1.

Using the principles of standard precautions, the nurse would wear gloves in what nursing
interventions?

A. Providing a back massage

B. Feeding a client
C. Providing hair care
D. Providing oral hygiene

2. The nurse is preparing to take vital sign in an alert client admitted to the hospital with
dehydration secondary to vomiting and diarrhea. What is the best method used to assess the
client’s temperature?
A. Oral
B. Axillary
C. Radial
D. Heat sensitive tape
3. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document
these findings as:

A. Tachypnea
B. Hyperpyrexia
C. Arrhythmia
D. Tachycardia
4. Which of the following actions should the nurse take to use a wide base support when
assisting a client to get up in a chair?

A. Bend at the waist and place arms under the client’s arms and lift
B. Face the client, bend knees and place hands on client’s forearm and lift
C. Spread his or her feet apart
D. Tighten his or her pelvic muscles

5. A client had oral surgery following a motor vehicle accident. The nurse assessing the client
finds the skin flushed and warm. Which of the following would be the best method to take the
client’s body temperature?

A. Oral
B. Axillary
C. Arterial line
D. Rectal
6.A client who is unconscious needs frequent mouth care. When performing a mouth care, the
best position of a client is:

A. Fowler’s position
B. Side lying
C. Supine
D. Trendelenburg
7. A client is hospitalized for the first time, which of the following actions ensure the safety of
the client?

A. Keep unnecessary furniture out of the way

B. Keep the lights on at all time

C. Keep side rails up at all time

D. Keep all equipment out of view

8. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea.
The nurse takes the client’s vital sign hereafter. What phrase of nursing process is being
implemented here by the nurse?

A. Assessment
B. Diagnosis
C. Planning
D. Implementation
9. It is best describe as a systematic, rational method of planning and providing nursing care for
individual, families, group and community

A. Assessment
B. Nursing Process
C. Diagnosis
D. Implementation
10. Exchange of gases takes place in which of the following organ?

A. Kidney
B. Lungs
C. Liver
D. Heart
11.Which of the following cluster of data belong to Maslow’s hierarchy of needs

A. Love and belonging

B. Physiologic needs
C. Self actualization
D. All of the above

12.This is characterized by severe symptoms relatively of short duration.

A. Chronic Illness
B. Acute Illness
C. Pain
D. Syndrome
13.Which of the following is the nurse’s role in the health promotion

A. Health risk appraisal

B. Teach client to be effective health consumer

C. Worksite wellness

D. None of the above

14.The nurse should not take a rectal temperature of a patient who has:

A. His arm in a cast

B. Nasal packing
C. External hemorrhoids
D. Gastrostomy feeding tubes

15.A sudden redness of the skin is known as:

A. Flush
 B. Cyanosis
C. Jaundice
D. Pallor

16.According to Maslow's hierarchy of needs, which of the following is a basic physiologic need
after oxygen?
A. Activity
B. Safety
C. Love
D. Self esteem

17.A patient states that he has difficulty sleeping in the hospital because of noise. Which of the
following would be an appropriate nursing action?

A. Administer a sedative at bedtime, as ordered by the physician

B. Ambulate the patient for 5 minutes before he retires
C. Give the patient a glass of warm milk before bedtime
D. Close the patient's door from 9pm to 7am

18. Which of the following clients is experiencing an abnormal change in vital signs? A
client whose (select all that apply):

1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening
3) Heart rate was 76 before eating and is 60 after eating
4) Respiratory rate was 14 when standing and is 22 after walking

19. A client who has experienced prolonged exposure to the cold is admitted to the hospital.
Which method of taking a temperature would be most appropriate for this client?

1) Axillary with an electronic thermometer

2) Oral with a glass thermometer
3) Rectal with an electronic thermometer
4) Tympanic with an infrared thermometer

20. A patient is agitated and continues to try to get out of bed. The nurse tries
unsuccessfully to reorient him. What should the nurse do next?
a. Apply a vest restraint.
b.Move the patient to a quieter room.
c. Ask another nurse to care for the patient.
d. Provide comfort measures.
21. Which change in hygiene practices may be necessary as the patient ages?

1) Brushing teeth twice a day

2) Bathing every other day
3) Decreasing moisturizer use
4) Increasing soap use

22. For a morbidly obese patient, which intervention should the nurse choose to counteract
the pressure created by the skin folds?

1) Cover the mattress with a sheepskin.

2) Keep the linens wrinkle free.
3) Separate the skin folds with towels.
4) Apply petrolatum barrier creams.

23. In which step of the nursing process does the nurse analyze data and identify client
problems?

1) Assessment
2) Diagnosis
3) Planning outcomes
4) Evaluation

24. In which phase of the nursing process does the nurse decide whether her actions have
successfully treated the client's health problem?

