CA Practice Question
CA Practice Question
1. In report from a transferring facility you receive 10. A client with ureterolithiasis is suffering from
information that your patient's Magnesium level severe pain upon admission. Pain medications
is 1.2. When the patient arrives you are ordered were given with relief, the next best thing for
by the doctor to administer Magnesium Sulfate the nurse to do is
via IV. Which of the following interventions • Monitor kidney function
takes priority? • Strain all urine
• None of the above are correct • Monitor urine output hourly
• Monitor the patient's for reduced deep • Check the result of the CT scan
tendon reflexes and initiate seizure 11. Cyclosporine was given to a client after renal
precautions transplant, the nurse is aware that this
• . Set-up bedside suction medication is given to
• Set-up IV Atropine at bedside due to the • Slow down progression of the disease
bradycardia effects of Magnesium Sulfate • Prevent infection
2. Which patient is at most risk for • Stop the progression of the disease
hypomagnesemia? • Prevent rejection
• A 55 year old chronic alcoholic 12. Which of the following is a pre -renal cause of
• A 25 year old suffering from Acute kidney injury?
hypoglycemia • Renal stones
• A 57 year old with hyperthyroidism • Nephritis
• A patient reporting overuse of antacids • all of the above
and laxatives • Hypertension
3. You are taking a patient's blood pressure 13. Health teaching for a kidney donor prior to
manually. As you pump up the cuff above the discharge should include all of the following,
systolic pressure for a few minutes you notice except
that the patient develop a carpal spasm. • Monitor urine output hourly
Which of the following is true? • Monitor BUN and Creatinine every 6
• This is known as Trousseau's Sign and is months
present in patients with hypercalcemia • Regular follow up
• This is known as Trousseau's Sign and is • no exception
present in patients with hypocalcemia 14. Irritative symptoms like dysuria, frequency,
• This is known as Chvostek's Sign hesitancy are manifested in
• The patient is having a normal nervous • BPH
response to an inflating blood pressure cuff • CYstitis
that is inflated above the systolic pressure • All of the above
4. Which patient below would have a potassium • Cystolithiasis
level of 5.5? 15. A client with cute pyelonephritis is in the
• A 76 year old who reports taking Lasix four emergency room for possible admission, the
times a day nurse anticipate in the history the presence of
• A 55 year old woman who have been • recent sexual intercourse
vomiting for 3 days consistently • cystitis a week ago
• A patient with liver failure • all of the above
• A patient with Addison's disease • urinary retention
5. Which of the following acid-base imbalance is 16. In spirometry, the volume that keeps the alveoli
expected in a client who was having severe open is
panic attack? • Inspiratory reserve volume
• pH 7.45 pCO2 34 HCO3 27 • Tidal volume
• pH 7.49 pCO2 46 HCO3 28 • Residual volume
• pH 7.48 pCO2 30 HCO3 21 • dead space volume
• pH 7.30 pCO2 46 HCO3 19 17. A client with Acute asthma attack is being
6. A client with prolonged gastric suction is assessed by the nurse, the peak flow meter is at
susceptible to develop the red zone in 1 second blow. The nurse knows
• Respiratory acidosis that the attack is
• Metabolic alkalosis • Moderate
• Metabolic acidosis • Severe
• Respiratory alkalosis • Status asthmaticus
7. Metabolic acidosis with hign anion gap is • Mild
possible caused by 18. A client with COPD develops Pulmonary heart
• Severe diarrhea disease, which of the following clinical
• Diabetic ketoacidosis manifestations are expected
• overdose of diuretics • distended right ventricle
• COPD • pulmonary hypertension
8. Hyponatremic Hypervolemia can be best • Polycythemia
managed by • Pneumonia
• Monitor I and O • Pneumothorax
• Monitor VS 19. Which of the following is not a manifestation of
• Restrict Fluid right pleural effusion
• Restrict sodium • None of the above
9. A client with CKD Stage 3has a GFR level of • Unequal tactile and vocal fremitus
• 15 – 29 ml/min • hyperresonant to tympanitic on
• Less tan15ml/min percussion
• 60 – 89 ml/min
• Diminished or absent breath sounds on sheet by the doctor, it is most important for the
the right lung nurse to
20. The nurse is caring for a client with a 3 way • Administer O2
bottle system and notices that there is • Calm the patient
continuous bubbling on • Position the client semi fowler’s
the 3rd bottle, the nurse would • Administer morphine
• Assess for leaks 29. A 55 year old male client, diabetic and
• Assess for obstruction hypertensive is admitted to the emergency
• Record then refer room with crushing substernal pain radiating to
• Continue monitoring the left arm left jaw and left neck lasting for
21. A client with COPD is about to be discharge more than 30 minutes. Admitting diagnosis is
from the hospital after an acute exacerbation, Myocardial infarction. The patient is very
outcome criteria for the client wound indicate anxious. The emergency room nurse expects
• States actions to reduce risk of respiratory the following assessment except
infections • Elevated troponin and CKMB isoenzyme
• Maintains low flow oxygen at home • ST elevation on ECG
• Promises to do pursed lip breathing at • Tachycardia
home • Hypertension
• Agrees to call physician in dyspnea 30. A 55 year old male client, diabetic and
occurs hypertensive is admitted to the emergency
22. Oxygen toxicity results from oxygen room with crushing substernal pain radiating to
concentrations above the left arm left jaw and left neck lasting for
• 60% more than 30 minutes. Admitting diagnosis is
• 20% Myocardial infarction. The patient is very
• 30% anxious. After stabilizing the client at the
• 40% emergency room, he is transferred at the
23. Which of the following is the priority nursing coronary care unit (CCU). At this time, priority
diagnosis in a client with tension nursing diagnosis is
pneumothorax? • Risk for infection
• Acute pain • Risk for Dysrrhythmias
• Decreased cardiac output • Risk for infection
• Risk for respiratory failure • Potential for shock
• Impaired gas exchange 31. : A 55 year old male client, diabetic and
24. The client shows ventricular fibrillation on hypertensive is admitted to the emergency
cardiac monitor at the nurse’s station. Which room with crushing substernal pain radiating to
action should the nurse implement first? the left arm left jaw and left neck lasting for
• Assess for carotid pulses. more than 30 minutes. Admitting diagnosis is
• Start cardiopulmonary resuscitation. Myocardial infarction. The patient is very
• Administer epinephrine IV. anxious. The client develops Congestive Heart
• Call a STAT code. failure, the doctor orders for Furosemide and
25. The client is in complete heart block. Which Digoxin, at this point it is very necessary for the
intervention should the nurse implement first? nurse to monitor for which of the following?
