TEST I - Foundation of Professional Nursing Practice

1. The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without
checking the client’s pulse. The standard that would be used to determine if the nurse was negligent is:

d. The actions of a reasonably prudent nurse with similar education and experience.

2. Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet
count of 22,000/μl. The female client is dehydrated and receiving dextrose 5% in half-normal saline
solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of
morphine sulfate. In administering the medication, Nurse Trish should avoid which route?

b. I.M

3. Dr. Garcia writes the following order for the client who has been recently admitted “Digoxin .125 mg
P.O. once daily.” To prevent a dosage error, how should the nurse document this order onto the
medication administration record?

c. “Digoxin 0.125 mg P.O. once daily”

4. A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis
should receive the highest priority?

a. Ineffective peripheral tissue perfusion related to venous congestion.

5. Nurse Betty is assigned to the following clients. The client that the nurse would see first after
endorsement?

b. A 44 year-old myocardial infarction (MI) client who is complaining of nausea

6. Nurse Gail places a client in a four-point restraint following orders from the physician. The client care
plan should include:

c. Check circulation every 15-30 minutes

7. A male client who has severe burns is receiving H2 receptor antagonist therapy. The nurse In-charge
knows the purpose of this therapy is to:

a. Prevent stress ulcer

8. The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish
records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on
these amounts, which action should the nurse take?

d. Continue to monitor and record hourly urine output

9. Tony, a basketball player twist his right ankle while playing on the court and seeks care for ankle pain
and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by Tony suggests
that ice application has been effective?

b. “My ankle feels warm”.

10.The physician prescribes a loop diuretic for a client. When administering this drug, the nurse
anticipates that the client may develop which electrolyte imbalance?

b. Hyperkalemia

11.She finds out that some managers have benevolent-authoritative style of management. Which of the
following behaviors will she exhibit most likely?

a. Have condescending trust and confidence in their subordinates

12. Nurse Amy is aware that the following is true about functional nursing

a. Provides continuous, coordinated and comprehensive nursing services

13.Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

b. Standard written order

14.A female client with a fecal impaction frequently exhibits which clinical manifestation?

d. Liquid or semi-liquid stools

15.Nurse Linda prepares to perform an otoscopic examination on a female client. For proper
visualization, the nurse should position the client's ear by:

c. Pulling the helix up and back

16.Which instruction should nurse Tom give to a male client who is having external radiation therapy:

a. Protect the irritated skin from sunlight

17.In assisting a female client for immediate surgery, the nurse In-charge is aware that she should:

c. Assist the client in removing dentures and nail polish

18. A male client is admitted and diagnosed with acute pancreatitis after a holiday celebration of
excessive food and alcohol. Which assessment finding reflects this diagnosis?

d. Sudden onset of continuous epigastric and back pain.

19.Which dietary guidelines are important for nurse Oliver to

b. Provide high-protein, high-carbohydrate diet

20.Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have
about the client?

a. Blood pressure and pulse rate.

21. Nurse Michelle witnesses a female client sustain a fall and suspects that the leg may be broken. The
nurse takes which priority action?

d. Immobilize the leg before moving the client

22.A male client is being transferred to the nursing unit for admission after receiving a radium implant
for bladder cancer. The nurse in-charge would take which priority action in the care of this client?

b. Admit the client into a private room

23.A newly admitted female client was diagnosed with agranulocytosis. The nurse formulates which
priority nursing diagnosis?

c. Risk for infection

24.A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an
air embolism. What is the priority action by the nurse?

b. Place the client on the left side in the Trendelenburg position

25.Nurse May attends an educational conference on leadership styles. The nurse is sitting with a nurse
employed at a large trauma center who states that the leadership style at the trauma center is task-
oriented and directive. The nurse determines that the leadership style used at the trauma center is:

a. Autocratic

26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang
a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution?

d. 2.5 cc

27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV
rate that will deliver this amount is:

a. 50 cc/ hour

28.The nurse is aware that the most important nursing action when a client returns from surgery is:

b. Assess the client for presence of pain

29.Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial
infarction?

a. BP – 80/60, Pulse – 110 irregular

30.Which is the most appropriate nursing action in obtaining a blood pressure measurement?

a. Take the proper equipment, place the client in a comfortable position, and record the appropriate
information in the client’s chart

31.Asking the questions to determine if the person understands the health teaching provided by the
nurse would be included during which step of the nursing process?

b. Evaluation

32.Which of the following item is considered the single most important factor in assisting the health
professional in arriving at a diagnosis or determining the person’s needs?

c. History of present illness

33.In preventing the development of an external rotation deformity of the hip in a client who must
remain in bed for any period of time, the most appropriate nursing action would be to use:

a. Trochanter roll extending from the crest of the ileum to the midthigh

34.Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

c. Stage III

35.When the method of wound healing is one in which wound edges are not surgically approximated
and integumentary continuity is restored by granulations, the wound healing is termed

a. Second intention healing

36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver
learns that the client lives alone and hasn’t been eating or drinking. When assessing him for
dehydration, nurse Oliver would expect to find:

d. Tachycardia

37.The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a
client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of
meperidine should the client receive?

a. 0.75

38.A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an
insulin unit?

d. It’s a measure of effect, not a standard measure of weight or quantity

39.Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade
temperature?

b. 38.9 °C

40.The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual
physical exam. One of the first physical signs of aging is:

c. Failing eyesight, especially close vision.

