. The nurse acts as s patient advocate
environment
when making the patient’s wishes known to the
b. Turning on the patient’s room ventilator
doctor.
c. Opening the door of the patient’s room leading
into the hospital corridor
20. (C) Capillary refill greater than 3
d. Failing to wear gloves when administering a
seconds and buccal cyanosis
bed bath
Capillary refill greater than 3 seconds and buccal
cyanosis indicate decreased oxygen to the tissues
which requires immediate attention/intervention.
3. Which of the following patients is at greater
Oriented to date, time and place, hemoglobin of
risk for contracting an infection?
13 g/dl are normal data.
a. A patient with leukopenia
21. (C) Patient’s NGT was removed 2 hours
b. A patient receiving broad-spectrum antibiotics
ago
c. A postoperative patient who has undergone
The change-of-shift report should indicate
orthopedic surgery
significant recent changes in the patient’s

5
d. A newly diagnosed diabetic patient c. The gloves should be adjusted by sliding the
gloved fingers under the sterile cuff and pulling
the glove over the wrist
4. Effective hand washing requires the use of: d. The inside of the glove is considered sterile

a. Soap or detergent to promote emulsification

b. Hot water to destroy bacteria 11.When removing a contaminated gown, the
c. A disinfectant to increase surface tension nurse should be careful that the first thing she
d. All of the above touches is the:

a. Waist tie and neck tie at the back of the gown

5. After routine patient contact, hand washing b. Waist tie in front of the gown
should last at least: c. Cuffs of the gown
d. Inside of the gown
a. 30 seconds
b. 1 minute
c. 2 minute 12.Which of the following nursing interventions is
d. 3 minutes considered the most effective form or universal
precautions?

6. Which of the following procedures always a. Cap all used needles before removing them
requires surgical asepsis? from their syringes
b. Discard all used uncapped needles and
a. Vaginal instillation of conjugated estrogen syringes in an impenetrable protective container
b. Urinary catheterization c. Wear gloves when administering IM injections
c. Nasogastric tube insertion d. Follow enteric precautions
d. Colostomy irrigation

13.All of the following measures are

7. Sterile technique is used whenever: recommended to prevent pressure ulcers except:

a. Strict isolation is required a. Massaging the reddened are with lotion

b. Terminal disinfection is performed b. Using a water or air mattress
c. Invasive procedures are performed c. Adhering to a schedule for positioning and
d. Protective isolation is necessary turning
d. Providing meticulous skin care

8. Which of the following constitutes a break in

sterile technique while preparing a sterile field for 14.Which of the following blood tests should be
a dressing change? performed before a blood transfusion?

a. Using sterile forceps, rather than sterile a. Prothrombin and coagulation time
gloves, to handle a sterile item b. Blood typing and cross-matching
b. Touching the outside wrapper of sterilized c. Bleeding and clotting time
material without sterile gloves d. Complete blood count (CBC) and electrolyte
c. Placing a sterile object on the edge of the levels.
sterile field
d. Pouring out a small amount of solution (15 to
30 ml) before pouring the solution into a sterile 15.The primary purpose of a platelet count is to
container evaluate the:

a. Potential for clot formation

9. A natural body defense that plays an active b. Potential for bleeding
role in preventing infection is: c. Presence of an antigen-antibody response
d. Presence of cardiac enzymes
a. Yawning
b. Body hair
c. Hiccupping 16.Which of the following white blood cell (WBC)
d. Rapid eye movements counts clearly indicates leukocytosis?

a. 4,500/mm³
10. All of the following statement are true about b. 7,000/mm³
donning sterile gloves except: c. 10,000/mm³
d. 25,000/mm³
a. The first glove should be picked up by grasping
the inside of the cuff.
b. The second glove should be picked up by 17. After 5 days of diuretic therapy with 20mg of
inserting the gloved fingers under the cuff furosemide (Lasix) daily, a patient begins to
outside the glove. exhibit fatigue, muscle cramping and muscle
weakness. These symptoms probably indicate
that the patient is experiencing:

6
 23.The mid-deltoid injection site is seldom used
a. Hypokalemia for I.M. injections because it:
b. Hyperkalemia
c. Anorexia a. Can accommodate only 1 ml or less of
d. Dysphagia medication
b. Bruises too easily
c. Can be used only when the patient is lying
18.Which of the following statements about chest down
X-ray is false? d. Does not readily parenteral medication

a. No contradictions exist for this test

b. Before the procedure, the patient should 24.The appropriate needle size for insulin
remove all jewelry, metallic objects, and buttons injection is:
above the waist
c. A signed consent is not required a. 18G, 1 ½” long
d. Eating, drinking, and medications are allowed b. 22G, 1” long
before this test c. 22G, 1 ½” long
d. 25G, 5/8” long

19.The most appropriate time for the nurse to

obtain a sputum specimen for culture is: 25.The appropriate needle gauge for intradermal
injection is:
a. Early in the morning
b. After the patient eats a light breakfast a. 20G
c. After aerosol therapy b. 22G
d. After chest physiotherapy c. 25G
d. 26G

20.A patient with no known allergies is to receive

penicillin every 6 hours. When administering the 26.Parenteral penicillin can be administered as
medication, the nurse observes a fine rash on the an:
patient’s skin. The most appropriate nursing
action would be to: a. IM injection or an IV solution
b. IV or an intradermal injection
a. Withhold the moderation and notify the c. Intradermal or subcutaneous injection
physician d. IM or a subcutaneous injection
b. Administer the medication and notify the
physician
c. Administer the medication with an 27.The physician orders gr 10 of aspirin for a
antihistamine patient. The equivalent dose in milligrams is:
d. Apply corn starch soaks to the rash
a. 0.6 mg
b. 10 mg
21.All of the following nursing interventions are c. 60 mg
correct when using the Ztrack method of drug d. 600 mg
injection except:

a. Prepare the injection site with alcohol 28.The physician orders an IV solution of
b. Use a needle that’s a least 1” long dextrose 5% in water at 100ml/hour. What would
c. Aspirate for blood before injection the flow rate be if the drop factor is 15 gtt = 1
d. Rub the site vigorously after the injection to ml?
promote absorption
a. 5 gtt/minute
b. 13 gtt/minute
22.The correct method for determining the c. 25 gtt/minute
vastus lateralis site for I.M. injection is to: d. 50 gtt/minute

a. Locate the upper aspect of the upper outer

quadrant of the buttock about 5 to 8 cm below 29.Which of the following is a sign or symptom of
the iliac crest a hemolytic reaction to blood transfusion?
b. Palpate the lower edge of the acromion
process and the midpoint lateral aspect of the a. Hemoglobinuria
arm b. Chest pain
c. Palpate a 1” circular area anterior to the c. Urticaria
umbilicus d. Distended neck veins
d. Divide the area between the greater femoral
trochanter and the lateral femoral condyle into
thirds, and select the middle third on the anterior 30.Which of the following conditions may require
of the thigh fluid restriction?

a. Fever

7
b. Chronic Obstructive Pulmonary Disease 37.An infected patient has chills and begins
c. Renal Failure shivering. The best nursing intervention is to:
d. Dehydration
a. Apply iced alcohol sponges
b. Provide increased cool liquids
31.All of the following are common signs and c. Provide additional bedclothes
symptoms of phlebitis except: d. Provide increased ventilation

a. Pain or discomfort at the IV insertion site

b. Edema and warmth at the IV insertion site 38.A clinical nurse specialist is a nurse who has:
c. A red streak exiting the IV insertion site
d. Frank bleeding at the insertion site a. Been certified by the National League for
Nursing
b. Received credentials from the Philippine
32.The best way of determining whether a Nurses’ Association
patient has learned to instill ear medication c. Graduated from an associate degree program
properly is for the nurse to: and is a registered professional nurse
d. Completed a master’s degree in the prescribed
a. Ask the patient if he/she has used ear drops clinical area and is a registered professional
before nurse.
b. Have the patient repeat the nurse’s
instructions using her own words
c. Demonstrate the procedure to the patient and 39.The purpose of increasing urine acidity
encourage to ask questions through dietary means is to:
d. Ask the patient to demonstrate the procedure
a. Decrease burning sensations
b. Change the urine’s color
33.Which of the following types of medications c. Change the urine’s concentration
can be administered via gastrostomy tube? d. Inhibit the growth of microorganisms

a. Any oral medications

b. Capsules whole contents are dissolve in water 40.Clay colored stools indicate:
c. Enteric-coated tablets that are thoroughly
dissolved in water a. Upper GI bleeding
d. Most tablets designed for oral use, except for b. Impending constipation
extended-duration compounds c. An effect of medication
d. Bile obstruction

34.A patient who develops hives after receiving

an antibiotic is exhibiting drug: 41.In which step of the nursing process would
the nurse ask a patient if the medication she
a. Tolerance administered relieved his pain?
b. Idiosyncrasy
c. Synergism a. Assessment
d. Allergy b. Analysis
c. Planning
d. Evaluation
35.A patient has returned to his room after
femoral arteriography. All of the following are
appropriate nursing interventions except: 42.All of the following are good sources of
vitamin A except:
a. Assess femoral, popliteal, and pedal pulses
every 15 minutes for 2 hours a. White potatoes
b. Check the pressure dressing for sanguineous b. Carrots
drainage c. Apricots
c. Assess a vital signs every 15 minutes for 2 d. Egg yolks
hours
d. Order a hemoglobin and hematocrit count 1
hour after the arteriography 43.Which of the following is a primary nursing
intervention necessary for all patients with a
Foley Catheter in place?
36.The nurse explains to a patient that a cough:
a. Maintain the drainage tubing and collection
a. Is a protective response to clear the bag level with the patient’s bladder
respiratory tract of irritants b. Irrigate the patient with 1% Neosporin solution
b. Is primarily a voluntary action three times a daily
c. Is induced by the administration of an c. Clamp the catheter for 1 hour every 4 hours to
antitussive drug maintain the bladder’s elasticity
d. Can be inhibited by “splinting” the abdomen d. Maintain the drainage tubing and collection
bag below bladder level to facilitate drainage by
gravity

8
 a. Increased urine acidity and relaxation of the
perineal muscles, causing incontinence
44.The ELISA test is used to: b. Urine retention, bladder distention, and
infection
a. Screen blood donors for antibodies to human c. Diuresis, natriuresis, and decreased urine
immunodeficiency virus (HIV) specific gravity
b. Test blood to be used for transfusion for HIV d. Decreased calcium and phosphate levels in the
antibodies urine
c. Aid in diagnosing a patient with AIDS
d. All of the above
Answer and Rationale- Practice Test I -
Foundation of Nursing
45.The two blood vessels most commonly used
for TPN infusion are the:
1. D. In the circular chain of infection, pathogens
a. Subclavian and jugular veins must be able to leave their reservoir and be
b. Brachial and subclavian veins transmitted to a susceptible host through a portal
c. Femoral and subclavian veins of entry, such as broken skin.
d. Brachial and femoral veins
2. C. Respiratory isolation, like strict isolation,
requires that the door to the door patient’s room
46.Effective skin disinfection before a surgical remain closed. However, the patient’s room
procedure includes which of the following should be well ventilated, so opening the window
methods? or turning on the ventricular is desirable. The
nurse does not need to wear gloves for
a. Shaving the site on the day before surgery respiratory isolation, but good hand washing is
b. Applying a topical antiseptic to the skin on the important for all types of isolation.
evening before surgery
c. Having the patient take a tub bath on the 3. A. Leukopenia is a decreased number of
morning of surgery leukocytes (white blood cells), which are
d. Having the patient shower with an antiseptic important in resisting infection. None of the other
soap on the evening v=before and the morning of situations would put the patient at risk for
surgery contracting an infection; taking
broadspectrum antibiotics might actually reduce
the infection risk.
47.When transferring a patient from a bed to a
chair, the nurse should use which muscles to 4. A. Soaps and detergents are used to help
avoid back injury? remove bacteria because of their ability to lower
the surface tension of water and act as
a. Abdominal muscles emulsifying agents. Hot water may lead to skin
b. Back muscles irritation or burns.
c. Leg muscles
d. Upper arm muscles 5. A. Depending on the degree of exposure to
pathogens, hand washing may last from 10
seconds to 4 minutes. After routine patient
48.Thrombophlebitis typically develops in contact, hand washing for 30 seconds effectively
patients with which of the following conditions? minimizes the risk of pathogen transmission.

a. Increases partial thromboplastin time 6. B. The urinary system is normally free of

b. Acute pulsus paradoxus microorganisms except at the urinary meatus.
c. An impaired or traumatized blood vessel wall Any procedure that involves entering this system
d. Chronic Obstructive Pulmonary Disease must use surgically aseptic measures to maintain
(COPD) a bacteria-free state.

7. C. All invasive procedures, including surgery,

49.In a recumbent, immobilized patient, lung catheter insertion, and administration of
ventilation can become altered, leading to such parenteral therapy, require sterile technique to
respiratory complications as: maintain a sterile environment. All equipment
must be sterile, and the nurse and the physician
a. Respiratory acidosis, ateclectasis, and must wear sterile gloves and maintain surgical
hypostatic pneumonia asepsis. In the operating room, the nurse and
b. Appneustic breathing, atypical pneumonia and physician are required to wear sterile gowns,
respiratory alkalosis gloves, masks, hair covers, and shoe covers for
c. Cheyne-Strokes respirations and spontaneous all invasive procedures. Strict isolation requires
pneumothorax the use of clean gloves, masks, gowns and
d. Kussmail’s respirations and hypoventilation equipment to prevent the transmission of highly
communicable diseases by contact or by airborne
routes. Terminal disinfection is the disinfection of
50.Immobility impairs bladder elimination, all contaminated supplies and equipment after a
resulting in such disorders as patient has been discharged to prepare them for
reuse by another patient. The purpose of

9
protective (reverse) isolation is to prevent a less than 20,000/mm3 is associated with
person with seriously impaired resistance from spontaneous bleeding.
coming into contact who potentially pathogenic
organisms. 16. D. Leukocytosis is any transient increase in
the number of white blood cells (leukocytes) in
8. C. The edges of a sterile field are considered the blood. Normal WBC counts range from 5,000
contaminated. When sterile items are allowed to to 100,000/mm3. Thus, a count of 25,000/mm3
come in contact with the edges of the field, the indicates leukocytosis.
sterile items also become contaminated.
17. A. Fatigue, muscle cramping, and muscle
9. B. Hair on or within body areas, such as the weaknesses are symptoms of hypokalemia (an
nose, traps and holds particles that contain inadequate potassium level), which is a potential
microorganisms. Yawning and hiccupping do side effect of diuretic therapy. The physician
not prevent microorganisms from entering or usually orders supplemental potassium to
leaving the body. Rapid eye movement marks the prevent hypokalemia in patients receiving
stage of sleep during which dreaming occurs. diuretics. Anorexia is another symptom of
hypokalemia. Dysphagia means difficulty
10. D. The inside of the glove is always swallowing.
considered to be clean, but not sterile.
18. A. Pregnancy or suspected pregnancy is the
11. A. The back of the gown is considered clean, only contraindication for a chest X-ray. However,
the front is contaminated. So, after removing if a chest X-ray is necessary, the patient can
gloves and washing hands, the nurse should wear a lead apron to protect the pelvic region
untie the back of the gown; slowly move from radiation. Jewelry, metallic objects, and
backward away from the gown, holding the inside buttons would interfere with the X-ray and thus
of the gown and keeping the edges off the floor; should not be worn above the waist. A signed
turn and fold the gown inside out; discard it in a consent is not required because a chest X-ray is
contaminated linen container; then wash her not an invasive examination. Eating, drinking and
hands again. medications are allowed because the X-ray is of
the chest, not the abdominal region.
12. B. According to the Centers for Disease
Control (CDC), blood-to-blood contact occurs 19. A. Obtaining a sputum specimen early in this
most commonly when a health care worker morning ensures an adequate supply of bacteria
attempts to cap a used needle. Therefore, used for culturing and decreases the risk
needles should never be recapped; instead they of contamination from food or medication.
should be inserted in a specially designed
puncture resistant, labeled container. Wearing 20. A. Initial sensitivity to penicillin is commonly
gloves is not always necessary manifested by a skin rash, even in individuals
when administering an I.M. injection. Enteric who have not been allergic to it previously.
precautions prevent the transfer of pathogens via Because of the danger of anaphylactic shock, he
feces. nurse should withhold the drug and
notify the physician, who may choose to
13. A. Nurses and other health care professionals substitute another drug. Administering an
previously believed that massaging a reddened antihistamine is a dependent nursing intervention
area with lotion would promote venous return that requires a written physician’s order.
and reduce edema to the area. However, Although applying corn starch to the rash may
research has shown that massage only increases relieve discomfort, it is not the nurse’s top
the likelihood of cellular ischemia and necrosis to priority in such a potentially life-threatening
the area. situation.

14. B. Before a blood transfusion is performed, 21. D. The Z-track method is an I.M. injection
the blood of the donor and recipient must be technique in which the patient’s skin is pulled in
checked for compatibility. This is done by blood such a way that the needle track is sealed off
typing (a test that determines a person’s blood after the injection. This procedure seals
type) and cross-matching (a procedure that medication deep into the muscle,
determines the compatibility of the donor’s and thereby minimizing skin staining and irritation.
recipient’s blood after the blood types has been Rubbing the injection site is contraindicated
matched). If the blood specimens because it may cause the medication to
are incompatible, hemolysis and antigen-antibody extravasate into the skin.
reactions will occur.
22. D. The vastus lateralis, a long, thick muscle
15. A. Platelets are disk-shaped cells that are that extends the full length of the thigh, is
essential for blood coagulation. A platelet count viewed by many clinicians as the site of choice
determines the number of thrombocytes in blood for I.M. injections because it has relatively few
available for promoting hemostasis and assisting major nerves and blood vessels. The middle third
with blood coagulation after injury. It also is used of the muscle is recommended as the injection
to evaluate the patient’s potential for bleeding; site. The patient can be in a supine or sitting
however, this is not its primary purpose. The position for an injection into this site.
normal count ranges from 150,000
to 350,000/mm3. A count of 100,000/mm3 or 23. A. The mid-deltoid injection site can
less indicates a potential for bleeding; count of accommodate only 1 ml or less of medication

10
because of its size and location (on the deltoid 33. D. Capsules, enteric-coated tablets, and most
muscle of the arm, close to the brachial artery extended duration or sustained release products
and radial nerve). should not be dissolved for use in a gastrostomy
tube. They are pharmaceutically manufactured in
24. D. A 25G, 5/8” needle is the recommended these forms for valid reasons, and altering them
size for insulin injection because insulin is destroys their purpose. The nurse should seek an
administered by the subcutaneous route. An 18G, alternate physician’s order when an ordered
1 ½” needle is usually used for I.M. injections in medication is inappropriate for delivery by tube.
children, typically in the vastus lateralis. A 22G, 1
½” needle is usually used for adult I.M. 34. D. A drug-allergy is an adverse reaction
injections, which are typically administered in the resulting from an immunologic response following
vastus lateralis or ventrogluteal site. a previous sensitizing exposure to the drug.
The reaction can range from a rash or hives to
25. D. Because an intradermal injection does not anaphylactic shock. Tolerance to a drug means
penetrate deeply into the skin, a small-bore 25G that the patient experiences a decreasing
needle is recommended. This type of injection physiologic response to repeated administration
is used primarily to administer antigens to of the drug in the same dosage. Idiosyncrasy is
evaluate reactions for allergy or an individual’s unique hypersensitivity to a drug,
sensitivity studies. A 20G needle is usually used food, or other substance; it appears to be
for I.M. injections of oilbased medications; a 22G genetically determined. Synergism, is a drug
needle for I.M. injections; and a 25G needle, interaction in which the sum of the drug’s
for I.M. injections; and a 25G needle, for combined effects is greater
subcutaneous insulin injections. than that of their separate effects.

26. A. Parenteral penicillin can be administered 35. D. A hemoglobin and hematocrit count would
I.M. or added to a solution and given I.V. It be ordered by the physician if bleeding were
cannot be administered subcutaneously or suspected. The other answers are appropriate
intradermally. nursing interventions for a patient who has
undergone femoral arteriography.
27. D. gr 10 x 60mg/gr 1 = 600 mg
36. A. Coughing, a protective response that
28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 clears the respiratory tract of irritants, usually is
gtt/minute involuntary; however it can be voluntary, as
when a patient is taught to perform coughing
29. A. Hemoglobinuria, the abnormal presence of exercises. An antitussive drug inhibits coughing.
hemoglobin in the urine, indicates a hemolytic Splinting the abdomen supports the abdominal
reaction (incompatibility of the donor’s muscles when a patient coughs.
and recipient’s blood). In this reaction, antibodies
in the recipient’s plasma combine rapidly with 37. C. In an infected patient, shivering results
donor RBC’s; the cells are hemolyzed in from the body’s attempt to increase heat
either circulatory or reticuloendothelial system. production and the production of neutrophils
Hemolysis occurs more rapidly in and phagocytotic action through increased
ABO incompatibilities than in Rh incompatibilities. skeletal muscle tension and contractions. Initial
Chest pain and urticaria may be symptoms of vasoconstriction may cause skin to feel cold to
impending anaphylaxis. Distended neck veins are the touch. Applying additional bed clothes helps
an indication of hypervolemia. to equalize the body
temperature and stop the chills. Attempts to cool
30. C. In real failure, the kidney loses their ability the body result in further shivering, increased
to effectively eliminate wastes and fluids. metabloism, and thus increased heat production.
Because of this, limiting the patient’s intake of
oral and I.V. fluids may be necessary. Fever, 38. D. A clinical nurse specialist must have
chronic obstructive pulmonary disease, and completed a master’s degree in a clinical
dehydration are conditions for which fluids should specialty and be a registered professional nurse.
be encouraged. The National League of Nursing accredits
educational programs in nursing and provides a
31. D. Phlebitis, the inflammation of a vein, can testing service to evaluate student nursing
be caused by chemical irritants (I.V. solutions or competence but it does not certify nurses. The
medications), mechanical irritants (the needle American Nurses Association identifies
or catheter used during venipuncture or requirements for certification and offers
cannulation), or a localized allergic examinations for certification in many areas
reaction to the needle or catheter. Signs and of nursing., such as medical surgical nursing.
symptoms of phlebitis include pain or discomfort, These certification (credentialing) demonstrates
edema and heat at the I.V. insertion site, and that the nurse has the knowledge and the
a red streak going up the arm or leg from the ability to provide high quality nursing care in the
I.V. insertion site. area of her certification. A graduate of an
associate degree program is not a clinical nurse
32. D. Return demonstration provides the most specialist: however, she is prepared to provide
certain evidence for evaluating the effectiveness bed side nursing with a high degree of knowledge
of patient teaching. and skill. She must successfully complete the
licensing examination to become a registered
professional nurse.

11
 partial thromboplastin time indicates a prolonged
39. D. Microorganisms usually do not grow in an bleeding time during fibrin clot formation,
acidic environment. commonly the result of anticoagulant (heparin)
therapy. Arterial blood disorders (such as pulsus
40. D. Bile colors the stool brown. Any paradoxus) and lung diseases (such as COPD) do
inflammation or obstruction that impairs bile flow not necessarily impede venous return of injure
will affect the stool pigment, yielding light, clay- vessel walls.
colored stool. Upper GI bleeding results in black
or tarry stool. Constipation is characterized by 49. A. Because of restricted respiratory
small, hard masses. Many medications and foods movement, a recumbent, immobilize patient is at
will discolor stool – for example, drugs containing particular risk for respiratory acidosis from poor
iron turn stool black.; beets gas exchange; atelectasis from reduced
turn stool red. surfactant and accumulated mucus in the
bronchioles, and hypostatic pneumonia from
41. D. In the evaluation step of the nursing bacterial growth caused by stasis of mucus
process, the nurse must decide whether the secretions.
patient has achieved the expected outcome that
was identified in the planning phase. 50. B. The immobilized patient commonly suffers
from urine retention caused by decreased muscle
42. A. The main sources of vitamin A are yellow tone in the perineum. This leads to
and green vegetables (such as carrots, sweet bladder distention and urine stagnation, which
potatoes, squash, spinach, collard greens, provide an excellent medium for bacterial growth
broccoli, and cabbage) and yellow fruits (such as leading to infection. Immobility also results in
apricots, and cantaloupe). Animal sources include more alkaline urine with excessive amounts of
liver, kidneys, cream, butter, and egg yolks. calcium, sodium and phosphate,
a gradual decrease in urine production, and an
43. D. Maintaing the drainage tubing and increased specific gravity.
collection bag level with the patient’s bladder
could result in reflux of urine into the kidney. Nursing Practice I -Foundation of
Irrigating the bladder with Neosporin and Professional Nursing Practice
clamping the catheter for 1 hour every 4 hours
must
be prescribed by a physician. 1. The nurse In-charge in labor and delivery unit
administered a dose of terbutaline to a client
44. D. The ELISA test of venous blood is used to without checking the client’s pulse. The standard
assess blood and potential blood donors to that would be used to determine if the nurse was
human immunodeficiency virus (HIV). A positive negligent is:
ELISA test combined with various signs and
symptoms helps to diagnose acquired a. The physician’s orders.
immunodeficiency syndrome (AIDS) b. The action of a clinical nurse specialist who is
recognized expert in the field.
45. D. Tachypnea (an abnormally rapid rate of c. The statement in the drug literature about
breathing) would indicate that the patient was administration of terbutaline.
still hypoxic (deficient in oxygen).The partial d. The actions of a reasonably prudent nurse with
pressures of arterial oxygen and carbon dioxide similar education and experience.
listed are within the normal range. Eupnea refers
to normal respiration.
2. Nurse Trish is caring for a female client with a
46. D. Studies have shown that showering with history of GI bleeding, sickle cell disease, and a
an antiseptic soap before surgery is the most platelet count of 22,000/µl. The female client is
effective method of removing microorganisms dehydrated and receiving dextrose 5% in half-
from the skin. Shaving the site of the intended normal saline solution at 150 ml/hr. The client
surgery might cause breaks in the skin, thereby complains of severe bone pain and is scheduled
increasing the risk of infection; however, if to receive a dose of morphine sulfate. In
indicated, shaving, should be done immediately administering the medication, Nurse Trish should
before surgery, not the day before. A topical avoid which route?
antiseptic would not remove microorganisms and a. I.V
would be beneficial only after proper cleaning and b. I.M
rinsing. Tub bathing might transfer organisms to c. Oral
another body site rather than rinse them away. d. S.C

47. C. The leg muscles are the strongest muscles

in the body and should bear the greatest stress 3. Dr. Garcia writes the following order for the
when lifting. Muscles of the abdomen, back, and client who has been recently admitted “Digoxin
upper arms may be easily injured. .125 mg P.O. once daily.” To prevent a dosage
error, how should the nurse document this order
48. C. The factors, known as Virchow’s triad, onto the medication administration record?
collectively predispose a patient to
thromboplebitis; impaired venous return to the a. “Digoxin .1250 mg P.O. once daily”
heart, blood hypercoagulability, and injury to a b. “Digoxin 0.1250 mg P.O. once daily”
blood vessel wall. Increased

12
c. “Digoxin 0.125 mg P.O. once daily” ice to the ankle for 30 minutes, which statement
d. “Digoxin .125 mg P.O. once daily” by Tony suggests that ice application has been
effective?

