SITUATION: Competent nurses know the theories and concepts that govern their profession,

furthermore apply and improve them while rendering nursing care to clients.
1. A staff nurse explains to a student nurse that it is truly important for a nurse to establish and develop
an interaction with every client. Who among the following theorists proposed that nursing is a significant
and therapeutic interpersonal process?
A. Florence Nightingale
B. Hildegard Peplau
C. Virginia Henderson
D. Faye Abdella
Answer B: Hildegard Peplau is the author of Interpersonal theory which says that nursing must be a
significant, therapeutic and interpersonal. Nurses participate in structuring health care systems to
facilitate natural ongoing tendency of humans to develop interpersonal relationships.
Nightingale says that the goal of Environmental theory is to facilitate the body’s reparative processes by
manipulating client’s environment. Client’s environment is manipulated to include appropriate noise,
nutrition, hygiene, light, comfort, socialization and hope.
2. Which statement best describes the self-care deficit theory?
A. Nursing care becomes necessary when the client is unable to fulfill biological, psychological,
developmental
or social needs.
B. To assist individuals, families, and groups in attaining and maintaining maximal level of total wellness
by
purposeful interventions.
C. Nurses must help the clients to perform their basic needs, moreover assist them in gaining their
independence as quickly as possible.
D. The delivery of the nursing care for the whole person needs the nurses to meet the physical,
emotional,
intellectual, social and spiritual aspects of the client and family.
Answer: A
Option B: Betty Nueman’s Systems Model of Nursing. Option C: Virginia Henderson’s 14 components of
Basic Nursing. Option D: Faye Abdellah’s Typology of 21 nursing problems.
3. A group of nursing students is discussing the different nursing theories in preparation for their case
study. One of them is correct when she says that “Human Becoming theory and Adaptation Model” are
theories of?
A. Martha Rogers
B. King and Watson
C. Dorethea Orem
D. Callista Roy
Answer: D
According to Adaptation Theory or adaptive model, the goal of nursing is to identify types of demands
placed on the client, assess adaptation to environment. Rogers’ Unitary Human Being says that
human/client continuously changes and coexists with environment. King’s Goal Attainment theory says
the goal of nursing is to use communication to help client re-establish positive adaptation to
environment. Watson’s Science of caring says nursing care does an interpersonal process comprise
interventions that result in meeting human needs. Orem’s Self care deficit theory says nursing care
becomes necessary when the client is unable to fulfill biological, psychological, developmental and social
needs.
4. When a nurse provides discharge instructions to a Chinese client regarding prescribed dietary
modifications, the client continuously turns away from her. Based on the Transcultural Theory, what
nursing action is appropriate for the nurse to do?
A. Continue the instructions, and verify if the client understands.
B. Tell the client the importance of the instructions for the maintenance of health care.
C. Walk around the client so that the nurse continuously faces the client
D. Give the client a dietary booklet and return later to continue with the instructions.
Answer: A
Chinese maintains a formal distance with others, which is a form of respect. They are uncomfortable
with face to face communications, especially when there is direct eye contact. If the client turns away
during the conversation, the nurse

must continue with the conversation. Option C is a direct conflict in the client’s culture. Option B may be
viewed as degrading. Option D may be viewed by the client as a rude gesture.
5. When a nurse educator is providing in-service education to staff nurses in the hospital regarding
transcultural nursing care, a new staff asks the nurse educator to describe the concept of acculturation.
The most appropriate response is:
A. “It is a subjective perspective of the person’s heritage and a sense of belonging to a group”.
B. “It is a group of individuals in a society that is culturally distinct and has a unique identity.”
C. “It is a group that shares some of the characteristics of the larger population group of which it is a
part.”
D. “It is a process of learning a different culture to adapt to a new changing environment.”
Answer: D
Acculturation is a process of learning a different culture to adapt to a new or changing environment.
Option A is ethnic identity. Option B is ethnic group. Option C is a subculture.
Situation: Across all settings in the practice of nursing, nurses are frequently confronted with ethical and
legal issues related to nursing care. It is the responsibility of the professional nurse to be aware of the
ethical principles, laws, and guidelines related to providing safe and quality nursing care.
6. A nurse is unable to contact a physician regarding a new medication which has higher than the
recommended dosage. Which action would the nurse take do next?
A. Hold the medication
B. Administer the dose prescribed
C. Administer the recommended dosage
D. Contact the nursing supervisor
Answer: D
If the physician writes an order that requires clarification, it is the nurse’s responsibility to contact the
physician for clarification. The nurse should then contact the nursing supervisor, if the physician cannot
be contacted or if the order remains as it was after the nurse talks to the physician. Under no
circumstances should the nurse proceed to carry out the order until clarification is obtained.
Reference: Kozier and Erbs Fundamentals of Nursing, 6th edition, pages 64.
7. A nurse gave an inaccurate dose of medication to a client. After assessment, he completes an incident
report, notifies the nursing supervisor of the medication error and calls the physician to report the
occurrence. The nurse who administered the inaccurate medication dose understands that:
A. Error will result in suspension
B. IR is a method of promoting quality care and risk management
C. Incident will be reported to the board of nursing
D. Incident will be documented in the personal file.
Answer: B
Documentation of unusual occurrence, incidents, and accidents, and of the nursing actions taken as a
result of an occurrence, is eternal to the institution or agency and allows the nurse and administration to
review the quality of care and determine any potential risks at present.
Reference: Kozier and Erbs Fundamentals of Nursing, 6th edition, pages 66.
8. A nurse who works on a night shift enters the medication room and finds a co-worker with a
tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a
syringe-containing a clear liquid, into the antecubital area. The most appropriate initial action by the
nurse is:
A. Call the police immediately
B. Call the security
C. Lock the co-worker in the medication room until help is obtained
D. Call the nursing supervisor
Answer: D
The nurse should report the impaired nurses. This incident needs to be reported to the nursing
supervisor who will then report to authorities, such as the police, as required. Option C is inappropriate
and unsafe action. Security may be called if disturbances occurred.
9. A nurse has made an error when documenting an assessment finding on a client. The nurse corrects
the error by:
A. Trying to erase the error to provide space to write in the correct data
B. Use whiteout to delete errors and writing in the correct data.
C. Drawing one line through the error, initialing and dating the line, and then documenting the line.

D. Documenting a late entry into the client’s record.

Answer: C
The nurse should follow the agency policies to correct the error. This includes drawing one line through
the error, initialing and dating the line, and then documenting the correct information. Erasures with the
use of whiteout are prohibited. A late entry is used to document additional information not remembered
at the initial time.
10. A clinical instructor provides a lecture to her students regarding client’s rights. She asks one of them
to identify a situation that represents an example of invasion of the privacy. Which of the following, if
identified by the student, indicates an understanding of a violation of this client right?
A. Performing a procedure without a consent
B. Telling the client that he or she cannot leave the hospital
C. Threatening to give a client a medication
D. Observing care provided to the client without the client’s permission
Answer: D
Invasion of privacy takes place when an individual’s private affairs are unreasonably intruded into.
Option B is false imprisonment. Option C is assault. Option A is battery.
11. A group of nurse is having their lunch at the canteen when one of them tells the group that she
heard their secretary contracted the disease from her husband. The nurse violated which legal tort?
A. Slander
B. Libel
C. Assault
D. Negligence
Answer: A
Defamation takes place when something untrue is said (slander) or written (libel) about a person
resulting in injury to that person’s good name and reputation. Option C occurs when a person puts
another person in fear of harmful or offensive contract. Negligence involves the actions of professionals
that fall below the standard of care for a specific professional group.
12. The nurse hears a client calling out for help and finds him lying on the floor. The nurse performs a
thorough assessment and assists the client back to bed. She then notifies the physician and completes
an IR. Which of the following should the document on the incident report?
A. The client was found lying on the floor
B. The client is stubborn and hard headed so he climbed over the side rails
C. The client fell out of bed
D. The client became restless and tried to get out of the bed
Answer: A
The IR should contain the client’s name, age, and diagnosis. It should contain a factual description of the
incident, any injuries experienced by those involved, and the outcome of the situation. Option A is the
only option that describes the facts as observed by the nurse.
Reference: Fundamentals of Nursing: Caring and Clinical judgment by Harkreader, page 38.
Situation: Nurse Angelina is working in the clinic when a client named Brad arrives for his doctor’s
appointment. Nurse Angelina performs assessment and history taking as part of nursing process.
13. Nurse Angelina performs an initial interview to Brad for which of the following purposes?
A. Initial interviews record pertinent information in the client’s chart for health team to read B. To
identify new or overlooked problems
C. To determine the status of a specific problem identified in the earlier assessment
D. Make nursing diagnosis for identified health problems
Answer: A
Initial interview or assessment is performed within a specific time after the admission to a health care
agency with the purpose of establishing a complete database for problem identification, reference, and
future comparison. Option C is a problem-focused assessment. Option B is Emergency assessment.
Option D is part of the nursing process already, which is the diagnosis or analysis.
Reference: Fundamentals of Nursing by Kozier and Erb, 7th edition, page 180.
14. During the interview, Brad starts to moan and complains abdominal pain. He reveals that this pain
occurred an hour after taking black coffee without breakfast for three weeks now. the nurse will this as:
A. Claims to have abdominal pains after intake of coffee unrelieved by analgesics

