NLE QUESTIONS

1. A client comes to the emergency department for checkup. While waiting for the
physician the client starts complaining of low abdominal pain and hematuria. The client
is afebrile. The nurse next assesses the client to determine a history of:

a. Blow or trauma to the bladder or abdomen

b. Renal cancer in the client’s family
c. Pyelonephritis
d. Glomerulonephritis

ANSWER: A. Blow or trauma to the bladder or abdomen

RATIONALE: Bladder trauma or injury should be considered or suspected in the client
with low abdominal pain and hematuria.

2. A nurse is caring for a post-partum client and monitoring signs of bleeding. Which of
the following signs, if noted in the mother, would be an early sign of excessive blood
loss?

a. A BP change from 130/88 to 124/80 mmHg

b. An increase in the respiratory rate from 18 to 22 breaths per minute
c. An increase in the pulse rate from 88 to 102 beats per minute
d. A temperature of 100.4 degree Fahrenheit

ANSWER: C. An increase in the pulse rate from 88 to 102 beats per minute
RATIONALE: During the fourth stage of labor, the maternal blood pressure, pulse and
respiration should be checked every 15 minutes during the first hour. A rising pulse is an
early sign of excessive blood loss because the heart pumps faster to compensate for
reduced blood volume. The blood pressure will fall as the blood volume diminishes but
a decreased in blood pressure would not be the earliest sign of hemorrhage.

3. A nurse is performing tracheostomy care to the client and replaced the

tracheostomy tube holder. The nurse ensures that the tube holder is not too tight by
checking if:

a. The tracheostomy does not move more than ½ inch when the client is
coughing
b. Four fingers can be slid comfortably under the holder
c. The client nod that he or she feels comfortable
d. Two fingers can slid comfortably under the holder
ANSWER: D. Two fingers can slid comfortably under the holder
RATIONALE: There should be enough room for two fingers to slide comfortably under the
tracheostomy holder. This ensures that the holder is tight enough to present
tracheostomy dislocation, while preventing excessive constriction around the neck.

4. A nurse in night shift is making rounds. The nurse enters the client’s room and found
out that the client becomes disoriented and confused. The best initial nursing
intervention is to:

a. Move the client to the nurses station

b. Play soft music during the night, and maintain well-lit room
c. Keep the television and a soft light on during the night
d. Use a night light and turn of the television

ANSWER: D. Use a night light and turn of the television

RATIONALE: Provision of a consistent daily routine and a low stimulating environment is
important when the client is oriented. Noise, including radio and television, may add to
the confusion and disorientation.

5. A nurse is assigned to a client scheduled for a colonoscopy and the physician has
provided detailed information to the client about then procedure. After confirming if
the client clearly understand the procedure, the nurse prepares the informed consent
for the client to sign it. The client informs the nurse that he does not know how to write.
What is the nurse appropriate action?

a. Send the client for the procedure without a signed informed consent
b. Contact a family member to present for the client and sign the inform
consent form
c. Contact the physician and inform that the client cannot write
d. Obtain a second nurse to also act as a witness and ask the client to
sign the form with an X

ANSWER: Obtain a second nurse to also act as a witness and ask the client to sign the
form with an X
RATIONALE: Clients cannot write may sign an informed consent with an X. this is
witnessed by two nurses. Nurses serve as a witness to the client’s signature and not to
the fact that the client is informed. It is the physician’s responsibility to inform the client
about a procedure. The nurse clarifies the facts presented by the physician. There is no
useful reason to contact the physician at this time. A client is not send to a procedure
without a signed informed consent.
6. A physician scheduled the client for pulmonary angiography. The client is fearful
about the procedure and ask the nurse if it is painful and if there is radiation exposure.
The nurse provides reassurance to the client based on the understanding that:

a. The procedure is somewhat painful, but there is minimal exposure to

radiation.
b. There is a very mild pain throughout the procedure and the exposure
to radiation is negligible
c. Discomfort may occur with needle insertion and there is minimal
exposure to radiation
d. There is absolutely no pain, although a moderate amount of radiation
must be used to get accurate result.

ANSWER: C. Discomfort may occur with needle insertion and there is minimal exposure
to radiation
RATIONALE: Pulmonary angiography involves minimal exposure to radiation. The
procedure is painless although the client may feel discomfort with insertion of the
needle for the catheter that is used for dye injection.

7. A client comes to the clinic for a checkup and complains skin irritation. The client is
advised to be back in the clinic 1 week for scratch skin test. The nurse provides which
instruction to the client?

a. Consume only fluids on the day of the test

b. Do nor ingest anything before the test
c. Shower using an antibacterial soap on the morning of the test
d. Discontinue the prescribed antihistamine 5 days before the test

ANSWER: D. Discontinue the prescribed antihistamine 5 days before the test

RATIONALE: Client preparation for the scratch skin test includes informing the client to
discontinue the administration of systemic corticosteroids or antihistamines for at least 5
days before the test. This medication must be discontinues to prevent suppression of the
inflammatory response to the allergen.

8. The nurse is caring for a client who had skeletal traction applied to the left leg. The
client asks the nurse how long he will stay in that condition. While talking to the nurse,
the client complaints of severe left leg pain. Which of the following actions should the
nurse take first?

a. Call the physician

b. Medicate the client with analgesic
c. Provide pin care
 d. Check the client’s alignment in bed

ANSWER: D. Check the client’s alignment in bed

RATIONALE: The nurse realigns the client and if that is ineffective then call the physician.

9. A client is admitted in short stay unit after the myelogram. A water-based contrast
agent was used. The nurse would give information to the client regarding activity
restrictions. Which of the following activity would the client avoid?

a. Bed rest for 6-8 hours, with head of bed flat

b. Bed rest for 2-4 hours, with head of bed flat
c. Bed rest for 2-4 hours, with head of bed elevated 15-30 degrees
d. Bed rest for 6-8 hours, with head of bed elevated 15-30 degrees

ANSWER: D. Bed rest for 6-8 hours, with head of bed elevated 15-30 degrees
RATIONALE: Following a myelogram, the client is placed on bed rest for 6-8 hours after
the procedure. When a water based contrast medium is used, the client is position with
the head of bed elevated 15-30 degrees.

10. A nurse is caring for a 12 year old female client who is a victim of physical and
sexual abuse. The client is newly admitted in the hospital and the nurse performs
assessment about the case of the client. Following assessment, the nurse founds out
that the child’s father is the abuser. That time, the father arrives and angrily approaches
the nurse and says, “I’m taking my daughter home. She told me what you people are
up to and we’re out of here!” The nurse makes which therapeutic response to the
child’s father?

a. “Over my dead body you will! She’s here and here she stays until the
doctor says different”
b. “Your doctor is sick and needs to be here.”
c. “Listen to me. If you attempt to take your daughter from this unit, the
police will bring her back”
d. “You seem very upset. Let’s talk at the nurse’s station. I want to help
you. It would be best if you agree to let your daughter stay here for
now.”

ANSWER: D. “You seem very upset. Let’s talk at the nurse’s station. I want to help you. It
would be best if you agree to let your daughter stay here for now.”
RATIONALE: When a suspected abused child is admitted to the hospital for further
evaluation and protection, the physician will usually work with the parents so they will
agree to the admission. Of the parents refuse to agree to the admission, the hospital
can request an immediate court order to retain the child for a specific length of time.
11. A client is starting a therapy with oxtriphylline (Choledyl). A nurse plans to teach the
client to limit the intake of which of the following while taking the medication?

a. Oysters lobster and shrimp

b. Cottage cheese, cream cheese, and dairy creamers
c. Grapefruit, oranges and pineapple
d. Coffee, cola and chocolate

ANSWER: D. Coffee, cola and chocolate

RATIONALE: Oxytriphylline is a xanthine bronchodilator. The nurse teaches the client to
limit the intake of xanthine containing food when taking this medication.

12. The nurse is reviewing the prescribed medication of a newly admitted client. The
nurse reviewed the order and notes that the physician has ordered the dose that is
twice the amount the client is taking before admission. The nurse verifies the medication
dose before the administration. What is the next most appropriate nursing action?

a. Administer the drug even the dosage is twice the amount because that is the
order of the physician
b. Verify the prescribed medication by calling the nurse supervisor
c. Carry out the order because there is no question about it
d. Contact the physician and verify the order

ANSWER: D. Contact the physician and verify the order

RATIONALE: If a nurse determines that a physician’s order is unclear, or if the nurse has a
question about an order, the nurse should contact the physician, before implementing
the order. Under no circumstances should the nurse carry out the order unless the
physician has clarified the order.

13. A nurse is caring for a client taking Trimethoprim-sulfamethoxazole (Bactrim). A nurse

instructed the client to report signs and symptoms that might be developed during the
course of the therapy:

a. Sore throat
b. Headache
c. Diarrhea
d. Nausea

ANSWER: A. Sore throat

RATIONALE: Client’s taking Trimethoprim-sulfamethoxazole should be informed about
early signs of blood disorder that can occur from this medication.

14. The nurse is assigned to monitor the condition of a 1 day postpartum client in the
postpartum room. The nurse notes that the lochia discharge of the client is red and has
foul smelling odor. The nurse determines that this assessment finding is:

a. Normal
b. Indicates the presence of infection
c. Indicates the need for increasing ambulation
d. Indicates the need for increasing oral fluids

ANSWER: B. Indicates the presence of infection

RATIONALE: Lochia, the discharge after birth is not for the first 1 to 3 days and gradually
decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia
indicates infection and these findings are not normal.

15. The nurse is discharging a client with chronic anxiety. The nurse wants to ensure a
safe environment for the client. The most appropriate maintenance goal should focus
on which of the following?

a. Eliminating all anxiety form daily situations

b. Identifying anxiety-producing situations
c. Continued contact with a crisis counselor
d. Ignoring feeling of anxiety

ANSWER: B. Identifying anxiety-producing situations

RATIONALE: Recognizing situations that produce anxiety allows the client to prepare to
cope with anxiety or avoid a specific stimulus. Counselors will not be available for all
anxiety producing situations, and this option does not encourage the development of
internal strength. Ignoring feelings will not resolve anxiety.

16. The nursing instructor provides a lecture to the nursing students regarding some
rights of the clients. The instructor asks the student to identify a situation that represents
an example of battery. Which of the following items indicates an understanding of a
violation of this right?

a. Threatening the client that he cannot leave the hospital

b. Performing a procedure without consent of the client
c. Threatening the client to take the medication
d. Sharing the client’s record to other personnel not involve in providing care
ANSWER: B. Performing a procedure without consent of the client
RATIONALE: Performing a procedure without consent of the client is a form of battery.
Threatening the client that he cannot leave the hospital constitute false imprisonment.
Threatening the client to take the medication is an example of assault and sharing the
client’s record to other personnel not involve in providing care is a form of invasion of
privacy.

17. A nurse is caring for a client admitted in the labor room. The nurse is completing an
assessment on a pregnant client in labor. The nurse notes the presence of the umbilical
cord protruding from the vagina. Which of the following would be the initial nursing
action?

a. Find the closest telephone and stat page the physician

b. Gently push the cord into the vagina
c. Call the delivery room to notify the staff that the client will be transported
immediately
d. Place the client in a Trendelenburg position

ANSWER: D. Place the client in a Trendelenburg position

RATIONALE: When cord prolapse occurs, prompt actions are taken to relieve cord
compression and increase fetal oxygenation. The mother should be positioned with the
105 hips higher than the head to shift the fetal presenting part toward the diaphragm.
The nurse should push the call light to summon help, and the other staff members should
call the physician and notify the delivery room.

18. A mother brought her child to the emergency room after the ingestion of about one
half bottle of acetylsalicylic acid (aspirin). The nurse in charge in the mergency room
anticipates that the most likely first treatment will be:

a. Administration of vitamin K
b. Administration of sodium bicarbonate
c. Dialysis
d. Administration of ipecac

ANSWER: D. Administration of ipecac

RATIONALE: Initial treatment of salicylate overdose includes inducing vomiting with
syrup of ipecac.

19. A client in the mental health unit and diagnosed with major depression recurrent
with psychotic features. What would be the most important plan of care that would
create a safe environment for the client?
 a. Self-care Deficit
b. Disturbed thought process
c. Deficient Knowledge
d. Imbalanced Nutrition

ANSWER: B. Disturbed thought process

RATIONALE: Major depression, recurrent psychotic features alerts the nurse in addition to
the criteria that designates the diagnosis of major depression; one also must deal with
the client’s psychosis. Psychosis is defined as a state in which a person’s mental
capacity to recognize reality and to communicate and relate to others is impaired, thus
interfering with the person’s capacity to deal with the demand of life.

20. The nurse is assigned to care for a client with phobia. The nurse exposes this client to
a short period of time to the phobic object while in a calm state. The nurse understood
that this form of behaviour modification can best describe as?

a. A form of behaviour modification therapy

b. A cognitive approach to changing behaviour
c. A behavioural approach to changing behaviour
d. A living, learning or working environment

ANSWER: A. A form of behaviour modification therapy

RATIONALE: Systematic desensitization is a form of therapy used when the client is
introduced to short period of exposure to the phobic object while in a relax state.
Gradually exposure is increased until the anxiety about or fear of the objects or
situation has ceased.

21. A male client arrive at the health care clinic and tells the nurse that he would like to
be tested for Lyme disease. The client tells the nurse that he was bitten by a lick and
remove the tick and flushed it down the toilet. Which of the following nursing action is
best to the client?

a. Refer the client for blood test immediately

b. Inform the client to return in 4-6 weeks to be tested because testing before this
time is not reliable
c. Tell the client that testing is not necessary unless arthralgia
d. Inform the client that there is not a test reliable for Lyme disease

ANSWER: D. Inform the client to return in 4-6 weeks to be tested because testing before
this time is not reliable
RATIONALE: A blood test is available to detect Lyme disease however the test in reliable
if performed before 4-6 weeks following the tick bite.
22. The nurse enters the female client room to administer medication. Inside the room
the client is in manic state. She is naked and making sexual rewards and gestures
towards the nurse. The best initial nursing action is to:

a. Confront the client on the inappropriateness of the behavior and offer her a time
out.
b. Ask the other nurse to calm the client
c. Approach the client and insist that she has to put on her clothes
d. Quietly approach the client and assist her in getting dressed

ANSWER: D. Quietly approach the client and assist her in getting dressed
RATIONALE: A person experiencing mania lacks insight and judgement, has poor
impulse control and is highly excitable. The nurse must take control without creating
increased stress or anxiety to the client.

23. The nurse is caring for a newborn infant. A new employee will be assign to the unit
and the nurse needs to provide a teaching session regarding sudden infant syndrome
to her colleague. The nurse tells the new employee that SIDS usually occur during sleep
and

a. Most frequently occurs in girls

b. Most frequently occurs from 2-4 months of life
c. Most frequently occurs in toddlers
d. Most frequently occurs during summer months.