4. A newly admitted female client was diagnosed a. “My ankle looks less swollen now”.
with deep vein thrombosis. Which nursing b. “My ankle feels warm”.
diagnosis should receive the highest priority? c. “My ankle appears redder now”.
d. “I need something stronger for pain relief”
a. Ineffective peripheral tissue perfusion related
to venous congestion.
b. Risk for injury related to edema. 10.The physician prescribes a loop diuretic for a
c. Excess fluid volume related to peripheral client. When administering this drug, the nurse
vascular disease. anticipates that the client may develop which
d. Impaired gas exchange related to increased electrolyte imbalance?
blood flow.
a. Hypernatremia
b. Hyperkalemia
5. Nurse Betty is assigned to the following c. Hypokalemia
clients. The client that the nurse would see first d. Hypervolemia
after endorsement?

a. A 34 year-old post operative appendectomy 11.She finds out that some managers have
client of five hours who is complaining of pain. benevolent-authoritative style of management.
b. A 44 year-old myocardial infarction (MI) client Which of the following behaviors will she exhibit
who is complaining of nausea. most likely?
c. A 26 year-old client admitted for dehydration
whose intravenous (IV) has infiltrated. a. Have condescending trust and confidence in
d. A 63 year-old post operative’s abdominal their subordinates.
hysterectomy client of three days whose b. Gives economic and ego awards.
incisional dressing is saturated c. Communicates downward to staffs.
with serosanguinous fluid. d. Allows decision making among subordinates.

6. Nurse Gail places a client in a four-point 12. Nurse Amy is aware that the following is true
restraint following orders from the physician. The about functional nursing
client care plan should include:
a. Provides continuous, coordinated and
a. Assess temperature frequently. comprehensive nursing services.
b. Provide diversional activities. b. One-to-one nurse patient ratio.
c. Check circulation every 15-30 minutes. c. Emphasize the use of group collaboration.
d. Socialize with other patients once a shift. d. Concentrates on tasks and activities.

7. A male client who has severe burns is 13.Which type of medication order might read
receiving H2 receptor antagonist therapy. The "Vitamin K 10 mg I.M. daily × 3 days?"
nurse In-charge knows the purpose of this
therapy is to: a. Single order
b. Standard written order
a. Prevent stress ulcer c. Standing order
b. Block prostaglandin synthesis d. Stat order
c. Facilitate protein synthesis.
d. Enhance gas exchange
14.A female client with a fecal impaction
frequently exhibits which clinical manifestation?
8. The doctor orders hourly urine output
measurement for a postoperative male client. a. Increased appetite
The nurse Trish records the following amounts of b. Loss of urge to defecate
output for 2 consecutive hours: 8 a.m.: 50 ml; 9 c. Hard, brown, formed stools
a.m.: 60 ml. Based on these amounts, which d. Liquid or semi-liquid stools
action should the nurse take?

a. Increase the I.V. fluid infusion rate 15.Nurse Linda prepares to perform an otoscopic
b. Irrigate the indwelling urinary catheter examination on a female client. For proper
c. Notify the physician visualization, the nurse should position the
d. Continue to monitor and record hourly urine client's ear by:
output
a. Pulling the lobule down and back
b. Pulling the helix up and forward
9. Tony, a basketball player twist his right ankle c. Pulling the helix up and back
while playing on the court and seeks care for d. Pulling the lobule down and forward
ankle pain and swelling. After the nurse applies

13
 22.A male client is being transferred to the
nursing unit for admission after receiving a
16. Which instruction should nurse Tom give to a radium implant for bladder cancer. The nurse in-
male client who is having external radiation charge would take which priority action in the
therapy: care of this client?

a. Protect the irritated skin from sunlight. a. Place client on reverse isolation.
b. Eat 3 to 4 hours before treatment. b. Admit the client into a private room.
c. Wash the skin over regularly. c. Encourage the client to take frequent rest
d. Apply lotion or oil to the radiated area when it periods.
is red or sore. d. Encourage family and friends to visit.

17.In assisting a female client for immediate 23.A newly admitted female client was diagnosed
surgery, the nurse In-charge is aware that she with agranulocytosis. The nurse formulates which
should: priority nursing diagnosis?

a. Encourage the client to void following a. Constipation

preoperative medication. b. Diarrhea
b. Explore the client’s fears and anxieties about c. Risk for infection
the surgery. d. Deficient knowledge
c. Assist the client in removing dentures and nail
polish.
d. Encourage the client to drink water prior to 24.A male client is receiving total parenteral
surgery. nutrition suddenly demonstrates signs and
symptoms of an air embolism. What is the
priority action by the nurse?
18. A male client is admitted and diagnosed with
acute pancreatitis after a holiday celebration of a. Notify the physician.
excessive food and alcohol. Which assessment b. Place the client on the left side in the
finding reflects this diagnosis? Trendelenburg position.
c. Place the client in high-Fowlers position.
a. Blood pressure above normal range. d. Stop the total parenteral nutrition.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and 25.Nurse May attends an educational conference
back pain. on leadership styles. The nurse is sitting with a
nurse employed at a large trauma center who
states that the leadership style at the trauma
19. Which dietary guidelines are important for center is task-oriented and directive. The nurse
nurse Oliver to implement in caring for the client determines that the leadership style used at the
with burns? trauma center is:

a. Provide high-fiber, high-fat diet a. Autocratic.

b. Provide high-protein, high-carbohydrate diet. b. Laissez-faire.
c. Monitor intake to prevent weight gain. c. Democratic.
d. Provide ice chips or water intake. d. Situational

20.Nurse Hazel will administer a unit of whole 26.The physician orders DS 500 cc with KCl 10
blood, which priority information should the mEq/liter at 30 cc/hr. The nurse in-charge is
nurse have about the client? going to hang a 500 cc bag. KCl is supplied 20
mEq/10 cc. How many cc’s of KCl will be added
a. Blood pressure and pulse rate. to the IV solution?
b. Height and weight.
c. Calcium and potassium levels a. .5 cc
d. Hgb and Hct levels. b. 5 cc
c. 1.5 cc
d. 2.5 cc
21. Nurse Michelle witnesses a female client
sustain a fall and suspects that the leg may be
broken. The nurse takes which priority action? 27.A child of 10 years old is to receive 400 cc of
IV fluid in an 8 hour shift. The IV drip factor is
a. Takes a set of vital signs. 60. The IV rate that will deliver this amount is:
b. Call the radiology department for X-ray.
c. Reassure the client that everything will be a. 50 cc/ hour
alright. b. 55 cc/ hour
d. Immobilize the leg before moving the client. c. 24 cc/ hour
d. 66 cc/ hour

14
28.The nurse is aware that the most important 34.Which stage of pressure ulcer development
nursing action when a client returns from surgery does the ulcer extend into the subcutaneous
is: tissue?

a. Assess the IV for type of fluid and rate of flow. a. Stage I

b. Assess the client for presence of pain. b. Stage II
c. Assess the Foley catheter for patency and c. Stage III
urine output d. Stage IV
d. Assess the dressing for drainage.

35.When the method of wound healing is one in

29. Which of the following vital sign assessments which wound edges are not surgically
that may indicate cardiogenic shock after approximated and integumentary continuity is
myocardial infarction? restored by granulations, the wound healing is
termed
a. BP – 80/60, Pulse – 110 irregular
b. BP – 90/50, Pulse – 50 regular a. Second intention healing
c. BP – 130/80, Pulse – 100 regular b. Primary intention healing
d. BP – 180/100, Pulse – 90 irregular c. Third intention healing
d. First intention healing

30.Which is the most appropriate nursing action

in obtaining a blood pressure measurement? 36.An 80-year-old male client is admitted to the
hospital with a diagnosis of pneumonia. Nurse
a. Take the proper equipment, place the client in Oliver learns that the client lives alone and hasn’t
a comfortable position, and record the been eating or drinking. When assessing him for
appropriate information in the client’s chart. dehydration, nurse Oliver would expect to find:
b. Measure the client’s arm, if you are not sure of
the size of cuff to use. a. Hypothermia
c. Have the client recline or sit comfortably in a b. Hypertension
chair with the forearm at the level of the heart. c. Distended neck veins
d. Document the measurement, which extremity d. Tachycardia
was used, and the position that the client was in
during the measurement.
37.The physician prescribes meperidine
(Demerol), 75 mg I.M. every 4 hours as needed,
31.Asking the questions to determine if the to control a client’s postoperative pain. The
person understands the health teaching provided package insert is “Meperidine, 100 mg/ml.” How
by the nurse would be included during which step many milliliters of meperidine should the
of the nursing process? client receive?

a. Assessment a. 0.75
b. Evaluation b. 0.6
c. Implementation c. 0.5
d. Planning and goals d. 0.25

32.Which of the following item is considered the 38. A male client with diabetes mellitus is
single most important factor in assisting the receiving insulin. Which statement correctly
health professional in arriving at a diagnosis or describes an insulin unit?
determining the person’s needs?
a. It’s a common measurement in the metric
a. Diagnostic test results system.
b. Biographical date b. It’s the basis for solids in the avoirdupois
c. History of present illness system.
d. Physical examination c. It’s the smallest measurement in the
apothecary system.
d. It’s a measure of effect, not a standard
33.In preventing the development of an external measure of weight or quantity.
rotation deformity of the hip in a client who must
remain in bed for any period of time, the most
appropriate nursing action would be to use: 39.Nurse Oliver measures a client’s temperature
at 102° F. What is the equivalent Centigrade
a. Trochanter roll extending from the crest of the temperature?
ileum to the midthigh.
b. Pillows under the lower legs. a. 40.1 °C
c. Footboard b. 38.9 °C
d. Hip-abductor pillow c. 48 °C
d. 38 °C

15
40.The nurse is assessing a 48-year-old client 46. Nurse Betty is assessing tactile fremitus in a
who has come to the physician’s office for his client with pneumonia. For this examination,
annual physical exam. One of the first physical nurse Betty should use the:
signs of aging is:
a. Fingertips
a. Accepting limitations while developing assets. b. Finger pads
b. Increasing loss of muscle tone. c. Dorsal surface of the hand
c. Failing eyesight, especially close vision. d. Ulnar surface of the hand
d. Having more frequent aches and pains.

47. Which type of evaluation occurs continuously

41.The physician inserts a chest tube into a throughout the teaching and learning process?
female client to treat a pneumothorax. The tube
is connected to water-seal drainage. The nurse a. Summative
in-charge can prevent chest tube air leaks by: b. Informative
c. Formative
a. Checking and taping all connections. d. Retrospective
b. Checking patency of the chest tube.
c. Keeping the head of the bed slightly elevated.
d. Keeping the chest drainage system below the 48.A 45 year old client, has no family history of
level of the chest. breast cancer or other risk factors for this
disease. Nurse John should instruct her to have
mammogram how often?
42.Nurse Trish must verify the client’s identity
before administering medication. She is aware a. Twice per year
that the safest way to verify identity is to: b. Once per year
c. Every 2 years
a. Check the client’s identification band. d. Once, to establish baseline
b. Ask the client to state his name.
c. State the client’s name out loud and wait a
client to repeat it. 49.A male client has the following arterial blood
d. Check the room number and the client’s name gas values: pH 7.30; Pao2 89 mmHg; Paco2 50
on the bed. mmHg; and HCO3 26mEq/L. Based on these
values, Nurse Patricia should expect which
condition?
43.The physician orders dextrose 5 % in water,
1,000 ml to be infused over 8 hours. The I.V. a. Respiratory acidosis
tubing delivers 15 drops/ml. Nurse John should b. Respiratory alkalosis
run the I.V. infusion at a rate of: c. Metabolic acidosis
d. Metabolic alkalosis
a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute 50.Nurse Len refers a female client with terminal
d. 18 drops/minute cancer to a local hospice. What is the goal of this
referral?

44.If a central venous catheter becomes a. To help the client find appropriate treatment
disconnected accidentally, what should the nurse options.
in-charge do immediately? b. To provide support for the client and family in
coping with terminal illness.
a. Clamp the catheter c. To ensure that the client gets counseling
b. Call another nurse regarding health care costs.
c. Call the physician d. To teach the client and family about cancer
d. Apply a dry sterile dressing to the site. and its treatment.

45.A female client was recently admitted. She 51.When caring for a male client with a 3-cm
has fever, weight loss, and watery diarrhea is stage I pressure ulcer on the coccyx, which of the
being admitted to the facility. While assessing the following actions can the nurse institute
client, Nurse Hazel inspects the client’s abdomen independently?
and notice that it is slightly concave. Additional
assessment should proceed in which order: a. Massaging the area with an astringent every 2
hours.
a. Palpation, auscultation, and percussion. b. Applying an antibiotic cream to the area three
b. Percussion, palpation, and auscultation. times per day.
c. Palpation, percussion, and auscultation. c. Using normal saline solution to clean the ulcer
d. Auscultation, percussion, and palpation. and applying a protective dressing as necessary.
d. Using a povidone-iodine wash on the
ulceration three times per day.

16
52.Nurse Oliver must apply an elastic bandage to catheter. The nurse avoids which of the following,
a client’s ankle and calf. He should apply the which contaminate the specimen?
bandage beginning at the client’s:
a. Wiping the port with an alcohol swab before
a. Knee inserting the syringe.
b. Ankle b. Aspirating a sample from the port on the
c. Lower thigh drainage bag.
d. Foot c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary
drainage bag.
53.A 10 year old child with type 1 diabetes
develops diabetic ketoacidosis and receives a
continuous insulin infusion. Which condition 59.Nurse Meredith is in the process of giving a
represents the greatest risk to this child? client a bed bath. In the middle of the procedure,
the unit secretary calls the nurse on the intercom
a. Hypernatremia to tell the nurse that there is an emergency
b. Hypokalemia phone call. The appropriate nursing action is to:
c. Hyperphosphatemia
d. Hypercalcemia a. Immediately walk out of the client’s room and
answer the phone call.
b. Cover the client, place the call light within
54.Nurse Len is administering sublingual reach, and answer the phone call.
nitrglycerin (Nitrostat) to the newly admitted c. Finish the bed bath before answering the
client. Immediately afterward, the client may phone call.
experience: d. Leave the client’s door open so the client can
be monitored and the nurse can answer the
a. Throbbing headache or dizziness phone call.
b. Nervousness or paresthesia.
c. Drowsiness or blurred vision.
d. Tinnitus or diplopia. 60. Nurse Janah is collecting a sputum specimen
for culture and sensitivity testing from a client
who has a productive cough. Nurse Janah plans
55.Nurse Michelle hears the alarm sound on the to implement which intervention to obtain the
telemetry monitor. The nurse quickly looks at the specimen?
monitor and notes that a client is in a ventricular
tachycardia. The nurse rushes to the client’s a. Ask the client to expectorate a small amount
room. Upon reaching the client’s bedside, the of sputum into the emesis basin.
nurse would take which action first? b. Ask the client to obtain the specimen after
breakfast.
a. Prepare for cardioversion c. Use a sterile plastic container for obtaining the
b. Prepare to defibrillate the client specimen.
c. Call a code d. Provide tissues for expectoration and obtaining
d. Check the client’s level of consciousness the specimen.

56.Nurse Hazel is preparing to ambulate a female 61. Nurse Ron is observing a male client using a
client. The best and the safest position for the walker. The nurse determines that the client is
nurse in assisting the client is to stand: using the walker correctly if the client:

a. On the unaffected side of the client. a. Puts all the four points of the walker flat on the
b. On the affected side of the client. floor, puts weight on the hand pieces, and then
c. In front of the client. walks into it.
d. Behind the client. b. Puts weight on the hand pieces, moves the
walker forward, and then walks into it.
c. Puts weight on the hand pieces, slides the
57.Nurse Janah is monitoring the ongoing care walker forward, and then walks into it.
given to the potential organ donor who has been d. Walks into the walker, puts weight on the hand
diagnosed with brain death. The nurse pieces, and then puts all four points of the walker
determines that the standard of care had been flat on the floor.
maintained if which of the following data is
observed?
62.Nurse Amy has documented an entry
a. Urine output: 45 ml/hr regarding client care in the client’s medical
b. Capillary refill: 5 seconds record. When checking the entry, the nurse
c. Serum pH: 7.32 realizes that incorrect information was
d. Blood pressure: 90/48 mmHg documented. How does the nurse correct this
error?

58. Nurse Amy has an order to obtain a urinalysis a. Erases the error and writes in the correct
from a male client with an indwelling urinary information.
b. Uses correction fluid to cover up the incorrect

17
information and writes in the correct information. a. Validity
c. Draws one line to cross out the incorrect b. Specificity
information and then initials the change. c. Sensitivity
d. Covers up the incorrect information completely d. Reliability
using a black pen and writes in the correct
information
68.Harry knows that he has to protect the rights
of human research subjects. Which of the
63.Nurse Ron is assisting with transferring a following actions of Harry ensures anonymity?
client from the operating room table to a
stretcher. To provide safety to the client, the a. Keep the identities of the subject secret
nurse should: b. Obtain informed consent
c. Provide equal treatment to all the subjects of
a. Moves the client rapidly from the table to the the study.
stretcher. d. Release findings only to the participants of the
b. Uncovers the client completely before study
transferring to the stretcher.
c. Secures the client safety belts after
transferring to the stretcher. 69.Patient’s refusal to divulge information is a
d. Instructs the client to move self from the table limitation because it is beyond the control of
to the stretcher. Tifanny”. What type of research is appropriate for
this study?

64.Nurse Myrna is providing instructions to a a. Descriptive- correlational

nursing assistant assigned to give a bed bath to a b. Experiment
client who is on contact precautions. Nurse Myrna c. Quasi-experiment
instructs the nursing assistant to use which of the d. Historical
following protective items when giving bed bath?

a. Gown and goggles 70.Nurse Ronald is aware that the best tool for
b. Gown and gloves data gathering is?
c. Gloves and shoe protectors
d. Gloves and goggles a. Interview schedule
b. Questionnaire
c. Use of laboratory data
65. Nurse Oliver is caring for a client with d. Observation
impaired mobility that occurred as a result of a
stroke. The client has right sided arm and leg
weakness. The nurse would suggest that the 71.Monica is aware that there are times when
client use which of the following assistive devices only manipulation of study variables is possible
that would provide the best stability for and the elements of control or randomization are
ambulating? not attendant. Which type of research is referred
to this?
a. Crutches
b. Single straight-legged cane a. Field study
c. Quad cane b. Quasi-experiment
d. Walker c. Solomon-Four group design
d. Post-test only design

66.A male client with a right pleural effusion

noted on a chest X-ray is being prepared for 72.Cherry notes down ideas that were derived
thoracentesis. The client experiences severe from the description of an investigation written
dizziness when sitting upright. To provide a safe by the person who conducted it. Which type
environment, the nurse assists the client to which of reference source refers to this?
position for the procedure?
a. Footnote
a. Prone with head turned toward the side b. Bibliography
supported by a pillow. c. Primary source
b. Sims’ position with the head of the bed flat. d. Endnotes
c. Right side-lying with the head of the bed
elevated 45 degrees.
d. Left side-lying with the head of the bed 73.When Nurse Trish is providing care to his
elevated 45 degrees. patient, she must remember that her duty is
bound not to do doing any action that will cause
the patient harm. This is the meaning of the
67.Nurse John develops methods for data bioethical principle:
gathering. Which of the following criteria of a
good instrument refers to the ability of the a. Non-maleficence
instrument to yield the same results upon its b. Beneficence
repeated administration? c. Justice
d. Solidarity

18
74.When a nurse in-charge causes an injury to a c. Assigns numbers for each of the patients,
female patient and the injury caused becomes place these in a fishbowl and draw 10 from it.
the proof of the negligent act, the presence of d. Decides to get 20 samples from the admitted
the injury is said to exemplify the principle of: patients

a. Force majeure
b. Respondeat superior 80. The nursing theorist who developed
c. Res ipsa loquitor transcultural nursing theory is:
d. Holdover doctrine
a. Florence Nightingale
b. Madeleine Leininger
75.Nurse Myrna is aware that the Board of c. Albert Moore
Nursing has quasi-judicial power. An example of d. Sr. Callista Roy
this power is:

a. The Board can issue rules and regulations that 81.Marion is aware that the sampling method
will govern the practice of nursing that gives equal chance to all units in the
b. The Board can investigate violations of the population to get picked is:
nursing law and code of ethics
c. The Board can visit a school applying for a a. Random
permit in collaboration with CHED b. Accidental
d. The Board prepares the board examinations c. Quota
d. Judgment

76. When the license of nurse Krina is revoked, it

means that she: 82.John plans to use a Likert Scale to his study to
determine the:
a. Is no longer allowed to practice the profession
for the rest of her life a. Degree of agreement and disagreement
b. Will never have her/his license re-issued since b. Compliance to expected standards
it has been revoked c. Level of satisfaction
c. May apply for re-issuance of his/her license d. Degree of acceptance
based on certain conditions stipulated in RA 9173
d. Will remain unable to practice professional
nursing 83.Which of the following theory addresses the
four modes of adaptation?

77.Ronald plans to conduct a research on the use a. Madeleine Leininger

of a new method of pain assessment scale. Which b. Sr. Callista Roy
of the following is the second step in c. Florence Nightingale
the conceptualizing phase of the research d. Jean Watson
process?

a. Formulating the research hypothesis 84.Ms. Garcia is responsible to the number of

b. Review related literature personnel reporting to her. This principle refers
c. Formulating and delimiting the research to:
problem
d. Design the theoretical and conceptual a. Span of control
framework b. Unity of command
c. Downward communication
d. Leader
78. The leader of the study knows that certain
patients who are in a specialized research setting
tend to respond psychologically to the conditions 85.Ensuring that there is an informed consent on
of the study. This referred to as : the part of the patient before a surgery is done,
illustrates the bioethical principle of:
a. Cause and effect
b. Hawthorne effect a. Beneficence
c. Halo effect b. Autonomy
d. Horns effect c. Veracity
d. Non-maleficence

79.Mary finally decides to use judgment sampling

on her research. Which of the following actions of 86.Nurse Reese is teaching a female client with
is correct? peripheral vascular disease about foot care;
Nurse Reese should include which instruction?
a. Plans to include whoever is there during his
study. a. Avoid wearing cotton socks.
b. Determines the different nationality of patients b. Avoid using a nail clipper to cut toenails.
frequently admitted and decides to get c. Avoid wearing canvas shoes.
representations samples from each. d. Avoid using cornstarch on feet.

19
 priority when caring for a newly admitted client
who's receiving a blood transfusion?
87.A client is admitted with multiple pressure
ulcers. When developing the client's diet plan, the a. Instructing the client to report any itching,
nurse should include: swelling, or dyspnea.
b. Informing the client that the transfusion
a. Fresh orange slices usually take 1 ½ to 2 hours.
b. Steamed broccoli c. Documenting blood administration in the client
c. Ice cream care record.
d. Ground beef patties d. Assessing the client’s vital signs when the
transfusion ends.

88.The nurse prepares to administer a cleansing

enema. What is the most common client position 94.A male client complains of abdominal
used for this procedure? discomfort and nausea while receiving tube
feedings. Which intervention is most appropriate
a. Lithotomy for this problem?
b. Supine
c. Prone a. Give the feedings at room temperature.
d. Sims’ left lateral b. Decrease the rate of feedings and the
concentration of the formula.
c. Place the client in semi-Fowler's position while
89.Nurse Marian is preparing to administer a feeding.
blood transfusion. Which action should the nurse d. Change the feeding container every 12 hours.
take first?

a. Arrange for typing and cross matching of the 95.Nurse Patricia is reconstituting a powdered
client’s blood. medication in a vial. After adding the solution to
b. Compare the client’s identification wristband the powder, she nurse should:
with the tag on the unit of blood.
c. Start an I.V. infusion of normal saline solution. a. Do nothing.
d. Measure the client’s vital signs. b. Invert the vial and let it stand for 3 to 5
minutes.
c. Shake the vial vigorously.
90.A 65 years old male client requests his d. Roll the vial gently between the palms.
medication at 9 p.m. instead of 10 p.m. so that
he can go to sleep earlier. Which type of nursing
intervention is required? 96.Which intervention should the nurse Trish use
when administering oxygen by face mask to a
a. Independent female client?
b. Dependent
c. Interdependent a. Secure the elastic band tightly around the
d. Intradependent client's head.
b. Assist the client to the semi-Fowler position if
possible.
91.A female client is to be discharged from an c. Apply the face mask from the client's chin up
acute care facility after treatment for right leg over the nose.
thrombophlebitis. The Nurse Betty notes that d. Loosen the connectors between the oxygen
the client's leg is pain-free, without redness or equipment and humidifier.
edema. The nurse's actions reflect which step of
the nursing process?
97.The maximum transfusion time for a unit of
a. Assessment packed red blood cells (RBCs) is:
b. Diagnosis
c. Implementation a. 6 hours
d. Evaluation b. 4 hours
c. 3 hours
d. 2 hours
92.Nursing care for a female client includes
removing elastic stockings once per day. The
Nurse Betty is aware that the rationale for this 98.Nurse Monique is monitoring the effectiveness
intervention? of a client's drug therapy. When should the nurse
Monique obtain a blood sample to measure
a. To increase blood flow to the heart the trough drug level?
b. To observe the lower extremities
c. To allow the leg muscles to stretch and relax a. 1 hour before administering the next dose.
d. To permit veins in the legs to fill with blood. b. Immediately before administering the next
dose.
c. Immediately after administering the next dose.
93.Which nursing intervention takes highest d. 30 minutes after administering the next dose.