B. After drinking coffee, the client experienced severe abdominal pain

C. Client complained of intermittent abdominal pain an hour after drinking coffee
D. Client reported abdominal pain an hour after drinking black coffee for three weeks now
Answer: D
The data gathered is a subjective data which is apparently only to the person affected and can be
described or verified only by the person. Nurse should not add anything from what the patient said since
it includes the client’s sensations, feelings, values, beliefs, and perception of the health status. Option A
and B: there is no supporting data that the client said he took any analgesics and severe abdominal pain
is not yet assessed in the situation, it can be written down as objective data until it is said that the nurse
used any pain rating scale. Option C: there is no supporting evidence that the abdominal pain is
intermittent in occurrence.
Reference: Fundamentals of Nursing by Kozier and Erb, 7th edition, page 182.
15. Nurse Angelina knows that the client is the best source of data. When she asks information from the
client’s wife, she considers this as what type of data?
A. Subjective data
B. Secondary data
C. Primary data
D. Objective data
Answer: C
Secondary objective data are information given by other than the client itself, just like relatives or any
significant person who identified and verified the information. just like in this situation, the girlfriend of
the client sees that he always drink coffee everyday with 4-5 cups. Secondary subjective is information or
data gathered based on the interpretation of person other than the client.
Reference: Fundamentals of Nursing by Kozier and Erb, 7th edition, page 182.
16. Which of the following can be best categorized a secondary subjective data?
A. The nurse measures a weight loss of 10 pounds since the last clinic visit. B. Spouse states the client
has lost all appetite.
C. The nurse palpates edema in lower extremities.
D. Client states pain when walking upstairs.
Answer: B
The best example of a secondary subjective data among the choices is option B because the data is from
the other person and based on the interpretation by the spouse who saw his husband not eating well.
Option A is an objective data. Option C is objective data. Option D is subjective data.
Reference: Fundamentals of Nursing by Kozier and Erb’s, 7th edition, page 182.
Situation: Nurses work in a wider setting and performing a different task and continue to progress in
their new roles and functions
17. Today, nurses are fulfilling expanded career roles which allow greater independence and autonomy.
The following are expanded career role of nurses except:
A. Nurse researcher
B. Nurse practitioner
C. Clinical nurse specialist
D. Staff nurse
Answer: D
Being a staff nurse is a typical career role of a nurse. This traditionally included activities that provide the
client with nursing care in the clinical setting to be able to achieve the highest possible level of health
and wellness. The expanded career roles of nurses today include: nurse practitioners, clinical nurse
specialists, nurse midwives, nurse researchers, nurse anesthetics, nurse entrepreneurs, nurse educators,
and nurse administrators. Nurse researcher-investigates nursing problems to improve nursing care and to
expand existing knowledge Nurse practitioner- a nurse who has an advanced education and is a graduate
of the nurse practitioner program Clinical nurse specialist – a nurse who has an advanced degree of
expertise and is considered to be an expert in a specialized area of practice.
Reference: Kozier, Fundamentals of Nursing, 8th edition, page 15
18. Nurse Katie had been working as a staff nurse in tertiary hospital for 4 years now. A client was
admitted and was placed at the ward where she is assigned. While looking for the actual health problem,
she also focuses on long-term goal for the health of the client. Her responses to the client with holistic
understanding. According to Benner, she will be categorized on which stage of nursing expertise?
A. Advanced beginner

B. Competent C. Proficient D. Expert

Answer: C
P. Benner describes five levels of proficiency in nursing. Stage I is novice, stage II – an advanced beginner,
stage III – competent, Stage IV – proficient and stage V – expert. Nurse Katie would be categorized in the
proficient level which should be 3-5 years’ experience. Perceives situation as a whole rather than in
parts, uses of maxims as guides for what to consider in a situation, and has holistic understanding of the
client, which improves decision-making. Focuses on long term.
Reference: Kozier, Fundamentals of Nursing. 8th edition, page 17.
Situation: Vital signs are a quick and efficient way of monitoring client’s condition or identifying
problems and evaluating the client’s response to intervention. When the nurse learns the physiological
variables influencing vital signs and recognizes the relationship of vital sign changes to other physical
assessment findings, precise determinations of the client’s health problems can be made.
19. A nurse documents deep respirations on the client record. Which criteria were most likely assessed?
A. A large amount of air inhaled and a small amount exhaled
B. A large amount of air inhaled and a large amount exhaled
C. A small amount of air inhaled and a small amount exhaled
D. A small amount of air inhaled and a large amount exhaled
Answer: B
Deep respirations involve a large amount of inhaled and exhaled air. Shallow respirations involve a small
amount of air exchange. Normal respirations entail easy effort, with about 500 ml of air on inhalation.
Reference: Kozier, Fundamentals of Nursing, 8th edition. Page 548
20. The nurse should report an assessment of:
A. 14 respirations per minute for an adult client
B. 16 respirations per minute for an 8-year old client
C. 25 respirations per minute for a toddler
D. 38 respirations per minute for a newborn
Answer: B
Acceptable average respiratory rate (breaths per minute) for newborns is 35 to 40, infant (6 months) is
30 to 50, toddler (2 years) is 22 to 32, and child is 20 to 30. Option A: adults average 12 to 20 respirations
per minute. Option C: acceptable average respiratory rate (breaths per minute) for newborns is 35 to 40;
infant (6 months) is 30 to 50; toddler (2 years) is 22 to 32; and child is 20 to 30. Option D: acceptable
average respiratory rate (breaths per minute) for newborns is 35 to 40; infant (6 months) is 30 to 50;
toddler (2 years) is 22 to 32; and child is 20 to 30
Reference: Perry Clinical Nursing Skills and technique. 6th edition, page 516-519
21. Which technique is best for assessing the respirations of a 3-year old? A. Use a stethoscope and
Auscultate the lungs
B. Place one hand against the chest when counting
C. Observe the rise and fall of the abdomen
D. Tell the child you will check his breathing
Answer: C
A child who knows respirations are being counted may alter the respiratory effort or become upset.
Observing the rise and fall of the abdomen without telling the child is the most accurate method.
Reference: Kozier, Fundamentals of Nursing, 8th edition, page 551.
22. Prior to evaluating a client’s respirations, which of the following factors that affect respirations must
the nurse be aware of?
I. II. III. IV. V. VI.
A. B. C.
Pain
Sleep
Fear
Coma Pneumothorax
Acid base imbalance I, II, III
IV, V, VI
All except V
D. All of the above
Answer: D
Entities that can cause alterations in respiratory functioning are: pain, coma, sleep, pneumothorax, fear,
fever, acid-base imbalance.
Reference: Kozier, Fundamentals of Nursing, 8th edition, page 549.
23. Documentation of a client with Kussmaul’s breathing is made when the nurse assesses:
A. Very slow respirations
B. Abnormally deep but regular respirations
C. Abnormally slow and irregular respirations
D. Irregular periods of apnea and hyperventilation
Answer: B
Kussmaul’s respiration – respirations are abnormally deep, regular, and increased in rate which is
common in diabetic ketoacidosis.
Option A: Bradypnea – Rate of breathing is regular but abnormally slow (less than 12 breaths per
minute). Option C: Hypoventilation – respiratory rate is abnormally low; depth of ventilation may be
depressed. Hypercarbia, an abnormally elevated level of carbon dioxide in the blood, may occur. Option
D: Cheyne-Stokes-Respiratory rate and depth are irregular, characterized by alternating periods of apnea
and hyperventilation.
Reference: Kozier, Fundamentals of Nursing. 8th edition, Page 549
: Perry Clinical Nursing Skills and Technique, 6th edition, page 518.
24. The nurse needs to measure the body temperature of a client who just has a cup of coffee. The nurse
should:
A. Take a rectal temperature
B. Take an axillary temperature
C. Wait for 30 minutes before taking the temperature
D. Postpone the measurement for 5 minutes
Answer: C
If a client has taking cold or hot food or fluids or smoking, the nurse should wait for 30 minutes before
taking the temperature orally to ensure that the temperature of the mouth is not affected by the
temperature of the fluid, food, or warm smoke.
Reference: Kozier, Fundamentals of Nursing, 8th edition, page 532.
25. When inserting a rectal thermometer, the nurse encounters resistance. The nurse should: A. Apply
mild pressure to advance
B. Ask the client to take deep breaths
C. Remove the thermometer immediately
D. Remove the thermometer and reinsert it gently
Answer: C
If resistance is felt during insertion, withdraw immediately. Never force thermometer to prevent trauma
to mucosa. Option A: if resistance is felt during insertion, withdraw immediately. Never force
thermometer to prevent trauma to mucosa. Option B: with non-dominant hand, separate client’s
buttocks to expose anus. Ask client to breathe slowly and relax. Fully exposes anus for thermometer
insertion. Relaxes anal sphincter for easier thermometer insertion. Option D: if resistance is felt during
insertion, withdraw immediately. Never force thermometer. Prevents trauma to mucosa. Reference:
Kozier, Fundamentals of Nursing, 8th edition, page 536
: Perry clinical Nursing Skills and Technique, 6th edition, page 498
26. When evaluating the client’s temperature levels, the nurse expects the client’s temperature to be
lower: A. In the morning
B. After exercising
C. During periods of stress
D. During the postoperative period
Answer: A
Daily fluctuations – temperature is lowest during early morning (4am to 6am). Option B: muscle activity
raises heat production. Option C: Stress elevates temperature. Option D: drugs may impair or promote
sweating, vasoconstriction, vasodilation, or interfere with the ability of the hypothalamus to regulate
temperature.
Reference: Kozier, Fundamentals of Nursing, 8th edition, page 545
: Perry Clinical Nursing Skills and Technique, 6th edition, page 513
27. To conduct an assessment of a possible pulse deficit:
A. A nurse measures the pulse after the client exercises

