80 FUNDA QUESTIONS d.

Malpractice
14. Which of the following is an example of nursing malpractice?
1. The most appropriate nursing order for a patient who develops dyspnea and a. The nurse administers penicillin to a patient with a documented history of
shortness of breath would be… allergy to the drug. The patient experiences an allergic reaction and has cerebral
a.Maintain the patient on strict bed rest at all times damage resulting from anoxia.
b.Maintain the patient in an orthopneic position as needed b. The nurse applies a hot water bottle or a heating pad to the abdomen of a
c.Administer oxygen by Venturi mask at 24%, as needed patient with abdominal cramping.
d. Allow a 1 hour rest period between activities c. The nurse assists a patient out of bed with the bed locked in position; the
patient slips and fractures his right humerus.
2. The nurse observes that Mr. Adams begins to have increased difficulty d. The nurse administers the wrong medication to a patient and the patient
breathing. She elevates the head of the bed to the high Fowler position, which vomits. This information is documented and reported to the physician and the
decreases his respiratory distress. The nurse documents this breathing as: nursing supervisor.
a. Tachypnea 15. Which of the following signs and symptoms would the nurse expect to find
b. Eupnca when assessing an Asian patient for postoperative pain following abdominal
c. Orthopnea surgery?
d. Hyperventilation a. Decreased blood pressure and heart rate and shallow respirations
b. Quiet crying
3. The physician orders a platelet count to be performed on Mrs. Smith after c. Immobility, diaphoresis, and avoidance of deep breathing or coughing
breakfast. The nurse is responsible for: d. Changing position every 2 hours
a. Instructing the patient about this diagnostic test 16. A patient is admitted to the hospital with complaints of nausea, vomiting,
b. Writing the order for this test diarrhea, and severe abdominal pain. Which of the following would immediately
c. Giving the patient breakfast alert the nurse that the patient has bleeding from the GI tract?
d. All of the above a. Complete blood count
b. Guaiac test
4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods c. Vital signs
allowed on a 500-mg low sodium diet. These include: d. Abdominal girth
a. A ham and Swiss cheese sandwich on whole wheat bread 17. The correct sequence for assessing the abdomen is:
b. Mashed potatoes and broiled chicken a. Tympanic percussion, measurement of abdominal girth, and inspection
c. A tossed salad with oil and vinegar and olives b. Assessment for distention, tenderness, and discoloration around the
d. Chicken bouillon umbilicus.
c. Percussions, palpation, and auscultation
5. The physician orders a maintenance dose of 5,000 units of subcutaneous d. Auscultation, percussion, and palpation
heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now 18. High-pitched gurgles head over the right lower quadrant are:
include: a. A sign of increased bowel motility
a. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin b. A sign of decreased bowel motility
time. c. Normal bowel sounds
b. Reporting an APTT above 45 seconds to the physician d. A sign of abdominal cramping
c. Assessing the patient for signs and symptoms of frank and occult bleeding 19. A patient about to undergo abdominal inspection is best placed in which of
d. All of the above the following positions?
a. Prone
6. The four main concepts common to nursing that appear in each of the current b. Trendelenburg
conceptual models are: c. Supine
a. Person, nursing, environment, medicine d. Side-lying
b. Person, health, nursing, support systems 20. For a rectal examination, the patient can be directed to assume which of
c. Person, health, psychology, nursing the following positions?
d. Person, environment, health, nursing a. Genupecterol
b. Sims
7. In Maslow’s hierarchy of physiologic needs, the human need of greatest c. Horizontal recumbent
priority is: d. All of the above
a. Love 21. During a Romberg test, the nurse asks the patient to assume which
b. Elimination position?
c. Nutrition a. Sitting
d. Oxygen b. Standing
8. The family of an accident victim who has been declared brain-dead seems c. Genupectoral
amenable to organ donation. What should the nurse do? d. Trendelenburg
a. Discourage them from making a decision until their grief has eased 22. If a patient’s blood pressure is 150/96, his pulse pressure is:
b. Listen to their concerns and answer their questions honestly a. 54
c. Encourage them to sign the consent form right away b. 96
d. Tell them the body will not be available for a wake or funeral c. 150
9. A new head nurse on a unit is distressed about the poor staffing on the 11 d. 246
p.m. to 7 a.m. shift. What should she do? 23. A patient is kept off food and fluids for 10 hours before surgery. His oral
a. Complain to her fellow nurses temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably
b. Wait until she knows more about the unit indicates:
c. Discuss the problem with her supervisor a. Infection
d. Inform the staff that they must volunteer to rotate b. Hypothermia
10. Which of the following principles of primary nursing has proven the most c. Anxiety
satisfying to the patient and nurse? d. Dehydration
a. Continuity of patient care promotes efficient, cost-effective nursing care 24. Which of the following parameters should be checked when assessing
b. Autonomy and authority for planning are best delegated to a nurse who respirations?
knows the patient well a. Rate
c. Accountability is clearest when one nurse is responsible for the overall plan b. Rhythm
and its implementation. c. Symmetry
d. The holistic approach provides for a therapeutic relationship, continuity, d. All of the above
and efficient nursing care. 25. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F
11. If nurse administers an injection to a patient who refuses that injection, she (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reported?
has committed: a. Respiratory rate only
a. Assault and battery b. Temperature only
b. Negligence c. Pulse rate and temperature
c. Malpractice d. Temperature and respiratory rate
d. None of the above 26. All of the following can cause tachycardia except:
12. If patient asks the nurse her opinion about a particular physicians and the a. Fever
nurse replies that the physician is incompetent, the nurse could be held liable for: b. Exercise
a. Slander c. Sympathetic nervous system stimulation
b. Libel d. Parasympathetic nervous system stimulation
c. Assault 27. Palpating the midclavicular line is the correct technique for assessing
d. Respondent superior a. Baseline vital signs
13. A registered nurse reaches to answer the telephone on a busy pediatric b. Systolic blood pressure
unit, momentarily turning away from a 3 month-old infant she has been weighing. c. Respiratory rate
The infant falls off the scale, suffering a skull fracture. The nurse could be d. Apical pulse
charged with: 28. The absence of which pulse may not be a significant finding when a patient
a. Defamation is admitted to the hospital?
b. Assault a. Apical
c. Battery b. Radial
c. Pedal b. Side rails should not be used
d. Femoral c. Side rails are a deterrent that prevent a patient from falling out of bed.
29. Which of the following patients is at greatest risk for developing pressure d. Side rails are a reminder to a patient not to get out of bed
ulcers? 43. Examples of patients suffering from impaired awareness include all of the
a. An alert, chronic arthritic patient treated with steroids and aspirin following except:
b. An 88-year old incontinent patient with gastric cancer who is confined to a. A semiconscious or over fatigued patient
his bed at home b. A disoriented or confused patient
c. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula c. A patient who cannot care for himself at home
d. A confused 78-year old patient with congestive heart failure (CHF) who d. A patient demonstrating symptoms of drugs or alcohol withdrawal
requires assistance to get out of bed. 44. The most common injury among elderly persons is:
30. The physician orders the administration of high-humidity oxygen by face a. Atheroscleotic changes in the blood vessels
mask and placement of the patient in a high Fowler’s position. After assessing b. Increased incidence of gallbladder disease
Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas c. Urinary Tract Infection
exchange related to increased secretions. Which of the following nursing d. Hip fracture
interventions has the greatest potential for improving this situation? 45. The most common psychogenic disorder among elderly person is:
a. Encourage the patient to increase her fluid intake to 200 ml every 2 hours a. Depression
b. Place a humidifier in the patient’s room. b. Sleep disturbances (such as bizarre dreams)
c. Continue administering oxygen by high humidity face mask c. Inability to concentrate
d. Perform chest physiotheraphy on a regular schedule d. Decreased appetite
31. The most common deficiency seen in alcoholics is: 46. Which of the following vascular system changes results from aging?
a. Thiamine a. Increased peripheral resistance of the blood vessels
b. Riboflavin b. Decreased blood flow
c. Pyridoxine c. Increased work load of the left ventricle
d. Pantothenic acid d. All of the above
32. Which of the following statement is incorrect about a patient with 47. Which of the following is the most common cause of dementia among
dysphagia? elderly persons?
a. The patient will find pureed or soft foods, such as custards, easier to a. Parkinson’s disease
swallow than water b. Multiple sclerosis
b. Fowler’s or semi Fowler’s position reduces the risk of aspiration during c. Amyotrophic lateral sclerosis (Lou Gerhig’s disease)
swallowing d. Alzheimer’s disease
c. The patient should always feed himself 48. The nurse’s most important legal responsibility after a patient’s death in a
d. The nurse should perform oral hygiene before assisting with feeding. hospital is:
33. To assess the kidney function of a patient with an indwelling urinary a. Obtaining a consent of an autopsy
(Foley) catheter, the nurse measures his hourly urine output. She should notify b. Notifying the coroner or medical examiner
the physician if the urine output is: c. Labeling the corpse appropriately
a. Less than 30 ml/hour d. Ensuring that the attending physician issues the death certification
b. 64 ml in 2 hours 49. Before rigor mortis occurs, the nurse is responsible for:
c. 90 ml in 3 hours a. Providing a complete bath and dressing change
d. 125 ml in 4 hours b. Placing one pillow under the body’s head and shoulders
34. Certain substances increase the amount of urine produced. These include: c. Removing the body’s clothing and wrapping the body in a shroud
a. Caffeine-containing drinks, such as coffee and cola. d. Allowing the body to relax normally
b. Beets 50. When a patient in the terminal stages of lung cancer begins to exhibit loss
c. Urinary analgesics of consciousness, a major nursing priority is to:
d. Kaolin with pectin (Kaopectate) a. Protect the patient from injury
35. A male patient who had surgery 2 days ago for head and neck cancer is b. Insert an airway
about to make his first attempt to ambulate outside his room. The nurse notes c. Elevate the head of the bed
that he is steady on his feet and that his vision was unaffected by the surgery. d. Withdraw all pain medications
Which of the following nursing interventions would be appropriate?
a. Encourage the patient to walk in the hall alone ______________________________________
b. Discourage the patient from walking in the hall for a few more days 1. Nurse Brenda is teaching a patient about a newly prescribed drug. What
c. Accompany the patient for his walk. could cause a geriatric patient to have difficulty retaining knowledge about
d. Consuit a physical therapist before allowing the patient to ambulate prescribed medications?
36. A patient has exacerbation of chronic obstructive pulmonary disease a. Decreased plasma drug levels
(COPD) manifested by shortness of breath; orthopnea: thick, tenacious b. Sensory deficits
secretions; and a dry hacking cough. An appropriate nursing diagnosis would be: c. Lack of family support
a. Ineffective airway clearance related to thick, tenacious secretions. d. History of Tourette syndrome
b. Ineffective airway clearance related to dry, hacking cough. 2. When examining a patient with abdominal pain the nurse in charge should
c. Ineffective individual coping to COPD. assess:
d. Pain related to immobilization of affected leg. a. Any quadrant first
37. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response b. The symptomatic quadrant first
would be: c. The symptomatic quadrant last
a. “Don’t worry. It’s only temporary” d. The symptomatic quadrant either second or third
b. “Why are you crying? I didn’t get to the bad news yet” 3. The nurse is assessing a postoperative adult patient. Which of the following
c. “Your hair is really pretty” should the nurse document as subjective data?
d. “I know this will be difficult for you, but your hair will grow back after the a. Vital signs
completion of chemotheraphy” b. Laboratory test result
38. An additional Vitamin C is required during all of the following periods c. Patient’s description of pain
except: d. Electrocardiographic (ECG) waveforms
a. Infancy 4. A male patient has a soft wrist-safety device. Which assessment finding
b. Young adulthood should the nurse consider abnormal?
c. Childhood a. A palpable radial pulse
d. Pregnancy b. A palpable ulnar pulse
39. A prescribed amount of oxygen s needed for a patient with COPD to c. Cool, pale fingers
prevent: d. Pink nail beds
a. Cardiac arrest related to increased partial pressure of carbon dioxide in 5. Which of the following planes divides the body longitudinally into anterior and
arterial blood (PaCO2) posterior regions?
b. Circulatory overload due to hypervolemia a. Frontal plane
c. Respiratory excitement b. Sagittal plane
d. Inhibition of the respiratory hypoxic stimulus c. Midsagittal plane
40. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of d. Transverse plane
the following is the most significant symptom of his disorder? 6. A female patient with a terminal illness is in denial. Indicators of denial
a. Lethargy include:
b. Increased pulse rate and blood pressure a. Shock dismay
c. Muscle weakness b. Numbness
d. Muscle irritability c. Stoicism
41. Which of the following nursing interventions promotes patient safety? d. Preparatory grief
a. Asses the patient’s ability to ambulate and transfer from a bed to a chair 7. The nurse in charge is transferring a patient from the bed to a chair. Which
b. Demonstrate the signal system to the patient action does the nurse take during this patient transfer?
c. Check to see that the patient is wearing his identification band a. Position the head of the bed flat
d. All of the above b. Helps the patient dangle the legs
42. Studies have shown that about 40% of patients fall out of bed despite the c. Stands behind the patient
use of side rails; this has led to which of the following conclusions? d. Places the chair facing away from the bed
a. Side rails are ineffective
8. A female patient who speaks a little English has emergency gallbladder a. Primary prevention
surgery, during discharge preparation, which nursing action would best help this b. Secondary prevention
patient understand wound care instruction? c. Tertiary prevention
a. Asking frequently if the patient understands the instruction d. Passive prevention
b. Asking an interpreter to replay the instructions to the patient. 22. What does the nurse in charge do when making a surgical bed?
c. Writing out the instructions and having a family member read them to the a. Leaves the bed in the high position when finished
patient b. Places the pillow at the head of the bed
d. Demonstrating the procedure and having the patient return the c. Rolls the patient to the far side of the bed
demonstration d. Tucks the top sheet and blanket under the bottom of the bed
9. Before administering the evening dose of a prescribed medication, the nurse 23. The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml.
on the evening shift finds an unlabeled, filled syringe in the patient’s medication how much of the drug should the nurse give?
drawer. What should the nurse in charge do? a. 2 ml
a. Discard the syringe to avoid a medication error b. 1 ml
b. Obtain a label for the syringe from the pharmacy c. ½ ml
c. Use the syringe because it looks like it contains the same medication the d. ¼ ml
nurse was prepared to give 24. Nurse Mackey is monitoring a patient for adverse reactions during
d. Call the day nurse to verify the contents of the syringe barbiturate therapy. What is the major disadvantage of barbiturate use?
10. When administering drug therapy to a male geriatric patient, the nurse must a. Prolonged half-life
stay especially alert for adverse effects. Which factor makes geriatric patients to b. Poor absorption
adverse drug effects? c. Potential for drug dependence
a. Faster drug clearance d. Potential for hepatotoxicity
b. Aging-related physiological changes 25. Which nursing action is essential when providing continuous enteral
c. Increased amount of neurons feeding?
d. Enhanced blood flow to the GI tract a. Elevating the head of the bed
11. A female patient is being discharged after cataract surgery. After providing b. Positioning the patient on the left side
medication teaching, the nurse asks the patient to repeat the instructions. The c. Warming the formula before administering it
nurse is performing which professional role? d. Hanging a full day’s worth of formula at one time
a. Manager 26. When teaching a female patient how to take a sublingual tablet, the nurse
b. Educator should instruct the patient to place the table on the:
c. Caregiver a. Top of the tongue
d. Patient advocate b. Roof of the mouth
12. A female patient exhibits signs of heightened anxiety. Which response by c. Floor of the mouth
the nurse is most likely to reduce the patient’s anxiety? d. Inside of the cheek
a. “Everything will be fine. Don’t worry.” 27. Which action by the nurse in charge is essential when cleaning the area
b. “Read this manual and then ask me any questions you may have.” around a Jackson-Pratt wound drain?
c. “Why don’t you listen to the radio?” a. Cleaning from the center outward in a circular motion
d. “Let’s talk about what’s bothering you.” b. Removing the drain before cleaning the skin
13. A scrub nurse in the operating room has which responsibility? c. Cleaning briskly around the site with alcohol
a. Positioning the patient d. Wearing sterile gloves and a mask
b. Assisting with gowning and gloving 28. The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8
c. Handling surgical instruments to the surgeon hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should
d. Applying surgical drapes run the I.V. infusion at a rate of:
14. A patient is in the bathroom when the nurse enters to give a prescribed a. 15 drop per minute
medication. What should the nurse in charge do? b. 21 drop per minute
a. Leave the medication at the patient’s bedside c. 32 drop per minute
b. Tell the patient to be sure to take the medication. And then leave it at the d. 125 drops per minute
bedside 29. A male patient undergoes a total abdominal hysterectomy. When assessing
c. Return shortly to the patient’s room and remain there until the patient takes the patient 10 hours later, the nurse identifies which finding as an early sign of
the medication shock?
d. Wait for the patient to return to bed, and then leave the medication at the a. Restlessness
bedside b. Pale, warm, dry skin
15. The physician orders heparin, 7,500 units, to be administered c. Heart rate of 110 beats/minute
subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The d. Urine output of 30 ml/hour
nurse should anticipate giving how much heparin for each dose? 30. Which pulse should the nurse palpate during rapid assessment of an
a. ¼ ml unconscious male adult?
b. ½ ml a. Radial
c. ¾ ml b. Brachial
d. 1 ¼ ml c. Femoral
16. The nurse in charge measures a patient’s temperature at 102 degrees F. d. Carotid
what is the equivalent Centigrade temperature? ______________________________________
a. 39 degrees C ANSWERS and RATIONALES for FUNDAMENTALS OF NURSING PRACTICE
b. 47 degrees C QUESTIONS
c. 38.9 degrees C
d. 40.1 degrees C
17. To evaluate a patient for hypoxia, the physician is most likely to order which
laboratory test? 1. B. When a patient develops dyspnea and shortness of breath, the
a. Red blood cell count orthopneic position encourages maximum chest expansion and keeps the
b. Sputum culture abdominal organs from pressing against the diaphragm, thus improving
c. Total hemoglobin ventilation. Bed rest and oxygen by Venturi mask at 24% would improve
d. Arterial blood gas (ABG) analysis oxygenation of the tissues and cells but must be ordered by a physician. Allowing
18. The nurse uses a stethoscope to auscultate a male patient’s chest. Which for rest periods decreases the possibility of hypoxia.
statement about a stethoscope with a bell and diaphragm is true? 2. C. Orthopnea is difficulty of breathing except in the upright position.
a. The bell detects high-pitched sounds best Tachypnea is rapid respiration characterized by quick, shallow breaths. Eupnea
b. The diaphragm detects high-pitched sounds best is normal respiration – quiet, rhythmic, and without effort.
c. The bell detects thrills best 3. C. A platelet count evaluates the number of platelets in the circulating
d. The diaphragm detects low-pitched sounds best blood volume. The nurse is responsible for giving the patient breakfast at the
19. A male patient is to be discharged with a prescription for an analgesic that scheduled time. The physician is responsible for instructing the patient about the
is a controlled substance. During discharge teaching, the nurse should explain test and for writing the order for the test.
that the patient must fill this prescription how soon after the date on which it was 4. B. Mashed potatoes and broiled chicken are low in natural sodium
written? chloride. Ham, olives, and chicken bouillon contain large amounts of sodium and
a. Within 1 month are contraindicated on a low sodium diet.
b. Within 3 months 5. D. All of the identified nursing responsibilities are pertinent when a patient
c. Within 6 months is receiving heparin. The normal activated partial thromboplastin time is 16 to 25
d. Within 12 months seconds and the normal prothrombin time is 12 to 15 seconds; these levels must
20. Which human element considered by the nurse in charge during remain within two to two and one half the normal levels. All patients receiving
assessment can affect drug administration? anticoagulant therapy must be observed for signs and symptoms of frank and
a. The patient’s ability to recover occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea,
b. The patient’s occupational hazards restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure
c. The patient’s socioeconomic status should be measured every 4 hours and the patient should be instructed to report
d. The patient’s cognitive abilities promptly any bleeding that occurs with tooth brushing, bowel movements,
21. An employer establishes a physical exercise area in the workplace and urination or heavy prolonged menstruation.
encourages all employees to use it. This is an example of which level of health 6. D. The focus concepts that have been accepted by all theorists as the
promotion? focus of nursing practice from the time of Florence Nightingale include the person
receiving nursing care, his environment, his health on the health illness
continuum, and the nursing actions necessary to meet his needs.
7. D. Maslow, who defined a need as a satisfaction whose absence causes
illness, considered oxygen to be the most important physiologic need; without it,
human life could not exist. According to this theory, other physiologic needs
(including food, water, elimination, shelter, rest and sleep, activity and
temperature regulation) must be met before proceeding to the next hierarchical
levels on psychosocial needs.
8. B. The brain-dead patient’s family needs support and reassurance in
making a decision about organ donation. Because transplants are done within
hours of death, decisions about organ donation must be made as soon as
possible. However, the family’s concerns must be addressed before members
are asked to sign a consent form. The body of an organ donor is available for
burial.
9. C. Although a new head nurse should initially spend time observing the
unit for its strengths and weakness, she should take action if a problem threatens
patient safety. In this case, the supervisor is the resource person to approach.
10. D. Studies have shown that patients and nurses both respond well to
primary nursing care units. Patients feel less anxious and isolated and more
secure because they are allowed to participate in planning their own care.
Nurses feel personal satisfaction, much of it related to positive feedback from the
patients. They also seem to gain a greater sense of achievement and esprit de
corps.
11. A. Assault is the unjustifiable attempt or threat to touch or injure another
person. Battery is the unlawful touching of another person or the carrying out of
threatened physical harm. Thus, any act that a nurse performs on the patient
against his will is considered assault and battery.
12. A. Oral communication that injures an individual’s reputation is considered
slander. Written communication that does the same is considered libel.
13. D. Malpractice is defined as injurious or unprofessional actions that harm
another. It involves professional misconduct, such as omission or commission of
an act that a reasonable and prudent nurse would or would not do. In this
example, the standard of care was breached; a 3-month-old infant should never
be left unattended on a scale.
14. A. The three elements necessary to establish a nursing malpractice are
nursing error (administering penicillin to a patient with a documented allergy to
the drug), injury (cerebral damage), and proximal cause (administering the
penicillin caused the cerebral damage). Applying a hot water bottle or heating
pad to a patient without a physician’s order does not include the three required
components. Assisting a patient out of bed with the bed locked in position is the
correct nursing practice; therefore, the fracture was not the result of malpractice.
Administering an incorrect medication is a nursing error; however, if such action
resulted in a serious illness or chronic problem, the nurse could be sued for
malpractice.
15. C. An Asian patient is likely to hide his pain. Consequently, the nurse must
observe for objective signs. In an abdominal surgery patient, these might include
immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as
increased heart rate, shallow respirations (stemming from pain upon moving the
diaphragm and respiratory muscles), and guarding or rigidity of the abdominal
wall. Such a patient is unlikely to display emotion, such as crying.
16. B. To assess for GI tract bleeding when frank blood is absent, the nurse
has two options: She can test for occult blood in vomitus, if present, or in stool –
through guaiac (Hemoccult) test. A complete blood count does not provide
immediate results and does not always immediately reflect blood loss. Changes
in vital signs may be cause by factors other than blood loss. Abdominal girth is
unrelated to blood loss.
17. D. Because percussion and palpation can affect bowel motility and thus
bowel sounds, they should follow auscultation in abdominal assessment.
Tympanic percussion, measurement of abdominal girth, and inspection are
methods of assessing the abdomen. Assessing for distention, tenderness and
discoloration around the umbilicus can indicate various bowel-related conditions,
such as cholecystitis, appendicitis and peritonitis.
18. C. Hyperactive sounds indicate increased bowel motility; two or three
sounds per minute indicate decreased bowel motility. Abdominal cramping with
hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction.
19. C. The supine position (also called the dorsal position), in which the patient
lies on his back with his face upward, allows for easy access to the abdomen. In
the prone position, the patient lies on his abdomen with his face turned to the
side. In the Trendelenburg position, the head of the bed is tilted downward to 30
to 40 degrees so that the upper body is lower than the legs. In the lateral
position, the patient lies on his side.
20. D. All of these positions are appropriate for a rectal examination. In the
genupectoral (knee-chest) position, the patient kneels and rests his chest on the
table, forming a 90 degree angle between the torso and upper legs. In Sims’
position, the patient lies on his left side with the left arm behind the body and his
right leg flexed. In the horizontal recumbent position, the patient lies on his back
with legs extended and hips rotated outward.
21. B. During a Romberg test, which evaluates for sensory or cerebellar
ataxia, the patient must stand with feet together and arms resting at the sides—
first with eyes open, then with eyes closed. The need to move the feet apart to
maintain this stance is an abnormal finding.
22. A. The pulse pressure is the difference between the systolic and diastolic
blood pressure readings – in this case, 54.
23. D. A slightly elevated temperature in the immediate preoperative or post
operative period may result from the lack of fluids before surgery rather than from
infection. Anxiety will not cause an elevated temperature. Hypothermia is an
abnormally low body temperature.
24. D. The quality and efficiency of the respiratory process can be determined
by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations.
25. D. Under normal conditions, a healthy adult breathes in a smooth
uninterrupted pattern 12 to 20 times a minute. Thus, a respiratory rate of 30
would be abnormal. A normal adult body temperature, as measured on an oral
thermometer, ranges between 97° and 100°F (36.1° and 37.8°C); an axillary
temperature is approximately one degree lower and a rectal temperature, one
degree higher. Thus, an axillary temperature of 99.6°F (37.6°C) would be
considered abnormal. The resting pulse rate in an adult ranges from 60 to 100
beats/minute, so a rate of 88 is normal.
26. D. Parasympathetic nervous system stimulation of the heart decreases the
heart rate as well as the force of contraction, rate of impulse conduction and
blood flow through the coronary vessels. Fever, exercise, and sympathetic
stimulation all increase the heart rate.
27. D. The apical pulse (the pulse at the apex of the heart) is located on the
midclavicular line at the fourth, fifth, or sixth intercostal space. Base line vital
signs include pulse rate, temperature, respiratory rate, and blood pressure. Blood
pressure is typically assessed at the antecubital fossa, and respiratory rate is
assessed best by observing chest movement with each inspiration and
expiration.
28. C. Because the pedal pulse cannot be detected in 10% to 20% of the
population, its absence is not necessarily a significant finding. However, the
presence or absence of the pedal pulse should be documented upon admission
so that changes can be identified during the hospital stay. Absence of the apical,
radial, or femoral pulse is abnormal and should be investigated.
29. B. Pressure ulcers are most likely to develop in patients with impaired
mental status, mobility, activity level, nutrition, circulation and bladder or bowel
control. Age is also a factor. Thus, the 88-year old incontinent patient who has
impaired nutrition (from gastric cancer) and is confined to bed is at greater risk.
30. A. Adequate hydration thins and loosens pulmonary secretions and also
helps to replace fluids lost from elevated temperature, diaphoresis, dehydration
and dyspnea. High- humidity air and chest physiotherapy help liquefy and
mobilize secretions.
31. A. Chronic alcoholism commonly results in thiamine deficiency and other
symptoms of malnutrition.
32. C. A patient with dysphagia (difficulty swallowing) requires assistance with
feeding. Feeding himself is a long-range expected outcome. Soft foods, Fowler’s
or semi-Fowler’s position, and oral hygiene before eating should be part of the
feeding regimen.
33. A. A urine output of less than 30ml/hour indicates hypovolemia or oliguria,
which is related to kidney function and inadequate fluid intake.
34. A. Fluids containing caffeine have a diuretic effect. Beets and urinary
analgesics, such as pyridium, can color urine red. Kaopectate is an anti diarrheal
medication.
35. C. A hospitalized surgical patient leaving his room for the first time fears
rejection and others staring at him, so he should not walk alone. Accompanying
him will offer moral support, enabling him to face the rest of the world. Patients
should begin ambulation as soon as possible after surgery to decrease
complications and to regain strength and confidence. Waiting to consult a
physical therapist is unnecessary.
36. A. Thick, tenacious secretions, a dry, hacking cough, orthopnea, and
shortness of breath are signs of ineffective airway clearance. Ineffective airway
clearance related to dry, hacking cough is incorrect because the cough is not the
reason for the ineffective airway clearance. Ineffective individual coping related to
COPD is wrong because the etiology for a nursing diagnosis should not be a
medical diagnosis (COPD) and because no data indicate that the patient is
coping ineffectively. Pain related to immobilization of affected leg would be an
appropriate nursing diagnosis for a patient with a leg fracture.
37. D. “I know this will be difficult” acknowledges the problem and suggests a
resolution to it. “Don’t worry..” offers some relief but doesn’t recognize the
patient’s feelings. “..I didn’t get to the bad news yet” would be inappropriate at
any time. “Your hair is really pretty” offers no consolation or alternatives to the
patient.
38. B. Additional Vitamin C is needed in growth periods, such as infancy and
childhood, and during pregnancy to supply demands for fetal growth and
maternal tissues. Other conditions requiring extra vitamin C include wound
healing, fever, infection and stress.
39. D. Delivery of more than 2 liters of oxygen per minute to a patient with
chronic obstructive pulmonary disease (COPD), who is usually in a state of
compensated respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit
the hypoxic stimulus for respiration. An increased partial pressure of carbon
dioxide in arterial blood (PACO2) would not initially result in cardiac arrest.
Circulatory overload and respiratory excitement have no relevance to the
question.
40. C. Presenting symptoms of hypokalemia ( a serum potassium level below
3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac
dysrhythmias. The combined effects of inadequate food intake and prolonged
diarrhea can deplete the potassium stores of a patient with GI problems.
41. D. Assisting a patient with ambulation and transfer from a bed to a chair
allows the nurse to evaluate the patient’s ability to carry out these functions
safely. Demonstrating the signal system and providing an opportunity for a return
demonstration ensures that the patient knows how to operate the equipment and
encourages him to call for assistance when needed. Checking the patient’s
identification band verifies the patient’s identity and prevents identification
mistakes in drug administration.
42. D. Since about 40% of patients fall out of bed despite the use of side rails,
side rails cannot be said to prevent falls; however, they do serve as a reminder
that the patient should not get out of bed. The other answers are incorrect
interpretations of the statistical data.
43. C. A patient who cannot care for himself at home does not necessarily
have impaired awareness; he may simply have some degree of immobility.
44. D. Hip fracture, the most common injury among elderly persons, usually
results from osteoporosis. The other answers are diseases that can occur in the
elderly from physiologic changes.
45. A. Sleep disturbances, inability to concentrate and decreased appetite are
symptoms of depression, the most common psychogenic disorder among elderly
persons. Other symptoms include diminished memory, apathy, disinterest in
appearance, withdrawal, and irritability. Depression typically begins before the
onset of old age and usually is caused by psychosocial, genetic, or biochemical
factors
46. D. Aging decreases elasticity of the blood vessels, which leads to
increased peripheral resistance and decreased blood flow. These changes, in
turn, increase the work load of the left ventricle.
47. D. Alzheimer;s disease, sometimes known as senile dementia of the
Alzheimer’s type or primary degenerative dementia, is an insidious; progressive,
irreversible, and degenerative disease of the brain whose etiology is still
unknown. Parkinson’s disease is a neurologic disorder caused by lesions in the
extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis,
dysphagia, and dysphonia. Multiple sclerosis, a progressive, degenerative
disease involving demyelination of the nerve fibers, usually begins in young
adulthood and is marked by periods of remission and exacerbation. Amyotrophic
lateral sclerosis, a disease marked by progressive degeneration of the neurons,
eventually results in atrophy of all the muscles; including those necessary for
respiration.
48. C. The nurse is legally responsible for labeling the corpse when death
occurs in the hospital. She may be involved in obtaining consent for an autopsy
or notifying the coroner or medical examiner of a patient’s death; however, she is
not legally responsible for performing these functions. The attending physician
may need information from the nurse to complete the death certificate, but he is
responsible for issuing it.
49. B. The nurse must place a pillow under the decreased person’s head and
shoulders to prevent blood from settling in the face and discoloring it. She is
required to bathe only soiled areas of the body since the mortician will wash the
entire body. Before wrapping the body in a shroud, the nurse places a clean
gown on the body and closes the eyes and mouth.
50. A. Ensuring the patient’s safety is the most essential action at this time.
The other nursing actions may be necessary but are not a major priority.
Answer B. Sensory deficits could cause a geriatric patient to have difficulty
retaining knowledge about prescribed medications. Decreased plasma drug
levels do not alter the patient’s knowledge about the drug. A lack of family
support may affect compliance, not knowledge retention. Toilette syndrome is
unrelated to knowledge retention.
Answer C. The nurse should systematically assess all areas of the abdomen, if
time and the patient’s condition permit, concluding with the symptomatic area.
Otherwise, the nurse may elicit pain in the symptomatic area, causing the
muscles in other areas to tighten. This would interfere with further assessment.
Answer C. Subjective data come directly from the patient and usually are
recorded as direct quotations that reflect the patient’s opinions or feelings about
a situation. Vital signs, laboratory test result, and ECG waveforms are examples
of objective data.
Answer C. A safety device on the wrist may impair circulation and restrict blood
supply to body tissues. Therefore, the nurse should assess the patient for signs
of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse
and pink nail beds are normal findings.
Answer A. Frontal or coronal plane runs longitudinally at a right angle to a sagittal
plane dividing the body in anterior and posterior regions. A sagittal plane runs
longitudinally dividing the body into right and left regions; if exactly midline, it is
called a midsagittal plane. A transverse plane runs horizontally at a right angle to
the vertical axis, dividing the structure into superior and inferior regions.
Answer A. Shock and dismay are early signs of denial-the first stage of grief. The
other options are associated with depression—a later stage of grief.
Answer B. After placing the patient in high Fowler’s position and moving the
patient to the side of the bed, the nurse helps the patient sit on the edge of the
bed and dangle the legs; the nurse then faces the patient and places the chair
next to and facing the head of the bed.
Answer D. Demonstrating by the nurse with a return demonstration by the patient
ensures that the patient can perform wound care correctly. Patients may claim to
understand discharge instruction when they do not. An interpreter of family
member may communicate verbal or written instructions inaccurately.
Answer A. As a safety precaution, the nurse should discard an unlabeled syringe
that contains medication. The other options are considered unsafe because they
promote error.
Answer B. Aging-related physiological changes account for the increased
frequency of adverse drug reactions in geriatric patients. Renal and hepatic
changes cause drugs to clear more slowly in these patients. With increasing age,
neurons are lost and blood flow to the GI tract decreases.
Answer B. When teaching a patient about medications before discharge, the
nurse is acting as an educator. The nurse acts as a manager when performing
such activities as scheduling and making patient care assignments. The nurse
performs the care giving role when providing direct care, including bathing
patients and administering medications and prescribed treatments. The nurse
acts as a patient advocate when making the patient’s wishes known to the
doctor.
Answer D. Anxiety may result from feeling of helplessness, isolation, or
insecurity. This response helps reduce anxiety by encouraging the patient to
express feelings. The nurse should be supportive and develop goals together
with the patient to give the patient some control over an anxiety-inducing
situation. Because the other options ignore the patient’s feeling and block
communication, they would not reduce anxiety.
Answer C. The scrub nurse assist the surgeon by providing appropriate surgical
instruments and supplies, maintaining strict surgical asepsis and, with the
circulating nurse, accounting for all gauze, sponges, needles, and instruments.
The circulating nurse assists the surgeon and scrub nurse, positions the patient,
applies appropriate equipment and surgical drapes, assists with gowning and
gloving, and provides the surgeon and scrub nurse with supplies.
Answer C. The nurse should return shortly to the patient’s room and remain there
until the patient takes the medication to verify that it was taken as directed. The
nurse should never leave medication at the patient’s bedside unless specifically
requested to do so.
Answer C. The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X
10,000 X = 7,500
X= 7,500/10,000 or ¾ ml
Answer C. To convert Fahrenheit degrees to centigrade, use this formula:
C degrees = (F degrees – 32) x 5/9
C degrees = (102 – 32) 5/9
+ 70 x 5/9
38.9 degrees C
Answer D. All of these test help evaluate a patient with respiratory problems.
However, ABG analysis is the only test evaluates gas exchange in the lungs,
providing information about patient’s oxygenation status.
Answer B. The diaphragm of a stethoscope detects high-pitched sound best; the
bell detects low pitched sounds best. Palpation detects thrills best.
Answer C. In most cases, an outpatient must fill a prescription for a controlled
substance within 6 months of the date on which the prescription was written.
Answer D. The nurse must consider the patient’s cognitive abilities to understand
drug instructions. If not, the nurse must find a family member or significant other
to take on the responsibility of administering medications in the home setting.
The patient’s ability to recover, occupational hazards, and socioeconomic status
do not affect drug administration.
Answer A. Primary prevention precedes disease and applies to health patients.
Secondary prevention focuses on patients who have health problems and are at
risk for developing complications. Tertiary prevention enables patients to gain
health from others’ activities without doing anything themselves.
Answer A. When making a surgical bed, the nurse leaves the bed in the high
position when finished. After placing the top linens on the bed without pouching
them, the nurse fanfolds these linens to the side opposite from where the patient
will enter and places the pillow on the bedside chair. All these actions promote
transfer of the postoperative patient from the stretcher to the bed. When making
an occupied bed or unoccupied bed, the nurse places the pillow at the head of
the bed and tucks the top sheet and blanket under the bottom of the bed. When
making an occupied bed, the nurse rolls the patient to the far side of the bed.
Answer C. The nurse should give ½ ml of the drug. The dosage is calculated as
follows:
250 mg/X=500 mg/1 ml
500x=250
X=1/2 ml
Answer C. Patients can become dependent on barbiturates, especially with
prolonged use. Because of the rapid distribution of some barbiturates, no
correlation exists between duration of action and half-life. Barbiturates are
absorbed well and do not cause hepatotoxicity, although existing hepatic damage
does require cautions use of the drug because barbiturates are metabolized in
the liver.
Answer A. Elevating the head of the bed during enteral feeding minimizes the
risk of aspiration and allows the formula to flow in the patient’s intestines. When
such elevation is contraindicated, the patient should be positioned on the right
side. The nurse should give enteral feeding at room temperature to minimize GI
distress. To limit microbial growth, the nurse should hang only the amount of
formula that can be infused in 3 hours.
Answer C. The nurse should instruct the patient to touch the tip of the tongue to
the roof of the mouth and then place the sublingual tablet on the floor of the
mouth. Sublingual medications are absorbed directly into the bloodstream form
the oral mucosa, bypassing the GI and hepatic systems. No drug is administered
on top of the tongue or on the roof of the mouth. With the buccal route, the tablet
is placed between the gum and the cheek.
Answer A. The nurse always should clean around a wound drain, moving from
center outward in ever-larger circles, because the skin near the drain site is more
contaminated than the site itself. The nurse should never remove the drain
before cleaning the skin. Alcohol should never be used to clean around a drain; it
may irritate the skin and has no lasting effect on bacteria because it evaporates.
The nurse should wear sterile gloves to prevent contamination, but a mask is not
necessary.
Answer C. Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour
(60 minutes) to find the number of milliliters per minute:
125/60 min = X/1 minute
60X = 125X = 2.1 ml/minute
To find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts
X = 32 gtts/minute, or 32 drops/minute
Answer A. Early in shock, hyperactivity of the sympathetic nervous system
causes increased epinephrine secretion, which typically makes the patient
restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the
skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of
shock. A urine output of 30 ml/hour is within normal limits.
Answer D. During a rapid assessment, the nurse’s first priority is to check the
patient’s vital functions by assessing his airway, breathing, and circulation. To
check a patient’s circulation, the nurse must assess his heart and vascular
network function. This is done by checking his skin color, temperature, mental
status and, most importantly, his pulse. The nurse should use the carotid artery
to check a patient’s circulation. In a patient with a circulatory problems or a
history of compromised circulation, the radial pulse may not be palpable. The
brachial pulse is palpated during rapid assessment of an infant.
NP1- FOUNDATION OF PROFESSIONAL NURSING PRACTICE
1. The nurse In-charge in labor and delivery unit administered a dose of
terbutaline to a client without checking the client’s pulse. The standard that would
be used to determine if the nurse was negligent is:
a. The physician’s orders.
b. The action of a clinical nurse specialist who is recognized expert in the field.
c. The statement in the drug literature about administration of terbutaline.
d. The actions of a reasonably prudent nurse with similar education and
experience.
2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell
disease, and a platelet count of 22,000/μl. The female client is dehydrated and
receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The client
complains of severe bone pain and is scheduled to receive a dose of morphine
sulfate. In administering the medication, Nurse Trish should avoid which route?
a. I.V b. I.M c. Oral d. S.C
3. Dr. Garcia writes the following order for the client who has been recently
admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how
should the nurse document this order onto the medication administration record?
a. “Digoxin .1250 mg P.O. once daily” b. “Digoxin 0.1250 mg P.O. once daily”
c. “Digoxin 0.125 mg P.O. once daily” d. “Digoxin .125 mg P.O. once daily”
4. A newly admitted female client was diagnosed with deep vein thrombosis.
Which nursing diagnosis should receive the highest priority?
a. Ineffective peripheral tissue perfusion related to venous congestion.
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral vascular disease.
d. Impaired gas exchange related to increased blood flow.
5. Nurse Betty is assigned to the following clients. The client that the nurse would
see first after endorsement?
a. A 34 year-old post operative appendectomy client of five hours who is
complaining of pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea.
c. A 26 year-old client admitted for dehydration whose intravenous (IV) has
infiltrated.
d. A 63 year-old post operative’s abdominal hysterectomy client of three days
whose incisional dressing is saturated with serosanguinous fluid.
6. Nurse Gail places a client in a four-point restraint following orders from the
physician. The client care plan should include:
a. Assess temperature frequently. b. Provide diversional activities.
c. Check circulation every 15-30 minutes. d. Socialize with other patients once a
shift.
7. A male client who has severe burns is receiving H2 receptor antagonist
therapy. The nurse In-charge knows the purpose of this therapy is to:
a. Prevent stress ulcer b. Block prostaglandin synthesis
c. Facilitate protein synthesis. d. Enhance gas exchange
8. The doctor orders hourly urine output measurement for a postoperative male
client. The nurse Trish records the following amounts of output for 2 consecutive
hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action
should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly urine output
9. Tony, a basketball player twist his right ankle while playing on the court and
seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for
30 minutes, which statement by Tony suggests that ice application has been
effective?
a. “My ankle looks less swollen now”. b. “My ankle feels warm”.
c. “My ankle appears redder now”. d. “I need something stronger for pain relief”
10.The physician prescribes a loop diuretic for a client. When administering this
drug, the nurse anticipates that the client may develop which electrolyte
imbalance?
a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hypervolemia
11.She finds out that some managers have benevolent-authoritative style of
management. Which of the following behaviors will she exhibit most likely?
a. Have condescending trust and confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among subordinates.
12. Nurse Amy is aware that the following is true about functional nursing
a. Provides continuous, coordinated and comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.
13.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3
days?"
a. Single order b. Standard written order c. Standing order d. Stat order
14.A female client with a fecal impaction frequently exhibits which clinical
manifestation?
a. Increased appetite b. Loss of urge to defecate
c. Hard, brown, formed stools d. Liquid or semi-liquid stools
15.Nurse Linda prepares to perform an otoscopic examination on a female client.
For proper visualization, the nurse should position the client's ear by:
a. Pulling the lobule down and back b. Pulling the helix up and forward
c. Pulling the helix up and back d. Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a male client who is having
external radiation therapy:
a. Protect the irritated skin from sunlight.
b. Eat 3 to 4 hours before treatment.
c. Wash the skin over regularly.
d. Apply lotion or oil to the radiated area when it is red or sore.
17.In assisting a female client for immediate surgery, the nurse In-charge is
aware that she should:
a. Encourage the client to void following preoperative medication.
b. Explore the client’s fears and anxieties about the surgery.
c. Assist the client in removing dentures and nail polish.
d. Encourage the client to drink water prior to surgery.
18. A male client is admitted and diagnosed with acute pancreatitis after a
holiday celebration of excessive food and alcohol. Which assessment finding
reflects this diagnosis?
a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric and back pain.
19. Which dietary guidelines are important for nurse Oliver to implement in caring
for the client with burns?
a. Provide high-fiber, high-fat diet b. Provide high-protein, high-carbohydrate diet.
c. Monitor intake to prevent weight gain. d. Provide ice chips or water intake.
20.Nurse Hazel will administer a unit of whole blood, which priority information
should the nurse have about the client?
a. Blood pressure and pulse rate. b. Height and weight.
c. Calcium and potassium levels d. Hgb and Hct levels.
21. Nurse Michelle witnesses a female client sustain a fall and suspects that the
leg may be broken. The nurse takes which priority action?
a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
c. Reassure the client that everything will be alright.
d. Immobilize the leg before moving the client.
22.A male client is being transferred to the nursing unit for admission after
receiving a radium implant for bladder cancer. The nurse in-charge would take
which priority action in the care of this client?
a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent rest periods.
d. Encourage family and friends to visit.
23.A newly admitted female client was diagnosed with agranulocytosis. The
nurse formulates which priority nursing diagnosis?
a. Constipation b. Diarrhea c. Risk for infection d. Deficient knowledge
24.A male client is receiving total parenteral nutrition suddenly demonstrates
signs and symptoms of an air embolism. What is the priority action by the nurse?
a. Notify the physician.
b. Place the client on the left side in the Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.
25.Nurse May attends an educational conference on leadership styles. The nurse
is sitting with a nurse employed at a large trauma center who states that the
leadership style at the trauma center is task-oriented and directive. The nurse
determines that the leadership style used at the trauma center is:
a. Autocratic. b. Laissez-faire. c. Democratic. d. Situational
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse
in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How
many cc’s of KCl will be added to the IV solution?
a. .5 cc b. 5 cc c. 1.5 cc d. 2.5 cc
27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV
drip factor is 60. The IV rate that will deliver this amount is:
a. 50 cc/ hour b. 55 cc/ hour c. 24 cc/ hour d. 66 cc/ hour
28.The nurse is aware that the most important nursing action when a client
returns from surgery is:
a. Assess the IV for type of fluid and rate of flow.
b. Assess the client for presence of pain.
c. Assess the Foley catheter for patency and urine output
d. Assess the dressing for drainage.
29. Which of the following vital sign assessments that may indicate cardiogenic
shock after myocardial infarction?
a. BP – 80/60, Pulse – 110 irregular
b. BP – 90/50, Pulse – 50 regular
c. BP – 130/80, Pulse – 100 regular
d. BP – 180/100, Pulse – 90 irregular
30.Which is the most appropriate nursing action in obtaining a blood pressure
measurement?
a. Take the proper equipment, place the client in a comfortable position, and
record the appropriate information in the client’s chart.
b. Measure the client’s arm, if you are not sure of the size of cuff to use.
c. Have the client recline or sit comfortably in a chair with the forearm at the level
of the heart.
d. Document the measurement, which extremity was used, and the position that
the client was in during the measurement.
31.Asking the questions to determine if the person understands the health
teaching provided by the nurse would be included during which step of the
nursing process?
a. Assessment b. Evaluation c. Implementation d. Planning and goals
32.Which of the following item is considered the single most important factor in
assisting the health professional in arriving at a diagnosis or determining the
person’s needs?
a. Diagnostic test results b. Biographical date
c. History of present illness d. Physical examination
33.In preventing the development of an external rotation deformity of the hip in a
client who must remain in bed for any period of time, the most appropriate
nursing action would be to use:
a. Trochanter roll extending from the crest of the ileum to the midthigh.
b. Pillows under the lower legs.
c. Footboard
d. Hip-abductor pillow
34.Which stage of pressure ulcer development does the ulcer extend into the
subcutaneous tissue?
a. Stage I b. Stage II c. Stage III d. Stage IV
35.When the method of wound healing is one in which wound edges are not
surgically approximated and integumentary continuity is restored by granulations,
the wound healing is termed
a. Second intention healing b. Primary intention healing
c. Third intention healing d. First intention healing
36.An 80-year-old male client is admitted to the hospital with a diagnosis of
pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating
or drinking. When assessing him for dehydration, nurse Oliver would expect to
find:
a. Hypothermia b. Hypertension c. Distended neck veins d. Tachycardia
37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as
needed, to control a client’s postoperative pain. The package insert is
“Meperidine, 100 mg/ml.” How many milliliters of meperidine should the
client receive?
a. 0.75 b. 0.6 c. 0.5 d. 0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement
correctly describes an insulin unit?
a. It’s a common measurement in the metric system.
b. It’s the basis for solids in the avoirdupois system.
c. It’s the smallest measurement in the apothecary system.
d. It’s a measure of effect, not a standard measure of weight or quantity.
39.Nurse Oliver measures a client’s temperature at 102° F. What is the
equivalent Centigrade temperature?
a. 40.1 °C b. 38.9 °C c. 48 °C d. 38 °C
40.The nurse is assessing a 48-year-old client who has come to the physician’s
office for his annual physical exam. One of the first physical
signs of aging is:
a. Accepting limitations while developing assets.
b. Increasing loss of muscle tone.
c. Failing eyesight, especially close vision.
d. Having more frequent aches and pains.
41.The physician inserts a chest tube into a female client to treat a
pneumothorax. The tube is connected to water-seal drainage. The nurse in-
charge can prevent chest tube air leaks by:
a. Checking and taping all connections.
b. Checking patency of the chest tube.
c. Keeping the head of the bed slightly elevated.
d. Keeping the chest drainage system below the level of the chest.
42.Nurse Trish must verify the client’s identity before administering medication.
She is aware that the safest way to verify identity is to:
a. Check the client’s identification band.
b. Ask the client to state his name.
c. State the client’s name out loud and wait a client to repeat it.
d. Check the room number and the client’s name on the bed.
43.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8
hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V.
infusion at a rate of:
a. 30 drops/minute b. 32 drops/minute c. 20 drops/minute d. 18 drops/minute
44.If a central venous catheter becomes disconnected accidentally, what should
the nurse in-charge do immediately?
a. Clamp the catheter b. Call another nurse
c. Call the physician d. Apply a dry sterile dressing to the site.
45.A female client was recently admitted. She has fever, weight loss, and watery
diarrhea is being admitted to the facility. While assessing the client, Nurse Hazel
inspects the client’s abdomen and notice that it is slightly concave. Additional
assessment should proceed in which order:
a. Palpation, auscultation, and percussion.
b. Percussion, palpation, and auscultation.
c. Palpation, percussion, and auscultation.
d. Auscultation, percussion, and palpation.
46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this
examination, nurse Betty should use the:
a. Fingertips b. Finger pads
c. Dorsal surface of the hand d. Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the teaching and
learning process?
a. Summative b. Informative c. Formative d. Retrospective
48.A 45 year old client, has no family history of breast cancer or other risk factors
for this disease. Nurse John should instruct her to have
mammogram how often?
a. Twice per year b. Once per year
c. Every 2 years d. Once, to establish baseline
49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89
mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values, Nurse
Patricia should expect which condition?
a. Respiratory acidosis b. Respiratory alkalosis
c. Metabolic acidosis d. Metabolic alkalosis
50.Nurse Len refers a female client with terminal cancer to a local hospice. What
is the goal of this referral?
a. To help the client find appropriate treatment options.
b. To provide support for the client and family in coping with terminal illness.
c. To ensure that the client gets counseling regarding health care costs.
d. To teach the client and family about cancer and its treatment.
51.When caring for a male client with a 3-cm stage I pressure ulcer on the
coccyx, which of the following actions can the nurse institute
independently?
a. Massaging the area with an astringent every 2 hours.
b. Applying an antibiotic cream to the area three times per day.
c. Using normal saline solution to clean the ulcer and applying a protective
dressing as necessary.
d. Using a povidone-iodine wash on the ulceration three times per day.
52.Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. He
should apply the bandage beginning at the client’s:
a. Knee b. Ankle c. Lower thigh d. Foot
53.A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and
receives a continuous insulin infusion. Which condition represents the greatest
risk to this child?
a. Hypernatremia b. Hypokalemia c. Hyperphosphatemia d. Hypercalcemia
54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly
admitted client. Immediately afterward, the client may experience:
a. Throbbing headache or dizziness b. Nervousness or paresthesia.
c. Drowsiness or blurred vision. d. Tinnitus or diplopia.
55.Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse
quickly looks at the monitor and notes that a client is in a ventricular tachycardia.
The nurse rushes to the client’s room. Upon reaching the client’s bedside, the
nurse would take which action first?
a. Prepare for cardioversion b. Prepare to defibrillate the client
c. Call a code d. Check the client’s level of consciousness
56.Nurse Hazel is preparing to ambulate a female client. The best and the safest
position for the nurse in assisting the client is to stand:
a. On the unaffected side of the client. b. On the affected side of the client.
c. In front of the client. d. Behind the client.
57.Nurse Janah is monitoring the ongoing care given to the potential organ donor
who has been diagnosed with brain death. The nurse determines that the
standard of care had been maintained if which of the following data is observed?
a. Urine output: 45 ml/hr b. Capillary refill: 5 seconds
c. Serum pH: 7.32 d. Blood pressure: 90/48 mmHg
58. Nurse Amy has an order to obtain a urinalysis from a male client with an
indwelling urinary catheter. The nurse avoids which of the following, which
contaminate the specimen?
a. Wiping the port with an alcohol swab before inserting the syringe.
b. Aspirating a sample from the port on the drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary drainage bag.
59.Nurse Meredith is in the process of giving a client a bed bath. In the middle of
the procedure, the unit secretary calls the nurse on the intercom to tell the nurse
that there is an emergency phone call. The appropriate nursing action is to:
a. Immediately walk out of the client’s room and answer the phone call.
b. Cover the client, place the call light within reach, and answer the phone call.
c. Finish the bed bath before answering the phone call.
d. Leave the client’s door open so the client can be monitored and the nurse can
answer the phone call.
60. Nurse Janah is collecting a sputum specimen for culture and sensitivity
testing from a client who has a productive cough. Nurse Janah plans to
implement which intervention to obtain the specimen?
a. Ask the client to expectorate a small amount of sputum into the emesis basin.
b. Ask the client to obtain the specimen after breakfast.
c. Use a sterile plastic container for obtaining the specimen.
d. Provide tissues for expectoration and obtaining the specimen.
61. Nurse Ron is observing a male client using a walker. The nurse determines
that the client is using the walker correctly if the client:
a. Puts all the four points of the walker flat on the floor, puts weight on the hand
pieces, and then walks into it.
b. Puts weight on the hand pieces, moves the walker forward, and then walks
into it.
c. Puts weight on the hand pieces, slides the walker forward, and then walks into
it.
d. Walks into the walker, puts weight on the hand pieces, and then puts all four
points of the walker flat on the floor.
62.Nurse Amy has documented an entry regarding client care in the client’s
medical record. When checking the entry, the nurse realizes that incorrect
information was documented. How does the nurse correct this error?
a. Erases the error and writes in the correct information.
b. Uses correction fluid to cover up the incorrect information and writes in the
correct information.
c. Draws one line to cross out the incorrect information and then initials the
change.
d. Covers up the incorrect information completely using a black pen and writes in
the correct information
63.Nurse Ron is assisting with transferring a client from the operating room table
to a stretcher. To provide safety to the client, the nurse should:
a. Moves the client rapidly from the table to the stretcher.
b. Uncovers the client completely before transferring to the stretcher.
c. Secures the client safety belts after transferring to the stretcher.
d. Instructs the client to move self from the table to the stretcher.
64.Nurse Myrna is providing instructions to a nursing assistant assigned to give a
bed bath to a client who is on contact precautions. Nurse Myrna instructs the
nursing assistant to use which of the following protective items when giving bed
bath?
a. Gown and goggles b. Gown and gloves
c. Gloves and shoe protectors d. Gloves and goggles
65. Nurse Oliver is caring for a client with impaired mobility that occurred as a
result of a stroke. The client has right sided arm and leg weakness. The nurse
would suggest that the client use which of the following assistive devices that
would provide the best stability for ambulating?
a. Crutches b. Single straight-legged cane
c. Quad cane d. Walker
66.A male client with a right pleural effusion noted on a chest X-ray is being
prepared for thoracentesis. The client experiences severe dizziness when sitting
upright. To provide a safe environment, the nurse assists the client to which
position for the procedure?
a. Prone with head turned toward the side supported by a pillow.
b. Sims’ position with the head of the bed flat.
c. Right side-lying with the head of the bed elevated 45 degrees.
d. Left side-lying with the head of the bed elevated 45 degrees.
67.Nurse John develops methods for data gathering. Which of the following
criteria of a good instrument refers to the ability of the instrument to yield the
same results upon its repeated administration?
a. Validity b. Specificity c. Sensitivity d. Reliability
68.Harry knows that he has to protect the rights of human research subjects.
Which of the following actions of Harry ensures anonymity?
a. Keep the identities of the subject secret
b. Obtain informed consent
c. Provide equal treatment to all the subjects of the study.
d. Release findings only to the participants of the study
69.Patient’s refusal to divulge information is a limitation because it is beyond the
control of Tifanny”. What type of research is appropriate for this study?
a. Descriptive- correlational b. Experiment
c. Quasi-experiment d. Historical
70.Nurse Ronald is aware that the best tool for data gathering is?
a. Interview schedule b. Questionnaire
c. Use of laboratory data d. Observation
71.Monica is aware that there are times when only manipulation of study
variables is possible and the elements of control or randomization are not
attendant. Which type of research is referred to this?
a. Field study b. Quasi-experiment
c. Solomon-Four group design d. Post-test only design
72.Cherry notes down ideas that were derived from the description of an
investigation written by the person who conducted it. Which type of reference
source refers to this?
a. Footnote b. Bibliography c. Primary source d. Endnotes
73.When Nurse Trish is providing care to his patient, she must remember that
her duty is bound not to do doing any action that will cause the patient harm. This
is the meaning of the bioethical principle:
a. Non-maleficence b. Beneficence c. Justice d. Solidarity
74.When a nurse in-charge causes an injury to a female patient and the injury
caused becomes the proof of the negligent act, the presence of the injury is said
to exemplify the principle of:
a. Force majeure b. Respondeat superior
c. Res ipsa loquitor d. Holdover doctrine
75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An
example of this power is:
a. The Board can issue rules and regulations that will govern the practice of
nursing
b. The Board can investigate violations of the nursing law and code of ethics
c. The Board can visit a school applying for a permit in collaboration with CHED
d. The Board prepares the board examinations
76. When the license of nurse Krina is revoked, it means that she:
a. Is no longer allowed to practice the profession for the rest of her life
b. Will never have her/his license re-issued since it has been revoked
c. May apply for re-issuance of his/her license based on certain conditions
stipulated in RA 9173
d. Will remain unable to practice professional nursing
77.Ronald plans to conduct a research on the use of a new method of pain
assessment scale. Which of the following is the second step in the
conceptualizing phase of the research process?
a. Formulating the research hypothesis
b. Review related literature
c. Formulating and delimiting the research problem
d. Design the theoretical and conceptual framework
78. The leader of the study knows that certain patients who are in a specialized
research setting tend to respond psychologically to the conditions of the study.
This referred to as :
a. Cause and effect b. Hawthorne effect
c. Halo effect d. Horns effect
79.Mary finally decides to use judgment sampling on her research. Which of the
following actions of is correct?
a. Plans to include whoever is there during his study.
b. Determines the different nationality of patients frequently admitted and decides
to get representations samples from each.
c. Assigns numbers for each of the patients, place these in a fishbowl and draw
10 from it.
d. Decides to get 20 samples from the admitted patients
80. The nursing theorist who developed transcultural nursing theory is:
a. Florence Nightingale b. Madeleine Leininger
c. Albert Moore d. Sr. Callista Roy
81.Marion is aware that the sampling method that gives equal chance to all units
in the population to get picked is:
a. Random b. Accidental c. Quota d. Judgment
82.John plans to use a Likert Scale to his study to determine the:
a. Degree of agreement and disagreement
b. Compliance to expected standards
c. Level of satisfaction
d. Degree of acceptance
83.Which of the following theory addresses the four modes of adaptation?
a. Madeleine Leininger b. Sr. Callista Roy
c. Florence Nightingale d. Jean Watson
84.Ms. Garcia is responsible to the number of personnel reporting to her. This
principle refers to:
a. Span of control b. Unity of command
c. Downward communication d. Leader
85.Ensuring that there is an informed consent on the part of the patient before a
surgery is done, illustrates the bioethical principle of:
a. Beneficence b. Autonomy c. Veracity d. Non-maleficence
86.Nurse Reese is teaching a female client with peripheral vascular disease
about foot care; Nurse Reese should include which instruction?
a. Avoid wearing cotton socks.
b. Avoid using a nail clipper to cut toenails.
c. Avoid wearing canvas shoes.
d. Avoid using cornstarch on feet.
87.A client is admitted with multiple pressure ulcers. When developing the client's
diet plan, the nurse should include:
a. Fresh orange slices b. Steamed broccoli
c. Ice cream d. Ground beef patties
88.The nurse prepares to administer a cleansing enema. What is the most
common client position used for this procedure?
a. Lithotomy b. Supine c. Prone d. Sims’ left lateral
89.Nurse Marian is preparing to administer a blood transfusion. Which action
should the nurse take first?
a. Arrange for typing and cross matching of the client’s blood.
b. Compare the client’s identification wristband with the tag on the unit of blood.
c. Start an I.V. infusion of normal saline solution.
d. Measure the client’s vital signs.
90.A 65 years old male client requests his medication at 9 p.m. instead of 10
p.m. so that he can go to sleep earlier. Which type of nursing intervention is
required?
a. Independent b. Dependent c. Interdependent d. Intradependent
91.A female client is to be discharged from an acute care facility after treatment
for right leg thrombophlebitis. The Nurse Betty notes that the client's leg is pain-
free, without redness or edema. The nurse's actions reflect which step of the
nursing process?
a. Assessment b. Diagnosis c. Implementation d. Evaluation
92.Nursing care for a female client includes removing elastic stockings once per
day. The Nurse Betty is aware that the rationale for this intervention?
a. To increase blood flow to the heart
b. To observe the lower extremities
c. To allow the leg muscles to stretch and relax
d. To permit veins in the legs to fill with blood.
93.Which nursing intervention takes highest priority when caring for a newly
admitted client who's receiving a blood transfusion?
a. Instructing the client to report any itching, swelling, or dyspnea.
b. Informing the client that the transfusion usually take 1 ½ to 2 hours.
c. Documenting blood administration in the client care record.
d. Assessing the client’s vital signs when the transfusion ends.
94.A male client complains of abdominal discomfort and nausea while receiving
tube feedings. Which intervention is most appropriate for this problem?
a. Give the feedings at room temperature.
b. Decrease the rate of feedings and the concentration of the formula.
c. Place the client in semi-Fowler's position while feeding.
d. Change the feeding container every 12 hours.
95.Nurse Patricia is reconstituting a powdered medication in a vial. After adding
the solution to the powder, she nurse should:
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5 minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.
96.Which intervention should the nurse Trish use when administering oxygen by
face mask to a female client?
a. Secure the elastic band tightly around the client's head.
b. Assist the client to the semi-Fowler position if possible.
c. Apply the face mask from the client's chin up over the nose.
d. Loosen the connectors between the oxygen equipment and humidifier.
97.The maximum transfusion time for a unit of packed red blood cells (RBCs) is:
a. 6 hours b. 4 hours c. 3 hours d. 2 hours
98.Nurse Monique is monitoring the effectiveness of a client's drug therapy.
When should the nurse Monique obtain a blood sample to measure the trough
drug level?
a. 1 hour before administering the next dose.
b. Immediately before administering the next dose.
c. Immediately after administering the next dose.
d. 30 minutes after administering the next dose.
99.Nurse May is aware that the main advantage of using a floor stock system is:
a. The nurse can implement medication orders quickly.
b. The nurse receives input from the pharmacist.
c. The system minimizes transcription errors.
d. The system reinforces accurate calculations.
100. Nurse Oliver is assessing a client's abdomen. Which finding should the
nurse report as abnormal?
a. Dullness over the liver.
b. Bowel sounds occurring every 10 seconds.
c. Shifting dullness over the abdomen.
d. Vascular sounds heard over the renal arteries
RATIO 
1. Answer: (D) The actions of a reasonably prudent nurse with similar education
and experience.
Rationale: The standard of care is determined by the average degree of skill,
care, and diligence by nurses in similar circumstances.
2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/μl, the clients tends to bleed easily.
Therefore, the nurse should avoid using the I.M. route because the area is a
highly vascular and can bleed readily when penetrated by a needle. The bleeding
can be difficult to stop.
3. Answer: (C) “Digoxin 0.125 mg P.O. once daily”
Rationale: The nurse should always place a zero before a decimal point so that
no one misreads the figure, which could result in a dosage error. The nurse
should never insert a zero at the end of a dosage that includes a decimal point
because this could be misread, possibly leading to a tenfold increase in the
dosage.
4. Answer: (A) Ineffective peripheral tissue perfusion related to venous
congestion.
Rationale: Ineffective peripheral tissue perfusion related to venous congestion
takes the highest priority because venous inflammation and clot formation
impede blood flow in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial infarction (MI) client who is complaining
of nausea.
Rationale: Nausea is a symptom of impending myocardial infarction (MI) and
should be assessed immediately so that treatment can be instituted and further
damage to the heart is avoided.
6. Answer: (C) Check circulation every 15-30 minutes.
Rationale: Restraints encircle the limbs, which place the client at risk for
circulation being restricted to the distal areas of the extremities. Checking the
client’s circulation every 15-30 minutes will allow the nurse to adjust the restraints
before injury from decreased blood flow occurs.
7. Answer: (A) Prevent stress ulcer
Rationale: Curling’s ulcer occurs as a generalized stress response in burn
patients. This results in a decreased production of mucus and increased
secretion of gastric acid. The best treatment for this prophylactic use of antacids
and H2 receptor blockers.
8. Answer: (D) Continue to monitor and record hourly urine output
Rationale: Normal urine output for an adult is approximately 1 ml/minute (60
ml/hour). Therefore, this client's output is normal. Beyond continued evaluation,
no nursing action is warranted.
9. Answer: (B) “My ankle feels warm”.
Rationale: Ice application decreases pain and swelling. Continued or increased
pain, redness, and increased warmth are signs of inflammation that shouldn't
occur after ice application
10. Answer: (B) Hyperkalemia
Rationale: A loop diuretic removes water and, along with it, sodium and
potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.
11. Answer:(A) Have condescending trust and confidence in their subordinates
Rationale: Benevolent-authoritative managers pretentiously show their trust and
confidence to their followers.
12. Answer: (A) Provides continuous, coordinated and comprehensive nursing
services.
Rationale: Functional nursing is focused on tasks and activities and not on the
care of the patients.
13. Answer: (B) Standard written order
Rationale: This is a standard written order. Prescribers write a single order for
medications given only once. A stat order is written for
medications given immediately for an urgent client problem. A standing order,
also known as a protocol, establishes guidelines for treating a
particular disease or set of symptoms in special care areas such as the coronary
care unit. Facilities also may institute medication protocols that specifically
designate drugs that a nurse may not give.
14. Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid stools results from seepage of
unformed bowel contents around the impacted stool in the rectum. Clients
with fecal impaction don't pass hard, brown, formed stools because the feces
can't move past the impaction. These clients typically report the urge
to defecate (although they can't pass stool) and a decreased appetite.
15. Answer: (C) Pulling the helix up and back
Rationale: To perform an otoscopic examination on an adult, the nurse grasps
the helix of the ear and pulls it up and back to straighten the ear canal. For a
child, the nurse grasps the helix and pulls it down to straighten the ear canal.
Pulling the lobule in any direction wouldn't straighten the ear canal for
visualization.
16. Answer: (A) Protect the irritated skin from sunlight.
Rationale: Irradiated skin is very sensitive and must be protected with clothing or
sunblock. The priority approach is the avoidance of strong sunlight.
17. Answer: (C) Assist the client in removing dentures and nail polish.
Rationale: Dentures, hairpins, and combs must be removed. Nail polish must be
removed so that cyanosis can be easily monitored by observing the nail beds.
18. Answer: (D) Sudden onset of continuous epigastric and back pain.
Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain
from inflammation, edema, and possible hemorrhage. Continuous, unrelieved
epigastric or back pain reflects the inflammatory process in the pancreas.
19. Answer: (B) Provide high-protein, high-carbohydrate diet.
Rationale: A positive nitrogen balance is important for meeting metabolic needs,
tissue repair, and resistance to infection. Caloric goals may be as high as 5000
calories per day.
20. Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to recognize the signs of an
anaphylactic or hemolytic reaction to the transfusion.
21. Answer: (D) Immobilize the leg before moving the client.
Rationale: If the nurse suspects a fracture, splinting the area before moving the
client is imperative. The nurse should call for emergency help if the client is not
hospitalized and call for a physician for the hospitalized client.
22. Answer: (B) Admit the client into a private room.
Rationale: The client who has a radiation implant is placed in a private room and
has a limited number of visitors. This reduces the exposure of others to the
radiation.
23. Answer: (C) Risk for infection
Rationale: Agranulocytosis is characterized by a reduced number of leukocytes
(leucopenia) and neutrophils (neutropenia) in the blood. The client is at high risk
for infection because of the decreased body defenses against microorganisms.
Deficient knowledge related to the nature of the disorder may be appropriate
diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side in the Trendelenburg position.
Rationale: Lying on the left side may prevent air from flowing into the pulmonary
veins. The Trendelenburg position increases intrathoracic pressure, which
decreases the amount of blood pulled into the vena cava during aspiration.
25. Answer: (A) Autocratic.
Rationale: The autocratic style of leadership is a task-oriented and directive.
26. Answer: (D) 2.5 cc
Rationale: 2.5 cc is to be added, because only a 500 cc bag of solution is being
medicated instead of a 1 liter.
27. Answer: (A) 50 cc/ hour
Rationale: A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8
hours = 50 cc/hr.
28. Answer: (B) Assess the client for presence of pain.
Rationale: Assessing the client for pain is a very important measure.
Postoperative pain is an indication of complication. The nurse should also assess
the client for pain to provide for the client’s comfort.
29. Answer: (A) BP – 80/60, Pulse – 110 irregular
Rationale: The classic signs of cardiogenic shock are low blood pressure, rapid
and weak irregular pulse, cold, clammy skin, decreased urinary output, and
cerebral hypoxia.
30. Answer: (A) Take the proper equipment, place the client in a comfortable
position, and record the appropriate information in the client’s chart.
Rationale: It is a general or comprehensive statement about the correct
procedure, and it includes the basic ideas which are found in the other options
31. Answer: (B) Evaluation
Rationale: Evaluation includes observing the person, asking questions, and
comparing the patient’s behavioral responses with the expected outcomes.
32. Answer: (C) History of present illness
Rationale: The history of present illness is the single most important factor in
assisting the health professional in arriving at a diagnosis or determining the
person’s needs.
33. Answer: (A) Trochanter roll extending from the crest of the ileum to the mid-
thigh.
Rationale: A trochanter roll, properly placed, provides resistance to the external
rotation of the hip.
34. Answer: (C) Stage III
Rationale: Clinically, a deep crater or without undermining of adjacent tissue is
noted.
35. Answer: (A) Second intention healing
Rationale: When wounds dehisce, they will allowed to heal by secondary
intention
36. Answer: (D) Tachycardia
Rationale: With an extracellular fluid or plasma volume deficit, compensatory
mechanisms stimulate the heart, causing an increase in heart rate.
37. Answer: (A) 0.75
Rationale: To determine the number of milliliters the client should receive, the
nurse uses the fraction method in the following equation.
75 mg/X ml = 100 mg/1 ml
To solve for X, cross-multiply:
75 mg x 1 ml = X ml x 100 mg
75 = 100X
75/100 = X
0.75 ml (or ¾ ml) = X
38. Answer: (D) It’s a measure of effect, not a standard measure of weight or
quantity.
Rationale: An insulin unit is a measure of effect, not a standard measure of
weight or quantity. Different drugs measured in units may have no relationship to
one another in quality or quantity.
39. Answer: (B) 38.9 °C
Rationale: To convert Fahrenheit degreed to Centigrade, use this formula
°C = (°F – 32) ÷ 1.8
°C = (102 – 32) ÷ 1.8
°C = 70 ÷ 1.8
°C = 38.9
40. Answer: (C) Failing eyesight, especially close vision.
Rationale: Failing eyesight, especially close vision, is one of the first signs of
aging in middle life (ages 46 to 64). More frequent aches and pains begin in the
early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later
years (age 80 and older).
41. Answer: (A) Checking and taping all connections
Rationale: Air leaks commonly occur if the system isn’t secure. Checking all
connections and taping them will prevent air leaks. The chest drainage system is
kept lower to promote drainage – not to prevent leaks.
42. Answer: (A) Check the client’s identification band.
Rationale: Checking the client’s identification band is the safest way to verify a
client’s identity because the band is assigned on admission and isn’t be removed
at any time. (If it is removed, it must be replaced). Asking the client’s name or
having the client repeated his name would be appropriate only for a client who’s
alert, oriented, and able to understand what is being said, but isn’t the safe
standard of practice. Names on bed aren’t always reliable
43. Answer: (B) 32 drops/minute
Rationale: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour
(60 minutes). Find the number of milliliters per minute as follows:
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/ 15 gtt
X = 32 gtt/minute, or 32 drops/minute
44. Answer: (A) Clamp the catheter
Rationale: If a central venous catheter becomes disconnected, the nurse should
immediately apply a catheter clamp, if available. If a clamp isn’t available, the
nurse can place a sterile syringe or catheter plug in the catheter hub. After
cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace
the I.V. extension and restart the infusion.
45. Answer: (D) Auscultation, percussion, and palpation.
Rationale: The correct order of assessment for examining the abdomen is
inspection, auscultation, percussion, and palpation. The reason for this approach
is that the less intrusive techniques should be performed before the more
intrusive techniques. Percussion and palpation can alter natural findings during
auscultation.
46. Answer: (D) Ulnar surface of the hand
Rationale: The nurse uses the ulnar surface, or ball, of the hand to asses tactile
fremitus, thrills, and vocal vibrations through the chest wall. The
fingertips and finger pads best distinguish texture and shape. The dorsal surface
best feels warmth.
47. Answer: (C) Formative
Rationale: Formative (or concurrent) evaluation occurs continuously throughout
the teaching and learning process. One benefit is that the nurse can adjust
teaching strategies as necessary to enhance learning. Summative, or
retrospective, evaluation occurs at the conclusion of the teaching and learning
session. Informative is not a type of evaluation.
48. Answer: (B) Once per year
Rationale: Yearly mammograms should begin at age 40 and continue for
as long as the woman is in good health. If health risks, such as family
history, genetic tendency, or past breast cancer, exist, more frequent
examinations may be necessary.
49. Answer: (A) Respiratory acidosis
Rationale: The client has a below-normal (acidic) blood pH value and an above-
normal partial pressure of arterial carbon dioxide (Paco2) value, indicating
respiratory acidosis. In respiratory alkalosis, the pH value is above normal and in
the Paco2 value is below normal. In metabolic acidosis, the pH and bicarbonate
(Hco3) values are below normal. In metabolic alkalosis, the pH and Hco3 values
are above normal.
50. Answer: (B) To provide support for the client and family in coping with
terminal illness.
Rationale: Hospices provide supportive care for terminally ill clients and their
families. Hospice care doesn’t focus on counseling regarding health care costs.
Most client referred to hospices have been treated for their disease without
success and will receive only palliative care in the hospice.
51. Answer: (C) Using normal saline solution to clean the ulcer and applying a
protective dressing as necessary.
Rationale: Washing the area with normal saline solution and applying a
protective dressing are within the nurse’s realm of interventions and will protect
the area. Using a povidone-iodine wash and an antibiotic cream require a
physician’s order. Massaging with an astringent can further damage the skin.
52. Answer: (D) Foot
Rationale: An elastic bandage should be applied form the distal area to the
proximal area. This method promotes venous return. In this case, the nurse
should begin applying the bandage at the client’s foot. Beginning at the ankle,
lower thigh, or knee does not promote venous return.
53. Answer: (B) Hypokalemia
Rationale: Insulin administration causes glucose and potassium to move into the
cells, causing hypokalemia.
54. Answer: (A) Throbbing headache or dizziness
Rationale: Headache and dizziness often occur when nitroglycerin is taken at the
beginning of therapy. However, the client usually develops tolerance
55. Answer: (D) Check the client’s level of consciousness
Rationale: Determining unresponsiveness is the first step assessment action to
take. When a client is in ventricular tachycardia, there is a significant decrease in
cardiac output. However, checking the unresponsiveness ensures whether the
client is affected by the decreased cardiac output.
56. Answer: (B) On the affected side of the client.
Rationale: When walking with clients, the nurse should stand on the affected side
and grasp the security belt in the midspine area of the small of the back. The
nurse should position the free hand at the shoulder area so that the client can be
pulled toward the nurse in the event that there is a forward fall. The client is
instructed to look up and outward rather than at his or her feet.
57. Answer: (A) Urine output: 45 ml/hr
Rationale: Adequate perfusion must be maintained to all vital organs in order for
the client to remain visible as an organ donor. A urine output of 45 ml per hour
indicates adequate renal perfusion. Low blood pressure and delayed capillary
refill time are circulatory system indicators of inadequate perfusion. A serum pH
of 7.32 is acidotic, which adversely affects all body tissues.
58. Answer: (D ) Obtaining the specimen from the urinary drainage bag.
Rationale: A urine specimen is not taken from the urinary drainage bag. Urine
undergoes chemical changes while sitting in the bag and does not necessarily
reflect the current client status. In addition, it may become contaminated with
bacteria from opening the system.
59. Answer: (B) Cover the client, place the call light within reach, and answer the
phone call.
Rationale: Because telephone call is an emergency, the nurse may need to
answer it. The other appropriate action is to ask another nurse to accept the call.
However, is not one of the options. To maintain privacy and safety, the nurse
covers the client and places the call light within the client’s reach. Additionally,
the client’s door should be closed or the room curtains pulled around the bathing
area.
60. Answer: (C) Use a sterile plastic container for obtaining the specimen.
Rationale: Sputum specimens for culture and sensitivity testing need to be
obtained using sterile techniques because the test is done to determine the
presence of organisms. If the procedure for obtaining the specimen is not sterile,
then the specimen is not sterile, then the specimen would be contaminated and
the results of the test would be invalid.
61. Answer: (A) Puts all the four points of the walker flat on the floor, puts weight
on the hand pieces, and then walks into it.
Rationale: When the client uses a walker, the nurse stands adjacent to the
affected side. The client is instructed to put all four points of the walker 2 feet
forward flat on the floor before putting weight on hand pieces. This will ensure
client safety and prevent stress cracks in the walker. The client is then instructed
to move the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the incorrect information and then
initials the change.
Rationale: To correct an error documented in a medical record, the nurse draws
one line through the incorrect information and then initials the error. An error is
never erased and correction fluid is never used in the medical record.
63. Answer: (C) Secures the client safety belts after transferring to the stretcher.
Rationale: During the transfer of the client after the surgical procedure is
complete, the nurse should avoid exposure of the client because of the risk for
potential heat loss. Hurried movements and rapid changes in the position should
be avoided because these predispose the client to hypotension. At the time of
the transfer from the surgery table to the stretcher, the client is still affected by
the effects of the anesthesia; therefore, the client should not move self. Safety
belts can prevent the client from falling off the stretcher.
64. Answer: (B) Gown and gloves
Rationale: Contact precautions require the use of gloves and a gown if direct
client contact is anticipated. Goggles are not necessary unless the
nurse anticipates the splashes of blood, body fluids, secretions, or excretions
may occur. Shoe protectors are not necessary.
65. Answer: (C) Quad cane
Rationale: Crutches and a walker can be difficult to maneuver for a client with
weakness on one side. A cane is better suited for client with weakness of the arm
and leg on one side. However, the quad cane would provide the most stability
because of the structure of the cane and because a quad cane has four legs.
66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from the chest wall, the client is positioned
sitting at the edge of the bed leaning over the bedside table with the feet
supported on a stool. If the client is unable to sit up, the client is positioned lying
in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees.
67. Answer: (D) Reliability
Rationale: Reliability is consistency of the research instrument. It refers to
the repeatability of the instrument in extracting the same responses upon
its repeated administration.
68. Answer: (A) Keep the identities of the subject secret
Rationale: Keeping the identities of the research subject secret will ensure
anonymity because this will hinder providing link between the information given
to whoever is its source.
69. Answer: (A) Descriptive- correlational
Rationale: Descriptive- correlational study is the most appropriate for this study
because it studies the variables that could be the antecedents of the increased
incidence of nosocomial infection.
70. Answer: (C) Use of laboratory data
Rationale: Incidence of nosocomial infection is best collected through the use of
biophysiologic measures, particularly in vitro measurements, hence laboratory
data is essential.
71. Answer: (B) Quasi-experiment
Rationale: Quasi-experiment is done when randomization and control of the
variables are not possible.
72. Answer: (C) Primary source
Rationale: This refers to a primary source which is a direct account of the
investigation done by the investigator. In contrast to this is a secondary source,
which is written by someone other than the original researcher.
73. Answer: (A) Non-maleficence
Rationale: Non-maleficence means do not cause harm or do any action that will
cause any harm to the patient/client. To do good is referred as beneficence.
74. Answer: (C) Res ipsa loquitor
Rationale: Res ipsa loquitor literally means the thing speaks for itself. This means
in operational terms that the injury caused is the proof that there was a negligent
act.
75. Answer: (B) The Board can investigate violations of the nursing law and code
of ethics
Rationale: Quasi-judicial power means that the Board of Nursing has the
authority to investigate violations of the nursing law and can issue summons,
subpoena or subpoena duces tecum as needed.
76. Answer: (C) May apply for re-issuance of his/her license based on certain
conditions stipulated in RA 9173
Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked license
maybe re-issued provided that the following conditions are met: a)
the cause for revocation of license has already been corrected or removed; and,
b) at least four years has elapsed since the license has been revoked.
77. Answer: (B) Review related literature
Rationale: After formulating and delimiting the research problem, the researcher
conducts a review of related literature to determine the extent of what has been
done on the study by previous researchers.
78. Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the study of Elton Mayo and company
about the effect of an intervention done to improve the working conditions of the
workers on their productivity. It resulted to an increased productivity but not due
to the intervention but due to the psychological effects of being observed. They
performed differently because they were under observation.
79. Answer: (B) Determines the different nationality of patients frequently
admitted and decides to get representations samples from each.
Rationale: Judgment sampling involves including samples according to the
knowledge of the investigator about the participants in the study.
80. Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the theory on transcultural theory
based on her observations on the behavior of selected people within a culture.
81. Answer: (A) Random
Rationale: Random sampling gives equal chance for all the elements in the
population to be picked as part of the sample.
82. Answer: (A) Degree of agreement and disagreement
Rationale: Likert scale is a 5-point summated scale used to determine the degree
of agreement or disagreement of the respondents to a statement in a study
83. Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the Adaptation Model which involves the
physiologic mode, self-concept mode, role function mode and dependence
mode.
84. Answer: (A) Span of control
Rationale: Span of control refers to the number of workers who report directly to
a manager.
85. Answer: (B) Autonomy
Rationale: Informed consent means that the patient fully understands about the
surgery, including the risks involved and the alternative solutions. In giving
consent it is done with full knowledge and is given freely. The action of allowing
the patient to decide whether a surgery is to be done or not exemplifies the
bioethical principle of autonomy.
86. Answer: (C) Avoid wearing canvas shoes.
Rationale: The client should be instructed to avoid wearing canvas shoes.
Canvas shoes cause the feet to perspire, which may, in turn, cause skin
irritation and breakdown. Both cotton and cornstarch absorb perspiration. The
client should be instructed to cut toenails straight across with nail
clippers.
87. Answer: (D) Ground beef patties
Rationale: Meat is an excellent source of complete protein, which this client
needs to repair the tissue breakdown caused by pressure ulcers.
Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only
some incomplete protein, making it less helpful in tissue repair.
88. Answer: (D) Sims’ left lateral
Rationale: The Sims' left lateral position is the most common position used to
administer a cleansing enema because it allows gravity to aid the flow of fluid
along the curve of the sigmoid colon. If the client can't assume this position nor
has poor sphincter control, the dorsal recumbent or right lateral position may be
used. The supine and prone positions are inappropriate and uncomfortable for
the client.
89. Answer: (A) Arrange for typing and cross matching of the client’s blood.
Rationale: The nurse first arranges for typing and cross matching of the client's
blood to ensure compatibility with donor blood. The other options,
although appropriate when preparing to administer a blood transfusion, come
later.
90. Answer: (A) Independent
Rationale: Nursing interventions are classified as independent, interdependent,
or dependent. Altering the drug schedule to coincide with the client's daily routine
represents an independent intervention, whereas consulting with the physician
and pharmacist to change a client's medication because of adverse reactions
represents an interdependent intervention. Administering an already-prescribed
drug on time is a dependent intervention. An intradependent nursing intervention
doesn't exist.
91. Answer: (D) Evaluation
Rationale: The nursing actions described constitute evaluation of the expected
outcomes. The findings show that the expected outcomes have been achieved.
Assessment consists of the client's history, physical examination, and laboratory
studies. Analysis consists of considering assessment information to derive the
appropriate nursing diagnosis. Implementation is the phase of the nursing
process where the nurse puts the plan of care into action.
92. Answer: (B) To observe the lower extremities
Rationale: Elastic stockings are used to promote venous return. The nurse needs
to remove them once per day to observe the condition of the skin underneath the
stockings. Applying the stockings increases blood flow to the heart. When the
stockings are in place, the leg muscles can still stretch and relax, and the veins
can fill with blood.
93. Answer:(A) Instructing the client to report any itching, swelling, or dyspnea.
Rationale: Because administration of blood or blood products may cause serious
adverse effects such as allergic reactions, the nurse must monitor the client for
these effects. Signs and symptoms of life-threatening allergic reactions include
itching, swelling, and dyspnea. Although the nurse should inform the client of the
duration of the transfusion and should document its administration, these actions
are less critical to the client's immediate health. The nurse should assess vital
signs at least hourly during the transfusion.
94. Answer: (B) Decrease the rate of feedings and the concentration of the
formula.
Rationale: Complaints of abdominal discomfort and nausea are common in
clients receiving tube feedings. Decreasing the rate of the feeding and the
concentration of the formula should decrease the client's discomfort. Feedings
are normally given at room temperature to minimize abdominal cramping. To
prevent aspiration during feeding, the head of the client's bed should be elevated
at least 30 degrees. Also, to prevent bacterial growth, feeding containers should
be routinely changed every 8 to 12 hours.
95. Answer: (D) Roll the vial gently between the palms.
Rationale: Rolling the vial gently between the palms produces heat, which helps
dissolve the medication. Doing nothing or inverting the vial wouldn't help dissolve
the medication. Shaking the vial vigorously could cause the medication to break
down, altering its action.
96. Answer: (B) Assist the client to the semi-Fowler position if possible.
Rationale: By assisting the client to the semi-Fowler position, the nurse promotes
easier chest expansion, breathing, and oxygen intake. The nurse should secure
the elastic band so that the face mask fits comfortably and snugly rather than
tightly, which could lead to irritation. The nurse should apply the face mask from
the client's nose down to the chin — not vice versa. The nurse should check the
connectors between the oxygen equipment and humidifier to ensure that they're
airtight; loosened connectors can cause loss of oxygen.
97. Answer: (B) 4 hours
Rationale: A unit of packed RBCs may be given over a period of between 1 and 4
hours. It shouldn't infuse for longer than 4 hours because the risk of
contamination and sepsis increases after that time. Discard or return to the blood
bank any blood not given within this time, according to facility policy.
98. Answer: (B) Immediately before administering the next dose.
Rationale: Measuring the blood drug concentration helps determine whether the
dosing has achieved the therapeutic goal. For measurement of the trough, or
lowest, blood level of a drug, the nurse draws a blood sample immediately before
administering the next dose. Depending on the drug's duration of action and half-
life, peak blood drug levels typically are drawn after administering the next dose.
99. Answer: (A) The nurse can implement medication orders quickly.
Rationale: A floor stock system enables the nurse to implement medication
orders quickly. It doesn't allow for pharmacist input, nor does it minimize
transcription errors or reinforce accurate calculations.
100. Answer: (C) Shifting dullness over the abdomen.
Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal
finding. The other options are normal abdominal findings.
NP2- MCN AND CHN
1. May arrives at the health care clinic and tells the nurse that her last menstrual
period was 9 weeks ago. She also tells the nurse that a home pregnancy test
was positive but she began to have mild cramps and is now having moderate
vaginal bleeding. During the physical examination of the client, the nurse notes
that May has a dilated cervix. The nurse determines that May is experiencing
which type of abortion?
a. Inevitable b. Incomplete c. Threatened d. Septic
2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal
visit. Which of the following data, if noted on the client’s record, would alert the
nurse that the client is at risk for a spontaneous abortion?
a. Age 36 years b. History of syphilis
c. History of genital herpes d. History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who is newly admitted to the
hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a
plan of care for the client and determines that which of the following nursing
actions is the priority?
a. Monitoring weight b. Assessing for edema
c. Monitoring apical pulse d. Monitoring temperature
4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin
needs during pregnancy. The nurse determines that the client understands
dietary and insulin needs if the client states that the second half of pregnancy
require:
a. Decreased caloric intake b. Increased caloric intake
c. Decreased Insulin d. Increase Insulin
5. Nurse Michelle is assessing a 24 year old client with a diagnosis of
hydatidiform mole. She is aware that one of the following is unassociated with
this condition?
a. Excessive fetal activity.
b. Larger than normal uterus for gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.
6. A pregnant client is receiving magnesium sulfate for severe pregnancy
induced hypertension (PIH). The clinical findings that would warrant use of the
antidote , calcium gluconate is:
a. Urinary output 90 cc in 2 hours. b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min. d. Rapid rise in blood pressure.
7. During vaginal examination of Janah who is in labor, the presenting part is at
station plus two. Nurse, correctly interprets it as:
a. Presenting part is 2 cm above the plane of the ischial spines.
b. Biparietal diameter is at the level of the ischial spines.
c. Presenting part in 2 cm below the plane of the ischial spines.
d. Biparietal diameter is 2 cm above the ischial spines.
8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A
condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin
is:
a. Contractions every 1 ½ minutes lasting 70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart rate.
d. Fetal heart rate baseline 140-160 bpm.
9. Calcium gluconate is being administered to a client with pregnancy induced
hypertension (PIH). A nursing action that must be initiated as the plan of care
throughout injection of the drug is:
a. Ventilator assistance b. CVP readings c. EKG tracings d. Continuous CPR
10. A trial for vaginal delivery after an earlier caesareans, would likely to be given
to a gravida, who had:
a. First low transverse cesarean was for active herpes type 2 infections; vaginal
culture at 39 weeks pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this
pregnancy is in a vertex presentation.
11.Nurse Ryan is aware that the best initial approach when trying to take a crying
toddler’s temperature is:
a. Talk to the mother first and then to the toddler.
b. Bring extra help so it can be done quickly.
c. Encourage the mother to hold the child.
d. Ignore the crying and screaming.
12.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What
should the nurse do to prevent trauma to operative site?
a. Avoid touching the suture line, even when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow restraints.
13. Which action should nurse Marian include in the care plan for a 2 month old
with heart failure?
a. Feed the infant when he cries.
b. Allow the infant to rest before feeding.
c. Bathe the infant and administer medications before feeding.
d. Weigh and bathe the infant before feeding.
14.Nurse Hazel is teaching a mother who plans to discontinue breast feeding
after 5 months. The nurse should advise her to include which foods in her infant’s
diet?
a. Skim milk and baby food. b. Whole milk and baby food.
c. Iron-rich formula only. d. Iron-rich formula and baby food.
15.Mommy Linda is playing with her infant, who is sitting securely alone on the
floor of the clinic. The mother hides a toy behind her back and the infant looks for
it. The nurse is aware that estimated age of the infant
would be:
a. 6 months b. 4 months c. 8 months d. 10 months
16.Which of the following is the most prominent feature of public health nursing?
a. It involves providing home care to sick people who are not confined in the
hospital.
b. Services are provided free of charge to people within the catchments area.
c. The public health nurse functions as part of a team providing a public health
nursing services.
d. Public health nursing focuses on preventive, not curative, services.
17.When the nurse determines whether resources were maximized in
implementing Ligtas Tigdas, she is evaluating
a. Effectiveness b. Efficiency c. Adequacy d. Appropriateness
18.Vangie is a new B.S.N. graduate. She wants to become a Public Health
Nurse. Where should she apply?
a. Department of Health b. Provincial Health Office
c. Regional Health Office d. Rural Health Unit
19.Tony is aware the Chairman of the Municipal Health Board is:
a. Mayor b. Municipal Health Officer
c. Public Health Nurse d. Any qualified physician
20.Myra is the public health nurse in a municipality with a total population of
about 20,000. There are 3 rural health midwives among the RHU personnel. How
many more midwife items will the RHU need?
a. 1 b. 2 c. 3 d. The RHU does not need any more midwife item.
21.According to Freeman and Heinrich, community health nursing is a
developmental service. Which of the following best illustrates this statement?
a. The community health nurse continuously develops himself personally and
professionally.
b. Health education and community organizing are necessary in providing
community health services.
c. Community health nursing is intended primarily for health promotion and
prevention and treatment of disease.
d. The goal of community health nursing is to provide nursing services to people
in their own places of residence.
22.Nurse Tina is aware that the disease declared through Presidential
Proclamation No. 4 as a target for eradication in the Philippines is?
a. Poliomyelitis b. Measles c. Rabies d. Neonatal tetanus
23.May knows that the step in community organizing that involves training of
potential leaders in the community is:
a. Integration b. Community organization
c. Community study d. Core group formation
24.Beth a public health nurse takes an active role in community participation.
What is the primary goal of community organizing?
a. To educate the people regarding community health problems
b. To mobilize the people to resolve community health problems
c. To maximize the community’s resources in dealing with health problems.
d. To maximize the community’s resources in dealing with health problems.
25.Tertiary prevention is needed in which stage of the natural history of disease?
a. Pre-pathogenesis b. Pathogenesis c. Prodromal d. Terminal
26.The nurse is caring for a primigravid client in the labor and delivery area.
Which condition would place the client at risk for disseminated
intravascular coagulation (DIC)?
a. Intrauterine fetal death. b. Placenta accreta.
c. Dysfunctional labor. d. Premature rupture of the membranes.
27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would
be:
a. 80 to 100 beats/minute b. 100 to 120 beats/minute
c. 120 to 160 beats/minute d. 160 to 180 beats/minute
28.The skin in the diaper area of a 7 month old infant is excoriated and red.
Nurse Hazel should instruct the mother to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each diaper change.
d. Decrease the infant’s fluid intake to decrease saturating diapers.
29.Nurse Carla knows that the common cardiac anomalies in children with Down
Syndrome (tri-somy 21) is:
a. Atrial septal defect b. Pulmonic stenosis
c. Ventricular septal defect d. Endocardial cushion defect
30.Malou was diagnosed with severe preeclampsia is now receiving I.V.
magnesium sulfate. The adverse effects associated with magnesium sulfate is:
a. Anemia b. Decreased urine output
c. Hyperreflexia d. Increased respiratory rate
31.A 23 year old client is having her menstrual period every 2 weeks that last for
1 week. This type of menstrual pattern is bets defined by:
a. Menorrhagia b. Metrorrhagia c. Dyspareunia d. Amenorrhea
32.Jannah is admitted to the labor and delivery unit. The critical laboratory result
for this client would be:
a. Oxygen saturation b. Iron binding capacity c. Blood typing d. Serum Calcium
33.Nurse Gina is aware that the most common condition found during the
second-trimester of pregnancy is:
a. Metabolic alkalosis b. Respiratory acidosis c. Mastitis d. Physiologic anemia
34.Nurse Lynette is working in the triage area of an emergency department. She
sees that several pediatric clients arrive simultaneously. The client who needs to
be treated first is:
a. A crying 5 year old child with a laceration on his scalp.
b. A 4 year old child with a barking coughs and flushed appearance.
c. A 3 year old child with Down syndrome who is pale and asleep in
his mother’s arms.
d. A 2 year old infant with stridorous breath sounds, sitting up in his
mother’s arms and drooling.
35.Maureen in her third trimester arrives at the emergency room with painless
vaginal bleeding. Which of the following conditions is suspected?
a. Placenta previa b. Abruptio placentae
c. Premature labor d. Sexually transmitted disease
36.A young child named Richard is suspected of having pinworms. The
community nurse collects a stool specimen to confirm the diagnosis. The nurse
should schedule the collection of this specimen for:
a. Just before bedtime b. After the child has been bathe
c. Any time during the day d. Early in the morning
37.In doing a child’s admission assessment, Nurse Betty should be alert to note
which signs or symptoms of chronic lead poisoning?
a. Irritability and seizures b. Dehydration and diarrhea
c. Bradycardia and hypotension d. Petechiae and hematuria
38.To evaluate a woman’s understanding about the use of diaphragm for family
planning, Nurse Trish asks her to explain how she will use the appliance. Which
response indicates a need for further health teaching?
a. “I should check the diaphragm carefully for holes every time I use it”
b. “I may need a different size of diaphragm if I gain or lose weight more than 20
pounds”
c. “The diaphragm must be left in place for atleast 6 hours after intercourse”
d. “I really need to use the diaphragm and jelly most during the middle of my
menstrual cycle”.
39.Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver
should frequently assess a child with laryngotracheobronchitis for:
a. Drooling b. Muffled voice c. Restlessness d. Low-grade fever
40.How should Nurse Michelle guide a child who is blind to walk to the
playroom?
a. Without touching the child, talk continuously as the child walks down the hall.
b. Walk one step ahead, with the child’s hand on the nurse’s elbow.
c. Walk slightly behind, gently guiding the child forward.
d. Walk next to the child, holding the child’s hand.
41.When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia
should expect that the child most likely would have an:
a. Loud, machinery-like murmur.
b. Bluish color to the lips.
c. Decreased BP reading in the upper extremities
d. Increased BP reading in the upper extremities.
42.The reason nurse May keeps the neonate in a neutral thermal environment is
that when a newborn becomes too cool, the neonate requires:
a. Less oxygen, and the newborn’s metabolic rate increases.
b. More oxygen, and the newborn’s metabolic rate decreases.
c. More oxygen, and the newborn’s metabolic rate increases.
d. Less oxygen, and the newborn’s metabolic rate decreases.
43.Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to
assess whether this infant has:
a. Stable blood pressure b. Patant fontanelles
c. Moro’s reflex d. Voided
44.Nurse Carla should know that the most common causative factor of dermatitis
in infants and younger children is:
a. Baby oil b. Baby lotion c. Laundry detergent d. Powder with cornstarch
45.During tube feeding, how far above an infant’s stomach should the nurse hold
the syringe with formula?
a. 6 inches b. 12 inches c. 18 inches d. 24 inches
46. In a mothers’ class, Nurse Lhynnete discussed childhood diseases such as
chicken pox. Which of the following statements about chicken pox is correct?
a. The older one gets, the more susceptible he becomes to the complications of
chicken pox.
b. A single attack of chicken pox will prevent future episodes, including conditions
such as shingles.
c. To prevent an outbreak in the community, quarantine may be imposed by
health authorities.
d. Chicken pox vaccine is best given when there is an impending outbreak in the
community.
47.Barangay Pinoy had an outbreak of German measles. To prevent congenital
rubella, what is the BEST advice that you can give to women in the first trimester
of pregnancy in the barangay Pinoy?
a. Advice them on the signs of German measles.
b. Avoid crowded places, such as markets and movie houses.
c. Consult at the health center where rubella vaccine may be given.
d. Consult a physician who may give them rubella immunoglobulin.