20
 place the client at risk for circulation being
restricted to the distal areas of the extremities.
99.Nurse May is aware that the main advantage Checking the client’s circulation every 15-30
of using a floor stock system is: minutes will allow the nurse to adjust the
restraints before injury from decreased blood
a. The nurse can implement medication orders flow occurs.
quickly.
b. The nurse receives input from the pharmacist. 7. Answer: (A) Prevent stress ulcer
c. The system minimizes transcription errors. Rationale: Curling’s ulcer occurs as a generalized
d. The system reinforces accurate calculations. stress response in burn patients. This results in a
decreased production of mucus and
increased secretion of gastric acid. The best
100. Nurse Oliver is assessing a client's treatment for this prophylactic use of antacids
abdomen. Which finding should the nurse report and H2 receptor blockers.
as abnormal?
8. Answer: (D) Continue to monitor and record
a. Dullness over the liver. hourly urine output
b. Bowel sounds occurring every 10 seconds. Rationale: Normal urine output for an adult is
c. Shifting dullness over the abdomen. approximately 1 ml/minute (60 ml/hour).
d. Vascular sounds heard over the renal arteries. Therefore, this client's output is normal. Beyond
continued evaluation, no nursing action is
warranted.
Nursing Practice I -Foundation of
Professional Nursing Practice- Answer 9. Answer: (B) “My ankle feels warm”.
Rationale: Ice application decreases pain and
swelling. Continued or increased pain, redness,
1. Answer: (D) The actions of a reasonably and increased warmth are signs of inflammation
prudent nurse with similar education and that shouldn't occur after ice application
experience.
Rationale: The standard of care is determined by 10. Answer: (B) Hyperkalemia
the average degree of skill, care, and diligence by Rationale: A loop diuretic removes water and,
nurses in similar circumstances. along with it, sodium and potassium. This may
result in hypokalemia, hypovolemia,
2. Answer: (B) I.M and hyponatremia.
Rationale: With a platelet count of 22,000/µl, the
clients tends to bleed easily. Therefore, the nurse 11. Answer:(A) Have condescending trust and
should avoid using the I.M. route because confidence in their subordinates
the area is a highly vascular and can bleed Rationale: Benevolent-authoritative managers
readily when penetrated by a needle. The pretentiously show their trust and confidence to
bleeding can be difficult to stop. their followers.
3. Answer: (C) “Digoxin 0.125 mg P.O. once 12. Answer: (A) Provides continuous, coordinated
daily” and comprehensive nursing services.
Rationale: The nurse should always place a zero Rationale: Functional nursing is focused on tasks
before a decimal point so that no one misreads and activities and not on the care of the patients.
the figure, which could result in a dosage
error. The nurse should never insert a zero at 13. Answer: (B) Standard written order
the end of a dosage that includes a decimal point Rationale: This is a standard written order.
because this could be misread, possibly leading Prescribers write a single order for medications
to a tenfold increase in the dosage. given only once. A stat order is written for
medications given immediately for an urgent
4. Answer: (A) Ineffective peripheral tissue client problem. A standing order, also known as a
perfusion related to venous congestion. protocol, establishes guidelines for treating a
Rationale: Ineffective peripheral tissue perfusion particular disease or set of symptoms in special
related to venous congestion takes the highest care areas such as the coronary care unit.
priority because venous inflammation and clot Facilities also may institute medication protocols
formation impede blood flow in a client with that specifically designate drugs that a nurse may
deep vein thrombosis. not give.
5. Answer: (B) A 44 year-old myocardial 14. Answer: (D) Liquid or semi-liquid stools
infarction (MI) client who is complaining of Rationale: Passage of liquid or semi-liquid stools
nausea. results from seepage of unformed bowel contents
Rationale: Nausea is a symptom of impending around the impacted stool in the rectum. Clients
myocardial infarction (MI) and should be with fecal impaction don't pass hard, brown,
assessed immediately so that treatment can be formed stools because the feces can't move past
instituted and further damage to the heart is the impaction. These clients typically report the
avoided. urge
to defecate (although they can't pass stool) and a
6. Answer: (C) Check circulation every 15-30 decreased appetite.
minutes.
Rationale: Restraints encircle the limbs, which 15. Answer: (C) Pulling the helix up and back

21
Rationale: To perform an otoscopic examination Rationale: Lying on the left side may prevent air
on an adult, the nurse grasps the helix of the ear from flowing into the pulmonary veins. The
and pulls it up and back to straighten the Trendelenburg position increases intrathoracic
ear canal. For a child, the nurse grasps the helix pressure, which decreases the amount of blood
and pulls it down to straighten the ear canal. pulled into the vena cava during aspiration.
Pulling the lobule in any direction
wouldn't straighten the ear canal for 25. Answer: (A) Autocratic.
visualization. Rationale: The autocratic style of leadership is a
task-oriented and directive.
16. Answer: (A) Protect the irritated skin from
sunlight. 26. Answer: (D) 2.5 cc
Rationale: Irradiated skin is very sensitive and Rationale: 2.5 cc is to be added, because only a
must be protected with clothing or sunblock. The 500 cc bag of solution is being medicated instead
priority approach is the avoidance of strong of a 1 liter.
sunlight.
27. Answer: (A) 50 cc/ hour
17. Answer: (C) Assist the client in removing Rationale: A rate of 50 cc/hr. The child is to
dentures and nail polish. receive 400 cc over a period of 8 hours = 50
Rationale: Dentures, hairpins, and combs must cc/hr.
be removed. Nail polish must be removed so that
cyanosis can be easily monitored by observing 28. Answer: (B) Assess the client for presence of
the nail beds. pain.
Rationale: Assessing the client for pain is a very
18. Answer: (D) Sudden onset of continuous important measure. Postoperative pain is an
epigastric and back pain. indication of complication. The nurse should also
Rationale: The autodigestion of tissue by the assess the client for pain to provide for the
pancreatic enzymes results in pain from client’s comfort.
inflammation, edema, and possible hemorrhage.
Continuous, unrelieved epigastric or back pain 29. Answer: (A) BP – 80/60, Pulse – 110
reflects the inflammatory process in the irregular
pancreas. Rationale: The classic signs of cardiogenic shock
are low blood pressure, rapid and weak irregular
19. Answer: (B) Provide high-protein, high- pulse, cold, clammy skin, decreased urinary
carbohydrate diet. output, and cerebral hypoxia.
Rationale: A positive nitrogen balance is
important for meeting metabolic needs, tissue 30. Answer: (A) Take the proper equipment,
repair, and resistance to infection. Caloric goals place the client in a comfortable position, and
may be as high as 5000 calories per day. record the appropriate information in the client’s
chart.
20. Answer: (A) Blood pressure and pulse rate. Rationale: It is a general or comprehensive
Rationale: The baseline must be established to statement about the correct procedure, and it
recognize the signs of an anaphylactic or includes the basic ideas which are found in the
hemolytic reaction to the transfusion. other options

21. Answer: (D) Immobilize the leg before 31. Answer: (B) Evaluation
moving the client. Rationale: Evaluation includes observing the
Rationale: If the nurse suspects a fracture, person, asking questions, and comparing the
splinting the area before moving the client is patient’s behavioral responses with the expected
imperative. The nurse should call for emergency outcomes.
help if the client is not hospitalized and call for a
physician for the hospitalized client. 32. Answer: (C) History of present illness
Rationale: The history of present illness is the
22. Answer: (B) Admit the client into a private single most important factor in assisting the
room. health professional in arriving at a diagnosis or
Rationale: The client who has a radiation implant determining the person’s needs.
is placed in a private room and has a limited
number of visitors. This reduces the exposure of 33. Answer: (A) Trochanter roll extending from
others to the radiation. the crest of the ileum to the mid-thigh.
Rationale: A trochanter roll, properly placed,
23. Answer: (C) Risk for infection provides resistance to the external rotation of the
Rationale: Agranulocytosis is characterized by a hip.
reduced number of leukocytes (leucopenia) and
neutrophils (neutropenia) in the blood. The client 34. Answer: (C) Stage III
is at high risk for infection because of the Rationale: Clinically, a deep crater or without
decreased body defenses against undermining of adjacent tissue is noted.
microorganisms. Deficient knowledge related to
the nature of the disorder may be appropriate 35. Answer: (A) Second intention healing
diagnosis but is not the priority. Rationale: When wounds dehisce, they will
allowed to heal by secondary intention
24. Answer: (B) Place the client on the left side in
the Trendelenburg position.

22
36. Answer: (D) Tachycardia 2.1 ml/X gtt = 1 ml/ 15 gtt
Rationale: With an extracellular fluid or plasma X = 32 gtt/minute, or 32 drops/minute
volume deficit, compensatory mechanisms
stimulate the heart, causing an increase in heart 44. Answer: (A) Clamp the catheter
rate. Rationale: If a central venous catheter becomes
disconnected, the nurse should immediately
37. Answer: (A) 0.75 apply a catheter clamp, if available. If a clamp
Rationale: To determine the number of milliliters isn’t available, the nurse can place a sterile
the client should receive, the nurse uses the syringe or catheter plug in the catheter hub.
fraction method in the following equation. After cleaning the hub with alcohol or povidone-
75 mg/X ml = 100 mg/1 ml iodine solution, the nurse must replace the I.V.
To solve for X, cross-multiply: extension and restart the infusion.
75 mg x 1 ml = X ml x 100 mg
75 = 100X 45. Answer: (D) Auscultation, percussion, and
75/100 = X palpation.
0.75 ml (or ¾ ml) = X Rationale: The correct order of assessment for
examining the abdomen is inspection,
38. Answer: (D) It’s a measure of effect, not a auscultation, percussion, and palpation. The
standard measure of weight or quantity. reason for this approach is that the less intrusive
Rationale: An insulin unit is a measure of effect, techniques should be performed before the more
not a standard measure of weight or quantity. intrusive techniques. Percussion and palpation
Different drugs measured in units may have no can alter natural findings during auscultation.
relationship to one another in quality or quantity.
46. Answer: (D) Ulnar surface of the hand
39. Answer: (B) 38.9 °C Rationale: The nurse uses the ulnar surface, or
Rationale: To convert Fahrenheit degreed to ball, of the hand to asses tactile fremitus, thrills,
Centigrade, use this formula and vocal vibrations through the chest wall. The
°C = (°F – 32) ÷ 1.8 fingertips and finger pads best distinguish texture
°C = (102 – 32) ÷ 1.8 and shape. The dorsal surface best feels warmth.
°C = 70 ÷ 1.8
°C = 38.9 47. Answer: (C) Formative
Rationale: Formative (or concurrent) evaluation
40. Answer: (C) Failing eyesight, especially close occurs continuously throughout the teaching and
vision. learning process. One benefit is that the nurse
Rationale: Failing eyesight, especially close can adjust teaching strategies as necessary to
vision, is one of the first signs of aging in middle enhance learning. Summative, or retrospective,
life (ages 46 to 64). More frequent aches and evaluation occurs at the conclusion of the
pains begin in the early late years (ages 65 to teaching and learning session. Informative is not
79). Increase in loss of muscle tone occurs in a type of evaluation.
later years (age 80 and older).
48. Answer: (B) Once per year
41. Answer: (A) Checking and taping all Rationale: Yearly mammograms should begin at
connections age 40 and continue for
Rationale: Air leaks commonly occur if the as long as the woman is in good health. If health
system isn’t secure. Checking all connections and risks, such as family
taping them will prevent air leaks. The chest history, genetic tendency, or past breast cancer,
drainage system is kept lower to promote exist, more frequent
drainage – not to prevent leaks. examinations may be necessary.

42. Answer: (A) Check the client’s identification 49. Answer: (A) Respiratory acidosis
band. Rationale: The client has a below-normal (acidic)
Rationale: Checking the client’s identification blood pH value and an above-normal partial
band is the safest way to verify a client’s identity pressure of arterial carbon dioxide (Paco2) value,
because the band is assigned on admission and indicating respiratory acidosis. In respiratory
isn’t be removed at any time. (If it is removed, it alkalosis, the pH value is above normal and in the
must be replaced). Asking the client’s name or Paco2 value is below normal. In metabolic
having the client repeated his name would be acidosis, the pH and bicarbonate (Hco3) values
appropriate only for a client who’s alert, oriented, are below normal. In metabolic alkalosis, the pH
and able to understand what is being said, but and Hco3 values are above normal.
isn’t the safe standard of practice. Names on bed
aren’t always reliable 50. Answer: (B) To provide support for the client
and family in coping with terminal illness.
43. Answer: (B) 32 drops/minute Rationale: Hospices provide supportive care for
Rationale: Giving 1,000 ml over 8 hours is the terminally ill clients and their families. Hospice
same as giving 125 ml over 1 hour (60 minutes). care doesn’t focus on counseling regarding health
Find the number of milliliters per minute as care costs. Most client referred to hospices have
follows: been treated for their disease without success
125/60 minutes = X/1 minute and will receive only palliative care in the
60X = 125 = 2.1 ml/minute hospice.
To find the number of drops per minute:

23
51. Answer: (C) Using normal saline solution to 59. Answer: (B) Cover the client, place the call
clean the ulcer and applying a protective dressing light within reach, and answer the phone call.
as necessary. Rationale: Because telephone call is an
Rationale: Washing the area with normal saline emergency, the nurse may need to answer it.
solution and applying a protective dressing are The other appropriate action is to ask another
within the nurse’s realm of interventions and will nurse to accept the call. However, is not one of
protect the area. Using a povidone-iodine wash the options. To maintain privacy and safety, the
and an antibiotic cream require a physician’s nurse covers the client and places the call light
order. Massaging with an astringent can further within the client’s reach. Additionally, the client’s
damage the skin. door should be closed or the room curtains pulled
around the bathing area.
52. Answer: (D) Foot
Rationale: An elastic bandage should be applied 60. Answer: (C) Use a sterile plastic container for
form the distal area to the proximal area. This obtaining the specimen.
method promotes venous return. In this case, the Rationale: Sputum specimens for culture and
nurse should begin applying the bandage at the sensitivity testing need to be obtained using
client’s foot. Beginning at the ankle, lower thigh, sterile techniques because the test is done to
or knee does not promote venous return. determine the presence of organisms. If the
procedure for obtaining the specimen is not
53. Answer: (B) Hypokalemia sterile, then the specimen is not sterile, then the
Rationale: Insulin administration causes glucose specimen would be contaminated and the results
and potassium to move into the cells, causing of the test would be invalid.
hypokalemia.
61. Answer: (A) Puts all the four points of the
54. Answer: (A) Throbbing headache or dizziness walker flat on the floor, puts weight on the hand
Rationale: Headache and dizziness often occur pieces, and then walks into it.
when nitroglycerin is taken at the beginning of Rationale: When the client uses a walker, the
therapy. However, the client usually develops nurse stands adjacent to the affected side. The
tolerance client is instructed to put all four points of the
walker 2 feet forward flat on the floor before
55. Answer: (D) Check the client’s level of putting weight on hand pieces. This will ensure
consciousness client safety and prevent stress cracks in the
Rationale: Determining unresponsiveness is the walker. The client is then instructed to move the
first step assessment action to take. When a walker forward and walk into it.
client is in ventricular tachycardia, there is a
significant decrease in cardiac output. However, 62. Answer: (C) Draws one line to cross out the
checking the unresponsiveness ensures whether incorrect information and then initials the
the client is affected by the decreased cardiac change.
output. Rationale: To correct an error documented in a
medical record, the nurse draws one line through
56. Answer: (B) On the affected side of the the incorrect information and then initials the
client. error. An error is never erased and correction
Rationale: When walking with clients, the nurse fluid is never used in the medical record.
should stand on the affected side and grasp the
security belt in the midspine area of the small of 63. Answer: (C) Secures the client safety belts
the back. The nurse should position the free hand after transferring to the stretcher.
at the shoulder area so that the client can be Rationale: During the transfer of the client after
pulled toward the nurse in the event that there is the surgical procedure is complete, the nurse
a forward fall. The client is instructed to look up should avoid exposure of the client because of
and outward rather than at his or her feet. the risk for potential heat loss. Hurried
movements and rapid changes in the position
57. Answer: (A) Urine output: 45 ml/hr should be avoided because these predispose the
Rationale: Adequate perfusion must be client to hypotension. At the time of the transfer
maintained to all vital organs in order for the from the surgery table to the stretcher, the client
client to remain visible as an organ donor. A is still affected by the effects of the anesthesia;
urine output of 45 ml per hour indicates adequate therefore, the client should not move self. Safety
renal perfusion. Low blood pressure and delayed belts can prevent the client from falling off the
capillary refill time are circulatory system stretcher.
indicators of inadequate perfusion. A serum pH of
7.32 is acidotic, which adversely affects all body 64. Answer: (B) Gown and gloves
tissues. Rationale: Contact precautions require the use of
gloves and a gown if direct client contact is
58. Answer: (D ) Obtaining the specimen from anticipated. Goggles are not necessary unless the
the urinary drainage bag. nurse anticipates the splashes of blood, body
Rationale: A urine specimen is not taken from the fluids, secretions, or excretions may occur. Shoe
urinary drainage bag. Urine undergoes chemical protectors are not necessary.
changes while sitting in the bag and does not
necessarily reflect the current client status. In 65. Answer: (C) Quad cane
addition, it may become contaminated with Rationale: Crutches and a walker can be difficult
bacteria from opening the system. to maneuver for a client with weakness on one
side. A cane is better suited for client with

24
weakness of the arm and leg on one side. needed.
However, the quad cane would provide the most
stability because of the structure of the cane and 76. Answer: (C) May apply for re-issuance of
because a quad cane has four legs. his/her license based on certain conditions
stipulated in RA 9173
66. Answer: (D) Left side-lying with the head of Rationale: RA 9173 sec. 24 states that for equity
the bed elevated 45 degrees. and justice, a revoked license maybe re-issued
Rationale: To facilitate removal of fluid from the provided that the following conditions are met: a)
chest wall, the client is positioned sitting at the the cause for revocation of license has already
edge of the bed leaning over the bedside table been corrected or removed; and, b) at least four
with the feet supported on a stool. If the client is years has elapsed since the license has been
unable to sit up, the client is positioned lying in revoked.
bed on the unaffected side with the head of the
bed elevated 30 to 45 degrees. 77. Answer: (B) Review related literature
Rationale: After formulating and delimiting the
67. Answer: (D) Reliability research problem, the researcher conducts a
Rationale: Reliability is consistency of the review of related literature to determine the
research instrument. It refers to extent of what has been done on the study by
the repeatability of the instrument in extracting previous researchers.
the same responses upon
its repeated administration. 78. Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the
68. Answer: (A) Keep the identities of the subject study of Elton Mayo and company about the
secret effect of an intervention done to improve the
Rationale: Keeping the identities of the research working conditions of the workers on their
subject secret will ensure anonymity because this productivity. It resulted to an increased
will hinder providing link between the information productivity but not due to the intervention but
given to whoever is its source. due to the psychological effects of being
observed. They performed differently because
69. Answer: (A) Descriptive- correlational they were under observation.
Rationale: Descriptive- correlational study is the
most appropriate for this study because it studies 79. Answer: (B) Determines the different
the variables that could be the antecedents of the nationality of patients frequently admitted and
increased incidence of nosocomial infection. decides to get representations samples from
each.
70. Answer: (C) Use of laboratory data Rationale: Judgment sampling involves including
Rationale: Incidence of nosocomial infection is samples according to the knowledge of the
best collected through the use of biophysiologic investigator about the participants in the study.
measures, particularly in vitro measurements,
hence laboratory data is essential. 80. Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the
71. Answer: (B) Quasi-experiment theory on transcultural theory based on her
Rationale: Quasi-experiment is done when observations on the behavior of selected people
randomization and control of the variables are within a culture.
not possible.
81. Answer: (A) Random
72. Answer: (C) Primary source Rationale: Random sampling gives equal chance
Rationale: This refers to a primary source which for all the elements in the population to be picked
is a direct account of the investigation done by as part of the sample.
the investigator. In contrast to this is a
secondary source, which is written by someone 82. Answer: (A) Degree of agreement and
other than the original researcher. disagreement
Rationale: Likert scale is a 5-point summated
73. Answer: (A) Non-maleficence scale used to determine the degree of agreement
Rationale: Non-maleficence means do not cause or disagreement of the respondents to a
harm or do any action that will cause any harm statement in a study
to the patient/client. To do good is referred as
beneficence. 83. Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the
74. Answer: (C) Res ipsa loquitor Adaptation Model which involves the physiologic
Rationale: Res ipsa loquitor literally means the mode, self-concept mode, role function mode and
thing speaks for itself. This means in operational dependence mode.
terms that the injury caused is the proof that
there was a negligent act. 84. Answer: (A) Span of control
Rationale: Span of control refers to the number
75. Answer: (B) The Board can investigate of workers who report directly to a manager.
violations of the nursing law and code of ethics
Rationale: Quasi-judicial power means that the 85. Answer: (B) Autonomy
Board of Nursing has the authority to investigate Rationale: Informed consent means that the
violations of the nursing law and can issue patient fully understands about the surgery,
summons, subpoena or subpoena duces tecum as including the risks involved and the alternative

25
solutions. In giving consent it is done with full Rationale: Elastic stockings are used to promote
knowledge and is given freely. The action of venous return. The nurse needs to remove them
allowing the patient to decide whether a surgery once per day to observe the condition of the skin
is to be done or not exemplifies the bioethical underneath the stockings. Applying the stockings
principle of autonomy. increases blood flow to the heart. When the
stockings are in place, the leg muscles can still
86. Answer: (C) Avoid wearing canvas shoes. stretch and relax, and the veins can fill with
Rationale: The client should be instructed to blood.
avoid wearing canvas shoes. Canvas shoes cause
the feet to perspire, which may, in turn, cause 93. Answer:(A) Instructing the client to report
skin any itching, swelling, or dyspnea.
irritation and breakdown. Both cotton and Rationale: Because administration of blood or
cornstarch absorb perspiration. The client should blood products may cause serious adverse effects
be instructed to cut toenails straight across with such as allergic reactions, the nurse must
nail monitor the client for these effects. Signs and
clippers. symptoms of life-threatening allergic reactions
include itching, swelling, and dyspnea. Although
87. Answer: (D) Ground beef patties the nurse should inform the client of the duration
Rationale: Meat is an excellent source of of the transfusion and should document its
complete protein, which this client needs to administration, these actions are less critical to
repair the tissue breakdown caused by pressure the client's immediate health. The nurse should
ulcers. assess vital signs at least hourly during the
Oranges and broccoli supply vitamin C but not transfusion.
protein. Ice cream supplies only some incomplete
protein, making it less helpful in tissue repair. 94. Answer: (B) Decrease the rate of feedings
and the concentration of the formula.
88. Answer: (D) Sims’ left lateral Rationale: Complaints of abdominal discomfort
Rationale: The Sims' left lateral position is the and nausea are common in clients receiving tube
most common position used to administer a feedings. Decreasing the rate of the feeding and
cleansing enema because it allows gravity to aid the concentration of the formula should decrease
the flow of fluid along the curve of the sigmoid the client's discomfort. Feedings are normally
colon. If the client can't assume this position nor given at room temperature to minimize
has poor sphincter control, the dorsal recumbent abdominal cramping. To prevent aspiration
or right lateral position may be used. The supine during feeding, the head of the client's bed
and prone positions are inappropriate and should be elevated at least 30 degrees. Also, to
uncomfortable for the client. prevent bacterial growth, feeding containers
should be routinely changed every 8 to 12 hours.
89. Answer: (A) Arrange for typing and cross
matching of the client’s blood. 95. Answer: (D) Roll the vial gently between the
Rationale: The nurse first arranges for typing and palms.
cross matching of the client's blood to ensure Rationale: Rolling the vial gently between the
compatibility with donor blood. The other options, palms produces heat, which helps dissolve the
although appropriate when preparing to medication. Doing nothing or inverting the vial
administer a blood transfusion, come later. wouldn't help dissolve the medication. Shaking
the vial vigorously could cause the medication to
90. Answer: (A) Independent break down, altering its action.
Rationale: Nursing interventions are classified as
independent, interdependent, or dependent. 96. Answer: (B) Assist the client to the semi-
Altering the drug schedule to coincide with the Fowler position if possible.
client's daily routine represents an independent Rationale: By assisting the client to the semi-
intervention, whereas consulting with the Fowler position, the nurse promotes easier chest
physician and pharmacist to change a client's expansion, breathing, and oxygen intake. The
medication because of adverse reactions nurse should secure the elastic band so that the
represents an interdependent intervention. face mask fits comfortably and snugly rather than
Administering an already-prescribed drug on time tightly, which could lead to irritation. The nurse
is a dependent intervention. An intradependent should apply the face mask from the client's nose
nursing intervention doesn't exist. down to the chin — not vice versa. The nurse
should check the connectors between the oxygen
91. Answer: (D) Evaluation equipment and humidifier to ensure that they're
Rationale: The nursing actions described airtight; loosened connectors can cause loss of
constitute evaluation of the expected outcomes. oxygen.
The findings show that the expected outcomes
have been achieved. Assessment consists of the 97. Answer: (B) 4 hours
client's history, physical examination, and Rationale: A unit of packed RBCs may be given
laboratory studies. Analysis consists of over a period of between 1 and 4 hours. It
considering assessment information to derive the shouldn't infuse for longer than 4 hours because
appropriate nursing diagnosis. Implementation is the risk of contamination and sepsis increases
the phase of the nursing process where the nurse after that time. Discard or return to the blood
puts the plan of care into action. bank any blood not given within this time,
according to facility policy.
92. Answer: (B) To observe the lower extremities

26
98. Answer: (B) Immediately before A) Increased nasal congestion.
administering the next dose. B) Nasal polyps.
Rationale: Measuring the blood drug C) Bleeding tendencies.
concentration helps determine whether the D) Tinnitus and diplopia.
dosing has achieved the therapeutic goal. For
measurement of the trough, or lowest, blood
level of a drug, the nurse draws a blood sample 5. A client with tuberculosis is to be admitted in
immediately before administering the next dose. the hospital. The nurse who will be assigned to
Depending on the drug's duration of action and care for the client must institute appropriate
half-life, peak blood drug levels typically are precautions. The nurse should:
drawn after administering the next dose.
A) Place the client in a private room.
99. Answer: (A) The nurse can implement B) Wear an N 95 respirator when caring for the
medication orders quickly. client.
Rationale: A floor stock system enables the nurse C) Put on a gown every time when entering the
to implement medication orders quickly. It room.
doesn't allow for pharmacist input, nor does it D) Don a surgical mask with a face shield when
minimize transcription errors or reinforce entering the room.
accurate calculations.

100. Answer: (C) Shifting dullness over the 6. Which of the following is the most frequent
abdomen. cause of noncompliance to the medical treatment
Rationale: Shifting dullness over the abdomen of open-angle glaucoma?
indicates ascites, an abnormal finding. The other
options are normal abdominal findings. A) The frequent nausea and vomiting
accompanying use of miotic drug.
Pre-board Exam for November 2009 NLE B) Loss of mobility due to severe driving
restrictions.
C) Decreased light and near-vision
1. A pregnant woman who is at term is admitted accommodation due to miotic effects of
to the birthing unit in active labor. The client has pilocarpine.
only progressed from 2cm to 3 cm in 8 hours. D) The painful and insidious progression of this
She is diagnosed with hypotonic dystocia and the type of glaucoma.
physician ordered Oxytocin (Pitocin) to augment
her contractions. Which of the following is the
most important aspect of nursing intervention at 7. In the morning shift, the nurse is making
this time? rounds in the nursing care units. The nurse
enters in a client’s room and notes that the
A) Timing and recording length of contractions. client’s tube has become disconnected from the
B) Monitoring. Pleurovac. What would be the initial nursing
C) Preparing for an emergency cesarean birth. action?
D) Checking the perineum for bulging.
A) Apply pressure directly over the incision site.
B) Clamp the chest tube near the incision site.
2. A client who hallucinates is not in touch with C) Clamp the chest tube closer to the drainage
reality. It is important for the nurse to: system.
D) Reconnect the chest tube to the Pleurovac.
A) Isolate the client from other patients.
B) Maintain a safe environment.
C) Orient the client to time, place, and person. 8. Which of the following complications during a
D) Establish a trusting relationship. breech birth the nurse needs to be alarmed?

A) Abruption placenta.
3. The nurse is caring to a child client who has B) Caput succedaneum.
had a tonsillectomy. The child complains of C) Pathological hyperbilirubinemia.
having dryness of the throat. Which of the D) Umbilical cord prolapse.
following would the nurse give to the child?

A) Cola with ice 9. The nurse is caring to a client diagnosed with

B) Yellow noncitrus Jello severe depression. Which of the following nursing
C) Cool cherry Kool-Aid approach is important in depression?
D) A glass of milk
A) Protect the client against harm to others.
B) Provide the client with motor outlets for
4. The physician ordered Phenylephrine (Neo- aggressive, hostile feelings.
Synephrine) nasal spray to a 13-year-old client. C) Reduce interpersonal contacts.
The nurse caring to the client provides D) Deemphasizing preoccupation with
instructions that the nasal spray must be used elimination, nourishment, and sleep.
exactly as directed to prevent the development
of:
10. A 3-month-old client is in the pediatric unit.

27
During assessment, the nurse is suspecting that nurse.
the baby may have hypothyroidism when mother D) Client assignments will be equally divided
states that her baby does not: among the nurses.

A) Sit up.
B) Pick up and hold a rattle. 15. The nurse is assigned to care for a child client
C) Roll over. admitted in the pediatrics unit. The client is
D) Hold the head up. receiving digoxin. Which of the following
questions will be asked by the nurse to the
parents of the child in order to assess the client’s
11. The physician calls the nursing unit to leave risk for digoxin toxicity?
an order. The senior nurse had conversation with
the other staff. The newly hired nurse answers A) “Has he been exposed to any childhood
the phone so that the senior nurses may continue communicable diseases in the past 2-3 weeks?”
their conversation. The new nurse does not B) “Has he been taking diuretics at home?”
knowthe physician or the client to whom the C) “Do any of his brothers and sisters have
order pertains. The nurse should: history of cardiac problems?”
D) “Has he been going to school regularly?”
A) Ask the physician to call back after the nurse
has read the hospital policy manual.
B) Take the telephone order. 16. The nurse noticed that the signed consent
C) Refuse to take the telephone order. form has an error. The form states, “Amputation
D) Ask the charge nurse or one of the other of the right leg” instead of the left leg that is to
senior staff nurses to take the telephone order. be amputated. The nurse has administered
already the preoperative medications. What
should the nurse do?
12. The staff nurse on the labor and delivery unit
is assigned to care to a primigravida in transition A) Call the physician to reschedule the surgery.
complicated by hypertension. A new pregnant B) Call the nearest relative to come in to sign a
woman in active labor is admitted in the same new form.
unit. The nurse manager assigned the same C) Cross out the error and initial the form.
nurse to the second client. The nurse feels that D) Have the client sign another form.
the client with hypertension requires one-to-one
care. What would be the initial actionof the
nurse? 17. The nurse in the nursing care unit checks the
fluctuation in the water-seal compartment of a
A) Accept the new assignment and complete an closed chest drainage system. The fluctuation has
incident report describing a shortage of nursing stopped, the nurse would:
staff.
B) Report the incident to the nursing supervisor A) Vigorously strip the tube to dislodge a clot.
and request to be floated. B) Raise the apparatus above the chest to move
C) Report the nursing assessment of the client in fluid.
transitional labor to the nurse manager and C) Increase wall suction above 20 cm H2O
discuss misgivings about the new assignment. pressure.
D) Accept the new assignment and provide the D) Ask the client to cough and take a deep
best care. breath.

