Triage 35 items

Delegation 15 items
Pharmacology 10 items
Pedia 50 items
Maternal 50 items
Psych 50 items
MS 50 items
___________________
260 items

TRIAGE – 35 items

1. A 35-year old woman has just been brought into the ED (emergency department) by the police
after having been successfully assaulted. The patient is alert. Initial assessment reveals bruises and
abrasions on her face, breasts, arms, and hands. She makes minimal eye contact with the nurse and
speaks only when asked a question. What is the most appropriate action for the emergency nurse
to take?
A. Escort the patient to the bathroom for a shower and contact a social worker.
B. Notify the emergency physician that a vaginal examination must be done immediately.
C. Accompany the victim in a private treatment area and explain the sexual assault examination process.
D. Once the patient is in the treatment area, let her be alone to compose her
thoughts about the incident so that an accurate police report can be filed.

2. A 40- year old male involved in a house fire presents, conscious, to the ED with dyspnea, sooty
sputum and a brassy cough. He is receiving 100% oxygen via nonrebreather reservoir mask. The
ED nurse should FIRST:
A. Check for burn percentage
B. Prepare for intubation
C. Assess airway and breathing
D. Start fluid resuscitation

3. Which of these children is at highest risk for foreign body aspiration?

A. A 7-year-old with gastroenteritis
B. A 4-year-old with rhinitis
C. A 2-year-old with a history of chicken pox (varicella) exposure
D. A 6-year-old with a history of cerebral palsy

A 24-year old sanitation worker presents to the ED holding 3 amputated fingers in a soiled cloth. The
patient is awake, alert, and oriented, but appears to be anxious and upset. Upon examination of the
affected hand, you note that the first, second, and third finger are missing. The hand is swollen,
ecchymotic, and bleeding profusely from the stumps.
4. The nurse should FIRST:
A. Apply direct pressure to the stump to control bleeding
B. Administer an oral antibiotic.
C. Reapproximate the amputated digits and hold them in place with a pressure dressing.
D. Place the amputated digits in sterile water.

5. The full emergency operations cycle includes:

A. Planning, education, drills, and evaluation.
B. Scene management, hospital management, and city management.
C. Meetings, assembling reference notebooks, and construction of facilities.
D. Training exercises and critiquing.

6. A passenger train has derailed. First responders indicate that at least 56 people have been injured.
A nurse has gone in the ambulance to assist with care at the scene. Which of the following patients is
the highest priority for treatment and transport (“red category”)?
A. A 75-year-old with a femur, tibia, and fibula fractures; pale, moist skin and pelvic tenderness and
mobility on palpation.
B. A 45-year-old with metal rod impaled in the right forearm. The arm is neurovascularly intact. The
patient is ambulatory.
C. A 63-year-old with second degree and third degree burns over 95% of the body surface areas. The
patient is unconscious and has a thready pulse.
D. A 25-year-old with pain in the left lateral lower chest and a 5-inch laceration in the left forearm. The
wound spurts blood when uncovered. The patient is controlling the bleeding by applying pressure with a
bandana. Skin is pink and dry.

A 17-year-old female presents to the ED with a chief complaint of left-sided pelvic pain. The patient
states that the pain started 3 hours ago and has become constant, sharp and very severe. Her last
menstrual period was approximately 6 weeks ago. But she has been spotting for several days. The
patient states that she is sexually active. Initial vital signs are BP 120/70 mmHg, pulse 128/min,
respiration 22/min, and temperature 100 degrees F (37.8 degrees C). You suspect ectopic pregnancy.
7. What is the appropriate triage category for this patient?
A. Urgent
B. Emergent
C. Nonurgent
D. Referral to fast track

8. You are giving discharge instructions the parents of a newborn. The parents brought the baby to
your ED “to be checked out” because the family was involved in a motor vehicle crash. The baby who
was secured in an infant seat that his mother was holding appears to be uninjured. Mom was the
uninjured front seat passenger. You tell the parents that babies should be:
A. Placed in a rear-facing seat until they weigh 10lbs. (13.6 kg)
B. Placed in a forward- facing seat in the rear seat of the car until they weigh 30lbs (3.6 kg)
C. Placed in the rear-facing seat in the rear seat of the car until they weigh 20lbs (9.0kg).
D. In the rear-facing seat unless they are in the back seat.

9. What is the first step in crisis intervention?

A. Assist the person in gaining an intellectual understanding of the problem.
B. Explore coping mechanisms
C. Include support systems to review the client.
D. Assess the precipitating events and its impact on the person.

10. Depressed patient’s with suicidal ideation who are being evaluated are at greater risk for
committing suicide:
A. During the winter months
B. Before starting antidepressants
C. After the depression lifts
D. When they are agitated and unfocused

A 54-year-old patient is transferred to the ED from the accident scene after his right arm and
forearm were crushed in a cardboard bailing machine. There is severe tissue damage with unknown
bony involvement to the right arm and forearm. The patient fainted briefly after the accident but is
currently awake, alert and oriented. Vital signs are BP 156/98 mmHg, HR 112/min, and respirations
24/min. the patient is moaning in extreme pain. EMS personnel established an IV of Ringer’s lactate
and administered IV Meperidine (Demerol).
11. Upon the patient’s arrival in the ED, the ED nurse should FIRST:
A. Establish second large- bore IV
B. Prepare the patient for immediate surgery
C. Perform primary and secondary surveys
D. Administer more pain medications

12. A victim of an assault with a bat presents to the ED with blunt trauma to the head and neck. The
primary intervention to the patient would be to do:
A. Start an IV, draw trauma bloods, and infuse normal saline
B. Position airway, place on oxygen, and prepare for possible intubation.
C. Assess mental status, place on cardiac monitor, and check vital signs.
D. Place on cervical collar, administers pain meds and supplemental oxygen.

13. A 17 year-old high school student was brought to the ED by her parents, who states that she has
been crying incessantly and has been withdrawn and unable to sleep after breaking up with her
boyfriend 3 weeks ago. Parents express concern to the triage nurse by stating that they feel their
daughter will harm herself if she is not admitted to the hospital for observation. Triage assessment
reveals a tearful young female who is wringing her hands constantly. There is no evidence of physical
injury and the patient denies ingestion of any medication or harmful substance. Vital signs are BP
90/60 mmHg, HR 126/min, and RR 22/min. during her stay in the ED, this patient becomes agitated
and hostile toward her parents and the staff. Which of the following would be the appropriate action
for the ED nurse to take?
A. Call security and have the patient restrained immediately
B. Notify the consulting psychiatrist to obtain an order for a sedative.
C. Ensure the safety of the patient by minimizing environmental stimuli and politely request that the
parents wait outside in a nearby location.
D. Speak quietly to the patient in calm, compassionate manner for the purpose of defining the source of her
agitation.

A female patient who is 13 weeks pregnant by ultrasound presents to the ED with a complaint of
vomiting for several days. She states that she vomits everything that she eats and drinks. She states
that she feels very weak and dizzy. Vital signs are BP 88/52 mmHg, HR 120/min, RR 32/min, and
temperature 99.8 degrees F ( 37.7 degrees C).Her urine has 3+ketones, and is negative for protein
and negative for leukocytes. 14. A passenger train has derailed. First responders indicate that at least
56 people have been injured. A nurse has gone in the ambulance to assist with care at the scene.
14.Which of the following patients is the LOWEST priority for treatment and transport (‘black
category”)?
A. A 75-year-old with a femur, tibia, and fibula fractures; pale, moist skin and pelvic tenderness and
mobility on palpation.
B. A 45-year-old with metal rod impaled in the right forearm. The arm is neurovascularly intact. The
patient is ambulatory.
C. A 63-year-old with second degree and third degree burns over 95% of the body surface areas. The
patient is unconscious and has a thready pulse.
D. A 25-year-old with pain in the left lateral lower chest and a 5-inch laceration in the left forearm. The
wound spurts blood when uncovered. The patient is controlling the bleeding by applying pressure with a
bandana. Skin is pink and dry.

15. Your ED received four patients from a motor vehicle crash. Which patient needs to be stabilized
and transferred to a Level I facility first?
A. A 16-year old female; driver; no seat belt. Injuries to right arm and leg, with abdominal trauma. Vital
signs stable.
B. An 18-year old female; front seta passenger. Multiple facial lacerations and fractures, positive loss of
consciousness. Decreasing oxygen saturation and positive chest trauma.
C. A 17-year old female; rear seat passenger, no seat belt. She is 22 weeks pregnant, with abdominal
trauma, low BP, tachycardia and respiratory distress.
D. A 15-year old female; rear seat passenger with seat belt. Injuries to right leg and chest. Vital signs
stable.
16. Which of the following patients represents the highest triage acuity level?
A. 12 year old reporting a “stye on the left eye”
B. A 34 year old with “pepper spray to both eyes”.
C. A 22-year-old who is “unable to remove my contact lens”
D. A 4-year –old with “itchy, sticky eyes”

17. You are a camp nurse providing emergency care to a group on an outing. Which of the following
campers you suspect to have the highest likelihood of experiencing frostbite?
A. An 18-year-old female who jogs frequently.
B. A 25-year-old black male who smokes less than 1 pack per day.
C. A 45-year-old female who has the history of recent cataract surgery.
D. A 16-yaer-old male with asthma and a cold.

Tricky Triage 18. A patient is in a withdrawn catatonic state and exhibits waxy flexibility. During the initial
phase of hospitalization for this client, the nurse’s first priority is to:
1. Watch for edema and cyanosis of the extremity
2. Encourage patient to discus events that led to the catatonic state
3. Provide a warm, nurturing relationship, with therapeutic use of touch
4. Identify the predisposing factors of the illness

Triage 19. The nurse can anticipate that the person most likely to be at risk for depression is:
1. An elderly person with previous history of depressive episodes
2. A middle-aged man who is a moderate alcohol drinker
3. A housewife with 3 school-age children
4. A nursing student at exam time

Triage 20. In admitting a patient with Alzheimer’s disease to the unit, which placement variable would
have the highest priority?
1. Place the patient with a roommate
2. Place the patient without a roommate
3. Place the patient close to the nurse’s station
4. Place the patient at a distance to the nurse’s station

Triage 21. A hospitalized patient with Alzheimer’s disease is often fund wandering in the streets. What
measure(s) should be taken in the unit to prevent the patient from wandering off?
1. Place the patient in a day time restraints
2. Place the patient in a night time restraints
3. Provide a security guard at the door
4. Use electronic surveillance devices

Triage 22. Which nursing assessment would identify the earliest indication of increasing intracranial
pressure?
1. Temperature over 1020F
2. Change in level of consciousness
3. Widening pulse pressure
4. Unequal pupils

Triage: 23. Which client would be the highest risk for injury?
1. A 3-month-old in an infant seat sitting on a coffee table.
2. A 2-month-old playing in the living room unattended by an adult.
3. A 21/2 yea-old with a tracheostomy playing outside in the backyard
4. A 7-year-old who goes to after school care in a 38-year-old home

Triage 24. Before administering oxygen therapy, the nurse would:

1. Review the patient’s history for indications of COPD
2. Observe patient’s respiratory pattern
3. Draw arterial blood gases
4. Auscultate bilateral breath sounds

MS Skin/Triage 25. Which action is the highest priority for a teenager admitted with burns to 50% of the
body?
1. Counseling regarding problems of body image
2. Maintaining respiratory isolation
3. Maintain aseptic technique during procedures
4. Encourage peers to visit on a regular basis.

26. The priority nursing intervention to a suicidal patient in the ED includes:

A. placing the patient in a private area
B. Talking to the patient about any suicidal plans
C. Implementing a “no suicide” safety contract
D. Praising the patients positive attributes

27. A 17-year-old female presents to the ED with a chief complaint of left-sided pelvic pain. The patient
states that the pain started 3 hours ago and has become constant, sharp and very severe. Her last menstrual
period was approximately 6 weeks ago. But she has been spotting for several days. The patient
states that she is sexually active. Initial vital signs are BP 120/70 mmHg, pulse 128/min, respiration
22/min, and temperature 100 degrees F( 37.8 degrees C). You suspect ectopic pregnancy.
What is the appropriate triage category for this patient?
A. Urgent
B. Emergent
C. Non-urgent
D. Referral to fast track

28. Parents bring their 5-day-old infant to the ED for “poor feeding”. Mom reports the baby was feeding
well until yesterday evening. Your triage exam reveals a term infant who is pale, slightly mottled, and
listless, with poor muscle tone. Vital signs are HR 160 beat/min, respirations 44 breaths/min, with mild
retractions, and temperature 100.8 degrees F (38.2 degrees C). Capillary refill time is 3 seconds centrally
and 4 seconds peripherally. Based on your assessment you would do next:
A. Send the family to the registration desk
B. Triage the infant as emergent and send the infant directly to the treatment area.
C. Placed mother and baby behind the curtain at triage so you can see if the infant will breastfeed.
D. Triage the infant as urgent and send the family to the waiting room.