ANSWER: B. Most frequently occurs from 2-4 months of life

RATIONALE: sudden infant death syndrome usually occurs during sleep and during
winter months and most frequently occurs between the second and fourth month of life.
The syndrome is more common in boys.

24. When preparing the client for discharge after thyroidectomy, the nurse should
teach the client to observe for signs of hyperthyroidism. The nurse would be aware that
the client understands the teaching when the client says, “I should call my physician If I
develop:

a. Fatigue and an increased pulse rate

b. Muscle cramps and sluggishness
c. Dry hair and intolerance to cold
d. Tachycardia and an increased in weight

ANSWER: C. Dry hair and intolerance to cold

RATIONALE: Dry, sparse hair and cold intolerance are characteristics of adaptations to
low serum thyroxine.
25. A client diagnosed with multiple myeloma asks the nurse how the disease may
progress. In providing information to this client, the nurse should discuss the possibility
that:

a. Frequent Urinary Tract Infection may result

b. Blood transfusion may be necessary
c. Intravenous therapy may be administered at home
d. The disease is exacerbated by exposure to ultra violet rays

ANSWER: B. Blood transfusion may be necessary

RATIONALE: Blood products (packed RBC, or platelet) are administer when warranted.

26. A nurse enters the medication room and finds another nurse that is about to insert a
needle attached to the syringe containing a clear fluid into the antecubital area. The
nurse appropriate initial action is:

a. Lock the nurse inside the medication room until help is obtain
b. Call the police
c. Call the security
d. All the nursing supervisor

ANSWER: D. All the nursing supervisor

RATIONALE: Nurse Practice acts require reporting impaired nurse. This incident needs to
be reported to the nursing supervisor, who will then report to the board of nursing and
authorities.

27. A nurse formulated a plan of care for a client experiencing dystocia and includes
several nursing intervention in the plan of care. The nurse emphasizes the plan of care
and selects which of the following nursing interventions as the highest priority?

a. Monitoring the fetal heart rate

b. Providing comfort measure
c. Changing the clients position frequently
d. Keeping the significant other informed about the progress of labor

ANSWER: A. Monitoring fetal heart rate

RATIONALE: The priority is to monitor fetal heart rate. Although providing comfort
measures, changing the client’s position frequently and keeping the significant other
informed of the progress of the labor are component of the plan of care, the fetus status
would be appropriate
28. The nurse is performing a follow-up assessment with the client discharged a month
ago. The client is taking Flouxetine (Prozax). What would be the important information
the nurse need to obtain regarding the side effect related to the medication?

a. Gastrointestinal dysfunctions
b. Problems with excessive sweating
c. Cardiovascular symptoms
d. Problems with mouth dryness

ANSWER: A. Gastrointestinal dysfunction

RATIONALE: The most common side effects related to the medication includes central
nervous system and gastrointestinal system by causing nausea, vomiting, cramping and
diarrhea

The nurse is caring for a client with internal radiation implant. The nurse should observe
which of the following principles?

a. Limit the time with the client to 1 hour per shift

b. Individuals less than 16 years old may be allowed to go in the room as long as
they are 6th feet away from the client
c. Do not allow pregnant woman into the client’s room
d. Remove dosimeter badge when entering the client’s room

ANSWER: C. Do not allow pregnant woman into the client’s room.

RATIONALE: The time that the nurse spends in room of a client with an internal radiation
implants is 30 minutes per 8-hour shift. The dosimeter badge should be worn when in the
client’s room. Children younger than 16 years of age and pregnant women are not
allowed in the client’s room.

The nurse is assigned to monitor a client with a diagnosis of chronic gastritis. The nurse is
aware that this client is at risk for which of the following vitamin deficiency?

a. Vitamin E
b. Vitamin C
c. Vitamin B12
d. Vitamin A

ANSWER: C. Vitamin B12.

RATIONALE: Chronic gastritis causes deterioration and atrophy of the lining of the
stomach, leading to the loss of function of parietal cells. The source of the intrinsic factor
is loss which results inability to absorb vitamin B12.
29. The home health care nurse visits the client with cancer. The client is complaining of
pain. The most appropriate nursing assessment of the client’s pain would include which
of the following?

a. Pain relief after appropriate nursing intervention

b. Nonverbal cues from the client
c. The client’s pain rating
d. The nurse’s impression of the client’s pain

ANSWER: C. The client’s pain rating

RATIONALE: The client’s self-report is a critical component of pain assessment. The nurse
should ask the client about the description of the pain and listen carefully to the client’s
words used to describe the pain. The nurse’s impression of the client’s pain is not
appropriate in determining the client’s level of pain. Nonverbal cues of the client are
important but are not the most appropriate pain assessment measures.

30. A client is scheduled for indirect visualization of the larynx to assess the function of
the vocal cords. As the physician is performing the procedure, the nurse instructed the
client to do which of the following?

a. Try to swallow
b. Breath normally
c. Roll the tongue to the back of the mouth
d. Hold the breath

ANSWER: B. Breath normally

RATIONALE: Indirect laryngoscopy is done to assess the function of the vocal cords or to
obtain tissue for biopsy. Observations are made during rest and phonation by using
laryngeal mirror. The client is placed in an upright position to facilitate passage of
laryngeal mirror into the mouth and is instructed to breathe normally. The tongue would
not be move back because it occludes the airway. Swallowing cannot be done with
the mirror in place. The procedure takes longer that the time the client would be able to
hold the breath and this action is ineffective.

31. The client is unconscious in the physician assigned the nurse to do an

assessment. The nurse is assessing the motor function of the client. The nurse
would plan to use which of the following to test the client's peripheral response
to pain?
a. Pressure on the orbital rim
b. Squeezing of the sternocleidomastoid muscle
c. Sternal rub
d. Nail bed pressure
ANSWER: D. Nail bed pressure
RATIONALE: Motor testing of the unconscious client can be done only by testing
response to painful stimuli. Nail bed pressure tests a basic peripheral response.
Cerebral responses to pain tested using sternal rub, placing upward pressure on the
orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
32. An older client is admitted for hypertension and serum electrolytes studies have
abnormal results. The physician scheduled the client for an Aldosteronoma scan.
The Nurse recognizes that this scan is ordered to rule out disease of the:
a. Kidney cortex
b. Thyroid gland
c. Adrenal cortex
d. Pituitary gland

ANSWER: C. Adrenal Cortex

RATIONALE: An Aldosteronoma is an aldosterone secreting adrenal cortex.
33. The nurse planning to conduct a teaching session with the female client who is
diagnosed with urethritis caused by infection with Chlamydia. The nurse would
plan to include which of the following points in the teaching session?
a. The infection can be prevented by using spermicidal to alter the pH in the
perineal area.
b. Sexual partners during the last 12 months should be notified and treated.
c. Medication therapy should be continued for 3 weeks without interruption.
d. The most serious complication of this infection is sterility.

ANSWER: D. The most serious complication of this infection is sterility

RATIONALE: The most serious complication of Chlamydial infection is sterility. The
infection can be prevented by the use of latex condoms.
34. A client returns to his room following heart surgery. The nurse is aware that
Thrombus formation is a danger of all postoperative clients. The nurse should act
independently to prevent this complication by:
a. Massaging the client’s extremities
b. Urging the client to drink adequate fluids
c. Assisting the client to exercise in bed
d. Massaging the client’s extremities gently with lotion

ANSWER: C. Assisting the client to exercise in bed

RATIONALE: Inactivity causes venous stasis hypercoagulability, and arterial pressure
against the vein, all of which lead to thrombus formation, early ambulation in
exercise of the lower extremities reduce the occurrence of this phenomenon.
35. After a vehicle accident, client is scheduled for below-knee-amputation.
Following the surgery, the client tells the nurse, “I think I’m going crazy. I can feel
my left foot itching”. The nurse interprets the client’s statement to be:
a. An abnormal response that indicates the client is in denial about the limb
loss
 b. A normal response that indicates that the client needs more
psychological support
c. A normal response that indicates the presence of phantom limb
sensation
d. An abnormal response that indicates the presence of phantom limb pain

ANSWER: C. A normal response that indicates the presence of phantom limb

sensation
RATIONALE: Phantom limb sensation are felt in the area of the amputated limb.
These sensations can include itching, warmth and cold. The sensations are due to
intact peripheral nerves in the area amputated.
36. The nurse is planning an intervention to help a client with bipolar I disorder,
manic episode meet needs for rest and sleep, the nurse must remember that
the manic client:
a. Needs to expend energy to be tired enough to sleep
b. Is easily stimulated by the environment
c. Experiences few sleep pattern disturbances
d. Requires less sleep than the average person
ANSWER: B. Is easily simulated by the environment
RATIONALE: These individuals readily stimulation decrease activity.
37. The client had emergency coronary artery bypass surgery. The wife of the client
ask the nurse about the purpose of the dressing on the left leg of her husband,
the nurse best explain to the client’s wife that:
a. The arteries in distal extremities are examined during surgery
b. A filter is inserted in the leg to prevent embolization
c. This is the access site for the heart-lung machine
d. The saphenous vein was used to bypass the coronary artery

ANSWER: D. The saphenous vein was used to bypass the coronary artery
RATIONALE: This response provides information and reduce anxiety. The nurse
should understand that the greater saphenous vein in the leg is used to bypass the
diseased coronary artery because the surgical team can obtain the vein while the
other team perform the chest surgery, this shortens the surgical time and risk of
surgery.
38. The community health nurse is promoting cancer awareness program and
conducting a lecture on the female clients about breast examination. The nurse
would instruct the clients to perform the examination.
a. Weekly at the same time of the day
b. At the onset of menstrual period
c. Every month during ovulation
d. 1 week after menstrual begins

ANSWER: D. 1 week after menstrual begins

RATIONALE: The breast self-examination should be performed monthly seven days
after menstrual period.
 39. The home health nurse is conducting a home care instruction to the parents of
the child with congestive heart failure regarding the procedure for the
administration of digoxin (Lanoxin). Which statement if made by the parents
indicates the need for further instructions?
a. “I will take the child’s pulse before administering the medication”
b. “If the child vomits after medication administration, I will repeat the dose”
c. “I will not mix the medication with food”
d. “If more than 1 dose is missed, I will call the physician”

ANSWER: B. “If the child vomits after medication administration, I will repeat the
dose”
RATIONALE: The parents need to be instructed that if the child vomits after the
digoxin administered, they are not to be repeated

40. A newly admitted client with an acute myocardial infarction asks the nurse what
are the complications accompany this disease. The question of the client makes
the nurse aware that there is a possibility of death from complications. The nurse
should monitor the client during the first 48 hours is:
a. Ventricular tachycardia
b. Pulmonary embolism
c. Pulmonary edema
d. Failure of the Right Ventricle

ANSWER: A. Ventricular tachycardia

RATIONALE: At least ½ of all deaths occur from the life threatening dysthymias of
ventricular tachycardia.

41. A nurse provides a home care instruction to the parents of a child diagnosed with
celiac disease. The nurse teaches the parents of the child to include which of the
following food items in the child’s diet?

a. Rice
b. Oatmeal
c. Wheat bread
d. Rye toast

Answer: A. Rice.
Rationale: Dietary management is the mainstay of treatment in celiac disease. All
wheat, rye, barley, oats should be eliminated from the diet.

42. The nurse is caring for a client who suffered a second and third degree burn on the
anterior lower legs and anterior thorax. The client is just finished for an autograft and
grafting procedure. Which of the following would the nurse anticipate to be prescribed
for the client?
 a. Immobilization of the affected leg
b. Bathroom privileges
c. Placing the affected leg in a dependent position
d. Out of bed

Answer: A. Immobilization of the affected leg.

Rationale: Autograft placed over joints or on the lower extremities often are elevated
and immobilized following surgery for 3-7 days. This period immobilization allows the
autograft time to adhere and attach to the wound bed.

43. A nurse is caring to a client admitted in the labor room. The nurse performs an
assessment and monitors the fetal heart rate patterns. The nurse notes the presence of
episodic accelerations on the electronic fetal monitor tracing. Which of the following
actions is most appropriate?

a. Reposition the mother and check the monitor for changes in the fetal tracing
b. Notify the physician or nurse-midwife of the findings
c. Document the findings and tell the mother that the monitor indicates fetal well-
being
d. Take the mother’s vital signs and tell the mother that the bed rest is required to
conserve oxygen

Answer: C. Document the findings and tell the mother that the monitor indicates fetal
well-being.
Rationale: Acceleration are transient increase in the fetal heart rate that often
accompany contractions or are caused by fetal movement. Episodic accelerations are
thought to be a sign of fetal well-being and adequate oxygen reserve.

44. Female client with schizophrenia has been prescribed Chlorpromazine (Thorazine).
The client was alarmed with the color of her urine that becomes dark. The client has no
other urinary symptoms. The nurse tells the client:

a. That this is an expected side effect of the medication

b. To seek treatment for urinary tract infection
c. That this medication indicates toxicity
d. To increase intake of acid-ash foods and liquids

Answer: C. That this is an expected side effect of the medication.

Rationale: Chlorpromazine is and antipsychotic medication. A side effect of this
medication is that the color of the urine may darken. The client should be aware that
this effect is harmless
45. A severely depressed client is admitted in the mental health unit for 8 weeks. The
nurse observes that the client has not responded to any of the antidepressant
medication. The physician decides to try electroconvulsive therapy (ECT). Before the
treatment the nurse should:

a. Give the client a detailed explanation of the entire procedure

b. Have the client speak with other clients receiving ECT
c. Provide a simple explanation of the procedure and continue to reassure the
client
d. Limit the client’s intake to a light breakfast on the day of the treatment

Answer: C. Provide a simple explanation of the procedure and continue to reassure the
client.
Rationale: The nurse should offer support and use clear simple terms to allay the client’s
anxiety

46. A nurse is assisting in planning care to a newly admitted client. On entering the room
of the client, the nurse notes that the client’s legs are elevated. The trunk is position flat
and the head and shoulder are slightly elevated. The position of the client is
appropriate for prevention of:

a. Respiratory insufficiency
b. Shock
c. A head injury
d. Increased intracranial pressure

Answer: B. Shock.
Rationale: A client in shock is placed in a modified Trendelenburg position that includes
elevating the legs, leaving the trunk flat and elevated head and shoulders. This position
promotes increase venous return from the lower extremities without compressing the
abdominal organ against the diaphgram.

47. A nurse is developing a plan of care for a client who has had a cardiac
catherization, which of the following would the nurse include?

a. Keeping the client NPO for 4 hours after the procedure

b. Checking the vital signs every 15 minutes for 8 hours
c. Maintaining the supine position for a minimum of 4 hours
d. Ambulating the client 2hours after the procedure

Answer: C. Maintaining the supine position for a minimum of 4 hours.