) Assessment
2) Diagnosis
3) Planning outcomes
4) Evaluation

25. Arrange the steps of the nursing process in the sequence in which they generally occur.

A. Assessment
B. Evaluation
C. Planning outcomes
D. Planning interventions
E. Diagnosis

1) E, B, A, D, C
2) A, B, C, D, E
3) A, E, C, D, B
4) D, A, B, E, C

26. The nurse wishes to identify nursing diagnoses for a patient. She can best do this by
using a data collection form organized according to (select all that apply):
1) A body systems model
2) A head-to-toe framework
3) Maslow's hierarchy of needs
4) Gordon's functional health patterns

27. The nurse is preparing to admit a patient from the emergency department. The
transferring nurse reports that the patient with chronic lung disease has a 30+ year history of
tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very
hard to quit smoking. She immediately thinks to herself, "I know I tend to feel negatively
about people who use tobacco, especially when they have a serious lung condition; I figure if
I can stop smoking, they should be able to. I must remember how physically and
psychologically difficult that is, and be very careful not to let be judgmental of this patient."
This best illustrates:

1) Theoretical knowledge
2) Self-knowledge
3) Using reliable resources
4) Use of the nursing process

28. A patient is admitted with shortness of breath, so the nurse immediately listens to his breath
sounds. Which type of assessment is the nurse performing?
1) Ongoing assessment
2) Comprehensive physical assessment
3) Focused physical assessment
4) Psychosocial assessment

29. Constipation is a common problem for immobilized patients because of:

A.Decreased peristalsis and positional discomfort

B.An increased defacation reflex
C.Decreased tightening of the anal sphincter
D.Increased colon motility

30. You are working with a client who has a respiratory disease. You find that this client is able
to breathe only in an upright or standing position. In charting, you could describe the difficulty
breathing in any position other than an upright or standing position, or you could use the medical
term for this condition, which is:
A. orthopnea.
B. tachypnea.
C. bradypnea.
31. 3. A rectal glass temperature is taken for
a. 5 minutes
b. 3 minutes
c. 2 minutes
d. 10 minutes

32. The most accurate temperature is the

a. oral
b. axillary
c. rectal
d. tympanic

33. If a person’s heart doesn’t always beat hard enough to produce a wave of blood, their
pulse would be

a. irregular
b. regular
c. bounding
d. thread

34. The number of pulse, heartbeats, or respirations per minute is

a. quality
b. rate
c. volume
d. vital signs

35. On a Fahrenheit glass thermometer, how many degrees do the short lines indicate?
a. 1 degree
b. 2 degrees
c. 0.1 degree
d. 0.2 degree

36. If you count nine respirations in 30 seconds, you would report

a. 27 respirations per minute
b. 9 respirations per minute
c. 18 respirations per minute

37. A rectal temperature is not taken when a person

a. is unconscious
b. needs a core body temperature measurement
c. has a nasogastric tube
d. has had rectal surgery

38. If a person has a blue cast to their nail beds and feels cold to the touch, we say they
have
a. a pulse deficit
b. an irregular pulse rate
c. poor perfusion
d. a bounding pulse

39. Temperatures are not taken orally if a patient is receiving oxygen.

a. true
b. false

40. A nursing diagnosis represents the:

a. Proposed plan of care

b. Patient’s health problems
c. Assessment of patient’s data
d. Actual nursing intervention

41. The primary purpose for the regulation of nursing practice is to protect:

a. The public
b. Practicing nurses
c. The employing agency
d. Professional standards

42. The nurse is aware that the term bradycardia means:

a. a grossly irregular heartbeat
b. a heart rate of over 90 per minute
c. a heart rate of under 60 per minute
d. a heartbeat that has regular “skipped” beats

43. In Basic Life Support what does the acronym D R A B C D stand for?

a. Danger, Responsive, Airway, Breaths, Compressions, Defibrillation

b. Danger, Reaction, Airway, Breathing, Circulation, Defibrillation.

c. Defibrillation, Responsive, Airway, Compressions, Danger.

44. What do you look for when checking for “Absence of signs of life”?

a Unconscious.

b Unresponsive.

c Not breathing normally

. d All of the above.

45.A client who has experienced prolonged exposure to the cold is admitted to the hospital.
Which method of taking a temperature would be most appropriate for this client?

a.Axillary with an electronic thermometer

b .Oral with a glass thermometer
c. Rectal with an electronic thermometer
d. Tympanic with an infrared thermometer

46. 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with
dehydration. A nursing diagnosis of Risk for Impaired Skin Integrity is identified for this patient.
Which factor places the client at Risk for Impaired Skin Integrity

A. Dehydration
B. Constipation
C. Pain

47) For a morbidly obese patient, which intervention should the nurse choose to counteract the
pressure created by the skin folds?
a. Cover the mattress with a sheepskin.
b. Keep the linens wrinkle free.
c. Separate the skin folds with towels.
d. Apply petrolatum barrier creams.