29. The patient in the hospital becomes confused and disoriented. She pulls leaves form a lily-of-the-valley
plant and eats several of them. The floor nurse brings the patient to the ED for treatment. As the triage
nurse, you would choose which of the following category:
A. Emergent
B. Urgent
C. Non-urgent
D. Refer back to medical floor

30. Six patients report for treatment in 5 minutes. The triage nurse calls for additional help at triage
because:
A. The primary assessment of the patients should occur within the first 2 to 5 minutes of arrival at the ED.
B. Comprehensive triage takes 10 to 15 minutes per patient.
C. All of the patient care areas in the triage are full.
D. Patients satisfaction will be diminished if patient waits too long at triage.
31. An off-duty ED nurse stops at a motor vehicle crash (MVC). The nurse’s first priority in rendering aid
is:
A. Stabilization of the patient’s cervical, spine with simultaneous airway control
B. Breathing assessment and assistance
C. Circulatory assessment and assistance
D. His/her own safety

Triage CD/ Pedia

32. A 6-year-old boy is brought to the triage desk by his aunt. He has had fever and coughs for 3 days and
now has a red rash. The aunt does not know other details of the child’s health history. Your first action as
triage nurse should be to:
A. Contact the child’s parents for permission to treat
B. Institute isolation precaution with the child immediately
C. Obtain vital signs and examine the rash
D. Ask the aunt to wait her turn, since several other patients are waiting.

Triage: MS/ENDO
33. Which nursing diagnosis describes the most life-threatening problem in a patient with hyperglycemic,
hyperosmolar, nonketotic coma (HHNC)?
A. Fluid volume deficit
B. Fluid volume Excess
C. Impaired gas exchange
D.Altered cerebral tissue perfusion

Triage; MS/Cardio (1 item)

34. A 55-year-old female enters the ED complaining of sever chest pain that lasted for 5 hours. She starts
to complain of respiratory distress and is cool, pale and diaphoretic. Her respiratory rate is 22/min, and
respirations appear to be slightly labored. Which of the following takes priority in your care fro this
patient?
A. Administration of 100% oxygen via non-rebreather mask and reassessing respiratory status.
B. Obtaining 12-lead electrocardiogram
C. Establishing an IV of 0.9% normal saline solution and administering a 500-ml fluid bolus.
D. Performing endotracheal intubation

Triage/ SKIN
35.. Which of the following dressings should be applied to the patient with burns over 40% of the body
surface area (BSA) before transfer to a regional burn center?
A. Silver sulfadiazine (Silvadene) dressings
B. Mafenide ( Sulfamylon) dressings
C. Sterile, saline soaked dressings
D. Dry, sterile dressings

DELEGATION (15 items)

1. Which of the following client would be appropriate to assign to an unlicensed assistive personnel
(UAP)?
a. A 43-year-old client with a tracheostomy who is weaned from the ventilator.
b. A 76-year-old cardiovascular accident client with a gastrostomy tube feeding infusing at 40cc/hr who
needs nutritional counseling.
c. A 30-year-old client who has a fractured femur immobilized with a Thomas splint and pearson
attachment in Russel’s traction with balanced suspension.
d. An 84-year-old combative and confused client admitted with a drug overdose of aspirin
2. Which of the following assessments, if made by the registered nurse would be appropriate for unlicensed
assistive personnel?
a. Teaching a client how to administer insulin
b. Assessing the clients status postoperatively
c. Inserting a Foley catheter
d. Monitoring the vital signs of a postoperative client

3. A registered nurse and an unlicensed assistive personnel are working on a medical/surgical unit. The
nurse would delegate which of the following to unlicensed assistive personnel?
a. Adding a medication to an IV solution of 1,000 cc DIW
b. Administering a filled syringe to a diabetic client
c. Assisting the client who is 5 hours post-op to the bathroom
d. Transcribing a providers order

4. The nurse is working on a medical surgical unit that is short staffed and the clients are very sick. Which
of the following can the nurse delegate to unlicensed assistive personnel?
a. Draw STAT CBC
b. Assess the client’s respirations
c. Give discharge instructions
d. Assist with administering oral medications

5. When assessing task to an unlicensed assistive personnel, the nurse should consider:
a. Age
b. Experience
c. Competence
d. Willingness

6. The following clients are on medical surgical nursing care unit:

359-1) Mr. A., 59, had an exploratory laparotomy with permanent colostomy 2 days ago. He has an IV,
PCA, indwelling catheter, and nasogastric drainage to low wall suction. He is receiving IV push Decadron.
359-2) Mr. B., 85, suffered a cerebrovascular accident one week ago. He has a private sitter because he is
confused. He has left-sided paralysis.
360-1) Mrs. C., 35, is a 23-hour admitted for myelogram. She is ready for discharge.
360-2) Miss. D., 29, has severe asthma. She is experiencing some respiratory difficulty. She is on an
aminophylline drop and steroids.
361-1) Mrs. E., 75, a newly diagnosed diabetic, requires reinforcement about insulin administration.
361-2) Mrs. F., 95, was admitted from a nursing home with dehydration and hypokalemia. She will be
receiving KCL 10mEq in 50 ml D5W x 3.
These clients will be assigned to one LPN, and one RN. Which is the best assignment?
a. RN: 359-1, 359-2, 360-1;
LPN: 360-2, 361-1, 361-2
b. RN: 359-1, 360-2, 361-2
LPN: 359-2, 360-1, 361-1
c. RN: 360-2, 361-1, 361-2
LPN: 359-1,359-2,360-1
d. RN: 360-1,360-2,361-1
LPN: 359-1,359-2,361-2

7. A 28 year old female is admitted to the hospital with a diagnosis of appendicitis. Which of the following
skills would you delegate to an LPN ?
a. Vital signs and I&O on the day of admission
b. Evaluating the patient’s vital signs
c. Assessing the patient’s abdominal pain
d. Administering intravenous solution
8. You are caring for a 90 year old female the second day in the hospital after hip displacement. Which of
the following task would you delegate to an ULP?
a. Bathing and turning the patient
b. Listening and answering family and patient’s basic concerns
c. Removing Buck’s traction per physician’s order
d. Administering blood

9. Patients with the following diagnosis has been assigned to you. Delegate their general care to an RN ,
EXCEPT:
a. Scarlet fever
b. Meningitis
c. Encephalitis
d. Diverticulitis

10. The following patients has been assigned to you. Delegate their general care to an RN,
EXCEPT:
a. Intussusception 2 days after admission to the hospital
b. Diabetes insipidus and blood sugar level of 52 mg/dl
c. Diabetes insipidus and urine specific gravity of 1.001
d. Down syndrome, 20 years of age, with a WBC count of 10,000 ml.

11. A 20-year old is admitted to the hospital with a diagnosis of brain tumor and he has cast on his left leg.
Delegate the following assessment or interventions to an RN EXCEPT:
a. Teach client about relaxation techniques
b. Provide diversional activities for the patient to decrease discomfort and to help relieve the fear of
surgery.
c. Assess the patient’s neurovascular status
d. Look for swelling in the left leg, which may indicate vascular constriction of the extremity.

12. A 50-year old male is in the hospital recovering from old myocardial infarction (MI) and a cardiac
bypass graft (CABG) times three. He is afraid that he will have another MI. Delegate the following
assessment or interventions to an RN, EXCEPT:
a. Check color, pulse, and temperature of the patient’s legs.
b. Teach the patient about the importance of daily exercise and following the cardiac diet
c. Assess the patient’s respiration status, cardiac rhythm, and electrocardiogram (ECG).
d. Helps the patient verbalize his fear about MI.

13. Delegate the following patient’s general care to RN, EXCEPT:

a. A client with hypertension and blood pressure of 180/104 mmHg.
b. Emphysema and experiencing severe dyspnea on the first day of hospital
c. Ulcerative colitis on the first day of hospital
d. Prostate cancer on the second day on the hospital.

14. Delegate an RN, LPN, and ULP in a community-based nursing setting (long-term care facility) to an
appropriate task. Which is an LPN task?
a. Teaching facility policies and nursing procedures to the staff or to family members
b. Observe for dyspnea, and weakness during exertion
c. Administer treatments ( e.g. cleaning, draining wound)
d. Suctioning a tracheostomy tube

15. Delegate an RN, LPN, and ULP in a community-based nursing setting (home) to an appropriate ask.
The patient is diagnosed with chronic glomerulonephritis. Which is not an RN delegation?
a. Instruct the patient in a low-sodium diet
b. Assess the patient’s laboratory data
c. Encourage small frequent feedings and provide good oral hygiene
d. Evaluate the patient’s ability to cope with any fluid.

PHARMACOLOGY: ( 10 items)

1. In the early setting of myocardial infarction, beta blockers have been found to be useful because:
A. Decrease myocardial oxygen consumption.
B. Improve venous return
C. Increase contractility
D. Limit the infarct to subendocardial damage.

2. I f a patient who is managed for a chest pain in the ED is allergic to aspirin, what alternative
antithrombotic can be used?
A. Acetylsalicylic acid (“baby aspirin” ) 81 mg chewed.
B. Ticlopidine hydrochloride (Ticlid) 250 mg orally.
C. Enoxaparin (Lovenox) 1mg/kg intravenously
D. Eptifibatide (Integrelin) infusion intravenously.

3. A patient with chronic obstructive pulmonary disease is treated with a sustained-release oral
theophylline preparation. Which of the following condition would predispose the patient to
theophylline toxicity?
A. Diabetes mellitus
B. Congestive heart failure
C. Asthma
D. Renal disease

4. Intravenous propanolol (Inderal) has been ordered for your patient with thyroid storm. This drug
is used to:
A. Keep the heart rate under 100
B. Control hypertension
C. Decrease tremulousness
D. Stimulate thyroxine production

5. A patient with closed head injury is given 100g of mannitol ( Osmitrol). The expected outcome
from this infusion is:
A. Increased sensitivity to the cranial nerve
B. Decreased urinary output
C. Decreased gastric motility
D. Increased osmolarity of the glomerular filtrate

6. Which of the following would be a CONTRAINDICATED in the administration of activated

charcoal?
A. Hyperactive bowel sounds
B. Elevated blood Pressure
C. Acetaminophen (Tylenol) toxicity
D. Vitamin toxicity

7. The key antidote for acetaminophen poisoning is?

A. Naloxone (Narcan)
B. Glucagon
C. N- Acetylecysteine (Mucomyst)
D. Atropine
8. A patient experiencing an acute asthma exacerbation states that his routine medications include
use of cromolyn (Intal) inhaler. This medication is given to:
A. Relieve acute bronchospasm on as needed basis.
B. Block the release of chemical mediators from mast cells
C. Inhibit cough receptors in the bronchial lining
D. Block the uptake of calcium in the bronchial smooth muscle.

9. You are preparing to administer mannitol (Osmitrol) 130 g to a 150-lb (68.2-kg) patient with a
closed head injury. Which of the following nursing interventions should be considered?
A. Notify the physician of possible incorrect dose.
B. An inline IV filter should be used.
C. The medication should be administered over 8 hours.
D. An intracranial pressure monitor should be in place.

10. Which of these classes of drugs is a contributing factor in the development of gout?
A. Thiazide diuretics
B. Cortecosteriods
C. Oral anticoagulant
D. Estrogen replacement

PEDIATRIC NURSING

Neonatal – 5 items

1. A healthy neonate’s respiratory rate ranges from:

A. 10 to 12 breaths/minute
B. 12 to 18 breaths/minute
C. 20 to 30 breaths/minute
D. 32 to 60 breaths/minute
2. Which pulse is best to assess in a neonate?
A. Apical
B. Brachial
C. Carotid
D. Pedal
3. A neonate demonstrates the tonic neck reflex by:
A. Extending the leg on the same side to which his head is turned
B. Flexing the leg on the same side to which his head is turned
C. Extending the leg on the opposite side to which his head is turned
D. Abducting the leg on the opposite side to which his head is turned
4. The best way for the nurse to examine a small child is by proceeding;
A. Cephalocaudally (head-to-toe)
B. Proximally to distally
C. From the most intrusive area to the least intrusive area
D. From the least intrusive area to the most intrusive area
5. An enlarge scrotum in an infant younger than age 4 months indicates:
A. Hypospadias
B. Phimosis
C. Inguinal hernia
D. Hydrocele

ABUSE & SEXUAL CONCERNS – 5 ITEMS

1. A child’s gender identity typically is established between ages:

 A. 1 and 2
B. 2 and 4
C. 4 ½ and 8
D. 8 and 10
2. Follicle-stimulating hormone in males promotes
A. Spermatozoa production
B. Spermatozoa maturation
C. Semen production
D. Testosterone release
3. In pubescent boys, pubic hair growth begins at the base of the:
A. Scrotum
B. Penis
C. Scrotum and penis
D. Inguinal lymph glands
4. Cryptorchidism is characterized by:
A. Testicular torsion
B. Testicular tumors
C. Testicular inflammation
D. Undescended testes

5. All of the following are signs & symptoms of child abuse EXCEPT:
a. Battle sign
b. retinal hemorrhage
c. no stranger & separation anxiety
d. poor sucking reflex

GUT- 5 items

1. A neonate has a decreased ability to resorb:

A. Potassium
B. Sodium
C. Urea
D. Hydrogen
2. Nephrotic syndrome results from:
A. Glomerular injury
B. Ureteral injury
C. Bladder trauma
D. Meatal constriction

3. Acute renal failure in children most commonly is caused by:

A. Dehydration
B. Hypertension
C. Renal infection
D. Cancer
4. James, age 2, is admitted to the hospital for surgical repair for hypospadiasf which position?
A. High-Fowler’s
B. Supine
C. Prone
D. Semi-Fowler’s
5. Which side effect is most common after hemodialysis?
A. Seizures
B. Irritability
C. Restlessness
D. Tremor

Pedia Hemo
1. The parents of a child with hemophilia want to know the cause of the disease. Which of the following
would be the BEST response by the nurse?
1. "The father transmits the gene to his son."
2. "Both the mother and the father carry a recessive trait."
3. "The mother transmits the gene to her son."
4. "There is a 50% chance that the mother will pass the trait to each of her daughters."