Rationale: The supine position prevents hip flexion limiting injury and promoting healing
of the catheter insertion site; if the head of the bed is elevated, it should not exceed 20
degrees.

48. The mother of the child who had a myringotomy with insertion of tympanostomy
was so worried when the tubes have fallen out. The mother calls the nurse and asks for
immediate action. Which of the following is the most appropriate response of the nurse
to the mother?

a. “This is not an emergency, I will speak to the physician and call you right back”
b. “Place the tubes in hydrogen peroxide for 1 hour before replacing them in the
child’s ears”
c. “Replace the tube immediately so that the created opening does not close”
d. “This is an emergency and requires immediate intervention. Bring the child to the
emergency room”

Answer: D. “This is an emergency and requires immediate intervention. Bring the child to
the emergency room”
Rationale: the size and appearance of tampanostomy tube should be described to the
parents after surgery. They should be reassured that if the tube fall out, it is not an
emergency, but the physician should be notified.

49. A client is taking Amitriptyline hydrochloride (Elavil). The nurse evaluates that the
medication is most effective for this client if the client reports which of the following?

a. Having difficulty concentrating on an activity

b. Sleeping 14-16 hours a day
c. Ability to get to work on time each day
d. Decrease in appetite

Answer: C. Ability to get to work on time each day.

Rationale: Amitriptyline is a tricyclic antidepressant. Depressed individuals sleep for
extended periods, have a change in appetite, unable to go to work, and have difficulty
concentrating. They may also experience increased fatigue, feeling of guilt,
worthlessness, loss of interest in activities and possible suicidal tendencies

50. A postpartum client with a diagnosis of deep vein thrombosis is receiving a

continuous intravenous infusion of heparin sodium. The nurse reviews the laboratory
results and wants to know if the client is given an appropriate dose of heparin. Which of
the following laboratory results the nurse would check to determine if an effective dose
of the heparin is being delivered?
 a. Prothrombin time
b. International normalized ratio
c. Activated partial thromboplastin time
d. Platelet count

Answer: C. Activated partial thromboplastin time.

Rationale: Anticoagulation therapy may be used to prevent the extension of thrombus
by delaying the clotting time of the blood. Activated partial thromboplastin time should
be monitored, and the heparin dose should be adjusted to maintain a therapeutic level
of 1.5 – 2.5 times the control. The prothrombin time and the international normalized
ratio are used to monitor coagulation time when warfarin (Coumadin) is used. The
platelet count cannot be used to determine an adequate dosage for the heparin
infusion.

51. A nurse in charge observes that the staff nurse is not providing quality care to the
client, not able to meet client’s needs in a reasonable time frame, does not solve any
problem in the nursing unit and does not prioritize nursing care. Which of the following is
the responsibility of the charge nurse?
a. Report the staff nurse to the supervisor so that something is done to resolve the
problem
b. Ask other staff members to help the staff nurse get the work done
c. Supervise the staff nurse more closely so tasks are completed
d. Provide support and identify the underlying cause of the staff nurse’s problem

ANSWER: Provide support and identify the underlying cause of the staff nurse’s problem
RATIONALE: Option C empowers the charge nurse to assist the staff nurse while trying to
identify and reduce the behaviors that make it difficult for the staff nurse to function.

52. A nurse caring for the child with Kawasaki disease who just admitted to the hospital
is reviewing the order of the physician. The nurse expects to note an order which of the
following as part of the treatment plan for the child?
a. Digoxin
b. Morphine sulfate
c. Heparin infusion
d. Immune globulin

ANSWER: Immune globulin

RATIONALE: Immune globulin is administered intravenously to the child with Kawasaki
Disease to decrease the incidence of coronary artery lesions and aneurysms and to
decrease fever and inflammation.
53. The nurse provided the client all the information needed about the upcoming
endoscopic retrograde cholangiospancreatography procedure. The nurse determines
that the client needs additional information if the client makes which of the following
statements?
a. “I’m glad some IV medication will be given to relax me”
b. “I hope the throat spray keeps me from gagging”
c. “I’m glad I don’t have to lie still for this procedure”
d. I know I must sign the consent form”

ANSWER: “I’m glad I don’t have to lie still for this procedure”
RATIONALE: the client does not have to lie still for ERCP, which takes about an hour to
perform.

54. A physician’s order reads Potassium chloride 30mEq to be added to 1L normal saline
and to be given over 10-hour period. The available potassium chloride is 40mEq per
20ml. A nurse prepares how many milliliters of Potassium chloride to administer the
correct dose of medication?
a. 50ml
b. 15ml
c. 10ml
d. 20ml

ANSWER: 15ml
RATIONALE: Desire/Available x ml = 30mEq/40mEq x 20ml = 15ml

55. The nurse assigned a nursing student to formulate a post procedure plan of care to
a client who undergone bone biopsy. The nurse determines that the student needs to
research further about post procedure care if which inaccurate intervention is
documented?
a. Elevating the limb for 24 hours
b. Monitoring vital signs every 4 hours
c. Monitoring site for swelling, bleeding or hematoma
d. Administering Narcotic Analgesic intramuscularly

ANSWER: Administering Narcotic Analgesic intramuscularly

RATIONALE: After biopsy the client usually require mild analgesic.

56. The surgeon scheduled the client with hip fracture to be on Buck’s extension traction
before the surgery. The client asks the nurse why there is a need for the application of
this traction. The nurse’s response is based on the understanding the Buck’s traction
primarily:
 a. Provides comforts by reducing muscle spasms and provide fracture
immobilization
b. Allows bony healing to begin before surgery
c. Provides rigid immobilization of the fractured site
d. Lengthens the fractured leg to prevent severing of blood vessels

ANSWER: Provides comforts by reducing muscle spasms and provide fracture

immobilization
RATIONALE: Traction reduces muscle spasms and helps to immobilize the fracture

57. The physician scheduled the client with peptic ulcer disease for pyloroplasty. The
client wants clarification about the procedure discussed by the physician.
Unfortunately, the physician is on emergency call. The client asks the nurse about the
pyloroplasty procedure. The nurse plans to respond knowing that a pyloroplasty
involves:
a. Removal of the ulcer and a large portion of the cells that produce
hydrochloric acid
b. An incision and resuturing of the pylorus to relax the muscle and enlarge the
opening from the stomach to the duodenum
c. Removing the distal portion of the stomach
d. Cutting the vagus nerve

ANSWSER: An incision and resuturing of the pylorus to relax the muscle and enlarge the
opening from the stomach to the duodenum
RATIONALE: Option C describes the procedure for a pyloroplasty.
58. On the day before discharge from the hospital, the nurse provides instruction to the
client who delivered a healthy baby by cesarean delivery. Which of the following
statement if made by the client indicates a need for further instruction?
a. “I will lift nothing heavier that the newborn infant for at least 2 weeks”
b. “I will turn on my side and push up with my arms to get out of bed”
c. “I will notify the physician if I develop a fever”
d. “I will begin abdominal exercises immediately”

ANSWER: “I will begin abdominal exercises immediately”

RATIONALE: Abdominal exercises should not start immediately following abdominal
surgery, and the client should wait at least 3 to 4 weeks postoperatively to allow for
healing of the incision.

59. A client who has a cancer of the pancreas is admitted to the hospital for surgery.
The surgery includes the removal of the stomach, the head of the pancreas, the distal
end of the duodenum, the spleen. Following surgery, the nurse must be aware which
manifestation by the client that requires immediate attention?
a. Jaundice
b. Hyperglycemia
c. Weight loss
d. Indigestion
ANSWER: Hyperglycemia
RATIONALE: When the head of the pancreas is removed, the client has a greatly
reduced number of insulin-producing cells and hyperglycemia will occur. Immediate
attention is necessary.

60. A nurse is in charge to care for a young female client, a victim of sexual assault. The
nurse completed the physical assessment and important evidence was gathered. The
nurse notes that the client is withdrawn, confused, and at times physically immobile.
These behaviors are interpreted by the nurse as:
a. Indicative of the need for hospital admission
b. Evidence that the client is a high suicide risk
c. Signs of depression
d. Normal reaction to a devastating event

ANSWER: Normal reaction to a devastating event

RATIONALE: During the acute phase of the rape crisis, the client can display a wide
range of emotional and somatic responses. The symptoms noted indicate a normal
reaction to an intensely difficult crisis event.

61. The nurse inserted Foley catheter to a hospitalized client with head injury. The
client has begun urinating copious amount of dilute urine through the catheter. The
urine output 3000ml. The nurse implements which of the following new physician order
to administer?
a. Dexamethasone (Decadron)
b. Ethacrynic Acid (Edecrin)
c. Mannitol (Osmotri)
d. Desmopressin (DDAVP, Stimate)

ANSWER. Desmopressin (DDAVP, Stimate)

RATIONALE: A complication of head injury is diabetes insipidus. It can occur with injury
to the hypothalamus, the anti-diuretic hormone storage vesicle, or the posterior pituitary
gland. Urine output that exceeds 9L per day generally requires treatment with
Desmopressin.
 62. A nurse is completing the assessment of a client who is 4 hours postpartum.
Following assessment, the nurse notes that the client is cool, clammy skin and observed
that the client is also restless and excessively thirsty. The nurse prepares immediately to:
a. Begin hourly pad counts and prepare the client.
b. Begin fundal massage and start oxygen by mask.
c. Elevate the head of the bed and assess vital signs.
d. Assess for hypovolemia and notify health care provider.

ANSWER. D. Assess for hypovolemia and notify health care provider.

RATIONALE: Symptoms of hypovolemia include cool clammy pale skin, sensation of
anxiety or impending doom, restlessness and thirst. When these symptoms are present,
the nurse should further assess for hypolemia and notify healthcare provider.

63. The physician prescribed isoniazid (IHN) to a 2 year old child with HIV infection
who has a positive Mantoux test. The mother of the child asks the nurse how long will
her child need to take the prescribed medicine. The nurse informs the mother that the
medication will need to be taken for:
a. 9 months.
b. 12 months.
c. 4 months.
d. 6 months.

ANSWER. B. 12 months
RATIONALE: For children with HIV infection, a minimum of 12 months of treatment with
isoniazid is recommended.

64. The mother of a child with a diagnosis of esophageal atresia with

tracheoesophageal fistula brings her child to the clinic. A nurse reviews the record of
the infant. The nurse expects to note which most likely sign of this condition
documented in the record?
a. Severe projectile vomiting.
b. Incessant crying.
c. Coughing at night time.
d. Choking with feedings.

ANSWER. D. choking with feedings

RATIONALE: Any child who exhibits coughing at night time and choking with feedings
and cyanosis should suspected of tracheoesophageal fistula.
 65. The client displaying an aggressive behavior in the mental health unit. The
nurse visits the unit and observes the client’s aggressive behavior is escalating. Which
nursing intervention is least helpful to this client at this time?
a. Assist the client to an area that is quiet.
b. Maintain a safe distance with the client.
c. Initiate confinement measures.
d. Acknowledge the client’s behavior.

ANSWER. C. Initiate confinement measures.

RATIONALE: During the escalation period, the client’s behavior is moving towards loss of
control. Nursing actions include taking control, maintaining safe distance,
acknowledging behavior, moving the client to a quiet area, and medicating the client if
appropriate. To initiate confinement measures during this period is inappropriate.

66. The nurse is conducting a lecture session regarding cast care to a client that
will be discharged in the next two hours. The nurse would evaluate that the client
understands proper care of the cast if the client states that he or she should:
a. Use the finger tips to lift and move the leg.
b. Cover the casted leg with warm blanket.
c. Use the padded coat hanger end to scratch under the cast.
d. Avoid getting the cast wet.

ANSWER. D. avoid getting the cast wet.

RATIONALE: A plaster cast must remain dry to retain its strength.

67. The nurse in-charge placed the manic client in a seclusion room following an
outburst of violent behavior that involved a physical assault on another client. As the
client is in the seclusion room, the nurse in-charge would:
a. Remain silent because verbal interaction would be too stimulating.
b. Ask the client if she understands why seclusion is necessary.
c. Tell the client that she will be allowed to rejoin the others when she can
behave.
d. Informs the client that she is being secluded to help regain self-control.

ANSWER. D. Informs the client that she is being secluded to help regain self-control.
RATIONALE: The client is moved to a non-stimulating environment as a result of
behavior. It is best to inform the client the purpose of the seclusion.

68. A client newly diagnosed as having type I diabetes. The nurse explains to the
client self-monitoring of blood glucose is preferred to urine testing because it is:
a. Easier to perform.
 b. More accurate.
c. Done by the client.
d. Not influence by drainage.

ANSWER. B. More accurate

RATIONALE: Blood glucose testing is one direct accurate measure.

69. A client is to receive IV solution. When evaluating a client’s response to fluid

replacement therapy, the observation that indicates adequate tissue perfusion to vital
organs would be:
a. Blood pressure of 50/30 and 90/40 mmHg.
b. Central venous pressure reading 2 cm water.
c. Pulse rate of 120 and 110 in a 15 minute period.
d. Urinary output of 30ml per hour.

ANSWER. D. Urinary output of 30ml per hour.

RATIONALE: A rate of 30mL/hr is considered adequate perfusion of the kidney, heart,
and brain.

70. The nurse is developing a plan of care to a child scheduled for tonsillectomy.
A nurse is aware which of the following would present the highest risk for aspiration
during surgery?
a. Exudate in the throat area.
b. The presence of loose teeth.
c. Difficulty in swallowing.
d. Bleeding during surgery.

ANSWER. B. The presence of loose teeth

RATIONALE: In the preoperative period, the child should be observed for the presence
of loose teeth to lessen the risk of aspiration during surgery.

71. A physician ordered to transfuse unit of packed RBC for an assigned client. In
planning coverage for the client, the nurse just looked for another available nurse to
check the blood to be transfused. Once the blood was double checked, how long will
the assigned nurse stay with the client?
a. 15 minutes
b. 5 minutes
c. 45 minutes
d. 30 minutes

ANSWER: A. 15 minutes
RATIONALE: The nurse must remain with the client for the first 15 minutes of transfusion
which is the most frequent period of danger of transfusion reaction. This enables the
nurse to detect reactions and intervene quickly.

72. A nurse is providing health teaching to a client with Addison’s disease regarding diet
therapy. The nurse is aware that which of the following diets most likely the physician will
prescribe for this client?
a. Low carbohydrate intake
b. Normal sodium intake
c. High fat intake
d. Low protein intake

ANSWER: B. Normal sodium intake

RATIONALE: A high-complex carbohydrate and high protein diet will be prescribed for
the client with Addison’s disease. To prevent excess fluid and sodium loss, the client will
be taught to maintain a normal salt intake daily (3g) and to increase salt intake during
hot weather, before strenuous exercise, and in response to fever, vomiting or diarrhea.