B. Two nurses check the same pulse on opposite sides of the body
C. Two nurses assess the apical and radial pulses and determine the difference
D. The current pulse is compared with previous pulse measurements for differences
Answer: C
Locate apical and radial pulse sites. If two nurses are available, one nurse auscultates the apical pulse
and one nurse palpates the radial pulse. Both nurses count the pulse rate for 60 seconds simultaneously.
Subtract the radial rate from the apical rate to obtain the pulse deficit. The pulse deficit reflects the
number of ineffective cardiac contractions in 1 minute. If a pulse deficit is noted, assess for other signs
and symptoms of decreased cardiac output.
Reference: Kozier, Fundamentals of Nursing, 8th edition, page 545
: Perry Clinical Nursing Skills and technique, 6th edition, page 513
28. When assessing the pulse of a client on digitalis, what rate would the nurse expect when compared
to the pulse prior to starting the medication?
A. It would be doubled
B. It would be slightly higher C. It would not change
D. It would decrease
Answer: D
Digitalis will decrease the heart rate, thereby decreasing the pulse. Reference: Kozier, Fundamentals of
Nursing, 8th edition, page 547
29. A blood pressure cuff is correctly placed above the brachial pulsation at:
A. 1 1⁄2 inch
B. 2 1⁄4 inch
C. 1 inch
D. 2 inches
Answer: C
Position cuff 2.5 cm (1 inch) above site of brachial pulsation (antecubital space). Reference: Kozier,
Fundamentals of Nursing, 8th edition, page 556
30. A false high blood pressure reading may be obtained if the nurse:
A. Defiates the cuff too slowly
B. Has the client’s arm above the heart level
C. Holds the stethoscope too firmly over the antecubital fossa
D. Repeats the blood pressure assessment too quickly
Answer: A
Slowly release pressure valve, and allow manometer needle to fall at rate of 2 to 3 mm Hg/sec. note
point on manometer when first clear sound is heard. The sound will slowly increase in intensity. Too
rapid or slow a decline in mercury level can cause inaccurate readings. Loose-fitting cuff causes false high
readings. Option B: placement of arm above the level of the heart causes false low reading. Option C:
proper stethoscope placement ensures optimal sound reception. Stethoscope improperly positioned
causes muffled sounds that often result in false low systolic and false high diastolic readings. Option D:
continuous cuff inflation causes arterial occlusion, resulting in numbness and tingling of client’s arm.
Reference: Kozier, Fundamentals of Nursing, 8th edition, page 555
: Perry Clinical Nursing Skills and Technique, 6th edition, page 526
31. Blood pressure measurement is performed on the lower extremities when the client has:
A. An IV in the right arm
B. A left arteriovenous shunt
C. A right mastectomy
D. Bilateral upper extremity casts
Answer: D
The lower extremities may be used when the brachial arteries are inaccessible. Option A: the BP could
be taken in the left arm. Option B: the right arm could be used. Option C: the left arm could be used.
Reference: Perry Clinical Nursing Skills and technique, 6th edition, page 525.
32. When selecting the site and placement of the pulse oximetry sensor, the nurse uses: A. The clip-on
probe for obese clients
B. The fingers for hypothermic clients
C. The earlobe for clients with tremors
D. Disposable probes for clients with a latex allergy

Answer: C
If client has tremors or is likely to move, use earlobe. Option A: if client is obese, clip-on probe may not
fit properly; obtain a single use (tape on) probe. Option B: peripheral vasoconstriction related to
hypothermia can interfere with SpO2 determination. Option D: if client has a latex sensitivity or latex
allergy, avoid adhesive sensor that contains latex. Reference: Perry Clinical Nursing Skills and technique,
6th edition, page 534-535
33. The nurse informs a client that the alarm on the pulse oximeter will not produce sound when:
A. The client moves the probe
B. The probe falls off
C. The SpO2 falls below the set limit
D. The display reaches full strength during each cardiac cycle
Answer: D
Leave sensor in place until oximeter readout reaches constant value and pulse display reaches full
strength during each cardiac cycle. Options A and B: inform client that oximeteralarm will sound if sensor
falls off or if client moves sensor. Option C: if continuous Sp02 monitoring is planned, verify Sp02 alarm
limits, which are preset by the manufacturer at a low of 85% and a high of 100%.
Reference: Perry clinical Nursing Skills and technique, 6th edition, page 536 : Lippincott’s Nursing
Procedure, 5th edition, page 518-519.
Situation: Nurses commonly encounter clients with oxygenation problem. The fundamental knowledge
on the principles and interventions that affects the need of clients is much more important in the
practice of nursing.
34. A client with a history of asthma visits the clinic with complaint of difficulty of breathing. While
performing initial assessment, the nurse becomes concerned that the client’s respiratory status has
worsened based on which of the following?
A. Wheezing throughout the lung field
B. Noticeably diminished sounds
C. Loud wheezing only on expiration
D. Mild wheezing on expiration
Answer: B
The severity of wheezing is not a reliable way to determine severity of asthma attack. Nurses must be
knowledgeable of both normal and abnormal breath sounds. The significant finding in this assessment is
the absence of or diminished breath sounds which may means reduced or absence of moving air into
and out of the lungs.
35. The nurse receives an order to provide chest physiotherapy for a client for two times a day. The nurse
understands which schedule to be most therapeutic?
A. 7amand1pm
B. 6amand4pm
C. 9amand5pm
D. 8amand8pm
Answer: B
Chest physiotherapy and postural drainage are most effective upon first awakening and during an hour
before meals or two to three hours after the meals and must be followed by oral hygiene. Other options
are shortly before and after the meals.
36. The nurse is reviewing the normal limits for a head and neck assessment. Which of the following
findings would indicate the need for additional investigation?
A. A small, discrete, movable lymph nodes
B. The trachea is to the right of the substernal notch
C. A thyroid gland that is not visible or palpable
D. The muscles of the neck are symmetrical
Answer: B
The trachea should be midline in the substernal notch. It may be normal to feel a small, discrete,
movable lymph node. It is clinically insignificant. Thyroid should not be visible and palpable and muscle
of the neck should be symmetrical.
37. How would the nurse correctly document a low-pitched and gurgling breath sounds as:
A. Sonorous wheezes
B. Coarse crackles
C. Sibilant wheezes
D. Pleural friction rubs