2. Which of the following statements, if made to the nurse, indicates parental understanding about the
cause of their newborn's diagnosis of cystic fibrosis (CF)?
"The gene came from my husband's side of the family."
"The gene came from my wife's side of the family."
"There is a 50 percent chance that our next child will have the disease."
"Both of us carry a recessive trait for cystic fibrosis."

3. A toddler admitted with an elevated blood lead level is to be treated with intramuscular (IM) injections
of calcium disodium edetate (Calcium EDTA) and dimercaprol (BAL). Which of the following nursing
actions should have the highest priority?
1. Keep a tongue blade at the bedside.
2. Encourage the child to participate in play therapy.
3. Apply cool soaks to the injection site.
4. Rotate the injection sites.

4. The nurse is aware that which of the following statements, if made by the parents of a four-year-old child
with sickle cell anemia, indicates a need for further teaching?
1. "When my daughter complains of pain, I give her baby aspirin."
2. "I try to keep my daughter away from people with infections."
3. "I sometimes have to give my daughter some of her Demerol for pain."
4. "I encourage my daughter to drink a lot of water."

5 When assisting with a bone marrow aspiration, the nurse should:

1. Drop additional sterile supplies onto a sterile tray.
2. Have all sterile packs unwrapped for the procedure in case they are needed.
3. Reach over the tray and remove contaminated supplies.
4. Place the bottle of sterile liquid on the sterile field so it does not splash.

GROWTH & DEV’T 5 items

1. The nurse is discussing growth and development with the parents of a four-year-old child. The nurse
should identify which of the following as the type of play characteristic of this age group?
1. Solitary play.
2. Parallel play.
3. Associative play.
4. Aggressive play.

2. The school nurse conducts a class on childcare at the local high school. During the class, one of the
participants asks the nurse what age is best to start toilet training a child. Which of the following is the
BEST response by the nurse?
1. 11 months of age.
2. 14 months of age.
3. 17 months of age.
4. 20 months of age.
3. The school nurse observes a group of preschool children in the playroom. The nurse recognizes which
of the following activities as appropriate behavior for a five-year-old boy?
1. The boy plays with a large truck with another child.
2. The boy talks on a toy telephone and imitates his father.
3. The boy works on a puzzle with several other children.
4. The boy holds and cuddles a large stuffed animal.

4. A mother brings her nine-month-old child to the pediatrician's office for complaints of a fever of
102.2ºF (39ºC) and frequent vomiting. The nurse would expect which of the following reflexes to still be
present?
1. Babinski's reflex.
2. Moro's reflex.
3. Tonic neck reflex.
4. Grasp reflex.

5. The nurse in the pediatrician's office observes a child in the waiting room. The nurse notes the child can
walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet.
The nurse identifies the child's chronological age to be:
1. 1 year-old.
2. 2-years-old.
3. 3-years-old.
4. 5-years-old.

RESPI 5 items

1. An 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the
initial assessment, the nurse should expect to find which of the following early symptoms?
1. Kussmaul respirations and bradycardia.
2. Elevated temperature and slow respiratory rate.
3. Expiratory wheezing and substernal retractions.
4. Inspiratory stridor and restlessness.

2. The nurse is planning a diet for an eight-year-old with cystic fibrosis (CF). Which of the following
dietary requirements should be considered?
1. High protein, high fat, and high calories.
2. High protein, low fat, and high calories.
3. Low protein, low fat, and low carbohydrate.
4. High protein, high fat, and low carbohydrate.

3. The nurse in the outpatient clinic teaches the mother of a 10-year-old boy with asthma how to prevent
future asthmatic attacks. The nurse would be MOST concerned if the mother made which of the following
statements?
"My son plays the tuba in the grade school band."
"My son loves to help his dad rake leaves."
"My son participates in after-school activities three days a week."
"My son walks one mile to school every day with his friends."

4. The nurse is assessing a child with cystic fibrosis. The nurse would be MOST concerned if which of the
following was observed?
1. The child is expectorating thick yellow mucus.
2. There is increased mucus production with postural drainage.
3. Exertional dyspnea increases during the day.
4. The child complains about difficulty breathing.
5. The nurse is caring for an eight-year-old child after a tonsillectomy. The nurse would be MOST
concerned if which of the following was observed?
1. Heart rate of 88 beats per minute.
2. Expectorating bright red secretions.
2. 30 ml of dark brown secretions.
4. Infrequent swallowing.

GASTRO 5 items

1. The nurse is preparing discharge teaching for the parents of a newborn. Which of the following
information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria)
test?
1. Breastfed babies need to be a week old for the test, and infants on formula can be tested in three days.
2. The infant can have water but should not have formula for six hours before the test.
3. The test will need to be repeated at six weeks and at the three-month check-up.
4. Blood will be drawn at three one-hour intervals; there is no specific preparation.

2. The nurse is caring for a two-month-old infant. A pH probe test indicates that the infant has reflux.
Which nursing action is MOST appropriate?
1. Hold the next feeding.
2. Teach the mother CPR.
3. Maintain a normal feeding schedule.
4. Elevate the head of the bed.

3. The nurse is assessing an infant who had a repair of a cleft lip and palate. The respiratory assessment
reveals that the infant has upper airway congestion and slightly labored respirations. Which of the
following nursing actions would be MOST appropriate?
1. Elevate the head of the bed.
2. Suction the infant's mouth and nose.
3. Position the infant on one side.
4. Administer oxygen until breathing is easier.

4. The nurse knows that which of the following plans would be a priority for an infant with a positive PKU
blood test?
1. Place the infant on Lofenlac formula.
2. Administer medium-chain triglyceride (MCT) oil with each feeding.
3. Provide genetic counseling for the family.
4. Place the infant on Lorenzo's Oil treatments.

5. The nurse is instructing the parents of a child with celiac disease. The nurse knows that teaching has
been effective when the parents make which of the following statements?
1. "My child's diet should include raw vegetables, fruits, and crackers."
2. "My child's diet should be high in carbohydrates, high in calories, and high in proteins."
3. "The only restriction in my child's diet should be breads and cereals."
4. "My child's diet should be high in calories, high in protein, and restrict from pasta, hotdogs & meat
extenders.

NEURO 5 items
1. The nurse obtains a history from the father of a six-year-old boy with a history of epilepsy admitted with
uncontrolled seizures. It is MOST important for the nurse to ask which of the following questions?
1. "What part of the body was affected by the seizure?"
2. "What is the family history of seizure disorders?"
3. "What was your son doing before the seizure?"
4. "How long has it been since his last episode of seizures?"

2. The home care nurse is visiting an infant who had a myelomeningocele repair. The home care nurse
determines that the parents are accepting of their infant if which of the following is observed?
1. The parents state that the infant will outgrow this problem in time.
2. The parents ask a neighbor to perform bladder expression.
3. The parents measure the head circumference daily.
4. The parents relate that they believe the child will walk in one year.

3. The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by
which of the following observations?
1. The child is able to state his name when asked who he is.
2. The child reaches for a stuffed animal brought from home.
3. The child maintains himself in opisthotonos.
4. The child withdraws from mildly painful stimuli.

4. The nurse is performing teaching on a client with Bell's palsy. It is MOST important for the nurse to
include which of the following instructions?
1. Use artificial tears 4 times per day.
2. Wear sunglasses at all times.
3. Avoid sudden movements of the head.
4. Change the pillowcase daily.

5. An 8-year-old boy is brought to the physician's office by his mother. The mother is concerned because
the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains
of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial
rash on the trunk of his body.
Which of the following assessments would be MOST important for the nurse to perform?
1. Grasp the child's hands and ask him to squeeze the nurse's hands.
2. Stroke the plantar surface of the child's foot with a reflex hammer.
3. Gently flex the child's head and neck onto the chest.

Cardio 5 items

1. Cerebrovascular accident associated with congenital heart disease results mainly from:
A. Altered pulmonary blood flow
B. Cardiomegaly
C. Decreased exercise tolerance
D. Polycythemia
2. Blood pressure that varies among extremities is a common finding in children with:
A. Aortic stenosis
B. Coarctation of the aorta
C. Patent ductus arteriosus
D. Atrial septal defect
3. In a child with TOF, cyanosis results from:
A. a left-to-right shunt through a ventricular septal defect
B. A right-to-left shunt through a ventricular septal defect
C. An increase in pulmonary blood flow
D. A left-to-right shunt through a Blalock-Taussig shunt
4. The nurse knows that dixogin, like other cardiac glycosides, can be extremely toxic. Which of the
following is an early sign of digitalis toxicity?
A. Bradycardia
B. Increased activity
C. Respiratory distress
D. Tachycardia
5. Karen is scheduled to undergo cardiac catheterization. Which nursing action takes the highest priority
immediately after this procedure?
A. Obtaining a complete blood count
B. Increasing her oral fluid intake
C. Performing a neurologic assessment
D. Checking her vital signs

MUSCULO 5 items

1. The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced
suspension traction with a Thomas splint and Pearson attachment. The nurse notes that the patient's left leg
is externally rotated. The nurse should:
Place a trochanter roll on the outer aspect of the thigh.
Perform resistive range of motion of the left leg.
Adduct and internally rotate the left leg.
Instruct the patient to maintain the left leg in a neutral position.

2. The nurse is caring for a six-year-old boy several hours after the application of a hip spica cast. The
patient turns on the call light and complains of pain in his left foot. Which of the following actions should
the nurse take FIRST?
1. Elevate the left leg on two pillows.
2. Palpate the cast for warmth and wetness.
3. Administer pain medication as ordered.
4. Check the blanching sign on both feet.

3. A 20-year-old woman with a fracture of the left femur is placed in Buck's traction with a 7-lb weight.
The patient keeps sliding down in bed. The nurse should:
1. Elevate The Patient's Left Thigh On Two Pillows.
2. Elevate The Foot Of The Bed On Blocks.
3. Raise The Knee Gatch On The Bed 30º.
4. Instruct The Patient To Remain In The Middle Of The Bed.

4 A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been effective if
the client makes which of the following statements?
"I will have my parents put bed-boards on my bed."
"I should decrease my caloric intake."
"I should only take tub baths."
"I can remove the brace for one hour a day."

5. The nurse is caring for clients in the outpatient clinic. Which of the following messages should the nurse
return FIRST?
1. A mother reports that the umbilical cord of her five-day-old infant is dry and hard to the touch.
2. A mother reports that the "soft spot" on the head of her four-day-old infant feels slightly elevated when
the baby sleeps.
3. A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudates.
4. A father reports that he bumped the crib of his two-day-old infant and she violently extended her
extremities and returned to them their previous position.
 Maternal & Child Nursing (50 items)

Anatomy & Physiology, FAMILY PLANNING & Childbearing (10 items)

1. When teaching a patient about the cervical mucus contraceptive method, the nurse should instruct
her to avoid sexual intercourse when her cervical mucus is:
A. Clear and elastic
B. Cloudy and thick
C. Clear and thick
D. Cloudy and elastic

2. Which patient assessment finding contraindicates the use of a cervical cap?

A. Lactation
B. Diabetes mellitus
C. An abnormal Papanicolau (Pap) test result
D. Recurrent cystitis

3. Which contraceptive method does NOT provide protection against sexually transmitted disease?
A. Cervical cap and spermicide
B. Rubber condom
C. Diaphragm and spermicide
D. Intrauterine device (IUD)

4. A patient who has been taking oral contraceptive for the past 3 years, ask the nurse if how long she
should wait before attempting to become pregnant. Which advice should the nurse give?
A. She should wait for at least 1 month
B. She should wait for at least 6 months
C. She can try to conceive immediately
D. She should wait for at least 3 months.

