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INSTRUCTIONS: Select the correct answer for each of the following questions. Mark only one answer for each item by making the
box corresponding to the letter of your choice on the answer sheet provided.

In what stage of sleep does brain tissue and cognitive restoration occur?
B. Stage III
D. Delta sleep


Mr. Luigi is having difficulty falling asleep. Which of the following measures would promote sleep in this client?
A. Permit him to exercise vigorously 20 minutes nightly at 9:30pm
B. Encourage him to take a cool shower and hot cup of tea
C. Recommend watching TV nightly until midnight
D. Provide a back rub and a glass of warm milk


The key to nursing implementation for a patient in pain is:

A. Age and sex
B. Source of pain
C. Cultural implications
D. Individualized assessment


Pain is subjective assessment. For the nurse treating the person in pain means:
A. Pain depends on the physical source
B. Pain is whatever the patient says it is
C. Pain must be physical to justify medication
D. Objective data are essential in assessing pain


Chronic pain can be continuous or intermittent. A major characteristic of chronic pain is:
A. It is limited only for few weeks
B. Patient complain more of pain intensity
C. It actually lasts for more than 6 months
D. It always stays in exactly the same place


The nurse administers pain medication IM and she knows it would be effective:
A. Immediately
B. In 3-5 minutes
C. In 15-20 minutes
D. Over a period of time


Endorphins are the bodys general opiate-like substances that inhibit painful stimuli. In which personality are endorphins higher?
A. The depressed person who takes medication
B. The happy person who laughs a lot
C. The anxious person who cries a lot
D. The psychotic who sleeps 10 16 hours a day


The nurse is helping a client with asthma take his inhaled medication. Which of the following could be done to provide better
A. Call the pharmacy for a peak flow meter
B. Call the pharmacy to change the route to parenteral
C. Call the pharmacy to see if the medication comes as a topical application
D. Call the pharmacy for a spacer


To assess the quality of pain, the nurse would ask:

A. Tell me what your pain feels like.
B. Is your pain a crushing sensation?
C. How long have you had this pain?
D. Is it a sharp pain or dull pain?

10. Nutritional therapy for gallbladder disorders include:

A. Low fat diet
B. Low residue diet
C. High calorie diet
D. Low carbohydrate diet
11. The following are nursing interventions to stimulate the appetite of the client experiencing anorexia EXCEPT
A. Provide foods that have colors of red, orange, yellow and green
B. Serve food in a pleasant and attractive manner
C. Provide good hygienic measures
D. Provide three full meals a day

12. Roxanne asks the nurse if her 12 year-old son, with a height of 1.2 meters and a weight of 50 kgs, has a normal weight? Based on
his BMI, in which of the following categories does the child belongs?
A. Underweight
B. Overweight
C. Normal weight
D. Obese
13. A food that would not be allowed on a clear liquid diet is:
A. Coffee
B. Milkshake
C. Popsicle
D. Apple juice
14. Your adult client is for gastric intubation. Which size of Levins tube would you choose?
A. Fr 12-18
B. Fr 16-20
C. Fr 10-12
D. Fr 8-10
15. Which statement is correct regarding nasogastric tubes?
A. NGT should be irrigated using sterile water regularly
B. Patient should be in Fowlers position with head slightly flexed for tube insertion
C. When resistance is met during NGT irrigation, pressure should be increased to complete the irrigation and the MD should
be notified at its completion
D. Ice chips can be taken ad lib to promote comfort
16. The client is to receive 2000 ml of tube feeding every 4 hours. The nurse checks the clients gastric residual before administering
the feeding and obtains the 40 ml of gastric residual. What should the nurse do next?
A. Withhold the tube feeding and notify the MD
B. Dispose the residual and continue with the feeding
C. Delay feeding the client for 1 hour and recheck the residual
D. Readminister the residual to the client and continue the feeding
17. Diabetic Miriam, 38 y/o is readmitted to the hospital for evaluation for her condition. Which of these could be used to test for the
presence of sugar in the blood?
A. Clinitest
B. Benedicts test
D. Heat and acetic acid test
18. After a patient has been catheterized with an indwelling urinary (Foley) catheter, the physician prescribes bladder irrigations with
100 ml of Neosporin solution every 3 hours. The primary purpose of this type of irrigation is to:
A. Perform lavage on blood clots resulting from catheter insertion
B. Prevent formation of calculi
C. Maintain catheter patency
D. Decrease risk of bladder infections
19. The purpose of straight catheterization immediately after voiding is to determine the:
A. Development of a urethral infection
B. Amount of residual urine in the bladder
C. Urine specific gravity
D. Total amount of urine voided
20. A client has stress incontinence. When developing a care plan, the nurse should take into consideration that stress incontinence is
best defined as the involuntary loss of urine associated with:
A. A strong urge to urinate
B. Overdistention of the bladder
C. Activities that increase abdominal pressure
D. Obstruction of urethra
21. Which of the following is a primary nursing intervention necessary for all patients with a Foley catheter in place?
A. Maintain the drainage tubing and collection bag at level with the patients bladder
B. Irrigate the patient with 1% Neosporin solution 3 times daily
C. Clamp the catheter for 1 hour every 4 hours to maintain the bladders elasticity
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
22. On the fourth day after the procedure, the physician removes Mr. Gos indwelling urinary (Foley) catheter. Later that day, he
complains of wetting his pajamas to the nurse. Which nursing intervention is most appropriate?
A. Advising the patient to contract his perineal muscles periodically
B. Restricting his fluid intake
C. Applying a condom catheter