13. A newborn infant with Down syndrome is to 18. The pediatric nurse in the neonatal unit was
be discharged today. The nurse is preparing to informed that the baby that is brought to the
give the discharge teaching regarding the proper mother in the hospital room is wrong. The nurse
care at home. The nurse would anticipate that determines that two babies were placed in the
the mother is probably at the: wrong cribs. The most appropriate nursing action
would be to:
A) 40 years of age.
B) 20 years of age. A) Determine who is responsible for the mistake
C) 35 years of age. and terminate his or her employment.
D) 20 years of age. B) Record the event in an incident/variance
report and notify the nursing supervisor.
C) Reassure both mothers, report to the charge
14. The emergency department has shortage of nurse, and do not record.
staff. The nurse manager informs the staff nurse D) Record detailed notes of the event on the
in the critical care unit that she has to float to the mother’s medical record.
emergency department. What should the staff
nurse expect under these conditions?
19. Before the administration of digoxin, the
A) The float staff nurse will be informed of the nurse completes an assessment to a toddler
situation before the shift begins. client for signs and symptoms of digoxin toxicity.
B) The staff nurse will be able to negotiate the Which of the following is the earliest and most
assignments in the emergency department. significant sign of digoxin toxicity?
C) Cross training will be available for the staff

28
A) Tinnitus family and staff performance against the timeline
B) Nausea and vomiting for clients with the same diagnosis.
C) Vision problem C) Main focus is comprehensive coordination of
D) Slowing in the heart rate client care, avoid unnecessary duplication of
services, improve resource utilization and
decrease cost.
20. Which of the following treatment modality is D) Primary goal is to understand why predicted
appropriate for a client with paranoid tendency? outcomes have not been met and the correction
of identified problems.
A) Activity therapy.
B) Individual therapy.
C) Group therapy. 25. The physician orders a dose of IV phenytoin
D) Family therapy. to a child client. In preparing in the
administration of the drug, which nursing action
is not correct?
21. The client with rheumatoid arthritis is for
discharge. In preparing the client for discharge A) Infuse the phenytoin into a smaller vein to
on prednisone therapy, the nurse should advise prevent purple glove syndrome.
the client to: B) Check the phenytoin solution to be sure it is
clear or light yellow in color, never cloudy.
A) Wear sunglasses if exposed to bright light for C) Plan to give phenytoin over 30-60 minutes,
an extended period of time. using an in-line filter.
B) Take oral preparations of prednisone before D) Flush the IV tubing with normal saline before
meals. starting phenytoin.
C) Have periodic complete blood counts while on
the medication.
D) Never stop or change the amount of the 26. The pregnant woman visits the clinic for
medication without medical advice. check –up. Which assessment findings will help
the nurse determine that the client is in 8-week
gestation?
22. A pregnant client tells the nurse that she is
worried about having urinary frequency. What A) Leopold maneuvers.
will be the most appropriate nursing response? B) Fundal height.
C) Positive radioimmunoassay test (RIA test).
A) “Try using Kegel (perineal) exercises and D) Auscultation of fetal heart tones.
limiting fluids before bedtime. If you have
frequency associated with fever, pain on voiding,
or blood in the urine, call your doctor/nurse- 27. Which of the following nursing intervention is
midwife. essential for the client who had
B) “Placental progesterone causes irritability of pneumonectomy?
the bladder sphincter. Your symptoms will go
away after the baby comes.” A) Medicate for pain only when needed.
C) “Pregnant women urinate frequently to get rid B) Connect the chest tube to water-seal
of fetal wastes. Limit fluids to 1L/daily.” drainage.
D) “Frequency is due to bladder irritation from C) Notify the physician if the chest drainage
concentrate urine and is normal in pregnancy. exceeds 100mL/hr.
Increase your daily fluid intake to 3L.” D) Encourage deep breathing and coughing.

23. Which of the following will help the nurse 28. The nurse is providing a health teaching to a
determine that the expression of hostility is group of parents regarding Chlamydia
useful? trachomatis. The nurse is correct in the
statement, “Chlamydia trachomatis is not only an
A) Expression of anger dissipates the energy. intracellular bacterium that causes neonatal
B) Energy from anger is used to accomplish what conjunctivitis, but it also can cause:
needs to be done.
C) Expression intimidates others. A) Discoloration of baby and adult teeth.
D) Degree of hostility is less than the B) Pneumonia in the newborn.
provocation. C) Snuffles and rhagades in the newborn.
D) Central hearing defects in infancy.

24. The nurse is providing an orientation

regarding case management to the nursing 29. The nurse is assigned to care to a 17-year-
students. Which characteristics should the nurse old male client with a history of substance abuse.
include in the discussion in understanding case The client asks the nurse, “Have you ever tried or
management? used drugs?” The most correct response of the
nurse would be:
A) Main objective is a written plan that combines
discipline-specific processes used to measure A) “Yes, once I tried grass.”
outcomes of care. B) “No, I don’t think so.”
B) Main purpose is to identify expected client,

29
C) “Why do you want to know that?” C) Spermatozoal viability.
D) “How will my answer help you?” D) Secretory endometrium.

30. Which of the following describes a health care 35. An older adult client wakes up at 2 o’clock in
team with the principles of participative the morning and comes to the nurse’s station
leadership? saying, “I am having difficulty in sleeping.” What
is the best nursing response to the client?
A) Each member of the team can independently
make decisions regarding the client’s care A) “I’ll give you a sleeping pill to help you get
without necessarily consulting the other more sleep now.”
members. B) “Perhaps you’d like to sit here at the nurse’s
B) The physician makes most of the decisions station for a while.”
regarding the client’s care. C) “Would you like me to show you where the
C) The team uses the expertise of its members to bathroom is?”
influence the decisions regarding the client’s D) “What woke you up?”
care.
D) Nurses decide nursing care; physicians decide
medical and other treatment for the client. 36. The nurse is taking care of a multipara who is
at 42 weeks of gestation and in active labor, her
membranes ruptured spontaneously 2 hours ago.
31. A nurse is giving a health teaching to a While auscultating for the point of maximum
woman who wants to breastfeed her newborn intensity of fetal heart tones before applying an
baby. Which hormone, normally secreted during external fetal monitor, the nurse counts 100
the postpartum period, influences both the milk beats per minute. The immediate nursing action
ejection reflex and uterine involution? is to:

A) Oxytocin. A) Start oxygen by mask to reduce fetal distress.

B) Estrogen. B) Examine the woman for signs of a prolapsed
C) Progesterone. cord.
D) Relaxin. C) Turn the woman on her left side to increase
placental perfusion.
D) Take the woman’s radial pulse while still
32. One staff nurse is assigned to a group of 5 auscultating the FHR.
patients for the 12-hour shift. The nurse is
responsible for the overall planning, giving and
evaluating care during the entire shift. After the 37. The nurse must instruct a client with
shift, same responsibility will be endorsed to the glaucoma to avoid taking over-the-counter
next nurse in charge. This describes nursing care medications like:
delivered via the:
A) Antihistamines.
A) Primary nursing method. B) NSAIDs.
B) Case method. C) Antacids.
C) Functional method. D) Salicylates.
D) Team method.

38. A male client is brought to the emergency

33. The ambulance team calls the emergency department due to motor vehicle accident. While
department that they are going to bring a client monitoring the client, the nurse suspects
who sustained burns in a house fire. While increasing intracranial pressure when:
waiting for the ambulance, the nurse will
anticipate emergency care to include assessment A) Client is oriented when aroused from sleep,
for: and goes back to sleep immediately.
B) Blood pressure is decreased from 160/90 to
A) Gas exchange impairment. 110/70.
B) Hypoglycemia. C) Client refuses dinner because of anorexia.
C) Hyperthermia. D) Pulse is increased from 88-96 with occasional
D) Fluid volume excess. skipped beat.

34. Most couples are using “natural” family 39. The nurse is conducting a lecture to a class of
planning methods. Most accidental pregnancies in nursing students about advance directives to
couples preferred to use this method have been preoperative clients. Which of the following
related to unprotected intercourse before statement by the nurse js correct?
ovulation. Which of the following factor explains
why pregnancy may be achieved by unprotected A) “The spouse, but not the rest of the family,
intercourse during the preovulatory period? may override the advance directive.”
B) “An advance directive is required for a “do not
A) Ovum viability. resuscitate” order.”
B) Tubal motility. C) “A durable power of attorney, a form of
advance directive, may only be held by a blood

30
relative.” C) Maintain the client in high Fowler’s position.
D) “The advance directive may be enforced even D) Coordinate breathing and coughing exercise
in the face of opposition by the spouse.” with administration of analgesics.

40. A client diagnosed with schizophrenia is 46. The community nurse is teaching the group
shouting and banging on the door leading to the of mothers about the cervical mucus method of
outside, saying, “I need to go to an natural family planning. Which characteristics are
appointment.” What is the appropriate nursing typical of the cervical mucus during the “fertile”
intervention? period of the menstrual cycle?

A) Tell the client that he cannot bang on the A) Absence of ferning.

door. B) Thin, clear, good spinnbarkeit.
B) Ignore this behavior. C) Thick, cloudy.
C) Escort the client going back into the room. D) Yellow and sticky.
D) Ask the client to move away from the door.

47. A client with ruptured appendix had surgery

41. Which of the following action is an accurate an hour ago and is transferred to the nursing
tracheal suctioning technique? care unit. The nurse placed the client in a semi-
Fowler’s position primarily to:
A) 25 seconds of continuous suction during
catheter insertion. A) Facilitate movement and reduce complications
B) 20 seconds of continuous suction during from immobility.
catheter insertion. B) Fully aerate the lungs.
C) 10 seconds of intermittent suction during C) Splint the wound.
catheter withdrawal. D) Promote drainage and prevent
D) 15 seconds of intermittent suction during subdiaphragmatic abscesses.
catheter withdrawal.

48. Which of the following will best describe a

42. The client’s jaw and cheekbone is sutured management function?
and wired. The nurse anticipates that the most
important thing that must be ready at the A) Writing a letter to the editor of a nursing
bedside is: journal.
B) Negotiating labor contracts.
A) Suture set. C) Directing and evaluating nursing staff
B) Tracheostomy set. members.
C) Suction equipment. D) Explaining medication side effects to a client.
D) Wire cutters.

49. The parents of an infant client ask the nurse

43. A mother is in the third stage of labor. Which to teach them how to administer Cortisporin eye
of the following signs will help the nurse drops. The nurse is correct in advising the
determine the signs of placental separation? parents to place the drops:

A) The uterus becomes globular. A) In the middle of the lower conjunctival sac of
B) The umbilical cord is shortened. the infant’s eye.
C) The fundus appears at the introitus. B) Directly onto the infant’s sclera.
D) Mucoid discharge is increased. C) In the outer canthus of the infant’s eye.
D) In the inner canthus of the infant’s eye.

44. After therapy with the thrombolytic alteplase

(t-PA), what observation will the nurse report to 50. The nurse is assessing on the client who is
the physician? admitted due to vehicle accident. Which of the
following findings will help the nurse that there is
A) 3+ peripheral pulses. internal bleeding?
B) Change in level of consciousness and
headache. A) Frank blood on the clothing.
C) Occasional dysrhythmias. B) Thirst and restlessness.
D) Heart rate of 100/bpm. C) Abdominal pain.
D) Confusion and altered of consciousness.

45. A client who undergone left nephrectomy has

a large flank incision. Which of the following 51. The nurse is completing an assessment to a
nursing action will facilitate deep breathing and newborn baby boy. The nurse observes that the
coughing? skin of the newborn is dry and flaking and there
are several areas of an apparent macular rash.
A) Push fluid administration to loosen respiratory The nurse charts this as:
secretions.
B) Have the client lie on the unaffected side.

31
A) Icterus neonatorum 15.
B) Multiple hemangiomas C) In a 28- day cycle, ovulation occurs at or
C) Erythema toxicum about day 14. The egg lives for about 72 hours
D) Milia and the sperm live for about 24 hours. The fertile
period would be approximately between day 13
and 17.
52. The client is brought to the emergency D) In a 28-day cycle, ovulation occurs 8 days
department because of serious vehicle accident. before the next period or at about day 20. The
After an hour, the client has been declared brain fertile period is between day 20 and the
dead. The nurse who has been with the client beginning of the next period.
must now talk to the family about organ
donation. Which of the following consideration is
necessary? 57. Which of the following statement describes
the role of a nurse as a client advocate?
A) Include as many family members as possible.
B) Take the family to the chapel. A) A nurse may override clients’ wishes for their
C) Discuss life support systems. own good.
D) Clarify the family’s understanding of brain B) A nurse has the moral obligation to prevent
death. harm and do well for clients.
C) A nurse helps clients gain greater
independence and self-determination.
53. The nurse is teaching exercises that are good D) A nurse measures the risk and benefits of
for pregnant women increasing tone and fitness various health situations while factoring in cost.
and decreasing lower backache. Which of the
following should the nurse exclude in the exercise
program? 58. A community health nurse is providing a
health teaching to a woman infected with herpes
A) Stand with legs apart and touch hands to floor simplex 2. Which of the following health teaching
three times per day. must the nurse include to reduce the chances of
B) Ten minutes of walking per day with an transmission of herpes simplex 2?
emphasis on good posture.
C) Ten minutes of swimming or leg kicking in A) “Abstain from intercourse until lesions heal.”
pool per day. B) “Therapy is curative.”
D) Pelvic rock exercise and squats three times a C) “Penicillin is the drug of choice for treatment.”
day. D) “The organism is associated with later
development of hydatidiform mole.

54. A client with obsessive-compulsive behavior

is admitted in the psychiatric unit. The nurse 59. The nurse in the psychiatric ward informed
taking care of the client knows that the primary the male client that he will be attending the 9:00
treatment goal is to: AM group therapy sessions. The client tells the
nurse that he must wash his hands from 9:00 to
A) Provide distraction. 9:30 AM each day and therefore he cannot
B) Support but limit the behavior. attend. Which concept does the nursing staff
C) Prohibit the behavior. need to keep in mind in planning nursing
D) Point out the behavior. intervention for this client?

A) Depression underlines ritualistic behavior.

55. After ileostomy, the nurse expects that the B) Fear and tensions are often expressed in
drainage appliance will be applied to the stoma: disguised form through symbolic processes.
C) Ritualistic behavior makes others
A) When the client is able to begin self-care uncomfortable.
procedures. D) Unmet needs are discharged through
B) 24 hours later, when the swelling subsided. ritualistic behavior.
C) In the operating room after the ileostomy
procedure.
D) After the ileostomy begins to function. 10. The nurse assesses the health condition of
the female client. The client tells the nurse that
she discovered a lump in the breast last year and
56. A female client who has a 28-day menstrual hesitated to seek medical advice. The nurse
cycle asks the community health nurse when she understands that, women who tend to delay
get pregnant during her cycle. What will be the seeking medical advice after discovering the
best nursing response? disease are displaying what common defense
mechanism?
A) It is impossible to determine the fertile period
reliably. So it is best to assume that a woman is A) Intellectualization.
always fertile. B) Suppression.
B) In a 28-day cycle, ovulation occurs at or about C) Repression.
day 14. The egg lives for about 24 hours and the D) Denial.
sperm live for about 72 hours. The fertile period
would be approximately between day 11 and day

32
61. Which of the following situations cannot be A) Gloves are worn when handling the client’s
delegated by the registered nurse to the nursing tissue, excretions, and linen.
assistant? B) Both client and attending nurse must wear
masks at all times.
A) A postoperative client who is stable needs to C) Nurse and visitors must wear masks until
ambulate. chemotherapy is begun. Client is instructed in
B) Client in soft restraint who is very agitated cough and tissue techniques.
and crying. D) Full isolation; that is, caps and gowns are
C) A confused elderly woman who needs required during the period of contagion.
assistance with eating.
D) Routine temperature check that must be done
for a client at end of shift. 67. A client with lung cancer is admitted in the
nursing care unit. The husband wants to know
the condition of his wife. How should the nurse
62. In the admission care unit, which of the respond to the husband?
following client would the nurse give immediate
attention? A) Find out what information he already has.
B) Suggest that he discuss it with his wife.
A) A client who is 3 days postoperative with left C) Refer him to the doctor.
calf pain. D) Refer him to the nurse in charge.
B) A client who is postoperative hip pinning who
is complaining of pain.
C) New admitted client with chest pain. 68. A hospitalized client cannot find his
D) A client with diabetes who has a glucoscan handkerchief and accuses other cient in the room
reading of 180. and the nurse of stealing them. Which is the
most therapeutic approach to this client?

63. A couple seeks medical advice in the A) Divert the client’s attention.
community health care unit. A couple has been B) Listen without reinforcing the client’s belief.
unable to conceive; the man is being evaluated C) Inject humor to defuse the intensity.
for possible problems. The physician ordered D) Logically point out that the client is jumping to
semen analysis. Which of the following conclusions.
instructions is correct regarding collection of a
sperm specimen?
69. After a cystectomy and formation of an ileal
A) Collect a specimen at the clinic, place in iced conduit, the nurse provides instruction regarding
container, and give to laboratory personnel prevention of leakage of the pouch and backflow
immediately. of the urine. The nurse is correct to include in the
B) Collect specimen after 48-72 hours of instruction to empty the urine pouch:
abstinence and bring to clinic within 2 hours.
C) Collect specimen in the morning after 24 A) Every 3-4 hours.
hours of abstinence and bring to clinic B) Every hour.
immediately. C) Twice a day.
D) Collect specimen at night, refrigerate, and D) Once before bedtime.
bring to clinic the next morning.

70. Which telephone call from a student’s mother

64. The physician ordered Betamethasone to a should the school nurse take care of at once?
pregnant woman at 34 weeks of gestation with
sign of preterm labor. The nurse expects that the A) A telephone call notifying the school nurse
drug will: that the child’ pediatrician has informed the
mother that the child will need cardiac repair
A) Treat infection. surgery within the next few weeks.
B) Suppress labor contraction. B) A telephone call notifying the school nurse
C) Stimulate the production of surfactant. that the child’s pediatrician has informed the
D) Reduce the risk of hypertension. mother that the child has head lice.
C) A telephone call notifying the school nurse
that a child has a temperature of 102ºF and a
65. A tracheostomy cuff is to be deflated, which rash covering the trunk and upper extremities of
of the following nursing intervention should be the body.
implemented before starting the procedures? D) A telephone call notifying the school nurse
that a child underwent an emergency
A) Suction the trachea and mouth. appendectomy during the previous night.
B) Have the obdurator available.
C) Encourage deep breathing and coughing.
D) Do a pulse oximetry reading. 71. Which of the following signs and symptoms
that require immediate attention and may
indicate most serious complications during
66. A client is diagnosed with Tuberculosis and pregnancy?
respiratory isolation is initiated. This means that:

33
A) Severe abdominal pain or fluid discharge from the following statement will help the nurse to
the vagina. know that the mother needs additional teaching?
B) Excessive saliva, “bumps around the areolae,
and increased vaginal mucus. A) “I’ll give the medicine if my child gets into
C) Fatigue, nausea, and urinary frequency at any some toilet bowl cleaner.”
time during pregnancy. B) “I’ll give the medicine if my child gets into
D) Ankle edema, enlarging varicosities, and some aspirin.”
heartburn. C) “I’ll give the medicine if my child gets into
some plant bulbs.”
D) “I’ll give the medicine if my child gets into
72. The nurse is assessing the newborn boy. some vitamin pills.”
Apgar scores are 7 and 9. The newborn becomes
slightly cyanotic. What is the initial nursing
action? 77. To assess if the cranial nerve VII of the client
was damaged, which changes would not be
A) Elevate his head to promote gravity drainage expected?
of secretions.
B) Wrap him in another blanket, to reduce heat A) Drooling and drooping of the mouth.
loss. B) Inability to open eyelids on operative side.
C) Stimulate him to cry,, to increase C) Sagging of the face on the operative side.
oxygenation. D) Inability to close eyelid on operative side.
D) Aspirate his mouth and nose with bulb
syringe.
78. The community health nurse makes a home
visit to a family. During the visit, the nurse
73. The nurse is formulating a plan of care to a observes that the mother is beating her child.
client with a somatoform disorder. The nurse What is the priority nursing intervention in this
needs to have knowledge of which situation?
psychodynamic principle?
A) The symptoms of a somatoform disorder are A) Assess the child’s injuries.
an attempt to adjust to painful life situations or B) Report the incident to protective agencies.
to cope with conflicting sexual, aggressive, or C) Refer the family to appropriate support group.
dependent feelings. D) Assist the family to identify stressors and use
B) The major fundamental mechanism is of other coping mechanisms to prevent further
regression. incidents.
C) The client’s symptoms are imaginary and the
suffering is faked.
D) An extensive, prolonged study of the 79. The nurse in the neonatal care unit is
symptoms will be reassuring to the client, who supervising the actions of a certified nursing
seeks sympathy, attention and love. assistant in giving care to the newborns. The
nursing assistant mistakenly gives a formula
feeding to a newborn that is on water feeding
74. An infant is brought to the health care clinic only. The nurse is responsible for the mistake of
for three immunizations at the same time. The the nursing assistant:
nurse knows that hepatitis B, DPT, and
Haemophilus influenzae type B immunizations A) Always, as a representative of the institution.
should: B) Always, because nurses who supervise less-
A) Be drawn in the same syringe and given in trained individuals are responsible for their
one injection. mistakes.
B) Be mixed and inject in the same sites. C) If the nurse failed to determine whether the
C) Not be mixed and the nurse must give three nursing assistant was competent to take care of
injections in three sites. the client.
D) Be mixed and the nurse must give the D) Only if the nurse agreed that the newborn
injection in three sites. could be fed formula.

75. A female client with cancer has radium 80. The nurse is assigned to care for a client with
implants. The nurse wants to maintain the urinary calculi. Fluid intake of 2L/day is
implants in the correct position. The nurse should encouraged to the client. the primary reason for
position the client: this is to:

A) Flat in bed. A) Reduce the size of existing stones.

B) On the side only. B) Prevent crystalline irritation to the ureter.
C) With the foot of the bed elevated. C) Reduce the size of existing stones
D) With the head elevated 45-degrees (semi- D) Increase the hydrostatic pressure in the
Fowler’s). urinary tract.

76. The nurse wants to know if the mother of a 81. The nurse is counseling a couple in their mid
toddler understands the instructions regarding 30’s who have been unable to conceive for about
the administration of syrup of ipecac. Which of 6 months. They are concerned that one or both

34
of them may be infertile. What is the best advice C) Weakened (L) side of the client away from
the nurse could give to the couple? bed.
D) Weakened (R) side of the cient away from
A) “it is no unusual to take 6-12 months to get bed.
pregnant, especially when the partners are in
their mid-30s. Eat well, exercise, and avoid
stress.” 86. The child client has undergone hip surgery
B) “Start planning adoption. Many couples get and is in a spica cast. Which of the following toy
pregnant when they are trying to adopt.” should be avoided to be in the child’s bed?
C) “Consult a fertility specialist and start testing
before you get any older.” A) A toy gun.
D) “Have sex as often as you can, especially B) A stuffed animal.
around the time of ovulation, to increase your C) A ball.
chances of pregnancy.” D) Legos.

82. The nurse is caring for a cient who Is a 87. The LPN/LVN asks the registered nurse why
retired nurse. A 24-hour urine collection for oxytocin (Pitocin), 10 units (IV or IM) must be
Creatinine clearance is to be done. The client tells given to a client after birth fo the fetus. The
the nurse, “I can’t remember what this test is nurse is correct to explain that oxytocin:
for.” The best response by the nurse is:
A) Minimizes discomfort from “afterpains.”
A) “It provides a way to see if you are passing B) Suppresses lactation.
any protein in your urine.” C) Promotes lactation.
B) “It tells how well the kidneys filter wastes D) Maintains uterine tone.
from the blood.”
C) “It tells if your renal insufficiency has affected
your heart.” 88. The nurse in the nursing care unit is aware
D) “The test measures the number of particles that one of the medical staff displays unlikely
the kidney filters.” behaviors like confusion, agitation, lethargy and
unkempt appearance. This behavior has been
reported to the nurse manager several times, but
83. The nurse observes the female client in the no changes observed. The nurse should:
psychiatric ward that she is having a hard time
sleeping at night. The nurse asks the client about A) Continue to report observations of unusual
it and the client says, “I can’t sleep at night behavior until the problem is resolved.
because of fear of dying.” What is the best initial B) Consider that the obligation to protect the
nursing response? patient from harm has been met by the prior
reports and do nothing further.
A) “It must be frightening for you to feel that C) Discuss the situation with friends who are also
way. Tell me more about it.” nurses to get ideas .
B) “Don’t worry, you won’t die. You are just here D) Approach the partner of this medical staff
for some test.” member with these concerns.
C) “Why are you afraid of dying?”
D) “Try to sleep. You need the rest before
tomorrow’s test.” 89. The physician ordered tetracycline PO qid to a
child client who weights 20kg. The recommended
PO tetracycline dose is 25-50 mg/kg/day. What is
84. In the hospital lobby, the registered nurse the maximum single dose that can be safely
overhears a two staff members discussing about administered to this child?
the health condition of her client. What would be
the appropriate action for the registered nurse to A) 1 g
take? B) 500 mg
C) 250 mg
A) Join in the conversation, giving her input D) 125 mg
about the case.
B) Ignore them, because they have the right to
discuss anything they want to. 90. The nurse is completing an obstetric history
C) Tell them it is not appropriate to discuss such of a woman in labor. Which event in the obstetric
things. history will help the nurse suspects dysfunctional
D) Report this incident to the nursing supervisor. labor in the current pregnancy?

A) Total time of ruptured membranes was 24

85. The client has had a right-sided hours with the second birth.
cerebrovascular accident. In transferring the B) First labor lasting 24 hours.
client from the wheelchair to bed, in what C) Uterine fibroid noted at time of cesarean
position should a client be placed to facilitate safe delivery.
transfer? D) Second birth by cesarean for face
presentation.
A) Weakened (L) side of the cient next to bed.
B) Weakened (R) side of the client next to bed.

35
91. The nurse is planning to talk to the client with A) Beginning of labor.
an antisocial personality disorder. What would be B) Bladder infection.
the most therapeutic approach? C) Constipation.
D) Tension on the round ligament.
A) Provide external controls.
B) Reinforce the client’s self-concept.
C) Give the client opportunities to test reality. 97. The nurse is conducting a lecture to a group
D) Gratify the client’s inner needs. of volunteer nurses. The nurse is correct in
imparting the idea that the Good Samaritan law
protects the nurse from a suit for malpractice
92. The nurse is teaching a group of women when:
about fertility awareness, the nurse should
emphasize that basal body temperature: A) The nurse stops to render emergency aid and
leaves before the ambulance arrives.
A) Can be done with a mercury thermometer but B) The nurse acts in an emergency at his or her
no a digital one. place of employment.
B) The average temperature taken each morning. C) The nurse refuses to stop for an emergency
C) Should be recorded each morning before any outside of the scope of employment.
activity. D) The nurse is grossly negligent at the scene of
D) Has a lower degree of accuracy in predicting an emergency.
ovulation than the cervical mucus test.

98. A woman is hospitalized with mild

93. The nursing applicant has given the chance to preeclampsia. The nurse is formulating a plan of
ask questions during a job interview at a local care for this client, which nursing care is least
hospital. What should be the most important likely to be done?
question to ask that can increase chances of
securing a job offer? A) Deep-tendon reflexes once per shift.
B) Vital signs and FHR and rhythm q4h while
A) Begin with questions about client care awake.
assignments, advancement opportunities, and C) Absolute bed rest.
continuing education. D) Daily weight.
B) Decline to ask questions, because that is the
responsibility of the interviewer.
C) Ask as many questions about the facility as 99. While feeding a newborn with an unrepaired
possible. cardiac defect, the nurse keeps on assessing the
D) Clarify information regarding salary, benefits, condition of the client. The nurse notes that the
and working hours first, because this will help in newborn’s respiration is 72 breaths per minute.
deciding whether or not to take the job. What would be the initial nursing action?