48.Myrna a public health nurse knows that to determine possible sources of
sexually transmitted infections, the BEST method that may be undertaken is:
a. Contact tracing b. Community survey
c. Mass screening tests d. Interview of suspects
49.A 33-year old female client came for consultation at the health center with the
chief complaint of fever for a week. Accompanying symptoms were muscle pains
and body malaise. A week after the start of fever, the client noted yellowish
discoloration of his sclera. History showed that he waded in flood waters about 2
weeks before the onset of symptoms. Based on her history, which disease
condition will you suspect?
a. Hepatitis A b. Hepatitis B c. Tetanus d. Leptospirosis
50.Mickey a 3-year old client was brought to the health center with the chief
complaint of severe diarrhea and the passage of “rice water” stools. The client is
most probably suffering from which condition?
a. Giardiasis b. Cholera c. Amebiasis d. Dysentery
51.The most prevalent form of meningitis among children aged 2 months to 3
years is caused by which microorganism?
a. Hemophilus influenza b. Morbillivirus
c. Steptococcus pneumonia d. Neisseria meningitidis
52.The student nurse is aware that the pathognomonic sign of measles is
Koplik’s spot and you may see Koplik’s spot by inspecting the:
a. Nasal mucosa b. Buccal mucosa
c. Skin on the abdomen d. Skin on neck
53.Angel was diagnosed as having Dengue fever. You will say that there is slow
capillary refill when the color of the nailbed that you pressed does not return
within how many seconds?
a. 3 seconds b. 6 seconds c. 9 seconds d. 10 seconds
54.In Integrated Management of Childhood Illness, the nurse is aware that the
severe conditions generally require urgent referral to a hospital. Which of the
following severe conditions DOES NOT always require urgent referral to a
hospital?
a. Mastoiditis b. Severe dehydration
c. Severe pneumonia d. Severe febrile disease
55.Myrna a public health nurse will conduct outreach immunization in a barangay
Masay with a population of about 1500. The estimated number of infants in the
barangay would be:
a. 45 infants b. 50 infants c. 55 infants d. 65 infants
56.The community nurse is aware that the biological used in Expanded Program
on Immunization (EPI) should NOT be stored in the freezer?
a. DPT b. Oral polio vaccine c. Measles vaccine d. MMR
57.It is the most effective way of controlling schistosomiasis in an endemic area?
a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
d. Use of protective footwear, such as rubber boots
58.Several clients is newly admitted and diagnosed with leprosy. Which of the
following clients should be classified as a case of multibacillary leprosy?
a. 3 skin lesions, negative slit skin smear
b. 3 skin lesions, positive slit skin smear
c. 5 skin lesions, negative slit skin smear
d. 5 skin lesions, positive slit skin smear
59.Nurses are aware that diagnosis of leprosy is highly dependent on recognition
of symptoms. Which of the following is an early sign of
leprosy?
a. Macular lesions b. Inability to close eyelids
c. Thickened painful nerves d. Sinking of the nosebridge
60.Marie brought her 10 month old infant for consultation because of fever,
started 4 days prior to consultation. In determining malaria risk, what will you do?
a. Perform a tourniquet test.
b. Ask where the family resides.
c. Get a specimen for blood smear.
d. Ask if the fever is present everyday.
61.Susie brought her 4 years old daughter to the RHU because of cough and
colds. Following the IMCI assessment guide, which of the following is a danger
sign that indicates the need for urgent referral to a hospital?
a. Inability to drink b. High grade fever
c. Signs of severe dehydration d. Cough for more than 30 days
62.Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the IMCI
guidelines, how will you manage Jimmy?
a. Refer the child urgently to a hospital for confinement.
b. Coordinate with the social worker to enroll the child in a feeding program.
c. Make a teaching plan for the mother, focusing on menu planning for her child.
d. Assess and treat the child for health problems like infections and intestinal
parasitism.
63.Gina is using Oresol in the management of diarrhea of her 3-year old child.
She asked you what to do if her child vomits. As a nurse you will tell her to:
a. Bring the child to the nearest hospital for further assessment.
b. Bring the child to the health center for intravenous fluid therapy.
c. Bring the child to the health center for assessment by the physician.
d. Let the child rest for 10 minutes then continue giving Oresol more slowly.
64.Nikki a 5-month old infant was brought by his mother to the health center
because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after a skin
pinch and her eyes are sunken. Using the IMCI guidelines, you will classify this
infant in which category?
a. No signs of dehydration b. Some dehydration
c. Severe dehydration d. The data is insufficient.
65.Chris a 4-month old infant was brought by her mother to the health center
because of cough. His respiratory rate is 42/minute. Using the Integrated
Management of Child Illness (IMCI) guidelines of assessment, his breathing is
considered as:
a. Fast b. Slow c. Normal d. Insignificant
66.Maylene had just received her 4th dose of tetanus toxoid. She is aware that
her baby will have protection against tetanus for
a. 1 year b. 3 years c. 5 years d. Lifetime
67.Nurse Ron is aware that unused BCG should be discarded after how many
hours of reconstitution?
a. 2 hours b. 4 hours c. 8 hours d. At the end of the day
68.The nurse explains to a breastfeeding mother that breast milk is sufficient for
all of the baby’s nutrient needs only up to:
a. 5 months b. 6 months c. 1 year d. 2 years
69.Nurse Ron is aware that the gestational age of a conceptus that is considered
viable (able to live outside the womb) is:
a. 8 weeks b. 12 weeks c. 24 weeks d. 32 weeks
70.When teaching parents of a neonate the proper position for the neonate’s
sleep, the nurse Patricia stresses the importance of placing the neonate on his
back to reduce the risk of which of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
71.Which finding might be seen in baby James a neonate suspected of having an
infection?
a. Flushed cheeks b. Increased temperature
c. Decreased temperature d. Increased activity level
72.Baby Jenny who is small-for-gestation is at increased risk during the
transitional period for which complication?
a. Anemia probably due to chronic fetal hyposia
b. Hyperthermia due to decreased glycogen stores
c. Hyperglycemia due to decreased glycogen stores
d. Polycythemia probably due to chronic fetal hypoxia
73.Marjorie has just given birth at 42 weeks’ gestation. When the nurse
assessing the neonate, which physical finding is expected?
a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body
74.After reviewing the Myrna’s maternal history of magnesium sulfate during
labor, which condition would nurse Richard anticipate as a potential problem in
the neonate?
a. Hypoglycemia b. Jitteriness
c. Respiratory depression d. Tachycardia
75.Which symptom would indicate the Baby Alexandra was adapting 86. Nurse John is knowledgeable that usually individual twins will grow
appropriately to extra-uterine life without difficulty? appropriately and at the same rate as singletons until how many weeks?

a. Nasal flaring a. 16 to 18 weeks b. 18 to 22 weeks

b. Light audible grunting c. 30 to 32 weeks d. 38 to 40 weeks
c. Respiratory rate 40 to 60 breaths/minute
d. Respiratory rate 60 to 80 breaths/minute 87. Which of the following classifications applies to monozygotic twins for whom
the cleavage of the fertilized ovum occurs more than 13 days after fertilization?
76. When teaching umbilical cord care for Jennifer a new mother, the nurse
Jenny would include which information? a. conjoined twins
b. diamniotic dichorionic twins
a. Apply peroxide to the cord with each diaper change c. diamniotic monochorionic twin
b. Cover the cord with petroleum jelly after bathing d. monoamniotic monochorionic twins
c. Keep the cord dry and open to air
d. Wash the cord with soap and water each day during a tub bath. 88. Tyra experienced painless vaginal bleeding has just been diagnosed as
having a placenta previa. Which of the following procedures is usually performed
77.Nurse John is performing an assessment on a neonate. Which of the following to diagnose placenta previa?
findings is considered common in the healthy neonate?
a. Amniocentesis
a. Simian crease b. Conjunctival hemorrhage b. Digital or speculum examination
c. Cystic hygroma d. Bulging fontanelle c. External fetal monitoring
d. Ultrasound
78.Dr. Esteves decides to artificially rupture the membranes of a mother who is
on labor. Following this procedure, the nurse Hazel checks the fetal heart tones 89. Nurse Arnold knows that the following changes in respiratory functioning
for which the following reasons? during pregnancy is considered normal:

a. To determine fetal well-being. a. Increased tidal volume

b. To assess for prolapsed cord b. Increased expiratory volume
c. To assess fetal position c. Decreased inspiratory capacity
d. To prepare for an imminent delivery. d. Decreased oxygen consumption

79.Which of the following would be least likely to indicate anticipated bonding 90. Emily has gestational diabetes and it is usually managed by which of the
behaviors by new parents? following therapy?

a. The parents’ willingness to touch and hold the new born. a. Diet
b. The parent’s expression of interest about the size of the new born. b. Long-acting insulin
c. The parents’ indication that they want to see the newborn. c. Oral hypoglycemic
d. The parents’ interactions with each other. d. Oral hypoglycemic drug and insulin

80.Following a precipitous delivery, examination of the client's vagina reveals
a fourth-degree laceration. Which of the following would be contraindicated when
caring for this client?
a. Applying cold to limit edema during the first 12 to 24 hours.
b. Instructing the client to use two or more peripads to cushion the area.
c. Instructing the client on the use of sitz baths if ordered.
d. Instructing the client about the importance of perineal (kegel) exercises.
91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of
the following condition?
a. Hemorrhage b. Hypertension c. Hypomagnesemia d. Seizure
92. Cammile with sickle cell anemia has an increased risk for having a sickle cell
crisis during pregnancy. Aggressive management of a sickle cell crisis includes
which of the following measures?

81. A pregnant woman accompanied by her husband, seeks admission to the a. Antihypertensive agents b. Diuretic agents
labor and delivery area. She states that she's in labor and says she attended the c. I.V. fluids d. Acetaminophen (Tylenol) for pain
facility clinic for prenatal care. Which question should the nurse Oliver ask her
first? 93. Which of the following drugs is the antidote for magnesium toxicity?

a. “Do you have any chronic illnesses?” a. Calcium gluconate (Kalcinate)

b. “Do you have any allergies?” b. Hydralazine (Apresoline)
c. “What is your expected due date?” c. Naloxone (Narcan)
d. “Who will be with you during labor?” d. Rho (D) immune globulin (RhoGAM)

82.A neonate begins to gag and turns a dusky color. What should the nurse do
first?
a. Calm the neonate.
b. Notify the physician.
c. Provide oxygen via face mask as ordered
d. Aspirate the neonate’s nose and mouth with a bulb syringe.
83. When a client states that her "water broke," which of the following actions
would be inappropriate for the nurse to do?
a. Observing the pooling of straw-colored fluid.
b. Checking vaginal discharge with nitrazine paper.
c. Conducting a bedside ultrasound for an amniotic fluid index.
d. Observing for flakes of vernix in the vaginal discharge.
94. Marlyn is screened for tuberculosis during her first prenatal visit. An
intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is
given. She is considered to have a positive test for which of the following results?
a. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours.
b. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.
c. A flat circumcised area under 10 mm in diameter appears in 6 to 12 hours.
d. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours.
95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her physician’s office
with complaints of fever, nausea, vomiting, malaise, unilateral flank pain, and
costovertebral angle tenderness. Which of the following diagnoses is most likely?
a. Asymptomatic bacteriuria b. Bacterial vaginosis
c. Pyelonephritis d. Urinary tract infection (UTI)

84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous
respirations but is successfully resuscitated. Within several hours she develops
respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's
diagnosed with respiratory distress syndrome, intubated, and placed on a
ventilator. Which nursing action should be included in the baby's plan of care to
prevent retinopathy of prematurity?
a. Cover his eyes while receiving oxygen.
b. Keep her body temperature low.
c. Monitor partial pressure of oxygen (Pao2) levels.
d. Humidify the oxygen.
96. Rh isoimmunization in a pregnant client develops during which of the
following conditions?
a. Rh-positive maternal blood crosses into fetal blood, stimulating fetal
antibodies.
b. Rh-positive fetal blood crosses into maternal blood, stimulating
maternal antibodies.
c. Rh-negative fetal blood crosses into maternal blood, stimulating
maternal antibodies.
d. Rh-negative maternal blood crosses into fetal blood, stimulating fetal
antibodies.