Mrs.W.,age 24 has been taking a combined oral contraceptive fro 3 months after the birth of her
second son. She reports to the clinic nurse that she feels bloated and that her ring and shoes feel tight.
5. Combined oral contraceptives prevent pregnancy by inhibiting the production of:
A. Luteinizing hormone (LH) and estrogen
B. Follicle-stimulating hormone (FSH) and prolactin
C. Estrogen and progesterone
D. FSH and LH

6. Which instruction about proper diaphragm use is INCORRECT?

A. Store the diaphragm in a cool, dry place
B. Use a water-soluble jelly
C. Be refitted for a new one after a weight gain or loss of 15 lb (6.8 kg) or more
D. Check the diaphragm for tears or holes after each use
Rationale:
D. the patient should check the diaphragm for tears or holes before using to determine if she must use an
alternative contraceptive method. Using no-water-soluble jelly, such as petrolatum, or storing the
diaphragm in a location that is not cool and dry may cause the rubber to deteriorate. To ensure proper fit,
the patient must be refitted fro a new diaphragm after a weight gain or loss of 15 lb (6.8 kg) or more.
Mrs. K., a 27-year-old gravida 3 para 2012, has been elected to have an intrauterine device (IUD)
inserted today in the clinic.
7. Which factor in Mrs. K.’s history indicates that she is a good candidate for an IUD?
A. Marital status
B. Parity
C. Age
D. Gravidity
Rationale:
B. Parity-the condition of a woman with regard to her having produced viable offspring-helps determine
the patient’s suitability for IUD use. A nulliparous patient (one with no living children) who wishes to
become pregnant later should not use an IUD because of possible adverse effects that could alter her future
fertility. Age, gravidity (the condition of being pregnant without regard to the outcome), and marital status
are irrelevant to the patient’s suitability for IUD.

8. Although exact mechanism of action is unknown, the IUD is thought to achieve contraception by
inhibiting all of the following except:
A. Fertilization
B. Spermatozoa transport
C. Ovulation
D. Implantation of the fertilized ovum
Rationale:
C. Experts believe that IUD creates a local sterile, inflammatory reaction within the uterus. This reaction
increases the number of uterine leukocytes, whose by-products are toxic to spermatozoa and embryonic
cells. The copper ions in certain IUD’s may later the spermatozoa motility, capacitation, and survival. If
fertilization does not occur, the inflammatory process within the uterus may prevent implantation of the
fertilized ovum.

9. Which assessment finding is NOT a contraindication for IUD use?

A. History of ectopic pregnancy
B. History of PID
C. AIDS
D. History of preterm labor
Rationale:
D. History of preterm labor is not a contraindication for IUD use, although the physiologic factors
responsible for the onset of preterm labor are complex and not fully understood. Because IUD users are at
increased risk for developing PID or ectopic pregnancy, patients with either disorder is not advised to use
IUD. PID is the most common serious complication of IUD use; a woman who uses an IUD has a 50%
greater chance of developing PID than sexually active woman using no contraception. Ectopic pregnancy is
another serious complication associated with IUD’s; the patient with a damage fallopian tube from a
previous ectopic pregnancy should avoid using an IUD to help prevent damage to the remaining tube.
Because AIDS results in a suppressed immune system, a patient with this disease should avoid using IUD
to prevent possible complications, such as PID, which may be life-threatening.

10. The physician prescribes 100mg of clomiphene citrate (Clomid) for 5 days starting on day 5 of
Mrs.H’s menstrual cycle. Which statement indicates that Mrs. H understands the instructions about
this drug?
A. “I will maintain basal body temperature (BBT) chart to determine temperature changes”
B. “I will abstain from sexual intercourse during the 5 days I’m taking the drug”
C. “Slight abdominal bloating and painful breasts indicate that the drug is effective”
D. “This drug will not cause any changes in my cervical mucus”
Rationale:
A. Clomiphene citrate (Clomid) stimulates ovulation, which is indicated by a drop in body temperature
followed by a rise of 0.50 to 10F. This temperature raise is caused by an increase in progesterone secreted
by the corpus luteum. Because progesterone is thermogenic, this temperature increase is maintained during
the second half of the menstrual cycle. Abstaining from intercourse during this time is unnecessary.
Clomiphene causes thickening of the cervical mucus but should not cause painful breasts or bloating.
 ANTEPARTAL PERIOD (10 items)

A 36-year-old female who is 32 weeks pregnant by dates present to the ED with her chief complaint
of sudden vaginal bleeding, severe low abdominal cramping, and low back pain for the past 6 hours.
The patient has been saturating one pad per hour. She also reports decrease in fetal movement over
the past few hours. The patient has had no prenatal care during this pregnancy. Vital signs are BP
100/60 mmHg, HR 112/min, RR 24/min, and temperature 101.2 degrees F( 38.4 degrees C) orally.
1. You suspect that this patient has:
A. Placenta previa
B. Pelvis inflammatory disease
C. Abruptio placenta
D. Threatened abortion
Rationale:
C. Abruptio placenta is typically characterized by vaginal bleeding and is associated with low abdominal,
pelvic, or back pain or a combination. The amount of bleeding in abruption placentae is variable, as
bleeding may be concealed in the uterus. Uterine tenderness is present in abruption placenta.
A. Placenta previa is typically characterized by painless, bright-red vaginal bleeding. There is usually no
report of a decrease in fetal movement.
B. Pelvic inflammatory disease does not cause onset of vaginal bleeding
D. “Threatened abortion” is a term used for vaginal bleeding before viability of the fetus (20 to 24 weeks).

2. The most appropriate nursing diagnosis for a patient who is bleeding from abruption placentae is:
A. Pain
B. Fluid volume deficit
C. Impaired gas exchange
D. altered tissue perfusion
Rationale:
Therefore, fluid volume deficit is the highest priority nursing diagnosis for this patient.
A. Pain is an important secondary nursing diagnosis.
C. Impaired gas exchange is an important secondary nursing diagnosis.
D. Altered tissue perfusion is an important secondary nursing diagnosis.

3. Your initial documented assessment of this patient (question #1) would include all of the following
except:
A. Fetal heart tones
B. Orthostatic vital signs
C. Temperature
D. Respiratory rate
Rationale:
A. Fetal heart tones are detectable by Doppler methods at 10-12 weeks gestation. Based on the patient’s last
menstrual cycle, if she were found to be pregnant, she would be approximately 7 weeks gestation.
B. This would be assessed for and documented.
C. This would be assessed for and documented.
D. This would be assessed for and documented.

4. Heparin is the preferred anticoagulant for pregnant cardiac patient because it:
A. Can be administered orally
B. Has a serum half-life of 3 to 4 days
C. Does not affect the patients active partial thromboplastin time (APPT)
D. Does not cross the placental barrier
Rationale:
D. Heparin is the preferred anticoagulant agent for pregnant women because it is composed of large
molecules and does not cross the placental barrier; therefore, it does not affect coagulation in fetus. Heparin
prolongs the patient’s activated partial thromboplastin time (APPT); in fact results of the daily APTT is
used to determine the drugs dosage. Heparin’s serum half-life (the time it takes for the half of the serum
concentration to decrease) is 1 to2 hours, not 3 to 4 days. Heparin is not administered orally, because it is
broken down by the digestive system; it is administered intravenously or subcutaneously.

5. During the second trimester, the nurse would expect Mrs. N. to :

A. Realistically prepare for childbirth
B. Anticipate labor and delivery
C. Identify the fetus as a separate human being
D. Feels ambivalent about the pregnancy
Rationale:
C. During the second trimester, when fetal movement and the fetal heartbeat become detectable, the mother
typically views her fetus as a separate being. Ambivalence is common during first trimester, because the
mother’s though usually are centered on herself, she may find reasons why she should not be pregnant.
Anticipating labor and delivery and realistically preparing for childbirth are common during the third
trimester.

6. At 36 week’s gestation, Mrs.N’s. hemoglobin level has fallen to 11.2 g/dl from her pregnant level of
14.5g/dl. This decrease is probably the result of:
A. An expanded plasma volume
B. Increased fibrinogen levels
C. A low vit. C intake
D. Iron deficiency anemia
Rationale:
A. Plasma volume begins to increase during the 6th to the 10th week of gestation and peaks during the 32nd
week; the RBC mass also increases, but because this occurs later in pregnancy, hemoglobin level drops.
Iron deficiency anemia, which affects 15% of all pregnant women , causes hemoglobin levels to fall below
11.0g/dl and serum ferritin levels (which reflects iron source) to fall below 12cgm/liter. Decrease Vit. C
intake would not cause the hemoglobin level to drop; neither would increase fibrinogen levels, which help
prevent maternal hemorrhage during childbirth. Other factors that would affect the patient’s hemoglobin
level include the rate of RBC breakdown and iron neutralization by the bone marrow, dietary iron intake,
and the ability of the gastrointestinal tract to absorb iron.

Mrs. S., a 26-year-old mother of 5-year-old twin sons, is making her initial visit to the antepartal
clinic. Her obstetric history reveals the birth of a stillborn infant in the 38th week of gestation and the
birth of her twins in the 35th week of gestation. The physician has confirmed her current pregnancy
and estimated at to be 16 week’s of gestation.
7. Based on Mrs. S’.s obstetric history, the nurse should classify her as:
A. Gravida 3 para 1201
B. Gravida 2 para1102
C. Gravida 4 para 1202
D. Gravida 3 para 1102
Rationale:
D. Because the patient has had two previous pregnancies, her current classification is gravida 3. because
her first pregnancy went to term, her second pregnancy resulted in preterm birth (twins) at 35th weeks
gestation, and her history indicates no abortions and two living children, the rest of her classification is para
1102.

8. Mrs. S.’s blood is Rh-negative. The physician would schedule the administration of human Rh0(D)
immune globulin (RhoGAM) at the 28th week of gestation if Mrs. S had a:
A. Negative indirect Coomb’s test result
B. Negative direct Coomb’s result
C. Positive indirect Coomb’s result
D. Positive direct Coomb’s result
Rationale:
A. An indirect Coomb’s test determines whether an Rh-negative patient has a circulating antibodies against
Rh-positive RBC’s; a negative result calls for one 300-mcg dose of human Rh0(D) immune globulin
(RhoGAM) IM at 26 to 28 weeks gestation. If the fetus is Rh-positive, the Rh0(D) immune globulin will
suppress the patient’s immune response to the Rh-positive RBC’s; this prevents Rh isoimmunization, a
serious blood incompatibility that may lead to fetal and neonatal anemia; jaundice ;liver, heart and spleen
enlargement; and fetal hypoxia and death. If the neonate’s blood is identified as Rh-positive after birth, the
patient may require a postpartum dosage of Rh0 (D) immune globulin to prevent maternal sensitization in
future pregnancies. The direct Coombs’ test would be performed on the neonate to determine if maternal
Rh-positive antibodies crossed the placenta and attacked the neonate’s Rh-positive RBC’s.

Mrs.C., a 30-year-old gravida 6 para 2305 with a history of chronic hypertension, arrives at the labor
and delivery area with dark red vaginal bleeding. She states that the bleeding started suddenly and
that she has severe abdominal pain. The physician diagnoses abruption placentae.
9. Disseminated intravascular coagulation (DIC) is a possible complication of abruption placentae.
Which assessment finding would indicate that Mrs.C has developed DIC?
A. Rapid clotting at the venipuncture sites
B. Bleeding of nose and gums
C. Increased central venous pressure
D. Joint pain
Rationale:
B. Bleeding of the nose, gums, and vagina are the classic signs of DIC; the disorders also commonly causes
prolonged bleeding, not rapid clotting, at the venipuncture sites. This abnormal bleeding is caused
decreased number of platelets, which prevents spontaneous bleeding; depletion of coagulation factors; and
increased levels of fibrin split products, which have an anticoagulant effect. Joint pain and increased central
venous pressure are not associated with DIC.

10. After examining Mrs. M., the physician administers a nonstress test (NST). The NST indicates
nonreactive results. Which procedure will the physician probably order next?
A. Oxytocin contraction test
B. Serum estriol level assessment
C. Ultrasonography
D. Amniocentesis
Rationale:
A. The physician probably will order an oxytocin contraction test (OCT) after the patient has a nonreactive
result in the nonstress test (NST). He NST, which measures the fetus’s heartbeat hen movement occurs, is
commonly performed on diabetic patients because of the increased risk of stillbirth. Reactive (favorable)
results show two or three fetal heart rate (FHR) accelerations of 15 or more beats/minute lasting at least 15
seconds within a 20 minute period; nonreactive (unfavorable) results may indicate fetal hypoxia.

INTRAPARTAL PERIOD (LABOR & DELIVERY) – 10 items

1. A nurse is caring for a client in labor. The nurse documents that the client is beginning the second
stage of labor when which of the following assessments is noted?
1. The client begins to expel clear vaginal fluid
2. The contractions are regular
3. The membranes have ruptured
4. The cervix is completely dilated

R: 4. The 2nd stage of labor begins when the cervix is completely dilated & ends w/ birth of the
neonate.
2. A nurse in the labor room is caring for a client, in the active stage of labor. The nurse is assessing
the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing
action is to:
1. Place the mother in a supine position
 2. Document the findings and continue to monitor the fetal patterns
3. Administer oxygen via face mask
4. Increase the rate of the intravenous (IV) oxytocin (Pitocin) infusion
R: Late decelerations are due to uteroplacental insufficiency as a result of decreased bld flow & O2
to the fetus during the uterine contractions. This causes hypoxemia; therefore, O2 is necessary. The
supine position is avoided because it decrease uterine bld flow to the fetus. The client should be
turned onto her side to displace pressure of the gravid uterus on the inferior vena cava.