• Obtain a STAT electrocardiogram (ECG). Priority nursing diagnosis for this patient is
• Prepare to insert a pacemaker. • Ineffective myocardial tissue perfusion
• Administer atropine, an antidysrhythmic • Anxiety related to fear of impending
as ordered. death
• Monitor vital signs • Potential for cardiogenic shock
26. The nurse knows that the hallmark symptom of • Acute pain
peripheral arterial occlusion disease is 32. When the nurse was given the order sheet by
• Phlebothrombosis the doctor, it is most important for the nurse to
• Intermittent claudication • Position the client semi fowler’s
• hairless skin • Administer morphine
• Edema • Calm the patient
27. SITUATION: A 55 year old male client, diabetic • Administer O2
and hypertensive is admitted to the 33. The emergency room nurse expects the
emergency room with crushing substernal pain following assessment except
radiating to the left arm left jaw and left neck • Hypertension
lasting for more than 30 minutes. Admitting • ST segment elevation on ECG
diagnosis is Myocardial infarction. The patient is • Elevated troponin and CKMB isoenzyme
very anxious. Priority nursing diagnosis for this • Tachycardia
patient is 34. After stabilizing the client at the emergency
• Anxiety related to fear of impending death room, he is transferred at the coronary care
• Acute pain unit (CCU). At this time, priority nursing
• Ineffective myocardial tissue perfusion diagnosis is
• Potential for cardiogenic shock • Risk for Dysrrhythmias
28. A 55 year old male client, diabetic and • Potential for shock
hypertensive is admitted to the emergency • Risk for infection
room with crushing substernal pain radiating to • Anxiety related to anticipated pain
the left arm left jaw and left neck lasting for 35. The client develops Congestive Heart failure,
more than 30 minutes. Admitting diagnosis is the doctor orders for Furosemide and Digoxin,
Myocardial infarction. The patient is very at this point it is very necessary for the nurse to
anxious. When the nurse was given the order monitor for which of the following?
• Urine output • “The abnormal genes come from both
• Blood pressure parents”
• Serum potassium • “No, the gene is coming from the father’s
• Heart rate line of abnormal chromosome in the
36. A client with cholycystitis and sperm”
choledocholithiasis underwent 43. A client with Dengue hemorrhagic fever asks
cholecystectomy and choledochotomy and the nurse why platelet transfusion necessary to
returns from surgery with an intravenous line, a control bleeding in his condition. The nurse is
penrose drain and a T tube in place. To correct when he states that
evaluate the effectiveness of the T tube, the • Platelets are better than transfusing whole
nurse should understand that the primary blood
reason for using it with this client is to • Platelets are necessary for arresting
• Prevent the bile from entering the bleeding in small vessels
peritoneal cavity • Platelets are needed for clotting
• Promote wound drainage mechanism
• Minimize the passage of bile into the • Platelets are decreasing in patients with
duodenum Dengue
• Provide a way to irrigate the tract 44. Vitamin K is the antidote for the overdose of
37. A client with cholycystitis and Warfarin because
choledocholithiasis underwent • Warfarin inhibits clotting factor X,IX,VII,II
cholecystectomy and choledochotomy and production
returns from surgery with an intravenous line, a • Warfarin inhibits prothrombin activation
penrose drain and a T tube in place. How • Warfarin binds with vitamin K
much bile would the nurse expect the T tube to • Warfarin blocks vitamin K in the colon
drain during the first 24 hours after surgery? 45. The mother of a male patient with Sickle cell
• 250 to 350 ml disease asks the nurse, “How come my child is
• 150 to 250 ml in pain?" The nurse best response is
• 100 to 200 ml • The pain is not due to sickle cell disease
• 350 to 500 ml • The abnormal gene is causing the pain
38. The presence of the T tube makes it important • The abnormal genes produce pain
for the nurse to develop a plan of care that substances causing severe pain
includes providing extra attention to • The abnormal cells blocked the blood
• Intake and output vessels causing decreased O2 flow
• Acid base balance 46. A client diagnosed with stable angina is
• Electrolyte imbalance undergoing a 12-lead electrocardiogram.