D. Suggesting that the patient void as soon as the urge occurs

23. To ensure the most accurate results of a urine culture and sensitivity, the nurse should:
A. Collect a midstream urine sample
B. Utilize a 24-hour urine sample
C. Obtain a double-voided urine specimen
D. Use only the first voiding of the day
24. A 24 hour urine collection was ordered. You should:
A. Add food preservative to the urine when needed
B. Measure the urine output for the previous 24 hours
C. Take the weight of the client before starting the collection of urine
D. Add the last urine voided just before the 24 hour period ends
25. The correct procedure for collecting a urine specimen from an indwelling catheter is to:
A. Open the spigot on the collecting bag and allow urine to empty into the specimen container
B. Disconnect the drainage tube from the collecting bag and allow urine to flow from the tubing into the specimen container
C. Disconnect the drainage tube from the indwelling catheter and allow urine to flow from the tubing into the specimen
D. Remove urine from the drainage tube with a sterile needle into the specimen container
26. The nurse found a container with the patients urine specimen sitting on a counter in the bathroom. The client states that the
specimen has been sitting in the bathroom at least 2 hours. What would be the nurses most appropriate action?
A. Discard the urine and obtain a new specimen
B. Send the urine to the laboratory as quickly as possible
C. Add fresh urine to the collected specimen and send the specimen to the laboratory
D. Place the specimen in the refrigerator until it can be transported to the laboratory
27. The purpose of wet-to-damp dressings is to:
A. Occlude the wound
B. Absorb exudates without disrupting new granulation tissue
C. Heal the wound by primary intention
D. Protect the wound from microorganisms
28. Which of the following promotes normal defecation?
A. Providing privacy for defecation
B. Limiting the clients fluid intake
C. Having the client use laxatives
D. Ignoring the duodenocolic reflex
29. Which of the following symptom that differentiates a paralytic ileus from an impaction?
A. Abdominal cramping
B. Decreased or absent bowel tones
C. Flatulence
D. Small loose stool
30. Touching and stroking are specific nursing interventions for clients who are:
A. aphasic
B. unconscious
C. disoriented
D. hearing impaired
31. The best position for administering a cleansing enema to facilitate evacuation is:
A. Semi-fowlers
B. Left lateral Sims
C. Supine
D. Knee-chest
32. A hypertonic solution enema is contraindicated for a patient who is:
A. Malnourished
B. Dehydrated
C. Febrile
D. Recovering from appendectomy
33. A cleansing enema acts primarily by:
A. Removing fluid from the circulation to the bowel
B. Distending the colon and stimulating peristalsis through colon irritation, leading to evacuation
C. Cleansing the transverse colon
D. Expelling flatus