73. A nurse is teaching a mother who has been diagnosed with mastitis. Which of the
following statements if made by the client indicates a need for further teaching?
a. “I need to wear a supportive bra to relived the discomfort”
b. “I need to take antibiotics, and I should begin to feel better in 24-48 hours”
c. “I need to stop breast feeding until this condition resolves”
d. “I can use analgesics to assess in alleviating some of the discomfort”

ANSWER: C. “I need to stop breast feeding until this condition resolves”

RATIONALE: In most cases, the mother can continue to breast-feed with both breasts. If
the affected breast is too sore, the mother can pump the breast gently. Regular
emptying of the breast is important to prevent abscess formation. Antibiotic therapy
assists in resolving the mastitis within 24-48 hours. Additional supporting measures
include ice packs, breast supports, and analgesics.

74. A nurse is caring for a client diagnosed with Pheochromocytoma. The client is
hungry and asks the nurse of something to eat and drink. The most appropriate choice
of food and drinks for the client to meet nutritional needs would be which of the
following?
a. Toast with peanut butter and cocoa
b. Vanilla wagers and coffee with cream and sugar
c. Crackers with cheese and tea
d. Graham crackers and warm milk
ANSWER: D. Graham crackers and warm milk
RATIONALE: The client with Pheochromocytoma needs to be provided with a diet high in
vitamins, minerals and calories. Beverages that contain caffeine, tea, cola, cocoa are
prohibited because they can precipitate hypertensive crisis.

75. A nurse is assigned to a female client who is newly admitted to the mental health
unit for anorexia nervosa. The nurse visits the client in her room and found out that the
client is engaged in rigorous push-ups. Which nursing action is most appropriate?
a. Interrupt the client and offer to take her for a walk
b. Allow the client to complete her exercise program
c. Tell the client that she is not allowed to exercise rigorously
d. Interrupt the client and weigh her immediately

ANSWER: A. Interrupt the client and offer to take her for a walk
RATIONALE: Client with anorexia nervosa frequently are preoccupied with rigorous
exercise and push themselves beyond normal limits to work off caloric intake. The nurse
must provide for appropriate exercise and place limits to rigorous activities.

76. A nurse is making rounds; he enters a client’s room. The client is begging to the nurse
to be released from the hospital. The nurse checks the client records and found out that
the client was voluntarily admitted two days ago with a diagnosis of an anxiety
disorder. Which of the following will the nurse take?
a. Contact the physician
b. Call the client’s family
c. Persuade the client to stay a few more days
d. Tell the client that discharge is not possible at this time

ANSWER: A. Contact the physician

RATIONALE: generally, the client seeks voluntary admission. Voluntary clients have the
right to demand and obtain release. If the client is a minor, the release may be
contingent on the consent of the parents or guardian. The nurse needs to be familiar
with the state and facility policies and procedures. Many states require that the client
submit a written release notice to the facility staff, who reevaluates the client’s condition
for possible conversion to involuntary status, according to criteria established by law.

77. The client is admitted in the emergency room for a lower leg injury. The deformity of
the leg of the clients is visible, and the affected leg is shorter than the other. The area is
painful, swollen, and beginning to become ecchymotic. The nurse interprets that this
client has experience a
a. Sprain
b. Strain
c. Confusion
d. Fracture

ANSWER: D. Fracture
RATIONALE: Typical sign and symptoms of fracture include pain, loss of function in the
area, deformity, shortening of the extremity, crepitus, swelling and ecchymosis.

78. Mr. Cruz, 40 years old client was diagnosed with chronic pancreatitis. The nurse
checks the laboratory results, anticipating a laboratory report that indicates a serum
amylase level of
a. 100 units/L
b. 500 units/L
c. 35 units/L
d. 300 units/L

ANSWER: D. 300 units/L

RATIONALE: The normal serum amylase is 25 o 151 IU/L in client with chronic
pancreatitis, the increase in serum amylase does not exceed 3 times the normal value.

79. A nurse was hired to be a home care nurse to assist the family in caring for a
newborn with congenital tracheoesophageal fistula who is receiving enteral feedings.
The nurse receives a telephone call and a woman introduced herself to the nurse as a
family friend and wishes to know the condition of the client and inquire if there is
anything she can do to assist the parents. The best nursing action is to:

a. Report the friend’s telephone call to the nurse manager for referral to the client’s
social worker
b. Inform the friend that the family has no need for assistance at this time because
the nurse is making daily visits
c. Request that the friend come to the client’s home, where she can be taught to
administer the feedings
d. Inform the friend to directly contact the family and offer her assistance to them

ANSWER: D. Inform the friend to directly contact the family and offer her assistance to
them
RATIONALE: A nurse must uphold the client’s right and does not give any information
regarding a client’s care needs to anyone who is not directly involved in the client’s
care. To request that the friend come for teaching is direct violation of the client’s right
to privacy. There is no information in the question to indicate that the family desire
assistance from the friend. To refer the call to the nurse manager and social worker
again assumes that the friend’s assistance and involvement is desired by the family.
Informing the friend that the nurse is visiting daily is providing information that is
considered confidential.

80. A nurse assigned a nursing student to perform a cardiovascular assessment on a

postpartum woman. The nurse asks the student about the procedure to elicit human’s
sign. Which response by the nursing student would indicate an understanding of this
assessment technique?
a. “I will ask the woman to extend her legs flat on the bed, and I will grasp the foot
and gently dorsiflex it forward”
b. “I will ask the woman to raise the legs up to the waist and then lower the legs
slowly”
c. “I will ask the woman to extend the legs flat on the bed, and I will grasp the foot
and sharply extend it backward”
d. “I will ask the woman to raise the legs and to try to lower them against pressure
from my hand”

ANSWER: C“I will ask the woman to extend the legs flat on the bed, and I will grasp the
foot and sharply extend it backward”
RATIONALE: To elicit homan’s sign, the nurse asks the woman to extend her legs on the
bed. The nurse grasps the foot and dorsiflexes it forward. If this cause any discomfort or
resistance, the nurse should notify the physician or midwife that homan’s sign is present.

81. A home care nurse arrives at the client’s home for the scheduled home visit. The
client tells the home care nurse of his decision to refuse external cardiac message.
Which of the following is the most appropriate initial nursing action?

a. Document the client’s request in the home care nursing care plan
b. Notify the physician of the client’s request
c. Conduct a client conference with the home care staff to share the client’s
request
d. Discuss the client’s request with the family

ANSWER: B. Notify the physician of the client’s request

RATIONALE: External cardiac Massage is a life-saving treatment that a client can refuse.
The most appropriate initial nursing action is to notify the physician, because written do
not Resuscitate (DNR) order from the physician is needed. The DNR order must be
reviewed or renewed on a regular basis per agency policy.

82. The nurse is providing information to the client in an arm cast about signs and
symptoms of compartment syndrome. The nurse determines that the client understands
the information if the client stated that he/she should report which of the following early
symptoms of compartment syndrome?

a. Pain that increases when the arm is independent

b. Cold, bluish-colored fingers
c. Numbness and tingling in the fingers
d. Pain that is relieved only by oxycodone and aspirin

ANSWER: C. Numbness and tingling in the fingers

RATIONALE: The earliest symptoms of compartment syndrome is paresthesia (numbness
and tingling).

83. Following an abdominal surgery, the client develops internal hemorrhage, the nurse
performs further assessment, the nurse should expect the client to exhibit:

a. Tachycardia
b. Bradypnea
c. Polyuria
d. Hypertension

ANSWER: A. Tachycardia
RATIONALE: With shock the heart rate accelerates to increase blood flow and oxygen to
body tissue.

84. A client is admitted in the mental health unit complaining of loose, watery stool, and
difficulty walking. The nurse would expect the serum lithium level to be which of the
following?

a. 1.0 mEq/L
b. 0.7 mEq/L
c. 1.3 mEq/L
d. 1.8 mEq/L

ANSWER: D. 1.8 mEq/L

RATIONALE: The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. A serum lithium
level of 1.8 mEq/L indicates moderate toxicity. Serum lithium concentration of 1.5-2.5
mEq/L may produce vomiting, diarrhea, ataxia, incoordination, muscle twitching, and
slurred speech.

85. A newly nursing graduate is attending an orientation regarding the nursing model of
practice implemented in the hospital. The nurse is told that the model is primary nursing
approach. The nurse understands that which of the following is the characteristic of this
type of nursing model of practice?
 a. The nurse manager assigns tasks to the staff members
b. A single registered nurse is responsible for planning and providing
individualized nursing care
c. Critical paths are used in providing care
d. Nursing staff are led by an RN leader in providing care to a group of clients

ANSWER: B. A single registered nurse is responsible for planning and providing

individualized nursing care; RATIONALE: Primary nursing is concerned with keeping the
nurse at the bedside actively involved in direct care while planning goal-directed,
individualized client care.

86. A nurse in a surgical unit receives a postoperative client from the post anesthesia
care unit. After the initial assessment of the client, the nurse plants to monitor and
continue with post-operative assessment activities. Which of the following would be
appropriate?

a. Every 30 minutes for the first hour, every hour for two hours, then every four
hours as needed
b. Every hour for two hours, then every four hours as needed
c. Every 5 minutes for the first half hour, every 15 minutes for two hours, every 30
minutes for four
hours and then every hour as needed
d. Every 15 minutes for the first hour, every 30 minutes for the second hour, every
hour for four
hours and then every four hours as needed

ANSWER: D. Every 15minutes for the first hour, every 30 minutes for the second hour,
every hour for four hours and then every four hours as needed
RATIONALE: When the postoperative client arrives from the post anesthesia care unit,
the nurse performs an initial assessment. Common time frames for continuing post-
operative assessment activities are every 15 minutes for the first hour, every 30 minutes
for the second hour, and then every hour for four hours and every four hours as needed.

87. The home health nurse is scheduled to visit a client at home and found out that the
client is dependent on drugs. Which of the following assessment questions would assist
the nurse to provide appropriate nursing care?

a. The nurse does not ask any questions in fear that the client is in denial and will
throw the nurse out of the home.
b. “Why did you get started on these drugs?”
c. “How long did you think you could take these drugs without someone finding
out?”
d. “How much do you use and what effect does it have on you?”

ANSWER: D. “How much do you use and what effect does it have on you?”
RATIONALE: Whenever the nurse employs an assessment for a client who is dependent
on drugs, it is best for the nurse to attempt to elicit information by beg judgmental and
direct.

88. A nurse receives a telephone call from a female client who states that she wants to
kill herself and holding a bottle of poisonous substance. The best nursing action is to:

a. Use therapeutic communication techniques, especially the reflection of

feelings
b. Keep the client talking and signal another staff member to race the call so
that appropriate help can be sent
c. Insist that the client give you her name and address so that you can get the
police there immediately
d. Keep the client talking and allow the client to ventilate feelings

ANSWER: B. Keep the client talking and signal another staff member to race the call so
that appropriate help can be sent
RATIONALE: In a crisis the nurse must take an authoritative, active role to promote the
client’s safety. A bottle of poisonous substance that will be used to kill her is the “crisis”.
The client’s safety is the prime concern. Keeping the client on the phone and getting
help to the client is the best intervention.

88. On the day shift, the registered nurse that has receives an assignment. While making
initial rounds and checking all the assigned clients, which clients will the registered nurse
give first priority of care?

a. A client who is ambulatory

b. A post-operative client who has just receives pain medication
c. A client with a fever who is diaphoretic and restless
d. a client scheduled for physical therapy at 1 PM

ANSWER: C. A client with a fever who is diaphoretic and restless

RATIONALE: A nurse would plan to care first for a client who had a fever and restless
because the client’s needs are the priority. Waiting for pain medication to take effect
before providing care to the post-operative client is best.

89. The admitting office calls the nursing unit and informs the nurse in charge that a
child with rheumatic fever will be arriving in the unit for admission. On admission, the
nurse prepares to ask the mother of the child, which question to elicit assessment
information specific to the development of rheumatic fever?

a. “Has the child complained of headache?”

b. “Has the child had nausea and vomiting?”
 c. “Did the child have a sore throat or an unexplained fever within the last 2
months?”
d. “Has the child complained of back pain?”

ANSWER: C. “Did the child have a sore throat or an unexplained fever within the last 2
months?”
RATIONALE: Rheumatic fever characteristically presents 2-6 weeks after an untreated or
partially treated group A beta hemolytic streptococcal infections of the upper
respiratory tract. Initially the nurse determines whether the child has a sore throat or an
unexplained fever within the past 2 months.

90. A client comes to the clinic for a check-up and suspected of having Tuberculosis.
The nurse understands the most accurate method for confirming the diagnosis is:

a. Obtaining client’s health history

b. A sputum culture positive for Mycobacterium Tuberculosis
c. A positive purified Protein Derivative Test (PPD)
d. A chest X-ray positive for lung lesion

ANSWER: B. A sputum culture positive for Mycobacterium Tuberculosis

RATIONALE: The most accurate means of confirming the diagnosis of Tuberculosis is by
sputum culture.

91. The physician advised the client to take senna (Senokot) to treat constipation. The
client is curious to know the effect of the medication. The client asks the nurse how this
medication works. The nurse would incorporate which of the following when
formulating a response to the client?

a. Senna accumulates water and increases peristalsis

b. Senna coats the bowel wall and makes it slippery
c. Senna stimulates the vagus nerve to improve the bowel tone
d. Senna adds fiber and bulk to the stool

ANSWER: A. Senna accumulates water and increases peristalsis

RATIONALE: Senna works by changing the transport of water in the large intestine which
causes accumulation of water in the mass of stool and increase peristalsis.

92. The nurse on the day shift is scheduled to care for three clients. One client is
scheduled for a cardiac catheterization at 10 AM; the other has tracheostomy and is
on a mechanical ventilator. And the other client was newly diagnosed with diabetes
mellitus and is scheduled for discharged to home. How would the nurse plan the order
of care of the clients for the day?
 a. A client with tracheostomy and scheduled for cardiac catheterization would at
the same time be given the highest priority in the plan of care, client for
discharge does not need much attention
b. A client with tracheostomy and is on mechanical ventilator, Client scheduled for
a cardiac catheterization followed by the client with diabetes mellitus scheduled
for discharged.
c. A client scheduled for a cardiac catheterization, client with diabetes mellitus
and for discharged to home, client with tracheostomy
d. A client with diabetes mellitus, clients scheduled for a cardiac catheterization,
client with tracheostomy

ANSWER: B. A client with tracheostomy and is on mechanical ventilator, Client

scheduled for a cardiac catheterization followed by the client with diabetes mellitus
scheduled for discharged.
RATIONALE: Airway is always high priority and the nurse would assess the client who has
a tracheostomy and is on a mechanical ventilator first. The nurse next step of care
would assess the client scheduled for cardiac catheterization, followed by the client
scheduled for discharge.