48) The nurse is preparing to admit a patient from the emergency department. The
transferring nurse reports that the patient with chronic lung disease has a 30+ year history of
tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very
hard to quit smoking. She immediately thinks to herself, "I know I tend to feel negatively
about people who use tobacco, especially when they have a serious lung condition; I figure if
I can stop smoking, they should be able to. I must remember how physically and
psychologically difficult that is, and be very careful not to let be judgmental of this patient."
This best illustrate
a.Theoreticalknowledge
b.Self-knowledge
c.Usingreliableresources
d.Use of the nursing process

49)Which of the following is an example of appropriate behavior when conducting a client

interview?
a. Recording all the information on the agency-approved form during the interview
b. Asking the client, "Why did you think it was necessary to seek health care at this time?"
c. Using precise medical terminology when asking the client questions
d. Sitting, facing the client in a chair at the client's bedside, using active listening

50) The nurse calculates a body mass index (BMI) of 16 for a young adult woman who
comes to the physician's office for a college physical. This patient is considered:
a. Obese
b. Overweight
c. Average
d. Underweight

51) Constipation is a common problem for immobilized patients because of:

a. Decreased peristalsis and positional discomfort
b.An increased defecation reflex
c.Decreased tightening of the anal sphincter
d.Increased colon motility

52) A patient states that he has difficulty sleeping in the hospital because of noise. Which of the
following would be an appropriate nursing action?
a.Administer a sedative at bedtime, as ordered by the physician
b.Ambulate the patient for 5 minutes before he retires
c.Give the patient a glass of warm milk before bedtime
d.Close the patient's door from 9pm to 7am.

53) Which of the following statements does the nurse most need to keep in mind when collecting
a sputum specimen?

a.Sputum is to be coughed up after a deep breath.

b.Healthy individuals can produce sputum.
c.Sputum is the same as saliva or "spit."
d.Mouth care is not to be given before collecting sputum.

54) When the nurse gathers baseline information on a client, the nurse will check the blood
pressure in both arms to detect deficits. There should be no more than how many mmHg
differences between the two?

a.25
b.18
c.15
d.10

55. How is the body mass index calculated?

(A) Weight in kilograms divided by height in meters (kg/m)

(B)Height in centimeters divided by weight in kilograms (cm/kg)
(C) Weight in grams divided by height in centimeters (g/cm)
(D) Weight in kilograms divided by height in meter squared (kg/m²)
(E) Weight in grams divided by height in meters (g/m)

56. What are the 6 elements in the chain of infection?

A. Agent, reservoir, portal of exit, portal of entry, mode of transportation, susceptible host

B. Agent, portal of growth, portal of exit, mode of transportation, susceptible host

C. Fungi, host, portal of entry, portal of exit, reservoir, agent, mode of transportation

57. What is the difference between Medical and Surgical asepsis?

A. One if clean and the other one is sterile

B. There is no difference

58. Objective data might include:

a) Chest pain.
b) Complaint of dizziness.
C) An evaluation of blood pressure
d) None of the above

59. Development of an infection occurs in a cycle that depends on the presenceof all the
following elements except:

A Causative agent,a portal of entry

b) Source for pathogen growth
c) Health care worker
d) A portal of exit, a mode of transmission, a susceptible host
60. All the flowing are essential standard precautions used in the care of all patients irrespective
of whether they are diagnosed infectious or not except one

A Hand hygiene
b Improper sharps and waste disposal
c Personal protective equipment
d Aseptic techniques

61. Which of the following is the appropriate route administration for insulin?

a) Intramuscular
b) Intradermal
c) Subcutaneous
d) Intravenous

62. There are many different nursing education program throughout the world that prepares
nurses which of these program is type of basic Nursing Programs

a) Diploma/Certificate Programs
b Baccalaureate Degree Programs in Nursing
c)Master's Degree Programs in Nursing
d) Doctoral Programs in Nursing

63. Which of the following is the meaning of PRN?

a) When advice
b)When necessary
c)Immediately
d)Now

64. he nurse is to administer an iron injection to an adult. How should this be administered?

a) Subcutaneous in the arm

b) Intradermal in the forearm
c) Intramuscular in the deltoid
d) Ztrack intramuscular in the gluteal

65. To assessment of immobilized patient focus on the following except

a)rangeof motion
b)activity tolerance
c )body alignment
d )Psychological condition
66. Non verbal massage is a mode of communication that include the following except

a) Tone& pitch ofvoice

b) Facial expression
c) Gesture
d) Touch
67. An instrument placed against a patient's chest to hear both lung and heart sounds.

a) stethoscope
b)otoscope
c) sphygmomanometer
d)telescope
68. Independent nursing intervention commonly used for immobilized patients include all of the
following except:

a. Active or passive ROM exercises, body repositioning, and activities of daily living (ADLs) as
tolerated
b. Deep breathing and coughing exercises with change of position every 2 hours
c. Diaphragmatic and abdominal breathing exercises and increased hydration
d. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy
69. Changes that occur in musculoskeletal system due to immobility

A decrease muscle endurance ,strength and mass

b Change in calcium metabolism with hyper calcium result in renal calculi
c) Alteration in calcium, fluid and electrolyte
d) Non of the above

70. A client has been admitted to a nursing home, and the nurse completes an assessment. Which
finding might lead the nurse to suspect a nutritional alteration?

a)Eye clear
b) Shiny hair
c)Ridged nails
d) Moist conjunctiva