Answer: B
Low pitched gurgling breath sounds are coarse crackles. Sonorous wheezes are low-pitched breath
sounds. Sibilant wheezes are high pitched musical sounds. Pleural friction rubs are creaking sound.
38. During the assessment, the client is unable to respond to questions given by the nurse and cannot
follow instructions. To facilitate the assessment process, which of the following would be the most
appropriate intervention by the nurse?
A. Provide simpler commands
B. Ask short, precise questions
C. Ask for longer, more detailed responses
D. Stop and complete a neurological assessment
Answer: A
If client is unable to respond to questions or orientation, offer simple commands, for example, “Squeeze
my fingers” consciously initiate meaningful behaviors, and unresponsiveness to stimuli. Options B and C:
if a client’s responses are inappropriate, ask short, to-the point questions regarding information the
client should know, for example: “Tell me your name.” “What is the name of this place?” “Tell me where
you live.” “What day is this?” “What month is this?” or “What season of the year is this?” measures
client’s orientation to person, place, and time. This may be noted in documenting “Oriented X 3.” If
disoriented in any way, include subjective and/or objective data rather than just documenting
“disoriented.” Option D: assess speech. Is it understandable and moderately placed? Is there an
improperly fitting dentures, or differences in dialect and language.
Reference: Perry Clinical Nursing Skills and Technique, 6th edition, page 549-551
39. The nurse is performing an assessment of the client’s thorax. Which of the following assessments
does the nurse evaluate to be a normal adult finding?
A. The thorax is barrel shaped
B. The costal margin is greater than 90 degrees
C. The accessory muscles are used during inspiration and expiration
D. The rib articulates at a 45 degree angle with the sternum.
Answer: D
The thorax is slightly elliptical in shape although the barrel shaped chest may be normal in the infant and
older adult. Costal angle should be less than 90 degrees during exhalation and at rest. No accessory
muscle should be used during normal respirations.
40. When preparing a client to collect a sputum specimen, it would be essential for the nurse to explain
which of the following aspects of the procedure?
A. Avoid mouth care prior to collecting the specimen
B. Breathe deeply followed by coughing up sputum
C. Collect the specimen before bedtime
D. Restrict fluids prior to expectorating sputum.
Answer: B
Breathing deeply should be followed by coughing up sputum in the collection of a sputum specimen in
the collection process of a sputum specimen. Mouth care should be offered prior to collecting a sputum
specimen. The specimen should be collected in the morning and fluids encouraged before coughing up
the specimen.
41. When planning care for a client with chronic lung disease who is receiving oxygen through a nasal
cannula, the nurse expects that:
A. The oxygen must always be humidified
B. The rate will be 2L/min
C. Arterial blood gases must be drawn every 4 hours
D. The rate will be 6L/min and above
Answer: B
The rate higher than 2L/min may destroy the hypoxic drive that stimulates respirations in the medulla in
clients with chronic lung disease. Oxygen delivered at low rates does not need to be humidified and
arterial blood gases are not required at regular intervals to determine flow rate.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process, and Practice. 7th edition,
page 1305
42. To perform postural drainage on a patient, the nurse should:
A. Encourage the patient to eat, drink 8 oz of water 30 minutes before the procedure
B. Suction the patient before performing the procedure
C. Ask the patient which position he finds most comfortable

D. Before the procedure, the client may be given a bronchodilator or Nebulization

Answer: D
Before the procedure, the client may be given a bronchodilator or Nebulization to loosen the secretions.
Option A: the nurse should encourage food or fluids after the procedure but not shortly after meals
because postural drainage during this time can be tiring and can induce vomiting. The best times are:
before breakfast, before lunch, in the late afternoon, and before bedtime. Option B: the nurse should
suction following the procedure if the patient cannot cough and expectorate secretions. Option C: the
nurse should put the patient in a position to drain the most congested area first. Reference: Kozier, B.
et.al. (2004) Fundamentals of Nursing, Concepts, Process, and Practice. 7th edition, page 1319-1320
43. Which chronological order should the nurse observes in suctioning the client?
I. II. III. IV. V.
A. B. C. D.
Answer: A
In chronological order: First step is to explain the procedure to client. Second, wash hands thoroughly.
Third, put on sterile glove. Fourth, lubricate catheter with normal saline. Then, apply suction for 5-10
seconds.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process, and Practice. 7th edition,
page 1319-1320
44. After suctioning the client with tracheostomy tube, which would be the best method for the nurse to
evaluate the effectiveness of tracheal suctioning?
A. Note subjective data such as, “My breathing is much improved now.”
B. Note objective findings such as decreased respiratory rate and pulse.
C. Consult with respiratory therapist to determine effectiveness
D. Auscultate the chest for change or clearing in adventitious breath sounds.
Answer: D
To assess the effectiveness of suctioning, the nurse auscultates the client’s chest to determine if the
adventitious sounds are cleared and to ensure the airway is clear of secretions. Option A: is subjective
data and not as conclusive. Option B: is correct but not as specific to suctioning as Option D. Option C: is
inappropriate.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process, and Practice. 7th edition,
page 1322-1325
Situation: Nutrition is basic need that must be met for all clients. Nurse must have knowledge required
to educate and care for healthy clients, as well as clients with nutritional needs or disorders requiring
alterations in dietary measures.
45. A female adult client in the ward with diabetes mellitus has been instructed regarding the dietary
exchange system. She tells the nurse that she would like to eat 8 ounces of non-fat yogurt, which is her
favorite for her breakfast. The nurse determines that the client understands the principle of the
exchange system if the client states that she will:
A. Not eat ice cream for one week
B. Omit 8 ounce of skim milk
C. Omit salad dressing and butter for the day
D. Eat only half of a meat exchange at supper
Answer: B
Yogurt belongs to the milk exchange. On exchange system, foods are exchanged within the food group.
Salad and butter belongs to fat exchange. Meats are on separate exchange. Ice cream is not
recommended in the diet of diabetic because of high fat and sugar.
46. A client is recovering from abdominal surgery and has a large abdominal wound. The nurse
encourages the client to eat which food item that is naturally high in Vitamin C?
A. Chicken
B. Bananas
C. Oranges
D. Milk
Answer: C
Citrus fruits and juices are especially high in Vitamin C. Bananas are for Potassium. Meats and dairy
products are foods high in B vitamins.
Put on sterile glove
Lubricate catheter with normal saline Apply suction for 5-10 seconds Explain procedure to client
Wash hands thoroughly
IV, V, I, II, III
II, IV, V, III, I
V, IV, I, III, II
V, II, IV, I, III