• The skin around the insertion site Which of the following results is not expected?
39. A client with acute pancreatitis was admitted • T-wave flattening
due to severe abdominal pain. The nurse • T-wave inversion
monitors for early signs of shock. Shock is • ST segment depression
extremely difficult to manage in pancreatitis • ST segment elevation
primarily because of the 47. A client is scheduled for a cardiac angiogram.
• Frequent incidence of tubular necrosis Which of the following should the nurse instruct
• Tendency toward congestive heart failure the client about this diagnostic test?
• Vasodilating effects of kinin peptides • General anesthesia is used.
• Frequency and severity of gastrointestinal • It is noninvasive.
hemorrhage • Contrast dye is injected.
40. The nurse is caring for a client with Addison’s • Clients can move about after the
disease, the nurse primary goal for this client in procedure.
the emergency room is 48. A client tells the nurse that he ingests an NSAID
• Preventing irreversible shock when the angina pain gets really bad, and it
• Relieving anxiety eliminates the pain. The nurse suspects the
• Preventing infection client is experiencing:
• Control hypertension • pericarditis.
41. Which of the following would be a major focus • aortic dissection.
of nursing care for the client following • mitral valve prolapse.
transphenoidal hypophysectomy? • musculoskeletal pain.
• Respiratory complications 49. The nurse is aware that the diagnostic criteria
• Cushing's syndrome for the confirmation of irritable bowel syndrome
• Fluctuating glucose level include:
• Cerebrospinal leak • pain increased by defecation.
42. The mother of a male patient with Sickle cell • pain associated with stool frequency.
disease asks the nurse, “Did my child get this • mucorrhea
abnormal gene from me?” The nurse responds • abdominal tenderness.
based on the understanding of sickle cell • Bloating
disease transmission. 50. The physician has prescribed neomycin
• “Yes, the disease is usually manifested in enemas for a patient with cirrhosis. The patient
the males and the mothers are the carrier questions why they are being used. Which
of the abnormal gene” response by the nurse is most appropriate?
• “We cannot say where the gene come • These enemas aid in reducing ascites.
from unless both of you will undergo • These enemas help prevent infection.
genetic consultation” • These enemas kill intestinal flora.
• These enemas help reduce straining environment although she complains of
during a bowel movement. occasional back pain. She has one nephew
OB post test with Down syndrome.Julia will undergo pelvic
exam. Kim will do which of the following first?
1. An 18-year-old woman comes to the
• Instruct her to void
physician's office for a routine prenatal
• Sign a consent b4 the procedure
checkup at 34 weeks gestation. Abdominal
• place her in lithotomy
palpation reveals the fetal position as right
• drink plenty of water
occipital anterior (ROA). At which of the
5. . Mrs. Julia McNamara is on her 3 ½ month of
following sites would the nurse expect to find
her pregnancy and under going prenatal
the fetal heart tone?
check-up at the RHU. This is her first time to
• . Below the umbilicus, on the mother's left
have the check up in a rural setting since she
side.
moved to their new house in Malay-balay,
• 2. Below the umbilicus, on the mother's
Bukidnon. She and her American husband
right side
Sean are volunteer social workers trying to
• 3. Above the umbilicus, on the mother's left
improve the literacy rate of different tribes in
side.
their area. She is adapting well to her new
• 4. Above the umbilicus, on the mother's
environment although she complains of
right side.
occasional back pain. She has one nephew
2. Mrs. Julia McNamara is on her 3 ½ month of
with Down syndrome. Kim explains to Julia why
her pregnancy and under going prenatal
she needs to undergo the pelvic exam. This
check-up at the RHU. This is her first time to
includes the following:
have the check up in a rural setting since she
• To determine probable signs of pregnancy
moved to their new house in Malay-balay,
• b. To determine fetal station
Bukidnon. She and her American husband
• c. To determine cervical effacement &
Sean are volunteer social workers trying to
dilatation
improve the literacy rate of different tribes in
• d. all of these
their area. She is adapting well to her new
6. Mrs. Julia McNamara is on her 3 ½ month of
environment although she complains of
her pregnancy and under going prenatal
occasional back pain. She has one nephew
check-up at the RHU. This is her first time to
with Down syndrome. McNamara asks the
have the check up in a rural setting since she
nurse how frequent she should visit the RHU for
moved to their new house in Malay-balay,
her regular pre-natal check up. Your best reply
Bukidnon. She and her American husband
is:
Sean are volunteer social workers trying to
• Once in every trimester and more frequent
improve the literacy rate of different tribes in
if there are risk factors and problems.
their area. She is adapting well to her new
• Once a month until the 6thmonth of
environment although she complains of
pregnancy then more frequent until
occasional back pain. She has one nephew
9thmonth.
with Down syndrome. If Mrs. Mc Namara left
• On a monthly basis until the 9thmonth of
home Matt born at 38 weeks, Patricia at 36
pregnancy.
weeks, her twins Ron and Mara at 42 weeks,
• Her visit will be based on her work
Kurt at 35 weeks, what is her GTPALM
schedules.
considering she had an abortion?