85. Which of the following is normal newborn calorie intake? 97. To promote comfort during labor, the nurse John advises a client to assume
certain positions and avoid others. Which position may cause maternal
a. 110 to 130 calories per kg. hypotension and fetal hypoxia?
b. 30 to 40 calories per lb of body weight.
c. At least 2 ml per feeding a. Lateral position b. Squatting position
d. 90 to 100 calories per kg c. Supine position d. Standing position
98. Celeste who used heroin during her pregnancy delivers a neonate. When
assessing the neonate, the nurse Lhynnette expects to find:
a. Lethargy 2 days after birth.
b. Irritability and poor sucking.
c. A flattened nose, small eyes, and thin lips.
d. Congenital defects such as limb anomalies.
99. The uterus returns to the pelvic cavity in which of the following time frames?
a. 7th to 9th day postpartum.
b. 2 weeks postpartum.
c. End of 6th week postpartum.
d. When the lochia changes to alba.
100. Maureen, a primigravida client, age 20, has just completed a difficult,
forceps-assisted delivery of twins. Her labor was unusually long and required
oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert
for:
a. Uterine inversion b. Uterine atony
c. Uterine involution d. Uterine discomfort
RATIO 2 
1. Answer: (A) Inevitable
Rationale: An inevitable abortion is termination of pregnancy that cannot be
prevented. Moderate to severe bleeding with mild cramping and cervical dilation
would be noted in this type of abortion.
2. Answer: (B) History of syphilis
Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are
causes of spontaneous abortion.
3. Answer: (C) Monitoring apical pulse
Rationale: Nursing care for the client with a possible ectopic pregnancy is
focused on preventing or identifying hypovolemic shock and controlling pain. An
elevated pulse rate is an indicator of shock.
4. Answer: (B) Increased caloric intake
Rationale: Glucose crosses the placenta, but insulin does not. High fetal
demands for glucose, combined with the insulin resistance caused by hormonal
changes in the last half of pregnancy can result in elevation of maternal blood
glucose levels. This increases the mother’s demand for insulin and is referred to
as the diabetogenic effect of pregnancy.
5. Answer: (A) Excessive fetal activity.
Rationale: The most common signs and symptoms of hydatidiform mole includes
elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than
normal uterus for gestational age, failure to detect fetal heart activity even with
sensitive instruments, excessive nausea and vomiting, and early development of
pregnancy-induced hypertension. Fetal activity would not be noted.
6. Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia,
which requires administration of calcium gluconate.
7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
Rationale: Fetus at station plus two indicates that the presenting part is 2 cm
below the plane of the ischial spines.
8. Answer: (A) Contractions every 1 ½ minutes lasting 70-80 seconds.
Rationale: Contractions every 1 ½ minutes lasting 70-80 seconds, is indicative of
hyperstimulation of the uterus, which could result in injury to the mother and the
fetus if Pitocin is not discontinued.
9. Answer: (C) EKG tracings
Rationale: A potential side effect of calcium gluconate administration is cardiac
arrest. Continuous monitoring of cardiac activity (EKG) throught administration of
calcium gluconate is an essential part of care.
10. Answer: (D) First low transverse caesarean was for breech position. Fetus in
this pregnancy is in a vertex presentation.
Rationale: This type of client has no obstetrical indication for a caesarean section
as she did with her first caesarean delivery.
11. Answer: (A) Talk to the mother first and then to the toddler.
Rationale: When dealing with a crying toddler, the best approach is to talk to the
mother and ignore the toddler first. This approach helps the toddler get used to
the nurse before she attempts any procedures. It also gives the toddler an
opportunity to see that the mother trusts the nurse.
12. Answer: (D) Place the infant’s arms in soft elbow restraints.
Rationale: Soft restraints from the upper arm to the wrist prevent the infant from
touching her lip but allow him to hold a favorite item such as a blanket. Because
they could damage the operative site, such as objects as pacifiers, suction
catheters, and small spoons shouldn’t be placed in a baby’s mouth after cleft
repair. A baby in a prone position may rub her face on the sheets and traumatize
the operative site. The suture line should be cleaned gently to prevent infection,
which could interfere with healing and damage the cosmetic appearance of the
repair.
13. Answer: (B) Allow the infant to rest before feeding.
Rationale: Because feeding requires so much energy, an infant with heart failure
should rest before feeding.
14. Answer: (C) Iron-rich formula only.
Rationale: The infants at age 5 months should receive iron-rich formula and that
they shouldn’t receive solid food, even baby food until age 6 months.
15. Answer: (D) 10 months
Rationale: A 10 month old infant can sit alone and understands object
permanence, so he would look for the hidden toy. At age 4 to 6 months, infants
can’t sit securely alone. At age 8 months, infants can sit securely alone but
cannot understand the permanence of objects.
16. Answer: (D) Public health nursing focuses on preventive, not curative,
services.
Rationale: The catchments area in PHN consists of a residential community,
many of whom are well individuals who have greater need for
preventive rather than curative services.
17. Answer: (B) Efficiency
Rationale: Efficiency is determining whether the goals were attained at the least
possible cost.
18. Answer: (D) Rural Health Unit
Rationale: R.A. 7160 devolved basic health services to local government units
(LGU’s ). The public health nurse is an employee of the LGU.
19. Answer: (A) Mayor
Rationale: The local executive serves as the chairman of the Municipal Health
Board.
20. Answer: (A) 1
Rationale: Each rural health midwife is given a population assignment of about
5,000.
21. Answer: (B) Health education and community organizing are necessary in
providing community health services.
Rationale: The community health nurse develops the health capability of people
through health education and community organizing activities.
22. Answer: (B) Measles
Rationale: Presidential Proclamation No. 4 is on the Ligtas Tigdas Program.
23. Answer: (D) Core group formation
Rationale: In core group formation, the nurse is able to transfer the technology of
community organizing to the potential or informal community leaders through a
training program.
24. Answer: (D) To maximize the community’s resources in dealing with health
problems.
Rationale: Community organizing is a developmental service, with the goal of
developing the people’s self-reliance in dealing with community
health problems. A, B and C are objectives of contributory objectives to this goal.
25. Answer: (D) Terminal
Rationale: Tertiary prevention involves rehabilitation, prevention of permanent
disability and disability limitation appropriate for convalescents, the disabled,
complicated cases and the terminally ill (those in the terminal stage of a disease).
26. Answer: (A) Intrauterine fetal death.
Rationale: Intrauterine fetal death, abruptio placentae, septic shock, and amniotic
fluid embolism may trigger normal clotting mechanisms; if clotting factors are
depleted, DIC may occur. Placenta accreta, dysfunctional labor, and premature
rupture of the membranes aren't associated with DIC.
27. Answer: (C) 120 to 160 beats/minute
Rationale: A rate of 120 to 160 beats/minute in the fetal heart appropriate for
filling the heart with blood and pumping it out to the system.
28. Answer: (A) Change the diaper more often.
Rationale: Decreasing the amount of time the skin comes contact with wet soiled
diapers will help heal the irritation.
29. Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen most in children with Down
syndrome, asplenia, or polysplenia.
30. Answer: (B) Decreased urine output
Rationale: Decreased urine output may occur in clients receiving I.V. magnesium
and should be monitored closely to keep urine output at
greater than 30 ml/hour, because magnesium is excreted through the kidneys
and can easily accumulate to toxic levels.
31. Answer: (A) Menorrhagia
Rationale: Menorrhagia is an excessive menstrual period.
32. Answer: (C) Blood typing
Rationale: Blood type would be a critical value to have because the risk of blood
loss is always a potential complication during the labor and delivery process.
Approximately 40% of a woman’s cardiac output is delivered to the uterus,
therefore, blood loss can occur quite rapidly in the event of uncontrolled bleeding.
33. Answer: (D) Physiologic anemia
Rationale: Hemoglobin values and hematocrit decrease during pregnancy as the
increase in plasma volume exceeds the increase in red blood cell production.
34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in his
mother’s arms and drooling.
Rationale: The infant with the airway emergency should be treated first, because
of the risk of epiglottitis.
35. Answer: (A) Placenta previa
Rationale: Placenta previa with painless vaginal bleeding.
36. Answer: (D) Early in the morning
Rationale: Based on the nurse’s knowledge of microbiology, the specimen should
be collected early in the morning. The rationale for this
timing is that, because the female worm lays eggs at night around the perineal
area, the first bowel movement of the day will yield the best
results. The specific type of stool specimen used in the diagnosis of pinworms is
called the tape test.
37. Answer: (A) Irritability and seizures
Rationale: Lead poisoning primarily affects the CNS, causing increased
intracranial pressure. This condition results in irritability and changes in level of
consciousness, as well as seizure disorders, hyperactivity, and learning
disabilities.
38. Answer: (D) “I really need to use the diaphragm and jelly most during the
middle of my menstrual cycle”.
Rationale: The woman must understand that, although the “fertile” period is
approximately mid-cycle, hormonal variations do occur and can result in early or
late ovulation. To be effective, the diaphragm should be inserted before every
intercourse.
39. Answer: (C) Restlessness
Rationale: In a child, restlessness is the earliest sign of hypoxia. Late signs of
hypoxia in a child are associated with a change in color, such as pallor or
cyanosis.
40. Answer: (B) Walk one step ahead, with the child’s hand on the nurse’s elbow.
Rationale: This procedure is generally recommended to follow in guiding a
person who is blind.
41. Answer: (A) Loud, machinery-like murmur.
Rationale: A loud, machinery-like murmur is a characteristic finding associated
with patent ductus arteriosus.
42. Answer: (C) More oxygen, and the newborn’s metabolic rate increases.
Rationale: When cold, the infant requires more oxygen and there is an increase
in metabolic rate. Non-shievering thermogenesis is a complex process that
increases the metabolic rate and rate of oxygen consumption, therefore, the
newborn increase heat production.
43. Answer: (D) Voided
Rationale: Before administering potassium I.V. to any client, the nurse must first
check that the client’s kidneys are functioning and that the client is voiding. If the
client is not voiding, the nurse should withhold the potassium and notify the
physician.
44. Answer: (c) Laundry detergent
Rationale: Eczema or dermatitis is an allergic skin reaction caused by an
offending allergen. The topical allergen that is the most common causative factor
is laundry detergent.
45. Answer: (A) 6 inches
Rationale: This distance allows for easy flow of the formula by gravity, but the
flow will be slow enough not to overload the stomach too rapidly.
46. Answer: (A) The older one gets, the more susceptible he becomes to the
complications of chicken pox.
Rationale: Chicken pox is usually more severe in adults than in children.
Complications, such as pneumonia, are higher in incidence in adults.
47. Answer: (D) Consult a physician who may give them rubella immunoglobulin.
Rationale: Rubella vaccine is made up of attenuated German measles viruses.
This is contraindicated in pregnancy. Immune globulin, a specific prophylactic
against German measles, may be given to pregnant women.
48. Answer: (A) Contact tracing
Rationale: Contact tracing is the most practical and reliable method of finding
possible sources of person-to-person transmitted infections, such as sexually
transmitted diseases.
49. Answer: (D) Leptospirosis
Rationale: Leptospirosis is transmitted through contact with the skin or mucous
membrane with water or moist soil contaminated with urine of infected animals,
like rats.
50. Answer: (B) Cholera
Rationale: Passage of profuse watery stools is the major symptom of cholera.
Both amebic and bacillary dysentery are characterized by the
presence of blood and/or mucus in the stools. Giardiasis is characterized by fat
malabsorption and, therefore, steatorrhea.
51. Answer: (A) Hemophilus influenzae
Rationale: Hemophilus meningitis is unusual over the age of 5 years. In
developing countries, the peak incidence is in children less than 6 months of age.
Morbillivirus is the etiology of measles. Streptococcus pneumoniae and Neisseria
meningitidis may cause meningitis, but age distribution is not specific in young
children.
52. Answer: (B) Buccal mucosa
Rationale: Koplik’s spot may be seen on the mucosa of the mouth or the throat.
53. Answer: (A) 3 seconds
Rationale: Adequate blood supply to the area allows the return of the color of the
nailbed within 3 seconds.
54. Answer: (B) Severe dehydration
Rationale: The order of priority in the management of severe dehydration is as
follows: intravenous fluid therapy, referral to a facility where IV fluids can be
initiated within 30 minutes, Oresol or nasogastric tube. When the foregoing
measures are not possible or effective, then urgent referral to the hospital is
done.
55. Answer: (A) 45 infants
Rationale: To estimate the number of infants, multiply total population by 3%.
56. Answer: (A) DPT
Rationale: DPT is sensitive to freezing. The appropriate storage temperature of
DPT is 2 to 8° C only. OPV and measles vaccine are highly
sensitive to heat and require freezing. MMR is not an immunization in the
Expanded Program on Immunization.
57. Answer: (C) Proper use of sanitary toilets
Rationale: The ova of the parasite get out of the human body together with feces.
Cutting the cycle at this stage is the most effective way of preventing the spread
of the disease to susceptible hosts.
58. Answer: (D) 5 skin lesions, positive slit skin smear
Rationale: A multibacillary leprosy case is one who has a positive slit skin smear
and at least 5 skin lesions.
59. Answer: (C) Thickened painful nerves
Rationale: The lesion of leprosy is not macular. It is characterized by a change in
skin color (either reddish or whitish) and loss of sensation, sweating and hair
growth over the lesion. Inability to close the eyelids (lagophthalmos) and sinking
of the nosebridge are late symptoms.
60. Answer: (B) Ask where the family resides.
Rationale: Because malaria is endemic, the first question to determine malaria
risk is where the client’s family resides. If the area of residence is not a known
endemic area, ask if the child had traveled within the past 6 months, where she
was brought and whether she stayed overnight in that area.
61. Answer: (A) Inability to drink
Rationale: A sick child aged 2 months to 5 years must be referred urgently to a
hospital if he/she has one or more of the following signs: not able to feed or drink,
vomits everything, convulsions, abnormally sleepy or difficult to awaken.
62. Answer: (A) Refer the child urgently to a hospital for confinement.
Rationale: “Baggy pants” is a sign of severe marasmus. The best management is
urgent referral to a hospital.
63. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol
more slowly.
Rationale: If the child vomits persistently, that is, he vomits everything that he
takes in, he has to be referred urgently to a hospital. Otherwise, vomiting is
managed by letting the child rest for 10 minutes and then continuing with Oresol
administration. Teach the mother to give Oresol more slowly.
64. Answer: (B) Some dehydration
Rationale: Using the assessment guidelines of IMCI, a child (2 months to 5 years
old) with diarrhea is classified as having SOME DEHYDRATION if he shows 2 or
more of the following signs: restless or irritable, sunken eyes, the skin goes back
slow after a skin pinch.
65. Answer: (C) Normal
Rationale: In IMCI, a respiratory rate of 50/minute or more is fast breathing for an
infant aged 2 to 12 months.
66. Answer: (A) 1 year
Rationale: The baby will have passive natural immunity by placental transfer of
antibodies. The mother will have active artificial immunity
lasting for about 10 years. 5 doses will give the mother lifetime protection.
67. Answer: (B) 4 hours
Rationale: While the unused portion of other biologicals in EPI may be given until
the end of the day, only BCG is discarded 4 hours after
reconstitution. This is why BCG immunization is scheduled only in the morning.
68. Answer: (B) 6 months
Rationale: After 6 months, the baby’s nutrient needs, especially the baby’s iron
requirement, can no longer be provided by mother’s milk
alone.
69. Answer: (C) 24 weeks
Rationale: At approximately 23 to 24 weeks’ gestation, the lungs are developed
enough to sometimes maintain extrauterine life. The lungs are the most immature
system during the gestation period. Medical care for premature labor begins
much earlier (aggressively at 21 weeks’ gestation)
70. Answer: (B) Sudden infant death syndrome (SIDS)
Rationale: Supine positioning is recommended to reduce the risk of SIDS in
infancy. The risk of aspiration is slightly increased with the supine position.
Suffocation would be less likely with an infant supine than prone and the position
for GER requires the head of the bed to be elevated.
71. Answer: (C) Decreased temperature
Rationale: Temperature instability, especially when it results in a low temperature
in the neonate, may be a sign of infection. The neonate’s
color often changes with an infection process but generally becomes ashen or
mottled. The neonate with an infection will usually show a
decrease in activity level or lethargy.
72. Answer: (D) Polycythemia probably due to chronic fetal hypoxia
Rationale: The small-for-gestation neonate is at risk for developing polycythemia
during the transitional period in an attempt to decrease
hypoxia. The neonates are also at increased risk for developing hypoglycemia
and hypothermia due to decreased glycogen stores.
73. Answer: (C) Desquamation of the epidermis
Rationale: Postdate fetuses lose the vernix caseosa, and the epidermis may
become desquamated. These neonates are usually very alert. Lanugo is missing
in the postdate neonate.
74. Answer: (C) Respiratory depression
Rationale: Magnesium sulfate crosses the placenta and adverse neonatal effects
are respiratory depression, hypotonia, and bradycardia. The serum blood sugar
isn’t affected by magnesium sulfate. The neonate would be floppy, not jittery.
75. Answer: (C) Respiratory rate 40 to 60 breaths/minute
Rationale: A respiratory rate 40 to 60 breaths/minute is normal for a neonate
during the transitional period. Nasal flaring, respiratory rate more than 60
breaths/minute, and audible grunting are signs of respiratory distress.
76. Answer: (C) Keep the cord dry and open to air
Rationale: Keeping the cord dry and open to air helps reduce infection and
hastens drying. Infants aren’t given tub bath but are sponged off until the cord
falls off. Petroleum jelly prevents the cord from drying and encourages infection.
Peroxide could be painful and isn’t recommended.
77. Answer: (B) Conjunctival hemorrhage
Rationale: Conjunctival hemorrhages are commonly seen in neonates secondary
to the cranial pressure applied during the birth process. Bulging fontanelles are a
sign of intracranial pressure. Simian creases are present in 40% of the neonates
with trisomy 21. Cystic hygroma is a neck mass that can affect the airway.
78. Answer: (B) To assess for prolapsed cord
Rationale: After a client has an amniotomy, the nurse should assure that the cord
isn't prolapsed and that the baby tolerated the procedure well. The most effective
way to do this is to check the fetal heart rate. Fetal well-being is assessed via a
nonstress test. Fetal position is determined by vaginal examination. Artificial
rupture of membranes doesn't indicate an imminent delivery.
79. Answer: (D) The parents’ interactions with each other.
Rationale: Parental interaction will provide the nurse with a good assessment of
the stability of the family's home life but it has no indication for parental bonding.
Willingness to touch and hold the newborn, expressing interest about the
newborn's size, and indicating a desire to see the newborn are behaviors
indicating parental bonding.
80. Answer: (B) Instructing the client to use two or more peripads to cushion the
area
Rationale: Using two or more peripads would do little to reduce the pain or
promote perineal healing. Cold applications, sitz baths, and Kegel
exercises are important measures when the client has a fourth-degree laceration.
81. Answer: (C) “What is your expected due date?”
Rationale: When obtaining the history of a client who may be in labor, the nurse's
highest priority is to determine her current status, particularly her due date,
gravidity, and parity. Gravidity and parity affect the duration of labor and the
potential for labor complications. Later, the nurse should ask about chronic
illnesses, allergies, and support persons.
82. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe.
Rationale: The nurse's first action should be to clear the neonate's airway with a
bulb syringe. After the airway is clear and the neonate's color improves, the
nurse should comfort and calm the neonate. If the problem recurs or the
neonate's color doesn't improve readily, the nurse should notify the physician.
Administering oxygen when the airway isn't clear would be ineffective.
83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index.
Rationale: It isn't within a nurse's scope of practice to perform and interpret a
bedside ultrasound under these conditions and without
specialized training. Observing for pooling of straw-colored fluid, checking
vaginal discharge with nitrazine paper, and observing for flakes of vernix are
appropriate assessments for determining whether a client has ruptured
membranes.
84. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels.
Rationale: Monitoring PaO2 levels and reducing the oxygen concentration to
keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a
premature infant receiving oxygen. Covering the infant's eyes and humidifying
the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling
increases the risk of acidosis, the infant should be kept warm so that his
respiratory distress
isn't aggravated.
85. Answer: (A) 110 to 130 calories per kg.
Rationale: Calories per kg is the accepted way of determined appropriate
nutritional intake for a newborn. The recommended calorie requirement is 110 to
130 calories per kg of newborn body weight. This level will maintain a consistent
blood glucose level and provide enough calories for continued growth and
development.
86. Answer: (C) 30 to 32 weeks
Rationale: Individual twins usually grow at the same rate as singletons until 30 to
32 weeks’ gestation, then twins don’t’ gain weight as rapidly as singletons of the
same gestational age. The placenta can no longer keep pace with the nutritional
requirements of both fetuses after 32 weeks, so there’s some growth retardation
in twins if they remain in utero at 38 to 40 weeks.
87. Answer: (A) conjoined twins
Rationale: The type of placenta that develops in monozygotic twins depends on
the time at which cleavage of the ovum occurs. Cleavage in conjoined twins
occurs more than 13 days after fertilization. Cleavage that occurs less than 3 day
after fertilization results in diamniotic dicchorionic twins. Cleavage that occurs
between days 3 and 8 results in diamniotic monochorionic twins. Cleavage that
occurs between days 8 to 13 result in monoamniotic monochorionic twins.
88. Answer: (D) Ultrasound
Rationale: Once the mother and the fetus are stabilized, ultrasound evaluation of
the placenta should be done to determine the cause of the bleeding.
Amniocentesis is contraindicated in placenta previa. A digital or speculum
examination shouldn’t be done as this may lead to severe bleeding or
hemorrhage. External fetal monitoring won’t detect a placenta previa, although it
will detect fetal distress, which may result from blood loss or placenta separation.
89. Answer: (A) Increased tidal volume
Rationale: A pregnant client breathes deeper, which increases the tidal volume of
gas moved in and out of the respiratory tract with each breath. The expiratory
volume and residual volume decrease as the pregnancy progresses. The
inspiratory capacity increases during pregnancy. The increased oxygen
consumption in the pregnant client is 15% to 20% greater than in the
nonpregnant state.
90. Answer: (A) Diet
Rationale: Clients with gestational diabetes are usually managed by diet alone to
control their glucose intolerance. Oral hypoglycemic drugs are contraindicated in
pregnancy. Long-acting insulin usually isn’t needed for blood glucose control in
the client with gestational diabetes.
91. Answer: (D) Seizure
Rationale: The anticonvulsant mechanism of magnesium is believes to depress
seizure foci in the brain and peripheral neuromuscular blockade.
Hypomagnesemia isn’t a complication of preeclampsia. Antihypertensive drug
other than magnesium are preferred for sustained hypertension. Magnesium
doesn’t help prevent hemorrhage in preeclamptic clients.
92. Answer: (C) I.V. fluids
Rationale: A sickle cell crisis during pregnancy is usually managed by exchange
transfusion oxygen, and L.V. Fluids. The client usually needs a stronger
analgesic than acetaminophen to control the pain of a crisis. Antihypertensive
drugs usually aren’t necessary. Diuretic wouldn’t be used unless fluid overload
resulted.
93. Answer: (A) Calcium gluconate (Kalcinate)
Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten
milliliters of 10% calcium gluconate is given L.V. push over 3 to 5 minutes.
Hydralazine is given for sustained elevated blood pressure in preeclamptic
clients. Rho (D) immune globulin is given to women with Rh-negative blood to
prevent antibody formation from RH-positive conceptions. Naloxone is used to
correct narcotic toxicity.
94. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72
hours.
Rationale: A positive PPD result would be an indurated wheal over 10 mm in
diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a
flat circumcised area to be considered positive.
95. Answer: (C) Pyelonephritis
Rational: The symptoms indicate acute pyelonephritis, a serious condition in a
pregnant client. UTI symptoms include dysuria, urgency, frequency, and
suprapubic tenderness. Asymptomatic bacteriuria doesn’t cause symptoms.
Bacterial vaginosis causes milky white vaginal discharge but no systemic
symptoms.
96. Answer: (B) Rh-positive fetal blood crosses into maternal blood, stimulating
maternal antibodies.
Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross
into the maternal circulation and stimulate maternal antibody
production. In subsequent pregnancies with Rh-positive fetuses, maternal
antibodies may cross back into the fetal circulation and destroy the fetal blood
cells.
97. Answer: (C) Supine position
Rationale: The supine position causes compression of the client's aorta and
inferior vena cava by the fetus. This, in turn, inhibits maternal
circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The
other positions promote comfort and aid labor progress. For instance, the lateral,
or side-lying, position improves maternal and fetal circulation, enhances comfort,
increases maternal relaxation, reduces muscle tension, and eliminates pressure
points. The squatting position promotes comfort by taking advantage of gravity.
The standing position also takes advantage of gravity and aligns the fetus with
the pelvic angle.
98. Answer: (B) Irritability and poor sucking.
Rationale: Neonates of heroin-addicted mothers are physically dependent on the
drug and experience withdrawal when the drug is no
longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and
restlessness. Lethargy isn't associated with neonatal heroin
addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal
alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific
congenital anomalies.
99. Answer: (A) 7th to 9th day postpartum
Rationale: The normal involutional process returns the uterus to the pelvic cavity
in 7 to 9 days. A significant involutional complication is the failure of the uterus to
return to the pelvic cavity within the prescribed time period. This is known as
subinvolution.
100. Answer: (B) Uterine atony
Rationale: Multiple fetuses, extended labor stimulation with oxytocin, and
traumatic delivery commonly are associated with uterine atony, which may lead
to postpartum hemorrhage. Uterine inversion may precede or follow delivery and
commonly results from apparent excessive traction on the umbilical cord and
attempts to deliver the placenta manually. Uterine involution and some uterine
discomfort are normal after delivery.
NP3- MS/PSYCH
1. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid
colostomy when the stool is:
a. Green liquid b. Solid formed c. Loose, bloody d. Semiformed
2. Where would nurse Kristine place the call light for a male client with a right-
sided brain attack and left homonymous hemianopsia?
a. On the client’s right side
b. On the client’s left side
c. Directly in front of the client
d. Where the client like
3. A male client is admitted to the emergency department following an accident.
What are the first nursing actions of the nurse?
a. Check respiration, circulation, neurological response.
b. Align the spine, check pupils, and check for hemorrhage.
c. Check respirations, stabilize spine, and check circulation.
d. Assess level of consciousness and circulation.
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it
reduces preload and relieves angina by:
a. Increasing contractility and slowing heart rate.
b. Increasing AV conduction and heart rate.
c. Decreasing contractility and oxygen consumption.
d. Decreasing venous return through vasodilation.
5. Nurse Patricia finds a female client who is post-myocardial infarction (MI)
slumped on the side rails of the bed and unresponsive to shaking or shouting.
Which is the nurse next action?
a. Call for help and note the time.
b. Clear the airway
c. Give two sharp thumps to the precordium, and check the pulse.
d. Administer two quick blows.
6. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding.
The nurse should:
a. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.
7. A male client was on warfarin (Coumadin) before admission, and has been
receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68
seconds. What should Nurse Carla do?
a. Stop the I.V. infusion of heparin and notify the physician.
b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is lower than normal.
8. A client undergone ileostomy, when should the drainage appliance be applied
to the stoma?
a. 24 hours later, when edema has subsided.
b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care procedures.
9. A client undergone spinal anesthetic, it will be important that the nurse
immediately position the client in:
a. On the side, to prevent obstruction of airway by tongue.
b. Flat on back.
c. On the back, with knees flexed 15 degrees.
d. Flat on the stomach, with the head turned to the side.
10.While monitoring a male client several hours after a motor vehicle accident,
which assessment data suggest increasing intracranial pressure?
a. Blood pressure is decreased from 160/90 to 110/70.
b. Pulse is increased from 87 to 95, with an occasional skipped beat.
c. The client is oriented when aroused from sleep, and goes back to sleep
immediately.
d. The client refuses dinner because of anorexia.
11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following
symptoms may appear first?
a. Altered mental status and dehydration b. Fever and chills
c. Hemoptysis and Dyspnea d. Pleuritic chest pain and cough
12. A male client has active tuberculosis (TB). Which of the following symptoms
will be exhibit?
a. Chest and lower back pain
b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104°F (40°C) and nausea
d. Headache and photophobia
13. Mark, a 7-year-old client is brought to the emergency department. He’s
tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has
a nonproductive cough. He recently had a cold. Form this history; the client may
have which of the following conditions?
a. Acute asthma b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD) d. Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping and her
respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have
which of the following reactions?
a. Asthma attack b. Respiratory arrest
c. Seizure d. Wake up on his own
15. A 77-year-old male client is admitted for elective knee surgery. Physical
examination reveals shallow respirations but no sign of respiratory distress.
Which of the following is a normal physiologic change related to aging?
a. Increased elastic recoil of the lungs
b. Increased number of functional capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity
16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is
the most relevant to administration of this medication?
a. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse
oximeter.
b. Increase in systemic blood pressure.
c. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
d. Increase in intracranial pressure (ICP).
17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse
should teach the client to:
a. Report incidents of diarrhea. b. Avoid foods high in vitamin K
c. Use a straight razor when shaving. d. Take aspirin to pain relief.
18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The
nurse should treat excess hair at the site by:
a. Leaving the hair intact b. Shaving the area
c. Clipping the hair in the area d. Removing the hair with a depilatory.
19. Nurse Michelle is caring for an elderly female with osteoporosis. When
teaching the client, the nurse should include information about which major
complication:
a. Bone fracture b. Loss of estrogen
c. Negative calcium balance d. Dowager’s hump
20. Nurse Len is teaching a group of women to perform BSE. The nurse should
explain that the purpose of performing the examination is to discover:
a. Cancerous lumps b. Areas of thickness or fullness
c. Changes from previous examinations. d. Fibrocystic masses
21. When caring for a female client who is being treated for hyperthyroidism, it is
important to:
a. Provide extra blankets and clothing to keep the client warm.
b. Monitor the client for signs of restlessness, sweating, and excessive weight
loss during thyroid replacement therapy.
c. Balance the client’s periods of activity and rest.
d. Encourage the client to be active to prevent constipation.
22. Nurse Kris is teaching a client with history of atherosclerosis. To decrease
the risk of atherosclerosis, the nurse should encourage the client to:
a. Avoid focusing on his weight. b. Increase his activity level.
c. Follow a regular diet. d. Continue leading a high-stress lifestyle.
23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client
following a:
a. Laminectomy b. Thoracotomy c. Hemorrhoidectomy d. Cystectomy.
24. A 55-year old client underwent cataract removal with intraocular lens implant.
Nurse Oliver is giving the client discharge instructions. These instructions should
include which of the following?
a. Avoid lifting objects weighing more than 5 lb (2.25 kg).
b. Lie on your abdomen when in bed
c. Keep rooms brightly lit.
d. Avoiding straining during bowel movement or bending at the waist.
25. George should be taught about testicular examinations during:
a. when sexual activity starts b. After age 69
c. After age 40 d. Before age 20.
26. A male client undergone a colon resection. While turning him, wound
dehiscence with evisceration occurs. Nurse Trish first response is to:
a. Call the physician
b. Place a saline-soaked sterile dressing on the wound.
c. Take a blood pressure and pulse.
d. Pull the dehiscence closed.
27. Nurse Audrey is caring for a client who has suffered a severe
cerebrovascular accident. During routine assessment, the nurse notices Cheyne-
Strokes respirations. Cheyne-strokes respirations are:
a. A progressively deeper breaths followed by shallower breaths with apneic
periods.
b. Rapid, deep breathing with abrupt pauses between each breath.
c. Rapid, deep breathing and irregular breathing without pauses.
d. Shallow breathing with an increased respiratory rate.
28. Nurse Bea is assessing a male client with heart failure. The breath sounds
commonly auscultated in clients with heart failure are:
a. Tracheal b. Fine crackles c. Coarse crackles d. Friction rubs
29. The nurse is caring for Kenneth experiencing an acute asthma attack. The
client stops wheezing and breath sounds aren’t audible. The reason for this
change is that:
a. The attack is over.
b. The airways are so swollen that no air cannot get through.
c. The swelling has decreased.
d. Crackles have replaced wheezes.
30. Mike with epilepsy is having a seizure. During the active seizure phase, the
nurse should:
a. Place the client on his back remove dangerous objects, and insert a bite block.
b. Place the client on his side, remove dangerous objects, and insert a bite block.
c. Place the client o his back, remove dangerous objects, and hold down his
arms.
d. Place the client on his side, remove dangerous objects, and protect his head.
31. After insertion of a cheat tube for a pneumothorax, a client becomes
hypotensive with neck vein distention, tracheal shift, absent breath sounds, and
diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred.
What cause of tension pneumothorax should the nurse check for?
a. Infection of the lung.
b. Kinked or obstructed chest tube
c. Excessive water in the water-seal chamber
d. Excessive chest tube drainage
32. Nurse Maureen is talking to a male client, the client begins choking on his
lunch. He’s coughing forcefully. The nurse should:
a. Stand him up and perform the abdominal thrust maneuver from behind.
b. Lay him down, straddle him, and perform the abdominal thrust maneuver.
c. Leave him to get assistance
d. Stay with him but not intervene at this time.
33. Nurse Ron is taking a health history of an 84 year old client. Which
information will be most useful to the nurse for planning care?
a. General health for the last 10 years.
b. Current health promotion activities.
c. Family history of diseases.
d. Marital status.
34. When performing oral care on a comatose client, Nurse Krina should:
a. Apply lemon glycerin to the client’s lips at least every 2 hours.
b. Brush the teeth with client lying supine.
c. Place the client in a side lying position, with the head of the bed lowered.
d. Clean the client’s mouth with hydrogen peroxide.
35. A 77-year-old male client is admitted with a diagnosis of dehydration and
change in mental status. He’s being hydrated with L.V. fluids. When the nurse
takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough
producing yellow sputum and pleuritic chest pain. The nurse suspects this client
may have which of the following conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Myocardial infarction (MI)
c. Pneumonia
d. Tuberculosis
36. Nurse Oliver is working in a out patient clinic. He has been alerted that there
is an outbreak of tuberculosis (TB). Which of the following clients entering the
clinic today most likely to have TB?
a. A 16-year-old female high school student
b. A 33-year-old day-care worker
c. A 43-yesr-old homeless man with a history of alcoholism
d. A 54-year-old businessman
37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The
nurse is aware that which of the following reasons this is done?
a. To confirm the diagnosis
b. To determine if a repeat skin test is needed
c. To determine the extent of lesions
d. To determine if this is a primary or secondary infection
38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and
a decreased forced expiratory volume should be treated with which of the
following classes of medication right away?
a. Beta-adrenergic blockers b. Bronchodilators
c. Inhaled steroids d. Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two
packs of cigarettes per day has a chronic cough producing thick sputum,
peripheral edema and cyanotic nail beds. Based on this information, he most
likely has which of the following conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic
Lymphocytic Leukemia.
40. The treatment for patients with leukemia is bone marrow transplantation.
Which statement about bone marrow transplantation is not correct?
a. The patient is under local anesthesia during the procedure
b. The aspirated bone marrow is mixed with heparin.
c. The aspiration site is the posterior or anterior iliac crest.
d. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days
before the procedure.
41. After several days of admission, Francis becomes disoriented and complains
of frequent headaches. The nurse in-charge first action would be:
a. Call the physician b. Document the patient’s status in his charts.
c. Prepare oxygen treatment d. Raise the side rails
42. During routine care, Francis asks the nurse, “How can I be anemic if this
disease causes increased my white blood cell production?” The nurse in-charge
best response would be that the increased number of white blood cells (WBC) is:
a. Crowd red blood cells b. Are not responsible for the anemia.
c. Uses nutrients from other cells d. Have an abnormally short life span of cells.
43. Diagnostic assessment of Francis would probably not reveal:
a. Predominance of lymhoblasts b. Leukocytosis
c. Abnormal blast cells in the bone marrow d. Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial occlusion of the left leg
undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to
obtain pulses in his left foot using Doppler ultrasound. The nurse immediately
notifies the physician, and asks her to prepare the client for surgery. As the nurse
enters the client’s room to prepare him, he states that he won’t have any more
surgery. Which of the following is the best initial response by the nurse?
a. Explain the risks of not having the surgery
b. Notifying the physician immediately
c. Notifying the nursing supervisor
d. Recording the client’s refusal in the nurses’ notes
45. During the endorsement, which of the following clients should the on-duty
nurse assess first?
a. The 58-year-old client who was admitted 2 days ago with heart failure, blood
pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute.
b. The 89-year-old client with end-stage right-sided heart failure, blood pressure
of 78/50 mm Hg, and a “do not resuscitate” order
c. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and
is receiving L.V. heparin
d. The 75-year-old client who was admitted 1 hour ago with new-onset atrial
fibrillation and is receiving L.V. dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of substernal chest pain and states
that her heart feels like “it’s racing out of the chest”. She reports no history of
cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus
tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the
respiratory rate is 26 breaths/minutes. Which of the following drugs should the
nurse question the client about using?
a. Barbiturates b. Opioids c. Cocaine d. Benzodiazepines
47. A 51-year-old female client tells the nurse in-charge that she has found a
painless lump in her right breast during her monthly self-examination. Which
assessment finding would strongly suggest that this client's lump is cancerous?
a. Eversion of the right nipple and mobile mass
b. Nonmobile mass with irregular edges
c. Mobile mass that is soft and easily delineated
d. Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks the nurse, "What is the usual
treatment for this type of cancer?" Which treatment should the nurse name?
a. Surgery b. Chemotherapy c. Radiation d. Immunotherapy
49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report
classifies the lesion according to the TNM staging system as follows: TIS, N0,
M0. What does this classification mean?
a. No evidence of primary tumor, no abnormal regional lymph nodes, and no
evidence of distant metastasis
b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of
distant metastasis
c. Can't assess tumor or regional lymph nodes and no evidence of metastasis
d. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes,
and ascending degrees of distant metastasis
50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching
the client how to care for the neck stoma, the nurse should include which
instruction?
a. "Keep the stoma uncovered."
b. "Keep the stoma dry."
c. "Have a family member perform stoma care initially until you get used to the
procedure."
d. "Keep the stoma moist."
51. A 37-year-old client with uterine cancer asks the nurse, "Which is the most
common type of cancer in women?" The nurse replies that it's breast cancer.
Which type of cancer causes the most deaths in women?
a. Breast cancer b. Lung cancer
c. Brain cancer d. Colon and rectal cancer
52. Antonio with lung cancer develops Horner's syndrome when the tumor
invades the ribs and affects the sympathetic nerve ganglia. When assessing for
signs and symptoms of this syndrome, the nurse should note:
a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
b. chest pain, dyspnea, cough, weight loss, and fever.
c. arm and shoulder pain and atrophy of arm and hand muscles, both on the
affected side.
d. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should reply that it stands for:
a. prostate-specific antigen, which is used to screen for prostate cancer.
b. protein serum antigen, which is used to determine protein levels.
c. pneumococcal strep antigen, which is a bacteria that causes pneumonia.
d. Papanicolaou-specific antigen, which is used to screen for cervical cancer.
54. What is the most important postoperative instruction that nurse Kate must
give a client who has just returned from the operating room after receiving a
subarachnoid block?
a. "Avoid drinking liquids until the gag reflex returns."
b. "Avoid eating milk products for 24 hours."
c. "Notify a nurse if you experience blood in your urine."
d. "Remain supine for the time specified by the physician."
55. A male client suspected of having colorectal cancer will require which
diagnostic study to confirm the diagnosis?
a. Stool Hematest b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy d. Abdominal computed tomography (CT) scan
56. During a breast examination, which finding most strongly suggests that the
Luz has breast cancer?
a. Slight asymmetry of the breasts.
b. A fixed nodular mass with dimpling of the overlying skin
c. Bloody discharge from the nipple
d. Multiple firm, round, freely movable masses that change with the menstrual
cycle
57. A female client with cancer is being evaluated for possible metastasis. Which
of the following is one of the most common metastasis sites for cancer cells?
a. Liver b. Colon c. Reproductive tract d. White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to
confirm or rule out a spinal cord lesion. During the MRI scan, which of the
following would pose a threat to the client?
a. The client lies still.
b. The client asks questions.
c. The client hears thumping sounds.
d. The client wears a watch and wedding band.
59. Nurse Cecile is teaching a female client about preventing osteoporosis.
Which of the following teaching points is correct?
a. Obtaining an X-ray of the bones every 3 years is recommended to detect bone
loss.
b. To avoid fractures, the client should avoid strenuous exercise.
c. The recommended daily allowance of calcium may be found in a wide variety
of foods.
d. Obtaining the recommended daily allowance of calcium requires taking a
calcium supplement.
60. Before Jacob undergoes arthroscopy, the nurse reviews the assessment
findings for contraindications for this procedure. Which finding is a
contraindication?
a. Joint pain b. Joint deformity
c. Joint flexion of less than 50% d. Joint stiffness
61. Mr. Rodriguez is admitted with severe pain in the knees. Which form of
arthritis is characterized by urate deposits and joint pain, usually in the feet and
legs, and occurs primarily in men over age 30?
a. Septic arthritis b. Traumatic arthritis
c. Intermittent arthritis d. Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with
stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of
saline solution. How many milliliters per hour should be given?
a. 15 ml/hour b. 30 ml/hour c. 45 ml/hour d. 50 ml/hour
63. A 76-year-old male client had a thromboembolic right stroke; his left arm is
swollen. Which of the following conditions may cause swelling after a stroke?
a. Elbow contracture secondary to spasticity
b. Loss of muscle contraction decreasing venous return
c. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
d. Hypoalbuminemia due to protein escaping from an inflamed glomerulus
64. Heberden’s nodes are a common sign of osteoarthritis. Which of the following
statement is correct about this deformity?
a. It appears only in men
b. It appears on the distal interphalangeal joint
c. It appears on the proximal interphalangeal joint
d. It appears on the dorsolateral aspect of the interphalangeal joint.
65. Which of the following statements explains the main difference between
rheumatoid arthritis and osteoarthritis?
a. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t
b. Osteoarthritis is a localized disease rheumatoid arthritis is systemic
c. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
d. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t
66. Mrs. Cruz uses a cane for assistance in walking. Which of the following
statements is true about a cane or other assistive devices?
a. A walker is a better choice than a cane.
b. The cane should be used on the affected side
c. The cane should be used on the unaffected side
d. A client with osteoarthritis should be encouraged to ambulate without the cane
67. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30
insulin. There is no 70/30 insulin available. As a substitution, the nurse may give
the client:
a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
b. 21 U regular insulin and 9 U NPH.
c. 10 U regular insulin and 20 U NPH.
d. 20 U regular insulin and 10 U NPH.
68. Nurse Len should expect to administer which medication to a client with
gout?
a. aspirin b. furosemide (Lasix)
c. colchicines d. calcium gluconate (Kalcinate)
69. Mr. Domingo with a history of hypertension is diagnosed with primary
hyperaldosteronism. This diagnosis indicates that the client's hypertension is
caused by excessive hormone secretion from which of the following glands?
a. Adrenal cortex b. Pancreas c. Adrenal medulla d. Parathyroid
70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a
wetto- dry dressing change every shift, and blood glucose monitoring before
meals and bedtime. Why are wet-to-dry dressings used for this client?
a. They contain exudate and provide a moist wound environment.
b. They protect the wound from mechanical trauma and promote healing.
c. They debride the wound and promote healing by secondary intention.
d. They prevent the entrance of microorganisms and minimize wound discomfort.
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory
data would the nurse expect to find?
a. Hyperkalemia b. Reduced blood urea nitrogen (BUN)
c. Hypernatremia d. Hyperglycemia
72. A client is admitted for treatment of the syndrome of inappropriate antidiuretic
hormone (SIADH). Which nursing intervention is appropriate?
a. Infusing I.V. fluids rapidly as ordered
b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing I.V. fluids as ordered
73. A female client tells nurse Nikki that she has been working hard for the last 3
months to control her type 2 diabetes mellitus with diet and exercise. To
determine the effectiveness of the client's efforts, the nurse should check:
a. urine glucose level. b. fasting blood glucose level.
c. serum fructosamine level. d. glycosylated hemoglobin level.
74. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a
diabetic client at 7 a.m. At what time would the nurse expect the client to be most
at risk for a hypoglycemic reaction?
a. 10:00 am b. Noon c. 4:00 pm d. 10:00 pm
75. The adrenal cortex is responsible for producing which substances?
a. Glucocorticoids and androgens
b. Catecholamines and epinephrine
c. Mineralocorticoids and catecholamines
d. Norepinephrine and epinephrine
76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle
twitching and hyperirritability of the nervous system. When questioned, the client
reports numbness and tingling of the mouth and fingertips. Suspecting a
lifethreatening electrolyte disturbance, the nurse notifies the surgeon
immediately. Which electrolyte disturbance most commonly follows thyroid
surgery?
a. Hypocalcemia b. Hyponatremia c. Hyperkalemia d. Hypermagnesemia
77. Which laboratory test value is elevated in clients who smoke and can't be
used as a general indicator of cancer?
a. Acid phosphatase level b. Serum calcitonin level
c. Alkaline phosphatase level d. Carcinoembryonic antigen level
78. Francis with anemia has been admitted to the medical-surgical unit. Which
assessment findings are characteristic of iron-deficiency anemia?
a. Nights sweats, weight loss, and diarrhea
b. Dyspnea, tachycardia, and pallor
c. Nausea, vomiting, and anorexia
d. Itching, rash, and jaundice
79. In teaching a female client who is HIV-positive about pregnancy, the nurse
would know more teaching is necessary when the client says:
a. The baby can get the virus from my placenta."
b. "I'm planning on starting on birth control pills."
c. "Not everyone who has the virus gives birth to a baby who has the virus."
d. "I'll need to have a C-section if I become pregnant and have a baby."
80. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for
discharge to the home, the nurse should be sure to include which instruction?
a. "Put on disposable gloves before bathing."
b. "Sterilize all plates and utensils in boiling water."
c. "Avoid sharing such articles as toothbrushes and razors."
d. "Avoid eating foods from serving dishes shared by other family members."
81. Nurse Marie is caring for a 32-year-old client admitted with pernicious
anemia. Which set of findings should the nurse expect when assessing the
client?
a. Pallor, bradycardia, and reduced pulse pressure
b. Pallor, tachycardia, and a sore tongue
c. Sore tongue, dyspnea, and weight gain
d. Angina, double vision, and anorexia
82. After receiving a dose of penicillin, a client develops dyspnea and
hypotension. Nurse Celestina suspects the client is experiencing anaphylactic
shock. What should the nurse do first?
a. Page an anesthesiologist immediately and prepare to intubate the client.
b. Administer epinephrine, as prescribed, and prepare to intubate the client if
necessary.
c. Administer the antidote for penicillin, as prescribed, and continue to monitor
the client's vital signs.
d. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.
83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to
reduce inflammation. When teaching the client about aspirin, the nurse discusses
adverse reactions to prolonged aspirin therapy. These include:
a. weight gain. b. fine motor tremors
c. respiratory acidosis. d. bilateral hearing loss.
84. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV).
After recovering from the initial shock of the diagnosis, the client expresses a
desire to learn as much as possible about HIV and acquired immunodeficiency
syndrome (AIDS). When teaching the client about the immune system, the nurse
states that adaptive immunity is provided by which type of white blood cell?
a. Neutrophil b. Basophil c. Monocyte d. Lymphocyte
85. In an individual with Sjögren's syndrome, nursing care should focus on:
a. moisture replacement. b. electrolyte balance.
c. nutritional supplementation. d. arrhythmia management.
86. During chemotherapy for lymphocytic leukemia, Mathew develops abdominal
pain, fever, and "horse barn" smelling diarrhea. It would be most important for the
nurse to advise the physician to order:
a. enzyme-linked immunosuppressant assay (ELISA) test.
b. electrolyte panel and hemogram.
c. stool for Clostridium difficile test.
d. flat plate X-ray of the abdomen.
87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb
weight loss in 6 weeks. To confirm that the client has been infected with the
human immunodeficiency virus (HIV), the nurse expects the physician to order:
a. E-rosette immunofluorescence.
b. quantification of T-lymphocytes.
c. enzyme-linked immunosorbent assay (ELISA).
d. Western blot test with ELISA.
88. A complete blood count is commonly performed before a Joe goes into
surgery. What does this test seek to identify?
a. Potential hepatic dysfunction indicated by decreased blood urea nitrogen
(BUN) and creatinine levels
b. Low levels of urine constituents normally excreted in the urine
c. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
d. Electrolyte imbalance that could affect the blood's ability to coagulate properly
89. While monitoring a client for the development of disseminated intravascular
coagulation (DIC), the nurse should take note of what assessment parameters?
a. Platelet count, prothrombin time, and partial thromboplastin time
b. Platelet count, blood glucose levels, and white blood cell (WBC) count
c. Thrombin time, calcium levels, and potassium levels
d. Fibrinogen level, WBC, and platelet count
90. When taking a dietary history from a newly admitted female client, Nurse Len
should remember that which of the following foods is a common allergen?
a. Bread b. Carrots c. Orange d. Strawberries
91. Nurse John is caring for clients in the outpatient clinic. Which of the following
phone calls should the nurse return first?
a. A client with hepatitis A who states, “My arms and legs are itching.”
b. A client with cast on the right leg who states, “I have a funny feeling in my right
leg.”
c. A client with osteomyelitis of the spine who states, “I am so nauseous that I
can’t eat.”
d. A client with rheumatoid arthritis who states, “I am having trouble sleeping.”
92. Nurse Sarah is caring for clients on the surgical floor and has just received
report from the previous shift. Which of the following clients should the nurse see
first?
a. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of
dark drainage noted on the dressing.
b. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous
fluid noted in the Jackson-Pratt drain.
c. A 59-year-old with a collapsed lung due to an accident; no drainage noted in
the previous eight hours.
d. A 62-year-old who had an abdominal-perineal resection three days ago; client
complaints of chills.
93. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for
treatment of Grave’s disease. The nurse would be most concerned if which of the
following was observed?
a. Blood pressure 138/82, respirations 16, oral temperature 99 degrees
Fahrenheit.
b. The client supports his head and neck when turning his head to the right.
c. The client spontaneously flexes his wrist when the blood pressure is obtained.
d. The client is drowsy and complains of sore throat.
94. Julius is admitted with complaints of severe pain in the lower right quadrant of
the abdomen. To assist with pain relief, the nurse should take which of the
following actions?
a. Encourage the client to change positions frequently in bed.
b. Administer Demerol 50 mg IM q 4 hours and PRN.
c. Apply warmth to the abdomen with a heating pad.
d. Use comfort measures and pillows to position the client.
95. Nurse Tina prepares a client for peritoneal dialysis. Which of the following
actions should the nurse take first?
a. Assess for a bruit and a thrill. b. Warm the dialysate solution.
c. Position the client on the left side. d. Insert a Foley catheter
96. Nurse Jannah teaches an elderly client with right-sided weakness how to use
cane. Which of the following behaviors, if demonstrated by the client to the nurse,
indicates that the teaching was effective?
a. The client holds the cane with his right hand, moves the can forward followed
by the right leg, and then moves the left leg.
b. The client holds the cane with his right hand, moves the cane forward followed
by his left leg, and then moves the right leg.
c. The client holds the cane with his left hand, moves the cane forward followed
by the right leg, and then moves the left leg.
d. The client holds the cane with his left hand, moves the cane forward followed
by his left leg, and then moves the right leg.
97. An elderly client is admitted to the nursing home setting. The client is
occasionally confused and her gait is often unsteady. Which of the following
actions, if taken by the nurse, is most appropriate?
a. Ask the woman’s family to provide personal items such as photos or
mementos.
b. Select a room with a bed by the door so the woman can look down the hall.
c. Suggest the woman eat her meals in the room with her roommate.
d. Encourage the woman to ambulate in the halls twice a day.
98. Nurse Evangeline teaches an elderly client how to use a standard aluminum
walker. Which of the following behaviors, if demonstrated by the client, indicates
that the nurse’s teaching was effective?
a. The client slowly pushes the walker forward 12 inches, then takes small steps
forward while leaning on the walker.
b. The client lifts the walker, moves it forward 10 inches, and then takes several
small steps forward.
c. The client supports his weight on the walker while advancing it forward, then
takes small steps while balancing on the walker.
d. The client slides the walker 18 inches forward, then takes small steps while
holding onto the walker for balance.
99. Nurse Deric is supervising a group of elderly clients in a residential home
setting. The nurse knows that the elderly are at greater risk of developing
sensory deprivation for what reason?
a. Increased sensitivity to the side effects of medications.
b. Decreased visual, auditory, and gustatory abilities.
c. Isolation from their families and familiar surroundings.
d. Decrease musculoskeletal function and mobility.
100. A male client with emphysema becomes restless and confused. What step
should nurse Jasmine take next?
a. Encourage the client to perform pursed lip breathing.
b. Check the client’s temperature.
c. Assess the client’s potassium level.
d. Increase the client’s oxygen flow rate.
RATIO 3
1. Answer: (C) Loose, bloody
Rationale: Normal bowel function and soft-formed stool usually do not occur until
around the seventh day following surgery. The stool consistency is related to how
much water is being absorbed.
2. Answer: (A) On the client’s right side
Rationale: The client has left visual field blindness. The client will see only from
the right side.
3. Answer: (C) Check respirations, stabilize spine, and check circulation
Rationale: Checking the airway would be priority, and a neck injury should be
suspected.
4. Answer: (D) Decreasing venous return through vasodilation.
Rationale: The significant effect of nitroglycerin is vasodilation and decreased
venous return, so the heart does not have to work hard.
5. Answer: (A) Call for help and note the time.
Rationale: Having established, by stimulating the client, that the client is
unconscious rather than sleep, the nurse should immediately call for help. This
may be done by dialing the operator from the client’s phone and giving the
hospital code for cardiac arrest and the client’s room number to the operator, of if
the phone is not available, by pulling the emergency call button. Noting the time
is important baseline information for cardiac arrest procedure.
6. Answer: (C) Make sure that the client takes food and medications at
prescribed intervals.
Rationale: Food and drug therapy will prevent the accumulation of hydrochloric
acid, or will neutralize and buffer the acid that does accumulate.
7. Answer: (B) Continue treatment as ordered.
Rationale: The effects of heparin are monitored by the PTT is normally 30 to 45
seconds; the therapeutic level is 1.5 to 2 times the normal level.
8. Answer: (B) In the operating room.
Rationale: The stoma drainage bag is applied in the operating room. Drainage
from the ileostomy contains secretions that are rich in digestive enzymes and
highly irritating to the skin. Protection of the skin from the effects of these
enzymes is begun at once. Skin exposed to these enzymes even for a short time
becomes reddened, painful, and excoriated.
9. Answer: (B) Flat on back.
Rationale: To avoid the complication of a painful spinal headache that can last for
several days, the client is kept in flat in a supine position for approximately 4 to
12 hours postoperatively. Headaches are believed to be causes by the seepage
of cerebral spinal fluid from the puncture site. By keeping the client flat, cerebral
spinal fluid pressures are equalized, which avoids trauma to the neurons.
10. Answer: (C) The client is oriented when aroused from sleep, and goes back
to sleep immediately.
Rationale: This finding suggest that the level of consciousness is decreasing.
11. Answer: (A) Altered mental status and dehydration
Rationale: Fever, chills, hemortysis, dyspnea, cough, and pleuritic chest pain are
the common symptoms of pneumonia, but elderly clients may first appear with
only an altered lentil status and dehydration due to a blunted immune response.
12. Answer: (B) Chills, fever, night sweats, and hemoptysis
Rationale: Typical signs and symptoms are chills, fever, night sweats, and
hemoptysis. Chest pain may be present from coughing, but isn’t usual. Clients
with TB typically have low-grade fevers, not higher than 102°F (38.9°C). Nausea,
headache, and photophobia aren’t usual TB symptoms.
13. Answer:(A) Acute asthma
Rationale: Based on the client’s history and symptoms, acute asthma is the most
likely diagnosis. He’s unlikely to have bronchial pneumonia without a productive
cough and fever and he’s too young to have developed (COPD) and
emphysema.
14. Answer: (B) Respiratory arrest
Rationale: Narcotics can cause respiratory arrest if given in large quantities. It’s
unlikely the client will have asthma attack or a seizure or wake up on his own.
15. Answer: (D) Decreased vital capacity
Rationale: Reduction in vital capacity is a normal physiologic changes include
decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli,
and an increased in residual volume.
16. Answer: (C) Presence of premature ventricular contractions (PVCs) on a
cardiac monitor.
Rationale: Lidocaine drips are commonly used to treat clients whose arrhythmias
haven’t been controlled with oral medication and who are having PVCs that are
visible on the cardiac monitor. SaO2, blood pressure, and ICP are important
factors but aren’t as significant as PVCs in the situation.
17. Answer: (B) Avoid foods high in vitamin K
Rationale: The client should avoid consuming large amounts of vitamin K
because vitamin K can interfere with anticoagulation. The client may need to
report diarrhea, but isn’t effect of taking an anticoagulant. An electric razor-not a
straight razor-should be used to prevent cuts that cause bleeding. Aspirin may
increase the risk of bleeding; acetaminophen should be used to pain relief.
18. Answer: (C) Clipping the hair in the area
Rationale: Hair can be a source of infection and should be removed by clipping.
Shaving the area can cause skin abrasions and depilatories can irritate the skin.
19. Answer: (A) Bone fracture
Rationale: Bone fracture is a major complication of osteoporosis that results
when loss of calcium and phosphate increased the fragility of bones. Estrogen
deficiencies result from menopause-not osteoporosis. Calcium and vitamin D
supplements may be used to support normal bone metabolism, But a negative
calcium balance isn’t a complication of osteoporosis. Dowager’s hump results
from bone fractures. It develops when repeated vertebral fractures increase
spinal curvature.
20. Answer: (C) Changes from previous examinations.
Rationale: Women are instructed to examine themselves to discover changes
that have occurred in the breast. Only a physician can diagnose lumps that are
cancerous, areas of thickness or fullness that signal the presence of a
malignancy, or masses that are fibrocystic as opposed to malignant.
21. Answer: (C) Balance the client’s periods of activity and rest.
Rationale: A client with hyperthyroidism needs to be encouraged to balance
periods of activity and rest. Many clients with hyperthyroidism are hyperactive
and complain of feeling very warm.
22. Answer: (B) Increase his activity level.
Rationale: The client should be encouraged to increase his activity level.
Maintaining an ideal weight; following a low-cholesterol, low sodium diet; and
avoiding stress are all important factors in decreasing the risk of atherosclerosis.
23. Answer: (A) Laminectomy
Rationale: The client who has had spinal surgery, such as laminectomy, must be
log rolled to keep the spinal column straight when turning. Thoracotomy and
cystectomy may turn themselves or may be assisted into a comfortable position.
Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and
the client may resume normal activities immediately after surgery.
24. Answer: (D) Avoiding straining during bowel movement or bending at the
waist.
Rationale: The client should avoid straining, lifting heavy objects, and coughing
harshly because these activities increase intraocular pressure. Typically, the
client is instructed to avoid lifting objects weighing more than 15 lb (7kg) – not
5lb. instruct the client when lying in bed to lie on either the side or back. The
client should avoid bright light by wearing sunglasses.
25. Answer: (D) Before age 20.
Rationale: Testicular cancer commonly occurs in men between ages 20 and 30.
A male client should be taught how to perform testicular selfexamination before
age 20, preferably when he enters his teens.
26. Answer: (B) Place a saline-soaked sterile dressing on the wound.
Rationale: The nurse should first place saline-soaked sterile dressings on the
open wound to prevent tissue drying and possible infection. Then the nurse
should call the physician and take the client’s vital signs. The dehiscence needs
to be surgically closed, so the nurse should never try to close it.
27. Answer: (A) A progressively deeper breaths followed by shallower breaths
with apneic periods.
Rationale: Cheyne-Strokes respirations are breaths that become progressively
deeper fallowed by shallower respirations with apneas periods. Biot’s respirations
are rapid, deep breathing with abrupt pauses between each breath, and equal
depth between each breath. Kussmaul’s respirations are rapid, deep breathing
without pauses. Tachypnea is shallow breathing with increased respiratory rate.
28. Answer: (B) Fine crackles
Rationale: Fine crackles are caused by fluid in the alveoli and commonly occur in
clients with heart failure. Tracheal breath sounds are auscultated over the
trachea. Coarse crackles are caused by secretion accumulation in the airways.
Friction rubs occur with pleural inflammation.
29. Answer: (B) The airways are so swollen that no air cannot get through
Rationale: During an acute attack, wheezing may stop and breath sounds
become inaudible because the airways are so swollen that air can’t get through.
If the attack is over and swelling has decreased, there would be no more
wheezing and less emergent concern. Crackles do not replace wheezes during
an acute asthma attack.
30. Answer: (D) Place the client on his side, remove dangerous objects, and
protect his head.
Rationale: During the active seizure phase, initiate precautions by placing the
client on his side, removing dangerous objects, and protecting his head from
injury. A bite block should never be inserted during the active seizure phase.
Insertion can break the teeth and lead to aspiration.
31. Answer: (B) Kinked or obstructed chest tube
Rationales: Kinking and blockage of the chest tube is a common cause of a
tension pneumothorax. Infection and excessive drainage won’t cause a tension
pneumothorax. Excessive water won’t affect the chest tube drainage.
32. Answer: (D) Stay with him but not intervene at this time.
Rationale: If the client is coughing, he should be able to dislodge the object or
cause a complete obstruction. If complete obstruction occurs, the nurse should
perform the abdominal thrust maneuver with the client standing. If the client is
unconscious, she should lay him down. A nurse should never leave a choking
client alone.
33. Answer: (B) Current health promotion activities
Rationale: Recognizing an individual’s positive health measures is very useful.
General health in the previous 10 years is important, however, the current
activities of an 84 year old client are most significant in planning care. Family
history of disease for a client in later years is of minor significance. Marital status
information may be important for discharge planning but is not as significant for