47. The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, she
teaches the client about foods that are high in thiamine. The nurse determines that the client has the
best understanding of the dietary measures to follow if the client states an intention to increase the
intake of?
A. Pork
B. Milk
C. Chicken
D. Broccoli
Answer: A
The client with cirrhosis needs to consume foods high in thiamine. Pork products are especially high in
thiamine. Other good source includes nuts, whole grain, cereals and legumes. Milk contains ADEK
vitamins. Broccoli contains CEK and folic acid.
48. A clear liquid diet has been prescribed for a client who is recovering from gastric surgery. The nurse
would check with the dietary department to ensure that the nursing kitchen is stocked with which food
item that is allowed in this diet?
A. Chicken broth
B. Sherbet
C. Orange juice
D. Ice cream
Answer: A
Clear liquid diet consists of foods that are relatively transparent. Other options are included in full liquid
diet.
49. A client has been diagnosed with gout. When developing a dietary plan for him, the nurse plans to
include which item on a list of foods to be avoided?
A. Liver
B. Chocolate
C. Carrots
D. Tapioca
Answer: A
Liver should be omitted from the diet because of high purine content. All other options contains
negligible amounts of purine which may be consumed by the client.
50. The nurse is planning for care for a patient who is to receive total parenteral nutrition (TPN). Which
of the following nursing actions should be included in the immediate plan?
A. Teach the patient to test the urine for metabolites
B. Slow the infusion rate during periods of patient activity C. Test the patient’s blood glucose every 4 to 6
hours
D. Place the patient on a high fiber diet
Answer: C
Due to the concentrated amounts of glucose delivered to the patient with TPN, it is important to monitor
the patient blood glucose level. Option A: it is unnecessary to do this for this patient. Option B: the
infusion rate should not be slowed unless it is ordered by the physician. Option D: usually the patient is
NPO while on TPN. A high fiber-diet is unnecessary. Reference: Kozier, B. et.al. (2004) Fundamentals of
Nursing, Concepts, Process, and Practice. 7th edition, page 1216-1217
51. The nurse is about to administer a tube feeding to a client via NGT. What is the proper technique
with gravity tube feeding?
A. Feeding bag is hung 1 foot higher than the tube’s insertion point into the client
B. Nurse administers the next feeding only if there is less than 25 ml of residual volume from the
previous
feeding
C. Place the client in the left lateral position
D. Feeding is administered directly from the refrigerator
Answer: A
Option B: the residual volume should be less than 100 ml and the nurse should refer to agency policy if
she will continue to administer the next feeding. Option C: the client should be placed in sitting position,
a position of eating. The client should be placed in a Fowler’s position (at least 30 degrees elevation) in
bed. If it is contraindicated, the client should be placed in a slightly elevated right-side lying position that
is acceptable. Option D: Warm the feeding to room temperature because cold feeding may cause
abdominal cramping.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process, and Practice. 8th edition,
page 1216-1272

Situation: Fluids and electrolytes imbalance constitute a content area that is sometimes complex and
difficult to understand, however nurses often experiences working with client with fluids and electrolytes
problem. Therefore, nurses must have a good foundation of this concept.
52. During the routine assessment, the nurse auscultates crackles bilaterally over the lungs, and the
client complains of dyspnea. The client has been receiving IV fluids for the treatment of hyponatremia.
The most appropriate response by the nurse would be:
A. Obtain a blood sample to check serum sodium level
B. Notify the physician to stop the infusion
C. Weigh the client and record the result on the bedside of the flow sheet
D. Maintain the present rate of IV infusion and continue to monitor the respiratory status
Answer: B
Because the client is displaying signs of hypervolemia, the nurse should notify the physician to stop the
present infusion. The client may be receiving fluid too quickly, or the volume may have exceeded the
client’s needs. Maintaining the present IV rate could worsen his respiratory status and place him in a
state of respiratory distress. If the fluid excess is related to excessive administration of sodium-containing
fluids, discontinuing the infusion may all that is needed. Reference: Suzanne Smeltzer, Brunner and
Suddarth’s Medical Surgical Nursing 11th edition, page 313.
53. Several mechanisms in the movement of fluids are identified by the nurse. Which of the following
mechanisms requires adenosine triphosphate (ATP) to function?
A. Diffusion
B. Osmosis
C. Active transport
D. Capillary filtration
Answer: C
ATP is a form of energy that is required for active transport mechanism to function. Passive transport
mechanism- such as diffusion, osmosis, and filtration -require no energy to perform.
Reference: Suzanne Smeltzer, Brunner and Suddarth’s Medical Surgical Nursing 11th edition, page 303
54. The most appropriate nursing intervention for a client with hypercalcemia is:
A. Ambulate as soon as possible
B. Encourage compliance with fluid restrictions
C. Maintain the client on strict bed rest
D. Encourage the consumption of green, leafy vegetables
Answer: A
The client with hypercalcemia should be ambulated as soon as possible to prevent bones from releasing
calcium and increasing serum levels. The client should increase fluid intake to promote calcium excretion
from the kidneys and to prevent the risk of calculi formation. Green, leafy vegetables are calcium-rich
foods and should be avoided by the client with hypercalcemia.
Reference: Suzanne Smeltzer, Brunner and Suddarth’s Medical Surgical Nursing 11th edition, page 328
55. Signs and symptoms of acute hyperphosphatemia are usually caused by the effect of which
electrolyte imbalance?
A. Hypokalemia
B. Hypocalcemia
C. Hypomagnesemia
D. Hypochloremia
Answer: B
Hyperphosphatemia alone causes few clinical problems. However, because phosphorus and calcium have
an inverse relationship, calcium levels are low when phosphorus levels are high. Signs and symptoms are
effective of hypocalcemia. Tachycardia, palpitations and restlessness are among the earliest
manifestations. Anorexia, nausea, vomiting, hyperreflexia, tetany, and more serious dysrythmias may
follow if the imbalance worsens.
Reference: Joyce M. Black, Joyce M. Black, Medical Surgical Nursing 8th edition, page 163
56. The nurse encountered a 75-year old client in the emergency room with complaints of nausea,
diarrhea, and anorexia. Upon evaluation, it was determined that he can be treated at home. When
discussing the guidelines of managing diarrhea, the nurse knew that the client understood his care
measures when he said:
A. “I will drink two glasses of water a day to prevent dehydration.”
B. “I will drink tea when I get home.”
C. “I will increase foods with fiber, like oatmeal.”
D. “I will eat fried chicken for supper.”