3. Mrs. Julia McNamara is on her 3 ½ month of
• . G5T4P2A1L5M1
her pregnancy and under going prenatal
• b. G6T3P2A1L5M1
check-up at the RHU. This is her first time to
• c. G5T2P2A1L5M1
have the check up in a rural setting since she
• d. G6T4P2A1L5M1
moved to their new house in Malay-balay,
7. . Mrs. Mc Namara is experiencing discomforts
Bukidnon. She and her American husband
of pregnancy. As a student nurse, you must be
Sean are volunteer social workers trying to
able to give correct explanations and
improve the literacy rate of different tribes in
guidance about the causes and management
their area. She is adapting well to her new
of these discomforts.Julia is experiencing
environment although she complains of
episodes of dizziness and a 30-point drop in her
occasional back pain. She has one nephew
systolic pressure. Your first recommendation to
with Down syndrome.Nurse Kim is explaining to
her is to:
Julia the ultimate goal of prenatal check-up
• Have her BP monitored regularly.
which is:
• B. Perform regular exercise
• To identify risk factors and problems during
• C. Avoid supine position while sleeping or
her pregnancy.
resting.
• To manage problems and complications of
• D.All of these
pregnancy at an earlier time.
8. Mrs. Mc Namara is experiencing discomforts of
• To monitor the progress of pregnancy.
pregnancy. As a student nurse, you must be
• To decrease maternal morbidity and
able to give correct explanations and
mortality rates.
guidance about the causes and management
4. Mrs. Julia McNamara is on her 3 ½ month of
of these discomforts.To avoid varicosities in the
her pregnancy and under going prenatal
lower extremities, you would advice her to
check-up at the RHU. This is her first time to
EXCEPT:
have the check up in a rural setting since she
• Avoid prolong standing
moved to their new house in Malay-balay,
• B. Elevate the legs while resting
Bukidnon. She and her American husband
• C. Wear knee-high stockings
Sean are volunteer social workers trying to
• D. None of these
improve the literacy rate of different tribes in
9. Who is a primipara?
their area. She is adapting well to her new
• a woman who was pregnant once healthy children. During my first pregnancy, I
• B. a woman delivered once of a viable experienced a miscarriage at 16 weeks. The
fetus second pregnancy was when I had my twins
• C. a woman who has completed two born at 35 weeks. My last child was born at 37
pregnancies weeks.” The nurse assessed the fundus to be at
• D. a woman who has had a 12-week the level of the umbilicus. The nurse measured
miscarriage the fundic height to be 20 cms. Based on
10. You care for a woman in a prenatal clinic who Leopold’s maneuver, the fetus is not yet
thinks she might be pregnant. Which of the engaged Using McDonald’s method, what is
following assessment is most probable sign of the age of gestation in weeks?
pregnancy? • 24-25 weeks
• Nausea and vomiting • B. 22-23 weeks
• B. A positive pregnancy test • C. 20-21 weeks
• C. Amenorrhea • D. 18-19 weeks
• D. Urinary frequency 15. 15. A client comes to the clinic for her first
11. A client comes to the clinic for her first prenatal visit on August 2, 2010. According to
prenatal visit on August 2, 2010. According to her OB history, her last menstrual period is from
her OB history, her last menstrual period is from March 28 – April 2, 2010. She states, “I have 3
March 28 – April 2, 2010. She states, “I have 3 healthy children. During my first pregnancy, I
healthy children. During my first pregnancy, I experienced a miscarriage at 16 weeks. The
experienced a miscarriage at 16 weeks. The second pregnancy was when I had my twins
second pregnancy was when I had my twins born at 35 weeks. My last child was born at 37
born at 35 weeks. My last child was born at 37 weeks.” The nurse assessed the fundus to be at
weeks.” The nurse assessed the fundus to be at the level of the umbilicus. The nurse measured
the level of the umbilicus. The nurse measured the fundic height to be 20 cms. Based on
the fundic height to be 20 cms. Based on Leopold’s maneuver, the fetus is not yet
Leopold’s maneuver, the fetus is not yet engaged. What is the estimated age of
engaged. What is the pregnancy status of the gestation if the nurse will base on
client? Bartholomew’s rule?
• Nulligravida • 3 months
• 2. Primipara • B. 4 months
• 3. Multigravida • C. 5 months
• 4. Multipara • D. 6 months
12. 12. A client comes to the clinic for her first 16. How should the nurse measure the fundic
prenatal visit on August 2, 2010. According to height
her OB history, her last menstrual period is from • From the umbilicus to the xyphoid process
March 28 – April 2, 2010. She states, “I have 3 • B. From just above the symphysis pubis to
healthy children. During my first pregnancy, I the xyphoid process
experienced a miscarriage at 16 weeks. The • C. From the umbilicus to the fundus
second pregnancy was when I had my twins • D. From just above the symphysis pubis to
born at 35 weeks. My last child was born at 37 the fundus
weeks.” The nurse assessed the fundus to be at 17. 17. A 23 year old primigravida arrives at the
the level of the umbilicus. The nurse measured clinic for a check up. She is complaining of
the fundic height to be 20 cms. Based on nausea and vomiting upon rising and increase
Leopold’s maneuver, the fetus is not yet urination. She reports that her last menstrual
engaged. What is the OB score of the client? period was 2 months ago. A blood test
• . G4T1P2A1L3M1 confirms that she is pregnant. Which of the
• B. G4T1P1A1L3M1 following finding would be considered
• C. G3T1P1A1L3M1 abnormal:
• D. G3T1P2A1L3M2 • . a bluish tinge to the vagina upon cervical
13. 13. A client comes to the clinic for her first exam.