34. The doctor ordered for MgSO4 5 gram to be injected on each buttock? How many cc will you inject on each buttock if the stock
dose is 250 mg/cc in a 10 cc ampule?
A. 10 cc
B. 20 cc
C. 50 cc
D. 100 cc
35. Which of the ff. is a charting error?
A. Using a black ballpoint pen
B. Handwriting your nurses notes because your cursive writing is hard to read
C. Signing the nurses note that the relief nurse wrote about her patient while she was at
D. Including the date and time in each of the chart entries


36. An entry in the patients chart describes wound drainage as sanguineous. This means that it:
A. Is watery in appearance
B. Varies in color (either green-tinged or yellow)
C. Contains large amounts of red blood cells
D. Is foul smelling and comprised chiefly of serum
37. For routine client care, the Centers for Disease Control and Prevention recommend vigorous hand washing under a stream of
water for at least:
A. 10 seconds
B. 30 seconds
C. 1 minute
D. 2 minutes
38. If the nurse is wearing gloves, gown and mask, which item should be removed first when preparing to exit the clients room?
A. Gown
B. Gloves
C. Mask
D. The order is not important
39. For a patient confined to bed, which nursing activity is a part of the routine hour of sleep care but not for early morning care?
A. Providing a back massage
B. Providing a bed pan or urinal
C. Changing the linen
D. Washing the face and hands
40. The best site for injecting a drug to a 6 month old child is the:
A. dorsogluteal
B. vastus lateralis
C. ventrogluteal
D. rectus femoris
41. To straighten the ear canal of a 2 year-old child, you must:
A. pull the external ear upward, backward
B. pull the external ear downward, backward
C. pull the external ear downward, forward
D. pull the external ear upward, forward
42. The mother brought her child at the health center because of diarrhea. IVF was inserted to rehydrate the client. The doctor ordered
that the IVF should be regulated at 30 gtts/min for the first three hours and the remaining solution should run for 8 hours. What
will be the regulation of the remaining solution?
A. 5-16 gtts/min
B. 20-21 gtts/min
C. 24-25 gtts/min
D. 29-30 gtts/min
43. The nurse teaches a client about insulin and how to inject it. The nurse explains to the client techniques to prevent inflammation
and damage to tissue at the injection site. Which of the following techniques is best?
A. Injecting the needle at 45 degree angle
B. Administering the insulin in alternate sites
C. Avoiding massage at the injection site after giving insulin
D. Facing the bevel of the needle toward the patient when injecting the needle
44. A patient has a temperature of 101F and is shivering and complaining that he is cold. Which of the ff. symptoms would help
confirm that the fever is in the onset stage?
A. Pale, cold skin
B. Flushed, warm skin
C. Increased thirst
D. Sweating

45. Which action is unique when administering medication via Z-tract injection method?
A. The skin is pulled laterally before needle insertion
B. Injection sites are rotated along a Z on the abdomen
C. An air lock is established behind the bolus of medication
D. A Z is formed when dividing the buttocks into quadrants
46. As part of postmortem care, the nurse should:
A. Slightly raise the head of the bed
B. Carefully remove the dentures
C. Firmly tie the jaw & the head together, if the jaw is sagging
D. Gently close the eyes
47. An IVF of 0.3% NaCl 250 ml is to be infused in 4 hours using a microset. What is the regulation?
A. 62 mgtts/min
B. 30 mgtts/min
C. 65 mgtts/min
D. 60 mgtts/min
48. A patient has a vest restraint. While making this patients occupied bed, what must the nurse do to promote patient safety ?
A. Keep the vest restraint tied and lower both side rails
B. Keep the vest restraint tied and lower one side rail
C. Untie the vest restraint and lower both side rails
D. Untie the vest restraint and lower one side rail
49. When monitoring a patient who is at risk for hemorrhage, the nurse shouls assess the patient for
A. Warm, dry skin ; hypotension ; bounding pulse
B. Hypertension ; bounding pulse ; cold, clammy skin
C. Weak, thready pulse ; hypertension ; warm dry skin
D. Hypotension; cold clammy skin; weak, thready pulse
50. After surgery, a patient complains of mild incisional pain while performing deep-breathing and coughing exercises. What would
the nurse s best response?
A. Each day it will hurt less and less
B. This is an expected response after surgery
C. With a pillow, apply pressure against the incision
D. I will get the pain medication the physician ordered
51. To clean an indwelling urinary catheter (Foley) when providing perineal care, the nurse should
A. Scrub up and down the tube with soap and water
B. Wear a gown and gloves throughout the procedure
C. Wash the tubing before washing the urinary meatus
D. Bathe around the catheter moving away from the meatus
52. The most common reason why patients have a nasogastric tube in place after abdominal surgery is for the purpose of
A. Decompression
B. Instillation
C. Lavage
D. Gavage
53. A patient is at risk for dehydration and has an Encourage Fluids order from the physician. To increase the patients intake of
fluid, the nurse should
A. Provide drinks that the patient likes
B. Measure all the patients fluid intake and urine output
C. Require the patient to drink 4 ounces of fluid every hour
D. Explain to the patient that a feeding tube may have to be used
54. The patient is on a therapeutic diet that includes liquid supplements. When should these supplements be served ?
A. Between meals
B. When they arrive on the unit
C. Whenever the patient is hungry
D. If the patient eats less than half of a meal
55. When inserting a vaginal cream, the nurses initial action shouls be to
A. Apply a lubricant to the applicator
B. Put on sterile gloves for the procedure
C. Perform perineal care with soap and water
D. Place the patient in the left-side lying position
56. When transferring a patient who is weak on the right side from the bed to a chair, what should the nurse do ?
A. Place the feet of the patient close together
B. Plan to use a mechanical lift for for the transfer
C. Instruct the patient to bear weight equally on both legs
D. Put the right arm of the chair against the left side of the bed