Answer: C
Increasing roughage (fiber) in the diet helps to add bulk to the stool. Eight glasses of water remains the
recommended fluid recommendation, although there is some disagreement. Beverages with caffeine,
like tea, and fatty foods like fried chicken aggravate diarrhea.
Reference: Kozier, Fundamentals of Nursing, 8th edition, page 1337
Situation: Nurse Kurt is working in Del Carmen Hospital and is caring for clients with tubes. He responds
competently with every situation that requires his nursing care.
57. Nurse Kurt is observing the nurse trainee while preparing to insert a nasogastric tube. Which of the
following supplies if obtained by the nurse trainee would indicate a need for further education regarding
this procedure?
A. Half inch or 1 inch tape
B. Oil-soluble lubricant
C. A glass of tap water with a straw
D. A 50 ml catheter tip syringe
Answer: B
Water soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil based
lubricant should not be used for it might cause lipid pneumonia if accidentally inserted going to the
lungs. Option A is used to secure the tube. Option D is used to aspirate gastric contents to confirm
placement. The client will be asked to take a sip of water through a straw to facilitate passage of the
tube.
58. Nurse Kurt is observing now the nurse trainee who is inserting an NGT in an adult client. The trainee
is determining the length of tube insertion. Which of the following observation indicates accurate
measurement of the length of the tube to be inserted?
A. The trainee places the tube at the tip of the nose and measures by extending the tube to the earlobe
and then down to the xyphoid process
B. The trainee places the tube at the tip of the nose and measures by extending the tube to the earlobe
and then down to the top of sternum
C. The trainee marks the tube at 10 inches
D. The trainee marks the tube at 32 inches.
Answer: A
All other options are incorrect. Only Option A could guarantee a proper measurement for the insertion
of the tube. Adult average length is about 22-26 inches.
59. During the insertion, the client begins to cough and has difficulty of breathing. Which of the
following is the most appropriate nursing action?
A. Remove the tube and reinsert again when the respiratory distress subsides
B. Pull back on the tube and wait until the respiratory distress subsides
C. Notify the physician immediately
D. Quickly insert the tube
Answer: B
During the insertion of an NGT if the client experiences difficulty of breathing or respiratory distress,
withdraw the tube slightly, stop advancement, and wait until distress subsides.
60. Nurse Kurt is caring for client with NGT which was inserted for feeding purposes. Nurse Kurt knows
that reason why the stomach is used as a reservoir for food is because of its advantage in preventing
which complication?
A. Dumping syndrome
B. Duodenal ulcers
C. Hyperglycaemia
D. Gastric ulcers
Answer: A
When the stomach is used as a reservoir, the formula is released at a controlled rate, preventing the
occurrence of dumping syndrome.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process, and Practice. 7th edition,
page 1204
61. The physician has ordered an indwelling catheter inserted in a hospitalized male patient. Nurse Kurt
is aware that:
A. The male urethra is vulnerable to injury during insertion
B. Normally, a clean technique is used
C. The catheter is inserted 2-3 inches into the meatus.
D. Smaller catheters are usually necessary because of the size of the urethra.
Answer: A
Because of its length, the male urethra is prone to injury and requires that the catheter be inserted 6-8
inches or until urine flows. This procedure requires asepsis to prevent introducing bacteria into the
urinary tract. Larger catheters are used for male catheterization.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
page 1274
62. A client is admitted with frequent, loose stools. Prior to implementing orders to insert a Foley
catheter, which would be the initial action of the nurse?
A. Apply fecal incontinence bag
B. Perform perineal care
C. Administer an antidiarrheal agent
D. Insert a rectal tube
Answer: B
Careful perineal care should be performed prior to beginning the catheterization procedure to give
added cleanliness to the area, especially when diarrhea is present.
Option A: is not necessary. Option C and D: require a physician’s order and are not appropriate.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 1276-1278
63. Which would be the first priority when inserting an indwelling urinary catheter should Nurse Kurt
take into consideration?
A. Aseptic technique
B. Taping the catheter to the leg
C. Instilling water into the balloon
D. Inserting the catheter to the point where the urine flows.
Answer: A
Prevention of infection is a priority, whenever a foreign tube is being introduced into the body; there is
always a chance for infection to occur. Option B is incorrect. Option C is incorrect because it should be
sterile water and even then, it is not a priority. Option D contains incorrect information as the catheter is
usually inserted 2-3 inches beyond the flow of urine. Reference: Kozier, B. et.al. (2004) Fundamentals of
Nursing, Concepts, Process and Practice, 7th edition, pages 1276-1278
64. After securing the catheter to the client, Nurse Kurt should also secure the catheter to the bed linens
and hang the urine drainage bag:
A. Above the level of the bladder
B. At the level of the bladder
C. Below the level of the bladder
D. At any level the nurse prefers
Answer: C
The nurse should hang the urine drainage below the level of the bladder, and no tubing shall fall below
the top of the bag.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 1277
65. What is the priority of care after the urinary catheter is removed?
A. Encourage the client to eliminate fluid intake
B. Document size of catheter and client’s tolerance of procedure C. Evaluate the client for normal voiding
D. Documentation of client teaching
Answer: C
This is a priority. Within 24 hours clients should be voiding normally. Option A should be increased.
Option B is not totally correct. The size of the catheter should have been documented when it is placed.
Option D is important but is not a priority for this question.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 1276-1278
66. Another client has a chest tube inserted for the drainage of excess fluid in the lung cavity. On
assessment of the patency of the chest tube system, which finding would Nurse Kurt identify as
interfering with the effective functioning of chest tubes?
A. 15 cm water suction on chest tube system
B. An air leak in water seal chamber
C. Leaking blood around chest tube site
D. Clots of blood in the chest tube
Answer: B

An air leak would not allow negative pressure to be reestablished and would hinder complete resolution
of the pneumothorax. Therefore, partial atelectasis could be noted. Option A is an appropriate order for
chest tubes
Option C does not hinder the chest tube functioning. Option D would be an expected finding. It would be
important for the nurse to ensure tube patency.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 1325-1326
67. What action should Nurse Kurt take if pleur-evac attached to a chest tube breaks?
A. Immediately clamp the chest tube
B. Notify the physician
C. Place the end of the tube in sterile water
D. Reposition the client in the Fowler’s position
Answer: C
This is the safest for the client and will allow the nurse time to set up another pleurevac. Option A is
unsafe and could result in a mediastinal shift. The majority of physicians will request the chest tubes not
be clamped. Option B is not a priority. Option D is incorrect.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 1325-1326
68. Which nursing action would compromise safety when administering a tube feeding to a client with a
tracheostomy?
A. Place the client in supine position
B. Aspirate and return residual stomach contents
C. Determine placement of tube
D. Check bowel sounds
Answer: A
To minimize risk for aspiration, the client should be maintained in semi-Fowler’s position. Option B, C
and D are not specific for this procedure.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 1314-1317
69. To administer a soap-suds enema to an adult before abdominal surgery, the nurse should:
A. Fill the container with cold water to soothe the intestinal mucosa
B. Insert the tip of the rectal tube 1-2 inches into the rectum
C. Raise the fluid container 12-18 inches above the patient’s anus
D. Remove and place the rectal tube several times during the procedure.
Answer: C
This is the correct height for an adult. The container should be raised 3 inches above the anus for an
infant. Option A the container should be filled with warm water. Cold water will cause abdominal
cramping. Option B the tube should be inserted 3-4 inches for an adult, 2-3 inches for a child, and 1-1.5
inches for an infant. Option D the nurse should hold the tubing in the rectum constantly until the end of
the fluid instillation.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 1240-1244
70. The kind of laxative that acts by causing the stool to absorb water an swell is known as: A. Bulk
forming
B. Emollient C. Lubricant D. Stimulant
Answer: A
Emollients lubricate the stool; lubricants soften the stool making it easier to pass while stimulants
promote peristalsis by irritating the intestinal mucosa or stimulating the nerve endings of the intestinal
wall.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 1238
71. Nurse should recommend to their clients the avoidance of the habitual use of laxatives. Which of the
following is the rationale for this?
A. It will cause fecal impaction
B. It will cause chronic constipation
C. It will change the pH of the gastrointestinal tract
D. It will inhibit intestinal enzymes
Answer: B
Habitual use of laxatives is the most common cause of chronic constipation. The continuous/habitual use
of laxatives weakens the bowel’s natural responses to fecal distention. The nurse should teach the client
about dietary fiber intake, regular exercise, taking sufficient fluids and establishing a regular defecation
habit.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 1238

72. To perform an irrigation of a draining abdominal wound, the nurse should:

A. Direct the flow of fluid from the incision to the outer aspects of the wound
B. Direct the flow of fluid from the outside of the wound to the incision
C. Direct the flow of fluid from the top of the incision to the bottom of the incision
D. Direct the flow of fluid from the bottom of the incision to the top of the incision
Answer: A
The suture line is considered the least contaminated and is always cleansed first. The nurse should direct
the flow of fluid from the least contaminated to the most contaminated area. Option B, C and D these
would direct the flow of fluid from the most contaminated to the least contaminated area.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 882-883
73. The client with an ostomy tube asks the nurse how to control odor and gas production. Which
statement of the nurse is incorrect?
A. Increase intake of cabbage, eggs, fish and beans
B. Increase intake of spinach and parsley
C. Bismuth subcarbonate tablets are effective in reducing odor
D. Stool thickeners assist in odor control.
Answer: A
Options B, C and D are all correct in controlling odor and gas production. Increase intake of cabbage,
eggs, fish and beans these foods causes odor. Increase intake of spinach and parsley acts as deodorizers
in the intestinal tract. Bismuth subcarbonate tablets are effective in reducing odor. Stool thickeners such
as Lomotil assist in odor control.
Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner and Suddarth’s Textbook of Medical-Surgical
Nursing. 10th edition, vol. 1 page 105, 1062
Situation: Part of the nursing activities, which nurse must have essential knowledge are assisting and
preparing specimen for the some diagnostic procedures.
74. To obtain a specimen of stool to measure occult blood, the nurse should:
A. Take samples from different portions of the stool
B. Place all the stools in the clean, dry container
C. Ask the client to use a rectal swab
D. Stay with the client to make sure the specimen is collected correctly.
Answer: A
Findings of occult blood are more conclusive for GI bleeding when the entire specimen is found to
contain blood. Option B the nurse needs only a small amount of feces for the test to be performed.
Option C this would not provide enough of a sample. Option D the nurse should teach the client what to
do to obtain a specimen, and ask the client to explain the collection procedure to document the level of
learning.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition,
pages 764
75. The client has just had a liver biopsy. Which of the following nursing actions would be the priority
after the biopsy?
A. Assist the patient to turn on to the right side, monitor pulse and blood pressure every 30 minutes until
stable
B. Ambulate every 4 hours for the first day as long as client can tolerate this
C. Measure urine specific gravity every 8 hours for the next 48 hours
D. Maintain NPO status for 24 hours post-biopsy.
Answer: A
The nurse should assist the patient to turn on the right side because this position compresses the site of
the liver capsule against the chest wall and the escape of blood or bile through the perforation is
prevented. Complications of liver biopsy include hemorrhage or accidental penetration of biliary
canniculi. The nurse should assess for signs of hemorrhage (increased pulse, decreased blood pressure)
every 30 minutes for the first few hours and then hourly for 24 hours. The client should be monitored for
fever every 4 hours and remain on bed rest for 24 hours.
Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner and Suddarth’s Textbook of Medical-Surgical
Nursing. 10th edition, vol. 2, page 1080
76. The client who has cholelihiasis is scheduled for extracorporeal shock wave lithotripsy. The nurse
should tell the client about which of these symptoms that may occur after this procedure?
A. Colic-type pain B. Headache
C. Diarrhea
D. Hiccups