prenatal visit on August 2, 2010. According to • B. A white, non-malodorous discharge from
her OB history, her last menstrual period is from the vagina
March 28 – April 2, 2010. She states, “I have 3 • C. Mild contractions radiating from the
healthy children. During my first pregnancy, I back to the abdomen
experienced a miscarriage at 16 weeks. The • D. Increase vascularity, sensitivity and
second pregnancy was when I had my twins fullness of the breasts.
born at 35 weeks. My last child was born at 37 18. Which of the following would be the most
weeks.” The nurse assessed the fundus to be at accurate description of the occurrence of the
the level of the umbilicus. The nurse measured ovulation in the menstrual cycle?
the fundic height to be 20 cms. Based on • . midway in the cycle, regardless of the
Leopold’s maneuver, the fetus is not yet length of the cycle
engaged. Using Naegle’s rule, what is the • B. two weeks after the onset of menses
expected date of delivery of the client? • C. two weeks before the onset of menses
• December 30, 2011 • D. ten days after the cessation of the
• B. December 4, 2011 menstrual flow
• C. January 30, 2011 19. 19. The LOA position means that the:
• D. January 4, 2011 • . Lie is longitudinal and the fetal occiput is
14. 14. A client comes to the clinic for her first directed toward the left posterior portion of
prenatal visit on August 2, 2010. According to the maternal pelvis
her OB history, her last menstrual period is from
March 28 – April 2, 2010. She states, “I have 3
• B. Lie is transverse and the fetal mentum is • Person,environment,health,supportsyst
directed toward the left posterior portion of em
the maternal pelvis • Person,healthcareprovider,emotion,nur
• C. Lie is longitudinal and the fetal occiput is sing
directed toward the left anterior portion of • Person,environment,health,medicine
the maternal pelvis • Person,health,environment,nursing
• D. Lie is oblique and the fetal anterior 4. The physician has written an order for a drug
fontanel is directed toward the left for a client. The nurse believes the drug dosage
posterior portion of the maternal pelvis to be in error. What is the nurse’s responsibility?
20. 20. A placenta delivers with the maternal • make a notation on the client’s
surface evident. Which statement below is a medication record
true statement concerning this presentation? • ask the head nurse if the order is
• A. this is a common placental delivery correct
presentation • withhold the drug and ask the
• B. this is an abnormal placental delivery physician
presentation • administer the drug and question the
• C. the uterus does not contract well physician later
following this presentation 5. The order is for heparin 10,000 units SC. The
• D. this presentation reflects a placental dose on hand is 40,000 units/ml. How much
abnormality should the nurse administer?
21. The pregnant client reports that she has a 3- • 4 ml
year old child at home who was born at term, • 0.25 ml
had a miscarriage at 10 weeks gestation, and • 0.4 ml
delivered a set of twins at 28 weeks gestation • 0.04 ml
that died within 24 hours. In the prenatal 6. Before administering a drug to a client, the
record, the nurse should record: nurse should?
• Gravida 3, para2. • ask another nurse if the drug is
• 2. Gravida 3, para 3. prepared correctly
• 3. Gravida 4, para 2. • check the label on the drug container
• 4. Gravida 4, para 3. three times
22. You performed the leopold’s maneuver and • ask the client if this is the correct drug
found the following: breech presentation, fetal • have another nurse prepare the
back at the right side of the mother. Based on medication
these findings, you can hear the fetal heart 7. A major nursing responsibility in the
beat (PMI) BEST in which location? administration of medication is?
• Left lower quadrant • knowledge of the hospital’s drug
• 2. Right lower quadrant policy
• 3. Left upper quadrant • safe and accurate medication
• 4. Right upper quadrant administration
23. 23. In Leopold’s maneuver step #1, you • clear physician’s order
palpated a soft broad mass that moves with • adherence to the 5 rights of giving
the rest of the mass. The correct interpretation medication
of this finding is: 8. Garamycin 25 mg IM has been ordered every 6
• The mass palpated at the fundal part is the hrs. Garamycin 40 mg/ml is available. How
head part. many ml should the nurse administer?
• 2. The presentation is breech. • 55 ml.
• 3. The mass palpated is the back • 0.6 ml.
• 4. The mass palpated is the buttocks. • 0 ml.