57. When being given an enema, a patient complains of abdominal cramping. What should the nurse do ?
A. Lower the fluid container several inches
B. Stop the fluid until the cramping subsides
C. Turn the patient to the right lateral position
D. Have the patient flex the knees toward the abdomen
58. A newly admitted patient complains of not having had a good bowel movement in 10 days. Which question asked by the nurse
would identify symptoms of fecal impaction ?
A. Have you had small amounts of liquid stool ?
B. What types of food with fiber you eat ?
C. Do you notice a bad odor to your breath ?
D. Are you having nausea and vomiting ?
59. Restraints are mainly used to
A. Immobilize patients
B. Reduce agitation
C. Limit movement
D. Prevent injury
60. Increasing the flow rate of total parenteral solution (TPN) above the prescribed rate is dangerous because it can result in
A. Osmotic diuresis and hypoglycemia
B. Hypoglycemia and dumping syndrome
C. Electrolyte imbalance and osmotic diuresis
D. Dumping syndrome and electrolyte imbalance
61. After a gastrostomy tube feeding is completed, the nurse should
A. Instill 30 ml of air into the tube
B. Gently instill 30 ml of water
C. Check the dressing site
D. Encourage activity
62. What should the nurse do if a patients pulse is full and bounding ?
A. Measure the patients urine specific gravity
B. Monitor the patients serum glucose
C. Lower the head of the patients bed
D. Check the flow rate of the IV fluids
63. Which action comes first in a bladder-retraining program ?
A. Offer to toiulet the patient every 2 hours
B. Design an individual schedule for toileting
C. Provide adequate fluids during the retraining period
D. Assess the patients ability to cooperate with the program
64. The physician orders a 750-ml tap water enema. To mbest promote acceptance of the volume ordered, the nurse should
A. Administer the fluid slowly and have the patient take slow shallow breaths
B. Place the patient in the left lateral position and administer the fluid slowly
C. Have the patient take shallow breaths and keep the fluid at body temperature
D. Keep the fluid at body temperature and place the patient in the left lateral position
65. Which solution would be most effective for a patient who is unable to tolerate a large amount of enema fluid ?
A. Hypertonic fluid
B. Normal saline
C. Soapy water
D. Tap water
66. In the morning a patient has a loose watery stool. To determine if the patient has diarrhea, the nurse should ask
A. What did you have for dinner last night?
B. Have you been drinking fluid lately?
C. When was the last time you had a similar stool?
D. Are you experiencing any abdominal cramping?
67. Which is the most common psychological concern of patients who have a colostomy?
A. Maintenance of skin integrity
B. Frequency of defecation
C. Ability to control odor
D. Consistency of feces
68. When oxygen therapy via nasal cannula is ordered for a patient, the first action by the nurse is to
A. Post an oxygen in use sign on the door to the room
B. Adjust the oxygen level before applying the cannula
C. Explain the rules of fire safety and oxygen use
D. Lubricate the nares with water-soluble jelly
69. What is the primary purpose of implementing chest physiotherapy ?