R: 2. A normal FHR is 120-160 bpm. Bradycardia or late variable decelerations indicate fetal
distress & the need to discontinue the oxytocin. The goal of labor augmentation is to achieve 3 good-
quality contractions (appropriate intensity & duration) in a 10-minute period. The uterus should
return to resting tone between contractions, & there should be no evidence of fetal distress. Increased
urinary output is unrelated to the use of oxytocin.
3. A nurse is preparing to care for a client in labor. The physician has prescribed an intravenous
infusion of oxytocin (Pitocin). The nurse ensures that which of the following is implemented prior
to initiating the infusion?
1. Placing the client on complete bed rest
2. Continuous electronic fetal monitoring
3. An intravenous infusion of antibiotics
4. Placing a code cart at the client’s beside

4. A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal
monitor to the client’s abdomen. After attachment of the electronic fetal monitor, the initial
nursing assessment is which of the following?
1. Identifying the types of accelerations
2. Assessing the baseline fetal heart rate
3. Determining the frequency of the contractions
4. Determining the intensity of the contractions
R: 2. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline
rate will be identified if they occur. The intensity of contractions is assessed by an internal fetal
monitor, not an external fetal monitor. Options 1& 3 are important TO ASSESS BUT NOT AS THE
1ST PRIORITY. Fetal heart rate is evaluated by assessing both baseline & periodic changes. Periodic
changes occur in response to intermittent stress of uterine contractions & the base line beat-beat
variability of the fetal heart rate.

5. Which assessment finding is not a contraindication for using a tocolytic agent to manage
preterm labor?
A. Cervical dilatation of 2-3 cm
B. Active vaginal bleeding
C. Cervical dilatation of 4-5 cm
D. Fetal distress
Rationale:
A. Cervical dilatation of 2-3 cm is not contraindicated in the use of tocolytic agent, which inhibits
uterine contraction. Tocolytic agents should not be used when prolonging the pregnancy may jeopardize
maternal or fetal-wellbeing, such as in cases of active vaginal bleeding, fetal distress, cervical
dilatation of 4 cm or more, and chorioamnionitis. Because premature rupture of
membrane increases the risk of ascending intrauterine infection, the use of tocolytic agents in
women in this condition is still being investigated.

6. Which adverse effect is not associated in the with the tocolytic agent ritodrine (Yutopar)?
A. Fetal hypoxia
B. Maternal hyperkalemia
C. Maternal palpitation
D. Fetal hypoglycemia
 Rationale:
B.Ritodrine hydrochloride (Yutopar) is not associated with the development of maternal
hyperkalemia; however the drug may cause potassium to shift into the cells, resulting in hypokalemia.
Ritodrine, a beta- receptor agonist, stimulates the beta2-adrenergic receptors in smooth muscle, thereby
decreasing uterine activity. Beta-adrenergic therapy may cause fetal hypoglycemia, hypoxia,
tachycardia, and hypotension; maternal adverse effects include palpitation, tremor, tachycardia,
hypotension, nervousness, nausea and vomiting, headache, erythema, hyperglycemia, and metabolic
acidosis.

7. The nurse establishes an IV line and then connects Mrs. B to a fetal monitor. The fetal monitoring
strip shows an FHR deceleration occurring at 30 seconds after each contraction begins; the FHR
return to the baseline after the contraction is over. This type of deceleration is caused by:
A. Umbilical cord compression
B. Uteroplacental insufficiency
C. Fetal head compression
D. Cardiac anomalies
Rationale:
B. The monitoring strip shows late decelerations, which are caused by uteroplacental insufficiency –
inadequate fetal oxygenation resulting from decreased blood flow during uterine contractions.
Uteropalcental insufficiency may be caused by maternal hypotension, tetanic contractions, postmaturity,
abruption placentae, or pregnancy-induced hypertension. Fetal head compression typically causes early
deceleration, which begin and end at approximately at the same time after the contractions. Umbilical cord
compression results in variable decelerations, which are unpredictable in time of onset, duration, and
appearance. Cardiac anomalies do not cause decelerations.

8. The LOA position means that:

A. Lie in oblique and the fetal anterior fontanel is directed toward the left posterior portion of the maternal
pelvis
B. Lie is longitudinal and the fetal occiput is directed toward the left posterior portion of the maternal
pelvis
C. Lie is transverse and the fetal mentum is directed toward the left posterior portion of the maternal pelvis
D. Lie is longitudinal and the fetal occiput is directed toward the left anterior portion of the maternal pelvis
Rationale:
D. Because the fetus is in vertex presentation (in which the top of the skull is the presenting part), the lie
(the relationship of the fetus’s spine to the mother’s spine) is longitudinal (parallel), not transverse
(perpendicular) or oblique (angled); LOA means that the presenting landmark, the fetal occiput (back of the
skull), is directed toward the left anterior portion of the maternal pelvis.

9. Mrs. Q., is being infused with 1,000 ml of dextrose 5% in water. How should the nurse proceed
with administering the prescribed oxytocin?
A. Add 10 units of oxytocin to 1 liter of a prescribed solution, then piggy back the solution to the main IV
line.
B. Add 10 units of oxytocin to the main IV line
C. Add 10 units of oxytocin to 500 ml of a prescribed solution using an infusion control device, the
piggyback the solution to the main IV line.
D. Add 10 units of oxytocin in 1 liter of a prescribed solution using an infusion control device, then
piggyback the solution to main IV line.
Rationale:
D. To administer oxytocin, the nurse should add 10 units of the drug to a prescribed solution using an
infusion control device, and then piggyback the solution to the patient’s main IV line. The usual dose of
oxytocin is 10 units/1,000 ml of dextrose 5% in a balanced salt solution, such as Lactated Ringer’s solution
or water, yielding a concentration of 10mU/ml. the nurse should always add the oxytocin to another
solution that is piggybacked into the main Iv line; this permits immediate discontinuation if adverse
reactions should occur. She should use an infusion control device to ensure accurate dosage.

J., gravida 2 para 0010, is admitted to the labor and delivery area. Initial assessment reveals cervical
dilatation of 4 cm; cervical effacement 100%; station 0; contractions, moderately intense and
occurring every 5 to 6 minutes and lasting 45 to 60 seconds; the fetal membranes are intact. Fetal
heart tones are loudest in the left upper quadrant; FHR is 140 -150 beats/minute with normal
variability. Maternal vital signs include blood pressure of 124/70mmHg; pulse rate, 84beats/minute;
respiratory rate, 26 breaths/min; and temperature, 990F (37.20C). When performing Leopold’s
maneuver, the nurse detects a hard, round abject at the level of the fundus.

10. Assessment finding for J. indicates that the fetus is in a:

A. Cephalic presentation
B. Transverse position
C. Breech position
d. Posterior position
Rationale:
C. Fetal heart tones that sound loudest in the upper quadrant (above the level of the umbilicus) indicate a
breech presentation, in which the fetus’s buttocks or feet are the presenting parts. With a cephalic
presentation, fetal heart tones would be loudest below the umbilicus. With a posterior position, a specific
landmark on the presenting part would be directed toward the posterior portion of the maternal pelvis. With
a transverse lie, the fetus’s long axis would be perpendicular to the mother’s.

POSTPARTAL PERIOD 10 items

1. After delivery, a cardiac patient should not breast-feed if she is:

A. A class-II patient
B. Receiving heparin therapy
C. Receiving warfarin sodium (Coumadin) therapy
D. Receiving antibiotic therapy

2. Four hours after delivery, the nurse assesses Mrs. A. to determine which phase of maternal
adaptation she is in. which behavior would indicate that Mrs. S. is not in the “taking in” phase?
A. Depending on others for decisions
B. focusing her energy on herself instead of the neonate
C. Exercising
D. Talking about the childbirth experience

3. Which behavior of Mrs. A. would indicate the nurse’s breast-feeding teaching has been effective?
A. Breast feeding the neonate every 2-3 hours or on demand, whichever comes first
B. Breast-feeding the neonate every 4 hours
C. Allowing the neonate to breast-feed for only 3-5 minutes from each breast the first day after
delivery
D. Supplementing her breast-feeding with bottle feedings of glucose and water

Mrs. O., gravida 2 para 2002, has been admitted to the postpartal unit after an uncomplicated labor
and vaginal delivery. She plans to breast-feed her neonate.
4. Mrs.O, complains of sever cramping. The nurse knows that such cramping commonly is associated
with:
A. Uterine involution
B. Infection
C. Bladder distention
D. Retained placental fragments
5. A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn
infant. In the immediate postpartum period the nurse plans to take the woman’s vital signs:
1. Every 30 minutes during the first hour and then every hour for the next 2 hours
2. Every 15 minutes during the first hour and then every 30 minutes for the next 2
hours
3. Every hour for the first 2 hours and then every 4 hours
4. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours

6.A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing
action in performing this assessment is which of the following?
1. Ask the client to turn on her side
2. Ask the client to lie flat on her back with the knees and legs flat and straight
3. Ask the mother to urinate and empty her bladder
4. Massage the fundus gently prior to determining the level of the fundus

7. A nurse in a postpartum unit is instructing a mother regarding lochia and the amount of expected
lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but
should never exceed the need for:
1. 1 peripad a day
2. 2 peripads a day
3. 3 peripads a day
4. 8 peripads a day

8. C., a 32-year-old gravida 2 para 1001, is admitted to the labor and delivery area. Her contractions
are strong, and her labor is progressing normally. Fetal monitor shows regular, moderate
contraction severity 5-7 minutes and a FHR of 186 beats/minute. Suddenly, the patient’s membranes
rupture. While assessing the appearance of the amniotic fluid, the nurse notices the umbilical cord at
the introitus.
To prevent further complications, the nurse’s first action should be to:
A. Continue to check the FHR
B. Push the cord away from the presenting part
C. Notify the physician
D. help the patient to a sitting position
.

Mrs. F receives a pudendal block shortly before delivery.

9. After receiving a pudendal block, which reaction is Mrs. F. likely would experience?
A. Numbness of the birth canal and perineum to allow pushing during delivery
B. Numbness of the legs after delivery
C. Complete relief from uterine contractions during labor
D. delayed voiding after delivery because the nerves supplying the bladder are numb

10. The physician prescribes rubella vaccination because Mrs. D’s rubella titer is negative. Which
information should the nurse emphasize to Mrs. D before administering the vaccination?
A. The rubella vaccine provides passive immunity to the patient and protects her neonate from
acquiring the disease
B. She should avoid contact to her neonate for at least 24 hours after the vaccination
C. she should avoid pregnancy for at least 3 months
D. The rubella vaccine has no adverse effect

Medical Disorders Fertility & MATERNITY AND NEWBORN MEDICATIONS (10 items)
1. Epidural analgesia is administered to a woman for pain relief following a cesarean birth.
The nurse assigned to care for the woman ensures that which medication is readily available
if respiratory depression occurs?
1. Betamethasone (Celestone)
2. Morphine sulfate
3. Merperidine hydrochloride (Demerol)
4. Naloxone (Narcan)

2. Rho (D) immune globulin (RDIG) (anti-Rho (D) gamma globulin) is prescribed for a woman
following delivery of a newborn infant. The nurse provides information to the woman about
the purpose of the medication. The nurse determines that the woman understands the
purpose of the medication. The nurse determines that the woman understands the purpose
of the medication if the woman states that RDIG will protect her next baby from which of
the following?
1. Being affected by Rh incompatibility
2. Having Rh-positive blood
3. Developing a rubella infection
4. Developing physiological jaundice

3. Methylergonovine (methergine) is prescribed for a postpartum woman to treat postpartum

hemorrhage. Before administration of methylegonovine, the priority nursing assessment is to
check the:
1. Amount of lochia
2. Blood pressure
3. Deep tendon reflexes
4. Uterine tone

4. A nurse is preparing to administer beractant (Survanta) to a premature infant who has

respiratory distress syndrome (hyaline membrane disease). The nurse plans to administer
the medication by which of the following routes?
1. Subcutaneous
2. Intratracheal
3. Intramuscular
4. Intradermal

5. A nurse is caring for a client who is receiving pitocin (Oxytocin) for the induction of labor.
The nurse discontinues the pitocin infusion if which one of the following is noted on
assessment of the client?
1. Drowsiness
2. Fatigue
3. Early decelerations of the fetal heart rate
4. Uterine hyperstimulation

6. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A

nurse determines that the client is experiencing toxicity from the medication if which of the
following is noted on assessment?
1. Presence of deep tendon reflexes
2. Serum magnesium level of 6 mEq/L
3. Proteinuria of +3
4. Respirations of 10 per minute

7. A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for
the client determines that the magnesium sulfate therapy is effective if:
1. Ankle clonus is noted
2. The blood pressure decreases
 3. Seizures do not occur
4. Scotomas are present

8. Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage.