addressing the immediate medical problem.
34. Answer: (C) Place the client in a side lying position, with the head of the bed
lowered.
Rationale: The client should be positioned in a side-lying position with the head
of the bed lowered to prevent aspiration. A small amount of toothpaste should be
used and the mouth swabbed or suctioned to remove pooled secretions. Lemon
glycerin can be drying if used for extended periods. Brushing the teeth with the
client lying supine may lead to aspiration. Hydrogen peroxide is caustic to tissues
and should not be used.
35. Answer: (C) Pneumonia
Rationale: Fever productive cough and pleuritic chest pain are common signs
and symptoms of pneumonia. The client with ARDS has dyspnea and hypoxia
with worsening hypoxia over time, if not treated aggressively. Pleuritic chest pain
varies with respiration, unlike the constant chest pain during an MI; so this client
most likely isn’t having an MI. the client with TB typically has a cough producing
blood-tinged sputum. A sputum culture should be obtained to confirm the nurse’s
suspicions.
36. Answer: (C) A 43-yesr-old homeless man with a history of alcoholism
Rationale: Clients who are economically disadvantaged, malnourished, and have
reduced immunity, such as a client with a history of alcoholism, are at extremely
high risk for developing TB. A high school student, daycare worker, and
businessman probably have a much low risk of contracting TB.
37. Answer: (C ) To determine the extent of lesions
Rationale: If the lesions are large enough, the chest X-ray will show their
presence in the lungs. Sputum culture confirms the diagnosis. There can be
false-positive and false-negative skin test results. A chest X-ray can’t determine if
this is a primary or secondary infection.
38. Answer: (B) Bronchodilators
Rationale: Bronchodilators are the first line of treatment for asthma because
broncho-constriction is the cause of reduced airflow. Beta adrenergic blockers
aren’t used to treat asthma and can cause bronchoconstriction. Inhaled oral
steroids may be given to reduce the inflammation but aren’t used for emergency
relief.
39. Answer: (C) Chronic obstructive bronchitis
Rationale: Because of this extensive smoking history and symptoms the client
most likely has chronic obstructive bronchitis. Client with ARDS have acute
symptoms of hypoxia and typically need large amounts of oxygen. Clients with
asthma and emphysema tend not to have chronic cough or peripheral edema.
40. Answer: (A) The patient is under local anesthesia during the procedure
Rationale: Before the procedure, the patient is administered with drugs that
would help to prevent infection and rejection of the transplanted cells such as
antibiotics, cytotoxic, and corticosteroids. During the transplant, the patient is
placed under general anesthesia.
41. Answer: (D) Raise the side rails
Rationale: A patient who is disoriented is at risk of falling out of bed. The initial
action of the nurse should be raising the side rails to ensure patients safety.
42. Answer: (A) Crowd red blood cells
Rationale: The excessive production of white blood cells crowd out red blood
cells production which causes anemia to occur.
43. Answer: (B) Leukocytosis
Rationale: Chronic Lymphocytic leukemia (CLL) is characterized by increased
production of leukocytes and lymphocytes resulting in leukocytosis, and
proliferation of these cells within the bone marrow, spleen and liver.
44. Answer: (A) Explain the risks of not having the surgery
Rationale: The best initial response is to explain the risks of not having the
surgery. If the client understands the risks but still refuses the nurse should notify
the physician and the nurse supervisor and then record the client’s refusal in the
nurses’ notes.
45. Answer: (D) The 75-year-old client who was admitted 1 hour ago with new-
onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
Rationale: The client with atrial fibrillation has the greatest potential to become
unstable and is on L.V. medication that requires close monitoring. After
assessing this client, the nurse should assess the client with thrombophlebitis
who is receiving a heparin infusion, and then the 58- year-old client admitted 2
days ago with heart failure (his signs and symptoms are resolving and don’t
require immediate attention). The lowest priority is the 89-year-old with end stage
right-sided heart failure, who requires time-consuming supportive measures.
46. Answer: (C) Cocaine
Rationale: Because of the client’s age and negative medical history, the nurse
should question her about cocaine use. Cocaine increases myocardial oxygen
consumption and can cause coronary artery spasm, leading to tachycardia,
ventricular fibrillation, myocardial ischemia, and myocardial infarction. Barbiturate
overdose may trigger respiratory depression and slow pulse. Opioids can cause
marked respiratory depression, while benzodiazepines can cause drowsiness
and confusion.
47. Answer: (B) Nonmobile mass with irregular edges
Rationale: Breast cancer tumors are fixed, hard, and poorly delineated with
irregular edges. A mobile mass that is soft and easily delineated is most often a
fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial
detection of a cancerous mass. Nipple retraction — not eversion — may be a
sign of cancer.
48. Answer: (C) Radiation
Rationale: The usual treatment for vaginal cancer is external or intravaginal
radiation therapy. Less often, surgery is performed. Chemotherapy typically is
prescribed only if vaginal cancer is diagnosed in an early stage, which is rare.
Immunotherapy isn't used to treat vaginal cancer.
49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and no
evidence of distant metastasis
Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph
nodes, and no evidence of distant metastasis. No evidence of primary tumor, no
abnormal regional lymph nodes, and no evidence of distant metastasis is
classified as T0, N0, M0. If the tumor and regional lymph nodes can't be
assessed and no evidence of metastasis exists, the lesion is classified as TX,
NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the
regional lymph nodes, and ascending degrees of distant metastasis is classified
as T1, T2, T3, or T4; N0; and M1, M2, or M3.
50. Answer: (D) "Keep the stoma moist."
Rationale: The nurse should instruct the client to keep the stoma moist, such as
by applying a thin layer of petroleum jelly around the edges, because a dry stoma
may become irritated. The nurse should recommend placing a stoma bib over the
stoma to filter and warm air before it enters the stoma. The client should begin
performing stoma care without assistance as soon as possible to gain
independence in self-care activities.
51. Answer: (B) Lung cancer
Rationale: Lung cancer is the most deadly type of cancer in both women and
men. Breast cancer ranks second in women, followed (in descending order) by
colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer,
lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, and multiple
myeloma.
52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected side
of the face.
Rationale: Horner's syndrome, which occurs when a lung tumor invades the ribs
and affects the sympathetic nerve ganglia, is characterized by miosis, partial
eyelid ptosis, and anhidrosis on the affected side of the face. Chest pain,
dyspnea, cough, weight loss, and fever are associated with pleural tumors. Arm
and shoulder pain and atrophy of the arm and hand muscles on the affected side
suggest Pancoast's tumor, a lung tumor involving the first thoracic and eighth
cervical nerves within the brachial plexus. Hoarseness in a client with lung
cancer suggests that the tumor has extended to the recurrent laryngeal nerve;
dysphagia suggests that the lung tumor is compressing the esophagus.
53. Answer: (A) prostate-specific antigen, which is used to screen for prostate
cancer.
Rationale: PSA stands for prostate-specific antigen, which is used to screen for
prostate cancer. The other answers are incorrect.
54. Answer: (D) "Remain supine for the time specified by the physician."
Rationale: The nurse should instruct the client to remain supine for the time
specified by the physician. Local anesthetics used in a subarachnoid block don't
alter the gag reflex. No interactions between local anesthetics and food occur.
Local anesthetics don't cause hematuria.
55. Answer: (C) Sigmoidoscopy
Rationale: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy
aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects
blood, which is a sign of colorectal cancer; however, the test doesn't confirm the
diagnosis. CEA may be elevated in colorectal cancer but isn't considered a
confirming test. An abdominal CT scan is used to stage the presence of
colorectal cancer.
56. Answer: (B) A fixed nodular mass with dimpling of the overlying skin
Rationale: A fixed nodular mass with dimpling of the overlying skin is common
during late stages of breast cancer. Many women have slightly asymmetrical
breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign
condition. Multiple firm, round, freely movable masses that change with the
menstrual cycle indicate fibrocystic breasts, a benign condition.
57. Answer: (A) Liver
Rationale: The liver is one of the five most common cancer metastasis sites. The
others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract,
and WBCs are occasional metastasis sites.
58. Answer: (D) The client wears a watch and wedding band.
Rationale: During an MRI, the client should wear no metal objects, such as
jewelry, because the strong magnetic field can pull on them, causing injury to the
client and (if they fly off) to others. The client must lie still during the MRI but can
talk to those performing the test by way of the microphone inside the scanner
tunnel. The client should hear thumping sounds, which are caused by the sound
waves thumping on the magnetic field.
59. Answer: (C) The recommended daily allowance of calcium may be found in a
wide variety of foods.
Rationale: Premenopausal women require 1,000 mg of calcium per day.
Postmenopausal women require 1,500 mg per day. It's often, though not always,
possible to get the recommended daily requirement in the foods we eat.
Supplements are available but not always necessary. Osteoporosis doesn't show
up on ordinary X-rays until 30% of the bone loss has occurred. Bone
densitometry can detect bone loss of 3% or less. This test is sometimes
recommended routinely for women over 35 who are at risk. Strenuous exercise
won't cause fractures.
60. Answer: (C) Joint flexion of less than 50%
Rationale: Arthroscopy is contraindicated in clients with joint flexion of less than
50% because of technical problems in inserting the instrument into the joint to
see it clearly. Other contraindications for this procedure include skin and wound
infections. Joint pain may be an indication, not a contraindication, for
arthroscopy. Joint deformity and joint stiffness aren't contraindications for this
procedure.
61. Answer: (D) Gouty arthritis
Rationale: Gouty arthritis, a metabolic disease, is characterized by urate deposits
and pain in the joints, especially those in the feet and legs. Urate
deposits don't occur in septic or traumatic arthritis. Septic arthritis results from
bacterial invasion of a joint and leads to inflammation of the synovial
lining. Traumatic arthritis results from blunt trauma to a joint or ligament.
Intermittent arthritis is a rare, benign condition marked by regular, recurrent joint
effusions, especially in the knees.
62. Answer: (B) 30 ml/hou
Rationale: An infusion prepared with 25,000 units of heparin in 500 ml of saline
solution yields 50 units of heparin per milliliter of solution. The equation is set up
as 50 units times X (the unknown quantity) equals 1,500 units/hour, X equals 30
ml/hour.
63. Answer: (B) Loss of muscle contraction decreasing venous return
Rationale: In clients with hemiplegia or hemiparesis loss of muscle contraction
decreases venous return and may cause swelling of the affected extremity.
Contractures, or bony calcifications may occur with a stroke, but don’t appear
with swelling. DVT may develop in clients with a stroke but is more likely to occur
in the lower extremities. A stroke isn’t linked to protein loss.
64. Answer: (B) It appears on the distal interphalangeal joint
Rationale: Heberden’s nodes appear on the distal interphalageal joint on both
men and women. Bouchard’s node appears on the dorsolateral aspect of the
proximal interphalangeal joint.
65. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis is
systemic
Rationale: Osteoarthritis is a localized disease, rheumatoid arthritis is systemic.
Osteoarthritis isn’t gender-specific, but rheumatoid arthritis is. Clients have
dislocations and subluxations in both disorders.
66. Answer: (C) The cane should be used on the unaffected side
Rationale: A cane should be used on the unaffected side. A client with
osteoarthritis should be encouraged to ambulate with a cane, walker, or other
assistive device as needed; their use takes weight and stress off joints.
67. Answer: (A) a. 9 U regular insulin and 21 U neutral protamine Hagedorn
(NPH).
Rationale: A 70/30 insulin preparation is 70% NPH and 30% regular insulin.
Therefore, a correct substitution requires mixing 21 U of NPH and 9 U of regular
insulin. The other choices are incorrect dosages for the prescribed insulin.
68. Answer: (C) colchicines
Rationale: A disease characterized by joint inflammation (especially in the great
toe), gout is caused by urate crystal deposits in the joints. The physician
prescribes colchicine to reduce these deposits and thus ease joint inflammation.
Although aspirin is used to reduce joint inflammation and pain in clients with
osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no
effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout.
Calcium gluconate is used to reverse a negative calcium balance and relieve
muscle cramps, not to treat gout.
69. Answer: (A) Adrenal cortex
Rationale: Excessive secretion of aldosterone in the adrenal cortex is responsible
for the client's hypertension. This hormone acts on the renal tubule, where it
promotes reabsorption of sodium and excretion of potassium and hydrogen ions.
The pancreas mainly secretes hormones involved in fuel metabolism. The
adrenal medulla secretes the catecholamines — epinephrine and
norepinephrine. The parathyroids secrete parathyroid hormone.
70. Answer: (C) They debride the wound and promote healing by secondary
intention
Rationale: For this client, wet-to-dry dressings are most appropriate because
they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting
healing by secondary intention. Moist, transparent dressings contain exudate and
provide a moist wound environment. Hydrocolloid dressings prevent the entrance
of microorganisms and minimize wound discomfort. Dry sterile dressings protect
the wound from mechanical trauma and promote healing.
71. Answer: (A) Hyperkalemia
Rationale: In adrenal insufficiency, the client has hyperkalemia due to reduced
aldosterone secretion. BUN increases as the glomerular filtration rate is reduced.
Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol
secretion leads to impaired glyconeogenesis and a reduction of glycogen in the
liver and muscle, causing hypoglycemia.
72. Answer: (C) Restricting fluids
Rationale: To reduce water retention in a client with the SIADH, the nurse should
restrict fluids. Administering fluids by any route would further increase the client's
already heightened fluid load.
73. Answer: (D) glycosylated hemoglobin level.
Rationale: Because some of the glucose in the bloodstream attaches to some of
the hemoglobin and stays attached during the 120-day life span of red blood
cells, glycosylated hemoglobin levels provide information about blood glucose
levels during the previous 3 months. Fasting blood glucose and urine glucose
levels only give information about glucose levels at the point in time when they
were obtained. Serum fructosamine levels provide information about blood
glucose control over the past 2 to 3 weeks.
74. Answer: (C) 4:00 pm
Rationale: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after
administration. Because the nurse administered NPH insulin at 7 a.m., the client
is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.
75. Answer: (A) Glucocorticoids and androgens
Rationale: The adrenal glands have two divisions, the cortex and medulla. The
cortex produces three types of hormones: glucocorticoids, mineralocorticoids,
and androgens. The medulla produces catecholamines — epinephrine and
norepinephrine.
76. Answer: (A) Hypocalcemia
Rationale: Hypocalcemia may follow thyroid surgery if the parathyroid glands
were removed accidentally. Signs and symptoms of hypocalcemia may be
delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause
serum sodium, potassium, or magnesium abnormalities. Hyponatremia may
occur if the client inadvertently received too much fluid; however, this can happen
to any surgical client receiving I.V. fluid therapy, not just one recovering from
thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with
reduced renal excretion of potassium and magnesium, not thyroid surgery.
77. Answer: (D) Carcinoembryonic antigen level
Rationale: In clients who smoke, the level of carcinoembryonic antigen is
elevated. Therefore, it can't be used as a general indicator of cancer. However, it
is helpful in monitoring cancer treatment because the level usually falls to normal
within 1 month if treatment is successful. An elevated acid phosphatase level
may indicate prostate cancer. An elevated alkaline phosphatase level may reflect
bone metastasis. An elevated serum calcitonin level usually signals thyroid
cancer.
78. Answer: (B) Dyspnea, tachycardia, and pallor
Rationale: Signs of iron-deficiency anemia include dyspnea, tachycardia, and
pallor as well as fatigue, listlessness, irritability, and headache. Night sweats,
weight loss, and diarrhea may signal acquired immunodeficiency syndrome
(AIDS). Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching,
rash, and jaundice may result from an allergic or hemolytic reaction.
79. Answer: (D) "I'll need to have a C-section if I become pregnant and have a
baby."
Rationale: The human immunodeficiency virus (HIV) is transmitted from mother
to child via the transplacental route, but a Cesarean section delivery isn't
necessary when the mother is HIV-positive. The use of birth control will prevent
the conception of a child who might have HIV. It's true that a mother who's HIV
positive can give birth to a baby who's HIV negative.
80. Answer: (C) "Avoid sharing such articles as toothbrushes and razors."
Rationale: The human immunodeficiency virus (HIV), which causes AIDS, is
most concentrated in the blood. For this reason, the client shouldn't share
personal articles that may be blood-contaminated, such as toothbrushes and
razors, with other family members. HIV isn't transmitted by bathing or by eating
from plates, utensils, or serving dishes used by a person with AIDS.
81. Answer: (B) Pallor, tachycardia, and a sore tongue
Rationale: Pallor, tachycardia, and a sore tongue are all characteristic findings in
pernicious anemia. Other clinical manifestations include anorexia; weight loss; a
smooth, beefy red tongue; a wide pulse pressure; palpitations; angina;
weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced
pulse pressure, weight gain, and double vision aren't characteristic findings in
pernicious anemia.
82. Answer: (B) Administer epinephrine, as prescribed, and prepare to intubate
the client if necessary.
Rationale: To reverse anaphylactic shock, the nurse first should administer
epinephrine, a potent bronchodilator as prescribed. The physician is likely to
order additional medications, such as antihistamines and corticosteroids; if these
medications don't relieve the respiratory compromise associated with
anaphylaxis, the nurse should prepare to intubate the client. No antidote for
penicillin exists; however, the nurse should continue to monitor the client's vital
signs. A client who remains hypotensive may need fluid resuscitation and fluid
intake and output monitoring; however, administering epinephrine is the first
priority.
83. Answer: (D) bilateral hearing loss.
Rationale: Prolonged use of aspirin and other salicylates sometimes causes
bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves
within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight
gain or fine motor tremors. Large or toxic salicylate doses may cause respiratory
alkalosis, not respiratory acidosis.
84. Answer: (D) Lymphocyte
Rationale: The lymphocyte provides adaptive immunity — recognition of a foreign
antigen and formation of memory cells against the antigen.
Adaptive immunity is mediated by B and T lymphocytes and can be acquired
actively or passively. The neutrophil is crucial to phagocytosis. The basophil
plays an important role in the release of inflammatory mediators. The monocyte
functions in phagocytosis and monokine production.
85. Answer: (A) moisture replacement.
Rationale: Sjogren's syndrome is an autoimmune disorder leading to progressive
loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture
replacement is the mainstay of therapy. Though malnutrition and electrolyte
imbalance may occur as a result of Sjogren's syndrome's effect on the GI tract, it
isn't the predominant problem. Arrhythmias aren't a problem associated with
Sjogren's syndrome.
86. Answer: (C) stool for Clostridium difficile test.
Rationale: Immunosuppressed clients — for example, clients receiving
chemotherapy, — are at risk for infection with C. difficile, which causes "horse
barn" smelling diarrhea. Successful treatment begins with an accurate diagnosis,
which includes a stool test. The ELISA test is diagnostic for human
immunodeficiency virus (HIV) and isn't indicated in this case. An electrolyte panel
and hemogram may be useful in the overall evaluation of a client but aren't
diagnostic for specific causes of diarrhea. A flat plate of the abdomen may
provide useful information about bowel function but isn't indicated in the case of
"horse barn" smelling diarrhea.
87. Answer: (D) Western blot test with ELISA.
Rationale: HIV infection is detected by analyzing blood for antibodies to HIV,
which form approximately 2 to 12 weeks after exposure to HIV and denote
infection. The Western blot test — electrophoresis of antibody proteins — is more
than 98% accurate in detecting HIV antibodies when used in conjunction with the
ELISA. It isn't specific when used alone. Erosette immunofluorescence is used to
detect viruses in general; it doesn't confirm HIV infection. Quantification of T-
lymphocytes is a useful monitoring test but isn't diagnostic for HIV. The ELISA
test detects HIV antibody particles but may yield inaccurate results; a positive
ELISA result must be confirmed by the Western blot test.
88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
Rationale: Low preoperative HCT and Hb levels indicate the client may require a
blood transfusion before surgery. If the HCT and Hb levels decrease during
surgery because of blood loss, the potential need for a transfusion increases.
Possible renal failure is indicated by elevated BUN or creatinine levels. Urine
constituents aren't found in the blood. Coagulation is determined by the presence
of appropriate clotting factors, not electrolytes.
89. Answer: (A) Platelet count, prothrombin time, and partial thromboplastin time
Rationale: The diagnosis of DIC is based on the results of laboratory studies of
prothrombin time, platelet count, thrombin time, partial thromboplastin time, and
fibrinogen level as well as client history and other assessment factors. Blood
glucose levels, WBC count, calcium levels, and potassium levels aren't used to
confirm a diagnosis of DIC.
90. Answer: (D) Strawberries
Rationale: Common food allergens include berries, peanuts, Brazil nuts,
cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic
reactions.
91. Answer: (B) A client with cast on the right leg who states, “I have a funny
feeling in my right leg.”
Rationale: It may indicate neurovascular compromise, requires immediate
assessment.
92. Answer: (D) A 62-year-old who had an abdominal-perineal resection three
days ago; client complaints of chills.
Rationale: The client is at risk for peritonitis; should be assessed for further
symptoms and infection.
93. Answer: (C) The client spontaneously flexes his wrist when the blood
pressure is obtained.
Rationale: Carpal spasms indicate hypocalcemia.
94. Answer: (D) Use comfort measures and pillows to position the client.
Rationale: Using comfort measures and pillows to position the client is a non-
pharmacological methods of pain relief.
95. Answer: (B) Warm the dialysate solution.
Rationale: Cold dialysate increases discomfort. The solution should be warmed
to body temperature in warmer or heating pad; don’t use microwave oven.
96. Answer: (C) The client holds the cane with his left hand, moves the cane
forward followed by the right leg, and then moves the left leg.
Rationale: The cane acts as a support and aids in weight bearing for the weaker
right leg.
97. Answer: (A) Ask the woman’s family to provide personal items such as
photos or mementos.
Rationale: Photos and mementos provide visual stimulation to reduce sensory
deprivation.
98. Answer: (B) The client lifts the walker, moves it forward 10 inches, and then
takes several small steps forward.
Rationale: A walker needs to be picked up, placed down on all legs.
99. Answer: (C) Isolation from their families and familiar surroundings.
Rationale: Gradual loss of sight, hearing, and taste interferes with normal
functioning.
100. Answer: (A) Encourage the client to perform pursed lip breathing.
Rationale: Purse lip breathing prevents the collapse of lung unit and helps client
control rate and depth of breathing.
NP4- MS/PSYCH
1. Randy has undergone kidney transplant, what assessment would prompt
Nurse Katrina to suspect organ rejection?
a. Sudden weight loss b. Polyuria c. Hypertension d. Shock
2. The immediate objective of nursing care for an overweight, mildly hypertensive
male client with ureteral colic and hematuria is to decrease:
a. Pain b. Weight c. Hematuria d. Hypertension
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a
subtotal thyroidectomy is performed. The nurse is aware that this medication is
given to:
a. Decrease the total basal metabolic rate.
b. Maintain the function of the parathyroid glands.
c. Block the formation of thyroxine by the thyroid gland.
d. Decrease the size and vascularity of the thyroid gland.
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute
hypoglycemia also can develop in the client who is diagnosed with:
a. Liver disease b. Hypertension c. Type 2 diabetes d. Hyperthyroidism
5. Tracy is receiving combination chemotherapy for treatment of metastatic
carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:
a. Ascites b. Nystagmus c. Leukopenia d. Polycythemia
6. Norma, with recent colostomy expresses concern about the inability to control
the passage of gas. Nurse Oliver should suggest that the client plan to:
a. Eliminate foods high in cellulose.
b. Decrease fluid intake at meal times.
c. Avoid foods that in the past caused flatus.
d. Adhere to a bland diet prior to social events.
7. Nurse Ron begins to teach a male client how to perform colostomy irrigations.
The nurse would evaluate that the instructions were understood when the client
states, “I should:
a. Lie on my left side while instilling the irrigating solution.”
b. Keep the irrigating container less than 18 inches above the stoma.”
c. Instill a minimum of 1200 ml of irrigating solution to stimulate
evacuation of the bowel.”
d. Insert the irrigating catheter deeper into the stoma if cramping
occurs during the procedure.”
8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing
fluid and electrolyte imbalances. The client is somewhat confused and complains
of nausea and muscle weakness. As part of the prescribed therapy to correct this
electrolyte imbalance, the nurse would expect to:
a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.
9. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2
liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10
gtt/ml. The nurse should set the flow to provide:
a. 18 gtt/min b. 28 gtt/min c. 32 gtt/min d. 36 gtt/min
10.Terence suffered form burn injury. Using the rule of nines, which has the
largest percent of burns?
a. Face and neck b. Right upper arm and penis
c. Right thigh and penis d. Upper trunk
11. Herbert, a 45 year old construction engineer is brought to the hospital
unconscious after falling from a 2-story building. When assessing the client, the
nurse would be most concerned if the assessment revealed:
a. Reactive pupils b. A depressed fontanel
c. Bleeding from ears d. An elevated temperature
12. Nurse Sherry is teaching male client regarding his permanent artificial
pacemaker. Which information given by the nurse shows her knowledge deficit
about the artificial cardiac pacemaker?
a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports
13.The nurse is ware that the most relevant knowledge about oxygen
administration to a male client with COPD is
a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the
client breath.
c. Oxygen is administered best using a non-rebreathing mask
d. Blood gases are monitored using a pulse oximeter.
14.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest
tubes are inserted, and one-bottle water-seal drainage is instituted in the
operating room. In the postanesthesia care unit Tonny is placed in Fowler's
position on either his right side or on his back. The nurse is aware that this
position:
a. Reduce incisional pain. b. Facilitate ventilation of the left lung.
c. Equalize pressure in the pleural space. d. Increase venous return
15.Kristine is scheduled for a bronchoscopy. When teaching Kristine what to
expect afterward, the nurse's highest priority of information would be:
a. Food and fluids will be withheld for at least 2 hours.
b. Warm saline gargles will be done q 2h.
c. Coughing and deep-breathing exercises will be done q2h.
d. Only ice chips and cold liquids will be allowed initially.
16.Nurse Tristan is caring for a male client in acute renal failure. The nurse
should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to
be used to treat:
a. hypernatremia. b. hypokalemia. c. hyperkalemia. d. hypercalcemia.
17.Ms. X has just been diagnosed with condylomata acuminata (genital warts).
What information is appropriate to tell this client?
a. This condition puts her at a higher risk for cervical cancer; therefore, she
should have a Papanicolaou (Pap) smear annually.
b. The most common treatment is metronidazole (Flagyl), which should eradicate
the problem within 7 to 10 days.
c. The potential for transmission to her sexual partner will be eliminated if
condoms are used every time they have sexual intercourse.
d. The human papillomavirus (HPV), which causes condylomata acuminata, can't
be transmitted during oral sex.
18.Maritess was recently diagnosed with a genitourinary problem and is being
examined in the emergency department. When palpating the her kidneys, the
nurse should keep which anatomical fact in mind?
a. The left kidney usually is slightly higher than the right one.
b. The kidneys are situated just above the adrenal glands.
c. The average kidney is approximately 5 cm (2") long and 2 to 3 cm (¾" to 1-
1/8") wide.
d. The kidneys lie between the 10th and 12th thoracic vertebrae.
19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The
nurse is aware that the diagnostic test are consistent with CRF if the result is:
a. Increased pH with decreased hydrogen ions.
b. Increased serum levels of potassium, magnesium, and calcium.
c. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.
d. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.
20. Katrina has an abnormal result on a Papanicolaou test. After admitting that
she read her chart while the nurse was out of the room, Katrina asks what
dysplasia means. Which definition should the nurse provide?
a. Presence of completely undifferentiated tumor cells that don't resemble cells of
the tissues of their origin.
b. Increase in the number of normal cells in a normal arrangement in a tissue or
an organ.
c. Replacement of one type of fully differentiated cell by another in tissues where
the second type normally isn't found.
d. Alteration in the size, shape, and organization of differentiated cells.
21. During a routine checkup, Nurse Mariane assesses a male client with
acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer.
What is the most common AIDS-related cancer?
a. Squamous cell carcinoma b. Multiple myeloma
c. Leukemia d. Kaposi's sarcoma
22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to
use a spinal (subarachnoid) block during surgery. In the operating room, the
nurse positions the client according to the anesthesiologist's instructions. Why
does the client require special positioning for this type of anesthesia?
a. To prevent confusion
b. To prevent seizures
c. To prevent cerebrospinal fluid (CSF) leakage
d. To prevent cardiac arrhythmias
23.A male client had a nephrectomy 2 days ago and is now complaining of
abdominal pressure and nausea. The first nursing action should be to:
a. Auscultate bowel sounds. b. Palpate the abdomen.
c. Change the client's position. d. Insert a rectal tube.
24.Wilfredo with a recent history of rectal bleeding is being prepared for a
colonoscopy. How should the nurse Patricia position the client for this test
initially?
a. Lying on the right side with legs straight
b. Lying on the left side with knees bent
c. Prone with the torso elevated
d. Bent over with hands touching the floor
25.A male client with inflammatory bowel disease undergoes an ileostomy. On
the first day after surgery, Nurse Oliver notes that the client's stoma appears
dusky. How should the nurse interpret this finding?
a. Blood supply to the stoma has been interrupted.
b. This is a normal finding 1 day after surgery.
c. The ostomy bag should be adjusted.
d. An intestinal obstruction has occurred.
26.Anthony suffers burns on the legs, which nursing intervention helps prevent
contractures?
a. Applying knee splints
b. Elevating the foot of the bed
c. Hyperextending the client's palms
d. Performing shoulder range-of-motion exercises
27.Nurse Ron is assessing a client admitted with second- and third-degree burns
on the face, arms, and chest. Which finding indicates a potential problem?
a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
b. Urine output of 20 ml/hour.
c. White pulmonary secretions.
d. Rectal temperature of 100.6° F (38° C).
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak
to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:
a. Turn him frequently.
b. Perform passive range-of-motion (ROM) exercises.
c. Reduce the client's fluid intake.
d. Encourage the client to use a footboard.
29.Nurse Maria plans to administer dexamethasone cream to a female client who
has dermatitis over the anterior chest. How should the nurse apply this topical
agent?
a. With a circular motion, to enhance absorption.
b. With an upward motion, to increase blood supply to the affected area
c. In long, even, outward, and downward strokes in the direction of hair growth
d. In long, even, outward, and upward strokes in the direction opposite hair
growth
30.Nurse Kate is aware that one of the following classes of medication protect
the ischemic myocardium by blocking catecholamines and
sympathetic nerve stimulation is:
a. Beta -adrenergic blockers b. Calcium channel blocker
c. Narcotics d. Nitrates
31.A male client has jugular distention. On what position should the nurse place
the head of the bed to obtain the most accurate reading of jugular vein
distention?
a. High Fowler’s b. Raised 10 degrees c. Raised 30 degrees d. Supine position
32.The nurse is aware that one of the following classes of medications
maximizes cardiac performance in clients with heart failure by increasing
ventricular contractility?
a. Beta-adrenergic blockers b. Calcium channel blocker
c. Diuretics d. Inotropic agents
33.A male client has a reduced serum high-density lipoprotein (HDL) level and an
elevated low-density lipoprotein (LDL) level. Which of the following dietary
modifications is not appropriate for this client?
a. Fiber intake of 25 to 30 g daily
b. Less than 30% of calories form fat
c. Cholesterol intake of less than 300 mg daily
d. Less than 10% of calories from saturated fat
34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2
days ago with an acute myocardial infarction. Which of the following actions
would breach the client confidentiality?
a. The CCU nurse gives a verbal report to the nurse on the telemetry unit before
transferring the client to that unit
b. The CCU nurse notifies the on-call physician about a change in the client’s
condition
c. The emergency department nurse calls up the latest electrocardiogram results
to check the client’s progress.
d. At the client’s request, the CCU nurse updates the client’s wife on his condition
35. A male client arriving in the emergency department is receiving
cardiopulmonary resuscitation from paramedics who are giving ventilations
through an endotracheal (ET) tube that they placed in the client’s home. During a
pause in compressions, the cardiac monitor shows narrow QRS complexes and
a heart rate of beats/minute with a palpable pulse. Which of the following actions
should the nurse take first?
a. Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over
10 minutes.
b. Check endotracheal tube placement.
c. Obtain an arterial blood gas (ABG) sample.
d. Administer atropine, 1 mg L.V.
36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg.
Nurse Katrina determines that mean arterial pressure (MAP) is which of the
following?
a. 46 mm Hg b. 80 mm Hg c. 95 mm Hg d. 90 mm Hg
37. A female client arrives at the emergency department with chest and stomach
pain and a report of black tarry stool for several months. Which of the following
order should the nurse Oliver anticipate?
a. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels
b. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split
product values.
c. Electrocardiogram, complete blood count, testing for occult blood,
comprehensive serum metabolic panel.
d. Electroencephalogram, alkaline phosphatase and aspartate aminotransferase
levels, basic serum metabolic panel
38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which
of the following conditions is suspected by the nurse when a decrease in platelet
count from 230,000 ul to 5,000 ul is noted?
a. Pancytopenia
b. Idiopathic thrombocytopemic purpura (ITP)
c. Disseminated intravascular coagulation (DIC)
d. Heparin-associated thrombosis and thrombocytopenia (HATT)
39. Which of the following drugs would be ordered by the physician to improve
the platelet count in a male client with idiopathic thrombocytopenic purpura
(ITP)?
a. Acetylsalicylic acid (ASA) b. Corticosteroids
c. Methotrezate d. Vitamin K
40. A female client is scheduled to receive a heart valve replacement with a
porcine valve. Which of the following types of transplant is this?
a. Allogeneic b. Autologous c. Syngeneic d. Xenogeneic
41. Marco falls off his bicycle and injuries his ankle. Which of the following
actions shows the initial response to the injury in the extrinsic pathway?
a. Release of Calcium
b. Release of tissue thromboplastin
c. Conversion of factors XII to factor XIIa
d. Conversion of factor VIII to factor VIIIa
42. Instructions for a client with systemic lupus erythematosus (SLE) would
include information about which of the following blood dyscrasias?
a. Dressler’s syndrome b. Polycythemia
c. Essential thrombocytopenia d. Von Willebrand’s disease
43. The nurse is aware that the following symptoms is most commonly an early
indication of stage 1 Hodgkin’s disease?
a. Pericarditis b. Night sweat c. Splenomegaly d. Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of the following functions must
frequently assessed?
a. Blood pressure b. Bowel sounds c. Heart sounds d. Breath sounds
45. The nurse knows that neurologic complications of multiple myeloma (MM)
usually involve which of the following body system?
a. Brain b. Muscle spasm c. Renal dysfunction d. Myocardial irritability
46. Nurse Patricia is aware that the average length of time from human
immunodeficiency virus (HIV) infection to the development of acquired
immunodeficiency syndrome (AIDS)?
a. Less than 5 years b. 5 to 7 years c. 10 years d. More than 10 years
47. An 18-year-old male client admitted with heat stroke begins to show signs of
disseminated intravascular coagulation (DIC). Which of the following laboratory
findings is most consistent with DIC?
a. Low platelet count
b. Elevated fibrinogen levels
c. Low levels of fibrin degradation products
d. Reduced prothrombin time
48. Mario comes to the clinic complaining of fever, drenching night sweats, and
unexplained weight loss over the past 3 months. Physical examination reveals a
single enlarged supraclavicular lymph node. Which of the following is the most
probable diagnosis?
a. Influenza b. Sickle cell anemia c. Leukemia d. Hodgkin’s disease
49. A male client with a gunshot wound requires an emergency blood
transfusion. His blood type is AB negative. Which blood type would be the safest
for him to receive?
a. AB Rh-positive b. A Rh-positive c. A Rh-negative d. O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning
chemotherapy.
50. Stacy is discharged from the hospital following her chemotherapy treatments.
Which statement of Stacy’s mother indicated that she understands when she will
contact the physician?
a. “I should contact the physician if Stacy has difficulty in sleeping”.
b. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
c. “My physician should be called if Stacy is irritable and unhappy”.
d. “Should Stacy have continued hair loss, I need to call the doctor”.
51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair.
The best response for the nurse is:
a. “Stacy looks very nice wearing a hat”.
b. “You should not worry about her hair, just be glad that she is alive”.
c. “Yes it is upsetting. But try to cover up your feelings when you are with her or
else she may be upset”.
d. “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be
different in texture”.
52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the
nurse in-charge should:
a. Provide frequent mouthwash with normal saline.
b. Apply viscous Lidocaine to oral ulcers as needed.
c. Use lemon glycerine swabs every 2 hours.
d. Rinse mouth with Hydrogen Peroxide.
53. During the administration of chemotherapy agents, Nurse Oliver observed
that the IV site is red and swollen, when the IV is touched Stacy shouts in pain.
The first nursing action to take is:
a. Notify the physician
b. Flush the IV line with saline solution
c. Immediately discontinue the infusion
d. Apply an ice pack to the site, followed by warm compress.
54. The term “blue bloater” refers to a male client which of the following
conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
55. The term “pink puffer” refers to the female client with which of the following
conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
56. Jose is in danger of respiratory arrest following the administration of a
narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would
expect the paco2 to be which of the following values?
a. 15 mm Hg b. 30 mm Hg c. 40 mm Hg d. 80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80
mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
represents which of the following conditions?
a. Metabolic acidosis b. Metabolic alkalosis
c. Respiratory acidosis d. Respirator y alkalosis
58. Norma has started a new drug for hypertension. Thirty minutes after she
takes the drug, she develops chest tightness and becomes short of breath and
tachypneic. She has a decreased level of consciousness. These signs indicate
which of the following conditions?
a. Asthma attack b. Pulmonary embolism
c. Respiratory failure d. Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice.
To rule out cirrhosis of the liver:
59. Which laboratory test indicates liver cirrhosis?
a. Decreased red blood cell count b. Decreased serum acid phosphate level
c. Elevated white blood cell count d. Elevated serum aminotransferase
60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales
is at increased risk for excessive bleeding primarily because of:
a. Impaired clotting mechanism b. Varix formation
c. Inadequate nutrition d. Trauma of invasive procedure
61. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation
is most common with this condition?
a. Increased urine output b. Altered level of consciousness
c. Decreased tendon reflex d. Hypotension
62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of
Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best
action would be:
a. “I’ll see if your physician is in the hospital”.
b. “Maybe your reacting to the drug; I will withhold the next dose”.
c. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
d. “Frequently, bowel movements are needed to reduce sodium level”.
63. Which of the following groups of symptoms indicates a ruptured abdominal
aortic aneurysm?
a. Lower back pain, increased blood pressure, decreased re blood cell (RBC)
count, increased white blood (WBC) count.
b. Severe lower back pain, decreased blood pressure, decreased RBC count,
increased WBC count.
c. Severe lower back pain, decreased blood pressure, decreased RBC count,
decreased RBC count, decreased WBC count.
d. Intermitted lower back pain, decreased blood pressure, decreased RBC count,
increased WBC count.
64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood
under his buttocks. Which of the following steps should the nurse take first?
a. Call for help. b. Obtain vital signs
c. Ask the client to “lift up” d. Apply gloves and assess the groin site
65. Which of the following treatment is a suitable surgical intervention for a client
with unstable angina?
a. Cardiac catheterization b. Echocardiogram
c. Nitroglycerin d. Percutaneous transluminal coronary angioplasty (PTCA)
66. The nurse is aware that the following terms used to describe reduced cardiac
output and perfusion impairment due to ineffective pumping of the heart is:
a. Anaphylactic shock b. Cardiogenic shock
c. Distributive shock d. Myocardial infarction (MI)
67. A client with hypertension ask the nurse which factors can cause blood
pressure to drop to normal levels?
a. Kidneys’ excretion to sodium only.
b. Kidneys’ retention of sodium and water
c. Kidneys’ excretion of sodium and water
d. Kidneys’ retention of sodium and excretion of water
68. Nurse Rose is aware that the statement that best explains why furosemide
(Lasix) is administered to treat hypertension is:
a. It dilates peripheral blood vessels.
b. It decreases sympathetic cardioacceleration.
c. It inhibits the angiotensin-coverting enzymes
d. It inhibits reabsorption of sodium and water in the loop of Henle.
69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic
lupus erythematosus (SLE) is:
a. Elavated serum complement level
b. Thrombocytosis, elevated sedimentation rate
c. Pancytopenia, elevated antinuclear antibody (ANA) titer
d. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels
70. Arnold, a 19-year-old client with a mild concussion is discharged from the
emergency department. Before discharge, he complains of a headache. When
offered acetaminophen, his mother tells the nurse the headache is severe and
she would like her son to have something stronger. Which of the following
responses by the nurse is appropriate?
a. “Your son had a mild concussion, acetaminophen is strong enough.”
b. “Aspirin is avoided because of the danger of Reye’s syndrome in children or
young adults.”
c. “Narcotics are avoided after a head injury because they may hide a worsening
condition.”
d. Stronger medications may lead to vomiting, which increases the intracarnial
pressure (ICP).”
71. When evaluating an arterial blood gas from a male client with a subdural
hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following
responses best describes the result?
a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure
(ICP)
b. Emergent; the client is poorly oxygenated
c. Normal
d. Significant; the client has alveolar hypoventilation
72. When prioritizing care, which of the following clients should the nurse Olivia
assess first?
a. A 17-year-old clients 24-hours postappendectomy
b. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
c. A 50-year-old client 3 days postmyocardial infarction
d. A 50-year-old client with diverticulitis
73. JP has been diagnosed with gout and wants to know why colchicine is used
in the treatment of gout. Which of the following actions of colchicines explains
why it’s effective for gout?
a. Replaces estrogen b. Decreases infection
c. Decreases inflammation d. Decreases bone demineralization
74. Norma asks for information about osteoarthritis. Which of the following
statements about osteoarthritis is correct?
a. Osteoarthritis is rarely debilitating
b. Osteoarthritis is a rare form of arthritis
c. Osteoarthritis is the most common form of arthritis
d. Osteoarthritis afflicts people over 60
75. Ruby is receiving thyroid replacement therapy develops the flu and forgets to
take her thyroid replacement medicine. The nurse understands that skipping this
medication will put the client at risk for developing which of the following
lifethreatening complications?
a. Exophthalmos b. Thyroid storm c. Myxedema coma d. Tibial myxedema
76. Nurse Sugar is assessing a client with Cushing's syndrome. Which
observation should the nurse report to the physician immediately?
a. Pitting edema of the legs b. An irregular apical pulse
c. Dry mucous membranes d. Frequent urination
77. Cyrill with severe head trauma sustained in a car accident is admitted to the
intensive care unit. Thirty-six hours later, the client's urine output suddenly rises
above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which
laboratory findings support the nurse's suspicion of diabetes insipidus?
a. Above-normal urine and serum osmolality levels
b. Below-normal urine and serum osmolality levels
c. Above-normal urine osmolality level, below-normal serum osmolality level
d. Below-normal urine osmolality level, above-normal serum osmolality level
78. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome
(HHNS) is stabilized and prepared for discharge. When preparing the client for
discharge and home management, which of the following statements indicates
that the client understands her condition and how to control it?
a. "I can avoid getting sick by not becoming dehydrated and by paying attention
to my need to urinate, drink, or eat more than usual."
b. "If I experience trembling, weakness, and headache, I should drink a glass of
soda that contains sugar."
c. "I will have to monitor my blood glucose level closely and notify the physician if
it's constantly elevated."
d. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in
carbohydrates."
79. A 66-year-old client has been complaining of sleeping more, increased
urination, anorexia, weakness, irritability, depression, and bone pain that
interferes with her going outdoors. Based on these assessment findings, the
nurse would suspect which of the following disorders?
a. Diabetes mellitus b. Diabetes insipidus
c. Hypoparathyroidism d. Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering from addisonian crisis about
the need to take fludrocortisone acetate and hydrocortisone at home. Which
statement by the client indicates an understanding of the instructions?
a. "I'll take my hydrocortisone in the late afternoon, before dinner."
b. "I'll take all of my hydrocortisone in the morning, right after I wake up."
c. "I'll take two-thirds of the dose when I wake up and one-third in the late
afternoon."
d. "I'll take the entire dose at bedtime."
81. Which of the following laboratory test results would suggest to the nurse Len
that a client has a corticotropin-secreting pituitary adenoma?
a. High corticotropin and low cortisol levels
b. Low corticotropin and high cortisol levels
c. High corticotropin and high cortisol levels
d. Low corticotropin and low cortisol levels
82. A male client is scheduled for a transsphenoidal hypophysectomy to remove
a pituitary tumor. Preoperatively, the nurse should assess for potential
complications by doing which of the following?
a. Testing for ketones in the urine
b. Testing urine specific gravity
c. Checking temperature every 4 hours
d. Performing capillary glucose testing every 4 hours
83. Capillary glucose monitoring is being performed every 4 hours for a client
diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of
regular insulin according to glucose results. At 2 p.m., the client has a capillary
glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse
Mariner should expect the dose's:
a. onset to be at 2 p.m. and its peak to be at 3 p.m.
b. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
c. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
d. onset to be at 4 p.m. and its peak to be at 6 p.m.
84. The physician orders laboratory tests to confirm hyperthyroidism in a female
client with classic signs and symptoms of this disorder. Which test result would
confirm the diagnosis?
a. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes
during the TSH stimulation test
b. A decreased TSH level
c. An increase in the TSH level after 30 minutes during the TSH stimulation test
d. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4)
as detected by radioimmunoassay
85. Rico with diabetes mellitus must learn how to self-administer insulin. The
physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100
isophane insulin suspension (NPH) to be taken before breakfast. When teaching
the client how to select and rotate insulin injection sites, the nurse should provide
which instruction?
a. "Inject insulin into healthy tissue with large blood vessels and nerves."
b. "Rotate injection sites within the same anatomic region, not among different
regions."
c. "Administer insulin into areas of scar tissue or hypotrophy whenever possible."
d. "Administer insulin into sites above muscles that you plan to exercise heavily
later that day."
86. Nurse Sarah expects to note an elevated serum glucose level in a client with
hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other
laboratory finding should the nurse anticipate?
a. Elevated serum acetone level b. Serum ketone bodies
c. Serum alkalosis d. Below-normal serum potassium level
87. For a client with Graves' disease, which nursing intervention promotes
comfort?
a. Restricting intake of oral fluids
b. Placing extra blankets on the client's bed
c. Limiting intake of high-carbohydrate foods
d. Maintaining room temperature in the low-normal range
88. Patrick is treated in the emergency department for a Colles' fracture
sustained during a fall. What is a Colles' fracture?
a. Fracture of the distal radius b. Fracture of the olecranon
c. Fracture of the humerus d. Fracture of the carpal scaphoid
89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the
development of this disorder?
a. Calcium and sodium b. Calcium and phosphorous
c. Phosphorous and potassium d. Potassium and sodium
90. Johnny a firefighter was involved in extinguishing a house fire and is being
treated to smoke inhalation. He develops severe hypoxia 48 hours after the
incident, requiring intubation and mechanical ventilation. He most likely has
developed which of the following conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Atelectasis
c. Bronchitis
d. Pneumonia
91. A 67-year-old client develops acute shortness of breath and progressive
hypoxia requiring right femur. The hypoxia was probably caused by which of the
following conditions?
a. Asthma attack b. Atelectasis c. Bronchitis d. Fat embolism
92. A client with shortness of breath has decreased to absent breath sounds on
the right side, from the apex to the base. Which of the following conditions would
best explain this?
a. Acute asthma b. Chronic bronchitis
c. Pneumonia d. Spontaneous pneumothorax
93. A 62-year-old male client was in a motor vehicle accident as an unrestrained
driver. He’s now in the emergency department complaining of difficulty of
breathing and chest pain. On auscultation of his lung field, no breath sounds are
present in the upper lobe. This client may have which of the following conditions?
a. Bronchitis b. Pneumonia c. Pneumothorax d. Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills the area of the thoracic
cavity?
a. The space remains filled with air only
b. The surgeon fills the space with a gel
c. Serous fluids fills the space and consolidates the region
d. The tissue from the other lung grows over to the other side
95. Hemoptysis may be present in the client with a pulmonary embolism because
of which of the following reasons?
a. Alveolar damage in the infracted area
b. Involvement of major blood vessels in the occluded area
c. Loss of lung parenchyma
d. Loss of lung tissue
96. Aldo with a massive pulmonary embolism will have an arterial blood gas
analysis performed to determine the extent of hypoxia. The acid-base disorder
that may be present is?
a. Metabolic acidosis b. Metabolic alkalosis
c. Respiratory acidosis d. Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22-year-old client is admitted with
a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest
drainage system. Bubbling soon appears in the water seal chamber. Which of the
following is the most likely cause of the bubbling?
a. Air leak b. Adequate suction c. Inadequate suction d. Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a postoperative client. The
client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The
IV infusion set has a drop factor of 10 drops per milliliter. The nurse should
regulate the client’s IV to deliver how many drops per minute?
a. 18 b. 21 c. 35 d. 40
99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with
congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The
bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount
should the nurse administer to the child?
a. 1.2 ml b. 2.4 ml c. 3.5 ml d. 4.2 ml
100. Nurse Alexandra teaches a client about elastic stockings. Which of the
following statements, if made by the client, indicates to the nurse that the
teaching was successful?
a. “I will wear the stockings until the physician tells me to remove them.”
b. “I should wear the stockings even when I am sleep.”
c. “Every four hours I should remove the stockings for a half hour.”
d. “I should put on the stockings before getting out of bed in the morning.”
RATIO 4
1. Answer: (C) Hypertension
Rationale: Hypertension, along with fever, and tenderness over the grafted
kidney, reflects acute rejection.
2. Answer: (A) Pain
Rationale: Sharp, severe pain (renal colic) radiating toward the genitalia and
thigh is caused by uretheral distention and smooth muscle spasm; relief form
pain is the priority.
3. Answer: (D) Decrease the size and vascularity of the thyroid gland.
Rationale: Lugol’s solution provides iodine, which aids in decreasing the
vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery
is performed.
4. Answer: (A) Liver Disease
Rationale: The client with liver disease has a decreased ability to metabolize
carbohydrates because of a decreased ability to form glycogen (glycogenesis)
and to form glucose from glycogen.
5. Answer: (C) Leukopenia
Rationale: Leukopenia, a reduction in WBCs, is a systemic effect of
chemotherapy as a result of myelosuppression.
6. Answer: (C) Avoid foods that in the past caused flatus.
Rationale: Foods that bothered a person preoperatively will continue to do so
after a colostomy.
7. Answer: (B) Keep the irrigating container less than 18 inches above the
stoma.”
Rationale: This height permits the solution to flow slowly with little force so that
excessive peristalsis is not immediately precipitated.
8. Answer: (A) Administer Kayexalate
Rationale: Kayexalate,a potassium exchange resin, permits sodium to be
exchanged for potassium in the intestine, reducing the serum potassium level.
9. Answer:(B) 28 gtt/min
Rationale: This is the correct flow rate; multiply the amount to be infused (2000
ml) by the drop factor (10) and divide the result by the amount of time in minutes
(12 hours x 60 minutes)
10. Answer: (D) Upper trunk
Rationale: The percentage designated for each burned part of the body using the
rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity
9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left
lower extremity 18%; Perineum 1%.
11. Answer: (C) Bleeding from ears
Rationale: The nurse needs to perform a thorough assessment that could
indicate alterations in cerebral function, increased intracranial pressures,
fractures and bleeding. Bleeding from the ears occurs only with basal skull
fractures that can easily contribute to increased intracranial pressure and brain
herniation.
12. Answer: (D) may engage in contact sports
Rationale: The client should be advised by the nurse to avoid contact sports. This
will prevent trauma to the area of the pacemaker generator.
13. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for
breathing.
Rationale: COPD causes a chronic CO2 retention that renders the medulla
insensitive to the CO2 stimulation for breathing. The hypoxic state of the client
then becomes the stimulus for breathing. Giving the client oxygen in low
concentrations will maintain the client’s hypoxic drive.
14. Answer: (B) Facilitate ventilation of the left lung.
Rationale: Since only a partial pneumonectomy is done, there is a need to
promote expansion of this remaining Left lung by positioning the client on the
opposite unoperated side.
15. Answer: (A) Food and fluids will be withheld for at least 2 hours.
Rationale: Prior to bronchoscopy, the doctors sprays the back of the throat with
anesthetic to minimize the gag reflex and thus facilitate the insertion of the
bronchoscope. Giving the client food and drink after the procedure without
checking on the return of the gag reflex can cause the client to aspirate. The gag
reflex usually returns after two hours.
16. Answer: (C) hyperkalemia.
Rationale: Hyperkalemia is a common complication of acute renal failure. It's life-
threatening if immediate action isn't taken to reverse it. The administration of
glucose and regular insulin, with sodium bicarbonate if necessary, can
temporarily prevent cardiac arrest by moving potassium into the cells and
temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and
hypercalcemia don't usually occur with acute renal failure and aren't treated with
glucose, insulin, or sodium bicarbonate.
17. Answer: (A) This condition puts her at a higher risk for cervical cancer;
therefore, she should have a Papanicolaou (Pap) smear annually.
Rationale: Women with condylomata acuminata are at risk for cancer of the
cervix and vulva. Yearly Pap smears are very important for early detection.
Because condylomata acuminata is a virus, there is no permanent cure. Because
condylomata acuminata can occur on the vulva, a condom won't protect sexual
partners. HPV can be transmitted to other parts of the body, such as the mouth,
oropharynx, and larynx.
18. Answer: (A) The left kidney usually is slightly higher than the right one.
Rationale: The left kidney usually is slightly higher than the right one. An adrenal
gland lies atop each kidney. The average kidney measures approximately 11 cm
(4-3/8") long, 5 to 5.8 cm (2" to 2¼") wide, and 2.5 cm (1") thick. The kidneys are
located retroperitoneally, in the posterior aspect of the abdomen, on either side of
the vertebral column. They lie between the 12th thoracic and 3rd lumbar
vertebrae.
19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5
mg/dl.
Rationale: The normal BUN level ranges 8 to 23 mg/dl; the normal serum
creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C are
abnormally elevated, reflecting CRF and the kidneys' decreased ability to remove
nonprotein nitrogen waste from the blood. CRF causes decreased pH and
increased hydrogen ions — not vice versa. CRF also increases serum levels of
potassium, magnesium, and phosphorous, and decreases serum levels of
calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to
7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%.
20. Answer: (D) Alteration in the size, shape, and organization of differentiated
cells
Rationale: Dysplasia refers to an alteration in the size, shape, and organization of
differentiated cells. The presence of completely undifferentiated tumor cells that
don't resemble cells of the tissues of their origin is called anaplasia. An increase
in the number of normal cells in a normal arrangement in a tissue or an organ is
called hyperplasia. Replacement of one type of fully differentiated cell by another
in tissues where the second type normally isn't found is called metaplasia.
21. Answer: (D) Kaposi's sarcoma
Rationale: Kaposi's sarcoma is the most common cancer associated with AIDS.
Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone
and aren't associated specifically with AIDS.
22. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage
Rationale: The client receiving a subarachnoid block requires special positioning
to prevent CSF leakage and headache and to ensure proper anesthetic
distribution. Proper positioning doesn't help prevent confusion, seizures, or
cardiac arrhythmias.
23. Answer: (A) Auscultate bowel sounds.
Rationale: If abdominal distention is accompanied by nausea, the nurse must first
auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect
gastric or small intestine dilation and these findings must be reported to the
physician. Palpation should be avoided postoperatively with abdominal
distention. If peristalsis is absent, changing positions and inserting a rectal tube
won't relieve the client's discomfort.
24. Answer: (B) Lying on the left side with knees bent
Rationale: For a colonoscopy, the nurse initially should position the client on the
left side with knees bent. Placing the client on the right side with legs straight,
prone with the torso elevated, or bent over with hands touching the floor wouldn't
allow proper visualization of the large intestine.
25. Answer: (A) Blood supply to the stoma has been interrupted
Rationale: An ileostomy stoma forms as the ileum is brought through the
abdominal wall to the surface skin, creating an artificial opening for waste
elimination. The stoma should appear cherry red, indicating adequate arterial
perfusion. A dusky stoma suggests decreased perfusion, which may result from
interruption of the stoma's blood supply and may lead to tissue damage or
necrosis. A dusky stoma isn't a normal finding. Adjusting the ostomy bag wouldn't
affect stoma color, which depends on blood supply to the area. An intestinal
obstruction also wouldn't change stoma color.
26. Answer: (A) Applying knee splints
Rationale: Applying knee splints prevents leg contractures by holding the joints in
a position of function. Elevating the foot of the bed can't prevent contractures
because this action doesn't hold the joints in a position of function.
Hyperextending a body part for an extended time is inappropriate because it can
cause contractures. Performing shoulder range-of-motion exercises can prevent
contractures in the shoulders, but not in the legs.
27. Answer: (B) Urine output of 20 ml/hour.
Rationale: A urine output of less than 40 ml/hour in a client with burns indicates a
fluid volume deficit. This client's PaO2 value falls within the normal range (80 to
100 mm Hg). White pulmonary secretions also are normal. The client's rectal
temperature isn't significantly elevated and probably results from the fluid volume
deficit.
28. Answer: (A) Turn him frequently.
Rationale: The most important intervention to prevent pressure ulcers is frequent
position changes, which relieve pressure on the skin and underlying tissues. If
pressure isn't relieved, capillaries become occluded, reducing circulation and
oxygenation of the tissues and resulting in cell death and ulcer formation. During
passive ROM exercises, the nurse moves each joint through its range of
movement, which improves joint mobility and circulation to the affected area but
doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain
healthy skin and ensure tissue repair. A footboard prevents plantar flexion and
footdrop by maintaining the foot in a dorsiflexed position.
29. Answer: (C) In long, even, outward, and downward strokes in the direction of
hair growth
Rationale: When applying a topical agent, the nurse should begin at the midline
and use long, even, outward, and downward strokes in the direction of hair
growth. This application pattern reduces the risk of follicle irritation and skin
inflammation.
30. Answer: (A) Beta -adrenergic blockers
Rationale: Beta-adrenergic blockers work by blocking beta receptors in the
myocardium, reducing the response to catecholamines and sympathetic nerve
stimulation. They protect the myocardium, helping to reduce the risk of another
infraction by decreasing myocardial oxygen demand. Calcium channel blockers
reduce the workload of the heart by
decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote
vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen
consumption bt decreasing left ventricular end diastolic pressure (preload) and
systemic vascular resistance (afterload).
31. Answer: (C) Raised 30 degrees
Rationale: Jugular venous pressure is measured with a centimeter ruler to obtain
the vertical distance between the sternal angle and the point of highest pulsation
with the head of the bed inclined between 15 to 30 degrees. Increased pressure
can’t be seen when the client is supine or when the head of the bed is raised 10
degrees because the point that marks the pressure level is above the jaw
(therefore, not visible). In high Fowler’s position, the veins would be barely
discernible above the clavicle.
32. Answer: (D) Inotropic agents
Rationale: Inotropic agents are administered to increase the force of the heart’s
contractions, thereby increasing ventricular contractility and ultimately increasing
cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease
the heart rate and ultimately decreased the workload of the heart. Diuretics are
administered to decrease the overall vascular volume, also decreasing the
workload of the heart.
33. Answer: (B) Less than 30% of calories form fat
Rationale: A client with low serum HDL and high serum LDL levels should get
less than 30% of daily calories from fat. The other modifications are appropriate
for this client.
34. Answer: (C) The emergency department nurse calls up the latest
electrocardiogram results to check the client’s progress
Rationale: The emergency department nurse is no longer directly involved with
the client’s care and thus has no legal right to information about his present
condition. Anyone directly involved in his care (such as the telemetry nurse and
the on-call physician) has the right to information about his condition. Because
the client requested that the nurse update his wife on his condition, doing so
doesn’t breach confidentiality.
35. Answer: (B) Check endotracheal tube placement.
Rationale: ET tube placement should be confirmed as soon as the client arrives
in the emergency department. Once the airways is secured, oxygenation and
ventilation should be confirmed using an end-tidal carbon dioxide monitor and
pulse oximetry. Next, the nurse should make sure L.V. access is established. If
the client experiences symptomatic bradycardia, atropine is administered as
ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse
should try to find the cause of the client’s arrest by obtaining an ABG sample.
Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation and
atrial flutter – not symptomatic bradycardia.
36. Answer: (C) 95 mm Hg
Rationale: Use the following formula to calculate MAP
MAP = systolic + 2 (diastolic)
3
MAP=126 mm Hg + 2 (80 mm Hg)
3
MAP=286 mm HG
3
MAP=95 mm Hg
37. Answer: (C) Electrocardiogram, complete blood count, testing for occult
blood, comprehensive serum metabolic panel.
Rationale: An electrocardiogram evaluates the complaints of chest pain,
laboratory tests determines anemia, and the stool test for occult blood
determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase
and lactate dehydrogenase levels are appropriate for a cardiac primary problem.
A basic metabolic panel and alkaline phosphatase and aspartate
aminotransferase levels assess liver function. Prothrombin time, partial
thromboplastin time, fibrinogen and fibrin split products are measured to verify
bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity.
38. Answer: (D) Heparin-associated thrombosis and thrombocytopenia (HATT)
Rationale: HATT may occur after CABG surgery due to heparin use during
surgery. Although DIC and ITP cause platelet aggregation and bleeding, neither
is common in a client after revascularization surgery. Pancytopenia is a reduction
in all blood cells.
39. Answer: (B) Corticosteroids
Rationale: Corticosteroid therapy can decrease antibody production and
phagocytosis of the antibody-coated platelets, retaining more functioning
platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used to treat
an excessive anticoagulate state from warfarin overload, and ASA decreases
platelet aggregation.