Alter the tracheobronchial mucosa

Change th econsistency of sputum
Mobilize secretions
Induce coughing

70. What should the nurse do when applying a pulse oximetry sensor to the patients finger ?
A. Send the patients rings home with a family member
B. Remove frosted nail polish from the patients nails
C. Keep th ehand continuously elevated on a pillow
D. Shave any hair on the finger
71. When teaching the use of an incentive spirometer, the nurse knows that the patient understands its correct use when the patient
A. Snaps the ball to the top of the chamber and exhales rapidly
B. Seals the lips around the tube and inhales rapidly
C. Inhales slowly and keeps the ball floating
D. Gets the ball to rise and lower smoothly
72. When inserting an oral airway, the initial action of the nurse is to
A. Insert it with the tip end toward the tongue
B. Sweep the oral cavity with a gloved finger
C. Ensure that the airway is the correct size
D. Lightly lubricate the lips with Vaseline
73. To prevent aspiration after meals by a patient who has difficulty swallowing, the nurse should first
A. Position the patient in low-Fowlers position
B. Provide a pitcher of water at the bedside
C. Encourage mouth care when necessary
D. Inspect the mouth for pocketed food
74. To prevent aspiration while administering physical hygiene to a patient receiving a nasogastric tube feeding, the nurse should
A. Lower the height of the bag
B. Seek additional assistance
C. Slow the rate of flow
D. Shut the feeding off
75. To prevent skin breakdown around the nares of a patient receiving oxygen through a nasal cannula, the nurse should
A. Remove the tubing for 15 minutes every 2 hours
B. Turn and position the patient every 2 hours
C. Provide oral hygiene whenever necessary
D. Adjust the cannula so it is comfortable
76. What is the most important intervention by the nurse to increase both circulation and respiration in a patient?
A. Encourage the use of a spirometer
B. Reposition the patient every 2 hours
C. Massage bony prominences with lotion
D. Teach the patient to cough and breath deeply
77. Which statement would indicate that the patient needed further teaching regarding care of the eyes and eye medications?
A. Excess medication on the eyelid can be wiped away
B. I should gaze downward while instilling the eye drops
C. I should place one drop of the medication inside my lower eyelid
D. The risk of transmitting infection from one eye to the other is high
78. The nurse would recognize that further teaching was needed about the administration of eye drops when the patient says, I
A. Wipe my eye moving from the outer toward my nose
B. Hold the eyedropper about inch above my eye
C. Close my eyes after putting the drops in my eye
D. Put the fluid in a pocket in the lower lid
79. What should the nurse do when blood appears at the hub of the neddle while aspirating an intramuscular injection ?
A. Remove the syringe and attach a new needle
B. Discard the syringe and prepare a new injection
C. Interrupt the procedure and notify the physician
D. Withdraw the needle slightly and inject the solution
80. What should the nurse do first when injecting an intravenous medication via an already exixting intravenous line ?
A. Select the port closest to the needle entry site
B. Pinch the tubing above the port being used
C. Determine patency of the intravenous line
D. Clean the injection port with an antiseptic