Answer: A
After the extracorporeal shock wave lithotripsy, the nurse should monitor for biliary colic (there is pain in
the upper right abdomen that radiates to the back or right shoulder) and nausea. The colicky pain is
caused by passage of stone fragments through the biliary tree into the small intestine. Headache,
diarrhea, and hiccups are unrelated manifestations.
Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner and Suddarth’sTextbookl of Medical-Surgical
Nursing, 10th edition vol. 2, page 1127
77. A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide
which instruction?
A. “Take your temperature every 4 hours.”
B. “Increase your fluid intake to 2 to 3 L per day.”
C. “Apply an antibacterial dressing to the incision daily.”
D. “Be aware that your urine will be cherry red for 5 t0 7 days.”
Answer: B
Increasing fluid intake flushes the renal calculi fragments through, and prevents obstruction of the
urinary system. Option A measuring temperature every 4 hours isn’t needed. Option C Lithotripsy
doesn’t require an incision. Option D Hematuria may occur a few hours after lithotripsy but then should
disappear.
Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner and Suddarth’s Textbook of Medical-Surgical
Nursing. 10th edition, vol. 2 page 1339-1341
78. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse
should anticipate which laboratory test result?
A. Decreased serum sodium level
B. Decreased serum creatinine level
C. Increased hematocrit
D. Increased blood urea nitrogen (BUN) level
Answer: A
In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which
decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing
hyponatremia. Option B and C in SIADH, the serum creatinine level isn’t affected by the client’s fluid
status and remains within normal limits. Option D typically, the hematocrit and BUN level decrease.
Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner and Suddarth’s Textbook of Medical-Surgical
Nursing. 10th edition, vol. 2 page 1212
79. The nurse is preparing the client for an abdominal paracentesis. The nurse should place the client in
which of the following positions?
A. Supine
B. Left lateral position with legs flexed
C. Sitting position
D. Right side-lying position
Answer: C
Abdominal paracentesis is carried out to obtain a fluid specimen for laboratory study and to relieve
pressure on the abdominal organs due to the presence of excess fluid. The client should assume a sitting
or upright position in bed, in a chair or on the edge of the bed supported by pillows.
Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice, 7th edition, pages 774,
779
80. In obtaining the cerebrospinal fluid, the needle is inserted:
A. Between L1 and L2
B. Between L3 and L4
C. Between S1 and S2
D. Between L2 and L3
Answer: B
In a lumbar puncture, cerebrospinal fluid is aspirated through a needle inserted into the subarachnoid
space of the spinal canal between L3 and L4 or L4 and L5. At this level, the needle avoids damaging the
spinal cord and major nerve roots. Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process
and Practice, 7th edition, page 774
81. A client who is scheduled for a bone marrow aspiration asks the nurse about the site that will be
used for the procedure. The nurse tells the client that in addition to the iliac crest, the _____ may be
used.
A. Femur

B. Ribs
C. Sternum D. Scapula
Answer: C
The most common sites for bone marrow aspiration in adults are the iliac crest and the sternum. These
areas are rich in marrow and are easily accessible for testing. The femur, scapula, and ribs are incorrect
sites.
Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical
Nursing: Health and Illness perspectives (7th edition). St. Loius: Mosby, p. 810.
Kozier, B. et.al. (2004)Fundamentals of Nursing, Concepts, Process, and Practice. 7th edition, page 777
82. A patient with pneumonia should have which of the following tests performed to determine an
appropriate antibiotic?
A. Arterial blood gas
B. Chest X-ray
C. Complete blood count
D. Sputum culture and sensitivity
Answer: D
Sputum culture and sensitivity will identify the organism and the antibiotic to which the organism is
sensitive. The other diagnostic tests can’t determine the organism’s sensitivity to an antibiotic.
Reference: Archer E. & Ward, B. Fundamentals of Nursing. 2nd edition.Springhouse Publishing.
83. The nurse understands that which of the following foods should be omitted from a patient’s diet
before an electroencephalogram (EEG)?
A. Coffee
B. A glass of orange juice
C. Cheese
D. Strawberry ice cream
Answer: A
Coffee contains caffeine, beverage that contain caffeine are usually restricted prior to an
electroencephalogram (EEG) for 1 to 2 days. The nurse should advise the client not to consume coffee,
tea and chocolate prior to the test. Option B without coffee, tea and other stimulants, orange juice is not
a stimulant. Option C lemon sherbet acceptable.Option D strawberry ice cream acceptable.
Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner and Suddarth’s Textbook of Medical –Surgical
Nursing. 10th edition, vol. 2, page 1845
Situation: A number of factors other than the drug itself can affect its action. The nurse should be aware
that a client may not respond in the same manner to successive dosages of the drug. In addition, the
identical drug and dosage may affect clients differently. Nurses should possess vital knowledge in the
administration of medications.
84. What is the best way for the nurse to improve client compliance with the prescribed medication
schedule?
A. Encourage the client to hire a visiting nurse
B. Give all instructions at least three times
C. Change the administration schedule to longer intervals
D. Devise the simplest medication schedule possible
Answer: D
To improve client compliance, nurses should simplify the medication schedule. Compliance drops sharply
when more than three medications are prescribed, geriatric clients tend to use more than one
medication concurrently. It’s too costly and impractical to hire a visiting nurse in most instances.
Although instructions may need to be repeated, giving all instructions at least three times doesn’t
necessarily ensure compliance. Moreover, a physician, not the nurse, must decide how often a
medication should be given.
85. Why would the nurse be interested in a client’s dietary history when administering drugs?
A. Vegetarian diets can cause more adverse drug reactions than diets containing meat
B. The number of calories consumed can alter a drug’s metabolism
C. Dietary intake can alter the effectiveness of some drugs
D. High-sodium diets can increase the half-life of some drugs
Answer: C
Dietary intake can alter the effectiveness of some drugs; for example, certain antibiotics are bound and
made ineffective by dairy products. A vegetarian diet doesn’t cause more adverse drug reactions than
does a diet containing meat.