93. The client has a left-sided weakness and using a cane. The nurse observes the client
walking using a cane. The nurse would intervene and correct the client if the nurse
observed that the client:

a. Hold the cane on the right side

b. Keeps the cane 6 inches out to the side of the right foot
c. Leans on the cane when the right leg swings through
d. Moves the cane when the right leg is moved

ANSWER: D. Moves the cane when the right leg is moved

RATIONALE: The cane is held on the stronger side to minimize stress on the affected
extremity and provide a wide base of support and move forward with the affected leg.

94. A nurse is completing an assessment with a client with chronic airflow limitations and
notes that the client has a “barrel chest”. The nurse expects that this client has which of
the following forms of chronic airflow limitation?

a. Emphysema
b. Chronic obstructive bronchitis
c. Bronchial asthma and bronchitis
d. Bronchial asthma

ANSWER: A. Emphysema
RATIONALE: The client with emphysema has hyper inflation of the alveoli and flattening
of the diaphragm. This lead to increased anteropoasterior diameter referred to as barrel
chest.

95. A charge nurse assigned a nursing assistant to care to a client with delirium. While
the nurse is on her way to the other client’s room, she happens to hear the nursing
assistant talking in an unusually loud voice to the client. The charge nurse nurse takes
which appropriate action?

a. Informs the client that everything is all right.

b. Explains to the nursing assistant that yelling in the client’s room is tolerated only if
the client is talking loudly.
c. Ascertains the client’s safety, calmly asks the nursing assistant to join the nurse
outside the room, and informs the nursing assistant that her voice was unusually
loud.
d. Speaks to the nursing assistant immediately while in the client’s room to solve the
problem.

ANSWER: C. Ascertains the client’s safety, calmly asks the nursing assistant to join the
nurse outside the room, and informs the nursing assistant that her voice was
unusually loud.
RATIONALE: The nurse must ascertain the client is safe, hen discuss the matter with
the nursing assistant in an area away from the hearing of the client. If the client
heard the conversation, the client may become more confused or agitated.

96. A physician ordered to administer Apmhotericin B (Fungizone) intravenously to the

client diagnosed with histoplasmosis. The nurse plans to do which of the following during
administration of the medication?

a. Monitor for hypothermia

b. Assess the intravenous infusion site
c. Monitor for an excessive urine output
d. Administer a concurrent fluid change

ANSWER: B. Assess the intravenous infusion site

RATIONALE: Apmhotericin B is a toxic medication, which can produce symptoms during
administration such as chills, fever, headache, vomiting, and impaired renal function.
The medication is very irritating to the IV site, commonly causing thrombophlebitis. The
nurse administering this medication monitors for these complications.
 PART 2

SITUATION 1: Ana Locca is admitted to the emergency room with a stiff neck and
temperature of 102 degree (38.9 C). She has had an earache for 1 week, but has not
sought treatment for it.

1. Nuchal rigidity will NOT be seen in which of the following?

a. Meningitis
b. Intracranial mass with herniation
c. Intracranial hematoma
d. Cerebral concussion

ANSWER: D. Cerebral concussion

RATIONALE: Nuchal rigidity when the neck becomes rigid when flexion is attempted
resulting from cerebral hemorrhage. This does not usually occur with cerebral
concussion.

2. Which of the following is a contraindication to lumbar puncture?

a. Unequal pupils
b. Lack of lateralization
c. Suspicion of meningitis
d. Nuchal rigidity

ANSWER: A. Unequal pupils

RATIONALE: Unequal pupils indicate possible increased intracranial pressure, which
makes a lumbar puncture very dangerous.

3. In addition to a brief explanation of the lumbar puncture procedure, which of

the following is also the responsibility of the nurse?
a. Administer Narcotic to the client
b. Position the client safely and properly in a lateral recumbent position with his
knees flexed
c. Administer procaine hydrochloride
d. Prepare a suture set so that it will be ready after procedure

ANSWER: B. Position the client safely and properly in a lateral recumbent position with
his knees flexed
RATIONALE: Position the patient carefully, laying on one side in a curled up position with
the lumbar spine exposed (knees drawn up to the chest). This will make access to the
lumbar spine easier.
 4. Bacterial meningitis is confirmed by the cerebrospinal fluid culture. Ms. Locca has
been transferred to a dimly lit private room. Why?
a. Increased stimulation such as bright lights may precipitate in seizure
b. Inappropriate secretion of antidiuretic hormone (ADH) can be minimized
c. It is easier to check his pupils in a darkened room
d. Most clients with meningitis have photophobia

ANSWER: D. Most clients with meningitis have photophobia

RATIONALE: Meningitis is often accompanied by photophobia, a visual intolerance to
light; therefore the patient will be more comfortable in a dark room.

5. Ms. Locca is placed on a hypothermia blanket. Twenty minutes following the

start of hypothermia treatments, what response would the nurse most likely
expect to find?
a. Lowered vital signs
b. Elevated vital signs
c. Unchanged vital sings
d. Complaints of hot and cold flashes

ANSWER: C. Unchanged vital sings

RATIONALE: Hypothermia blanket was not more effective than other cooling methods.
Hypothermia blanket therapy was associated with more temperature fluctuations and
with more episodes of rebound hypothermia.

SITUATION 2: Julie Halili is 28 year old admitted on the nurses shift with a fever of 38.9 C
her complaints indicate dysuria, frequency and malaise. Acute pyelonephritis is
suspected.

6. Which of the following diagnostic findings would be LEAST likely to be found in

acute pyelonephritis?
a. Cloudy, fouls-smelling urine
b. Bacteria and pus in the urine
c. Low WBC count
d. Hematuria

ANSWER: C. Low WBC count

RATIONALE: Low WBC count is usually caused by viral infections that temporarily disrupt
the work of bone marrow.

7. What is the most important nursing action when caring for Ms. Halili?
a. Encourage ambulation
b. Force fluids up to 3000 ml/day
 c. Restricts protein in the diet
d. Keep urine acid

ANSWER: B. Force fluids up to 3000 ml/day

RATIONALE: Increase fluid intake will help treat the symptoms of infection (e.g. elevated
temperature, dysuria)

8. Long term management for Ms. Halili includes preventing reinfection. Which of
the following nursing instructions would be in the teaching?
a. Void at least every 6 hours
b. Use vaginal spray to mask the odor
c. Empty her bladder before and after intercourse
d. Discontinue antibiotics when pain disappears

ANSWER: C. Empty her bladder before and after intercourse

RATIONALE: Void before and after intercourse to rid urethra of bacteria acquired during
sex.

9. Before administering the initial dose of PYRIDIUM, what would the nurse tell Ms.
Halili about this drug?
a. This drug causes transient nausea
b. Food interferes with absorption
c. It colors the urine red or orange
d. Bladder spasm are a side effect

ANSWER: It colors the urine red or orange

RATIONALE: This is a normal effect and is not cause for alarm. Darkened urine may also
cause stains to your underwear, which may or may not be removed by laundering.

10. Sulfamethoxazole-trimethorpin (Bactrim DS) is a common antimicrobial agent

ordered in combination with phenazopyridine hydrochloride (Pyridium). What
does “DS” stand for
a. “Does Specific”
b. “Decreased symptoms”
c. “Double strength”
d. “Deficient strain”

ANSWER: C. “Double strength”

RATIONALE: DS stands for Double strength
SITUATION: Alden Pastillas is admitted to the emergency room with an abdominal
gunshot wound.

11. Which of the following descriptions of the bleeding is best for the nurse’s notes?

a. A moderate to large amount of sanguineous drainage noted from the

abdominal wound.
b. Severe bleeding from the wound
c. Copious amounts of blood coming from the abdomen
d. Sanguineous drainage from the abdominal wound soaked 2 towels and 6
abdominal pads in 10 minutes

ANSWER: D. Sanguineous drainage from the abdominal wound soaked 2 towels and 6
abdominal pads in 10 minutes
RATIONALE: It is important to completely document any pertinent information based
from thorough assessment to help your doctor make an accurate diagnosis.

12. Towels can be used to pack the gunshot wound would be?

a. The injury is usually fatal

b. The wound is already grossly contaminated
c. Towels would absorb more than ABD pads
d. The client is probably bleeding minimally

ANSWER: B. Towels would absorb more than ABD pads

RATIONALE: Controlling the bleeding is the priority, using a towel dressing can help
blood to clot and seal the wound. An infection can be treated later.

13. Mr. Pastillas has also a knife protruding from his chest. The best nursing action is to do
which of the following?

a. Immediately remove the knife

b. Leave the knife until an operative setup is arranged
c. Clean the exposed knife with povidone iodine solution
d. Cover area with a sterile towel soaked in saline

ANSWER: B. Leave the knife until an operative setup is arranged

RATIONALE: Leave the object in the wound if it is still there and be very careful not to
move it, which may cause further damage. The object is actually helping to stem the
blood flow. Pulling it out will likely increase blood loss, while pushing it in may cause
further injury to the internal organs.
 14. Mr. Pastillasis unable to void. A catheterization yields a small amount of bloody
urine. This is most likely an indication of which of the following?

a. Urethral tear
b. Urethritis
c. Ruptured bladder
d. Prostatitis

ANSWER: A. Urethral tear

RATIONALE: Urethral injury due to trauma is a common complication associated with

Foley catheters especially if the catheter is inserted forcefully or roughly. One of the
manifestation indicating trauma to the urethra is presence of small amount of bloody
urine.

15. Select the Most correct statement about subcutaneous emphysema.

a. It is caused by air sucked into the chest wall from a superficial wound.
b. It is caused by internal injury
c. It can always be noted easily
d. It is not exacerbated by coughing

ANSWER: B. It is caused by internal injury

RATIONALE: Internal trauma is one of the major causes of subcutaneous emphysema
causing air to enter the skin in the chest through the lung or neck. When the pleural
membranes are ruptured as it occurs during penetrating trauma of the chest, air may
move from your lungs to the muscles and subcutaneous tissue of the chest wall.

SITUATION: Wally Manalo, is admitted to ER with gunshot wound. Several blood

transfusion are ordered.

16. When administering a blood transfusion, what is a mandatory nursing function

requiring two nurses?

a. Check the type and cross match data, numbers on the lab slips, and the
information in the blood with that on the client’s blood band.
b. Check the type and cross match data, numbers on the lab slips, and the
information in the blood with that on the client’s chart.
c. Check the best possible vein to ensure correct infusion.
d. Ensure that Mr. Manalo is rational in order to establish a baseline of bahavior.

ANSWER: A. Check the type and cross match data, numbers on the lab slips, and the
information in the blood with that on the client’s blood band.
RATIONALE: The safe transfusion of blood and blood products requires strict adherence
to patient identification processes during all steps in the transfusion chain, including
collecting the product from blood bank. Blood bank scientists must know they are
issuing to the correct patient and require complete patient identification. This includes:
full name, date of birth and MRN.

17. Mr. Manalo’s girlfriend volunteered to donate blood for him. What information is
necessary to ascertain if she can be a donor?

a. History of gonorrhoea within the last year

b. History of hepatitis within the last 5 years
c. History of bacterial endocarditis within the last 4 years
d. History of upper respiratory infection within the last 6 months

ANSWER: D. History of upper respiratory infection within the last 6 months

RATIONALE: Upper respiratory infection is usually caused by a viral infection and
treatment is directed at managing symptoms while the body's own immune system
fights the infection.

18. When assembling the equipment to start the blood transfusion, which of the
following solutions is used to start the IV?

a. Sterile water
b. Normal saline
c. 10% Dextrose in water
d. Lactated Ringer’s solution

ANSWER: B. Normal saline

RATIONALE: Of the various intravenous solutions, only isotonic saline (0.9%) is
recommended for use with blood components. Other commonly used intravenous
solutions will cause varying degrees of difficulty when mixed with red cells.5% dextrose
in water will hemolyze red cells. Intravenous solutions containing calcium, such as
Lactated Ringer’s solution, can cause clots to form in blood. Prior to blood transfusion,
completely flush incompatible intravenous solutions and drugs from the blood
administration set with isotonic saline.

19. The nurse must remain at the bedside for 15 minutes after the blood transfusion is
started to assess for any transfusion reaction. Which of the following is NOT found during
a transfusion reaction?

a. Chills, fever, and dyspnea

b. Decreased BP and Increased Pulse rate
c. Bleeding under the skin at the IV site
 d. Hives and itching

ANSWER: C. Bleeding under the skin at the IV site

RATIONALE: Bleeding under the skin at the IV site is a sign of infiltration which is
indicative of IV complication.

20. Which one of the following nursing actions must be taken immediately if a
transfusion reaction occurs?

a. Notify the physician

b. Check the V/S, and take a urine sample
c. Stop the BT and infuse normal saline
d. Slowdown the rate of blood flow and continue the assessment

ANSWER: C. Stop the BT and infuse normal saline

RATIONALE: If a transfusion reaction occurs, the transfusion is stopped and the person
is given an antihistamine. More serious allergic reactions may be treated
with hydrocortisone or even with epinephrine.

SITUATION: Gabriel Dimasalang, a 25 year old construction worker is injured when his
foot and ankles are crushed be a heavy, jagged tool. The foot becomes cold and dark
and the pedal pulses are absent. He is scheduled for a below the knee amputation.

21. What instruction would the nurse give Mr. Dimansalang if he is to be taught
quadriceps-setting exercised preoperatively?

a. Alternately pinch the buttocks together and relax them

b. Lift the buttock of the bed while lying flat
c. Move the buttocks and both legs in order to place the feet in plantar flexion
d. Move the pattellas proximally and press the popliteal spaces against the bed

ANSWER: D. Move the pattellas proximally and press the popliteal spaces against
the bed
RATIONALE: This exercise helps build the quadriceps muscle that attaches to the
knee.

22. Which of the following would be best included in the plan of care for Mr.
Dimansalang during the first 24 hours postoperatively?

a. Apply a heating pad to the stamp to relieve discomfort

b. Have a tourniquet in view at the bedside
 c. Anticipate the need for large doses of narcotic analgesics
d. Encourage him to look at the stump

ANSWER: C. Anticipate the need for large doses of narcotic analgesics

RATIONALE: The major goals of the patient may include relief of pain, absence of
altered sensory perceptions, wound healing, acceptance of altered body image,
resolution of the grieving process, independence in self-care, restoration of physical
mobility, and absence of complications. Surgical pain can be effectively controlled
with opioid analgesics, nonpharmaceutical interventions, or evacuation of the
hematoma or accumulated fluid.