81. The nurse recognizes that the patient understands the teaching about how to self-administer a rectal suppository when the patient
A. Bears down during insertion of the suppository
B. Requests sterile gloves to perform the procedure
C. Allows the suppository to warm to room temperature
D. Inserts the suppository immediately after its removal from the refrigerator
82. What is the most important for the nurse to do when administering a topical medicated cream to a patients skin ?
A. Use medical aseptic technique when applying the medication
B. Wash the area before administering the medication
C. Pat the medication onto the surface of the skin
D. Apply a moderate layer of the medication
83. Which behavior would indicate an inappropriate technique to use with a metered-dose inhaler (MDI) ?
A. Shaking the drug before pressing down on the inhaler
B. Pressing down on the inhaler while inhaling quickly
C. Holding the breath at the height of inhalation
D. Tilting the head back slightly
84. Nursing care that is unique to a poratble wound drainage system such as a Hemovac, which is different from tubes such as a T
tube or an indwelling urinary catheter, is the need to
A. Maintain patency of the drainage tube
B. Assess characteristics of the drainage
C. Ensure negative pressure
D. Measure output
85. The nurse recognizes that a patient scheduled for bowel surgery has an enema before surgery primarily to reduce
A. Postoperatrive peristalsis
B. Postoperative constipation
C. Incontinence during surgery
D. Contamination of the sterile field
86. When caring for patients with a variety of wounds, which type of wound would heal by primary intention ?
A. Surgical incision
B. Laceration
C. Deep burn
D. Abrasion
87. Postoperatively, a patient complains of pain in the calf. What should be the most appropriate intervention by the nurse ?
A. Alert the physician
B. Implement warm soaks
C. Administer cold compress
D. Apply anti-embolic stockings
88. Which adaptation indicates postoperative laryngeal spasm after extubation ?
A. Rales
B. Gurgles
C. Crackles
D. Wheezing
89. What should the nurse do to best help the patient deal with the psychological aspects of strict isolation ?
A. Draw a smiley face on the mask
B. Wear a gown only when direct contact is expected
C. Explain the reason for, and importance of, isolation
D. Talk with the patient often from a slightly opened door
90. What should the nurse do first to remove protective clothing when leaving a contact isolation room ?
A. Untie the gown at the waist
B. Untie the gown at the neck
C. Remove the gloves
D. Remove the mask
91. Which question should the nurse ask a patient with an infection when taking a nursing history as opposed to a medical history ?
A. Have you done any traveling lately?
B. How long has the infection been present?
C. When did you first notice your symptoms?
D. How does the infection affect your daily routine?
92. Which laboratory result needs to be reported to the physician for a patient admitted to the hospital with a medical diagnosis of
fever of unknown origin ?
A. 1.020 urine specific gravity
B. 20,000 white blood cell count
C. 14.5 hemoglobin
D. 42 hematocrit

93. Which action associated with handwashing is guided by a principle of medical asepsis ?
A. Wash with the hands held higher than the elbows
B. Rinse with the hands held lower than the elbows
C. Turn the water on with a clean paper towel
D. Adjust the water to a hot temperature
94. Further teaching about an isolation mask is indicated when a family member visiting a patient on airborne precautions says, I
A. Fold the mask within itself to contain microorganisms before I throw it away
B. Pinch the metal band on the mask snugly around the bridge of my nose
C. Change my mask whenever it gets wet
D. Put on new mask everytime I visit
95. Where should soiled linen be placed when it is removed from a bed ?
A. In a soiled linen hamper
B. On the overbed table
C. Into the floor
D. On a chair
96. The nurse should remove a dirty sheet from an unoccupied bed by
A. Pushing the sheet together
B. Rolling the sheet into itself
C. Sliding the sheet to the side of the bed
D. Fanfolding the sheet to the foot of the bed
97. Which actions violates principles of surgical asepsis ?
A. Recapping a syringe once 3 cc of normal saline are withdrawn from a vial
B. Holding a wet sterile 4x4 with sterile forceps while the handle is higher than the tip
C. Failing to wipe the rubber port of a newly opened sterile multiple-dose vial with an alcohol swab
D. Pouring Betadine on a 4x4 that is lying in its opened sterile paper wrapper while on an overbed table
98. Mrs. Simon is obese. When administering a subcutaneously injection to an obese patient, it is best for the nurse to
A. Inject needle at a 15 degree angle over the stretched skin of the client
B. Pinch skin at the injection site and use airlock technique
C. Pull skin of patient down to administer the drug in a Z track
D. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle
99. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedure is
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the
exhalation cycle
C. In both percussion and vibration, the hands are on top of each other and hand activity is in tune with clients breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes secretions along with the inhalation of air.
100.Priority attention should be given to which of these clients ?
A. Linda who shows severe anxiety due to trauma of the accident
B. Ryan who has chest injury, is pale and with difficulty of breathing
C. Noel who has lacerations on the arms with mild bleeding
D. Andy whose left ankle sweeled and has some abrasions