Although excessive calories may alter the distribution of a drug, caloric intake doesn’t affect a drug’s
metabolism. Dietary intake, including sodium, doesn’t affect the half-life of any drug.
86. Nurse Athena is administering a client’s dose of sublingual nitroglycerin. The client asks the nurse
why it is administered sublingually rather than orally. Which of the following is the best response to
Nurse Athena?
A. “It is absorbed more rapidly sublingually than when swallowed.”
B. “It is absorbed more rapidly when swallowed than sublingually.”
C. “The absorption rates are the same so it does not matter.”
D. “Sublingual provides a sustained release of the medication.”
Answer: A
The thin layer of epithelium and the vast network of capillaries under the tongue enhance sublingual
absorption. This medication dissolves rapidly and is absorbed immediately. The other options are
incorrect.
87. Nurse Athena is about to administer 25 mg of promethazine (Phenergan) intramuscularly to a client
weighing 180 lbs. Nurse Athena knows that this medication should be given into a large and well-
developed muscle mass. The preferred site of injection for this client would be which of the following?
A. Deltoid muscle
B. Dorsogluteal muscle
C. Vastuslateralis D. Ventrogluteal
Answer: D
For an adult with a well-developed muscle mass, the preferred IM injection site for the medications
requiring a large muscle mass is the ventrogluteal. The vastuslateralis muscle is the preferred IM
injection site for children under 7 months of age. The other options are incorrect.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice.7th edition,
page 826.
88. Aphrodite, a 23 year old nursing student, went to the clinic to have Hepatitis B vaccine. The nurse
attendant knows that she will administer the vaccine in the:
A. Ventrogluteal site
B. Vastuslateralis site
C. Dorsogluteal site
D. Deltoid site
Answer: D
The deltoid site/muscle is found on the lateral aspect of the upper arm. It is not often used for
intramuscular injections because it is relatively small and very close to the radial nerve. It is sometimes
considered for adults because of the rapid absorption from the deltoid area but no more than 1 ml of
the solution can be administered. This site is the recommended site for the administration of Hepatitis B
vaccine in adults.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice.7th edition,
page 827.
89. Nurse Athena is preparing an IM injection of vistaril which is irritating to the subcutaneous tissue. To
prevent staining of the medication and irritation to the tissues, it is best to take which of the following
action?
A. Apply ice to the injection site
B. Use a small gauge needle
C. Use the Z-track technique
D. Administer at a 45-degree angle
Answer: C
The Z-track technique prevents “tracking” and is used for administering medications that are especially
irritating to the subcutaneous tissue. With Z-track, the skin is pulled approximately 1 inch laterally away
from the injection site, the medication is injected, the needle is withdrawn and the tissue is released.
The other options are incorrect.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice. 7th edition,
page 830
90. Nurse Athena is preparing a liquid medication and knows than an appropriate technique for the
nurse to use when preparing a liquid medication is to?
A. Measure the level of the medication at the meniscus
B. Draw up small amounts with a needle and a syringe
C. Pour from the same side as the medication label on the bottle
D. Place the cup on a counter and pour and measure from above
Answer: A
Medications poured into medication cups should be done so at eye level. Pour the desired volume of
liquid so that the base of the meniscus is level with line on scale. Nurse looks at base of meniscus to
confirm volume poured. Option B:

medications drawn into syringes (without a needle) should be drawn slowly to prevent air bubbles from
entering the syringe. Air displaces medications and may lead to inaccurate measurement of doses.
Option C: pour liquid medications away from a label to ensure that liquid will not run down a label,
making it difficult to read. Option D: Medications poured into medication cups should be done so at eye
level.
Reference: Perry and Potter. Fundamentals of Nursing, 6th edition. Page 853
Situation: In all settings and clients, nurses require applying her knowledge in physical assessments and
should be able to elicit and distinguish normal and abnormal findings.
91. Nurse Odette is palpating the client’s pulse. Her finger pads are over the inner side of a client’s ankle,
just below the medial malleolus. Based on the position of Nurse Odette’s finger pads, she is palpating:
A. Femoral
B. Dorsalispedis
C. Popliteal
D. Posterior tibial
Answer: D
This is the right pulse. Option A: this pulse site is located just below the inguinal ligament between the
symphysis pubis and the anterior iliac spine. Option B: this pulse site is located along the top of the foot,
between the great and first toe. Option C: this pulse site is located behind the knee.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Process and Practice. 7th edition,
page 498-500
92. When discussing the pulse of the client to a group of student, Nurse Odette mentions about the
difference between the apical and the radial pulse. The student correctly understands if she identifies
that what Nurse Odette’s discussing refers to:
A. Heart arrhythmia
B. Pulse amplitude
C. Pulse deficit
D. Ventricular rhythm
Answer: C
The difference between the apical and radial pulse is also called pulse deficit. The other terms refer to
the volume and the rhythm of the pulse.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Theories and Practice.7th edition,
New Jersey Prentice Hall.Page 499, 503.
93. Nurse Odette is about to take the temperature of the elder client. However, the client reports that
she has just drunk hot chocolate. Nurse Odette knows that she would wait for how long before taking
the temperature orally?
A. 5 minutes B. 15 minutes C. 30 minutes D. 1 hour
Answer: C
If a client has been taking cold or hot foods and fluids or smoking, the nurse should wait 30 minutes
before taking the temperature orally to ensure that the temperature of the mouth is not affected by the
temperature of the food, fluid or warm smoke.
Reference: :Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Theories and Practice.7th edition,
New Jersey Prentice Hall.Page 490.
94. An elevation of the body temperature above normal is referred to as: A. Afebrile
B. Pyrexia
C. Hypothermia D. Hypertension
Answer: B
Pyrexia is an elevation of body temperature. Hypothermia is low body temperature. Hypertension is
elevated blood pressure. Afebrile means that the client has no fever.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Theories and Practice.7th edition,
New Jersey Prentice Hall.Page 488.
95. What type of fever would Nurse Odette document if the client had a wide range of temperature
fluctuations over normal for a period of 24 hours?

A. Intermittent B. Remittent C. Relapsing

D. Constant
Answer: B
A remittent fever widely fluctuates above normal over a 24-hour period. An intermittent fever rises
above normal between periods of normal or subnormal temperatures. A relapsing fever is short febrile
periods of a few days interspersed with 1-2 days of normal temperature. A constant fever remains above
normal.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Theories and Practice.7th edition,
New Jersey Prentice Hall.Page 488.
96. One of the clients complains of dyspnea while Nurse Odette is performing rounds in the ward. As she
intervene with the client, which position should Nurse Odette place him to facilitate respirations?
A. Take the blood pressure
B. Remove the pillows from under the client’s head
C. Elevate the head of the bed
D. Elevate the foot of the bed
Answer: C
Dyspnea is difficult respirations. Elevating the head of the bed allows the abdominal organs to descend,
giving the diaphragm greater room for expansion and facilitates lung expansion as well. any other
intervention would not facilitate respiration.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Theories and Practice.7th edition,
New Jersey Prentice Hall. Page 507
97. The nurse is assessing the breath sounds of the client and observes a continuous high pitched
musical sound occurring on expiration and inspiration. The nurse documents this as:
A. Stridor B. Stertor C. Wheeze D. Bubbling
Answer: C
Wheeze/wheezing is a continuous high-pitched musical squeak or whistling sound occurring on
expiration and sometimes on inspiration when air moves through a narrowed and partially obstructed
airway.
Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction
Stertor – snorling or sonorous respirations
Bubbling – gurgling sounds heard as air passes through moist secretions in the respiratory tract.
Reference: Kozier, B. et.al. (2004) Fundamentals of Nursing, Concepts, Theories and Practice.7th edition,
New Jersey Prentice Hall. Page 507
98. To determine if the tissue underlying the lower lobe of a patient’s right lung is filled with fluid, Nurse
Odette is expected to use which of the following methods of physical examination?
A. Auscultation
B. Inspection
C. Palpation
D. Percussion
Answer: D
Percussion is the process of striking a patient’s body surface with short, sharp, blows of the fingers to
determine the size, position, and density of underlying tissue, auscultation, inspection, or palpation
would not help attain this result.
99. Nurse Odette is performing a neurologic exam on a patient. After the exam, which of the following
should be recorded as objective data?
A. +4 patellar reflexes in both of the patient’s legs
B. Patient’s description of ringing in his ears
C. Patient’s sensations of numbness in his right arm
D. Patient’s assessment, “The room is spinning.”
Answer: A
Objective data such as +4 patellar reflexes in both of the patient’s legs are data that can be perceived by
the senses, verified by another person observing the same patient, and tested against accepted
standards or norms. Subjective data (for example, tinnitus, numbness, and vertigo) are apparent only to
the person affected and can be described and verified by only that person.
100. A health male client is present in a clinic for his check-up. The nurse is performing a cardiac
assessment on a healthy 12 year-old child, and should palpate the client’s PMI (point of maximum
impulse) at the:
A. Right midclavicular line between the 3rd and 4th intercostal space B. Right midclavicular line between
the 4th and 5th intercostal space C. Left midclavicular line between the 3rd and 4th intercostal space D.
Left midclavicular line between the 4th and 5th intercostal space
Answer: D
The PMI is felt between the 4th and 5thintercostals space along the midclavicular line in a healthy
person.
Option A and B the heart is on the left side
Option C this location is too high for this client
Reference: Kozier, B.et.al. (2004) Fundamentals of Nursing, Concepts, and Process and Practice. 7th
edition, page 581-582