A) Burp the newborn.

94. The nurse advised the pregnant woman that B) Stop the feeding.
smoking and alcohol should be avoided during C) Continue the feeding.
pregnancy. The nurse takes into account that the D) Notify the physician.
developing fetus is most vulnerable to
environment teratogens that cause malformation
during: 100. A client who undergone appendectomy 3
days ago is scheduled for discharge today. The
A) The entire pregnancy. nurse notes that the client is restless, picking at
B) The third trimester. bedclothes and saying, “I am late on my
C) The first trimester. appointment,” and calling the nurse by the wrong
D) The second trimester. name. The nurse suspects:

A) Panic reaction.
95. A male client tells the nurse that there is a B) Medication overdose.
big bug in his bed. The most therapeutic nursing C) Toxic reaction to an antibiotic.
response would be: D) Delirium tremens.

A) Silence.
B) “Where’s the bug? I’ll kill it for you.” Answer and Rationale :Pre-board Exam for
C) “I don’t see a bug in your bed, but you seem November 2009 NLE
afraid.”
D) “You must be seeing things.”
1. A. The oxytocic effect of Pitocin increases the
intensity and durations of contractions; prolonged
96. A pregnant client in late pregnancy is contractions will jeopardize the safetyof the fetus
complaining of groin pain that seems worse on and necessitate discontinuing the drug.
the right side. Which of the following is the most
likely cause of it? 2. B. It is of paramount importance to prevent
the client from hurting himself or herself or
others.

36
 of Down syndrome include advanced maternal
3. B. After tonsillectomy, clear, cool liquids age, especially with the first pregnancy.
should be given. Citrus, carbonated, and hot or
cold liquids should be avoided because they may 14. B. Assignments should be based on scope of
irritate the throat. Red liquids should be avoided practice and expertise.
because they give the appearance of blood if the
child vomits. Milk and milk products including 15. B. The child who is concurrently taking
pudding are avoided because they coat the digoxin and diuretics is at increased risk for
throat, cause the child to clear the throat, and digoxin toxicity due to the loss of potassium. The
increase the risk of bleeding. child and parents should be taught what foods
are high in potassium, and the child should be
4. A. Phenylephrine, with frequent and continued encouraged to eat a high-potassium diet. In
use, can cause rebound congestion of mucous addition, the child’s serum potassium level should
membranes. be carefully monitored.

5. B. The N 95 respirator is a high-particulate 16. A. The responsible for an accurate informed

filtration mask that meets the CDC performance consent is the physician. An exception to this
criteria for a tuberculosis respirator. answer would be a life-threatening emergency,
but there are no data to support another
6. C. The most frequent cause of noncompliance response.
to the treatment of chronic, or open-angle
glaucoma is the miotic effects of pilocarpine. 17. D. Asking the client to cough and take a deep
Pupillary constriction impedes normal breath will help determine if the chest tube is
accommodation, making night driving difficult kinked or if the lungs has reexpanded.
and hazardous, reducing the client’s ability to
read for extended periods and making 18. B. Every event that exposes a client to harm
participation in games with fast-moving objects should be recorded in an incident report, as well
impossible. as reported to the appropriate supervisors in
order to resolve the current problems and permit
7. B. This stops the sucking of air through the the institution to prevent the problem from
tube and prevents the entry of contaminants. In happening again.
addition, clamping near the chest wall provides
for some stability and may prevent the clamp 19. D. One of the earliest signs of digoxin toxicity
from pulling on the chest tube. is Bradycardia. For a toddler, any heart rate that
falls below the norm of about 100-120 bpm
8. D. Because umbilical cord’s insertion site is would indicate Bradycardia and would necessitate
born before the fetal head, the cord may be holding the medication and notifying the
compressed by the after-coming head in a breech physician.
birth.
20. B. This option is least threatening.
9. B. It is important to externalize the anger
away from self. 21. D. In preparing the client for discharge that is
receiving prednisone, the nurse should caution
10. D. Development normally proceeds the client to (a) take oral preparations after
cephalocaudally; so the first major meals; (b) remember that routine checks of vital
developmental milestone that the infant achieves signs, weight, and lab studies are critical; (c)
is the ability to hold the head up within the first NEVER STOP OR CHANGE THE AMOUNT OF
8-12 weeks of life. In hypothyroidism, the MEDICATION WITHOUT MEDICAL ADVICE; (d)
infant’s muscle tone would be poor and the infant store the medication in a light-resistant
would not be able to achieve this milestone. container.

11. D. Get a senior nurse who know s the 22. A. Progesterone also reduces smooth muscle
policies, the client, and the doctor. Generally motility in the urinary tract and predisposes the
speaking, a nurse should not accept telephone pregnant woman to urinary tract infections.
orders. However, if it is necessary to take one, Women should contact their doctors if they
follow the hospital’s policy regarding telephone exhibit signs of infection. Kegel exercise will help
orders. Failure to followhospital policy could be strengthen the perineal muscles; limiting fluids at
considered negligence. In this case, the nurse bedtime reduces the possibility of being
was new and did not know the hospital’s policy awakened by the necessity of voiding.
concerning telephone orders. The nurse was also
unfamiliar with the doctor and the client. 23. B. This is the proper use of anger.
Therefore the nurse should not take the order
unless a) no one else is available and b) it is an 24. C. There are several models of case
emergency situation. management, but the commonality is
comprehensive coordination of care to better
12. C. The nurse is obligated to inform the nurse predict needs of high-risk clients, decrease
manager about changes in the condition of the exacerbations and continually monitor progress
client, which may change the decision made by overtime.
the nurse manager.
25. A. Phenytoin should be infused or injected
13. A. Perinatal risk factors for the development into larger veins to avoid the discoloration know

37
as purple glove syndrome; infusing into a smaller
vein is not appropriate. 42. D. The priority for this client is being able to
establish an airway.
26. C. Serum radioimmunoassay (RIA) is
accurate within 7days of conception. This test is 43. A. Signs of placental separation include a
specific for HCG, and accuracy is not change in the shape of the uterus from ovoid to
compromised by confusion with LH. globular.

27. D. Surgery and anesthesia can increase 44. B. This could indicate intracranial bleeding.
mucus production. Deep breathing and coughing Alteplase is a thrombolytic enzyme that lyses
are essential to prevent atelectasis and thrombi and emboli. Bleeding is an adverse
pneumonia in the client’s only remaining lung. effect. Monitor clotting times and signs of any
gastrointestinal or internal bleeding.
28. B. Newborns can get pneumonia (tachypnea,
mild hypoxia, cough, eosinophilia) and 45. D. Because flank incision in nephrectomy is
conjunctivitis from Chlamydia. directly below the diaphragm, deep breathing is
painful. Additionally, there is a greater incisional
29. D. The client may perceive this as avoidance, pull each time the person moves than there is
but it is more important to redirect back to the with abdominal surgery. Incisional pain following
client, especially in light of the manipulative nephrectomy generally requires analgesics
behavior of drug abusers and adolescents. administration every 3-4 hours for 24-48 hours
after surgery. Therefore, turning, coughing and
30. C. It describes a democratic process in which deep-breathing exercises should be planned to
all members have input in the client’s care. maximize the analgesic effects.

31. A. Contraction of the milk ducts and let-down 46. B. Under high estrogen levels, during the
reflex occur under the stimulation of oxytocin period surrounding ovulation, the cervical mucus
released by the posterior pituitary gland. becomes thin, clear, and elastic (spinnbarkeit),
facilitating sperm passage.
32. B. In case management, the nurse assumes
total responsibility for meeting the needs of the 47. D. After surgery for a ruptured appendix, the
client during the entire time on duty. client should be placed in a semi-Fowler’s
position to promote drainage and to prevent
33. A. Smoke inhalation affects gas exchange. possible complications.

34. C. Sperm deposited during intercourse may 48. C. Directing and evaluation of staff is a major
remain viable for about 3 days. If ovulation responsibility of a nursing manager.
occurs during this period, conception may result.
49. A. The recommended procedure for
35. B. This option shows acceptance (key administering eyedrops to any client calls for the
concept) of this age-typical sleep pattern (that of drops to be placed in the middle of the lower
waking in the early morning). conjunctival sac.

36. D. Taking the mother’s pulse while listening 50. B. Thirst and restlessness indicate
to the FHR will differentiate between the hypovolemia and hypoxemia. Internal bleeding is
maternal and fetal heart rates and rule out fetal difficult to recognized and evaluate because it is
Bradycardia. not apparent.

37. A. Antihistamines cause pupil dilation and 51. C. Erythema toxicum is the normal,
should be avoided with glaucoma. nonpathological macular newborn rash.

38. A. This suggests that the level of 52. D. The family needs to understand what brain
consciousness is decreasing. death is before talking about organ donation.
They need time to accept the death of their
39. D. An advance directive is a form of informed family member. An environment conducive to
consent, and only a competent adult or the discussing an emotional issue is needed.
holder of a durable power of attorney has the
right to consent or refuse treatment. If the 53. A. Bending from the waist in pregnancy tends
spouse does not hold the power of attorney, the to make backache worse.
decisions of the holder, even if opposed by the
spouse, are enforced. 54. B. Support and limit setting decrease anxiety
and provide external control.
40. C. Gentle but firm guidance and nonverbal
direction is needed to intervene when a client 55. C. The stoma drainage bag is applied in the
with schizophrenic symptoms is being disruptive. operating room. Drainage from the ileostomy
contains secretions that are rich in digestive
41. C. Suctioning is only done for 10 seconds, enzymes and highly irritating to the skin.
intermittently, as the catheter is being Protection of the skin from the effects of these
withdrawn. enzymes is begun at once. Skin exposed to these
enzymes even for a short time becomes
reddened, painful and excoriated.

38
 outlet valve for easy drainage every 3-4 hours.
56. B. It is the most accurate statement of (the pouch should be changed every 3-5 days, or
physiological facts for a 28-day menstrual cycle: sooner if the adhesive is loose).
ovulation at day 14, egg life span 24 hours,
sperm life span of 72 hours. Fertilization could 70. C. A high fever accompanied by a body rash
occur from sperm deposited before ovulation. could indicate that the child has a communicable
disease and would have exposed other students
57. C. An advocate role encourage freedom of to the infection. The school nurse would want to
choice, includes speaking out for the client, and investigate this telephone call immediately so
supports the client’s best interests. that plans could be instituted to control the
spread of such infection.
58. A. Abstinence will eliminate any unnecessary
pain during intercourse and will reduce the 71. A. Severe abdominal pain may indicate
possibility of transmitting infection to one’s complications of pregnancy such as abortion,
sexual partner. ectopic pregnancy, or abruption placenta; fluid
discharge from the vagina may indicate
59. B. Anxiety is generated by group therapy at premature rupture of the membrane.
9:00 AM. The ritualistic behavioral defense of
hand washing decreases anxiety by avoiding 72. D. Gentle aspiration of mucus helps maintain
group therapy. a patent airway, required for effective gas
exchange.
60. D. Denial is a very strong defense
mechanism used to allay the emotional effects of 73. A. Somatoform disorders provide a way of
discovering a potential threat. Although denial coping with conflicts.
has been found to be an effective mechanism for
survival in some instances, such as during 74. C. Immunization should never be mixed
natural disasters, it may in greater pathology in a together in a syringe, thus necessitating three
woman with potential breast carcinoma. separate injections in three sites. Note: some
manufacturers make a premixed combination of
61. B. The registered nurse cannot delegate the immunization that is safe and effective.
responsibility for assessment and evaluation of
clients. The status of the client in restraint 75. A. Clients with radioactive implants should be
requires further assessment to determine if there positioned flat in bed to prevent dislodgement of
are additional causes for the behavior. the vaginal packing. The client may roll to the
side for meals but the upper body should not be
62. C. The client with chest pain may be having a raised more than 20 degrees.
myocardial infarction, and immediate assessment
and intervention is a priority. 76. A. Syrup of ipecac is not administered when
the ingested substances is corrosive in nature.
63. B. Is correct because semen analysis requires Toilet bowl cleaners, as a collective whole, are
that a freshly masturbated specimen be obtained highly corrosive substances. If the ingested
after a rest (abstinence) period of 48-72 hours. substance “burned” the esophagus going down, it
will “burn” the esophagus coming back up when
64. C. Betamethasone, a form of cortisone, acts the child begins to vomit after administration of
on the fetal lungs to produce surfactant. syrup of ipecac.

65. A. Secretions may have pooled above the 77. B. Inability to open eyelids on operative side
tracheostomy cuff. If these are not suctioned is seen with cranial nerve III damage.
before deflation, the secretions may be aspirated.
78. A. Assessment of physical injuries (like
66. C. Proper handling of sputum is essential to bruises, lacerations, bleeding and fractures) is
allay droplet transference of bacilli in the air. the first priority.
Clients need to be taught to cover their nose and
mouth with tissues when sneezing or coughing. 79. C. The nurse who is supervising others has a
Chemotherapy generally renders the client legal obligation to determine that they are
noninfectious within days to a few weeks, usually competent to perform the assignment, as well as
before cultures for tubercle bacilli are negative. legal obligation to provide adequate supervision.
Until chemical isolation is established, many
institutions require the client to wear a mask 80. D. Increasing hydrostatic pressure in the
when visitors are in the room or when the nurse urinary tract will facilitate passage of the calculi.
is in attendance. Client should be in a well-
ventilated room, without air recirculation, to 81. A. Infertility is not diagnosed until atleast
prevent air contamination. 12months of unprotected intercourse has failed
to produce a pregnancy. Older couples will
67. A. It is best to establish baseline information experience a longer time to get pregnant.
first.
82. B. Determining how well the kidneys filter
68. B. Listening is probably the most effective wastes states the purpose of a Creatinine
response of the four choices. clearance test.

69. A. Urine flow is continuous. The pouch has an 83. A. Acknowledging a feeling tone is the most

39
therapeutic response and provides a broad of the erect human posture and pressure exerted
opening for the client to elaborate feelings. by the growing fetus.

84. C. The behavior should be stopped. The first 97. D. The Good Samaritan Law does not impose
is to remind the staff that confidentiality maybe a duty to stop at the scene of an emergency
violated. outside of the scope of employment, therefore
nurses who do not stop are not liable for suit.
85. C. With a right-sided cerebrovascular
accident the client would have left-sided 98. C. Although reducing environment stimuli and
hemiplegia or weakness. The client’s good side activity is necessary for a woman with mild
should be closest to the bed to facilitate the preeclampsia, she will most probably have
transfer. bathroom privileges.

86. D. Legos are small plastic building blocks that 99. B. A normal respiratory rate for a newborn is
could easily slip under the child’s cast and lead to 30-40 breaths per minute.
a break in skin integrity and even infection.
Pencils, backscratchers, and marbles are some 100. D. The behavior described is likely to be
other narrow or small items that could easily slip symptoms of delirium tremens, or alcohol
under the child’s cast and lead to a break in skin withdrawal (often unsuspected on a surgical
integrity and infection. unit.)

87. D. Oxytocin (Pitocin) is used to maintain

uterine tone. 1. A 10 year old who has sustained a head injury
is brought to the emergency department by his
88. B. The submission of reports about incidents mother. A diagnosis of a mild concussion is
that expose clients to harm does not remove the made. At the time of discharge, nurse Ron should
obligation to report ongoing behavior as long as instruct the mother to:
the risk to the client continues.
A. Withhold food and fluids for 24 hours.
89. C. The recommended dosage of tetracycline B. Allow him to play outdoors with his friends.
is 25-50mg/kg/day. If the child weighs 20kg and C. Arrange for a follow up visit with the child’s
the maximum dose is 50mg/kg, this would primary care provider in one week.
indicate a total daily dose of 1000mg of C. Check for any change in responsiveness every
tetracycline. In this case, the child is being given two hours until the follow-up visit.
this medication four times a day. Therefore the
maximum single dose that can be given is 250mg
(1000 mg of tetracycline divided by four doses.) 2. A male client has suffered a motor accident
and is now suffering from hypovolemic shock.
90. C. An abnormality in the uterine muscle could Nurse Helen should frequency assess the client’s
reduce the effectiveness of uterine contractions vital signs during the compensatory stage of
and lengthen the duration of subsequent labors. shock, because:

91. A. Personality disorders stem from a weak A. Arteriolar constriction occurs

superego, implying a lack of adequate controls. B. The cardiac workload decreases
C. Decreased contractility of the heart occurs
92. C. The basal body temperature is the lowest D. The parasympathetic nervous system is
body temperature of a healthy person that is triggered
taken immediately after waking and before
getting out of bed. The BBT usually varies from
36.2 ºC to 36.3ºC during menses and for about 3. A paranoid male client with schizophrenia is
5-7 days afterward. About the time of ovulation, losing weight, reluctant to eat, and voicing
a slight drop in temperature may be seen, after concerns about being poisoned. The best
ovulation in concert with the increasing intervention by nurse Dina would be to:
progesterone levels of the early luteal phase, the
BBT rises 0.2-0.4 ºC. This elevation remains until A. Allow the client to open canned or pre-
2-3 days before menstruation, or if pregnancy packaged food
has occurred. B. Restrict the client to his room until 2 lbs are
gained
93. A. This choice implies concern for client care C. Have a staff member personally taste all of the
and self-improvement. client’s food
D. Tell the client the food has been x-rayed by
94. C. The first trimester is the period of the staff and is safe
organogenesis, that is, cell differentiation into the
various organs, tissues, and structures.
4. One day the mother of a young adult confides
95. C. This response does not contradict the to nurse Frida that she is very troubled by he
client’s perception, is honest, and shows child’s emotional illness. The nurse’s most
empathy. therapeutic initial response would be:

96. D. Tension on round ligament occurs because A. “You may be able to lessen your feelings of
guilt by seeking counseling”

40
B. “It would be helpful if you become involved in legs and portions of his trunk. Which of the
volunteer work at this time” following I.V. fluids is given first?
C. “I recognize it’s hard to deal with this, but try
to remember that this too shall pass” A. Albumin
D. “Joining a support group of parents who are B. D5W
coping with this problem can be quite helpful. C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of
potassium per 100 ml
5. To check for wound hemorrhage after a client
has had a surgery for the removal of a tumor in
the neck, nurse grace should: 11. During the first 48 hours after a severe burn
of 40% of the clients body surface, the nurse’s
A. Loosen an edge of the dressing and lift it to assessment should include observations for water
see the wound intoxication. Associated adaptations include:
B. Observe the dressing at the back of the neck
for the presence of blood A. Sooty-colored sputum
C. Outline the blood as it appears on the dressing B. Frothy pink-tinged sputum
to observe any progression C. Twitching and disorientation
D. Press gently around the incision to express D. Urine output below 30ml per hour
accumulated blood from the wound

12. After a muscle biopsy, nurse Willy should

6. A 16-year-old primigravida arrives at the labor teach the client to:
and birthing unit in her 38th week of gestation
and states that she is labor. To verify that the A. Change the dressing as needed
client is in true labor nurse Trina should: B. Resume the usual diet as soon as desired
C. Bathe or shower according to preference
A. Obtain sides for a fern test D. Expect a rise in body temperature for 48 hours
B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue 13. Before a client whose left hand has been
amputated can be fitted for a prosthesis, nurse
Joy is aware that:
7. As part of the diagnostic workup for pulmonic
stenosis, a child has cardiac catheterization. A. Arm and shoulder muscles must be developed
Nurse Julius is aware that children with pulmonic B. Shrinkage of the residual limb must be
stenosis have increased pressure: completed
C. Dexterity in the other extremity must be
A. In the pulmonary vein achieved
B. In the pulmonary artery D. Full adjustment to the altered body image
C. On the left side of the heart must have occurred
D. On the right side of the heart

14. Nurse Cathy applies a fetal monitor to the

8. An obese client asks nurse Julius how to lose abdomen of a client in active labor. When the
weight. Before answering, the nurse should client has contractions, the nurse notes a 15 beat
remember that long-term weight loss occurs best per minute deceleration of the fetal heart rate
when: below the baseline lasting 15 seconds. Nurse
Cathy should:
A. Eating patterns are altered
B. Fats are limited in the diet A. Change the maternal position
C. Carbohydrates are regulated B. Prepare for an immediate birth
D. Exercise is a major component C. Call the physician immediately
D. Obtain the client’s blood pressure

9. As a very anxious female client is talking to

the nurse May, she starts crying. She appears to 15. A male client receiving prolonged steroid
be upset that she cannot control her crying. The therapy complains of always being thirsty and
most appropriate response by the nurse would urinating frequently. The best initial action by the
be: nurse would be to:

A. “Is talking about your problem upsetting you?” A. Perform a finger stick to test the client’s blood
B. “It is Ok to cry; I’ll just stay with you for now” glucose level
C. “You look upset; lets talk about why you are B. Have the physician assess the client for an
crying.” enlarged prostate
D. “Sometimes it helps to get it out of your C. Obtain a urine specimen from the client for
system.” screening purposes
D. Assess the client’s lower extremities for the
presence of pitting edema
10. A patient has partial-thickness burns to both

41
16. Nurse Bea recognizes that a pacemaker is gestation, admitted to the hospital after vaginal
indicated when a client is experiencing: bleeding secondary to placenta previa, the
nurse’s primary objective would be:
A. Angina
B. Chest pain A. Provide a calm, quiet environment
C. Heart block B. Prepare the client for an immediate cesarean
D. Tachycardia birth
C. Prevent situations that may stimulate the
cervix or uterus
17. When administering pancrelipase (Pancreases D. Ensure that the client has regular cervical
capsules) to child with cystic fibrosis, nurse Faith examinations assess for labor
knows they should be given:

A. With meals and snacks 23. When planning discharge teaching for a
B. Every three hours while awake young female client who has had a
C. On awakening, following meals, and at pneumothorax, it is important that the nurse
bedtime include the signs and symptoms of a
C. After each bowel movement and after postural pneumothorax and teach the client to seek
draianage medical assistance if she experiences:

A. Substernal chest pain

18. A preterm neonate is receiving oxygen by an B. Episodes of palpitation
overhead hood. During the time the infant is C. Severe shortness of breath
under the hood, it would be appropriate for nurse D. Dizziness when standing up
Gian to:

A. Hydrate the infant q15 min 24. After a laryngectomy, the most important
B. Put a hat on the infant’s head equipment to place at the client’s bedside would
C. Keep the oxygen concentration consistent be:
D. Remove the infant q15 min for stimulation
A. Suction equipment
B. Humidified oxygen
19. A client’s sputum smears for acid fast bacilli C. A nonelectric call bell
(AFB) are positive, and transmission-based D. A cold-stream vaporizer
airborne precautions are ordered. Nurse Kyle
should instruct visitors to:
25. Nurse Oliver interviews a young female client
A.Limit contact with non-exposed family with anorexia nervosa to obtain information for
members the nursing history. The client’s history is likely to
B. Avoid contact with any objects present in the reveal a:
client’s room
C. Wear an Ultra-Filter mask when they are in A. Strong desire to improve her body image
the client’s room B. Close, supportive mother-daughter
D. Put on a gown and gloves before going into relationship
the client’s room C. Satisfaction with and desire to maintain her
present weight
D. Low level of achievement in school, with little
20. A client with a head injury has a fixed, dilated concerns for grades
right pupil; responds only to painful stimuli; and
exhibits decorticate posturing. Nurse Kate should 26. Nurse Bea should plan to assist a client with
recognize that these are signs of: an obsessive-compulsive disorder to control the
use of ritualistic behavior by:
A. Meningeal irritation
B. Subdural hemorrhage A. Providing repetitive activities that require little
C. Medullary compression thought
D. Cerebral cortex compression B. Attempting to reduce or limit situations that
increase anxiety
C. Getting the client involved with activities that
21. After a lateral crushing chest injury, obvious will provide distraction
right-sided paradoxic motion of the client’s chest D. Suggesting that the client perform menial
demonstrates multiple rib fraactures, resulting in tasks to expiate feelings of guilt
a flail chest. The complication the nurse should
carefully observe for would be: 27. A 2 ½ year old child undergoes a
ventriculoperitoneal shunt revision. Before
A. Mediastinal shift discharge, nurse John, knowing the expected
B. Tracheal laceration developmental behaviors for this age group,
C. Open pneumothorax should tell the parents to call the physician if the
D. Pericardial tamponade child:

A. Tries to copy all the father’s mannerisms

22. When planning care for a client at 30-weeks B. Talks incessantly regardless of the presence of

42
others
C. Becomes fussy when frustrated and displays a
shortened attention span 34. Nurse Wilma recognizes that failure of a
D. Frequently starts arguments with playmates newborn to make the appropriate adaptation to
by claiming all toys are “mine” extrauterine life would be indicated by:

A. flexed extremities
28. A urinary tract infection is a potential danger B. Cyanotic lips and face
with an indwelling catheter. Nurse Gina can best C. A heart rate of 130 beats per minute
plan to avoid this complication by: D. A respiratory rate of 40 breath per minute

A. Assessing urine specific gravity

B. Maintaining the ordered hydration 35. The laboratory calls to state that a client’s
C. Collecting a weekly urine specimen lithium level is 1.9 mEq/L after 10 days of lithium
D. Emptying the drainage bag frequently therapy. Nurse Reese should:

A. Notify the physician of the findings because

29. A client has sustained a fractured right femur the level is dangerously high
in a fall on stairs. Nurse Troy with the emergency B. Monitor the client closely because the level of
response team assess for signs of circulatory lithium in the blood is slightly elevated
impairment by: C. Continue to administer the medication as
ordered because the level is within the
A. Turning the client to side lying position therapeutic range
B. Asking the client to cough and deep breathe D. Report the findings to the physician so the
C. Taking the client’s pedal pulse in the affected dosage can be increased because the level is
limb below therapeutic range
D. Instructing the client to wiggle the toes of the
right foot
36. A client has a regular 30-day menstrual
cycles. When teaching about the rhythm method,
30. To assess orientation to place in a client Which the client and her husband have chosen to
suspected of having dementia of the alzheimers use for family planning, nurse Dianne should
type, nurse Chris should ask: emphasize that the client’s most fertile days are:

A. “Where are you?” A. Days 9 to 11

B. “Who brought you here?” B. Days 12 to 14
C. “Do you know where you are?” C. Days 15 to 17
D. “How long have you been there?” D. Days 18 to 20

31. Nurse Mary assesses a postpartum client who 37. Before an amniocentesis, nurse Alexandra
had an abruption placentae and suspects that should:
disseminated intravascular coagulation (DIC) is
occurring when assessments demonstrate: A. Initiate the intravenous therapy as ordered by
the physiscian
A. A boggy uterus B. Inform the client that the procedure could
B. Multiple vaginal clots precipitate an infection
C. Hypotension and tachycardia C. Assure that informed consent has been
D. Bleeding from the venipuncture site obtained from the client
D. Perform a vaginal examination on the client to
assess cervical dilation
32. When a client on labor experiences the urge
to push a 9cm dilation, the breathing pattern that
nurse Rhea should instruct the client to use is 38. While a client is on intravenous magnesium
the: sulfate therapy for preeclampsia, it is essential
for nurse Amy to monitor the client’s deep tendon
A. Expulsion pattern reflexes to:
B. Slow paced pattern
C. Shallow chest pattern A. Determine her level of consciousness
D. blowing pattern B. Evaluate the mobility of the extremities
C. Determine her response to painful stimuli
D. Prevent development of respiratory distress
33. Nurse Ronald should explain that the most
beneficial between-meal snack for a client who is
recovering from the full-thickness burns would be 39. A preschooler is admitted to the hospital with
a: a diagnosis of acute glomerulonephritis. The
child’s history reveals a 5-pound weight gain in
A. Cheeseburger and a malted one week and peritoneal edema. For the most
B. Piece of blueberry pie and milk accurate information on the status of the child’s
C. Bacon and tomato sandwich and tea edema, nursing intervention should include:
D. Chicken salad sandwich and soft drink