Prior to administering the medication, a nurse contacts the health care provider who
prescribed the medication if which of the following conditions is documented in the client’s
medical history?
1. Peripheral vascular disease
2. Hypothyroidism
3. Hypotension
4. Diabetes mellitus

9. Vitamin K (AquaMEPHYTON) is prescribed for a neonatic. A nurse prepares the

medication and selects which muscle site to administer the medication?
1. Deltoid
2. Triceps
3. Vastus lateralis
4. biceps

10. A nursing instructor asks a nursing student to describe the procedure for administering
erythromycin (0.5% Ilotycin) ointment to the eyes of a neonate. The instructor determines
that the student needs to further research this procedure if the student states:
1. “I will cleanse the neonate’s eyes before instilling ointment.”
2. “I will flush the eyes after instilling the ointment.”
3. “I will instill the eye ointment into each of the neonate’s conjunctival sacs within 1 hour
after birth.
4. “Administration of the eye ointment may be delayed until an hour or so after birth so
that eye contact and parent-infant attachment and bonding can occur.”

PSYCHIATRIC NURSING

PSYCH MEDICATIONS-10 items

1. A client in the hyperactive phase of a mood disorder, bipolar type is receiving lithium carbonate. The
nurse notes that the client’s lithium blood level is 1.8 mEq/L. It would be most appropriate for the nurse to:
a. Continue the usual dose of lithium and note any adverse reactions
b. Discontinue the drug until the lithium serum level drops to 0.5 mEq/L
c. Notify the physician immediately, since the lithium serum level may be toxic
d. Ask the physician to increase the dose of lithium, since the serum level is too low

2. The nurse evaluates that the teaching about taking the medication amitriptyline (Elavil) has been
understood when the client states:
a. “I must discontinue this medication if side effects occur.”
b. “I don’t need to be concerned about taking my medications.”
c. “It is necessary to take each dose of my medication as ordered.”
d. “I may find it necessary to adjust the dosage if side effects occur.”

3. The physician has ordered imipramine (Tofranil), 75 mg tid, for a client. An appropriate nursing action
in giving this drug is to:
a. Avoid administration of barbiturates or steroids with this drug
b. Warn the client not to eat cheese, fermenting products, and chicken liver
c. Observe the client for increased tolerance so that the therapeutic dosage is maintained
d. Have the client chicken for intraocular pressure and provide instructions to watch for symptoms of
glaucoma
4. After 2 weeks of drug therapy, the nurse notices that the client has become jaundiced. The nurse
continues to give the neuroleptic until the psychiatrist can be consulted. In situations such as this:
a. Jaundice is a benign side effect and has little significance
b. Jaundice is sufficient reason to discontinue the neuroleptic
c. The blood level of neuroleptics must be maintained once established
d. The psychiatrist’s order for the neuroleptic should be reduced by the nurse

5. A client with depression is to receive a tricylic medication. A precaution that the nurse must keep in
mind when initiating treatment with this group of drugs is that:
a. Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis
b. They must be given with milk and crackers to avoid hyperacidity and discomfort
c. The blood level may not be sufficient to cause noticeable improvement for 2 to 3 weeks
d. Blood levels will need to be obtained weekly for 3 months to check for appropriate levels

6. When administered for a heroin overdose, the planned effect of naloxone hydrochloride (Narcan) is to:
a. Compete with narcotics for receptors controlling respiration
b. Decrease analgesia and the comatose state induced by hereon
c. Accelerate metabolism of hereon and stimulate respiratory centers
d. Stimulate cortical sites controlling consciousness and cardiovascular function.
7. If clients do not abide by their diet restrictions while taking a monoamine oxidase inhibitor, it is likely
that they will develop:
a. Generalized urticaria
b. An occipital headache
c. Severe muscle spasms
d. Sudden, severe hypotension

8. Which of the following behaviors indicates to the nurse that the client’s antipsychotic medication is
having a desired effect?
a. The client states that her “voices” are not as threatening.
b. The client reports having inner feelings of restlessness.
c. The client sleeps all day.
d. The client reports muscular stiffening in her face and arms.

9. Which of the following behaviors indicates to the nurse that the client understands her teaching related to
lithium treatment? The client
a. takes her lithium one hour after meals.
b. states she will stop taking her lithium when her mania subsides.
c. goes on a low salt diet to counter weight gain.
d. states she will withhold her lithium if she experiences diarrhea, vomiting, and diaphoresis.

10. The nurse realizes that Mr. L., a client taking buspirone hydrocholoride (BuSpar), needs additional
medication teaching when he says,
a. “I’ll take my drugs as soon as I feel anxious.”
b. “I won’t drink any alcohol.”
c. “I’ll report any troubles with my heart or seeing.”
d. “Ill have my blood checked every months.”

THERAPEUTIC COMMUNICATION-10 items

1. _ On the second day after admission, a suicidal client asks the nurse, “Why am I being observed around
the clock and why is my freedom to move around the unit restricted?” The nurse’s most appropriate reply
would be:
a. “Why do you think we are observing you?”
b. “What makes you think that we are observing you?”
c. “We are concerned that you might try to harm yourself.”
d. “Your doctor has ordered it and is the one you should ask about it.”
2. A female client has been on the psychiatric unit for several days. She arouses anxiety and frustration in
the staff and manipulates so well that she intimidates any nurse who comes near her. One morning, the
client yells out at the nurse, “You’ve worked it so that I can’t go out with the group today to bowl. You’re
as cunning as a fox- I hate you! Get out or I’ll hit you!” The best response by the nurse would be:
a. “Tell me what I did to hurt you.”
b. “Go ahead and hit me if you have a need to.”
c. “I don’t really like to hear your treats and insults. Can you tell me the reason you feel this way?”
d. “You are being rude and I don’t like it. Your behavior is stopping me from wanting to stay with you.”

3. One evening the nurse finds a client who has been experiencing persecutory delusions trying to get out
the door. The client states, “Please lot me go. I trust you. The Mafia are going to kill me tonight.” The
nurse should respond:
a. “You are frightened. Come with me to your room and we can talk about it.”
b. “Nobody here wants to harm you, you know that. I’ll come with you to your room.”
c. “Come with me to your room. I’ll lock the door and no one will get in the harm you.”
d. “Thank you for trusting me. Maybe you can trust me when I tell you no one can kill you while you’re
here.”

4. During the admission procedure a client appears to be responding to voiced. The client cries out at
intervals, “No, no, I didn’t kill him. You know the truth; tells that policeman. Please help me!” The nurse
should:
a. Sit there quietly and not respond at all to the client’s statements
b. Respond to the client by asking, “Whom are they saying you killed?”
c. Respond by saying, “I want to help you and I realize you must be very frightened.”
d. Saying, “Do not become so upset. No one is talking to you; the accusing voices are part of your illness.”

5. Which of the following statements indicates to the nurse that a client with obsessive-compulsive disorder
has developed insight into her problem?
a. “I don’t realize that the dangers are more in my mind.”
b. “I don’t hear the voices anymore.”
c. “I check on my family 12 times every day.”
d. “I slept eight hours last night.”

6. During the focused assessment of a client with major depression, the nurse may ask which of the
following questions?
a. “You seem to have a lot of energy; when did you last have six or more hours of sleep?”
b. “You seem to be angry with your family now; when was it that you last got along?”
c. “Have you had any thoughts of harming yourself?”
d. “You seem to be listening to something. Could you tell me about it?”

7. The suicidal client who was admitted to the unit approximately 7 days ago is preparing for discharge. In
evaluating the coping strategies learned during hospitalization, the nurse would recognize which of the
following statements, if made by the client, indicates that further teaching needs to occur?
a. “I think this has been a very positive experience in my life”
b. “I know I must continue to take my medications just as prescribed”
c. “I now know that I can’t be all things to all people?
d. “I know that I probably won’t have depression in the future”

8. A client being discharged has a history of command hallucinations to harm self or others. The nurse
teaches the client about interventions for hallucinations and anxiety. The nurse knows the client
understands this teaching when the client says,
a. “It’s important for me to take my medication so I won’t be anxious”
b. “I will call my clinical specialist when I’m hallucinating so that I can talk about my feelings and plans
and not hurt anyone”
c. “I can go to group and talk so that I don’t hurt anyone”
d. “If I get enough sleep and eat well, I won’t get anxious and hear things”

9. The client has been admitted to the psychiatric unit on a voluntary basis. The client has reported a history
of depression over the past 5 years. Which of the following comments by the nurse would help gain the
most assessment data regarding the recent sleeping patterns of the client?
a. “Have you been having trouble sleeping at home?”
b. “How did you sleep last night?”
c. “Tell me about your sleeping patterns.”
d. “You look as if you could use some sleep.”

10. The nurse observes a withdrawn client blocking the hallway, walking three steps forward and then two
steps backward. Other clients are agitated in trying to get past. The nurse intervenes in this problem by
a. Standing along side of client and saying, “You’re very anxious today.”
b. Stopping the behavior and saying, “You’re going to get exhausted.”
c. Having the client taken to the TV lounge and saying. “Relax and watch television now.”
d. Walking along side of client and saying, “You’re not going anywhere very fast doing this.”

Psychiatric Mental Disorders-10 items

1. A 23-year-old has been admitted to a psychiatric hospital after a month of unusual behavior that included
eating and sleeping very little, talking and singing constantly, and frequent shopping sprees. In the hospital,
the client is demanding, bossy, and sarcastic. The symptoms the client is exhibiting are usually found in
clients with the diagnosis of:
a. Mood disorder
b. Major depression
c. Personality disorder
d. Schizophrenic disorder

2. A male client with delusions of persecution and auditory hallucinations is admitted for psychiatric
evaluation after stabbing a friend. Later, the nurse on the unit greets the client by saying. “Good evening.
How are you?” The client, who has been referring to himself as “man,” answer, “The man is bad.” This is
an example of:
a. Dissociation
b. Transference
c. Displacement
d. Reaction formation

3. A client with a diagnosis of paranoid schizophrenia reports to the nurse that he hears a voice that says,
“Don’t take those poisoned pills from that nurse!” Which one of the following nursing diagnoses would it
be appropriate for the nurse to make regarding this statement?
a. Sensory perceptual alteration: auditory, related to anxiety as evidence by auditory hallucination.
b. Altered thought processes related to anxiety as evidence by delusions of persecution.
c. Defensive coping related to impaired reality testing as evidence by paranoid ideation.
d. Impaired verbal communication related to disturbances inform of thinking as evidence by use of
symbolic references.

4. The nurse would formulate which of the following outcome criteria for a client with borderline
personality disorder? The client
a. displays anger frequently.
b. acts to her neediness.
c. experiences troubling thoughts. Without self-mutilation.
d. idolizes her nurse.
5. A man is brought into the police station after he ran toward a boy who resembled his son. At the police
station he was unable to recall any personal information. The prescreening nurse inferred that the man has
which one of the following dissociative disorders?
a. Amnesia.
b. Fugue.
c. Personality disorder.
d. Stress disorder.

6. The nurse makes the following assessment of a 14-year-old gymnast: underweight, hair loss, yellowish
skin, facial lanugo, and peripheral edema. These findings are suggestive of which of the following
disorders?
a. Anorexia nervosa.
b. Bulimia nervosa.
c. Acquired immunodeficiency.
d. Ulcerative colitis.

7. Which of the following assessment findings would the nurse observe in a client with schizophrenia?
a. Associative looseness, affect disturbance, ambivalence, autistic thinking.
b. Euphoria, distractivility, dramatic mannerisms, energetic.
c. Argumentative, anhedonia, poor judgment, manipulative.
d. Psychomotor retardation, intense sadness, loss of energy, suicidal.

8. The client is complaining of difficulty concentrating, having outbursts of anger, and feeling “keyed up”
all the time and that peer relations are poor. The nurse obtaining the client’s history discovers that the
symptoms started about 67 months ago. The client reveals that his or her best friend was killed in a drive-
by shooting while they were sitting on the porch talking. The nurse suspects the client is experiencing
a. Obsessive-Compulsive Disorder.
b. Panic Disorder.
C. Post Traumatic Stress Disorder.
d. Social Phobia.

9. The client arrives in the emergency room after being in an automobile accident. The client was
physically unharmed yet was hyperventilating and complaining of dizziness and nausea. In addition, the
client appeared confused and had difficulty focusing on what was going on. The nurse would assess the
client’s level of anxiety as
a. Mild.
b. Moderate.
c. Severe.
d. Panic.

10. A client with a diagnosis of catatonic excitement has been pacing rapidly nonstop for several hours, not
eating or drinking. The nurse recognizes that in this situation.
a.There is an urgent need for physical and medical control.
b. There is an urgent need for restraint.
c. There is a need to encourage verbalization of feelings.
d. The client will soon become catatonic stuporous.