Funda • 1.6 ml
9. When preparing for a subcutaneous injection,
1. Maslow’s Hierarchy of Human Needs places the proper size of syringe and needle would
importance on the basic needs that promote be:
survival.Which of the following are examples of • Syringe 3ml and needle gauge 21 to 23
this need? • Tuberculin syringe 1 ml with needle
• Shelter, oxygen, food, water, rest and gauge 26 or 27
sleep • Syringe 2ml and needle gauge 22
• Food, water, elimination, oxygen, rest • Syringe l-3ml and needle gauge 25 to
& sleep 27
• Relationships, shelter, accomplishment 10. The nurse is to introduce a drug via
and love intramuscular injection using deep large
• Oxygen, water, clothes and insurances muscle mass. The preferred site of injection for
2. Which of the following are characteristics of 30 years old would be located by which of the
human needs? following?
• A. Human needs are universal • 2-3 fingerbreadths below the acromion
• B. Human needs are met in different process
ways • Superior outer Lateral quadrant of the
• C. Human needs can be delayed 4 quadrants of the buttock
• D. Unmet needs can result to • Middle Third Anterior Lateral thigh
problems • Heel of the hand placed on greater
3. The four concepts common to nursing that trochanter, fingers pointed to anterior
appear in each of the current conceptual superior iliac spine with the middle and
models are: index finger abducted
11. The nurse is administering eardrops to an adult 19. The doctor ordered the nurse to administer
client. To straighten the ear canal in an adult Furoxone susp 30 mg p.o. QID. The nurse
client before instilling ear drops, the nurse checks the label of Furoxone that reads:
gently pull the: Furoxone antibacterial suspension in 160 ml
• pull pinna back and up bottle available at 5mg per ml of the solution.
• pull pina down and forward The supply dosage of furoxone is
• pull pinna back and down • 1. 5 mg
• pull pina down and circular • 2. 160 ml
12. When instilling eye drops, instruct your patient • 3. 5 mg/ml
to: • 4. none of these
• look down and away 20. 20. The total amount of furoxone in the
• look up and away bottle is
• look straight ahead • 1. 160 ml
• look up and directly at the dropper • 2. 5 mg/ 160 ml
13. To achieve maximum absorption, the nurse • 3. 1 ml
should instill the eye drops into the: • 4. 5 mg/ml
• A. conjuctival sac 21. 21. The strength of furoxone in the 160 ml
• pupil bottle is
• sclera • 1. 5 mg
• vitreous humor • 2. 5 mg/ml
14. In the course of providing care, the nurse • 3. 800 mg/ bottle
discovers a possible error in the physician’s • 4. both b and c
order. How should the nurse respond: 22. 22. Based on the order of the doctor, the
• arry out the order without question. nurse will administer how many ml of furoxone
• Carry out the order and inform the per dose?
physician about the concern. • 1. 960 ml
• Refuse to carry out the order under • 2. 6 ml
any circumstances. • 3. 5 ml
• Verify the order with physician, and • 4. 150 ml
then decide whether or not to carry out 23. 23. You are the nurse assigned to Duncan,
the order. a client with asthma. You are doing his initial
15. Medications are often available in variety of assessment for your shift. Since you have
forms. Which of the following is / are CORRECT? knowledge about this disease, you expect to
• Syrup is an aqueous solution of sugar find wheezing which would be described as:
often used to disguise unpleasant – • 1. Shrill harsh sound
tasting drugs. • 2. Grating or rubbing sound
• Elixir is a sweetened and aromatic • 3. Fine, medium, coarse
solution of alcohol used as a vehicle crackling sound
for medicinal agents. • 4. High pitched squeaky musical
• Tablet is a powdered drug compressed sound
into a small hard disc. 24. 24. Mang Tintay’s habit caused him to
• Suspension is water based medication. develop emphysema and be hospitalized. His
Shake bottle before use. initial management included oxygen therapy
16. Needles are made of stainless steel and most of 2 liters per minute via nasal cannula. His
of them are disposable. The appropriate daughter asked you why he needs low levels of
gauge used for an intramuscular injection for oxygen unlike the other clients who have
adolescent is: higher levels. Your best response would be
• 1. Gauge 25 hypoxemia:
• 2. Gauge 23 • 1. Suppresses the drive of the
• 3. Gauge 27 client to breathe
• 4. Gauge 18 • 2. Stimulates the respiration of
17. 17. The doctor ordered the nurse to the client.
administer Furoxone susp 30 mg p.o. QID. The • 3. Establishes normal breathing
nurse checks the label of Furoxone that reads: pattern.
Furoxone antibacterial suspension in 160 ml • 4. Maintains the carbon dioxide
bottle available at 5mg per ml of the solution. level in equilibrium.
The drug classification of furoxone is 25. 25. Mang Tintay can now be discharged.
• oral drug You are teaching him and his family home
• antibacterial care instructions including postural drainage.
• suspension They ask why postural drainage should be
• none of these done. You explain to them that it is done to:
18. 18. The doctor ordered the nurse to • 1. Improve drainage of
administer Furoxone susp 30 mg p.o. QID. The secretions after it has been loosened
nurse checks the label of Furoxone that reads: by percussion.
Furoxone antibacterial suspension in 160 ml • 2. Move secretions from lower to
bottle available at 5mg per ml of the solution. the upper segment of the lungs.
The route in administering furoxone is • 3. Enhance breathing by
• 1. Oral clearing the alveoli.
• 2. Suspension • 4. Aid in keeping the lungs clear
• 3. Injectable by draining all the lung segments.