43
A. Obtaining the child’s daily weight C. The extrinsic factor is not absorbed
B. Doing a visual inspection of the child D. Bilirubin accumulates in the plasma
C. Measuring the child’s intake and output
D. Monitoring the child’s electrolyte values
46. Realizing that the hypokalemia is a side effect
of steroid therapy, nurse Monette should monitor
40. Nurse Mickey is administering a client taking steroid medication for:
dexamethasome (Decadron) for the early
management of a client’s cerebral edema. This A. Hyperactive reflexes
treatment is effective because: B. An increased pulse rate
C. Nausea, vomiting, and diarrhea
A. Acts as hyperosmotic diuretic D. Leg weakness with muscle cramps
B. Increases tissue resistance to infection
C. Reduces the inflammatory response of tissues
D. Decreases the information of cerebrospinal 47. When assessing a newborn suspected of
fluid having Down syndrome, nurse Rey would expect
to observe:

41. During newborn nursing assessment, a A. long thin fingers

positive Ortolani’s sign would be indicated by: B. Large, protruding ears
C. Hypertonic neck muscles
A. A unilateral droop of hip D. Simian lines on the hands
B. A broadening of the perineum
C. An apparent shortening of one leg
D. An audible click on hip manipulation 48. A 10 year old girl is admitted to the pediatric
unit for recurrent pain and swelling of her joints,
particularly her knees and ankles. Her diagnosis
42. When caring for a dying client who is in the is juvenile rheumatoid arthritis. Nurse Janah
denial stage of grief, the best nursing approach recognizes that besides joint inflammation, a
would be to: unique manifestation of the rheumatoid process
involves the:
A. Agree and encourage the client’s denial
B. Allow the denial but be available to discuss A. Ears
death B. Eyes
C. Reassure the client that everything will be OK C. Liver
D. Leave the client alone to confront the feelings D. Brain
of impending loss

49. A disturbed client is scheduled to begin group

43. To decrease the symptoms of therapy. The client refuses to attend. Nurse Lolit
gastroesophageal reflux disease (GERD), the should:
physician orders dietary and medication
management. Nurse Helen should teach the A. Accept the client’s decision without discussion
client that the meal alteration that would be most B. Have another client to ask the client to
appropriate would be: consider
C. Tell the client that attendance at the meeting
A. Ingest foods while they are hot is required
B. Divide food into four to six meals a day D. Insist that the client join the group to help the
C.Eat the last of three meals daily by 8pm socialization process
D. Suck a peppermint candy after each meal

50. Because a severely depressed client has not

44. After a mastectomy or hysterectomy, clients responded to any of the antidepressant
may feel incomplete as women. The statement medications, the psychiatrist decides to try
that should alert nurse Gina to this feeling would electroconvulsive therapy (ECT). Before the
be: treatment the nurse should:

A. “I can’t wait to see all my friends again” A. Have the client speak with other clients
B. “I feel washed out; there isn’t much left” receiving ECT
C. “I can’t wait to get home to see my B. Give the client a detailed explanation of the
grandchild” entire procedure
D. “My husband plans for me to recuperate at our C. Limit the client’s intake to a light breakfast on
daughter’s home” the days of the treatment
D. Provide a simple explanation of the procedure
and continue to reassure the client
45. A client with obstruction of the common bile
duct may show a prolonged bleeding and clotting
time because: 51. Nurse Vicky is aware that teaching about
colostomy care is understood when the client
A. Vitamin K is not absorbed states, “I will contact my physician and report
B. The ionized calcium levels falls ____":

44
A. If I notice a loss of sensation to touch in the
stoma tissue”
B. When mucus is passed from the stoma 57. Nurse Katrina prepares an older-adult client
between irrigations” for sleep, actions are taken to help reduce the
C. The expulsion of flatus while the irrigating fluid likelihood of a fall during the night. Targeting the
is running out” most frequent cause of falls, the nurse should:
D. If I have difficulty in inserting the irrigating
tube into the stoma” A. Offer the client assistance to the bathroom
B. Move the bedside table closer to the client’s
bed
52. The client’s history that alerts nurse Henry to C. Encourage the client to take an available
assess closely for signs of postpartum infection sedative
would be: D. Assist the client to telephone the spouse to
say “goodnight”
A. Three spontaneous abortions
B. negative maternal blood type
C. Blood loss of 850 ml after a vaginal birth 58. When evaluating a growth and development
D. Maternal temperature of 99.9° F 12 hours of a 6 month old infant, nurse Patty would expect
after delivery the infant to be able to:

A. Sit alone, display pincer grasp, wave bye bye

53. A client is experiencing stomatitis as a result B. Pull self to a standing position, release a toy
of chemotherapy. An appropriate nursing by choice, play peek-a-boo
intervention related to this condition would be C. Crawl, transfer toy from one hand to the
to: other, display of fear of strangers
D. Turn completely over, sit momentarily without
A. Provide frequent saline mouthwashes support, reach to be picked up
B. Use karaya powder to decrease irritation
C. Increase fluid intake to compensate for the
diarrhea 59. A breastfeeding mother asks the nurse what
D. Provide meticulous skin care of the abdomen she can do to ease the discomfort caused by a
with Betadine cracked nipple. Nurse Tina should instruct the
client to:

54. During a group therapy session, one of the A. Manually express milk and feed it to the baby
clients ask a male client with the diagnosis of in a bottle
antisocial personality disorder why he is in the B. Stop breastfeeding for two days to allow the
hospital. Considering this client’s type of nipple to heal
personality disorder, the nurse might expect him C. Use a breast shield to keep the baby from
to respond: direct contact with the nipple
D. Feed the baby on the unaffected breast first
A. “I need a lot of help with my troubles” until the affected breast heals
B. “Society makes people react in old ways”
C. “I decided that it’s time I own up to my
problems” 60. Nurse Sandy observes that there is blood
D. “My life needs straightening out and this might coming from the client’s ear after head injury.
help” Nurse Sandy should:

A. Turn the client to the unaffected side

55. A child visits the clinic for a 6-week checkup B. Cleanse the client’s ear with sterile gauze
after a tonsillectomy and adenoidectomy. In C. Test the drainage from the client’s ear with
addition to assessing hearing, the nurse should Dextrostix
include an assessment of the child’s: D. Place sterile cotton loosely in the external ear
of the client
A. Taste and smell
B. Taste and speech
C. Swallowing and smell 61. Nurse Gio plans a long term care for parents
D. Swallowing and speech of children with sickle-cell anemia, which includes
periodic group conferences. Some of the
discussions should be directed towards:
56. A client is diagnosed with cancer of the jaw.
A course of radiation therapy is to be followed by A. Finding special school facilities for the child
surgery. The client is concerned about the side B. Making plans for moving to a more therapeutic
effects related to the radiation treaments. Nurse climate
Ria should explain that the major side effects C. Choosing a means of birth control to avoid
that will experienced is: future pregnancies
D. Airing their feelings regarding the transmission
A. Fatigue of the disease to the child
B. Alopecia
C. Vomiting
D. Leucopenia 62. The central problem the nurse might face

45
with a disturbed schizophrenic client is the A. Develop language skills
client’s: B. Avoid his own regressive behavior
C. Mainstream into a regular class in school
A. Suspicious feelings D. Recognize himself as an independent person
B. Continuous pacing of worth
C. Relationship with the family
D. Concern about working with others
68. Nurse Wally knows that the most important
aspect of the preoperative care for a child with
63. When planning care with a client during the Wilms’ tumor would be:
postoperative recovery period following an
abdominal hysterectomy and bilateral salpingo- A. Checking the size of the child’s liver
oophorectomy, nurse Frida should include the B. Monitoring the child’s blood pressure
explanation that: C. Maintaining the child in a prone position
D. Collecting the child’s urine for culture and
A. Surgical menopause will occur sensitivity
B. Urinary retention is a common problem
C. Weight gain is expected, and dietary plan are
needed 69. At 11:00 pm the count of hydrocodone
D. Depression is normal and should be expected (Vicodin) is incorrect. After several minutes of
searching the medication cart and medication
administration records, no explanation can be
64. An adolescent client with anorexia nervosa found. The primary nurse should notify the:
refuses to eat, stating, “I’ll get too fat.” Nurse
Andrea can best respond to this behavior initially A. Nursing unit manager
by: B. Hospital administrator
C. Quality control manager
A. Not talking about the fact that the client is not D. Physician ordering the medication
eating
B. Stopping all of the client’s priviledges until
food is eaten 70. When caring for the a client with a
C. Telling the client that tube feeding will pneumothorax, who has a chest tube in place,
eventually be necessary nurse Kate should plan to:
D. Pointing out to the client that death can occur
with malnutrition. A. Administer cough suppressants at appropriate
intervals as ordered
B. Empty and measure the drainage in the
65. A pain scale is used to assess the degree of collection chamber each shift
pain. The client rates the pain as an 8 on a scale C. Apply clamps below the insertion site when
of 10 before medication and a 7 on a scale of 10 ever getting the client out of bed
after being medicated. Nurse Glenda determines D. Encourage coughing, deep breathing, and
that the: range of motion to the arm on the affected side

A. Client has a low pain tolerance

B. Medication is not adequately effective 71. According to C.E.Winslow, which of the
C. Medication has sufficiently decreased the pain following is the goal of Public Health?
level
D. Client needs more education about the use of A. For people to attain their birthrights of health
the pain scale and longevity
B. For promotion of health and prevention of
disease
66. To enhance a neonate’s behavioral C. For people to have access to basic health
development, therapeutic nursing measures services
should include: D. For people to be organized in their health
efforts
A. Keeping the baby awake for longer periods of
time before each feeding
B. Assisting the parents to stimulate their baby 72. What other statistic may be used to
through touch, sound, and sight. determine attainment of longevity?
C. Encouraging parental contact for at least one
15-minute period every four hours. A. Age-specific mortality rate
D. Touching and talking to the baby at least B. Proportionate mortality rate
hourly, beginning within two to four hours after C. Swaroop’s index
birth D. Case fatality rate

67. Before formulating a plan of care for a 6 year 73. Which of the following is the most prominent
old boy with attention deficit hyperactivity feature of public health nursing?
disorder (ADHD), nurse Kyla is aware that the
initial aim of therapy is to help the client to: A. It involves providing home care to sick people
who are not confined in the hospital

46
B. Services are provided free of charge to people D. It develops the family’s initiative in providing
within the catchment area. for health needs of its members.
C. The public health nurse functions as part of a
team providing a public health nursing services.
D. Public health nursing focuses on preventive, 80. The PHN bag is an important tool in providing
not curative, services. nursing care during a home visit. The most
important principle of bag technique states that
it:
74. Which of the following is the mission of the
Department of Health? A. Should save time and effort.
B. Should minimize if not totally prevent the
A. Health for all Filipinos spread of infection.
B. Ensure the accessibility and quality of health C. Should not overshadow concern for the patient
care and his family.
C. Improve the general health status of the D. May be done in a variety of ways depending
population on the home situation, etc.
D. Health in the hands of the Filipino people by
the year 2020
81. Nurse Willy reads about Path Goal theory.
Which of the following behaviors is manifested by
75. Nurse Pauline determines whether resources the leader who uses this theory?
were maximized in implementing Ligtas Tigdas,
she is evaluating: A. Recognizes staff for going beyond expectations
by giving them citations
A. Effectiveness B. Challenges the staff to take individual
B. Efficiency accountability for their own practice
C. Adequacy C. Admonishes staff for being laggards
D. Appropriateness D. Reminds staff about the sanctions for non
performance

76. Lissa is a B.S.N. graduate. She want to

become a Public Health Nurse. Where will she 82. Nurse Cathy learns that some leaders are
apply? transactional leaders. Which of the following does
NOT characterize a transactional leader?
A. Department of Health
B. Provincial Health Office A. Focuses on management tasks
C. Regional Health Office B. Is a caretaker
D. Rural Health Unit C. Uses trade-offs to meet goals
D. Inspires others with vision

77. As an epidemiologist, Nurse Celeste is

responsible for reporting cases of notifiable 83. Functional nursing has some advantages,
diseases. What law mandates reporting of cases which one is an EXCEPTION?
of notifiable diseases?
A. Psychological and sociological needs are
A. Act 3573 emphasized.
B. R.A. 3753 B. Great control of work activities.
C. R.A. 1054 C. Most economical way of delivering nursing
D. R.A. 1082 services.
D. Workers feel secure in dependent role

78. Nurse Fay is aware that isolation of a child

with measles belongs to what level of 84. Which of the following is the best guarantee
prevention? that the patient’s priority needs are met?

A. Primary A. Checking with the relative of the patient

B. Secondary B. Preparing a nursing care plan in collaboration
C. Intermediate with the patient
D. Tertiary C. Consulting with the physician
D. Coordinating with other members of the team

79. Nurse Gina is aware that the following is an

advantage of a home visit? 85. Nurse Tony stresses the need for all the
employees to follow orders and instructions from
A. It allows the nurse to provide nursing care to a him and not from anyone else. Which of the
greater number of people. following principles does he refer to?
B. It provides an opportunity to do first hand
appraisal of the home situation. A. Scalar chain
C. It allows sharing of experiences among people B. Discipline
with similar health problems. C. Unity of command
D. Order

47
 components of a client's general background drug
history?
86. Nurse Joey discusses the goal of the
department. Which of the following statements is A. Allergies and socioeconomic status
a goal? B. Urine output and allergies
C. Gastric reflex and age
A. Increase the patient satisfaction rate D. Bowel habits and allergies
B. Eliminate the incidence of delayed
administration of medications
C. Establish rapport with patients 93. Which procedure or practice requires surgical
D. Reduce response time to two minutes asepsis?

A. Hand washing
87. Nurse Lou considers shifting to B. Nasogastric tube irrigation
transformational leadership. Which of the C. I.V. cannula insertion
following statements best describes this type of D. Colostomy irrigation
leadership?

A. Uses visioning as the essence of leadership 94. The nurse is performing wound care using
B. Serves the followers rather than being served surgical asepsis. Which of the following practices
C. Maintains full trust and confidence in the violates surgical asepsis?
subordinates
D. Possesses innate charisma that makes others A. Holding sterile objects above the waist
feel good in his presence. B. Pouring solution onto a sterile field cloth
C. Considering a 1" (2.5-cm) edge around the
sterile field contaminated
88. Nurse Mae tells one of the staff, “I don’t have D. Opening the outermost flap of a sterile
time to discuss the matter with you now. See me package away from the body
in my office later” when the latter asks if they
can talk about an issue. Which of the following
conflict resolution strategies did she use? 95. On admission, a client has the following
arterial blood gas (ABG) values: PaO2, 50 mm
A. Smoothing Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3–, 28
B. Compromise mEq/L. Based on these values,
C. Avoidance the nurse should formulate which nursing
D. Restriction diagnosis for this client?

A. Risk for deficient fluid volume

89. Nurse Bea plans of assigning competent B. Deficient fluid volume
people to fill the roles designed in the hierarchy. C. Impaired gas exchange
Which process refers to this? D. Metabolic acidosis

A. Staffing
B. Scheduling 96. The use of larvivorous fish in malaria control
C. Recruitment is the basis for which strategy of malaria
D. Induction control?

A. Stream seeding
90. Nurse Linda tries to design an organizational B. Stream clearing
structure that allows communication to flow in all C. Destruction of breeding places
directions and involve workers in decision D. Zooprophylaxis
making. Which form of organizational structure is
this?
97. In Integrated Management of Childhood
A. Centralized Illness, severe conditions generally require
B. Decentralized urgent referral to a hospital. Which of the
C. Matrix following severe conditions DOES NOT always
D. Informal require urgent referral to a hospital?

A. Mastoiditis
91. When documenting information in a client's B. Severe dehydration
medical record, the nurse should: C. Severe pneumonia
D. Severe febrile disease
A. erase any errors.
B. use a #2 pencil.
C. leave one line blank before each new entry. 98. A mother brought her daughter, 4 years old,
D. end each entry with the nurse's signature and to the RHU because of cough and colds. Following
title. the IMCI assessment guide, which of the
following is a danger sign that indicates the need
for urgent referral to a hospital?
92. Which of the following factors are major

48
A. Inability to drink A new dietary regimen, with a balance of foods
B. High grade fever from the food pyramid, must be established and
C. Signs of severe dehydration continued forweight reduction to occur and be
D. Cough for more than 30 days maintained.

9. B. “It is Ok to cry; I’ll just stay with you

99. Food fortification is one of the strategies to for now”
prevent micronutrient deficiency conditions. R.A. This portrays a nonjudgmental attitude that
8976 mandates fortification of certain food items. recognizes the client’s needs.
Which of the following is among these food
items? 10. C. Lactated Ringer’s solution
Lactated Ringer’s solution replaces lost sodium
A. Sugar and corrects metabolic acidosis, both of which
B. Bread commonly occur following a burn. Albumin is
C. Margarine used as adjunct therapy, not primary fluid
D. Filled milk replacement. Dextrose isn’t given to burn
patients during the first 24 hours because it can
cause pseudodiabetes. The patient is
100. The major sign of iron deficiency anemia is hyperkalemic from the potassium shift from the
pallor. What part is best examined for pallor? intracellular space to the plasma, so potassium
would be detrimental.
A. Palms
B. Nailbeds 11. C. Twitching and disorientation
C. Around the lips Excess extracellular fluid moves into cells (water
D. Lower conjunctival sac intoxication); intracellular fluid excess in
sensitive brain cells causes altered mental status;
other signs include anorexia nervosa, nausea,
1. C. Check for any change in vomiting, twitching, sleepiness, and convulsions.
responsiveness every two hours until the
follow-up visit 12. B. Resume the usual diet as soon as
Signs of an epidural hematoma in children desired
usually do not appear for 24 hours or more As long as the client has no nausea or vomiting,
hours; a follow-up visit usually is arranged for there are no dietary restriction.
one to two days after the injury.
13. B. Shrinkage of the residual limb must
2. A. Arteriolar constriction occurs be completed
The early compensation of shock is Shrinkage of the residual limb, resulting from
cardiovascular and is seen in changes in pulse, reduction of subcutaneous fat and interstitial
BP, and pulse pressure; blood is shunted to vital fluid, must occur for an adequate fit between the
centers, particularly heart and brain. limb and the prosthesis.

3. A. Allow the client to open canned or pre- 14. A. Change the maternal position
packaged food Stimulation of the sympathetic nervous system is
The client’s comfort, safety, and nutritional status an initial response to mild hypoxia that
are the priorities; the client may feel comfortable accompanies partial cord compression (umbilical
to eat if the food has been sealed before reaching vein) during contractions; changing the maternal
the mental health facility. position can alleviate the compression.

4. D. “Joining a support group of parents 15. A. Perform a finger stick to test the
who are coping with this problem can be client’s blood glucose level
quite helpful. The client has signs of diabetes, which may result
Taking with others in similar circumstances from steroid therapy, testing the blood glucose
provides support and allows for sharing of level is a method of screening for diabetes, thus
experiences. gathering more data.

5. B. Observe the dressing at the back of the 16. C. Heart block

neck for the presence of blood This is the primary indication for a pacemaker
Drainage flows by gravity. because there is an interfere with the electrical
conduction system of the heart.
6. C. Prepare her for a pelvic examination
Pelvic examination would reveal dilation and 17. A. With meals and snacks
effacement Pancreases capsules must be taken with food and
snacks because it acts on the nutrients and
7. D. On the right side of the heart readies them for absorption.
Pulmonic stenosis increases resistance to blood
flow, causing right ventricular hyperthropy; with 18. B. Put a hat on the infant’s head
right ventricular failure there is an increase in Oxygen has cooling effect, and the baby should
pressure on the right side of the heart. be kept warm so that metabolic activity and
oxygen demands are not increased.
8. A. Eating patterns are altered

49
 This indicates a fibrinogenemia; massive clotting
19. C. Wear an Ultra-Filter mask when they in the area of the separation has resulted in a
are in the client’s room lowered circulating fibrinogen.
Tubercle bacilli are transmitted through air
currents; therefore personal protective 32. D. blowing pattern
equipment such as an Ultra-Filter mask is Clients should use a blowing pattern to overcome
necessary. the premature urge to push.

20. D. Cerebral cortex compression 33. A. Cheeseburger and a malted

Cerebral compression affects pyramidal tracts, Of the selections offered, this is the highest in
resulting in decorticate rigidity and cranial nerve calories and protein, which are needed for
injury, which cause pupil dilation. increased basal metabolic rate and for tissue
repair.
21. A.Mediastinal shift
Mediastinal structures move toward the uninjured 34. B. Cyanotic lips and face
lung, reducing oxygenation and venous return. Central cyanosis (blue lips and face) indicates
lowered oxygenation of the blood, caused by
22. C. Prevent situations that may stimulate either decreased lung expansion or right to left
the cervix or uterus shunting of blood.
Stimulation of the cervix or uterus may cause
bleeding or hemorrhage and should be avoided. 35. A. Notify the physician of the findings
because the level is dangerously high
23. C. Severe shortness of breath Levels close to 2 mEq/L are dangerously close to
This could indicate a recurrence of the the toxic level; immediate action must be taken.
pneumothorax as one side of the lung is
inadequate to meet the oxygen demands of the 36. C. Days 15 to 17
body. Ovulation occurs approximately 14 days before
the next menses, about the 16th day in 30 day
24. A. Suction equipment cycle; the 15th to 17th days would be the best
Respiratory complications can occur because of time to avoid sexual intercourse.
edema of the glottis or injury to the recurrent
laryngeal nerve. 37. C. Assure that informed consent has
been obtained from the client
25. A. Strong desire to improve her body An invasive procedure such as amniocentesis
image requires informed consent.
Clients with anorexia nervosa have a disturbed
self image and always see themselves as fat and 38. D. Prevent development of respiratory
needing further reducing. distress
Respiratory distress or arrest may occur when
26. B. Attempting to reduce or limit the serum level of magnesium sulfate reaches 12
situations that increase anxiety to 15 mg/dl; deep tendon reflexes disappear
Persons with high anxiety levels develop various when the serum level is 10 to 12 mg/dl; the drug
behaviors to relieve their anxiety; by reducing is withheld in the absence of deep tendon
anxiety, the need for these obsessive-compulsive reflexes; the therapeutic serum level is 5 to 8
action is reduced. mg/dl.

27. C. Becomes fussy when frustrated and 39. A. Obtaining the child’s daily weight
displays a shortened attention span Weight monitoring is the most useful means of
Shortened attention span and fussy behavior may assessing fluid balance and changes in the
indicate a change in intracranial pressure and/or edematous state; 1 liter of fluid weighs about 2.2
shunt malfunction. pounds.

28. B. Maintaining the ordered hydration 40. C. Reduces the inflammatory response of
Promoting hydration maintains urine production tissues
at a higher rate, which flushes the bladder and Corticosteroids act to decrease inflammation
prevents urinary stasis and possible infection. which decreases edema.

29. C. Taking the client’s pedal pulse in the 41. D. An audible click on hip manipulation
affected limb With specific manipulation, an audible click may
Monitoring a pedal pulse will assess circulation to be heard of felt as he femoral head slips into the
the foot. acetabulum.

30. A. “Where are you?” 42. B. Allow the denial but be available to
“Where are you?” is the best question to elicit discuss death
information about the client’s orientation to place This does not remove client’s only way of coping,
because it encourages a response that can be and it permits future movement through the
assessed. grieving process when the client is ready.

31. D. Bleeding from the venipuncture site 43. B. Divide food into four to six meals a
day

50
The volume of food in the stomach should be
kept small to limit pressure on the cardiac 57. A. Offer the client assistance to the
sphincter. bathroom
Statistics indicate that the most frequent cause of
44. B. “I feel washed out; there isn’t much falls by hospitalized clients is getting up or
left” attempting to get up to the bathroom unassisted.
The client’s statement infers an emptiness with
an associated loss. 58. D. Turn completely over, sit momentarily
without support, reach to be picked up
45. A. Vitamin K is not absorbed These abilities are age-appropriate for the 6
Vitamin K, a fat soluble vitamin, is not absorbed month old child.
from the GI tract in the absence of bile; bile
enters the duodenum via the common bile duct. 59. D. Feed the baby on the unaffected
breast first until the affected breast heals
46. D. Leg weakness with muscle cramps The most vigorous sucking will occur during the
Impulse conduction of skeletal muscle is impaired first few minutes of breastfeeding when the
with decreased potassium levels, muscular infant would be on the unaffected breast; later
weakness and cramps may occur with suckling is less traumatic.
hypokalemia.
60. D. Place sterile cotton loosely in the
47. D. Simian lines on the hands external ear of the client
This is characteristic finding in newborns with This would absorb the drainage without causing
Down syndrome. further trauma.

48. B. Eyes 61. D. Airing their feelings regarding the

Rheumatoid arthritis can cause inflammation of transmission of the disease to the child
the iris and ciliary body of the eyes which may Discussion with parents who have children with
lead to blindness. similar problems helps to reduce some of their
discomfort and guilt.
49. A. Accept the client’s decision without
discussion 62. A. Suspicious feelings
This is all the nurse can do until trust is The nurse must deal with these feelings and
established; facing the client to attend will establish basic trust to promote a therapeutic
disrupt the group. milieu.

50. D. Provide a simple explanation of the 63. A. Surgical menopause will occur
procedure and continue to reassure the When a bilateral oophorectomy is performed,
client both ovaries are excised, eliminating ovarian
The nurse should offer support and use clear, hormones and initiating response.
simple terms to allay client’s anxiety.
64. D. Pointing out to the client that death
51. D. If I have difficulty in inserting the can occur with malnutrition.
irrigating tube into the stoma” The client expects the nurse to focus on eating,
This occurs with stenosis of the stoma; forcing but the emphasis should be placed on feelings
insertion of the tube could cause injury. rather than actions.

52. C. Blood loss of 850 ml after a vaginal 65. B. Medication is not adequately effective
birth The expected effect should be more than a one
Excessive blood loss predisposes the client to an point decrease in the pain level.
increased risk of infection because of decreased
maternal resistance; they expected blood loss is 66. B. Assisting the parents to stimulate
350 to 500 ml. their baby through touch, sound, and sight.
Stimuli are provided via all the senses; since the
53. A. Provide frequent saline mouthwashes infant’s behavioral development is enhanced
This is soothing to the oral mucosa and helps through parent-infant interactions, these
prevent infection. interactions should be encouraged.

54. B. “Society makes people react in old 67. D. Recognize himself as an independent
ways” person of worth
The client is incapable of accepting responsibility Academic deficits, an inability to function within
for self-created problems and blames society for constraints required of certain settings, and
the behavior. negative peer attitudes often lead to low self-
esteem.
55. A. Taste and smell
Swelling can obstruct nasal breathing, interfering 68. B. Monitoring the child’s blood pressure
with the senses of taste and smell. Because the tumor is of renal origin, the rennin
angiotensin mechanism can be involved, and
56. A. Fatigue blood pressure monitoring is important.
Fatigue is a major problem caused by an increase
in waste products because of catabolic 69. A. Nursing unit manager
processes.