TREATMENT MODALITIES-10 items

1. A hyperactive, manic client might be redirected therapeutically by:

a. Asking the client to guide other clients as they clean their rooms
b. Encouraging the client to tear pictures out of magazines for a scrap book
c. Suggesting the client initiate social activities on the unit for the client group
d. Providing a pencil and paper and encouraging the client to write a short story
2. A physician has been a client of the psychiatric service for the past 3 days. The client has questioned the
authority of the treatment team, has advised other clients that their treatment plans are wrong, and generally
has been disruptive in group therapy. The nurse’s most appropriate response would be to:
a. Ignore the client and hope the disruptive behavior will stop
b. Tell the other clients that they should not pay attention to what the client says
c. Restrict the client’s contract with other clients until the disruptive behavior cases
d. Understand that the client is unable to control this behavior and that limits must be set

3. An extremely depressed client is to begin electroconvulsive therapy. The nurse in explaining this
procedure, should emphasize that:
a. Answers to any questions will be provided
b. A period of amnesia will follow the treatment
c. The treatments will make the client feel better
d. The client will not be alone during the treatment

4. An elderly, depressed client frequently paces the halls, becoming physically tired from the activity. To
help the client reduce this activity, the nurses should:
a. Supply the client with simple, monotonous tasks
b. Request a sedative order from the client’s physician
c. Restrain the client in a chair reducing the opportunity to pace
d. Place the client in a single room, thus limiting pacing to a smaller area

5. While the nurse is talking with a client, a female client comes up and yells, “I hate you. You’re talking
about me again.” And throws a glass of juice at the nurse. The best nursing approach would be to:
a. Understand her behavior and say, “You hate me? Tell me about that.”
b. Ignore both the behavior and the client, clean up the juice, and talk to her when she is better
c. Remove the client to an isolation room because she needs to have limits placed on her behavior
d. Verbalize feelings of annoyance as an example to the client that it is more acceptable verbalize feelings
than to act out

6. Mr. K. is admitted for panic attacks. He frequently experiences shortness of breath, palpitation, nausea,
diaphoresis, and tremors. What should the nurse include in the care plan for Mr. K. when he is having a
panic attack?
a. Calm reassurance, deep breathing, and medication as ordered.
b. Teach Mr. K. problem solving in relation to his anxiety.
c. Explain the physiologic responses of anxiety.
d. Explore alternate methods for dealing with the cause of his anxiety.

7. Mr. L., a client with major depression, is scheduled for electroconvulsive therapy (ECT) tomorrow. The
nurse would plan for which of the following activities?
a. Force fluids six to eight hours before treatment.
b. Administer succinylcholine (Inestine, Anectine) during pretreatment care.
c. Encourage Mr. L.’s wife to accompany him.
d. Reoreint Mr. L. frequently during post treatment care.

8. Mr. T. has hypochondriasis-believing he is dying of stomach cancer despite repeated and extensive
diagnostic testing that has all been negative. He has become reclusive and is preoccupied with his physical
complaints. The nurse would include which of the following in Mr. T.’s nursing are plan? Mr. T. will
a. Focus on the sings and symptoms of stomach cancer.
b. attend a support group for persons with cancer
c. Complete a contract to attend social and diversional activities daily.
d. Receive secondary gain from his physical symptoms.

9. The nurse is caring for a client with anorexia nervosa who is to be placed on behavior modification.
Which is appropriate to include in the nursing care plan?
a. Remind the client frequently toe at all the food served on the tray.
b. Increase phone calls allowed the client by one per day for each pound gained.
c. Include the family with the client in therapy sessions two times per week.
d. Weight the client each day at 6:00 A.M. in hospital gown and slippers after she voids.

10. Mrs. P. is a client with an OCD who has checking rituals and thoughts that her family will be harmed.
Which of the following indicates to the nurse that Mrs. P. is improving? Mrs. P.
a. obsesses about her family’s health.
b. adheres to the unit schedule.
c. loses two pounds in one week.
d. Awaken eight times during the night.

PSYCHIATRIC CONCEPTS-10 items

1. The nurse is meeting a new client on the unit. Which action, by the nurse, is most effective in initiating
the nurse-client relationship?
a.Introduce self and explain the purpose and the plan for the relationship.
b. Describe the nurse’s family and ask the client to describe his/her family?
c. Wait until the client indicates a readiness to establish a relationship.
d. Ask the client the reason she/he was brought to the hospital.

2. The nurse is talking with a mother to assess her child. A positive response to which question would
indicate the child is in the anal stage of psychosexual development as described by Freud?
a. “Does he put everything in his mouth?”
b. “Does he say ‘No!’ to everything you say?”
c. “Does he like to dress up and printed to be his father?”
d. “Does he seem jealous when you show affection to his father?

3. Which of the following nursing diagnoses would be most appropriate for a client who is diagnosed as
bipolar I disorder, single manic episode and is Intrusive, argumentative, and severely critical of peers?
a. Impaired social interaction related to narcissistic behavior as evidenced by inability to sustain relationships.
b. Risk for injury related to extreme hyperactivity as evidence by increased agitation and lack of control
over behavior.
c. Social isolation related to feelings of inadequacy in social interaction as evidenced by problematic
interaction with others.
d. Defensive coping related to social learning patterns as evidenced by difficulty interacting with others.

4. Mr. T., a severely depressed client, received ECT this morning. Which of the findings listed below
would the nurse least expect to assess post-treatment?
a. Head ache.
b. Memory loss
c. Ileus.
d. Disorientation.

5. A woman comes into the emergency room in a state of severe anxiety after a car accident. The most
important nursing intervention would be to
a. Remain with the client.
b. Put the client in a quiet room.
c. Teach the client deep breathing.
d. Encourage the client to talk about feelings and concerns.

6. Which of the following is a reasonable outcome for the elderly client with dementia who has a nursing
diagnosis of Self-Care Deficit?
a. The client will be admitted to a nursing home to have activities of daily living (ADLs) needs met
b. The client will function a the highest level of independence possible
c. The client will complete all ADLs independently within a 1 – to 1 ½ hour time frame
d. The nursing staff will attend to all the client’s ADL needs during the hospital stay
7. The nurse has been working with a victim of rape in an outpatient setting for the past 4 weeks. When
planning the short-term goals for these sessions, which of the following is inappropriate?
a. The client will resolve feelings of fear and anxiety related to the rape trauma
b. The client will experience healing of the physical wounds that were incurred at the time of the rape
c. The client will verbalize feelings about the rape event
d. The client will participate in the treatment plan by keeping appointments and follow

8. An elderly client has been identified as a victim of physical abuse. In planning of care, priority is placed
on
a. Obtaining treatment for the abusing family member.
b. Adhering to the mandatory abuse reporting laws.
c. Notifying the case worker to intervene in the family situation
d. Removing the client from any immediate danger.

9. In planning care for the suicidal client, the nurse meets with family members and identifies community
resources that may be of help to the client after discharge. The nurse takes these actions because the nurse
is aware that suicidal clients.
a. Demonstrate delusions of grandeur.
b. Have limited social support systems
c. Tend to be non-compliant.
d. Rarely can return to their occupations.

10. In planning care for the suicidal clients on the unit, the nurse needs to be aware that extra precautions
are warranted at which of the following times?
a. Days shift
b. Weekdays
c. 7 A.M to 10 A.M
d. Shift change

MEDICAL SURGICAL NURSING

Respi 5 items
Cardiac 5 items
Neurosensory 5 items
Musculo 5 items
G.I. 5 items
Endo & Onco 10 items
Hema & Infectious 5 items
Renal 5 items
Fluid & E 5 items
________________________
50 items

RESPIRATORY – 5 items

1. Mr. A., a patient with status asthmaticus, becomes less responsive. Arterial blood gas analysis
reveals a partial pressure of carbon dioxide in arterial blood (PaCO2) of 60mmHg and PaO2 of
55mmHg. The data most likely indicate acute:
A. Pneumonitis
B. Respiratory failure
C. Pulmonary edema
D. Pulmonary embolism

M., a 19-year-old college student, is on the varsity football team. During a game, he is tackled and
sustains fractured ribs on the right side of the chest. He is taken to the emergency department in a
local hospital.
2. Which initial manifestation should the nurse expect with this patient?
A. Shallow, painful breathing
B. Diminished breath sounds on the affected side
C. A clicking sensation during inspiration
D. Paradoxical respirations

3. Which condition would most likely indicate that M.’s chest tube should be removed?
A. Lung reexpansion on chest x-ray
B. 120 ml of chest tube drainage in 24 hours
C. Cessation of pain and dyspnea
D. Absence of fluid fluctuation in the water-seal chamber

4. Which method would best prevent the air from entering the pleural cavity after removal of M.’s
chest tubes?
A. Breathing with an open mouth
B. Breathing through pursed lips
C. Performing Valsalva maneuver
D. Breathing quickly and shallowly (panting)

Mr. S., a 65-year-old retired steel mill worker, is admitted to the unit with dyspnea upon exertion. He
has a long history of smoking. Initial assessment includes barrel chest, ankle edema, persistent cough
wit copious sputum production, and variable wheezing on expiration. Laboratory test results include
a hematocrit greater than 60% and a partial pressure of carbon dioxide in arterial blood gas
(PaCO2) of 65mmHg. The physician diagnosis chronic obstructive pulmonary disease (COPD).
5. Mr. S.’s, ankle edema and respiratory problem would make the nurses suspect hypertrophy of the
which heart chamber?
A. Left ventricle
B. Right ventricle
C. Right atrium
D. Left atrium

CARDIAC SYSTEM

1 Intermittent claudication is an indication of which condition?

A. Mitral regurgitation
B. Venous insufficiency
C. Arterial insufficiency
D. Phlebitis

2 Which statement does not accurately describe Raynaud’s disease?

A. It is precipitated by exposure to cold air or by emotional stress
B. Its is characterized by episodic digital vasospasm associated with skin color changes
C. It usually occurs in men ages 40 to 60
D. It is typically seen in fingers and toes

Mr. S., age 36, is admitted to the hospital with a diagnosis of congestive heart failure (CHF). The
3 When assessing Mr. S., for signs and symptoms of digoxin toxicity, the nurse should watch all of the
following except:
A. Anorexia, nausea and vomiting, diarrhea, and abdominal pain
B. Bradycardia, tachycardia, bigeminy, ectopic beats, and pulse deficits
C. Abdominal distention, weakness, paralysis, apathy, depression, and hallucinations
D. Headache, double or blurred vision, drowsiness, confusion, restlessness, and muscle weakness.

Mrs. J., a 58-year-old patient with long standing hypertension, is admitted for shortness of breath.
During morning rounds the nurse notices that Mrs. J. has developed an S4 gallop, crackles, and
diminished breath sounds, which indicate CHF.
4 Mrs. J., is admitted a year later with a diagnosis of malignant hypertension. Which drug is
commonly used to treat this disorder?
A. ACE inhibitors and diuretics administered orally
B. Vasodilators and diuretics administered intravenously
C. Beta blockers and angiotensin converting enzymes (ACE) inhibitors administered orally
D. Adrenergic blockers and vasodilators administered intravenously

Mr. T., a 57-year-old steelworker with a history of angina, has been having more frequent attacks of
chest pain. He is admitted to the ED with chest pain unrelieved by three nitroglycerin tablets. The
physician diagnosis Prinzmetal’s variant angina.
5 Mr.T.’s MI extends, and begins to show signs of left ventricular failure. Which sign would appear
first?
A. An S3 heart sound
B. An S4 heart sound
C. Pink, frothy sputum
D. Crackles an cough

NEUROSENSORY SYSTEM 5 ITEMS

1. Which medication is not appropriate for a patient with a craniotomy?

A. Phenytoin (Dilantin)
B. Codeine
C. Meperidine (Demerol)
D. Dexamethasone (decadron)

2. All of the following signs indicate increased intracranial pressure except:

A. Decreased level of consciousness
B. Papilledema
C. Vomiting
D. Tachycardia

3. Which assessment most strongly suggest Meniere’s disease?

A. Vertigo
B. Nausea
C. Neurosensory hearing loss
D. Tinnitus

4Characteristic clinical manifestation of ALS do not include:

A. Uncontrolled outburst of crying
B. Aphagia and dysarthria
C. Loss of bowel and urine control
D. Fasciculation of the involved muscles

5. rs. D.’s physician orders myelogram using a water-soluble contrast medium. Which nursing
activity is most appropriate for Mrs.D after his procedure?
A. Monitoring level of consciousness
B. Restricting fluids for 6 to 10 hours
C. Placing the patient in a recumbent position for 12 to 24 hours
D. Elevating the head of the bed 15 to 30 degrees