• 4. none of these 26. 26. You are taking care of Johanna, a 59-
year-old female admitted due to acute blood
loss. The attending physician ordered two units • 4. “Discontinue the procedure
of packed RBC. After starting the blood only if there are no more formed fecal
transfusion, you stayed with your client for the returns.”
first 15 minutes to monitor for any untoward 31. 31. Owen, a 27-year-old male, is brought
reactions then you left Johanna to do rounds to the emergency department of your hospital
to your other patients. When you returned, you with admitting diagnosis of Traumatic Brain
observed that the transfusion has stopped. Injury. You know that Glasgow Coma Scale
What will be your next action? score is interpreted as: the lower the score, the
• 1. Gently swirl the blood bag more serious the brain injury. Mr. Owen opens
back and forth his eyes upon pain infliction, has no verbal
• 2. Flush the line with normal saline response, and is in flexion. You correctly assess
and discontinue the transfusion his GCS score when you give:
• 3. Open the flow clamp to the • 7
maximum • 6
• 4. Discontinue the transfusion • 5
27. 27. Tetay, another patient who is for blood • 4
transfusion, is also under your care. A few 32. 32. Nurse Sandy is assigned in the Pediatric
minutes after the initiation of the first unit of Intensive Care Unit (PICU). She is preparing the
packed RBC, Tetay showed signs of dyspnea, medication of her client who weighs 52.8lbs.
tachycardia, sudden anxiety, and neck vein The doctor ordered Amoxicillin 125 mg QID. Her
distension. Your most appropriate intervention drug guide states that the safe range for the
would be: drug is 20-40mg/kg/day.
• 1. Administer IV Benadryl as She computed the correct minimum safe dose
ordered if she obtained:
• 2. Collect the first post transfusion • 1. 1056 mg/day
urine • 2. 960 mg/day
• 3. Position Tetay in an upright • 3. 500 mg/day
position, with the feet dependent • 4. 480 mg/day
• 4. Maintain the patency of the 33. 33. She knows that what the doctor
transfusion tubing ordered is a safe dose since the total daily
28. 28. You are assigned to take care of dose is:
Sonny, a 44-year-old male diagnosed with TB • A. 1056 mg/day
meningitis. He has a nasogastric tube (NGT) for • B. 960 mg/day
feeding. Before giving his Osterized feeding, • C. 500 mg/day
you first confirm tube placement. Your best • D. 480 mg/day
action would be: 34. 34. Marty, a 5 year old boy, diagnosed
• 1. Reinsert a new nasogastric with Vitamin B deficiency, is to be given 30
tube. ml/hr of D5LR. Nurse Zy will be using an infusion
• 2. Place the tube lower than the set calibrated at 60gtts/ml. How many gtts/min
nose, allow gravity to drain the would the nurse regulate the IV.
secretions and assess • 1. 30 gttsmin
• 3. Introduce 10 to 15 ml of air • 2. 15 gtts/min
and auscultate abdominal area to • 3. 10 gtts/min
listen to the gurgling sound • 4. 7.5gtts/min
• 4. Aspirate gastric content, use 35. 35. You will be guiding a student nurse in
litmus paper and note pH level administering a drug to your client using the Z
29. 29. Laudimer, a 47-year-old male is track method. You inform her the following
diagnosed with CVA. He has weakness on the guidelines except:
left side of his body which makes him at risk for • 1. This method requires that
aspiration during feeding. You prevent this medication be administered slowly to
when you: allow time for tissue to expand and
• 1. Use straw for feeding. begin absorption of medication.
• 2. Place the food on the • 2. In this technique, use the ulnar
unaffected side of the mouth side of the nondominant hand to pull
• . 3. Assist the client to semi the skin to the side and pierce the skin
Fowler’s position when feeding. quickly and smoothly at a 45 degree
• 4. Give client clear liquid diet. angle.
30. 30. Cleansing enema is prescribed for • 3. This technique leaves a zigzag
Lance, a client who is to undergo pelvic path which prevents the seepage of
surgery. You delegated this task to Vina, a the medication into the SQ tissues and
nursing aide. You instructed her to do cleansing subsequent discomfort.
enema until the return flow is clear. You know • 4. This technique is used for IM
that Vina understood your direction when she drugs that are irritating to the tissue or
says, I will: drugs that cause discoloration such as
• Be using 1 liter of tap water to have a iron.
clear return flow” 36. 36. IV therapy has long been part of the
• 2. “Help the client assume left responsibilities of nurses. Nurse Jacklyn is to
Sims’s position to attain the desired administer Ampicillin via SIVP to a client with
return flow.” heparin lock. She would be doing the
• 3. “Inform you when the return medication administration correctly when she
flow is clear.” injects the solutions in which order?
• 1. NSS, Heparin, NSS, Antibiotics
• 2. Heparin, NSS, Antibiotics, NSS • 3. When the doctor has signed
• 3. Antibiotics, NSS, Heparin, his order.
Antibiotics • 4. As soon as the medication or
• 4. NSS, Antibiotics, NSS, Heparin treatment is at hand or prepared.