40. Answer: (D) Xenogeneic
Rationale: An xenogeneic transplant is between is between human and another
species. A syngeneic transplant is between identical twins, allogeneic transplant
is between two humans, and autologous is a transplant from the same individual.
41. Answer: (B)
Rationale: Tissue thromboplastin is released when damaged tissue comes in
contact with clotting factors. Calcium is released to assist the conversion of
factors X to Xa. Conversion of factors XII to XIIa and VIII to VIII a are part of the
intrinsic pathway.
42. Answer: (C) Essential thrombocytopenia
Rationale: Essential thrombocytopenia is linked to immunologic disorders, such
as SLE and human immunodeficiency vitus. The disorder known as von
Willebrand’s disease is a type of hemophilia and isn’t linked to SLE. Moderate to
severe anemia is associated with SLE, not polycythermia. Dressler’s syndrome is
pericarditis that occurs after a myocardial infarction and isn’t linked to SLE.
43. Answer: (B) Night sweat
Rationale: In stage 1, symptoms include a single enlarged lymph node (usually),
unexplained fever, night sweats, malaise, and generalized pruritis. Although
splenomegaly may be present in some clients, night sweats are generally more
prevalent. Pericarditis isn’t associated with Hodgkin’s disease, nor is
hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms.
Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the
disease.
44. Answer: (D) Breath sounds
Rationale: Pneumonia, both viral and fungal, is a common cause of death in
clients with neutropenia, so frequent assessment of respiratory rate and breath
sounds is required. Although assessing blood pressure, bowel sounds, and heart
sounds is important, it won’t help detect pneumonia.
45. Answer: (B) Muscle spasm
Rationale: Back pain or paresthesia in the lower extremities may indicate
impending spinal cord compression from a spinal tumor. This should be
recognized and treated promptly as progression of the tumor may result in
paraplegia. The other options, which reflect parts of the nervous system, aren’t
usually affected by MM.
46. Answer: (C)10 years
Rationale: Epidermiologic studies show the average time from initial contact with
HIV to the development of AIDS is 10 years.
47. Answer: (A) Low platelet count
Rationale: In DIC, platelets and clotting factors are consumed, resulting in
microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease
and the prothrombin time increases. Fibrin degeneration products increase as
fibrinolysis takes places.
48. Answer: (D) Hodgkin’s disease
Rationale: Hodgkin’s disease typically causes fever night sweats, weight loss,
and lymph mode enlargement. Influenza doesn’t last for months. Clients with
sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of
the mucous membrane, fatigue, and decreased tolerance for exercise; they don’t
show fever, night sweats, weight loss or lymph node enlargement. Leukemia
doesn’t cause lymph node enlargement.
49. Answer: (C) A Rh-negative
Rationale: Human blood can sometimes contain an inherited D antigen. Persons
with the D antigen have Rh-positive blood type; those lacking the antigen have
Rh-negative blood. It’s important that a person with Rhnegative blood receives
Rh-negative blood. If Rh-positive blood is administered to an Rh-negative
person, the recipient develops anti-Rh agglutinins, and sub sequent transfusions
with Rh-positive blood may cause serious reactions with clumping and hemolysis
of red blood cells.
50. Answer: (B) “I will call my doctor if Stacy has persistent vomiting and
diarrhea”.
Rationale: Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are
signs of toxicity and the patient should stop the medication and notify the health
care provider. The other manifestations are expected side effects of
chemotherapy.
51. Answer: (D) “This is only temporary; Stacy will re-grow new hair in 3-6
months, but may be different in texture”.
Rationale: This is the appropriate response. The nurse should help the mother
how to cope with her own feelings regarding the child’s disease so as not to
affect the child negatively. When the hair grows back, it is still of the same color
and texture.
52. Answer: (B) Apply viscous Lidocaine to oral ulcers as needed.
Rationale: Stomatitis can cause pain and this can be relieved by applying topical
anesthetics such as lidocaine before mouth care. When the patient is already
comfortable, the nurse can proceed with providing the patient with oral rinses of
saline solution mixed with equal part of water or hydrogen peroxide mixed water
in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.
53. Answer: (C) Immediately discontinue the infusion
Rationale: Edema or swelling at the IV site is a sign that the needle has been
dislodged and the IV solution is leaking into the tissues causing the edema. The
patient feels pain as the nerves are irritated by pressure and the IV solution. The
first action of the nurse would be to discontinue the infusion right away to prevent
further edema and other complication.
54. Answer: (C) Chronic obstructive bronchitis
Rationale: Clients with chronic obstructive bronchitis appear bloated; they have
large barrel chest and peripheral edema, cyanotic nail beds, and at times,
circumoral cyanosis. Clients with ARDS are acutely short of breath and
frequently need intubation for mechanical ventilation and large amount of
oxygen. Clients with asthma don’t exhibit characteristics of chronic disease, and
clients with emphysema appear pink and cachectic.
55. Answer: (D) Emphysema
Rationale: Because of the large amount of energy it takes to breathe, clients with
emphysema are usually cachectic. They’re pink and usually breathe through
pursed lips, hence the term “puffer.” Clients with ARDS are usually acutely short
of breath. Clients with asthma don’t have any particular characteristics, and
clients with chronic obstructive bronchitis are bloated and cyanotic in
appearance.
56. Answer: D 80 mm Hg
Rationale: A client about to go into respiratory arrest will have inefficient
ventilation and will be retaining carbon dioxide. The value expected would be
around 80 mm Hg. All other values are lower than expected.
57. Answer: (C) Respiratory acidosis
Rationale: Because Paco2 is high at 80 mm Hg and the metabolic measure,
HCO3- is normal, the client has respiratory acidosis. The pH is less than 7.35,
academic, which eliminates metabolic and respiratory alkalosis as possibilities. If
the HCO3- was below 22 mEq/L the client would have metabolic acidosis.
58. Answer: (C) Respiratory failure
Rationale: The client was reacting to the drug with respiratory signs of impending
anaphylaxis, which could lead to eventually respiratory failure. Although the signs
are also related to an asthma attack or a pulmonary embolism, consider the new
drug first. Rheumatoid arthritis doesn’t manifest these signs.
59. Answer: (D) Elevated serum aminotransferase
Rationale: Hepatic cell death causes release of liver enzymes alanine
aminotransferase (ALT), aspartate aminotransferase (AST) and lactate
dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and
irreversible disease of the liver characterized by generalized inflammation and
fibrosis of the liver tissues.
60. Answer: (A) Impaired clotting mechanism
Rationale: Cirrhosis of the liver results in decreased Vitamin K absorption and
formation of clotting factors resulting in impaired clotting mechanism.
61. Answer: (B) Altered level of consciousness
Rationale: Changes in behavior and level of consciousness are the first sins of
hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and
develops when the liver is unable to convert protein metabolic product ammonia
to urea. This results in accumulation of ammonia and other toxic in the blood that
damages the cells.
62. Answer: (C) “I’ll lower the dosage as ordered so the drug causes only 2 to 4
stools a day”.
Rationale: Lactulose is given to a patients with hepatic encephalopathy to reduce
absorption of ammonia in the intestines by binding with ammonia and promoting
more frequent bowel movements. If the patient experience diarrhea, it indicates
over dosage and the nurse must reduce the amount of medication given to the
patient. The stool will be mashy or soft. Lactulose is also very sweet and may
cause cramping and bloating.
63. Answer: (B) Severe lower back pain, decreased blood pressure, decreased
RBC count, increased WBC count.
Rationale: Severe lower back pain indicates an aneurysm rupture, secondary to
pressure being applied within the abdominal cavity. When ruptured occurs, the
pain is constant because it can’t be alleviated until the aneurysm is repaired.
Blood pressure decreases due to the loss of blood. After the aneurysm ruptures,
the vasculature is interrupted and blood volume is lost, so blood pressure
wouldn’t increase. For the same reason, the RBC count is decreased – not
increased. The WBC count increases as cell migrate to the site of injury.
64. Answer: (D) Apply gloves and assess the groin site
Rationale: Observing standard precautions is the first priority when dealing with
any blood fluid. Assessment of the groin site is the second priority. This
establishes where the blood is coming from and determineshow much blood has
been lost. The goal in this situation is to stop the bleeding. The nurse would call
for help if it were warranted after the
assessment of the situation. After determining the extent of the bleeding, vital
signs assessment is important. The nurse should never move the client, in case
a clot has formed. Moving can disturb the clot and cause rebleeding.
65. Answer: (D) Percutaneous transluminal coronary angioplasty (PTCA)
Rationale: PTCA can alleviate the blockage and restore blood flow and
oxygenation. An echocardiogram is a noninvasive diagnosis test. Nitroglycerin is
an oral sublingual medication. Cardiac catheterization is a diagnostic tool – not a
treatment.
66. Answer: (B) Cardiogenic shock
Rationale: Cardiogenic shock is shock related to ineffective pumping of the heart.
Anaphylactic shock results from an allergic reaction. Distributive shock results
from changes in the intravascular volume distribution and is usually associated
with increased cardiac output. MI isn’t a shock state, though a severe MI can
lead to shock.
67. Answer: (C) Kidneys’ excretion of sodium and water
Rationale: The kidneys respond to rise in blood pressure by excreting sodium
and excess water. This response ultimately affects sysmolic blood pressure by
regulating blood volume. Sodium or water retention would only further increase
blood pressure. Sodium and water travel together across the membrane in the
kidneys; one can’t travel without the other.
68. Answer: (D) It inhibits reabsorption of sodium and water in the loop of Henle.
Rationale: Furosemide is a loop diuretic that inhibits sodium and water
reabsorption in the loop Henle, thereby causing a decrease in blood pressure.
Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular
smooth muscle and decreasing blood pressure. Adrenergic blockers decrease
sympathetic cardioacceleration and decrease blood pressure. Angiotensin-
converting enzyme inhibitors decrease blood pressure due to their action on
angiotensin.
69. Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA) titer
Rationale: Laboratory findings for clients with SLE usually show pancytopenia,
elevated ANA titer, and decreased serum complement levels. Clients may have
elevated BUN and creatinine levels from nephritis, but the increase does not
indicate SLE.
70. Answer: (C) Narcotics are avoided after a head injury because they may hide
a worsening condition.
Rationale: Narcotics may mask changes in the level of consciousness that
indicate increased ICP and shouldn’t acetaminophen is strong enough ignores
the mother’s question and therefore isn’t appropriate. Aspirin is contraindicated in
conditions that may have bleeding, such as trauma, and for children or young
adults with viral illnesses due to the danger of Reye’s syndrome. Stronger
medications may not necessarily lead to vomiting but will sedate the client,
thereby masking changes in his level of consciousness.
71. Answer: (A) Appropriate; lowering carbon dioxide (CO2) reduces intracranial
pressure (ICP)
Rationale: A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating
properties; therefore, lowering Paco2 through hyperventilation will lower ICP
caused by dilated cerebral vessels. Oxygenation is evaluated through Pao2 and
oxygen saturation. Alveolar hypoventilation would be reflected in an increased
Paco2.
72. Answer: (B) A 33-year-old client with a recent diagnosis of Guillain-Barre
syndrome
Rationale: Guillain-Barre syndrome is characterized by ascending paralysis and
potential respiratory failure. The order of client assessment should follow client
priorities, with disorder of airways, breathing, and then circulation. There’s no
information to suggest the postmyocardial infarction client has an arrhythmia or
other complication. There’s no evidence to suggest hemorrhage or perforation for
the remaining clients as a priority of care.
73. Answer: (C) Decreases inflammation
Rationale: Then action of colchicines is to decrease inflammation by reducing the
migration of leukocytes to synovial fluid. Colchicine doesn’t replace estrogen,
decrease infection, or decrease bone demineralization.
74. Answer: (C) Osteoarthritis is the most common form of arthritis
Rationale: Osteoarthritis is the most common form of arthritis and can be
extremely debilitating. It can afflict people of any age, although most are elderly.
75. Answer: (C) Myxedema coma
Rationale: Myxedema coma, severe hypothyroidism, is a life-threatening
condition that may develop if thyroid replacement medication isn't taken.
Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid
storm is life-threatening but is caused by severe hyperthyroidism. Tibial
myxedema, peripheral mucinous edema involving the lower leg, is associated
with hypothyroidism but isn't life-threatening.
76. Answer: (B) An irregular apical pulse
Rationale: Because Cushing's syndrome causes aldosterone overproduction,
which increases urinary potassium loss, the disorder may lead to hypokalemia.
Therefore, the nurse should immediately report signs and symptoms of
hypokalemia, such as an irregular apical pulse, to the physician. Edema is an
expected finding because aldosterone overproduction causes sodium and fluid
retention. Dry mucous membranes and frequent urination signal dehydration,
which isn't associated with Cushing's syndrome.
77. Answer: (D) Below-normal urine osmolality level, above-normal serum
osmolality level
Rationale: In diabetes insipidus, excessive polyuria causes dilute urine, resulting
in a below-normal urine osmolality level. At the same time, polyuria depletes the
body of water, causing dehydration that leads to an above-normal serum
osmolality level. For the same reasons, diabetes insipidus doesn't cause above-
normal urine osmolality or below-normal serum osmolality levels.
78. Answer: (A) "I can avoid getting sick by not becoming dehydrated and by
paying attention to my need to urinate, drink, or eat more than usual."
Rationale: Inadequate fluid intake during hyperglycemic episodes often leads to
HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and
polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a
glass of nondiet soda would be appropriate for hypoglycemia. A client whose
diabetes is controlled with oral antidiabetic agents usually doesn't need to
monitor blood glucose levels. A highcarbohydrate diet would exacerbate the
client's condition, particularly if fluid intake is low.
79. Answer: (D) Hyperparathyroidism
Rationale: Hyperparathyroidism is most common in older women and is
characterized by bone pain and weakness from excess parathyroid hormone
(PTH). Clients also exhibit hypercaliuria-causing polyuria. While clients with
diabetes mellitus and diabetes insipidus also have polyuria, they don't have bone
pain and increased sleeping. Hypoparathyroidism is characterized by urinary
frequency rather than polyuria.
80. Answer: (C) "I'll take two-thirds of the dose when I wake up and one-third in
the late afternoon."
Rationale: Hydrocortisone, a glucocorticoid, should be administered according to
a schedule that closely reflects the body's own secretion of this hormone;
therefore, two-thirds of the dose of hydrocortisone should be taken in the
morning and one-third in the late afternoon. This dosage schedule reduces
adverse effects.
81. Answer: (C) High corticotropin and high cortisol levels
Rationale: A corticotropin-secreting pituitary tumor would cause high corticotropin
and high cortisol levels. A high corticotropin level with a low cortisol level and a
low corticotropin level with a low cortisol level would be associated with
hypocortisolism. Low corticotropin and high cortisol levels would be seen if there
was a primary defect in the adrenal glands.
82. Answer: (D) Performing capillary glucose testing every 4 hours
Rationale: The nurse should perform capillary glucose testing every 4 hours
because excess cortisol may cause insulin resistance, placing the client at risk
for hyperglycemia. Urine ketone testing isn't indicated because the client does
secrete insulin and, therefore, isn't at risk for ketosis. Urine specific gravity isn't
indicated because although fluid balance can be compromised, it usually isn't
dangerously imbalanced. Temperature regulation may be affected by excess
cortisol and isn't an accurate indicator of infection.
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Rationale: Regular insulin, which is a short-acting insulin, has an onset of 15 to
30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2
p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from
4 p.m. to 6 p.m.
84. Answer: (A) No increase in the thyroid-stimulating hormone (TSH) level after
30 minutes during the TSH stimulation test
Rationale: In the TSH test, failure of the TSH level to rise after 30 minutes
confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency
of this hormone. Below-normal levels of T3 and T4, as detected by
radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs
in malnutrition and liver disease and may result from administration of phenytoin
and certain other drugs.
85. Answer: (B) "Rotate injection sites within the same anatomic region, not
among different regions."
Rationale: The nurse should instruct the client to rotate injection sites within the
same anatomic region. Rotating sites among different regions may cause
excessive day-to-day variations in the blood glucose level; also, insulin
absorption differs from one region to the next. Insulin should be injected only into
healthy tissue lacking large blood vessels, nerves, or scar tissue or other
deviations. Injecting insulin into areas of hypertrophy may delay absorption. The
client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or
atrophy); to prevent lipodystrophy, the client should rotate injection sites
systematically. Exercise speeds drug absorption, so the client shouldn't inject
insulin into sites above muscles that will be exercised heavily.
86. Answer: (D) Below-normal serum potassium level
Rationale: A client with HHNS has an overall body deficit of potassium resulting
from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state
caused by the relative insulin deficiency. An elevated serum acetone level and
serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic
acidosis, not serum alkalosis, may occur in HHNS.
87. Answer: (D) Maintaining room temperature in the low-normal range
Rationale: Graves' disease causes signs and symptoms of hypermetabolism,
such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight
loss. To reduce heat intolerance and diaphoresis, the nurse should keep the
client's room temperature in the low-normal range. To replace fluids lost via
diaphoresis, the nurse should encourage, not restrict, intake of oral fluids.
Placing extra blankets on the bed of a client with heat intolerance would cause
discomfort. To provide needed energy and calories, the nurse should encourage
the client to eat high-carbohydrate foods.
88. Answer: (A) Fracture of the distal radius
Rationale: Colles' fracture is a fracture of the distal radius, such as from a fall on
an outstretched hand. It's most common in women. Colles' fracture doesn't refer
to a fracture of the olecranon, humerus, or carpal scaphoid.
89. Answer: (B) Calcium and phosphorous
Rationale: In osteoporosis, bones lose calcium and phosphate salts, becoming
porous, brittle, and abnormally vulnerable to fracture. Sodium and potassium
aren't involved in the development of osteoporosis.
90. Answer: (A) Adult respiratory distress syndrome (ARDS)
Rationale: Severe hypoxia after smoke inhalation is typically related to ARDS.
The other conditions listed aren’t typically associated with smoke inhalation and
severe hypoxia.
91. Answer: (D) Fat embolism
Rationale: Long bone fractures are correlated with fat emboli, whichcause
shortness of breath and hypoxia. It’s unlikely the client has developed asthma or
bronchitis without a previous history. He could develop atelectasis but it typically
doesn’t produce progressive hypoxia.
92. Answer: (D) Spontaneous pneumothorax
Rationale: A spontaneous pneumothorax occurs when the client’s lung collapses,
causing an acute decreased in the amount of functional lung used in
oxygenation. The sudden collapse was the cause of his chest pain and shortness
of breath. An asthma attack would show wheezing breath sounds, and bronchitis
would have rhonchi. Pneumonia would have bronchial breath sounds over the
area of consolidation.
93. Answer: (C) Pneumothorax
Rationale: From the trauma the client experienced, it’s unlikely he has bronchitis,
pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB
would be heard.
94. Answer: (C) Serous fluids fills the space and consolidates the region
Rationale: Serous fluid fills the space and eventually consolidates, preventing
extensive mediastinal shift of the heart and remaining lung. Air can’t be left in the
space. There’s no gel that can be placed in the pleural space. The tissue from
the other lung can’t cross the mediastinum, although a temporary mediastinal
shift exits until the space is filled.
95. Answer: (A) Alveolar damage in the infracted area
Rationale: The infracted area produces alveolar damage that can lead to the
production of bloody sputum, sometimes in massive amounts. Clot formation
usually occurs in the legs. There’s a loss of lung parenchyma and subsequent
scar tissue formation.
96. Answer: (D) Respiratory alkalosis
Rationale: A client with massive pulmonary embolism will have a large region
and blow off large amount of carbon dioxide, which crosses the unaffected
alveolar-capillary membrane more readily than does oxygen and results in
respiratory alkalosis.
97. Answer: (A) Air leak
Rationale: Bubbling in the water seal chamber of a chest drainage system stems
from an air leak. In pneumothorax an air leak can occur as air is pulled from the
pleural space. Bubbling doesn’t normally occur with either adequate or
inadequate suction or any preexisting bubbling in the water seal chamber.
98. Answer: (B) 21
Rationale: 3000 x 10 divided by 24 x 60.
99. Answer: (B) 2.4 ml
Rationale: .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.
100. Answer: (D) “I should put on the stockings before getting out of bed in the
morning.
Rationale: Promote venous return by applying external pressure on veins.
NP5-MS/PSYCH
1. Mr. Marquez reports of losing his job, not being able to sleep at night, and
feeling upset with his wife. Nurse John responds to the client, “You may want to
talk about your employment situation in group today.” The Nurse is using which
therapeutic technique?
a. Observations b. Restating c. Exploring d. Focusing
2. Tony refuses his evening dose of Haloperidol (Haldol), then becomes
extremely agitated in the dayroom while other clients are watching television. He
begins cursing and throwing furniture. Nurse Oliver first action is to:
a. Check the client’s medical record for an order for an as-needed I.M. dose of
medication for agitation.
b. Place the client in full leather restraints.
c. Call the attending physician and report the behavior.
d. Remove all other clients from the dayroom.
3. Tina who is manic, but not yet on medication, comes to the drug treatment
center. The nurse would not let this client join the group session because:
a. The client is disruptive. b. The client is harmful to self.
c. The client is harmful to others d. The client needs to be on medication first.
4. Dervid, an adolescent boy was admitted for substance abuse and
hallucinations. The client’s mother asks Nurse Armando to talk with his husband
when he arrives at the hospital. The mother says that she is afraid of what the
father might say to the boy. The most appropriate nursing intervention would be
to:
a. Inform the mother that she and the father can work through this problem
themselves.
b. Refer the mother to the hospital social worker.
c. Agree to talk with the mother and the father together.
d. Suggest that the father and son work things out.
5. What is Nurse John likely to note in a male client being admitted for alcohol
withdrawal?
a. Perceptual disorders. b. Impending coma.
c. Recent alcohol intake. d. Depression with mutism.
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it
“doesn’t help” and refuses to take it. What should the nurse say or do?
a. Withhold the drug.
b. Record the client’s response.
c. Encourage the client to tell the doctor.
d. Suggest that it takes awhile before seeing the results.
7. Dervid, an adolescent has a history of truancy from school, running away from
home and “barrowing” other people’s things without their permission. The
adolescent denies stealing, rationalizing instead that as long as no one was
using the items, it was all right to borrow them. It is important for the nurse to
understand the psychodynamically, this behavior may be largely attributed to a
developmental defect related to the:
a. Id b. Ego c. Superego d. Oedipal complex
8. In preparing a female client for electroconvulsive therapy (ECT), Nurse
Michelle knows that succinylcoline (Anectine) will be administered for which
therapeutic effect?
a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
d. Analgesia.
9. Nurse Gina is aware that the dietary implications for a client in manic phase of
bipolar disorder is:
a. Serve the client a bowl of soup, buttered French bread, and apple slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.
10.What parental behavior toward a child during an admission procedure should
cause Nurse Ron to suspect child abuse?
a. Flat affect b. Expressing guilt
c. Acting overly solicitous toward the child. d. Ignoring the child.
11.Nurse Lynnette notices that a female client with obsessive-compulsive
disorder washes her hands for long periods each day. How should the nurse
respond to this compulsive behavior?
a. By designating times during which the client can focus on the behavior.
b. By urging the client to reduce the frequency of the behavior as rapidly as
possible.
c. By calling attention to or attempting to prevent the behavior.
d. By discouraging the client from verbalizing anxieties.
12.After seeking help at an outpatient mental health clinic, Ruby who was raped
while walking her dog is diagnosed with posttraumatic stress disorder (PTSD).
Three months later, Ruby returns to the clinic, complaining of fear, loss of control,
and helpless feelings. Which nursing intervention is most appropriate for Ruby?
a. Recommending a high-protein, low-fat diet.
b. Giving sleep medication, as prescribed, to restore a normal sleepwake cycle.
c. Allowing the client time to heal.
d. Exploring the meaning of the traumatic event with the client.
13.Meryl, age 19, is highly dependent on her parents and fears leaving home to
go away to college. Shortly before the semester starts, she complains that her
legs are paralyzed and is rushed to the emergency department. When physical
examination rules out a physical cause for her paralysis, the physician admits her
to the psychiatric unit where she is diagnosed with conversion disorder. Meryl
asks the nurse, "Why has this happened to me?" What is the nurse's best
response?
a. "You've developed this paralysis so you can stay with your parents. You must
deal with this conflict if you want to walk again."
b. "It must be awful not to be able to move your legs. You may feel better if you
realize the problem is psychological, not physical."
c. "Your problem is real but there is no physical basis for it. We'll work on what is
going on in your life to find out why it's happened."
d. "It isn't uncommon for someone with your personality to develop a conversion
disorder during times of stress."
14.Nurse Krina knows that the following drugs have been known to be effective
in treating obsessive-compulsive disorder (OCD):
a. benztropine (Cogentin) and diphenhydramine (Benadryl).
b. chlordiazepoxide (Librium) and diazepam (Valium)
c. fluvoxamine (Luvox) and clomipramine (Anafranil)
d. divalproex (Depakote) and lithium (Lithobid)
15.Alfred was newly diagnosed with anxiety disorder. The physician prescribed
buspirone (BuSpar). The nurse is aware that the teaching instructions for newly
prescribed buspirone should include which of the following?
a. A warning about the drugs delayed therapeutic effect, which is from 14 to 30
days.
b. A warning about the incidence of neuroleptic malignant syndrome (NMS).
c. A reminder of the need to schedule blood work in 1 week to check blood levels
of the drug.
d. A warning that immediate sedation can occur with a resultant drop in pulse.
16.Richard with agoraphobia has been symptom-free for 4 months. Classic signs
and symptoms of phobias include:
a. Insomnia and an inability to concentrate.
b. Severe anxiety and fear.
c. Depression and weight loss.
d. Withdrawal and failure to distinguish reality from fantasy.
17.Which medications have been found to help reduce or eliminate panic
attacks?
a. Antidepressants b. Anticholinergics c. Antipsychotics d. Mood stabilizers
18.A client seeks care because she feels depressed and has gained weight. To
treat her atypical depression, the physician prescribes tranylcypromine sulfate
(Parnate), 10 mg by mouth twice per day. When this drug is used to treat atypical
depression, what is its onset of action?
a. 1 to 2 days b. 3 to 5 days c. 6 to 8 days d. 10 to 14 days
19. A 65 years old client is in the first stage of Alzheimer's disease. Nurse
Patricia should plan to focus this client's care on:
a. Offering nourishing finger foods to help maintain the client's nutritional status.
b. Providing emotional support and individual counseling.
c. Monitoring the client to prevent minor illnesses from turning into major
problems.
d. Suggesting new activities for the client and family to do together.
20.The nurse is assessing a client who has just been admitted to the emergency
department. Which signs would suggest an overdose of an antianxiety agent?
a. Combativeness, sweating, and confusion
b. Agitation, hyperactivity, and grandiose ideation
c. Emotional lability, euphoria, and impaired memory
d. Suspiciousness, dilated pupils, and increased blood pressure
21.The nurse is caring for a client diagnosed with antisocial personality disorder.
The client has a history of fighting, cruelty to animals, and stealing. Which of the
following traits would the nurse be most likely to uncover during assessment?
a. History of gainful employment
b. Frequent expression of guilt regarding antisocial behavior
c. Demonstrated ability to maintain close, stable relationships
d. A low tolerance for frustration
22.Nurse Amy is providing care for a male client undergoing opiate withdrawal.
Opiate withdrawal causes severe physical discomfort and can be life-threatening.
To minimize these effects, opiate users are commonly detoxified with:
a. Barbiturates b. Amphetamines c. Methadone d. Benzodiazepines
23.Nurse Cristina is caring for a client who experiences false sensory
perceptions with no basis in reality. These perceptions are known as:
a. Delusions b. Hallucinations c. Loose associations d. Neologisms
24. Nurse Marco is developing a plan of care for a client with anorexia nervosa.
Which action should the nurse include in the plan?
a. Restricts visits with the family and friends until the client begins to eat.
b. Provide privacy during meals.
c. Set up a strict eating plan for the client.
d. Encourage the client to exercise, which will reduce her anxiety.
25.Tim is admitted with a diagnosis of delusions of grandeur. The nurse is aware
that this diagnosis reflects a belief that one is:
a. Highly important or famous.
b. Being persecuted
c. Connected to events unrelated to oneself
d. Responsible for the evil in the world.
26.Nurse Jen is caring for a male client with manic depression. The plan of care
for a client in a manic state would include:
a. Offering a high-calorie meals and strongly encouraging the client to finish all
food.
b. Insisting that the client remain active through the day so that he’ll sleep at
night.
c. Allowing the client to exhibit hyperactive, demanding, manipulative behavior
without setting limits.
d. Listening attentively with a neutral attitude and avoiding power struggles.
27.Ramon is admitted for detoxification after a cocaine overdose. The client tells
the nurse that he frequently uses cocaine but that he can control his use if he
chooses. Which coping mechanism is he using?
a. Withdrawal b. Logical thinking c. Repression d. Denial
28.Richard is admitted with a diagnosis of schizotypal personality disorder.
Which signs would this client exhibit during social situations?
a. Aggressive behavior b. Paranoid thoughts
c. Emotional affect d. Independence needs
29. Nurse Mickey is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is to:
a. Avoid shopping for large amounts of food.
b. Control eating impulses.
c. Identify anxiety-causing situations
d. Eat only three meals per day.
30.Rudolf is admitted for an overdose of amphetamines. When assessing the
client, the nurse should expect to see:
a. Tension and irritability b. Slow pulse c. Hypotension d. Constipation
31.Nicolas is experiencing hallucinations tells the nurse, “The voices are telling
me I’m no good.” The client asks if the nurse hears the voices. The most
appropriate response by the nurse would be:
a. “It is the voice of your conscience, which only you can control.”
b. “No, I do not hear your voices, but I believe you can hear them”.
c. “The voices are coming from within you and only you can hear them.”
d. “Oh, the voices are a symptom of your illness; don’t pay any attention to them.”
32.The nurse is aware that the side effect of electroconvulsive therapy that a
client may experience:
a. Loss of appetite b. Postural hypotension
c. Confusion for a time after treatment d. Complete loss of memory for a time
33.A dying male client gradually moves toward resolution of feelings regarding
impending death. Basing care on the theory of Kubler-Ross, Nurse Trish plans to
use nonverbal interventions when assessment reveals that the client is in the:
a. Anger stage b. Denial stage c. Bargaining stage d. Acceptance stage
34.The outcome that is unrelated to a crisis state is:
a. Learning more constructive coping skills
b. Decompensation to a lower level of functioning.
c. Adaptation and a return to a prior level of functioning.
d. A higher level of anxiety continuing for more than 3 months.
35.Miranda a psychiatric client is to be discharged with orders for haloperidol
(haldol) therapy. When developing a teaching plan for discharge, the nurse
should include cautioning the client against:
a. Driving at night b. Staying in the sun
c. Ingesting wines and cheeses d. Taking medications containing aspirin
36.Jen a nursing student is anxious about the upcoming board examination but is
able to study intently and does not become distracted by a roommate’s talking
and loud music. The student’s ability to ignore distractions and to focus on
studying demonstrates:
a. Mild-level anxiety b. Panic-level anxiety
c. Severe-level anxiety d. Moderate-level anxiety
37.When assessing a premorbid personality characteristics of a client with a
major depression, it would be unusual for the nurse to find that this client
demonstrated:
a. Rigidity b. Stubbornness c. Diverse interest d. Over meticulousness
38.Nurse Krina recognizes that the suicidal risk for depressed client is greatest:
a. As their depression begins to improve
b. When their depression is most severe
c. Before nay type of treatment is started
d. As they lose interest in the environment
39.Nurse Kate would expect that a client with vascular dementis would
experience:
a. Loss of remote memory related to anoxia
b. Loss of abstract thinking related to emotional state
c. Inability to concentrate related to decreased stimuli
d. Disturbance in recalling recent events related to cerebral hypoxia.
40.Josefina is to be discharged on a regimen of lithium carbonate. In the
teaching plan for discharge the nurse should include:
a. Advising the client to watch the diet carefully
b. Suggesting that the client take the pills with milk
c. Reminding the client that a CBC must be done once a month.
d. Encouraging the client to have blood levels checked as ordered.
41.The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female client.
Nurse Katrina would be aware that the teaching about the side effects of this
drug were understood when the client state, “I will call my doctor immediately if I
notice any:
a. Sensitivity to bright light or sun
b. Fine hand tremors or slurred speech
c. Sexual dysfunction or breast enlargement
d. Inability to urinate or difficulty when urinating
42.Nurse Mylene recognizes that the most important factor necessary for the
establishment of trust in a critical care area is:
a. Privacy b. Respect c. Empathy d. Presence
43.When establishing an initial nurse-client relationship, Nurse Hazel should
explore with the client the:
a. Client’s perception of the presenting problem.
b. Occurrence of fantasies the client may experience.
c. Details of any ritualistic acts carried out by the client
d. Client’s feelings when external; controls are instituted.
44.Tranylcypromine sulfate (Parnate) is prescribed for a depressed client who
has not responded to the tricyclic antidepressants. After teaching the client about
the medication, Nurse Marian evaluates that learning has occurred when the
client states, “I will avoid:
a. Citrus fruit, tuna, and yellow vegetables.”
b. Chocolate milk, aged cheese, and yogurt’”
c. Green leafy vegetables, chicken, and milk.”
d. Whole grains, red meats, and carbonated soda.”
45.Nurse John is a aware that most crisis situations should resolve in about:
a. 1 to 2 weeks b. 4 to 6 weeks c. 4 to 6 months d. 6 to 12 months
46. Nurse Judy knows that statistics show that in adolescent suicide behavior:
a. Females use more dramatic methods than males
b. Males account for more attempts than do females
c. Females talk more about suicide before attempting it
d. Males are more likely to use lethal methods than are females
47. Dervid with paranoid schizophrenia repeatedly uses profanity during an
activity therapy session. Which response by the nurse would be most
appropriate?
a. "Your behavior won't be tolerated. Go to your room immediately."
b. "You're just doing this to get back at me for making you come to therapy."
c. "Your cursing is interrupting the activity. Take time out in your room for 10
minutes."
d. "I'm disappointed in you. You can't control yourself even for a few minutes."
48.Nurse Maureen knows that the nonantipsychotic medication used to treat
some clients with schizoaffective disorder is:
a. phenelzine (Nardil) b. chlordiazepoxide (Librium)
c. lithium carbonate (Lithane) d. imipramine (Tofranil)
49.Which information is most important for the nurse Trinity to include in a
teaching plan for a male schizophrenic client taking clozapine (Clozaril)?
a. Monthly blood tests will be necessary.
b. Report a sore throat or fever to the physician immediately.
c. Blood pressure must be monitored for hypertension.
d. Stop the medication when symptoms subside.
50.Ricky with chronic schizophrenia takes neuroleptic medication is admitted to
the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and
diaphoresis. These findings suggest which lifethreatening reaction:
a. Tardive dyskinesia. b. Dystonia.
c. Neuroleptic malignant syndrome. d. Akathisia.
51.Which nursing intervention would be most appropriate if a male client develop
orthostatic hypotension while taking amitriptyline (Elavil)?
a. Consulting with the physician about substituting a different type of
antidepressant.
b. Advising the client to sit up for 1 minute before getting out of bed.
c. Instructing the client to double the dosage until the problem resolves.
d. Informing the client that this adverse reaction should disappear within 1 week.
52.Mr. Cruz visits the physician's office to seek treatment for depression, feelings
of hopelessness, poor appetite, insomnia, fatigue, low selfesteem, poor
concentration, and difficulty making decisions. The client states that these
symptoms began at least 2 years ago. Based on this report, the nurse Tyfany
suspects:
a. Cyclothymic disorder. b. Atypical affective disorder.
c. Major depression. d. Dysthymic disorder.
53. After taking an overdose of phenobarbital (Barbita), Mario is admitted to the
emergency department. Dr. Trinidad prescribes activated charcoal (Charcocaps)
to be administered by mouth immediately. Before administering the dose, the
nurse verifies the dosage ordered. What is the usual minimum dose of activated
charcoal?
a. 5 g mixed in 250 ml of water b. 15 g mixed in 500 ml of water
c. 30 g mixed in 250 ml of water d. 60 g mixed in 500 ml of water
54.What herbal medication for depression, widely used in Europe, is now being
prescribed in the United States?
a. Ginkgo biloba b. Echinacea c. St. John's wort d. Ephedra
55.Cely with manic episodes is taking lithium. Which electrolyte level should the
nurse check before administering this medication?
a. Calcium b. Sodium c. Chloride d. Potassium
56.Nurse Josefina is caring for a client who has been diagnosed with delirium.
Which statement about delirium is true?
a. It's characterized by an acute onset and lasts about 1 month.
b. It's characterized by a slowly evolving onset and lasts about 1 week.
c. It's characterized by a slowly evolving onset and lasts about 1 month.
d. It's characterized by an acute onset and lasts hours to a number of days.
57.Edward, a 66 year old client with slight memory impairment and poor
concentration is diagnosed with primary degenerative dementia of the
Alzheimer's type. Early signs of this dementia include subtle personality changes
and withdrawal from social interactions. To assess for progression to the middle
stage of Alzheimer's disease, the nurse should observe the client for:
a. Occasional irritable outbursts. b. Impaired communication.
c. Lack of spontaneity. d. Inability to perform self-care activities.
58.Isabel with a diagnosis of depression is started on imipramine (Tofranil), 75
mg by mouth at bedtime. The nurse should tell the client that:
a. This medication may be habit forming and will be discontinued as soon as the
client feels better.
b. This medication has no serious adverse effects.
c. The client should avoid eating such foods as aged cheeses, yogurt, and
chicken livers while taking the medication.
d. This medication may initially cause tiredness, which should become less
bothersome over time.
59.Kathleen is admitted to the psychiatric clinic for treatment of anorexia
nervosa. To promote the client's physical health, the nurse should plan to:
a. Severely restrict the client's physical activities.
b. Weigh the client daily, after the evening meal.
c. Monitor vital signs, serum electrolyte levels, and acid-base balance.
d. Instruct the client to keep an accurate record of food and fluid intake.
60.Celia with a history of polysubstance abuse is admitted to the facility. She
complains of nausea and vomiting 24 hours after admission. The nurse assesses
the client and notes piloerection, pupillary dilation, and lacrimation. The nurse
suspects that the client is going through which of the following withdrawals?
a. Alcohol withdrawal b. Cannibis withdrawal
c. Cocaine withdrawal d. Opioid withdrawal
61.Mr. Garcia, an attorney who throws books and furniture around the office after
losing a case is referred to the psychiatric nurse in the law firm's employee
assistance program. Nurse Beatriz knows that the client's behavior most likely
represents the use of which defense mechanism?
a. Regression b. Projection c. Reaction-formation d. Intellectualization
62.Nurse Anne is caring for a client who has been treated long term with
antipsychotic medication. During the assessment, Nurse Anne checks the client
for tardive dyskinesia. If tardive dyskinesia is present, Nurse Anne would most
likely observe:
a. Abnormal movements and involuntary movements of the mouth, tongue, and
face.
b. Abnormal breathing through the nostrils accompanied by a “thrill.”
c. Severe headache, flushing, tremors, and ataxia.
d. Severe hypertension, migraine headache,
63.Dennis has a lithium level of 2.4 mEq/L. The nurse immediately would assess
the client for which of the following signs or symptoms?
a. Weakness b. Diarrhea c. Blurred vision d. Fecal incontinence
64.Nurse Jannah is monitoring a male client who has been placed inrestraints
because of violent behavior. Nurse determines that it will be safe to remove the
restraints when:
a. The client verbalizes the reasons for the violent behavior.
b. The client apologizes and tells the nurse that it will never happen again.
c. No acts of aggression have been observed within 1 hour after the release of
two of the extremity restraints.
d. The administered medication has taken effect.
65.Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD.
The side effects of the following may be noted by the nurse:
a. Increased attention span and concentration
b. Increase in appetite
c. Sleepiness and lethargy
d. Bradycardia and diarrhea
66.Kitty, a 9 year old child has very limited vocabulary and interaction skills. She
has an I.Q. of 45. She is diagnosed to have Mental retardation of this
classification:
a. Profound b. Mild c. Moderate d. Severe
67.The therapeutic approach in the care of Armand an autistic child include the
following EXCEPT:
a. Engage in diversionary activities when acting -out
b. Provide an atmosphere of acceptance
c. Provide safety measures
d. Rearrange the environment to activate the child
68.Jeremy is brought to the emergency room by friends who state that he took
something an hour ago. He is actively hallucinating, agitated, with irritated nasal
septum.
a. Heroin b. Cocaine c. LSD d. Marijuana
69.Nurse Pauline is aware that Dementia unlike delirium is characterized by:
a. Slurred speech b. Insidious onset
c. Clouding of consciousness d. Sensory perceptual change
70.A 35 year old female has intense fear of riding an elevator. She claims “ As if I
will die inside.” The client is suffering from:
a. Agoraphobia b. Social phobia c. Claustrophobia d. Xenophobia
71.Nurse Myrna develops a counter-transference reaction. This is evidenced by:
a. Revealing personal information to the client
b. Focusing on the feelings of the client.
c. Confronting the client about discrepancies in verbal or non-verbal behavior
d. The client feels angry towards the nurse who resembles his mother.
72.Tristan is on Lithium has suffered from diarrhea and vomiting. What should
the nurse in-charge do first:
a. Recognize this as a drug interaction
b. Give the client Cogentin
c. Reassure the client that these are common side effects of lithium therapy
d. Hold the next dose and obtain an order for a stat serum lithium level
73.Nurse Sarah ensures a therapeutic environment for all the client. Which of the
following best describes a therapeutic milieu?
a. A therapy that rewards adaptive behavior
b. A cognitive approach to change behavior
c. A living, learning or working environment.
d. A permissive and congenial environment
74.Anthony is very hostile toward one of the staff for no apparent reason. He is
manifesting:
a. Splitting b. Transference c. Countertransference d. Resistance
75.Marielle, 17 years old was sexually attacked while on her way home from
school. She is brought to the hospital by her mother. Rape is an example of
which type of crisis:
a. Situational b. Adventitious c. Developmental d. Internal
76. Nurse Greta is aware that the following is classified as an Axis I disorder by
the Diagnosis and Statistical Manual of Mental Disorders, Text Revision (DSM-
IV-TR) is:
a. Obesity b. Borderline personality disorder
c. Major depression d. Hypertension
77.Katrina, a newly admitted is extremely hostile toward a staff member she has
just met, without apparent reason. According to Freudian theory, the nurse
should suspect that the client is experiencing which of the following phenomena?
a. Intellectualization b. Transference c. Triangulation d. Splitting
78.An 83year-old male client is in extended care facility is anxious most of the
time and frequently complains of a number of vague symptoms that interfere with
his ability to eat. These symptoms indicate which of the following disorders?
a. Conversion disorder b. Hypochondriasis c. Severe anxiety d. Sublimation
79. Charina, a college student who frequently visited the health center during the
past year with multiple vague complaints of GI symptoms before course
examinations. Although physical causes have been eliminated, the student
continues to express her belief that she has a serious illness. These symptoms
are typically of which of the following disorders?
a. Conversion disorder b. Depersonalization
c. Hypochondriasis d. Somatization disorder
80. Nurse Daisy is aware that the following pharmacologic agents are
sedativehypnotic medication is used to induce sleep for a client experiencing a
sleep disorder is:
a. Triazolam (Halcion) b. Paroxetine (Paxil)\
c. Fluoxetine (Prozac) d. Risperidone (Risperdal)
81. Aldo, with a somatoform pain disorder may obtain secondary gain. Which of
the following statement refers to a secondary gain?
a. It brings some stability to the family
b. It decreases the preoccupation with the physical illness
c. It enables the client to avoid some unpleasant activity
d. It promotes emotional support or attention for the client
82. Dervid is diagnosed with panic disorder with agoraphobia is talking with the
nurse in-charge about the progress made in treatment. Which of the following
statements indicates a positive client response?
a. “I went to the mall with my friends last Saturday”
b. “I’m hyperventilating only when I have a panic attack”
c. “Today I decided that I can stop taking my medication”
d. “Last night I decided to eat more than a bowl of cereal”
83. The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in
client with posttraumatic stress disorder can be demonstrated by which of the
following client self –reports?
a. “I’m sleeping better and don’t have nightmares”
b. “I’m not losing my temper as much”
c. “I’ve lost my craving for alcohol”
d. I’ve lost my phobia for water”
84. Mark, with a diagnosis of generalized anxiety disorder wants to stop taking
his lorazepam (Ativan). Which of the following important facts should nurse Betty
discuss with the client about discontinuing the medication?
a. Stopping the drug may cause depression
b. Stopping the drug increases cognitive abilities
c. Stopping the drug decreases sleeping difficulties
d. Stopping the drug can cause withdrawal symptoms
85. Jennifer, an adolescent who is depressed and reported by his parents as
having difficulty in school is brought to the community mental health center to be
evaluated. Which of the following other health problems would the nurse
suspect?
a. Anxiety disorder b. Behavioral difficulties
c. Cognitive impairment d. Labile moods
86. Ricardo, an outpatient in psychiatric facility is diagnosed with dysthymic
disorder. Which of the following statement about dysthymic disorder is true?
a. It involves a mood range from moderate depression to hypomania
b. It involves a single manic depression
c. It’s a form of depression that occurs in the fall and winter
d. It’s a mood disorder similar to major depression but of mild to moderate
severity
87. The nurse is aware that the following ways in vascular dementia different
from Alzheimer’s disease is:
a. Vascular dementia has more abrupt onset
b. The duration of vascular dementia is usually brief
c. Personality change is common in vascular dementia
d. The inability to perform motor activities occurs in vascular dementia
88. Loretta, a newly admitted client was diagnosed with delirium and has history
of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix),
and diazepam (Valium) for anxiety. This client’s impairment may be related to
which of the following conditions?
a. Infection b. Metabolic acidosis c. Drug intoxication d. Hepatic encephalopathy
89. Nurse Ron enters a client’s room, the client says, “They’re crawling on my
sheets! Get them off my bed!” Which of the following assessment is the most
accurate?
a. The client is experiencing aphasia
b. The client is experiencing dysarthria
c. The client is experiencing a flight of ideas
d. The client is experiencing visual hallucination
90. Which of the following descriptions of a client’s experience and behavior can
be assessed as an illusion?
a. The client tries to hit the nurse when vital signs must be taken
b. The client says, “I keep hearing a voice telling me to run away”
c. The client becomes anxious whenever the nurse leaves the bedside
d. The client looks at the shadow on a wall and tells the nurse she sees
frightening faces on the wall.
91. During conversation of Nurse John with a client, he observes that the client
shift from one topic to the next on a regular basis. Which of the following terms
describes this disorder?
a. Flight of ideas b. Concrete thinking
c. Ideas of reference d. Loose association
92. Francis tells the nurse that her coworkers are sabotaging the computer.
When the nurse asks questions, the client becomes argumentative. This
behavior shows personality traits associated with which of the following
personality disorder?
a. Antisocial b. Histrionic c. Paranoid d. Schizotypal
93. Which of the following interventions is important for a Cely experiencing with
paranoid personality disorder taking olanzapine (Zyprexa)?
a. Explain effects of serotonin syndrome
b. Teach the client to watch for extrapyramidal adverse reaction
c. Explain that the drug is less affective if the client smokes
d. Discuss the need to report paradoxical effects such as euphoria
94. Nurse Alexandra notices other clients on the unit avoiding a client diagnosed
with antisocial personality disorder. When discussing appropriate behavior in
group therapy, which of the following comments is expected about this client by
his peers?
a. Lack of honesty b. Belief in superstition
c. Show of temper tantrums d. Constant need for attention
95. Tommy, with dependent personality disorder is working to increase his
selfesteem. Which of the following statements by the Tommy shows teaching
was successful?
a. “I’m not going to look just at the negative things about myself”
b. “I’m most concerned about my level of competence and progress”
c. “I’m not as envious of the things other people have as I used to be”
d. “I find I can’t stop myself from taking over things other should be doing”
96. Norma, a 42-year-old client with a diagnosis of chronic undifferentiated
schizophrenia lives in a rooming house that has a weekly nursing clinic. She
scratches while she tells the nurse she feels creatures eating away at her skin.
Which of the following interventions should be done first?
a. Talk about his hallucinations and fears
b. Refer him for anticholinergic adverse reactions
c. Assess for possible physical problems such as rash
d. Call his physician to get his medication increased to control his psychosis
97. Ivy, who is on the psychiatric unit is copying and imitating the movements of
her primary nurse. During recovery, she says, “I thought the nurse was my
mirror. I felt connected only when I saw my nurse.” This behavior is known by
which of the following terms?
a. Modeling b. Echopraxia c. Ego-syntonicity d. Ritualism
98. Jun approaches the nurse and tells that he hears a voice telling him that he’s
evil and deserves to die. Which of the following terms describes the client’s
perception?
a. Delusion b. Disorganized speech c. Hallucination d. Idea of reference
99. Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated
schizophrenia. Which of the following defense mechanisms is probably used by
mike?
a. Projection b. Rationalization c. Regression d. Repression
100. Rocky has started taking haloperidol (Haldol). Which of the following
instructions is most appropriate for Ricky before taking haloperidol?
a. Should report feelings of restlessness or agitation at once
b. Use a sunscreen outdoors on a year-round basis
c. Be aware you’ll feel increased energy taking this drug
d. This drug will indirectly control essential hypertension
RATIO 5
1. Answer: (D) Focusing
Rationale: The nurse is using focusing by suggesting that the client discuss a
specific issue. The nurse didn’t restate the question, make observation, or ask
further question (exploring).
2. Answer: (D) Remove all other clients from the dayroom.
Rationale: The nurse’s first priority is to consider the safety of the clients in the
therapeutic setting. The other actions are appropriate responses after ensuring
the safety of other clients.
3. Answer: (A) The client is disruptive.
Rationale: Group activity provides too much stimulation, which the client will not
be able to handle (harmful to self) and as a result will be disruptive to others.
4. Answer: (C) Agree to talk with the mother and the father together.
Rationale: By agreeing to talk with both parents, the nurse can provide emotional
support and further assess and validate the family’s needs.
5. Answer: (A) Perceptual disorders.
Rationale: Frightening visual hallucinations are especially common in clients
experiencing alcohol withdrawal.
6. Answer: (D) Suggest that it takes awhile before seeing the results.
Rationale: The client needs a specific response; that it takes 2 to 3 weeks (a
delayed effect) until the therapeutic blood level is reached.
7. Answer: (C) Superego
Rationale: This behavior shows a weak sense of moral consciousness.
According to Freudian theory, personality disorders stem from a weak superego.
8. Answer: (C) Skeletal muscle paralysis.
Rationale: Anectine is a depolarizing muscle relaxant causing paralysis. It is used
to reduce the intensity of muscle contractions during the convulsive stage,
thereby reducing the risk of bone fractures or dislocation.
9. Answer: (D) Increase calories, carbohydrates, and protein.
Rationale: This client increased protein for tissue building and increased calories
to replace what is burned up (usually via carbohydrates).
10. Answer: (C) Acting overly solicitous toward the child.
Rationale: This behavior is an example of reaction formation, a coping
mechanism.
11. Answer: (A) By designating times during which the client can focus on the
behavior.
Rationale: The nurse should designate times during which the client can focus on
the compulsive behavior or obsessive thoughts. The nurse should urge the client
to reduce the frequency of the compulsive behavior gradually, not rapidly. She
shouldn't call attention to or try to prevent the behavior. Trying to prevent the
behavior may cause pain and terror in the client. The nurse should encourage
the client to verbalize anxieties to help distract attention from the compulsive
behavior.
12. Answer: (D) Exploring the meaning of the traumatic event with the client.
Rationale: The client with PTSD needs encouragement to examine and
understand the meaning of the traumatic event and consequent losses.
Otherwise, symptoms may worsen and the client may become depressed or
engage in self-destructive behavior such as substance abuse. The client must
explore the meaning of the event and won't heal without this, no matter how
much time passes. Behavioral techniques, such as relaxation therapy, may help
decrease the client's anxiety and induce sleep. The physician may prescribe
antianxiety agents or antidepressants cautiously to avoid dependence; sleep
medication is rarely appropriate. A special diet isn't indicated unless the client
also has an eating disorder or a nutritional problem.
13. Answer: (C) "Your problem is real but there is no physical basis for it. We'll
work on what is going on in your life to find out why it's happened."
Rationale: The nurse must be honest with the client by telling her that the
paralysis has no physiologic cause while also conveying empathy and
acknowledging that her symptoms are real. The client will benefit from psychiatric
treatment, which will help her understand the underlying cause of her symptoms.
After the psychological conflict is resolved, her
symptoms will disappear. Saying that it must be awful not to be able to move her
legs wouldn't answer the client's question; knowing that the cause is
psychological wouldn't necessarily make her feel better. Telling her that she has
developed paralysis to avoid leaving her parents or that her personality caused
her disorder wouldn't help her understand and resolve the underlying conflict.
14. Answer: (C) fluvoxamine (Luvox) and clomipramine (Anafranil)
Rationale: The antidepressants fluvoxamine and clomipramine have been
effective in the treatment of OCD. Librium and Valium may be helpful in treating
anxiety related to OCD but aren't drugs of choice to treat the illness. The other
medications mentioned aren't effective in the treatment of OCD.
15. Answer: (A) A warning about the drugs delayed therapeutic effect, which is
from 14 to 30 days.
Rationale: The client should be informed that the drug's therapeutic effect might
not be reached for 14 to 30 days. The client must be instructed to continue taking
the drug as directed. Blood level checks aren't necessary. NMS hasn't been
reported with this drug, but tachycardia is frequently reported.
16. Answer: (B) Severe anxiety and fear.
Rationale: Phobias cause severe anxiety (such as a panic attack) that is out of
proportion to the threat of the feared object or situation. Physical signs and
symptoms of phobias include profuse sweating, poor motor control, tachycardia,
and elevated blood pressure. Insomnia, an inability to concentrate, and weight
loss are common in depression. Withdrawal and failure to distinguish reality from
fantasy occur in schizophrenia.
17. Answer: (A) Antidepressants
Rationale: Tricyclic and monoamine oxidase (MAO) inhibitor antidepressants
have been found to be effective in treating clients with panic attacks. Why these
drugs help control panic attacks isn't clearly understood. Anticholinergic agents,
which are smooth-muscle relaxants, relieve physical symptoms of anxiety but
don't relieve the anxiety itself. Antipsychotic drugs are inappropriate because
clients who experience panic attacks aren't psychotic. Mood stabilizers aren't
indicated because panic attacks are rarely associated with mood changes.
18. Answer: (B) 3 to 5 days
Rationale: Monoamine oxidase inhibitors, such as tranylcypromine, have an
onset of action of approximately 3 to 5 days. A full clinical response may be
delayed for 3 to 4 weeks. The therapeutic effects may continue for 1 to 2 weeks
after discontinuation.
19. Answer: (B) Providing emotional support and individual counseling.
Rationale: Clients in the first stage of Alzheimer's disease are aware that
something is happening to them and may become overwhelmed and frightened.
Therefore, nursing care typically focuses on providing emotional support and
individual counseling. The other options are appropriate during the second stage
of Alzheimer's disease, when the
client needs continuous monitoring to prevent minor illnesses from progressing
into major problems and when maintaining adequate nutrition may become a
challenge. During this stage, offering nourishing finger foods helps clients to feed
themselves and maintain adequate nutrition.
20. Answer: (C) Emotional lability, euphoria, and impaired memory
Rationale: Signs of antianxiety agent overdose include emotional lability,
euphoria, and impaired memory. Phencyclidine overdose can cause
combativeness, sweating, and confusion. Amphetamine overdose can result in
agitation, hyperactivity, and grandiose ideation. Hallucinogen overdose can
produce suspiciousness, dilated pupils, and increased blood pressure.
21. Answer: (D) A low tolerance for frustration
Rationale: Clients with an antisocial personality disorder exhibit a low tolerance
for frustration, emotional immaturity, and a lack of impulse control. They
commonly have a history of unemployment, miss work repeatedly, and quit work
without other plans for employment. They don't feel guilt about their behavior and
commonly perceive themselves as victims. They also display a lack of
responsibility for the outcome of their actions. Because of a lack of trust in others,
clients with antisocial personality disorder commonly have difficulty developing
stable, close relationships.
22. Answer: (C) Methadone
Rationale: Methadone is used to detoxify opiate users because it binds with
opioid receptors at many sites in the central nervous system but doesn’t have the
same deterious effects as other opiates, such as cocaine, heroin, and morphine.
Barbiturates, amphetamines, and benzodiazepines are highly addictive and
would require detoxification treatment.
23. Answer: (B) Hallucinations
Rationale: Hallucinations are visual, auditory, gustatory, tactile, or olfactory
perceptions that have no basis in reality. Delusions are false beliefs, rather than
perceptions, that the client accepts as real. Loose associations are rapid shifts
among unrelated ideas. Neologisms are bizarre words that have meaning only to
the client.
24. Answer: (C) Set up a strict eating plan for the client.
Rationale: Establishing a consistent eating plan and monitoring the client’s
weight are very important in this disorder. The family and friends should be
included in the client’s care. The client should be monitored during meals-not
given privacy. Exercise must be limited and supervised.
25. Answer: (A) Highly important or famous.
Rationale: A delusion of grandeur is a false belief that one is highly important or
famous. A delusion of persecution is a false belief that one is being persecuted.
A delusion of reference is a false belief that one is connected to events unrelated
to oneself or a belief that one is responsible for the evil in the world.
26. Answer: (D) Listening attentively with a neutral attitude and avoiding power
struggles.
Rationale: The nurse should listen to the client’s requests, express willingness to
seriously consider the request, and respond later. The nurse should encourage
the client to take short daytime naps because he expends so much energy. The
nurse shouldn’t try to restrain the client when he feels the need to move around
as long as his activity isn’t harmful. High calorie finger foods should be offered to
supplement the client’s diet, if he can’t remain seated long enough to eat a
complete meal. The nurse shouldn’t be forced to stay seated at the table to finish
a meal. The nurse should set limits in a calm, clear, and self-confident tone of
voice.
27. Answer: (D) Denial
Rationale: Denial is unconscious defense mechanism in which emotional conflict
and anxiety is avoided by refusing to acknowledge feelings, desires, impulses, or
external facts that are consciously intolerable. Withdrawal is a common response
to stress, characterized by apathy. Logical thinking is the ability to think rationally
and make responsible decisions, which would lead the client admitting the
problem and seeking help. Repression is suppressing past events from the
consciousness because of guilty association.
28. Answer: (B) Paranoid thoughts
Rationale: Clients with schizotypal personality disorder experience excessive
social anxiety that can lead to paranoid thoughts. Aggressive behavior is
uncommon, although these clients may experience agitation with anxiety. Their
behavior is emotionally cold with a flattened affect, regardless of the situation.
These clients demonstrate a reduced capacity for close or dependent
relationships.
29. Answer: (C) Identify anxiety-causing situations
Rationale: Bulimic behavior is generally a maladaptive coping response to stress
and underlying issues. The client must identify anxiety-causing situations that
stimulate the bulimic behavior and then learn new ways of
coping with the anxiety.
30. Answer: (A) Tension and irritability
Rationale: An amphetamine is a nervous system stimulant that is subject to
abuse because of its ability to produce wakefulness and euphoria. An overdose
increases tension and irritability. Options B and C are incorrect because
amphetamines stimulate norepinephrine, which increase the heart rate and blood
flow. Diarrhea is a common adverse effect so option D in is incorrect.
31. Answer: (B) “No, I do not hear your voices, but I believe you can hear them”.
Rationale: The nurse, demonstrating knowledge and understanding, accepts the
client’s perceptions even though they are hallucinatory.
32. Answer: (C) Confusion for a time after treatment
Rationale: The electrical energy passing through the cerebral cortex during ECT
results in a temporary state of confusion after treatment.
33. Answer: (D) Acceptance stage
Rationale: Communication and intervention during this stage are mainly
nonverbal, as when the client gestures to hold the nurse’s hand.
34. Answer: (D) A higher level of anxiety continuing for more than 3 months.
Rationale: This is not an expected outcome of a crisis because by definition a
crisis would be resolved in 6 weeks.
35. Answer: (B) Staying in the sun
Rationale: Haldol causes photosensitivity. Severe sunburn can occur on
exposure to the sun.
36. Answer: (D) Moderate-level anxiety
Rationale: A moderately anxious person can ignore peripheral events and
focuses on central concerns.
37. Answer: (C) Diverse interest
Rationale: Before onset of depression, these clients usually have very narrow,
limited interest.
38. Answer: (A) As their depression begins to improve
Rationale: At this point the client may have enough energy to plan and execute
an attempt.
39. Answer: (D) Disturbance in recalling recent events related to cerebral
hypoxia.
Rationale: Cell damage seems to interfere with registering input stimuli, which
affects the ability to register and recall recent events; vascular dementia is
related to multiple vascular lesions of the cerebral cortex and subcortical
structure.
40. Answer: (D) Encouraging the client to have blood levels checked as ordered.
Rationale: Blood levels must be checked monthly or bimonthly when the client is
on maintenance therapy because there is only a small range between
therapeutic and toxic levels.
41. Answer: (B) Fine hand tremors or slurred speech
Rationale: These are common side effects of lithium carbonate.
42. Answer: (D) Presence
Rationale: The constant presence of a nurse provides emotional support
because the client knows that someone is attentive and available in case of an
emergency.
43. Answer: (A) Client’s perception of the presenting problem.
Rationale: The nurse can be most therapeutic by starting where the client is,
because it is the client’s concept of the problem that serves as the starting point
of the relationship.
44. Answer: (B) Chocolate milk, aged cheese, and yogurt’”
Rationale: These high-tyramine foods, when ingested in the presence of an MAO
inhibitor, cause a severe hypertensive response.
45. Answer: (B) 4 to 6 weeks
Rationale: Crisis is self-limiting and lasts from 4 to 6 weeks.
46. Answer: (D) Males are more likely to use lethal methods than are females
Rationale: This finding is supported by research; females account for 90% of
suicide attempts but males are three times more successful because of methods
used.