(Musculo) 5 items
1. A 15-year-old is treated in the emergency room for a fractured right ankle. A plaster walking cast
is applied and the client is instructed to walk with the aid of crutches once the cast has dried. While
instructing the client to ambulate with crutches the nurse most appropriately teaches the client to:
A. Move both crutches and the right foot forward simultaneously followed by the left foot
B. Move the right foot and the left foot forward together followed by the left foot and right crutch
C. Move crutches and feet in the following sequence: right crutch, left foot, left crutch, right foot
D. Place the crutches under the arms, bear weight on the axilla, and position both crutches 8-10 inches in
front of the body

2. The nurse is assisting a client who has broken ankle with crutch walking. The nurse knows the
client understands the instructions when the client:
A. Leans on the crutch pads to relieve pressure on the affected foot
B. Advances both crutches and the affected leg at the same time
C. Puts partial weight on the affected side
D. Advances both crutches and the unaffected leg at the same time
3. A 2-day-old infant is diagnosed as having congenital hip dysplasia of the right hip. The infant is
fitted with a Pavlick harness. Which of the following would not be included in the instructions for
home care of the patients?
A. Turn her every 3-4 hours
B. Watch for signs of skin breakdown
C. Keep her off the affected side
D. Give her sponge baths, not tub baths

Mrs. D., a 32-year-old homemaker, is admitted to the hospital with a history of urine retention. Her
physician suspects multiple sclerosis (MS).
4 Which diagnostic tool helps confirm the diagnosis of MS?
A. Skull x-rays
B. Cerebrospinal fluids
C. Electromyography
D. Electroencephalography

Mr. C., a 65-year-old retired assembly line worker, is admitted to the hospital with a diagnosis f
Parkinson’s disease.
5 The physician orders 1 mg of benztropine mesylate (Cogentin) P.O. daily for Mr. C., which finding
suggests a favorable effect from this medication?
A. Decreased tremors
B. Decreased muscle rigidity
C. Decreased confusion
D. Decreased dizziness

GASTROINTESTINAL SYSTEM

1. A client who is experiencing ascites is admitted to the hospital and will be undergoing a
paracentesis. What should be included in the nursing care plan?
A. Place client in Trendelenberg position for the procedure
B. Monitor client closely for evidence of vascular collapse
C. Have client remain on bed rest for 24 hours following the procedure
D. Encourage the client to drink plenty of fluids to distend the bladder prior to procedure

2. A woman is admitted for a suspected duodenal ulcer. The nurse is interviewing her for an
admission history. Which description of her pain would be most characteristic of duodenal ulcer?
A. Right upper quadrant that increases after meals
B. Aching in the epigastric area that wakens her from sleep
C. A sensation of painful pressure in the midsternal area
D. Sharp pain in the epigastric area that radiates to the right shoulder
Mr. F., age 60, is admitted to the hospital with ascites and jaundice to rule out cirrhosis of the liver.
3 The physician schedules Mr.F., for a liver biopsy to confirm the diagnosis of cirrhosis. Which
crucial information should the nurse tell Mrs.F before the procedure?
A. The procedure is painless
B. He should hold his breath on exhalation when biopsy needle is inserted
C. Pressure will be applied to his right side after the procedure
D. He must maintain a side-lying position after the procedure

Mr. M., a 42-year-old accountant, is admitted to the hospital with intestinal obstruction. A flat-plate
x-ray of the abdomen shows a mass, which may be malignant.
4 Which type of tube will Mr. M.’s physician require for intestinal decompression?
A. Levin
B. Salem sump
C. Ewald
D. Miller-Abbott

Mr. O., a 50-year-old postal worker, is admitted to the hospital with acute pancreatitis.
5 If Mr. O., begins to exhibit muscle twitching and irritability, the nurse should:
A. Call the physician because the patient may have hypocalcemia
B. Administer analgesics because the symptoms may be caused by pain
C. Check his serum amylase level
D. Reassure the patient that this is common among people who abuse alcohol

ENDOCRINE and ONCOLOGY

1. Which medication is not an oral hypoglycemic agent?

A. Glipizide (Glucotrol)
B. Tolbutamide (Orinase)
C. Chlorpropamide (Diabinese)
D. Diazoxide (Hyperstat)

2. When caring for Mrs. B., a diabetic patient starting prednisone (Deltasone) therapy for severe
arthritis, the nurse should expect:
A. Worsened diabetes control
B. No effect on diabetes control
C. Improved diabetes control
D. Frequent hypoglycemic reactions

3. Parenteral injections of cortisol for patients with Addison’s disease should be injected:
A. After the patient eats
B. Deep into the deltoid muscle
C. Deep into the gluteal muscle
D. Into the subcutaneous tissue

4 According to current American Cancer Society recommendations, women age 50 and over should
have a routine mammography:
A. Every 2 years
B. Every year
C. Only if symptomatic
D. Every 5 years

5 Which assessment finding to a patient with prostatic cancer indicates metastasis?

A. Pus in urine
B. Urinary frequency and decreased urinary stream
C. Decrease serum alkaline phosphatase level
D. A complaint of lumbosacral pain

Mr. V., age 55, is admitted to the hospital with a diagnosis of chronic lymphocytic leukemia
6.During routine care, the patient asks the nurse,”How can I be anemic if this disease causes
increased white cell production?” the nurse’s response would be that increased number of white
blood cells (WBC):
A. Are not responsible for the anemia
B. Crowd out red blood cells
C. Have an abnormally short life span
D. Use nutrients from other cells

7. Diagnostic assessment of Ms. V., would probably not reveal:

A. Leukocytois with a shift from the left
B. Abnormal blast cells in the marrow
C. An elevated thrombocyte count
D. A predominance of lymphocytes

8. Several days after admission Mr.V., becomes disoriented and complains of frequent headaches.
The nurse first action would be to:
A. Raise the rails of the bed
B. Call the physician
C. Document the patient’s status on detail in her chart
D. Prepare oxygen equipment

9. Which statement about bone marrow transplantation-the treatment of choice for patients under
age 40 with leukemia-is not correct?
A. The bone marrow aspirated is mixed with heparin
B. The patient is under local anesthesia
C. The recipient receives cyclophosphasmide (cytoxan) for 4 consecutive days
D. The aspiration site is the posterior or anterior iliac crest

Mrs. R., age 53 has been experiencing bone pain, recurrent infections and abdominal pain for the
past 5 years. After ordering a battery of tests, including x-ray studies, the physician diagnosis
multiple myeloma.
10.The physician orders the administration of melphalan (Alkeran) for Mrs.R., because this drug
causes pancytopenia, the nurse should assess the patient for:
A. Decreased WBC count
B. Alopecia
C. Skin pigmentation
D. Thrombophlebitis

HEMATOLOGIC AND INFECTIOUS 5 items

Ms. X., age25, complains of chronic fatigue, particularly after menstrual periods, which she says
sometimes last for 6 days; her sanitary often are saturated in 2 hours. After a general prescribed oral
ferrous sulfate (Feosol) therapy, Ms. X., remained fatigued and pale, and tiny bruises appear on her
arms. An internist refers her then to a hematologist, who diagnosed idiopathic thrombocytopenic
purpura (ITP) and admitted her to the hospital.
1. Which assessment finding is not typical of ITP?
A. Prolonged activated partial thromboplastin time
B. Prolonged bleeding
C. Decreased platelet count
D. Increased capillary fragility
Mr. V., age 24, is an AIDS patient with a diagnosis of Pneumocytis carinii pneumonia. During 2 weeks
of hospitalization with isolation precautions, he has had no visitors.
2. The patient with AIDS-related complex typically has a history of:
A. Hairy leukoplakia of the tongue and a chronic cough
B. Oral candidiasis, molluscum, contagiosum, and bullous impetigo
C. Sever fatigue, lymphadenopathy, and diarrhea
D. Memory loss, night sweats, and disorientation

3. Which type of infection control does an extremely ill hospitalized patient with AIDS require?
A. Blood and body fluid precautions
B. Respiratory isolation
C. Reverse isolation
D. Contact isolation

4. How is Lyme disease treated?

A. Antibiotic treatment with doxycycline or amoxicillin for 7-10 days.
B. Antibiotic treatment with cefuroxime axetil or erythromycin for 7-10 days.
C. There is no treatment; the disease must run its course.
D. Antibiotic treatment with doxycycline or amoxicillin for 3-4 weeks.

5. A 30-year-old nonsmoking patient who is in general good health is diagnosed with acute bronchitis
and is now being discharged. Which of the following patient responses indicate a need for further
patient education?
A. “I need to drink 8 to 10 glasses of water daily until I’m over this.”
B. “I should get a flu shot in about 6 weeks so I don’t get this again.”
C. “I can take over-the-counter cough suppressants to reduce my coughing at night.”
D. “I should come back to the hospital or see my doctor if my sputum turns rusty colored.”

RENAL 5 items

1. A nurse is caring for a client who has had renal biopsy. Which of the following intervention would
the nurse AVOID in the care of the client after this procedure?
1. Ambulating the client in the room and hall for short distances.
2. Forcing fluids to at least 3 liters in the first 24 hours.
3. Administering PRN narcotics.
4 Testing serial samples with dipstick for occults blood.

2. The nurse is receiving in transfer from post anesthesia care unit client who has had percutaneous
ultrasonic lithotripsy. For calculi in the renal pelvis. The nurse anticipates that the client’s care will
involve monitoring which of the following?
1. Jackson-Pratt drain
2. Ureteral stent
3. Suprapubic tube
4. Nephrostomy tube

3. A client is admitted to an emergency department following a motor-vehicle accident. The client

was wearing a lap seat belt when the accident occurred. The client has hematuria and lower
abdominal pain. To further determine whether the pain is due to bladder trauma, a nurse asks the
client if the pain is referred to which of the following areas?
1. Umbilicus
2. Shoulder
3. Hip
4. Costovertebral angle
4. A client with chronic renal failure (CRF) returns to the nursing unit after following a hemodialysis
treatment. On assessment the nurse notes that the client’s temperature is 100.20C. which of the
following is the most appropriate nursing action?
1. Encourage fluids
2. Continue to monitor vital signs
3. Notify the physician
4. Monitor the site of the shunt for infection

5. A client passes a urinary stone, and laboratory analysis of the stone indicates that the stone is
composed of calcium oxalate. On the basis of this analysis, the nurse would include which of the
following in the client’s dietary instructions?
1. Avoid green leafy vegetables, such as spinach
2. Avoid citrus fruits and citrus juices
3. Increase intakes of meat, fish, plum and cranberries
4. Increase intake of dairy products

Fluid & Electrolytes- 5 items

1. Your post-operative client is to receive potassium chloride. Regarding the administration of IV

potassium, you know:
1. potassium may be given as a straight intravenous push to avoid fluid overload
2. potassium is usually mixed 1000 mEq/1000 cc of IV fluid
3. intravenous potassium may only be mixed in normal saline
4. intravenous potassium should be administered through a large vein

2. A client with DM is admitted with a UTI. The initial assessment reveals T-102.5, P-98, BP-97/65,
and blood glucose 300 mg/dL. Prescriptions read: Intravenous fluids 5 % dextrose in water to infuse
@ 100 mL/ hr, cefoxitin (Mefoxin) 1 gm intravenously q 4 hrs, acetaminophen (Tylenol) 650 mg by
mouth every 4 hrs for temp. greater than 101.5 deg. F or pain, & sliding scale insulin for elevated
blood glucose. Which prescriptions will be questioned?
1. cefoxitin (Mefoxin) 1 gm intravenously q 4 hrs
2. D5W intravenous infusing 100 mL/hr
3. acetaminophen (Tylenol) 650 mg by mouth q 4 hrs
4. sliding scale insulin

3. A client with diabetes is experiencing DKA & is to receive intravenous fluids containing sodium
bicarbonate. Regarding the administration of this intravenous fluid you know:
1. sodium bicarbonate administration may result in alkalosis
2. most medications are compatible with sodium bicarbonate
3. sodium bicarbonate may not be given as an intravenous bolus or push
4. sodium bicarbonate may only be given IM

4. A client enters the hospital in acute renal failure. The client complains of drowsiness, nausea & has
Kussmaul’s breathing. Lab tests show a serum potassium of 6.8, serum sodium of 120, & bld pH of
7.2. W/c of the ff MD’s prescriptions should be questioned?
1. polystyrene sodium sulfonate (Kayexalate) 50 mg per rectum as enema
2. 2000-calorie, high carbohydrate, high protein diet when nausea subsides
3. hypertonic glucose (25%) 300 cc w/ regular insulin per IV infusion over 1 hour
4. limit po fluids per 8 hrs to no more than 100cc above the urinary output for the previous 8
hrs

5. A blunt trauma patient with a descending thoracic aortic tear has been rapidly transfused with 12
units of packed RBC. Based on the observation, the ED nurse should anticipate which of the
following blood products?
BP 96/64 mmHg PT 38 sec Hct 30%
HR 132/min PTT 105 sec
Respirations 19/min PLT 88,000/mm3
Hgb 11g/dl
A. Fresh frozen plasma
B. Cryoprecipitate
C. Platelets
D. Packed red blood cells