23. Following a surgery which is the best instruction to give Mr. Dimansalang?

a. Keep the stump elevated on the pillow until the wound is healed
b. Keep pillow between the thighs when in a supine position
c. Lie in a prone position from 30 minutes several times a day
d. Apply lotion to the stump several times a day after incision has healed

ANSWER: B. Keep pillow between the thighs when in a supine position

RATIONALE: If you have below the knee amputation, you may put a pillow behind or
between thighs when in supine to help straighten your knee. Avoid lying in prone
position, lie on stomach trice a day to help prevent hip tightening. Do not apply
moisturizing lotion to the amputated limb immediately before applying prosthesis
because other kinds of lotion can cause cracks which can lead to infection. Do not put
pillow under your stump.

24. Mr. Dimansalang will be taught about crutches until he can managed with
prosthesis independently. Which of the following crutch-walking instructions would be
INCORRECT?

a. Extend the arms while holding weights to strengthen the triceps

b. The crutches should be 16 inches less than the client’s total height
c. The axillary bars on the crutches should support the clients weight
d. Both crutches and the affected legs are move forward first followed by
normal leg

ANSWER: D. Both crutches and the affected legs are move forward first followed by
normal leg RATIONALE: In using crutches, move the crutches first, you’re injured leg next
and then your stronger leg. Extending arms while holding weights to strengthen the
triceps, crutches should be 16 inches less than the client’s total height and axillary bars
on the crutches should support clients weight are correct instructions in doing crutch-
walking.
SITUATION: Fernando Jose, 21 years old sustained a compound comminuted fracture in
the distal portion of the left femur while learning to ride his new motorcycle. He was
placed in a skeletal traction with a Thomas splint and a Peason attachment with a 20
pounds weight. A Steinman pin was inserted into femur distal to the fracture.

25. Which of the following is a definition of a compound comminuted fracture?

a. The fracture is associated with injuries to surrounding tissues and structures

b. Bone fragments are forcibly driven into one another
c. The bone splintered into fragments that extend through the skin
d. The line of the fracture forms a spiral that encircles the bone

ANSWER: C. The bone splintered into fragments that extend through the skin
RATIONALE: Compound comminuted fracture is a fracture in which bone has splintered
into several fragments which damages involve the skin or mucous membrane.

26. Mr. Jose is admitted to the orthopedic clinic. The nursing care plan would include
which of the following?

a. Ensure that the sole of the affected foot is supported against the foot of the
bed
b. Instruct the client to move about in bed as little as possible
c. Position Thomas splint around the upper thigh without pressure on the groin
d. Pace and remove the bed pan from the affected side

ANSWER: C. Position Thomas splint around the upper thigh without pressure on the groin
RATIONALE: Thomas splint is used for management of fracture of the lower limb. Support
the affected body part above and below fracture site is also important. Activity
restriction is required because of impaired mobility and to avoid strengthening the
injured body part.

27. Which of the following statement made by Mr. Jose indicated a need for further
teaching?

a. “A diet high in roughage and fiber will prevent constipation”

b. “Maintaining a positive nitrogen balance is important”
c. “Mr. Jose needs an increased calcium intake”
d. “The 2700 calories diet should provide nutrients that promote healing”

ANSWER: A. “A diet high in roughage and fiber will prevent constipation”

RATIONALE: A diet high in fiber will prevent constipation but eating too much fiber can
cause you to absorb less calcium which will be needed for the bone. Eating too few
calories can slow your healing process that’s why having enough calories is needed.

28. Because a Steinman pin has been inserted, Mr. Jose is at risk of acquiring which of
the following?

a. Flexion contracture of the knee

b. Impaired skin sensation
c. Addiction to pain management
d. Osteomyelitis

ANSWER: D. Osteomyelitis
RATIONALE: Steinman pin is at risk for acquiring infection. Osteomyelitis is an infectious
usually painful inflammatory disease of bone. It results from pin loosing or need for pin
or complete construct removal.

29. To maintain traction there must be a counter traction. How counteraction is best
applied to Mr. Jose’s leg?

a. By raising the head of the bed to 45 angle

b. By elevating the foot of the bed on 6 inches shock blocks
c. By using 20 pounds of weight using the Steinman pin
d. By keeping the Thomas splint in an inclined position

ANSWER: B. By elevating the foot of the bed on 6 inches shock blocks

RATIONALE: Counteraction is the resistance or back-pull, made to traction or pulling on
a limb for example in case of traction made on the leg, counter traction may be
affected by raising the foot of the bed so that the weight of the body pulls against the
weight attached to the limb.

30. Mr. Jose complains that the ropes hurt his thigh. Which of the following would be the
MOST appropriate nursing action?

a) Replace the spreader bar with a wider one

b) Place padding between the thigh and the rope
c) Employ distraction techniques
d) Medicate with mild analgesic

ANSWER: B. Place padding between the thigh and the rope

RATIONALE: Skin breakdown, nerve pressure, and circulatory impairment are
complications that may develop as a result of skin traction. Skin breakdown results from
irritation caused by contact of the skin with the tape or foam and shearing forces. It is
crucial to place padding in spots where the rope could be uncomfortable or painful to
the victim.

31. What is the purpose of Pearson attachment on Mr. Jose’s traction?

a. To support the lower part of the leg
b. To support the upper part of the leg
c. To provide traction to fracture
d. To prevent flexion contracture of the ankle

ANSWER: A. To support the lower part of the leg

RATIONALE: It is now used mainly to place traction on the leg in its long axis, in
treating fractures of the upper leg. It consists of a proximal ring that fits around
the upper leg and to which two long rigid slender steel rods are attached.
SITUATION: Henry a staff Nurse assigned to PGH caring different patients.
32. Nurse Henry caring for an elderly trauma patient should be aware that which of
the following measures should be used to accurately determine fluid volume
status?
a. Urinary output determination
b. Serial Hgb and Hct values
c. Invasive Hemodynamic monitoring
d. Serial blood pressure readings

ANSWER: A. Urinary output determination

RATIONALE: A normal urine output is considered normal not less than 30ml/hour.
Concentrated urine denotes fluid deficit.
33. Which of the following physical assessment findings in an elderly patient should
the nurse Henry report to the physician?
a. Large pupils
b. Increased lacrimal secretions
c. Thickened yellow lenses
d. Reddened sclera

ANSWER: A. Large pupils

RATIONALE: When someone's pupils dilate in an unusual way, it is called mydriasis.
This may be caused by an injury, psychological factors, or when someone takes
certain drugs or medications. This condition can be a symptom of an injury to the
brain from physical trauma or a stroke.
34. A patient arrives at the ER department with a history of a fall and complaint of
abdominal pain. Assessment findings are blood pressure 101/68, pulse 116 and
regular, respirations 22, capillary refill four seconds and thirst. Nurse Henry should
be aware that these signs and symptoms are indicative of:
a. Gallbladder inflammation
b. Intra-abdominal hemorrhage
c. Septicemia
 d. Cardiogenic Shock

ANSWER: B. Intra-abdominal hemorrhage

RATIONALE: During trauma the abdomen is one region which cannot be ignored.
Due to its Complex anatomy it is very important that all the areas in the abdomen be
examined both clinically and radiologically to rule out any abdominal bleeding as
a cause of Hemorrhagic Shock Following Trauma. Intra-abdominal hemorrhage
manifestations includes abdominal pain, fever, distended abdomen, low blood
pressure, pallor, black tarry stools, shortness of breath and tachycardia.

35. Which of the following statements if made by a patient who has diabetes
mellitus, would indicate an understanding of teaching on diabetes and alcohol?
a. “Alcohol may be taken in moderate amounts with my meals”
b. “Alcohol will cause increase in blood sugar”
c. “Alcohol will decrease my susceptibility to infections”
d. “Alcohol intake will cause a decrease need for insulin”

ANSWER: B. “Alcohol will cause increase in blood sugar”

RATIONALE: While moderate amounts of alcohol may cause blood sugar to rise,
excess alcohol can actually decrease your blood sugar level -- sometimes causing
it to drop into dangerous levels, especially for people with type 1 diabetes. Beer and
sweet wine contain carbohydrates and may raise blood sugar.
36. Which of the following nursing diagnosis would be most appropriate for a patient
with hyperthyroidism?
a. Altered nutrition, more than body requirements, related to slowed
metabolic rate
b. Impaired skin integrity related to edema and dryness
c. Altered comfort related to cold intolerance
d. Activity intolerance related to fatigue

ANSWER: D. Activity intolerance related to fatigue

RATIONALE: Patient with hyperthyroidism has hypermetabolic states with increased
energy requirements. They present symptom such as nervousness. These patients
are often emotionally hyperexcitable, irritable, and apprehensive; they cannot sit
quietly; they suffer from palpitations; and their pulse is abnormally rapid at rest as
well as on exertion.

37. A young woman is brought to ER following a motor vehicle accident. Assessment

findings indicate minor cuts and bruises, sullen mood guarded response to
questions. The nurse notes multiple old scars on the patient’s forearms. Which of
the following patient statement would require the nurse to investigate as a
priority?
a. “My parents are going to be so mad about the car. I don’t know what I
will tell them”
b. “I’m glad no one was hurt. The next time I’ll have to think of a different
way to take care of things”
 c. “I don’t want to go home. My parents are going to punish me for the car”
d. “I don’t like hospitals, when can I go home”

ANSWER: C. “I don’t want to go home. My parents are going to punish me for the
car”
RATIONALE: This statement requires the nurse to investigate due to the statement of
punishment that would indicate a threat.
38. Which of the following symptoms of depression would a nurse most likely observe
in children and adolescents but not in adults?
a. Loss of interest in usual activities
b. Significant weight loss
c. Acting-out behavior
d. Feeling of worthlessness

ANSWER: C. Acting-out behavior

RATIONALE: Acting out may include fighting, throwing fits, or stealing. In severe
cases, acting out is associated with antisocial behavior and other personality
disorders in teenagers and younger children
39. Which of the following behaviors by an adolescent patient who is suspected of
having a major depression would be best support a nursing diagnosis of self-
esteem disturbance?
a. Protest that others do not understand him
b. Inconsistent performance in school
c. Poor impulse control
d. Frequent criticism of others

ANSWER: B. Inconsistent performance in school

RATIONALE: How a person feels about themselves is a result of their experiences and
how they deal with situations. The most common causes of low self-esteem in teenagers
are: unsupportive parents, carers or others that play an influential role in their life, friends
who are bad influences, stressful life events such as divorce or moving houses, trauma
or abuse, poor performance at school or unrealistic goals, mood disorders such as
depression, anxiety, bullying or loneliness and ongoing medical issues
40. After a competition of an incident report, the nurse places the documents in the
patient’s chart. The nurse should understand the incident reports?
a. Are considered legal documents but rather risk management tool
b. Are maintained by the hospital and used as a staff evaluation tool
c. Will prevent legal action against the nurse
d. Should be reviewed by the patient prior to discharge
ANSWER: A. Are considered legal documents but rather risk management tool
RATIONALE: Incident report serves two purposes: (1) to inform facility administrators of
incidents that allow the risk management team to consider changes that might prevent
similar incidents and (2) to alert administration and the facility insurance company of
potential claims or need for further investigation.
41. When introducing solid foods to infants, the parents should be instructed to:

a. Introduce new food between regular meals

b. Introduce one new food every four to seven days
c. Mix new food in with infant formula
d. Mix new food in with infant cereal

Answer: A. Introduce new food between regular meals.

Rationale: breastmilk is still okay but by ages 4 months to 6 months, most babies are
ready to begin eating solid foods as a complement to breast-feeding or formula-
feeding. It's during this time that babies typically stop using their tongues to push food
out of their mouths and begin to develop the coordination to move solid food from the
front of the mouth to the back for swallowing.

42. A patient who has a spinal cord transection is in spinal shock. On assessment the
nurse would expect the patient to describe which of the following findings in the lower
extremities?

a. Loss of sensation
b. Complains of tingling
c. Excessive diaphoresis
d. Constant tremors

Answer: A. Loss of sensation.

Rationale: Spinal shock occurs only with physiologic or anatomic transection or near
transection of the spinal cord; however, in clinical and laboratory series, the spinal cord
is rarely anatomically transected. And surrounding the physiologic or anatomic
transection of the spinal cord that results in temporary loss or depression of all or most
spinal reflex activity below the level of the injury.

43. Which of the following plans is particularly important in the care of a patient who
has Alzheimer’s disease?

a. Using behavior modification techniques

b. Assessing the patient’s on an ongoing bias
c. Helping the patient explore emotional conflicts
d. Implementing a bowel training program

Answer: A. Using behavior modification techniques.

Rationale: As a caregiver, your support with these everyday tasks can help the person
with Alzheimer develop new coping strategies that will help to maximize his or her
independence and to provide support and help plan for the future.

44. A patient admitted to the hospital with a diagnosis of chronic renal failure should be
assessed for which of the following manifestations?
a. Hypotension
b. Fatigue
c. Flushed skin
d. Painful urination

Answer: B. Fatigue.
Rationale: Common symptoms include blood in urine, high blood pressure, and fatigue.

45. Following a prostectomy, the pathology report reveals that the patient has cancer
of the prostate. Which of the following blood test results would support this diagnosis?

a. Elevated acid phosphatase

b. Decreased uric acid
c. Elevated bicarbonate
d. Decreased creatinine

Answer: A. Elevated acid phosphatase.

Rationale: From the 1950s through the 1980s, acid phosphatase was widely used to
detect, stage, and monitor prostate cancer treatment response, with some success.
Gutman (1938) reported increased levels of acid phosphatase in patients with
metastatic prostate cancer.

46. In which of the following ways should the nurse intervene when a patient repeatedly
talks about his past?

a. Help the patient to establish goals for the future

b. Give the patient a diversional activity
c. Ask the patient to think of recent pleasures
d. Encourage the patient to share memories

Answer: D. Encourage the patient to share memories.

Rationale: Rather than trying to bring the person with Dementia and Alzheimer back to
reality, families and careers may try to enter their reality; building trust and empathy,
and reducing anxiety. This is known as validation therapy.
47. A nurse would instruct a patient who has had an ileostomy to avoid which of the
following foods?

a. Potatoes
b. Beef
c. Popcorn
d. Yogurt

Answer: C. Popcorn.
Rationale: Avoid nuts, seeds, raw fruits and vegetables (unless in a processed form like
smooth butters) and popcorn to that avoid bowel blockages.

48. A nurse should recognize that cardiac arrest in a previously healthy infants is usually
preceded by:

a. Ventricular arrhythmias
b. Respiratory failure
c. Generalized seizures
d. Distributive shock

Answer: B. Respiratory failure.

Rationale: Most commonly, infants and children sustain cardiac arrest as a result of
respiratory failure. Rarely in previously healthy children is cardiac arrest due to a
primary cardiac etiology.