47. Answer: (C) "Your cursing is interrupting the activity. Take time out in your
room for 10 minutes."
Rationale: The nurse should set limits on client behavior to ensure a comfortable
environment for all clients. The nurse should accept hostile or quarrelsome client
outbursts within limits without becoming personally offended, as in option A.
Option B is incorrect because it implies that the client's actions reflect feelings
toward the staff instead of the client's own misery. Judgmental remarks, such as
option D, may decrease the client's self-esteem.
48. Answer: (C) lithium carbonate (Lithane)
Rationale: Lithium carbonate, an antimania drug, is used to treat clients with
cyclical schizoaffective disorder, a psychotic disorder once classified under
schizophrenia that causes affective symptoms, including maniclike activity.
Lithium helps control the affective component of this disorder. Phenelzine is a
monoamine oxidase inhibitor prescribed for clients who don't respond to other
antidepressant drugs such as imipramine. Chlordiazepoxide, an antianxiety
agent, generally is contraindicated in psychotic clients. Imipramine, primarily
considered an antidepressant agent, is also used to treat clients with
agoraphobia and that undergoing cocaine detoxification.
49. Answer: (B) Report a sore throat or fever to the physician immediately.
Rationale: A sore throat and fever are indications of an infection caused by
agranulocytosis, a potentially life-threatening complication of clozapine. Because
of the risk of agranulocytosis, white blood cell (WBC) counts are
necessary weekly, not monthly. If the WBC count drops below 3,000/μl, the
medication must be stopped. Hypotension may occur in clients taking this
medication. Warn the client to stand up slowly to avoid dizziness from orthostatic
hypotension. The medication should be continued, even when symptoms have
been controlled. If the medication must be stopped, it should be slowly tapered
over 1 to 2 weeks and only under the supervision of a physician.
50. Answer: (C) Neuroleptic malignant syndrome.
Rationale: The client's signs and symptoms suggest neuroleptic malignant
syndrome, a life-threatening reaction to neuroleptic medication that requires
immediate treatment. Tardive dyskinesia causes involuntary movements of the
tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is
characterized by cramps and rigidity of the tongue,
face, neck, and back muscles. Akathisia causes restlessness, anxiety, and
jitteriness.
51. Answer: (B) Advising the client to sit up for 1 minute before getting out of bed.
Rationale: To minimize the effects of amitriptyline-induced orthostatic
hypotension, the nurse should advise the client to sit up for 1 minute before
getting out of bed. Orthostatic hypotension commonly occurs with tricyclic
antidepressant therapy. In these cases, the dosage may be reduced or the
physician may prescribe nortriptyline, another tricyclic
antidepressant. Orthostatic hypotension disappears only when the drug is
discontinued.
52. Answer: (D) Dysthymic disorder.
Rationale: Dysthymic disorder is marked by feelings of depression lasting at least
2 years, accompanied by at least two of the following symptoms: sleep
disturbance, appetite disturbance, low energy or fatigue, low selfesteem, poor
concentration, difficulty making decisions, and hopelessness. These symptoms
may be relatively continuous or
separated by intervening periods of normal mood that last a few days to a few
weeks. Cyclothymic disorder is a chronic mood disturbance of at least 2 years'
duration marked by numerous periods of depression and hypomania. Atypical
affective disorder is characterized by manic signs and symptoms. Major
depression is a recurring, persistent sadness or loss of interest or pleasure in
almost all activities, with signs and symptoms recurring for at least 2 weeks.
53. Answer: (C) 30 g mixed in 250 ml of water
Rationale: The usual adult dosage of activated charcoal is 5 to 10 times the
estimated weight of the drug or chemical ingested, or a minimum dose of 30 g,
mixed in 250 ml of water. Doses less than this will be ineffective; doses greater
than this can increase the risk of adverse reactions, although toxicity doesn't
occur with activated charcoal, even at the maximum dose.
54. Answer: (C) St. John's wort
Rationale: St. John's wort has been found to have serotonin-elevating properties,
similar to prescription antidepressants. Ginkgo biloba is prescribed to enhance
mental acuity. Echinacea has immune-stimulating properties. Ephedra is a
naturally occurring stimulant that is similar to ephedrine.
55. Answer: (B) Sodium
Rationale: Lithium is chemically similar to sodium. If sodium levels are reduced,
such as from sweating or diuresis, lithium will be reabsorbed by the kidneys,
increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake
of sodium and should drink adequate amounts of fluid each day. The other
electrolytes are important for normal body functions but sodium is most important
to the absorption of lithium.
56. Answer: (D) It's characterized by an acute onset and lasts hours to a number
of days
Rationale: Delirium has an acute onset and typically can last from several hours
to several days.
57. Answer: (B) Impaired communication.
Rationale: Initially, memory impairment may be the only cognitive deficit in a
client with Alzheimer's disease. During the early stage of this disease, subtle
personality changes may also be present. However, other than occasional
irritable outbursts and lack of spontaneity, the client is usually cooperative and
exhibits socially appropriate behavior. Signs of
advancement to the middle stage of Alzheimer's disease include exacerbated
cognitive impairment with obvious personality changes and impaired
communication, such as inappropriate conversation, actions, and responses.
During the late stage, the client can't perform self-care activities and may
become mute.
58. Answer: (D) This medication may initially cause tiredness, which should
become less bothersome over time.
Rationale: Sedation is a common early adverse effect of imipramine, a tricyclic
antidepressant, and usually decreases as tolerance develops. Antidepressants
aren't habit forming and don't cause physical or psychological dependence.
However, after a long course of high-dose therapy, the dosage should be
decreased gradually to avoid mild withdrawal symptoms. Serious adverse
effects, although rare, include myocardial infarction, heart failure, and
tachycardia. Dietary restrictions, such as avoiding aged cheeses, yogurt, and
chicken livers, are necessary for a client taking a monoamine oxidase inhibitor,
not a tricyclic antidepressant.
59. Answer: (C) Monitor vital signs, serum electrolyte levels, and acid-base
balance.
Rationale: An anorexic client who requires hospitalization is in poor physical
condition from starvation and may die as a result of arrhythmias, hypothermia,
malnutrition, infection, or cardiac abnormalities secondary to electrolyte
imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level,
and acid base balance is crucial. Option A may worsen anxiety. Option B is
incorrect because a weight obtained after breakfast is more accurate than one
obtained after the evening meal. Option D would reward the client with attention
for not eating and reinforce the control issues that are central to the underlying
psychological problem; also, the client may record food and fluid intake
inaccurately.
60. Answer: (D) Opioid withdrawal
Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol
withdrawal would show elevated vital signs. There is no real withdrawal from
cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and
agitation.
61. Answer: (A) Regression
Rationale: An adult who throws temper tantrums, such as this one, is displaying
regressive behavior, or behavior that is appropriate at a younger age. In
projection, the client blames someone or something other than the source. In
reaction formation, the client acts in opposition to his feelings. In
intellectualization, the client overuses rational explanations or
abstract thinking to decrease the significance of a feeling or event.
62. Answer: (A) Abnormal movements and involuntary movements of the mouth,
tongue, and face.
Rationale: Tardive dyskinesia is a severe reaction associated with long term use
of antipsychotic medication. The clinical manifestations include abnormal
movements (dyskinesia) and involuntary movements of the mouth, tongue (fly
catcher tongue), and face.
63. Answer: (C) Blurred vision
Rationale: At lithium levels of 2 to 2.5 mEq/L the client will experienced blurred
vision, muscle twitching, severe hypotension, and persistent nausea and
vomiting. With levels between 1.5 and 2 mEq/L the client experiencing vomiting,
diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At
lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecal incontinence occurs,
as well as seizures, cardiac dysrythmias, peripheral vascular collapse, and
death.
64. Answer: (C) No acts of aggression have been observed within 1 hour after
the release of two of the extremity restraints.
Rationale: The best indicator that the behavior is controlled, if the client exhibits
no signs of aggression after partial release of restraints. Options A, B, and D do
not ensure that the client has controlled the behavior.
65. Answer: (A) increased attention span and concentration
Rationale: The medication has a paradoxic effect that decrease hyperactivity and
impulsivity among children with ADHD. B, C, D. Side effects of Ritalin include
anorexia, insomnia, diarrhea and irritability.
66. Answer: (C) Moderate
Rationale: The child with moderate mental retardation has an I.Q. of 35- 50
Profound Mental retardation has an I.Q. of below 20; Mild mental retardation 50-
70 and Severe mental retardation has an I.Q. of 20-35.
67. Answer: (D) Rearrange the environment to activate the child
Rationale: The child with autistic disorder does not want change. Maintaining a
consistent environment is therapeutic. A. Angry outburst can be re-channeling
through safe activities. B. Acceptance enhances a trusting relationship. C.
Ensure safety from self-destructive behaviors like head banging and hair pulling.
68. Answer: (B) cocaine
Rationale: The manifestations indicate intoxication with cocaine, a CNS
stimulant. A. Intoxication with heroine is manifested by euphoria then impairment
in judgment, attention and the presence of papillary constriction. C. Intoxication
with hallucinogen like LSD is manifested by grandiosity, hallucinations,
synesthesia and increase in vital signs D. Intoxication with Marijuana, a
cannabinoid is manifested by sensation of slowed time, conjunctival redness,
social withdrawal, impaired judgment and hallucinations.