51
Controlled substance issues for a particular prevent transmission of infection to and
nursing unit are the responsibility of that unit’s from the client.
nurse manager. Path Goal theory according to House and
associates rewards good performance so that
70. D. Encourage coughing, deep breathing, others would do the same.
and range of motion to the arm on the
affected side 82. D. Inspires others with vision
All these interventions promote aeration of the Inspires others with a vision is characteristic of a
re-expanding lung and maintenance of function in transformational leader. He is focused more on
the arm and shoulder on the affected side. the day-to-day operations of the
department/unit.
71. A. For people to attain their birthrights
of health and longevity 83. A. Psychological and sociological needs
According to Winslow, all public health efforts are are emphasized.
for people to realize their birthrights of health When the functional method is used, the
and longevity. psychological and sociological needs of the
patients are neglected; the patients are regarded
72. C. Swaroop’s index as ‘tasks to be done”
Swaroop’s index is the percentage of the deaths
aged 50 years or older. Its inverse represents the 84. B. Preparing a nursing care plan in
percentage of untimely deaths (those who died collaboration with the patient
younger than 50 years). The best source of information about the priority
needs of the patient is the patient himself. Hence
73. D. Public health nursing focuses on using a nursing care plan based on his expressed
preventive, not curative, services. priority needs would ensure meeting his needs
The catchment area in PHN consists of a effectively.
residential community, many of whom are well
individuals who have greater need for preventive 85. C. Unity of command
rather than curative services. The principle of unity of command means that
employees should receive orders coming from
74. B. Ensure the accessibility and quality of only one manager and not from two managers.
health care This averts the possibility of sowing confusion
Ensuring the accessibility and quality of health among the members of the organization.
care is the primary mission of DOH.
86. A. Increase the patient satisfaction rate
75. B. Efficiency Goal is a desired result towards which efforts are
Efficiency is determining whether the goals were directed. Options AB, C and D are all objectives
attained at the least possible cost. which are aimed at specific end.

76. D. Rural Health Unit 87. A. Uses visioning as the essence of

R.A. 7160 devolved basic health services to local leadership
government units (LGU’s ). The public health Transformational leadership relies heavily on
nurse is an employee of the LGU. visioning as the core of leadership.

77. A. Act 3573 88. C. Avoidance

Act 3573, the Law on Reporting of Communicable This strategy shuns discussing the issue head-on
Diseases, enacted in 1929, mandated the and prefers to postpone it to a later time. In
reporting of diseases listed in the law to the effect the problem remains unsolved and both
nearest health station. parties are in a lose-lose situation.

78. A. Primary 89. A. Staffing

The purpose of isolating a client with a Staffing is a management function involving
communicable disease is to protect those who putting the best people to accomplish tasks and
are not sick (specific disease prevention). activities to attain the goals of the organization.

79. B. It provides an opportunity to do first 90. B. Decentralized

hand appraisal of the home situation. Decentralized structures allow the staff to make
Choice A is not correct since a home visit decisions on matters pertaining to their practice
requires that the nurse spend so much time with and communicate in downward, upward, lateral
the family. Choice C is an advantage of a group and diagonal flow.
conference, while choice D is true of a clinic
consultation. 91. D. end each entry with the nurse's
signature and title.
80. B. Should minimize if not totally prevent The end of each entry should include the nurse's
the spread of infection. signature and title; the signature holds the nurse
Bag technique is performed before and after accountable for the recorded information. Erasing
handling a client in the home to prevent errors in documentation on a legal document
transmission of infection to and from the client. such as a client's chart isn't permitted by law.
Because a client's medical record is considered a
81. A. Bag technique is performed before legal document, the nurse should make all
and after handling a client in the home to entries in ink. The nurse is accountable for the

52
information recorded and therefore shouldn't R.A. 8976 mandates fortification of rice, wheat
leave any blank lines in which another health flour, sugar and cooking oil with Vitamin A, iron
care worker could make additions. and/or iodine.

92. A. Allergies and socioeconomic status 100. A. Palms

General background data consist of such The anatomic characteristics of the palms allow a
components as allergies, medical history, habits, reliable and convenient basis for examination for
socioeconomic status, lifestyle, beliefs, and pallor.
sensory deficits. Urine output, gastric reflex, and
bowel habits are significant only if a disease 1. A woman in a child bearing age receives
affecting these functions is present. a rubella vaccination. Nurse Joy would
give her which of the following
93. C. I.V. cannula insertion instructions?
Caregivers must use surgical asepsis when
performing wound care or any procedure in which a. Refrain from eating eggs or egg
a sterile body cavity is entered or skin integrity is products for 24 hours
broken. To achieve surgical asepsis, objects must
be rendered or kept free of all pathogens.
b. Avoid having sexual intercourse
Inserting an I.V. cannula requires surgical
asepsis because it disrupts skin integrity and
involves entry into a sterile cavity (a vein). The c. Don’t get pregnant at least 3
other options are used to ensure medical asepsis months
or clean technique to prevent the spread of
infection. The GI tract isn't sterile; therefore, d. Avoid exposure to sun
irrigating a nasogastric tube or a colostomy
requires only clean technique. 2. Jonas who is diagnosed with
encephalitis is under the treatment of
94. B. Pouring solution onto a sterile field Mannitol. Which of the following patient
cloth outcomes indicate to Nurse Ronald that
Pouring solution onto a sterile field cloth violates the treatment of Mannitol has been
surgical asepsis because moisture penetrating effective for a patient that hasincreased
the cloth can carry microorganisms to the sterile intracranial pressure?
field via capillary action. The other options are
practices that help ensure surgical asepsis. a. Increased urinary output

95. C. Impaired gas exchange b. Decreased RR

The client has a below-normal value for the
partial pressure of arterial oxygen (PaO2) and an c. Slowed papillary response
above-normal value for the partial pressure of
arterial carbon dioxide (PaCO2), supporting the
d. Decreased level of consciousness
nursing diagnosis of Impaired gas exchange. ABG
values can't indicate a diagnosis of Fluid volume
deficit (or excess) or Risk for deficient fluid 3. Mary asked Nurse Maureen about
volume. Metabolic acidosis is a medical, not the incubation period of rabies. Which
nursing, diagnosis; in any event, these ABG statement by the Nurse Maureen is
values indicate respiratory, not metabolic, appropriate?
acidosis.
a. Incubation period is 6 months
96. A. Stream seeding
Stream seeding is done by putting tilapia fry in b. Incubation period is 1 week
streams or other bodies of water identified as
breeding places of the Anopheles mosquito. c. Incubation period is 1 month

97. B. Severe dehydration d. Incubation period varies

The order of priority in the management of depending on the site of the bite
severe dehydration is as follows: intravenous
fluid therapy, referral to a facility where IV fluids
4. Which of the following should Nurse
can be initiated within 30 minutes,
Cherry do first in taking care of a male
Oresol/nasogastric tube, Oresol/orem. When the
client with rabies?
foregoing measures are not possible or effective,
tehn urgent referral to the hospital is done.
a. Encourage the patient to take a
98. A. Inability to drink bath
A sick child aged 2 months to 5 years must be
referred urgently to a hospital if he/she has one b. Cover IV bottle with brown
or more of the following signs: not able to feed or paper bag
drink, vomits everything, convulsions, abnormally
sleepy or difficult to awaken. c. Place the patient near the
comfort room
99. A. Sugar

53
 d. Place the patient near the door d. 4 year old girl who lives next
door
5. Which of the following is the screening
test for dengue hemorrhagic fever? 10. What is the primary prevention of
leprosy?
a. Complete blood count
a. Nutrition
b. ELISA
b. Vitamins
c. Rumpel-leede test
c. BCG vaccination
d. Sedimentation rate
d. DPT vaccination
6. Mr. Dela Rosa is suspected to have
malaria after a business trip in 11. A bacteria which causes diphtheria is
Palawan. The most important diagnostic also known as?
test in malaria is:
a. Amoeba
a. WBC count
b. Cholera
b. Urinalysis
c. Klebs-loeffler bacillus
c. ELISA
d. Spirochete
d. Peripheral blood smear
12. Nurse Ron performed mantoux skin
7. The Nurse supervisor is planning for test today (Monday) to a male adult
patient’s assignment for the AM shift. The client. Which statement by the client
nurse supervisor avoids assigning which of indicates that he understood the
the following staff members to a client instruction well?
with herpes zoster?
a. I will come back later
a. Nurse who never had chicken
pox b. I will come back next month

b. Nurse who never had roseola c. I will come back on Friday

c. Nurse who never had german d. I will come back on Wednesday,

measles same time, to read the result

d. Nurse who never had mumps 13. A male client had undergone Mantoux
skin test. Nurse Ronald notes an 8mm
8. Clarissa is 7 weeks pregnant. Further area of indurations at the site of the skin
examination revealed that she is test. The nurse interprets the result as:
susceptible to rubella. When would be the
most appropriate for her to receive rubella a. Negative
immunization?
b. Uncertain and needs to be
a. At once repeated

b. During 2nd trimester c. Positive

c. During 3rd trimester d. Inconclusive

d. After the delivery of the baby 14. Tony will start a 6 month therapy with
Isoniazid (INH). Nurse Trish plans to teach
9. A female child with rubella should be the client to:
isolated from a:
a. Use alcohol moderately
a. 21 year old male cousin living in
the same house b. Avoid vitamin supplements while
o therapy
b. 18 year old sister who recently
got married c. Incomplete intake of dairy
products
c. 11 year old sister who had
rubeola during childhood

54
 d. May be discontinued if d. Burn
symptoms subsides
21. Which of the following is a live
15. Which is the primary characteristic attenuated bacterial vaccine?
lesion of syphilis?
a. BCG
a. Sore eyes
b. OPV
b. Sore throat
c. Measles
c. Chancroid
d. None of the above
d. Chancre
22. EPI is based on?
16. What is the fast breathing of Jana who
is 3 weeks old? a. Basic health services

a. 60 breaths per minute b. Scope of community affected

b. 40 breaths per minute c. Epidemiological situation

c. 10 breaths per minute d. Research studies

d. 20 breaths per minute 23. TT? provides how many percentage of

protection against tetanus?
17. Which of the following signs and
symptoms indicate some dehydration? a. 100

a. Drinks eagerly b. 99

b. Restless and irritable c. 80

c. Unconscious d. 90

d. A and B 24. Temperature of refrigerator to

maintain potency of measles and OPV
18. What is the first line for dysentery? vaccine is:

a. Amoxicillin a. -3c to -8c

b. Tetracycline b. -15c to -25c

c. Cefalexin c. +15c to +25c

d. Cotrimoxazole d. +3c to +8c

19. In home made oresol, what is the ratio 25. Diptheria is a:

of salt and sugar if you want to prepare
with 1 liter of water? a. Bacterial toxin

a. 1 tbsp. salt and 8 tbsp. sugar b. Killed bacteria

b. 1 tbsp. salt and 8 tsp. sugar c. Live attenuated

c. 1 tsp. salt and 8 tsp. sugar d. Plasma derivatives

d. 8 tsp. salt and 8 tsp. sugar 26. Budgeting is under in which part of
management process?
20. Gentian Violet is used for:
a. Directing
a. Wound
b. Controlling
b. Umbilical infections
c. Organizing
c. Ear infections
d. Planning

55
27. Time table showing planned work days d. Demographic
and shifts of nursing personnel is:
33. A researcher that makes a
a. Staffing generalization based on observations of
an individuals behavior is said to be which
b. Schedule type of reasoning:

c. Scheduling a. Inductive

d. Planning b. Logical

28. A force within an individual that c. Illogical

influences the strength of behavior?
d. Deductive
a. Motivation
34. The balance of a research’s benefit vs.
b. Envy its risks to the subject is:

c. Reward a. Analysis

d. Self-esteem b. Risk-benefit ratio

29. “To be the leading hospital in the c. Percentile

Philippines” is best illustrate in:
d. Maximum risk
a. Mission
35. An individual/object that belongs to a
b. Philosophy general population is a/an:

c. Vision a. Element

d. Objective b. Subject

30. It is the professionally desired norms c. Respondent

against which a staff performance will be
compared? d. Author

a. Job descriptions 36. An illustration that shows how the

members of an organization are
b. Survey connected:

c. Flow chart a. Flowchart

d. Standards b. Bar graph

31. Reprimanding a staff nurse for work c. Organizational chart

that is done incorrectly is an example of
what type of reinforcement? d. Line graph

a. Feedback 37. The first college of nursing that was

established in the Philippines is:
b. Positive reinforcement
a. Fatima University
c. Performance appraisal
b. Far Eastern University
d. Negative reinforcement
c. University of the East
32. Questions that are answerable only by
choosing an option from a set of given d. University of Sto. Tomas
alternatives are known as?
38. Florence nightingale is born on:
a. Survey
a. France
b. Close ended
b. Britain
c. Questionnaire

56
 c. U.S c. Kardex

d. Italy d. TPR sheet

39. Objective data is also called: 45. Jose has undergone thoracentesis. The
nurse in charge is aware that the best
a. Covert position for Jose is:

b. Overt a. Semi fowlers

c. Inference b. Low fowlers

d. Evaluation c. Side lying, unaffected side

40. An example of subjective data is: d. Side lying, affected side

a. Size of wounds 46. The degree of patients abdominal

distension may be determined by:
b. VS
a. Auscultation
c. Lethargy
b. Palpation
d. The statement of patient “My
hand is painful” c. Inspection

41. What is the best position in palpating d. Percussion

the breast?
47. A male client is addicted with
a. Trendelenburg hallucinogen. Which physiologic effect
should the nurse expect?
b. Side lying
a. Bradyprea
c. Supine
b. Bradycardia
d. Lithotomy
c. Constricted pupils
42. When is the best time in performing
breast self examination? d. Dilated pupils

a. 7 days after menstrual period 48. Tristan a 4 year old boy has suffered
from full thickness burns of the face, chest
b. 7 days before menstrual period and neck. What will be the priority nursing
diagnosis?
c. 5 days after menstrual period
a. Ineffective airway clearance
related to edema
d. 5 days before menstrual period

b. Impaired mobility related to pain

43. Which of the following should be given
the highest priority before performing
physical examination to a patient? c. Impaired urinary elimination
related to fluid loss
a. Preparation of the room
d. Risk for infection related to
epidermal disruption
b. Preparation of the patient

49. In assessing a client’s incision 1 day

c. Preparation of the nurse
after the surgery, Nurse Betty expect to
see which of the following as signs of a
d. Preparation of environment local inflammatory response?

44. It is a flip over card usually kept in a. Greenish discharge

portable file at nursing station.
b. Brown exudates at incision
a. Nursing care plan edges

b. Medicine and treatment record c. Pallor around sutures

57
 d. Redness and warmth a. Supine

50. Nurse Ronald is aware that the amiotic b. Left side lying
fluid in the third trimester weighs
approximately: c. Trendelinburg

a. 2 kilograms d. Semi-fowlers

b. 1 kilograms 56. Nurse Hazel knows that Myrna

understands her condition well when she
c. 100 grams remarks that urinary frequency is caused
by:
d. 1.5 kilograms
a. Pressure caused by the
51. After delivery of a baby girl. Nurse ascending uterus
Gina examines the umbilical cord and
expects to find a cord to: b. Water intake of 3L a day

a. Two arteries and two veins c. Effect of cold weather

b. One artery and one vein d. Increase intake of fruits and

vegetables
c. Two arteries and one vein
57. How many ml of blood is loss during
d. One artery and two veins the first 24 hours post delivery of Myrna?

52. Myrna a pregnant client reports that a. 100

her last menstrual cycle is July 11, her
expected date of birth is b. 500

a. November 4 c. 200

b. November 11 d. 400

c. April 4 58. Which of the following hormones

stimulates the secretion of milk?
d. April 18
a. Progesterone
53. Which of the following is not a good
source of iron? b. Prolactin

a. Butter c. Oxytocin

b. Pechay d. Estrogen

c. Grains 59. Nurse Carla is aware that Myla’s

second stage of labor is beginning when
d. Beef the following assessment is noted:

54. Maureen is admitted with a diagnosis a. Bay of water is broken

of ectopic pregnancy. Which of the
following would you anticipate? b. Contractions are regular

a. NPO c. Cervix is completely dilated

b. Bed rest d. Presence of bloody show

c. Immediate surgery 60. The leaking fluid is tested with

nitrazine paper. Nurse Kelly confirms that
d. Enema the client’s membrane have ruptures
when the paper turns into a:
55. Gina a postpartum client is diagnosed
with endometritis. Which position would a. Pink
you expect to place her based on this
diagnosis? b. Violet

58
 c. Green a. RA 8860

d. Blue b. RA 2777

61. After amniotomy, the priority nursing c. RI 8172

action is:
d. RR 6610
a. Document the color and
consistency of amniotic fluid 67. Nurse John is aware that the herbal
medicine appropriate for urolithiasis is:
b. Listen the fetal heart tone
a. Akapulco
c. Position the mother in her left
side b. Sambong

d. Let the mother rest c. Tsaang gubat

62. Which is the most frequent reason for d. Bayabas

postpartum hemorrhage?
68. Community/Public health bag is
a. Perineal lacerations defined as:

b. Frequent internal examination a. An essential and indispensable

(IE) equipment of the community
health nurse during home visit
c. CS
b. It contains drugs and equipment
d. Uterine atomy used by the community health
nurse
63. On 2nd postpartum day, which height
would you expect to find the fundus in a c. Is a requirement in the health
woman who has had a caesarian birth? center and for home visit

a. 1 finger above umbilicus d. It is a tool used by the

community health nurse in
b. 2 fingers above umbilicus rendering effective procedures
during home visit
c. 2 fingers below umbilicus
69. TT4 provides how many percentage of
d. 1 finger below umbilicus protection against tetanus?

64. Which of the following criteria allows a. 70

Nurse Kris to perform home deliveries?
b. 80
a. Normal findings during
assessment c. 90

b. Previous CS d. 99

c. Diabetes history 70. Third postpartum visit must be done

by public health nurse:
d. Hypertensive history
a. Within 24 hours after delivery
65. Nurse Carla is aware that one of the
following vaccines is done by b. After 2-4 weeks
intramuscular (IM) injection?
c. Within 1 week
a. Measles
d. After 2 months
b. OPV
71. Nurse Candy is aware that the family
c. BCG planning method that may give 98%
protection to another pregnancy to women
d. Tetanus toxoid
a. Pills
66. Asin law is on which legal basis:
b. Tubal ligation

59
 c. Lactational Amenorrhea method a. Narcan
(LAM)
b. Digoxin
d. IUD
c. Acetylcysteine
72. Which of the following is not a part of
IMCI case management process d. Flumazenil

a. Counsel the mother 78. A male child has an intelligence

quotient of approximately 40. Which kind
b. Identify the illness of environment and interdisciplinary
program most likely to benefit this child
c. Assess the child would be best described as:

d. Treat the child a. Habit training

73. If a young child has pneumonia when b. Sheltered workshop

should the mother bring him back for
follow up? c. Custodial

a. After 2 days d. Educational

b. In the afternoon 79. Nurse Judy is aware that following

condition would reflect presence of
c. After 4 days congenital G.I anomaly?

d. After 5 days a. Cord prolapse

74. It is the certification recognition b. Polyhydramios

program that develop and promotes
standard for health facilities: c. Placenta previa

a. Formula d. Oligohydramios

b. Tutok gamutan 80. Nurse Christine provides health

teaching for the parents of a child
c. Sentrong program movement diagnosed with celiac disease. Nurse
Christine teaches the parents to include
d. Sentrong sigla movement which of the following food items in the
child’s diet:
75. Baby Marie was born May 23,
1984. Nurse John will expect finger thumb a. Rye toast
opposition on:
b. Oatmeal
a. April 1985
c. White bread
b. February 1985
d. Rice
c. March 1985
81. Nurse Randy is planning to administer
d. June 1985 oral medication to a 3 year old
child. Nurse Randy is aware that the best
way to proceed is by:
76. Baby Reese is a 12 month old
child. Nurse Oliver would anticipate how
many teeth? a. “Would you like to drink your
medicine?”
a. 9
b. “If you take your medicine now,
I’ll give you lollipop”
b. 7

c. “See the other boy took his

c. 8
medicine? Now it’s your turn.”
d. 6
d. “Here’s your medicine. Would
you like a mango or orange juice?”
77. Which of the following is the primary
antidote for Tylenol poisoning?

60
82. At what age a child can brush her b. License Number
teeth without help?
c. Date of Application
a. 6 years
d. Signature of PRC chairperson
b. 7 years
88. Breastfeeding is being enforced by
c. 5 years milk code or:

d. 8 years a. EO 51

83. Ribivarin (Virazole) is prescribed for a b. R.A. 7600

female hospitalized child with RSV. Nurse
Judy prepare this medication via which c. R.A. 6700
route?
d. P.D. 996
a. Intra venous
89. Self governance, ability to choose or
b. Oral carry out decision without undue pressure
or coercion from anyone:
c. Oxygen tent
a. Veracity
d. Subcutaneous
b. Autonomy
84. The present chairman of the Board of
Nursing in the Philippines is: c. Fidelity

a. Maria Joanna Cervantes d. Beneficence

b. Carmencita Abaquin 90. A male patient complained because his

scheduled surgery was cancelled because
c. Leonor Rosero of earthquake. The hospital personnel
may be excused because of:
d. Primitiva Paquic
a. Governance
85. The obligation to maintain efficient
ethical standards in the practice of nursing b. Respondent superior
belong to this body:
c. Force majeure
a. BON
d. Res ipsa loquitor
b. ANSAP
91. Being on time, meeting deadlines and
c. PNA completing all scheduled duties is what
virtue?
d. RN
a. Fidelity
86. A male nurse was found guilty of
negligence. His license was revoked. Re- b. Autonomy
issuance of revoked certificates is after
how many years? c. Veracity

a. 1 year d. Confidentiality

b. 2 years 92. This quality is being demonstrated by

Nurse Ron who raises the side rails of a
c. 3 years confused and disoriented patient?

d. 4 years a. Responsibility

87. Which of the following information b. Resourcefulness

cannot be seen in the PRC identification
card? c. Autonomy

a. Registration Date d. Prudence

61
93. Which of the following is formal b. Change IV infusions
continuing education?
c. Transferring the client from bed
a. Conference to chair

b. Enrollment in graduate school d. Irrigation of NGT

c. Refresher course 99. During the evening round Nurse Tina

saw Mr. Toralba meditating and
d. Seminar afterwards started singing prayerful
hymns. What would be the best response
94. The BSN curriculum prepares the of Nurse Tina?
graduates to become?
a. Call the attention of the client
a. Nurse generalist and encourage to sleep

b. Nurse specialist b. Report the incidence to head

nurse
c. Primary health nurse
c. Respect the client’s action
d. Clinical instructor
d. Document the situation
95. Disposal of medical records in
government hospital/institutions must be 100. In caring for a dying client, you
done in close coordination with what should perform which of the
agency? following activities

a. Department of Health a. Do not resuscitate

b. Records Management Archives b. Assist client to perform ADL

Office
c. Encourage to exercise
c. Metro Manila Development
Authority d. Assist client towards a peaceful
death
d. Bureau of Internal Revenue
101. The Nurse is aware that the ability to
96. Nurse Jolina must see to it that the enter into the life of another person and
written consent of mentally ill patients perceive his current feelings and their
must be taken from: meaning is known:

a. Nurse a. Belongingness

b. Priest b. Genuineness

c. Family lawyer c. Empathy

d. Parents/legal guardians d. Respect

97. When Nurse Clarence respects the 102. The termination phase of the NPR is
client’s self-disclosure, this is a gauge for best described one of the following:
the nurses’
a. Review progress of therapy and
a. Respectfulness attainment of goals

b. Loyalty b. Exploring the client’s thoughts,

feelings and concerns
c. Trustworthiness
c. Identifying and solving patients
problem
d. Professionalism

d. Establishing rapport
98. The Nurse is aware that the following
tasks can be safely delegated by the nurse
to a non-nurse health worker except: 103. During the process of cocaine
withdrawal, the physician orders which of
the following:
a. Taking vital signs

62
 a. Haloperidol (Haldol) 109. Situation: A 19 year old nursing
student has lost 36 lbs for 4 weeks. Her
b. Imipramine (Tofranil) parents brought her to the hospital for
medical evaluation. The diagnosis was
c. Benztropine (Cogentin) ANOREXIA NERVOSA. The Primary gain of
a client with anorexia nervosa is:
d. Diazepam (Valium)
a. Weight loss
104. The nurse is aware that cocaine is
classified as: b. Weight gain

a. Hallucinogen c. Reduce anxiety

b. Psycho stimulant d. Attractive appearance

c. Anxiolytic 110. The nurse is aware that the primary

nursing diagnosis for the client is:
d. Narcotic
a. Altered nutrition : less than body
requirement
105. In community health nursing, it is
the most important risk factor in the
development of mental illness? b. Altered nutrition : more than
body requirement
a. Separation of parents
c. Impaired tissue integrity
b. Political problems
d. Risk for malnutrition
c. Poverty
111. After 14 days in the hospital, which
finding indicates that her condition in
d. Sexual abuse
improving?
106. All of the following are characteristics
a. She tells the nurse that she had
of crisis except
no idea that she is thin
a. The client may become resistive
b. She arrives earlier than
and active in stopping the crisis
scheduled time of group therapy
b. It is self-limiting for 4-6 weeks
c. She tells the nurse that she eat 3
times or more in a day
c. It is unique in every individual
d. She gained 4 lbs in two weeks
d. It may also affect the family of
the client
112. The nurse is aware that ataractics or
psychic energizers are also known as:
107. Freud states that temper tantrums is
observed in which of the following:
a. Anti manic
a. Oral
b. Anti depressants
b. Anal
c. Antipsychotics
c. Phallic
d. Anti anxiety
d. Latency
113. Known as mood elevators:
108. The nurse is aware that ego
a. Anti depressants
development begins during:

b. Antipsychotics
a. Toddler period

c. Anti manic
b. Preschool age

d. Anti anxiety
c. School age

114. The priority of care for a client with

d. Infancy
Alzheimer’s disease is

63
 a. Help client develop coping 120. The appropriate nutrition for Bipolar I
mechanism disorder, in manic phase is:

b. Encourage to learn new hobbies a. Low fat, low sodium

and interest
b. Low calorie, high fat
c. Provide him stimulating
environment c. Finger foods, high in calorie

d. Simplify the environment to d. Small frequent feedings

eliminate the need to make chores
121. Which of the following activity would
115. Autism is diagnosed at: be best for a depressed client?

a. Infancy a. Chess

b. 3 years old b. Basketball

c. 5 years old c. Swimming

d. School age d. Finger painting

116. The common characteristic of autism 122. The nurse is aware that clients with
child is: severe depression, possess which defense
mechanism:
a. Impulsitivity
a. Introjection
b. Self destructiveness
b. Suppression
c. Hostility
c. Repression
d. Withdrawal
d. Projection
117. The nurse is aware that the most
common indication in using ECT is: 123. Nurse John is aware that self
mutilation among Bipolar disorder patients
a. Schizophrenia is a means of:

b. Bipolar a. Overcoming fear of failure

c. Anorexia Nervosa b. Overcoming feeling of insecurity

d. Depression c. Relieving depression

118. A therapy that focuses on here and d. Relieving anxiety

now principle to promote self-acceptance?
124. Which of the following may cause an
a. Gestalt therapy increase in the cystitis symptoms?

b. Cognitive therapy a. Water

c. Behavior therapy b. Orange juice

d. Personality therapy c. Coffee

119. A client has many irrational d. Mango juice

thoughts. The goal of therapy is to change
her: 125. In caring for clients with renal calculi,
which is the priority nursing intervention?
a. Personality
a. Record vital signs
b. Communication
b. Strain urine
c. Behavior
c. Limit fluids
d. Cognition

64
 d. Administer analgesics as 131. During acute gout attack, the nurse
prescribed administer which of the following drug:

126. In patient with renal failure, the diet a. Prednisone (Deltasone)

should be:
b. Colchicines
a. Low protein, low sodium, low
potassium c. Aspirin

b. Low protein, high potassium d. Allopurinol (Zyloprim)

c. High carbohydrate, low protein 132. Information in the patients chart is

inadmissible in court as evidence when:
d. High calcium, high protein
a. The client objects to its use
127. Which of the following cannot be
corrected by dialysis? b. Handwriting is not legible

a. Hypernatremia c. It has too many unofficial

abbreviations
b. Hyperkalemia
d. The clients parents refuses to
c. Elevated creatinine use it

d. Decreased hemoglobin 133. Nurse Karen is revising a client plan

of care. During which step of the nursing
128. Tony with infection is receiving process does such revision take place?
antibiotic therapy. Later the client
complaints of ringing in the ears. This a. Planning
ototoxicity is damage to:
b. Implementation
a. 4th CN
c. Diagnosing
b. 8th CN
d. Evaluation
c. 7th CN
134. When examining a client with
d. 9th CN abdominal pain, Nurse Hazel should
assess:
129. Nurse Emma provides teaching to a
patient with recurrent urinary tract a. Symptomatic quadrant either
infection includes the following: second or first

a. Increase intake of tea, coffee b. The symptomatic quadrant last

and colas
c. The symptomatic quadrant first
b. Void every 6 hours per day
d. Any quadrant
c. Void immediately after
intercourse 135. How long will nurse John obtain an
accurate reading of temperature via oral
d. Take tub bath everyday route?