49. A patient is to be transfused with a unit of whole blood. If the patient were to
develop an allergic reaction, the nurse would expect to administer which of the
following drugs?

a. Benadryl
b. Chlotrimenton
c. Sudafed
d. Phenegran

Answer: B. Chlotrimenton.
Rationale: Chlor-Trimeton injection mixed with blood for transfusion significantly reduces
the incidence of allergic posttransfusion reactions. No reactions occurred in 46 allergic
patients, 17 of whom had a history of an allergic reaction to blood transfusion, when
they received 108 pints of blood with 20 mg. Chlor-Trimeton injection added. The
reaction rate in the same patients receiving 109 pints of blood with no added
antihistamine was 12 per cent. Moderate drowsiness in a few patients constituted the
only side action to Chlor-Trimeton.

50. When a patient who has diabetes mellitus experiences peripheral neuropathy, the
priority nursing diagnosis should be?

a. Altered health maintenance

b. Altered urinary elimination
c. Risk for impaired skin integrity
d. Noncompliance

Answer: C. Risk for impaired skin integrity.

Rationale: If your patient has developed peripheral neuropathy because of their
diabetes, the risk for a wound or ulcer developing is significantly increased. Often
patients with neuropathy have a lowered sensation of pain, and so they may not realize
if they have received an injury to their feet or if a pressure ulcer is developing.

51. When a patient who has diabetes mellitus experiences peripheral neuropathy, the
priority nursing diagnosis should be
a. Altered health maintenance
b. Altered urinary elimination
c. Risk for impaired skin integrity
d. Noncompliance

ANSWER: C. Risk for impaired skin integrity

RATIONALE: If the patient has developed peripheral neuropathy because of their
diabetes, the risk for a wound or ulcer developing is significantly increased. Often
patients with neuropathy have a lowered sensation of pain, and so they may not realize
if they have received an injury to their feet or if a pressure ulcer is developing.

52. A patient who has ulcerative colitis does not respond to the prescribed therapy and
is admitted to the hospital for a total colectomy and creation of an ileostomy. Which of
the following measures should be given priority in the patient’s preoperative care plan?
a. Correcting the patient’s fluid balance
b. Monitoring the patient’s emotional state
c. Promoting the patient’s acceptance of an ileostomy
d. Preventing the patient from the developing pressure source

ANSWER: A. Correcting the patient’s fluid balance

RATIONALE: A period of preparation with intensive replacement of fluid, blood, and
protein is necessary before surgery.
53. A patient who has had an ileostomy says to the nurse, “I will have to be isolated for
the rest of my life because no one will be able to stand this terrible odor”. Which of the
following responses by the nurse would be most likely be reassuring?
a. “The odor will gradually become less noticeable”
b. “I can understand your concern, but remaining in isolation does not reduce
the odor”
c. “There are techniques that can reduce the odor”
d. “The odor is a normal part of your condition and will not offend people”

ANSWER: C. “There are techniques that can reduce the odor”

RATIONALE: Pouching systems are designed to be odor proof. Unless you’re leaking
bowel movements underneath the wafer, there should be no odor while the pouching
system is attached. However, if odor is a problem for, there are deodorants that you can
put into the pouch to help. Some examples are drops, charcoal tablets, or lubricating
gel. You may need to experiment to find one that works best for you. There are also
deodorants you can take orally (by mouth) to decrease your bowel movement’s odor.
Check with your doctor or nurse before using any of these.

54. Which of the following instructions would a nurse include in the discharge plan for a
patient who had a transurethral resection of the prostate (TURP).
a. Limit the intake of caffeinated beverages
b. Resume normal activities of daily living
c. Maintain a diet low in fiber
d. Strain urine with each voiding

ANSWER: B. Resume normal activities of daily living

RATIONALE: To lower the risk of bleeding after the operation, it is important not to be too
active. Avoid lifting, gardening, golf or other demanding activities in the first two weeks
or so after surgery. Normal daily activities such as normal walking can occur
immediately after the procedure however try to avoid driving a car for at least a week
after the procedure. Sexual activity should be avoided for at least 4 weeks.

55. Which of the following clients would the nurse prepare for an emergency cesarean
delivery?
a. A woman who has a prolapsed cord
b. A woman with a twin gestation
c. A woman who has meconium-stained amniotic fluid
d. A woman has a nonreactive non-stress test

ANSWER: A. A woman who has a prolapsed cord

RATIONALE: In a prolapse, the umbilical cord drops (prolapses) through the open cervix
into the vagina ahead of the baby. The cord can then become trapped against the
baby's body during delivery. This can result in a loss of oxygen to the fetus, and may
even result in a stillbirth.

56. While a patient who has Hodgkin’s disease is receiving chemotherapy, it is important
to assess the patient for symptoms of
a. Thrombus formation
b. Ascites
c. Infection
d. Splenomegaly

ANSWER: C. Infection
RATIONALE: Chemotherapy causes systemic side effects (eg, myelosuppresion, nausea,
hair loss, and risk for infection). The risk for infection is significant for these patients, not
only from treatment-related myelosuppression but also from the defective immune
response that results from the disease itself.

57. The nurse caring for patient with jaundice should expect to see an elevation in
which of the following laboratory values?
a. Serum ammonia
b. Blood urea nitrogen
c. Serum bilirubin
d. Serum albumin

Answer: C. Serum bilirubin

RATIONALE: Jaundice, a yellowing of the skin, is directly related to elevations in serum
bilirubin and is often first observed in the sclera and mucous membranes.

58. Patients with eating disorder should also be assessed for which other psychiatric
disorder?
a. Depression
b. Borderline personality
c. Conduct disorder
d. Schizophrenia

ANSWER: A. Depression
RATIONALE: Eating disorders may occur with a wide range of other mental health
conditions. Common co-occurring conditions include anxiety disorders (including
generalized anxiety, social anxiety and obsessive-compulsive disorder), depression
and other mood disorders, post-traumatic stress disorder and substance use disorders.
59. Which of the following nursing diagnoses would be a priority for patient who has just
been admitted with a diagnosis of bipolar disorder, mania?
a. Decisional conflict related to making health care choices
b. Self-care deficit, bathing/hygiene, related to lack of attention
c. Hopelessness related to impending depression
d. Fatigue related to hyperactivity

ANSWER: D. Fatigue related to hyperactivity

RATIONALE: During the manic phase patients are elated and have a decreased need
for sleep due to high energy.

60. If a person has foreign object of unknown material that of not readily seen in one
eye, what would be the first action be?
a. Irrigate the eye with a boric acid solution
b. Examine the lower eyelid and then the upper eyelid
c. Irrigate the eye with copious amount of water (Normal Saline)
d. Shield the eye from pressure, and seek medical help

ANSWER: C. Irrigate the eye with copious amount of water (Normal Saline)
RATIONALE: Minor foreign objects include things like dust, grit, or an eyelash that is
easily removed. The most important point is to use a generous amount of water to
ensure the particle is completely flushed out of the eye.

SITUATION: Divina Mendoza’s left arm is badly mutilated in a boating accident and is
amputated just below the shoulder.

61. While the nurse is checking Ms. Mendoza’s dressing, she says she is anxious and asks
to have both her hands held. Which of the following is the nurse’s best response?

a. “Ms. Mendoza, I’m holding your hands.”

b. “Your left hand and arm were amputated the day of the boating
accident.”
c. “Your dressing is dry and clean where the surgeons removed your
arm.”
d. “Many persons think their missing extremity is still present immediately
after surgery”

ANSWER: D. “Many persons think their missing extremity is still present immediately after
surgery”
RATIONALE: Due to the nature of the accident and only for this case Ms. Mendoza may
have lost consciousness due to rapid loss of blood carrying oxygen. She may only be
able to recall events up to the point where she passed out. Therefore, a thorough
assessment of the accident is necessary to properly explain the situation that would
cause minimal distress and for Ms. Mendoza to realize the severity of the accident.

62. How can the nurse best help Ms. Mendoza adapt to her new body image?

a. Have her think of how she would like to look.

b. Talk to her husband about her change in body image.
c. Have her write her feelings.
d. Have her touch and reopen herself to her body.

ANSWER: D. Have her touch and reopen herself to her body.

RATIONALE: Having Ms. Mendoza reacquainted to her new image should be done
slowly by informing her that she has been in a boating accident and she was badly hurt
in the accident. Then have her feel her limbs.

63. Which of the following manifestations would MOST likely be observed?

a. Ascites
b. Elevated blood pressure
c. Low urine specific gravity
d. Hematuria.

ANSWER: D. Hematuria
RATIONALE: Blood in the urine is indicative of injury in the renal system. The situation is
indicative of rapid blood loss that would cause fluid volume deficit. Hypovolemia can
cause damages in the organs and dehydration. Dehydration can lead to high urine
specific gravity not low. Ascites may result from over hydration.

64. Because of their work commitments, Jay’s parents are not able to stay with him
in the hospital, in addition to the stress created by his separation from his parents. Jay
will MOST likely suffer from which of the following?

a. Intrusive procedures
b. Unfamiliar caretakers
c. Dying
d. Fear

ANSWER: D. Fear
RATIONALE: Parents are safety nets for children or their comfort zone. The separation is
causing stress for Jay which is a trigger or catalyst along with a, b, c.
65. When planning Jay’s nursing care, the nurse would include activities that
promote a sense of

a. Trust
b. Industry
c. Esteem
d. Initiative

ANSWER: A. Trust
RATIONALE: Trust is essential in development for independent functioning along with a
proper, acceptable, and understandable explanation for a child so it may promote the
said answer within the child. Be aware of overpromising and not delivering.

66. Jay is receiving prednisone by mouth. Which of the following action is NOT
indicated?

a. Give the prednisone after meals.

b. Withhold prednisone if Jay’s blood pressure becomes elevated.
c. Observe Jay closely for sign of infection.
d. Provide food high in potassium in Jay’s diet.

ANSWER: A. Give the prednisone after meals.

RATIONALE: Prednisone is usually taken with food. Corticosteroids can irritate stomach
thus taken with meals or after. It can also cause the body to retain fluid which can
elevate blood pressure, weaken the immune system, and hypokalemia since it
increases loss of potassium through the urine hence b, c, and d, are proper actions for a
client on prednisone.
67. Which of the following would be MOST appropriate for Jay while he is
hospitalized?

a. Playing with other children in the playroom.

b. Playing with housekeeping toys in his room.
c. Riding a push-pull toy in the hall.
d. Having a volunteer read him a story about a child in the hospital.

ANSWER: D. Having a volunteer read him a story about a child in the hospital.
RATIONALE: Having a volunteer read a story about a child in the hospital is safest
intervention since the child is on prednisone. Prednisone is used for many different
autoimmune diseases and inflammatory conditions, including asthma, COPD, CIDP,
rheumatic disorders, allergic disorders, ulcerative colitis, and Crohn's disease,
adrenocortical insufficiency, hypercalcemia due to cancer, thyroiditis, laryngitis, severe
tuberculosis, hives, lipid pneumonitis, pericarditis, multiple sclerosis, nephrotic
syndrome, sarcoidosis, to relieve the effects of shingles, lupus, myasthenia gravis,
poison oak exposure, Ménière's disease, autoimmune hepatitis, giant-cell arteritis, the
Herxheimer reaction that is common during the treatment of syphilis, Duchenne
muscular dystrophy, uveitis, and as part of a drug regimen to prevent rejection after
organ transplant.

68. Which of the following snacks would be Best choice for Jay?

a. 1 ounce processed cheese spread, celery sticks and cool-aid.

b. ½ peanut butter sandwich, apple slices, and ½ cup hot cocoa.
c. ½ cup corn flakes, milk, and raisins.
d. ½ cup vanilla pudding and grape juice.

ANSWER: B.
RATIONALE: It offers nutritious combination of food capable of meeting his nutritional
demands. It sounds more appetizing for a three year old. Assess patient for food
preference, allergies to, and tolerance.

69. During the acute phase of his illness, which position is BEST for Jay to be placed
in?

a. On his side.
b. On his back.
c. On his abdomen
d. Semi-fowler positions

Answer. D. Semi-fowler position

RATIONALE: Acute phase can indicate ineffective airway clearance. Best position is
semi-fowler for maximal air intake.

SITUATION: Mr. and Mrs. Solas have learned recently that their 3 year old daughter
Janine has an untreatable malignant tumor.

70. Because Janine is 3 years old the nurse can expect her to have which of the
following views of death?

a. Someone bad will carry her away.

b. Death occurs but it is not permanent.
c. Death and absence are the same.
d. Everyone must die.

Answer. B. Death occurs but it is not permanent.

RATIONALE: Preschoolers see death as something temporary. Their misconception is
reinforced by cartoons in which characters pop back to life moments after anvils drop
on them from the sky. Because young children are concrete thinkers, seeing things
exactly as they appear and hearing things literally, it is important that they are told
about death in simple, clear language.

71. Which of the following would probably NOT be effective in helping Janine express
her actions and feelings about her situation?

a. Provide her with dolls and puppets for symbolic play

b. Provide paper and color for her to draw with and have her describes her
drawings
c. Set up a regular time each day for her to talk about her feelings and concern
d. Read stories and talk about how the children in the stories feel

ANSWER: D. Read stories and talk about how the children in the stories feel
RATIONALE: Choices A, B, and D helps Janine express her actions and feelings about
her situation, However choice letter C talks about feelings of other children instead of
herself.

SITUATION: Luca Pastillas, a newlywed, comes to the mental health clinic because of
“nervousness”. She relates to the nurse that “my stomach has butterflies a lot of the
time. I haven’t missed any work, but it’s getting harder because I can’t concentrate
very long on anything.”

72. What level of anxiety is Mrs. Pastillas MOST likely experiencing?

a. Mild
b. Moderate
c. Severe
d. Panic

ANSWER: B. Moderate
RATIONALE: Moderate anxiety is similar to mild anxiety but can become more severe
and overwhelming, making you feel more nervous and agitated. At a moderate level of
anxiety, you're likely to focus exclusively on the stressful situation directly in front of you
and ignore other tasks. You might experience a faster heartbeat, dry mouth, sweating
and stomach pain or nausea. Your speech may be rapid and high-pitched, and your
hand and arm movements are likely more exaggerated. Nervous habits, like biting your
nails or wringing your hands, are common. This is also characterized by

73. Which would be BEST way to begin talking to Mrs. Pastillas nursing history?

a. “Tell me about your husband”

b. “What are you feeling now”
 c. “Have you ever felt this way before”
d. “Does anyone else in your family ever get these feelings?

ANSWER: C. “Have you ever felt this way before”

RATIONALE: Best way taking Mrs. Pastillas nursing history is to ask if she ever felt like this
before. Knowing could tell us if this is a symptom of a mental disorder.