69. Answer: (B) insidious onset
Rationale: Dementia has a gradual onset and progressive deterioration. It causes
pronounced memory and cognitive disturbances. A,C and D are all
characteristics of delirium.
70. Answer: (C) Claustrophobia
Rationale: Claustrophobia is fear of closed space. A. Agoraphobia is fear of open
space or being a situation where escape is difficult. B. Social phobia is fear of
performing in the presence of others in a way that will be humiliating or
embarrassing. D. Xenophobia is fear of strangers.
71. Answer: (A) Revealing personal information to the client
Rationale: Counter-transference is an emotional reaction of the nurse on the
client based on her unconscious needs and conflicts. B and C. These are
therapeutic approaches. D. This is transference reaction where a client has an
emotional reaction towards the nurse based on her past.
72. Answer: (D) Hold the next dose and obtain an order for a stat serum lithium
level
Rationale: Diarrhea and vomiting are manifestations of Lithium toxicity. The next
dose of lithium should be withheld and test is done to validate the observation. A.
The manifestations are not due to drug interaction. B. Cogentin is used to
manage the extra pyramidal symptom side effects of antipsychotics. C. The
common side effects of Lithium are fine hand tremors, nausea, polyuria and
polydipsia.
73. Answer: (C) A living, learning or working environment.
Rationale: A therapeutic milieu refers to a broad conceptual approach in which all
aspects of the environment are channeled to provide a therapeutic environment
for the client. The six environmental elements include structure, safety, norms;
limit setting, balance and unit modification. A. Behavioral approach in psychiatric
care is based on the premise that behavior can be learned or unlearned through
the use of reward and punishment. B. Cognitive approach to change behavior is
done by correcting distorted perceptions and irrational beliefs to correct
maladaptive behaviors. D. This is not congruent with therapeutic milieu.
74. Answer: (B) Transference
Rationale: Transference is a positive or negative feeling associated with a
significant person in the client’s past that are unconsciously assigned to another
A. Splitting is a defense mechanism commonly seen in a client with personality
disorder in which the world is perceived as all good or all bad C. Countert-
transference is a phenomenon where the nurse shifts feelings assigned to
someone in her past to the patient D. Resistance is the client’s refusal to submit
himself to the care of the nurse
75. Answer: (B) Adventitious
Rationale: Adventitious crisis is a crisis involving a traumatic event. It is not part
of everyday life. A. Situational crisis is from an external source that upset ones
psychological equilibrium C and D. Are the same. They are transitional or
developmental periods in life
76. Answer: (C) Major depression
Rationale: The DSM-IV-TR classifies major depression as an Axis I disorder.
Borderline personality disorder as an Axis II; obesity and hypertension, Axis III.
77. Answer: (B) Transference
Rationale: Transference is the unconscious assignment of negative or positive
feelings evoked by a significant person in the client’s past to another person.
Intellectualization is a defense mechanism in which the client avoids dealing with
emotions by focusing on facts. Triangulation refers to conflicts involving three
family members. Splitting is a defense
mechanism commonly seen in clients with personality disorder in which the world
is perceived as all good or all bad.
78. Answer: (B) Hypochondriasis
Rationale: Complains of vague physical symptoms that have no apparent
medical causes are characteristic of clients with hypochondriasis. In many cases,
the GI system is affected. Conversion disorders are characterized by one or
more neurologic symptoms. The client’s symptoms don’t suggest severe anxiety.
A client experiencing sublimation channels
maladaptive feelings or impulses into socially acceptable behavior
79. Answer: (C) Hypochondriasis
Rationale: Hypochodriasis in this case is shown by the client’s belief that she has
a serious illness, although pathologic causes have been eliminated. The
disturbance usually lasts at lease 6 with identifiable life stressor such as, in this
case, course examinations. Conversion disorders are characterized by one or
more neurologic symptoms. Depersonalization refers to persistent recurrent
episodes of feeling detached from one’s self or body. Somatoform disorders
generally have a chronic course with few remissions.
80. Answer: (A) Triazolam (Halcion)
Rationale: Triazolam is one of a group of sedative hypnotic medication that can
be used for a limited time because of the risk of dependence. Paroxetine is a
scrotonin-specific reutake inhibitor used for treatment of depression panic
disorder, and obsessive-compulsive disorder. Fluoxetine is a scrotonin-specific
reuptake inhibitor used for depressive disorders and obsessive-compulsive
disorders. Risperidome is indicated for psychotic disorders.
81. Answer: (D) It promotes emotional support or attention for the client
Rationale: Secondary gain refers to the benefits of the illness that allow the client
to receive emotional support or attention. Primary gain enables the client to avoid
some unpleasant activity. A dysfunctional family may disregard the real issue,
although some conflict is relieved. Somatoform pain disorder is a preoccupation
with pain in the absence of physical disease.
82. Answer: (A) “I went to the mall with my friends last Saturday”
Rationale: Clients with panic disorder tent to be socially withdrawn. Going to the
mall is a sign of working on avoidance behaviors. Hyperventilating is a key
symptom of panic disorder. Teaching breathing control is a major intervention for
clients with panic disorder. The client taking medications for panic disorder; such
as tricylic antidepressants and benzodiazepines, must be weaned off these
drugs. Most clients with panic disorder with agoraphobia don’t have nutritional
problems.
83. Answer: (A) “I’m sleeping better and don’t have nightmares”
Rationale:MAO inhibitors are used to treat sleep problems, nightmares, and
intrusive daytime thoughts in individual with posttraumatic stress disorder. MAO
inhibitors aren’t used to help control flashbacks or phobias or to decrease the
craving for alcohol.
84. Answer: (D) Stopping the drug can cause withdrawal symptoms
Rationale: Stopping antianxiety drugs such as benzodiazepines can cause the
client to have withdrawal symptoms. Stopping a benzodiazepine doesn’t tend to
cause depression, increase cognitive abilities, or decrease sleeping difficulties.
85. Answer: (B) Behavioral difficulties
Rationale: Adolescents tend to demonstrate severe irritability and behavioral
problems rather than simply a depressed mood. Anxiety disorder is more
commonly associated with small children rather than with adolescents. Cognitive
impairment is typically associated with delirium or dementia. Labile mood is more
characteristic of a client with cognitive impairment or bipolar disorder.
86. Answer: (D) It’s a mood disorder similar to major depression but of mild to
moderate severity
Rationale: Dysthymic disorder is a mood disorder similar to major depression but
it remains mild to moderate in severity. Cyclothymic disorder is a mood disorder
characterized by a mood range from moderate depression to hypomania. Bipolar
I disorder is characterized by a single manic episode with no past major
depressive episodes. Seasonalaffective disorder is a form of depression
occurring in the fall and winter.
87. Answer: (A) Vascular dementia has more abrupt onset
Rationale: Vascular dementia differs from Alzheimer’s disease in that it has a
more abrupt onset and runs a highly variable course. Personally change is
common in Alzheimer’s disease. The duration of delirium is usually brief. The
inability to carry out motor activities is common in Alzheimer’s disease.
88. Answer: (C) Drug intoxication
Rationale: This client was taking several medications that have a propensity for
producing delirium; digoxin (a digitalis glycoxide), furosemide (a thiazide diuretic),
and diazepam (a benzodiazepine). Sufficient supporting data don’t exist to
suspect the other options as causes.
89. Answer: (D) The client is experiencing visual hallucination
Rationale: The presence of a sensory stimulus correlates with the definition of a
hallucination, which is a false sensory perception. Aphasia refers to a
communication problem. Dysarthria is difficulty in speech production. Flight of
ideas is rapid shifting from one topic to another.
90. Answer: (D) The client looks at the shadow on a wall and tells the nurse she
sees frightening faces on the wall.
Rationale: Minor memory problems are distinguished from dementia by their
minor severity and their lack of significant interference with the client’s social or
occupational lifestyle. Other options would be included in the history data but
don’t directly correlate with the client’s lifestyle.
91. Answer: (D) Loose association
Rationale: Loose associations are conversations that constantly shift in topic.
Concrete thinking implies highly definitive thought processes. Flight of ideas is
characterized by conversation that’s disorganized from the onset. Loose
associations don’t necessarily start in a cogently, then becomes loose.
92. Answer: (C) Paranoid
Rationale: Because of their suspiciousness, paranoid personalities ascribe
malevolent activities to others and tent to be defensive, becoming quarrelsome
and argumentative. Clients with antisocial personality disorder can also be
antagonistic and argumentative but are less suspicious than paranoid
personalities. Clients with histrionic personality disorder are dramatic, not
suspicious and argumentative. Clients with schizoid personality disorder are
usually detached from other and tend to have eccentric behavior.
93. Answer: (C) Explain that the drug is less affective if the client smokes
Rationale: Olanzapine (Zyprexa) is less effective for clients who smoke
cigarettes. Serotonin syndrome occurs with clients who take a combination of
antidepressant medications. Olanzapine doesn’t cause euphoria, and
extrapyramidal adverse reactions aren’t a problem. However, the client should be
aware of adverse effects such as tardive dyskinesia.
94. Answer: (A) Lack of honesty
Rationale: Clients with antisocial personality disorder tent to engage in acts of
dishonesty, shown by lying. Clients with schizotypal personality disorder tend to
be superstitious. Clients with histrionic personality disorders tend to overreact to
frustrations and disappointments, have temper tantrums, and seek attention.
95. Answer: (A) “I’m not going to look just at the negative things about myself”
Rationale: As the clients makes progress on improving self-esteem, selfblame
and negative self evaluation will decrease. Clients with dependent personality
disorder tend to feel fragile and inadequate and would be extremely unlikely to
discuss their level of competence and progress. These clients focus on self and
aren’t envious or jealous. Individuals with dependent personality disorders don’t
take over situations because they see themselves as inept and inadequate.
96. Answer: (C) Assess for possible physical problems such as rash
Rationale: Clients with schizophrenia generally have poor visceral recognition
because they live so fully in their fantasy world. They need to have as in-depth
assessment of physical complaints that may spill over into their delusional
symptoms. Talking with the client won’t provide as assessment of his itching, and
itching isn’t as adverse reaction of antipsychotic drugs, calling the physician to
get the client’s medication increased doesn’t address his physical complaints.
97. Answer: (B) Echopraxia
Rationale: Echopraxia is the copying of another’s behaviors and is the result of
the loss of ego boundaries. Modeling is the conscious copying of someone’s
behaviors. Ego-syntonicity refers to behaviors that correspond with the
individual’s sense of self. Ritualism behaviors are repetitive and compulsive.
98. Answer: (C) Hallucination
Rationale: Hallucinations are sensory experiences that are misrepresentations of
reality or have no basis in reality. Delusions are beliefs not based in reality.
Disorganized speech is characterized by jumping from one topic to the next or
using unrelated words. An idea of reference is a belief that an unrelated situation
holds special meaning for the client.
99. Answer: (C) Regression
Rationale: Regression, a return to earlier behavior to reduce anxiety, is the basic
defense mechanism in schizophrenia. Projection is a defense mechanism in
which one blames others and attempts to justify actions; it’s used primarily by
people with paranoid schizophrenia and delusional disorder. Rationalization is a
defense mechanism used to justify one’s
action. Repression is the basic defense mechanism in the neuroses; it’s an
involuntary exclusion of painful thoughts, feelings, or experiences from
awareness.
100.Answer: (A) Should report feelings of restlessness or agitation at once
Rationale: Agitation and restlessness are adverse effect of haloperidol and can
be treated with antocholinergic drugs. Haloperidol isn’t likely to cause
photosensitivity or control essential hypertension. Although the client may
experience increased concentration and activity, these effects are due to a
decreased in symptoms, not the drug itself.
EMERGENCY NURSING
1. You are the charge nurse in an emergency department (ED) and must assign
two staff members to cover the triage area. Which team is the most appropriate
for this assignment?
a. An advanced practice nurse and an experienced LPN/LVN
b. An experienced LPN/LVN and an inexperienced RN
c. An experienced RN and an inexperienced RN
d. An experienced RN and a nursing assistant
2. You are working in the triage area of an ED, and four patients approach the
triage desk at the same time. List the order in which you will assess these
patients.
a. An ambulatory, dazed 25-year-old male with a bandaged head wound
b. An irritable infant with a fever, petechiae, and nuchal rigidity
c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
d. A 50-year-old female with moderate abdominal pain and occasional vomiting
_____, _____, _____, _____
3. In conducting a primary survey on a trauma patient, which of the following is
considered one of the priority elements of the primary survey?
a. Complete set of vital signs
b. Palpation and auscultation of the abdomen
c. Brief neurologic assessment
d. Initiation of pulse oximetry
4. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis,
and dizziness. This patient should be prioritized into which category?
a. High urgent b. Urgent c. Non-urgent d. Emergent
5. The physician has ordered cooling measures for a child with fever who is likely
to be discharged when the temperature comes down. Which of the following
would be appropriate to delegate to the nursing assistant?
a. Assist the child to remove outer clothing.
b. Advise the parent to use acetaminophen instead of aspirin.
c. Explain the need for cool fluids.
d. Prepare and administer a tepid bath.
6. It is the summer season, and patients with signs and symptoms of heat-related
illness present in the ED. Which patient needs attention first?
a. An elderly person complains of dizziness and syncope after standing in the
sun for several hours to view a parade
b. A marathon runner complains of severe leg cramps and nausea. Tachycardia,
diaphoresis, pallor, and weakness are observed.
c. A previously healthy homemaker reports broken air conditioner for days.
Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed.
d. A homeless person, poor historian, presents with altered mental status, poor
muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown.
7. You respond to a call for help from the ED waiting room. There is an elderly
patient lying on the floor. List the order for the actions that you must perform.
a. Perform the chin lift or jaw thrust maneuver.
b. Establish unresponsiveness.
c. Initiate cardiopulmonary resuscitation (CPR).
d. Call for help and activate the code team.
e. Instruct a nursing assistant to get the crash cart.
8. The emergency medical service (EMS) has transported a patient with severe
chest pain. As the patient is being transferred to the emergency stretcher, you
note unresponsiveness, cessation of breathing, and no palpable pulse. Which
task is appropriate to delegate to the nursing assistant?
a. Chest compressions b. Bag-valve mask ventilation
c. Assisting with oral intubation d. Placing the defibrillator pads
9. An anxious 24-year-old college student complains of tingling sensations,
palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are
noted. What priority nursing action should you take?
a. Notify the physician immediately.
b. Administer supplemental oxygen.
c. Have the student breathe into a paper bag.
d. Obtain an order for an anxiolytic medication.
10.An experienced traveling nurse has been assigned to work in the ED;
however, this is the nurse’s first week on the job. Which area of the ED is the
most
appropriate assignment for the nurse?
a. Trauma team
b. Triage
c. Ambulatory or fats track clinic
d. Pediatric medicine team
11.A tearful parent brings a child to the ED for taking an unknown amount of
children’s chewable vitamins at an unknown time. The child is currently alert and
asymptomatic. What information should be immediately reported to the
physician?
a. The ingested children’s chewable vitamins contain iron.
b. The child has been treated several times for ingestion of toxic substances.
c. The child has been treated several times for accidental injuries.
d. The child was nauseated and vomited once at home.
12.In caring for a victim of sexual assault, which task is most appropriate for an
LPN/LVN?
a. Assess immediate emotional state and physical injuries
b. Collect hair samples, saliva swabs, and scrapings beneath fingernails.
c. Provide emotional support and supportive communication.
d. Ensure that the “chain of custody” is maintained.
13.You are caring for a victim of frostbite to the feet. Place the following
interventions in the correct order.
a. Apply a loose, sterile, bulky dressing.
b. Give pain medication.
c. Remove the victim from the cold environment.
d. Immerse the feet in warm water 100o F to 105o F (40.6o C to 46.1o C)
14.A patient sustains an amputation of the first and second digits in a chainsaw
accident. Which task should be delegated to the LPN/LVN?
a. Gently cleanse the amputated digits with Betadine solution.
b. Place the amputated digits directly into ice slurry.
c. Wrap the amputated digits in sterile gauze moistened with saline.
d. Store the amputated digits in a solution of sterile normal saline.
15.A 36-year-old patient with a history of seizures and medication compliance of
phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the
MS personnel for repetitive seizure activity that started 45 minutes prior to arrival.
You anticipate that the physician will order which drug for status epilepticus?
a. PO phenytoin and carbamazepine b. IV lorazepam (Ativan)
c. IV carbamazepam d. IV magnesium sulfate
16.You are preparing a child for IV conscious sedation prior to repair of a facial
laceration. What information should you immediately report to the physician?
a. The parent is unsure about the child’s tetanus immunization status.
b. The child is upset and pulls out the IV.
c. The parent declines the IV conscious sedation.
d. The parent wants information about the IV conscious sedation.
17.An intoxicated patient presents with slurred speech, mild confusion, and
uncooperative behavior. The patient is a poor historian but admits to “drinking a
few on the weekend.” What is the priority nursing action for this patient?
a. Obtain an order for a blood alcohol level.
b. Contact the family to obtain additional history and baseline information.
c. Administer naloxone (Narcan) 2 - 4 mg as ordered.
d. Administer IV fluid support with supplemental thiamine as ordered.
18.When an unexpected death occurs in the ED, which of the following tasks is
most appropriate to delegate to the nursing assistant?
a. Escort the family to a place of privacy.
b. Go with the organ donor specialist to talk to the family.
c. Assist with postmortem care.
d. Assist the family to collect belongings.
19.Following emergency endotracheal intubation, you must verify tube placement
and secure the tube. List in order the steps that are required to perform this
function?
a. Obtain an order for a chest x-ray to document tube placement.
b. Secure the tube in place.
c. Auscultate the chest during assisted ventilation.
d. Confirm that the breath sounds are equal and bilateral.
20.A teenager arrives by private car. He is alert and ambulatory, but this shirt and
pants are covered with blood. He and his hysterical friends are yelling and trying
to explain that that they were goofing around and he got poked in the abdomen
with a stick. Which of the following comments should be given first
consideration?
a. “There was a lot of blood and we used three bandages.”
b. “He pulled the stick out, just now, because it was hurting him.”
c. “The stick was really dirty and covered with mud.”
d. “He’s a diabetic, so he needs attention right away.”
21.A prisoner, with a known history of alcohol abuse, has been in police custody
for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now,
disorientation, hallucination, and hyper-reactivity are observed. The medical
diagnosis is delirium tremens. What is the priority nursing diagnosis?
a. Risk for Injury related to seizures
b. Risk for Other-Directed Violence related to hallucinations
c. Risk for Situational Low Self-esteem related to police custody
d. Risk for Nutritional Deficit related to chronic alcohol abuse
22.You are assigned to telephone triage. A patient who was stung by a common
honey bee calls for advice, reports pain and localized swelling, but denies any
respiratory distress or other systemic signs of anaphylaxis. What is the action
that you should direct the caller to perform?
a. Call 911. b. Remove the stinger by scraping.
c. Apply a cool compress. d. Take an oral antihistamine.
23.In relation to submersion injuries, which task is most appropriate to delegate
to an LPN/LVN?
a. Talk to a community group about water safety issues.
b. Stabilize the cervical spine for an unconscious drowning victim.
c. Remove wet clothing and cover the victim with a warm blanket.
d. Monitor an asymptomatic near-drowning victim.
24.You are assessing a patient who has sustained a cat bite to the left hand. The
cat is up-to-date immunizations. The date of the patient’s last tetanus shot is
unknown. Which of the following is the priority nursing diagnosis?
a. Risk for Infection related to organisms specific to cat bites
b. Impaired Skin Integrity related to puncture wounds
c. Ineffective Health Maintenance related to immunization status
d. Risk for Impaired Mobility related to potential tendon damage
25.These patients present to the ED complaining of acute abdominal pain.
Prioritize them in order of severity.
a. A 35-year-old male complaining of severe, intermittent cramps with three
episodes of watery diarrhea, 2 hours after eating
b. A 11-year-old boy with a low-grade fever, left lower quadrant tenderness,
nausea, and anorexia for the past 2 days
c. A 40-year-old female with moderate left upper quadrant pain, vomiting small
amounts of yellow bile, and worsening symptoms over the past week
d. A 56-year-old male with a pulsating abdominal mass and sudden onset of
pressure-like pain in the abdomen and flank within the past hour
26.The nursing manager decides to form a committee to address the issue of
violence against ED personnel. Which combination of employees is best suited to
fulfill this assignment?
a. ED physicians and charge nurses
b. Experienced RNs and experienced paramedics
c. RNs, LPN/LVNs, and nursing assistants
d. At least one representative from each group of ED personnel
27.In a multiple-trauma victim, which assessment finding signals the most
serious and life-threatening condition?
a. A deviated trachea b. Gross deformity in a lower extremity
c. Decreased bowel sounds d. Hematuria
28.A patient in a one-car rollover presents with multiple injuries. Prioritize the
interventions that must be initiated for this patient.
a. Secure/start two large-bore IVs with normal saline
b. Use the chin lift or jaw thrust method to open the airway.
c. Assess for spontaneous respirations
d. Give supplemental oxygen per mask.
e. Obtain a full set of vital signs.
f. Remove patient’s clothing.
g. Insert a Foley catheter if not contraindicated.
29.In the work setting, what is your primary responsibility in preparing for disaster
management that includes natural disasters or bioterrorism incidents?
a. Knowledge of the agency’s emergency response plan
b. Awareness of the signs and symptoms for potential agnets of bioterrorism
c. Knowledge of how and what to report to the CDC
d. Ethical decision-making about exposing self to potentially lethal substances
30.You are giving discharge instructions to a woman who has been treated for
contusions and bruises sustained during an episode of domestic violence. What
is your priority intervention for this patient?
a. Transportation arrangements to a safe house
b. Referral to a counselor
c. Advise about contacting the police
d. Follow-up appointment for injuries
RATIO ER
1. ANSWER C – Triage requires at least one experienced RN. Pairing an
experienced RN with inexperienced RN provides opportunities for mentoring.
Advanced practice nurses are qualified to perform triage; however, their services
are usually required in other areas of the ED. An LPN/LVN is not qualified to
perform the initial patient assessment or decision making. Pairing an experienced
RN with a nursing assistant is the second best option, because the assistant can
obtain vital signs and assist in transporting.
2. ANSWER B, A, D, C – An irritable infant with fever and petechiae should be
further assessed for other meningeal signs. The patient with the head wound
needs additional history and assessment for intracranial pressure. The patient
with moderate abdominal pain is uncomfortable, but not unstable at this point.
For the ankle injury, medical evaluation can be delayed 24 – 48 hours if
necessary.
3. ANSWER C – A brief neurologic assessment to determine level of
consciousness and pupil reaction is part of the primary survey. Vital signs,
assessment of the abdomen, and initiation of pulse oximetry are considered part
of the secondary survey.
4. ANSWER D – Chest pain is considered an emergent priority, which is defined
as potentially life-threatening. Patients with urgent priority need treatment within
2 hours of triage (e.g. kidney stones). Non-urgent conditions can wait for hours or
even days. (High urgent is not commonly used; however, in 5-tier triage systems,
High urgent patients fall between emergent and urgent in terms of the time
lapsing prior to treatment).
5. ANSWER A – The nursing assistant can assist with the removal of the outer
clothing, which allows the heat to dissipate from the child’s skin. Advising and
explaining are teaching functions that are the responsibility of the RN. Tepid
baths are not usually performed because of potential for rebound and shivering.
6. ANSWER D – The homeless person has symptoms of heat stroke, a medical
emergency, which increases risk for brain damage. Elderly patients are at risk for
heat syncope and should be educated to rest in cool area and avoid future
similar situations. The runner is having heat crams, which can be managed with
rest and fluids. The housewife is experiencing heat exhaustion, and management
includes fluids (IV or parenteral) and cooling measures. The prognosis for
recovery is good.
7. ANSWER B, D, A, C, E – Establish unresponsiveness first. (The patient may
have fallen and sustained a minor injury.) If the patient is unresponsive, get help
and have someone initiate the code. Performing the chin lift or jaw thrust
maneuver opens the airway. The nurse is then responsible for starting CPR.
CPR should not be interrupted until the patient recovers or it is determined that
heroic efforts have been exhausted. A crash cart should be at the site when the
code team arrives; however, basic CPR can be effectively performed until the
team arrives.
8. ANSWER A – Nursing assistants are trained in basic cardiac life support and
can perform chest compressions. The use of the bag-valve mask requires
practice and usually a respiratory therapist will perform this function. The nurse
or the respiratory therapist should provide PRN assistance during intubation. The
defibrillator pads are clearly marked; however, placement should be done by the
RN or physician because of the potential for skin damage and electrical arcing.
9. ANSWER C – The patient is hyperventilating secondary to anxiety, and
breathing into a paper bag will allow rebreathing of carbon dioxide. Also,
encouraging slow breathing will help. Other treatments such as oxygen and
medication may be needed if other causes are identified.
10. ANSWER C – The fast track clinic will deal with relatively stable patients.
Triage, trauma, and pediatric medicine should be staffed with experienced
nurses who know the hospital routines and policies and can rapidly locate
equipment.
11. ANSWER A – Iron is a toxic substance that can lead to massive hemorrhage,
coma, shock, and hepatic failure. Deferoxame is an antidote that can be used for
severe cases of iron poisoning. Other information needs additional investigation,
but will not change the immediate diagnostic testing or treatment plan.
26. ANSWER D – At least one representative from each group should be
included because all employees are potential targets fro violence in the ED.
27. ANSWER A – A deviated trachea is a symptoms of tension pneumothorax.
All of the other symptoms need to be addressed, but are of lesser priority.
28. ANSWER C, B, D, A, E, F, G – For a multiple trauma victim, many
interventions will occur simultaneously as team members assist in the
resuscitation. Methods to open the airway such as the chin lift or jaw thrust can
be used simultaneously while assessing for spontaneous respirations. However,
airway and oxygenation are priority. Starting IVs for fluid resuscitation is part of
supporting circulation. (EMS will usually establish at least one IV in the field.)
Nursing assistants can be directed to take vitals and remove clothing. Foley
catheter is necessary to closely monitor output.