37. 37. According to studies, medication errors 42. 42. Evaluating is a planned, ongoing,
constitute a large percentage of deaths that purposeful activity in which clients and health
could have been prevented in hospitals. The 10 care professionals determine the client’s
rights of medication administration have been progress and effectiveness of nursing care.
set as a guide to nurses to address this Which of the following statements is reflects
problem. Nurse Kem is about to administer 1 outcome evaluation?
liter of D5LR for 6 hours to her client. Which • Jake has no adventitious breath
safety measure should she consider to ensure sounds after percussion.
that the right dose is given to the right client? • 2. Lucy, admitted in a semiprivate
• a. Never give a medication that room, has difficulty voiding using the
you haven’t prepared. bedpan because other clients can see
• b. Confirm client’s identification her.
before administering medication. • 3. Harold has taken his medications on
• c. Use proper measuring device time.
• d. Follow strictly the time of • 4. Winney can’t sleep continuously
medication since the door keeps on banging
38. 38. You are taking care of Lou, 23 year old which wakes him up.
psychiatric client. While talking to her, she 43. 43. The half-life (t½) of a drug is the time
suddenly told you, “Gusto ko nang mamatay.” required for 50% of the drug concentration to
( I want to die).You would conduct which type be eliminated. Metabolism and elimination
of assessment? affect the half-life of the drug. A patient is
• 1. Ongoing assessment given 100 mg of a drug that has a half-life of 12
• 2. Problem-focused assessment hours. The nurse is trying to determine the
• 3. Initial assessment amount of medicine in mg in the blood stream
• 4. Emergency assessment at the 5thhalf-life which is:
39. 39. Interviewing a client is a part of the • 1. 5 mg
routine assessment done by the nurses. Who • 2. 25 mg
among the following nurses conduct an • 3. 2mg
interview incorrectly? • 4. 3.12 mg
• 1. Nurse Bebe who stands beside 44. 44. Digoxin has a half-life of 36 hours. An
the client’s bed and looks down intravenous administration of 10 mg of a drug
towards the client when asking was given at 8:00 am. The drug has a half-life of
questions. four hours. What will be the time when
• 2. Nurse Rico who is maintaining approximately 1.25 mg of the drug remains in
2-3 feet distance while interviewing the the body after a single dose has been
client. administered:
• 3. Nurse Vladimir who conducts • 1. 4:00 p.m.
the interview in a well lighted and well • 2. 8:00 p.m.
ventilated place. • 3. 12:00 p.m.
• 4. Nurse Lyza who translates • 4. 4:00 a.m.
medical terminologies into layman’s 45. 45. Phenytoin can cause fetal hydantoin
terms so that the client could syndrome. This syndrome consists of broad
understand what the topic is. nasal bridge, cleft lip and palate,
40. 40. Diagnosing is the second phase of the microcephaly, and a mild form of mental
nursing process. There are several formats of retardation. A 6-year-old child with seizure
nursing diagnoses. Which of the following is an disorder is to receive Dilantin suspension 250mg
incorrect nursing diagnosis? PO once a day. The Dilantin suspension is
• 1. Constipation related to available at 125mg/5ml. How many teaspoons
prolonged laxative use should the nurse administer per dose?
• 2. Situational Low self esteem r/t • 1. 1 ½ tsp
feelings of rejection by husband as • 2. 2 tsp
manifested by hypersensitivity to • 3. 1 tbsp
criticism • 4. 1 tsp
• 3. Impaired Gas exchange r/t 46. 46. Ceftriaxone is a third-generation
Pneumonia cephalosporin antibiotic. The doctor
• 4. Potential Complication of prescribed Ceftriaxone (Rocephin) 800mg IV
Head Injury: Increased ICP one a day. The medication label reads 1g and
41. 41. Implementation is the fourth part of the reconstitute with 10 ml bacteriostatic water. A
nursing process. Nurses are part of the team nurse will prepare to draw how ml to administer
who saves an individual’s life; therefore we the dose?
have to function accurately and efficiently. • 1. 0.080 ml
When are you supposed to carry out a doctor’s • 2. 8 ml
order? • 3. 0.8 ml
• 1. When the significant other of • 4. 80 ml
the client is present 47. 47. Jimenez, a 23year old client who just
• 2. When there is already a returned to the nursing unit from surgery after
consent signed by the client or undergoing an emergency appendectomy.
authorized person. He is awake and complaining of mild incisional
pain. His dressing is dry and intact ,and he has
an intravenous infusion of Dextrose 5% in
Lactated Ringer’s Solution at 875ml.
Thedoctor’sorderreads:infusetheremaining875
mlD5LRat125ml/hr.HowmanyhourswilltheIVFlasts
?
• 1. 5
• 2. 6
• 3. 7
• 4. 8
48. 48.WhatistheflowrateiftheORnurseusedaninfusio
nsetwith15gtts/mlasthedropfactor?
• 1. 42gtts/min
• 2. 31gtts/min
• 3. 21gtts/min
• 4. 18gtts/min
49. 49.Basedonyourcomputedhourstorun,ifyourece
ivedthepatientat8am,thepresentIVFwill be
consumed at?
• 1. 1pm
• 2. 2pm
• 3. 3pm
• 4. 4pm
50. 50. At 10am, you noted that the level of
IVF is at 700 ml. This means that the IVF is:
• 1. Rapid
• 2. Ontime
• 3. Delayed
• 4. nfusing