130. Which assessment finding indicates a. 3 minutes

circulatory constriction in a male client
with a newly applied long leg cast? b. 1 minute

a. Blanching or cyanosis of legs c. 8 minutes

b. Complaints of pressure or d. 15 minutes

tightness
136. The one filing the criminal care
c. Inability to move toes against an accused party is said to be the?

d. Numbness of toes a. Guilty

65
 b. Accused d. External ear

c. Plaintiff 142. When performing Weber’s test, Nurse

Rosean expects that this client will hear
d. Witness
a. On unaffected side
137. A male client has a standing DNR
order. He then suddenly stopped b. Longer through bone than air
breathing and you are at his bedside.You conduction
would:
c. On affected side by bone
a. Call the physician conduction

b. Stay with the client and do d. By neither bone or air

nothing conduction

c. Call another nurse 143. Toy with a tentative diagnosis of

myasthenia gravis is admitted for
d. Call the family diagnostic make up. Myasthenia gravis
can confirmed by:
138. The ANA recognized nursing
informatics heralding its establishment as a. Kernigs sign
a new field in nursing during what year?
b. Brudzinski’s sign
a. 1994
c. A positive sweat chloride test
b. 1992
d. A positive edrophonium
c. 2000 (Tensilon) test

d. 2001 144. A male client is hospitalized with

Guillain-Barre Syndrome. Which
139. When is the first certification of assessment finding is the most
nursing informatics given? significant?

a. 1990-1993 a. Even, unlabored respirations

b. 2001-2002 b. Soft, non distended abdomen

c. 1994-1996 c. Urine output of 50 ml/hr

d. 2005-2008 d. Warm skin

140. The nurse is assessing a female client 145. For a female client with suspected
with possible diagnosis of intracranial pressure (ICP), a most
osteoarthritis. The most significant risk appropriate respiratory goal is:
factor for osteoarthritis is:
a. Maintain partial pressure of
a. Obesity arterial oxygen (Pa O2) above
80mmHg
b. Race
b. Promote elimination of carbon
dioxide
c. Job

c. Lower the PH
d. Age

d. Prevent respiratory alkalosis

141. A male client complains of
vertigo. Nurse Bea anticipates that the
client may have a problem with which 146. Which nursing assessment would
portion of the ear? identify the earliest sign of ICP?

a. Tymphanic membranes a. Change in level of consciousness

b. Inner ear b. Temperature of over 103°F

c. Auricle c. Widening pulse pressure

66
 d. Unequal pupils

147. The greatest danger of an

uncorrected atrial fibrillation for a male
patient will be which of the following:

a. Pulmonary embolism

b. Cardiac arrest

c. Thrombus formation

d. Myocardial infarction

148. Linda, A 30 year old post

hysterectomy client has visited the health
center. She inquired about BSE and asked
the nurse when BSE should be
performed. You answered that the BSE is
best performed:

a. 7 days after menstruation

b. At the same day each month

c. During menstruation

d. Before menstruation

149. An infant is ordered to recive 500 ml

of D5NSS for 24 hours. The Intravenous
Board Exam Nursing Test I NLE
drip is running at 60 gtts/min. How many
Scope of this Nursing Test I is parallel to the
drops per minute should the flow rate be?
NP1 NLE Coverage:

a. 60 gtts/min.
• Foundation of Nursing
• Nursing Research
b. 21 gtts/min • Professional Adjustment
• Leadership and Management
c. 30 gtts/min
1. The registered nurse is planning to delegate
d. 15 gtts/min tasks to unlicensed assistive personnel (UAP).
Which of the following task could the registered
150. Mr. Gutierrez is to receive 1 liter of nurse safely assigned to a UAP?
D5RL to run for 12 hours. The drop factor
of the IV infusion set is 10 drops per A) Monitor the I&O of a comatose toddler client
minute. Approximately how many drops with salicylate poisoning
per minutes should the IV be regulated? B) Perform a complete bed bath on a 2-year-old
with multiple injuries from a serious fall
a. 13-14 drops C) Check the IV of a preschooler with Kawasaki
disease
b. 17-18 drops D) Give an outmeal bath to an infant with
eczema
c. 10-12 drops
2. A nurse manager assigned a registered nurse
d. 15-16 drops from telemetry unit to the pediatrics unit. There
were three patients assigned to the RN. Which of
the following patients should not be assigned to
the floated nurse?

A) A 9-year-old child diagnosed with rheumatic

fever
B) A young infant after pyloromyotomy
C) A 4-year-old with VSD following cardiac
catheterization
D) A 5-month-old with Kawasaki disease

67
3. A nurse in charge in the pediatric unit is B) Inform the nursing supervisor and the charge
absent. The nurse manager decided to assign the nurse on the pediatric floor about the nurse’s lack
nurse in the obstetrics unit to the pediatrics unit. of skill and feelings of hesitations and request
Which of the following patients could the nurse assistance
manager safely assign to the float nurse? C) Ask several other nurses how they feel about
pediatrics and find someone else who is willing to
A) A child who had multiple injuries from a accept the assignment
serious vehicle accident D) Refuse the assignment and leave the unit
B) A child diagnosed with Kawasaki disease and requesting a vacation a day
with cardiac complications
C) A child who has had a nephrectomy for Wilm’s
tumor 8. An experienced nurse who voluntarily trained a
D) A child receiving an IV chelating therapy for less experienced nurse with the intention of
lead poisoning enhancing the skills and knowledge and
promoting professional advancement to the nurse
is called a:
4. The registered nurse is planning to delegate
task to a certified nursing assistant. Which of the A) mentor
following clients should not be assigned to a B) team leader
CAN? C) case manager
D) change agent
A) A client diagnosed with diabetes and who has
an infected toe
B) A client who had a CVA in the past two 9. The pediatrics unit is understaffed and the
months nurse manager informs the nurses in the
C) A client with Chronic renal failure obstetrics unit that she is going to assign one
D) A client with chronic venous insufficiency nurse to float in the pediatric units. Which
statement by the designated float nurse may put
her job at risk?
5. The nurse in the medication unit passes the
medications for all the clients on the nursing unit. A) “I do not get along with one of the nurses on
The head nurse is making rounds with the the pediatrics unit”
physician and coordinates clients’ activities with B) “I have a vacation day coming and would like
other departments. The nurse assistant changes to take that now”
the bed lines and answers call lights. A second C) “I do not feel competent to go and work on
nurse is assigned for changing wound dressings; that area”
a licensed practitioner nurse takes vital signs and D) “ I am afraid I will get the most serious clients
bathes theclients. This illustrates of what method in the unit”
of nursing care?

A) Case management method 10. The newly hired staff nurse has been working
B) Primary nursing method on a medical unit for 3 weeks. The nurse
C) Team method manager has posted the team leader
D) Functional method assignments for the following week. The new
staff knows that a major responsibility of the
team leader is to:
6. A registered nurse has been assigned to six
clients on the 12-hour shift. The RN is A) Provide care to the most acutely ill client on
responsible for every aspect of care such as the team
formulating the care of plan, intervention and B) Know the condition and needs of all the
evaluating the care during her shift. At the end of patients on the team
her shift, the RN will pass this same task to the C) Document the assessments completed by the
next RN in charge. This nursing care illustrates of team members
what kind of method? D) Supervise direct care by nursing assistants

A) primary nursing method

B) case method 11. A 15-year-old girl just gave birth to a baby
C) team method boy who needs emergency surgery. The nurse
D) functional method prepared the consent form and it should be
signed by:

7. A newly hired nurse on an adult medicine unit A) The Physician

with 3 months experience was asked to float to B) The Registered Nurse caring for the client
pediatrics. The nurse hesitates to perform C) The 15-year-old mother of the baby boy
pediatric skills and receive an interesting D) The mother of the girl
assignment that feels overwhelming. The nurse
should:
12. A nurse caring to a client with Alzheimer’s
A) resign on the spot from the nursing position disease overheard a family member say to the
and apply for a position that does not require client, “if you pee one more time, I won’t give
floating

68
you any more food and drinks”. What initial the physician even if the client does not
action is best for the nurse to take? understand what the outcome will be.

A) Take no action because it is the family

member saying that to the client 16. A hospitalized client with severe necrotizing
B) Talk to the family member and explain that ulcer of the lower leg is schedule for an
what she/he has said is not appropriate for the amputation. The client tells the nurse that he will
client not sign the consent form and he does not want
C) Give the family member the number for an any surgery or treatment because of religious
Elder Abuse Hot line beliefs about reincarnation. What is the role of
D) Document what the family member has said the RN?

A) call a family meeting

13. Which is true about informed consent? B) discuss the religious beliefs with the physician
C) encourage the client to have the surgery
A) A nurse may accept responsibility signing a D) inform the client of other options
consent form if the client is unable
B) Obtaining consent is not the responsibility of
the physician 17. While in the hospital lobby, the RN overhears
C) A physician will not subject himself to liability the three staff discussing the health condition of
if he withholds any facts that are necessary to her client. What would be the appropriate nursing
form the basis of an intelligent consent action for the RN to take?
D) If the nurse witnesses a consent for surgery,
the nurse is, in effect, indicating that the A) Tell them it is not appropriate to discuss the
signature is that of the purported person and that condition of the client
the person’s condition is as indicated at the time B) Ignore them, because it is their right to
of signing discuss anything they want to
C) Join in the conversation, giving them
supportive input about the case of the client
14. A mother in labor told the nurse that she was D) Report this incident to the nursing supervisor
expecting that her baby has no chance to survive
and expects that the baby will be born dead. The
mother accepts the fate of the baby and informs 18. A staff nurse has had a serious issue with her
the nurse that when the baby is born and colleague. In this situation, it is best to:
requires resuscitation, the mother refuses any
treatment to her baby and expresses hostility A) Discuss this with the supervisor
toward the nurse while the pediatric team is B) Not discuss the issue with anyone. It will
taking care of the baby. The nurse is legally probably resolve itself
obligated to: C) Try to discuss with the colleague about the
issue and resolve it when both are calmer
A) Notify the pediatric team that the mother has D) Tell other members of the network what the
refused resuscitation and any treatment for the team member did
baby and take the baby to the mother
B) Get a court order making the baby a ward of
the court 19. The nurse is caring to a client who just gave
C) Record the statement of the mother, notify birth to a healthy baby boy. The nurse may not
the pediatric team, and observe carefully for disclose confidential information when:
signs of impaired bonding and neglect as a
reasonable suspicion of child abuse A) The nurse discusses the condition of the client
D) Do nothing except record the mother’s in a clinical conference with other nurses
statement in the medical record B) The client asks the nurse to discuss the her
condition with the family
C) The father of a woman who just delivered a
15. The hospitalized client with a chronic cough is baby is on the phone to find out the sex of the
scheduled for bronchoscopy. The nurse is tasks baby
to bring the informed consent document into the D) A researcher from an institutionally approved
client’s room for a signature. The client asks the research study reviews the medical record of a
nurse for details of the procedure and demands patient
an explanation why the process of informed
consent is necessary. The nurse responds that
informed consent means: 20. A 17-year-old married client is scheduled for
surgery. The nurse taking care of the client
A) The patient releases the physician from all realizes that consent has not been signed after
responsibility for the procedure. preoperative medications were given. What
B) The immediate family may make decision should the nurse do?
against the patient’s will.
C) The physician must give the client or A) Call the surgeon
surrogates enough information to make health B) Ask the spouse to sign the consent
care judgments consistent with their values and C) Obtain a consent from the client as soon as
goals. possible
D) The patient agrees to a procedure ordered by

69
D) Get a verbal consent from the parents of the A) warm, flushed skin
client B) hunger and thirst
C) increase urinary output
D) palpitation and weakness
21. A 12-year-old client is admitted to the
hospital. The physician ordered Dilantin to the
client. In administering IV phenytoin (Dilantin) to 27. A client admitted to the hospital and
a child, the nurse would be most correct in diagnosed with Addison’s disease. What would be
mixing it with: the appropriate nursing action to the client?

A) Normal Saline A) administering insulin-replacement therapy

B) Heparinized normal saline B) providing a low-sodium diet
C) 5% dextrose in water C) restricting fluids to 1500 ml/day
D) Lactated Ringer’s solution D) reducing physical and emotional stress

22. The nurse is caring to a client who is 28. The nurse is to perform tracheal suctioning.
hypotensive. Following a large hematemesis, how During tracheal suctioning, which nursing action
should the nurse position the client? is essential to prevent hypoxemia?

A) Feet and legs elevated 20 degrees, trunk A) aucultating the lungs to determine the
horizontal, head on small pillow baseline data to assess the effectiveness of
B) Low Fowler’s with knees gatched at 30 suctioning
degrees B) removing oral and nasal secretions
C) Supine with the head turned to the left C) encouraging the patient to deep breathe and
D) Bed sloped at a 45 degree angle with the head cough to facilitate removal of upper-airway
lowest and the legs highest secretions
D) administering 100% oxygen to reduce the
effects of airway obstruction during suctioning.
23. The client is brought to the emergency
department after a serious accident. What would
be the initial nursing action of the nurse to the 29. An infant is admitted and diagnosed with
client? pneumonia and suspicious-looking red marks on
the swollen face resembling a handprint. The
A) assess the level of consciousness and nurse does further assessment to the client. How
circulation would the nurse document the finding?
B) check respirations, circulation, neurological
response A) Facial edema with ecchymosis and handprint
C) align the spine, check pupils, check for mark: crackles and wheezes
hemorrhage B) Facial edema, with red marks; crackles in the
D) check respiration, stabilize spine, check lung
circulation C) Facial edema with ecchymosis that looks like a
handprint
D) Red bruise mark and ecchymosis on face
24. A nurse is assigned to care to a client with
Parkinson’s disease. What interventions are
important if the nurse wants to improve nutrition 30. On the evening shift, the triage nurse
and promote effective swallowing of the client? evaluates several clients who were brought to the
emergency department. Which in the following
A) Eat solid food clients should receive highest priority?
B) Give liquids with meals
C) Feed the client A) an elderly woman complaining of a loss of
D) Sit in an upright position to eat appetite and fatigue for the past week
B) A football player limping and complaining of
pain and swelling in the right ankle
25. During tracheal suctioning, the nurse should C) A 50-year-old man, diaphoretic and
implement safety measures. Which of the complaining of severe chest pain radiating to his
following should the nurse implements? jaw
D) A mother with a 5-year-old boy who says her
A) limit suction pressure to 150-180 mmHg son has been complaining of nausea and vomited
B) suction for 15-20 seconds once since noon
C) wear eye goggles
D) remove the inner cannula
31. A 80-year-old female client is brought to the
emergency department by her caregiver, on the
26. The nurse is conducting a discharge nurse’s assessment; the following are the
instructions to a client diagnosed with diabetes. manifestations of the client: anorexia, cachexia
What sign of hypoglycemia should be taught to a and multiple bruises. What would be the best
client? nursing intervention?

70
A) check the laboratory data for serum albumin, hospital for 2 weeks. When a client’s family
hematocrit, and hemoglobin members come to visit, they would be adhering
B) talk to the client about the caregiver and to respiratory isolation precautions when they:
support system
C) complete a police report on elder abuse A) wash their hands when leaving
D) complete a gastrointestinal and neurological B) put on gowns, gloves and masks
assessment C) avoid contact with the client’s roommate
D) keep the client’s room door open

32. The night shift nurse is making rounds. When

the nurse enters a client’s room, the client is on 38. An infant is brought to the emergency
the floor next to the bed. What would be the department and diagnosed with pyloric stenosis.
initial action of the nurse? The parents of the client ask the nurse, “Why
does my baby continue to vomit?” Which of the
A) chart that the patient fell following would be the best nursing response of
B) call the physician the nurse?
C) chart that the client was found on the floor
next to the bed A) “Your baby eats too rapidly and overfills the
D) fill out an incident report stomach, which causes vomiting
B) “Your baby can’t empty the formula that is in
the stomach into the bowel”
33. The nurse on the night shift is about to C) “The vomiting is due to the nausea that
administer medication to a preschooler client and accompanies pyloric stenosis”
notes that the child has no ID bracelet. The best D) “Your baby needs to be burped more
way for the nurse to identify the client is to ask: thoroughly after feeding”

A) The adult visiting, “The child’s name is

____________________?” 39. A 70-year-old client with suspected
B) The child, “Is your name____________?” tuberculosis is brought to the geriatric care
C) Another staff nurse to identify this child facilities. An intradermal tuberculosis test is
D) The other children in the room what the child’s schedule to be done. The client asks the nurse
name is what is the purpose of the test. Which of the
following would be the best rationale for this?

34. The nurse caring to a client has completed A) reactivation of an old tuberculosis infection
the assessment. Which of the following will be B) increased incidence of new cases of
considered to be the most accurate charting of a tuberculosis in persons over 65 years old
lump felt in the right breast? C) greater exposure to diverse health care
workers
A) “abnormally felt area in the right breast, D) respiratory problems are characteristic in this
drainage noted” population
B) “hard nodular mass in right breast nipple”
C) “firm mass at five ‘ clock, outer quadrant, 1cm
from right nipple’ 40. The nurse is making a health teaching to the
D) “mass in the right breast 4cmx1cm parents of the client. In teaching parents how to
measure the area of induration in response to a
PPD test, the nurse would be most accurate in
35. The physician instructed the nurse that advising the parents to measure:
intravenous pyelogram will be done to the client.
The client asks the nurse what is the purpose of A) both the areas that look red and feel raised
the procedure. The appropriate nursing response B) The entire area that feels itchy to the child
is to: C) Only the area that looks reddened
D) Only the area that feels raised
A) outline the kidney vasculature
B) determine the size, shape, and placement of
the kidneys 41. A community health nurse is schedule to do
C) test renal tubular function and the patency of home visit. She visits to an elderly person living
the urinary tract alone. Which of the following observation would
D) measure renal blood flow be a concern?

A) Picture windows
36. A client visits the clinic for screening of B) Unwashed dishes in the sink
scoliosis. The nurse should ask the client to: C) Clear and shiny floors
D) Brightly lit rooms
A) bend all the way over and touch the toes
B) stand up as straight and tall as possible
C) bend over at a 90-degree angle from the waist 42. After a birth, the physician cut the cord of the
D) bend over at a 45-degree angle from the waist baby, and before the baby is given to the
mother, what would be the initial nursing action
of the nurse?
37. A client with tuberculosis is admitted in the

71
A) examine the infant for any observable
abnormalities
B) confirm identification of the infant and apply 48. The nurse is assigned to care the client with
bracelet to mother and infant infectious disease. The best antimicrobial agent
C) instill prophylactic medication in the infant’s for the nurse to use in handwashing is:
eyes
D) wrap the infant in a prewarmed blanket and A) Isopropyl alcohol
cover the head B) Hexachlorophene (Phisohex)
C) Soap and water
D) Chlorhexidine gluconate (CHG) (Hibiclens)
43. A 2-year-old client is admitted to the hospital
with severe eczema lesions on the scalp, face,
neck and arms. The client is scratching the 49. The mother of the client tells the nurse, “ I’m
affected areas. What would be the best nursing not going to have my baby get any
intervention to prevent the client from scratching immunization”. What would be the best nursing
the affected areas? response to the mother?

A) elbow restraints to the arms A) “You and I need to review your rationale for
B) Mittens to the hands this decision”
C) Clove-hitch restraints to the hands B) “Your baby will not be able to attend day care
D) A posey jacket to the torso without immunizations”
C) “Your decision can be viewed as a form of
child abuse and neglect”
44. The parents of the hospitalized client ask the D) “You are needlessly placing other people at
nurse how their baby might have gotten pyloric risk for communicable diseases”
stenosis. The appropriate nursing response would
be:
50. The nurse is teaching the client about breast
A) There is no way to determine this self-examination. Which observation should the
preoperatively client be taught to recognize when doing the
B) Their baby was born with this condition examination for detection of breast cancer?
C) Their baby developed this condition during the
first few weeks of life A) tender, movable lump
D) Their baby acquired it due to a formula allergy B) pain on breast self-examination
C) round, well-defined lump
D) dimpling of the breast tissue
45. A male client comes to the clinic for check-
up. In doing a physical assessment, the nurse Answer and Rationale: Board Exam Nursing Test
should report to the physician the most common I NLE
symptom of gonorrhea, which is:

A) pruritus 1. D. Bathing an infant with eczema can be

B) pus in the urine safely delegated to an aide; this task is basic and
C) WBC in the urine can competently performed by an aid.
D) Dysuria
2. B. The RN floated from the telemetry unit
would be least prepared to care for a young
46. Which of the following would be the most infant who has just had GI surgery and requires a
important goal in the nursing care of an infant specific feeding regimen.
client with eczema?
3. C. RN floated from the obstetrics unit should
A) preventing infection be able to care for a client with major abdominal
B) maintaining the comfort level surgery, because this nurse has experienced
C) providing for adequate nutrition caring for clients with cesarean births.
D) decreasing the itching
4. A. The patient is experiencing a potentially
serious complication related to diabetes and
47. The nurse is making a discharge instruction needs ongoing assessment by an RN
to a client receiving chemotherapy. The client is
at risk for bone marrow depression. The nurse 5. D. It describes functional nursing. Staff is
gives instructions to the client about how to assigned to specific task rather than specific
prevent infection at home. Which of the following clients.
health teaching would be included?
6. B. Case management. The nurse assumes
A) “Get a weekly WBC count” total responsibility for meeting the needs of the
B) “Do not share a bathroom with children or client during her entire duty.
pregnant woman”
C) “Avoid contact with others while receiving 7. B. The nurse is ethically obligated to inform
chemotherapy” the person responsible for the assignment and
D) “Do frequent hand washing and maintain good the person responsible for the unit about the
hygiene” nurse’s skill level. The nurse therefore avoids a

72
situation of abandoningclients and exposing them high risk for aspiration and undernutrition. Sitting
to greater risks upright promotes more effective swallowing.

8. A. This describes a mentor 25. C. It is important to protect the RN’s eyes

from the possible contamination of coughed-up
9. B. This action demonstrates a lack of secretions
responsibility and the nurse should attempt
negotiation with the nurse manager. 26. D. There has been too little food or too much
insulin. Glucose levels can be markedly
10. B. The team leader is responsible for the decreased (less than 50 mg/dl). Severe
overall management of all clients and staff on the hypoglycemia may be fatal if not detected
team, and this information is essential in order to
accomplish this 27. D. Because the client’s ability to react to
stress is decreased, maintaining a quiet
11. C. Even though the mother is a minor, she is environment becomes a nursing priority.
legally able to sign consent for her own child. Dehydration is a common problem in Addison’s
disease, so close observation of the client’s
12. B. This response is the most direct and hydration level is crucial.
immediate. This is a case of potential need for
advocacy and patient’s rights. 28. D. Presuctioning and postsuctioning
ventilation with 100% oxygen is important in
13. D. The nurse who witness a consent for reducing hypoxemia which occurs when the flow
treatment or surgery is witnessing only that the of gases in the airway is obstructed by the
client signed the form and that the client’s suctioning catheter.
condition is as indicated at the time of signing.
The nurse is not witnessing that the client is 29. B. This is an example of objective data of
“informed”. both pulmonary status and direct observation on
the skin by the nurse.
14. C. Although the statements by the mother
may not create a suspicion of neglect, when they 30. C. These are likely signs of an acute
are coupled with observations about impaired myocardial infarction (MI). An acute MI is a
bonding and maternal attachment, they may cardiovascular emergency requiring immediate
impose the obligation to report child neglect. The attention. Acute MI is potentially fatal if not
nurse is further obligated to notify caregivers of treated immediately.
refusal to consent to treatment
31. D. Assessment and more data collection are
15. C. It best explains what informed consent is needed. The client may have gastrointestinal or
and provides for legal rights of the patient neurological problems that account for the
symptoms. The anorexia could result from
16. B. The physician may not be aware of the medications, poor dentition, or indigestion, and
role that religious beliefs play in making a the bruises may be attributed to ataxia, frequent
decision about surgery. falls, vertigo or medication.

17. A. The behavior should be stopped. The first 32. B. This is closest to suggesting action-
step is to remind the staff that confidentiality assessment, rather than paperwork- and is
may be violated therefore the best of the four.

18. C. Waiting for emotions to dissipate and 33. C. The only acceptable way to identify a
sitting down with the colleague is the first rule of preschooler client is to have a parent or another
conflict resolution. staff member identify the client.

19. C. The nurse has no idea who the person is 34. C. It describes the mass in the greatest
on the phone and therefore may not share the detail.
information even if the patient gives permission
35. C. Intravenous pyelogram tests both the
20. A. The priority is to let the surgeon know, function and patency of the kidneys. After the
who in turn may ask the husband to sign the intravenous injection of a radiopaque contrast
consent. medium, the size, location, and patency of the
kidneys can be observed by roentgenogram, as
21. A. Phenytoin (Dilantin) can cause venous well as the patency of the urethra and bladder as
irritation due to its alkalinity, therefore it should the kidneys function to excrete the contrast
be mixed with normal saline. medium.

22. A. This position increases venous return, 36. C. This is the recommended position for
improves cardiac volume, and promotes screening for scoliosis. It allows the nurse to
adequate ventilation and cerebral perfusion inspect the alignment of the spine, as well as to
compare both shoulders and both hips.
23. D. Checking the airway would be a priority,
and a neck injury should be suspected 37. A. Handwashing is the best method for
reducing cross-contamination. Gowns and gloves
24. D. Client with Parkinson’s disease are at a are not always required when entering a client’s

73
room.

38. B. Pyloric stenosis is an anomaly of the upper

gastrointestinal tract. The condition involves a
thickening, or hypertrophy, of the pyloric
sphincter located at the distal end of the
stomach. This causes a mechanical intestinal
obstruction, which leads to vomiting after feeding
the infant. The vomiting associated with pyloric
stenosis is described as being projectile in
nature. This is due to the increasing amounts of
formula the infant begins to consume coupled
with the increasing thickening of the pyloric
sphincter.

39. B. Increased incidence of TB has been seen

in the general population with a high incidence
reported in hospitalized elderly clients.
Immunosuppression and lack of classic
manifestations because of the aging process are
just two of the contributing factors of tuberculosis
in the elderly.

40. D. Parents should be taught to feel the area

that is raised and measure only that.

41. C. It is a safety hazard to have shiny floors

because they can cause falls.

42. D. The first priority, beside maintaining a

newborn’s patent airway, is body temperature.

43. B. The purpose of restraints for this child is

to keep the child from scratching the affected
areas. Mittens restraint would prevent scratching,
while allowing the most movement permissible.

44. C. Pyloric stenosis is not a congenital

anatomical defect, but the precise etiology is
unknown. It develops during the first few weeks
of life.

45. B. Pus is usually the first symptom, because

the bacteria reproduce in the bladder.

46. A. Preventing infection in the infant with

eczema is the nurse’s most important goal. The
infant with eczema is at high risk for infection
due to numerous breaks in the skin’s integrity.
Intact skin is always the infant’s first line of
defense against infection.

47. D. Frequent hand washing and good hygiene

are the best means of preventing infection.

48. D. CHG is a highly effective antimicrobial

ingredient, especially when it is used consistently
over time.

49. A. The mother may have many reasons for

such a decision. It is the nurse’s responsibility to
review this decision with the mother and clarify
any misconceptions regarding immunizations that
may exist.

50. D. The tumor infiltrates nearby tissue, it can

cause retraction of the overlying skin and create
a dimpling appearance.

74