12. ANSWER C – The LPN/LVN is able to listen and provide emotional support
for her patients. The other tasks are the responsibility of an RN or, if available, a
SANE (sexual assault nurse examiner) who has received training to assess,
collect and safeguard evidence, and care for these victims.
13. ANSWER C, B, D, A – The victim should be removed from the cold
environment first, and then the rewarming process can be initiated. It will be
painful, so give pain medication prior to immersing the feet in warmed water.
14. ANSWER C – The only correct intervention is C. the digits should be gently
cleansed with normal saline, wrapped in sterile gauze moistened with saline, and
placed in a plastic bag or container. The container is then placed on ice.
29. ANSWER A – In preparing for disasters, the RN should be aware of the
emergency response plan. The plan gives guidance that includes roles of team
members, responsibilities, and mechanisms of reporting. Signs and symptoms of
many agents will mimic common complaints, such as flu-like symptoms.
Discussions with colleagues and supervisors may help the individual nurse to
sort through ethical dilemmas related to potential danger to self.
30. ANSWER A – Safety is a priority for this patient, and she should not return to
a place where violence could reoccur. The other options are important for the
long term management of this care.

15. ANSWER B – IV Lorazepam (Ativan) is the drug of choice for status

epilepticus. Tegretol is used in the management of generalized tonic-clonic,
absence or mixed type seizures, but it does not come in an IV form. PO (per os)
medications are inappropriate for this emergency situation. Magnesium sulfate is
given to control seizures in toxemia of pregnancy.

16. ANSWER C – Parent refusal is an absolute contraindication; therefore, the

physician must be notified. Tetanus status can be addressed later. The RN can
restart the IV and provide information about conscious sedation; if the parent still
notsatisfied, the physician can give more information.

17. ANSWER D – The patient presents with symptoms of alcohol abuse and
there is a risk for Wernicke’s syndrome, which is caused by a thiamine
deficiency. Multiples drug abuse is not uncommon; however, there is nothing in
the question that suggests an opiate overdose that requires naloxone. Additional
information or the results of the blood alcohol level are part of the total treatment
plan but should not delay the immediate treatment.

18. ANSWER C – Postmortem care requires some turning, cleaning, lifting, etc.,
and the nursing assistant is able to assist with these duties. The RN should take
responsibility for the other tasks to help the family begin the grieving process. In
cases of questionable death, belongings may be retained for evidence, so the
chain of custody would have to be maintained.

19. ANSWER C, D, B, A – Auscultating and confirming equal bilateral breath

sounds should be performed in rapid succession. If the sounds are not equal or if
the sounds are heard over the mid-epigastric area, tube placement must be
corrected immediately. Securing the tube is appropriate while waiting for the x-
ray study.

20. ANSWER B – An impaled object may be providing a tamponade effect, and

removal can precipitate sudden hemodynamic decompensation. Additional
history including a more definitive description of the blood loss, depth of
penetration, and medical history should be obtained. Other information, such as
the dirt on the stick or history of diabetes, is important in the overall treatment
plan, but can be addressed later.

21. ANSWER A – The patient demonstrates neurologic hyperactivity and is on

the verge of a seizure. Patient safety is the priority. The patient needs
chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin
(Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to
address the other problems. The other diagnoses are pertinent but not as
immediate.

22. ANSWER B – The stinger will continue to release venom into the skin, so
prompt removal of the stinger is advised. Cool compresses and antihistamines
can follow. The caller should be further advised about symptoms that require 911
assistance.

23. ANSWER D – The asymptomatic patient is currently stable but should be

observed for delayed pulmonary edema, cerebral edema, or pneumonia.
Teaching and care of critical patients is an RN responsibility. Removing clothing
can be delegated to a nursing assistant.

24. ANSWER A – Cat’s mouths contain a virulent organism, Pasteurella

multocida, that can lead to septic arthritis or bacteremia. There is also a risk for
tendon damage due to deep puncture wounds. These wounds are usually not
sutured. A tetanus shot can be given before discharge.

25. ANSWER D, B, C, A – The patient with a pulsating mass has an abdominal

aneurysm that may rupture and he may decompensate suddenly. The 11-year-
old boy needs evaluation to rule out appendicitis. The woman needs evaluation
for gallbladder problems that appear to be worsening. The 35-year-old man has
food poisoning, which is usually self-limiting.