74. Which of the following would be MOST appropriate goal for nursing diagnosis of
“Ineffective individual coping related to feelings of hopelessness and anger”?

a. The client will deny feelings of hopelessness and anger

b. The client will demonstrate cheerful affect
c. The client will voice no complaints
d. The client will share feelings with nurse and others

ANSWER: A. The client will deny feelings of hopelessness and anger

RATIONALE: In the 5 Stages of Grief (DABDA), Denial comes first. Patient will deny
feelings of hopelessness and anger.

75. Which of the following actions would be LEAST effective in helping the client cope
with painful feelings?

a. Focus on the positive aspects of life

b. Encourage the client to share feelings
c. Help the client of identity feelings
d. Provide reality orientation, and encourage realistic expectations of self

ANSWER: A. Focus on the positive aspects of life

RATIONALE: The patient has nervousness, and she’s about to get married. The nurse
needs to focus on the patients feeling at this time- not ignoring it.

76. Which of the following would NOT be appropriate questions for the nurse to ask
when assessing the depressed client?

a. “What are your expectations of yourself?”

b. “How do you cope with anger?”
c. “Don’t you know that it is morally wrong to think of suicide?”
d. “What kinds of things are pleasurable for you?”

ANSWER: C. “Don’t you know that it is morally wrong to think of suicide?”

RATIONALE: All choices are open-ended question and is therapeutic except choice
letter C. It’s a close statement that brings up the topic of suicide. It’s not appropriate at
this time. Letter C is a non-therapeutic question.

77. Which nursing action would be INAPPRPRIATE at this time.

a. Provide the Muang with a fully detailed explanation of SIDS

b. Allow the Muang to be alone with their daughter’s body for a short time
c. Call a relative or close friend to come to the hospital to be with them
d. Place an arm around their shoulder and say, “I’m so sorry.”

ANSWER: A. Provide the Muang with a fully detailed explanation of SIDS

RATIONALE: Providing fully detailed explanation of SIDS would be inappropriate at this
time because the parents are grieving at this time because their child has died. They
won’t be able to understand and digest a thing you will say.

78. While assessing the Muang during a follow-up home visit, what is the best indicator
of their successful coping with the loss of their daughter?

a. Moving to a new residence

b. Involving themselves in a SIDS support group
c. Attending their church regularly
d. Returning to work

ASNWER: B. Involving themselves in a SIDS support group

RATIONALE: They completed the Stage of Grief (DABDA). They’re in the stage where
they accept the faith of their daughter. Now, they’re involving their selves in the
support-not to happen to others what happen to their family.

79. A short time later, Mr. Muang says, “she was so healthy”. I just can’t understand
what would have caused this. “What did we do wrong?” What is the MOST appropriate
response?

a. “Try not to blame yourself for Ana’s death”

b. “No one knows the cause of SIDS”
c. “It sound like you feel responsible for what happened to Ana”
d. “Did Ana seem sick before bedtime?”

ANSWER: B. “No one knows the cause of SIDS”

RATIONALE: Telling the truth is the most appropriate thing to do at this time because they
are emotional. This would give them some closure that it’s not their fault. SIDS cause is
unknown. Therefore, it is logical and therapeutic to respond to them the nature of SIDS.
SITUATION: Ana Bilibid, a RN, assigned in Medical Unit.

80. A patient has been acting out most of the day. To which of the following
interventions should a nurse give priority?

a. Inform the patient of rules and regulations that must be followed

b. Isolate the patient until the patient gains self-control
c. Tell the patient to control the feelings motivating the behavior
d. Try to elicit the feelings behind the patient’s behavior

ANSWER: D. Try to elicit the feelings behind the patient’s behavior

RATIONALE: There would be a reason why the patient is acting out. That’s why we need
the patient to bring out what’s bothering him/her, because emotions can affect our
behavior directly, as in case of aggression etc.

81. A nurse should expect a patient to demonstrate which of the following findings after
receiving electroconvulsive therapy?

a. Seizures
b. Muscle spasms
c. Short term memory loss
d. Personality changes

ANSWER: C. Short term memory loss

RATIONALE: You may have some memory loss until you complete all of your treatments.
This memory loss should gradually reverse itself over the course of several weeks.
However, you may never remember many things that happened to you shortly before,
during, or soon after your course of treatment.

82. Which of the following instructions about urinary management should a nurse give
to a patient who is undergoing rehabilitation following a spinal cord injury?

a. “Limit your fluid intake during the day.”

b. “Empty your bladder on a timed schedule.”
c. “Drink a glass of cranberry juice every morning.”
d. “Avoid carbonated beverages at all times”

ANSWER: A. “Limit your fluid intake during the day.”

RATIONALE: Restrict fluids to 2 L/day and follow a straight catheterization protocol, as
ordered. The goal is to achieve a so-called balanced bladder, where fluid
intake approximates output. Because overdistention can trigger AD, bladder volumes
typically are targeted to 500 mL or less per catheterization.
83. A patient who has had a spinal cord injury reports an acute pounding headache. A
nurse should recognize that this is a symptom of

a. Autonomic dysreflexia
b. Spinal Shock
c. Grand mal seizures
d. Decerebration

ANSWER: A. Autonomic dysreflexia

RATIONALE: Autonomic dysreflexia (autonomic hyperreflexia) is an acute emergency
that occurs as a result of exaggerated autonomic responses to stimuli that are harmless
in normal people. This syndrome is characterized by a severe, pounding headache with
paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea,
nasal congestion, and bradycardia.

84. Which of the following pieces of equipment should a nurse have available at the
bedside of a patient who is experiencing dysphagia following an acute
cerebrovascular accident (CVA).

a. Oxygen Cannula
b. Tracheostomy tray
c. Suction set up
d. Padded tongue blade

ANSWER: C. Suction set up

RATIONALE: Impaired swallowing increases the patient’s risk for aspiration; therefore,
strategies such as having suction apparatus available, careful feeding, proper
positioning for eating are needed to reduce the risk

SITUATION: Ursula, 17 years old who has anorexia nervosa is hospitalized for the initial
treatment phase.

85. Which of the following statements indicated a correct understanding of the

treatment plan?

a. “I’ll write down everything that I eat in my food diary.”

b. “I have to be weighed before every meal.”
c. “I’ll have to eat foods high in salt with every meal.”
d. “You’ll have to watch me eat my meals”

ANSWER: D. “You’ll have to watch me eat my meals”

RATIONALE: The client with an eating disorder requires supervision during and after
meals to ensure that she eats and doesn’t try to vomit after eating.
86. Which of the following behaviours is considered a casual factor in the transmission of
hepatitis A?

a. Donating blood
b. Consuming shellfish
c. Having multiple sex partners
d. Getting a tattoo recently

ANSWER: C. Having multiple sex partners

RATIONALE: Hepatitis A can be transmitted during sexual activity; this is more likely with
oral–anal contact, anal intercourse, and a greater number of sex partners (CDC, 2002).
Hepatitis A can be transmitted also by eating raw shellfish from water polluted with
sewage however choice B did not indicate.

SITUATION: Philip Mercado, age 35 has been admitted to the mental health unit. Over
the past month he has had difficulty in sleeping and has lost his appetite. Although very
anxious and tense, he appears sad and has lost all initiative. He has difficulty in
concentrating and most of his thoughts center on his unworthiness and his failures.

87. Mr. Mercado is being interviewed by the admitting nurse. The statement that would
be the MOST appropriate at this time would be:

a. “Tell me what has been bothering you.”

b. “Why do you feel so bad about yourself?”
c. “Tell me how you feel about yourself.”
d. “What can we do to help you during your stay with us?”

ANSWER: C. “Tell me what has been bothering you.”

RATIONALE: This statement indicates exploration and focusing of patient’s feelings.

88. The action by the nurse that would be MOST therapeutic when Mr. Mendoza states,
“I am good, I’m better off dead”, would be:

a. Alerting the staff to provide 24 hours observation of the client.

b. Stating “I will stay with you until you are less depressed.”
c. Unobtrusively removing those articles that could be used in a suicide attempt.
d. Stating “I think you are good; you should think of living.”

ANSWER: B. Stating “I will stay with you until you are less depressed.”
RATIONALE: This statement indicates offering self. The nurse can offer his/her presence,
interest and desire to understand. It is important that this offer is unconditional, that is,
the client does not have to respond verbally to get the nurse attention.

89. In making nursing care plan for Mr. Mendoza, the approach that would be MOST
therapeutic would be:
 a. Allowing time for his slowness when planning activities
b. Encouraging the client to perform mental task to meet the need for punishment
c. Reassuming him that he is worthwhile and important
d. Helping Mr. Mendoza on family strength and support systems

ANSWER: D. Helping Mr. Mendoza on family strength and support systems

RATIONALE: There are many benefits to involving families in the care of their loved ones
with mental illness. Research confirms that family input in treatment decisions improves
patient outcomes, with maximum benefits occurring when the families are supported
and educated for these partnership roles (Heru, 2006; Zauszniewski et al, 2009).

90. Mr. Mendoza refuses to cooperate with the staff. All planned activities are rejected,
since he is “just too tired”. The nursing approach that best expresses an understanding
of his need is:

a. Accepting his behaviour calmly and without excessive comment setting firm
limits
b. Planning a rest period for him during activity time
c. Explaining what the activities are therapeutic for him
d. Helping him express his feelings of hostility toward activities

ANSWER: B. Planning a rest period for him during activity time

RATIONALE: It is best to plan activities according to each patient’s energy levels; some
feel best in the morning and others in the evening. A scheduled rest period may be
helpful, but patients should not be encouraged to take frequent naps or to remain in
bed all day.

91. Mr. Mendoza is to be discharged from the hospital. The statement by the nurse that
demonstrates the most understanding at this time is:

a. “Call the unit night or day if you have problems”

b. “I know you are going to be all right when you go home”
c. “I am going to miss you; we have become good friends”
d. “This is my phone number; call me and let me know how you are doing”

ANSWER: A. “Call the unit night or day if you have problems”

RATIONALE: It is the most understanding because it is also the most therapeutic
response. This response shows empathy since it offers help to the patient whenever he
needs assistance or help with something. Letter b is nontherapeutic because it gives
false reassurance while letter c and d is not proper for a nurse-patient relationship
because the nurse is attached personally to the patient.
SITUATION: Nurse Alden is assigned to care for Maine Dub, a 22 year old hyperactive,
elated client who exhibits flight of ideas.
92. Ms. Dub is not eating. Nurse Alden recognizes that this may be because she:

a. Feels that she does not deserve the food

b. Believes that she does not need the food
c. Wishes to avoid the clients in the dining room
d. Is so busy that she does not take time to eat

ANSWER: D. Is so busy that she does not take time to eat.

RATIONALE: The patient is in manic phase of a bipolar disorder which is characterized
by hyperactivity and flight of ideas. She is too busy that she does not take time to eat
and she does not think that she does not deserve the food nor does she think that she
does not deserve the food. Patients with mania do not avoid other people.

93. Nurse Alden can best respond to Ms. Dub’s eating problem by:

a. Providing a tray for her in her room

b. Assisting her that she is discerning of food
c. Ordering foods that she can hold in her hand to eat while moving around
d. Pointing out that the energy she is burning up must be replaced.

ANSWER: D. Pointing out that the energy she is burning up must be replaced. ;
RATIONALE: Patients with mania are at risk for injury because they are too hyped that
their body might have fatigue after that is why telling them that they need food is
important. Other options does not encourage eating.

SITUATION: Rica Palen, a 29 year old woman, believes that doorknobs are
contaminated and refuses to touch them, except with a paper tissue.

94. In dealing with this behavior the nurse should:

a. Encourage her to touch doorknobs by removing all available paper tissue until
she learn to deal with the situation
b. Explain to her that her idea about doorknobs is part of her illness and is not
necessary
c. Encourage her to scrub the doorknobs with a strong antiseptic so she does not
need to use tissues
d. Supply her with paper tissues to help her function until her anxiety is reduced

ANSWER: D. Supply her with paper tissues to help her function until her anxiety is
reduced
RATIONALE: The patient has a Contact contamination OCD which can be described as
a feeling of dirtiness or discomfort that is felt in response to physical contact with
harmful substances, disease or dirt, which will contaminate the body, most often the
hands. Relief can be felt in response to cleansing the contaminated areas, for example
through hand washing or by using paper tissue to avoid touching the ‘dirty doorknob’.
Other options only increase the illness and will make it worse.

95. Symptoms such as using tissue to touch doorknobs develop because the client is:

a. Consciously using this method of punishing herself

b. Listening to voices that tell her the doorknobs are unclean
c. Fulfilling a need to punish others by carrying out an annoying procedure
d. Unconsciously controlling unacceptable impulses or feelings

ANSWER: D. Unconsciously controlling unacceptable impulses or feelings

RATIONALE: OCD is characterized by repetitive behavior that is due to unconscious
controlling of unacceptable feelings and impulses.

96. Mental experiences operate on different level awareness. The level that best
portrays one’s attitude, feelings and desires is the;

a. Unconscious
b. Conscious
c. Preconscious
d. Fore conscious

ANSWER: A. Unconscious

RATIONALE: The unconscious mind is a reservoir of feelings, thoughts, urges, and

memories that outside of our conscious awareness. Most of the contents of the
unconscious are unacceptable or unpleasant, such as feelings of pain, anxiety, or
conflict.

97. The level of anxiety that best enhances an individual’s power of perception is

a. Moderate
b. Mild
c. Severe
d. Panic

ANSWER: B. Mild
RATIONALE: Mild anxiety helps people to focus and increases alertness which enhances
an individual’s power of perception.
98. Rica seeing a design on the wallpaper, perceives it as an animal. This is an example
of:

a. Delusion
b. Hallucination
c. Illusion
d. Idea of reference

ANSWER: C. Illusion
RATIONALE: An illusion is a false illustration of something, a deceptive impression, or a
false belief. Literally speaking, an illusion is something that is false and not factual. It
tricks the human brain into thinking an unreal into a real which plays with the senses.

99. Evidence of existence of the unconscious is best demonstrated by:

a. Déjà vu experiences
b. Slips of the tongue
c. The ease recall
d. Free-floating anxiety

ANSWER: A. Déjà vu experiences

RATIONALE: Déjà vu is a startling mental event. The phenomenon involves a strong
feeling that an experience is familiar, despite sensing or knowing that it never
happened before. Most people have experienced déjà vu at some point in their life,
but it occurs infrequently, perhaps once or twice a year at most.

100. Ms. Rica believes that the NBI is out to kill her. This is an example of:

a. Delusion of persecution
b. An error in judgment
c. A self-accusatory delusion
d. A hallucination

ANSWER: A. Delusion of persecution

RATIONALE: Persecutory delusions are a set of delusional conditions in which the
affected persons believe they are being persecuted. Specifically, they have been
defined as containing two central elements: The individual thinks that harm is occurring,
or is going to occur.