41.The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is
connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:

a. Checking and taping all connections

42.Nurse Trish must verify the client’s identity before administering medication. She is aware that the
safest way to verify identity is to:

a. Check the client’s identification band

43.The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing
delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of:
b. 32 drops/minute

44.If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do
immediately?

a. Clamp the catheter

45.A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being
admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen and notice
that it is slightly concave. Additional assessment should proceed in which order:

d. Auscultation, percussion, and palpation

46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty
should use the:

d. Ulnar surface of the hand

47. Which type of evaluation occurs continuously throughout the teaching and learning process?

c. Formative

48.A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse
John should instruct her to have mammogram how often?

b. Once per year

49.A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg;
and HCO3 26mEq/L. Based on these values, Nurse Patricia should expect which condition?

a. Respiratory acidosis

50.Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this
referral?

b. To provide support for the client and family in coping with terminal illness

TEST II - Community Health Nursing and Care of the Mother and Child

1. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks
ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps
and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse
notes that May has a dilated cervix. The nurse determines that May is experiencing which type of
abortion?

a. Inevitable

2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the
following data, if noted on the client’s record, would alert the nurse that the client is at risk for a
spontaneous abortion?
b. History of syphilis

3. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible
diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that
which of the following nursing actions is the priority?

c. Monitoring apical pulse

4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy.
The nurse determines that the client understands dietary and insulin needs if the client states that the
second half of pregnancy require:

b. Increased caloric intake

Nursing Crib – Student Nurses’ Community 27

5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware
that one of the following is unassociated with this condition?

a. Excessive fetal activity

6. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH).
The clinical findings that would warrant use of the antidote , calcium gluconate is:

b. Absent patellar reflexes

7. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse,
correctly interprets it as:

c. Presenting part in 2 cm below the plane of the ischial spines

8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the
nurse in-charge to discontinue I.V. infusion of Pitocin is:

a. Contractions every 1 ½ minutes lasting 70-80 seconds

9. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A
nursing action that must be initiated as the plan of care throughout injection of the drug is:

c. EKG tracings

10. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had:

d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex
presentation

11.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature
is:

a. Talk to the mother first and then to the toddler

12.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to
prevent trauma to operative site?
d. Place the infant’s arms in soft elbow restraints

13.Which action should nurse Marian include in the care plan for a 2 month old with heart failure?

b. Allow the infant to rest before feeding

14.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse
should advise her to include which foods in her infant’s diet?

c. Iron-rich formula only

15.Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the clinic. The
mother hides a toy behind her back and the infant looks for it. The nurse is aware that estimated age of
the infant would be:

d. 10 months

16.Which of the following is the most prominent feature of public health nursing?

d. Public health nursing focuses on preventive, not curative, services.

17.When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is
evaluating

b. Efficiency

18.Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse. Where should she
apply?

d. Rural Health Unit

19.Tony is aware the Chairman of the Municipal Health Board is:

a. Mayor

20.Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3
rural health midwives among the RHU personnel. How many more midwife items will the RHU need?

a. 1

21.According to Freeman and Heinrich, community health nursing is a developmental service. Which of
the following best illustrates this statement?

b. Health education and community organizing are necessary in providing community health services

22.Nurse Tina is aware that the disease declared through Presidential Proclamation No. 4 as a target for
eradication in the Philippines is?

b. Measles

23.May knows that the step in community organizing that involves training of potential leaders in the
community is:
d. Core group formation

24.Beth a public health nurse takes an active role in community participation. What is the primary goal
of community organizing?

d. To maximize the community’s resources in dealing with health problems.

25.Tertiary prevention is needed in which stage of the natural history of disease?

d. Terminal

26.The nurse is caring for a primigravid client in the labor and delivery area. Which condition would
place the client at risk for disseminated intravascular coagulation (DIC)?

a. Intrauterine fetal death

27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be:

c. 120 to 160 beats/minute

28.The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct
the mother to:

a. Change the diaper more often

29.Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (tri-somy
21) is:

d. Endocardial cushion defect

30.Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse
effects associated with magnesium sulfate is:

b. Decreased urine output

31.A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. This type of
menstrual pattern is bets defined by:

a. Menorrhagia

32.Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would
be:

c. Blood typing

33.Nurse Gina is aware that the most common condition found during the second-trimester of
pregnancy is:

d. Physiologic anemia

34.Nurse Lynette is working in the triage area of an emergency department. She sees that several
pediatric clients arrive simultaneously. The client who needs to be treated first is:

d. A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and drooling
35.Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which
of the following conditions is suspected?

a. Placenta previa

36.A young child named Richard is suspected of having pinworms. The community nurse collects a stool
specimen to confirm the diagnosis. The nurse should schedule the collection of this specimen for:

d. Early in the morning

37.In doing a child’s admission assessment, Nurse Betty should be alert to note which signs or symptoms
of chronic lead poisoning?

a. Irritability and seizures

38.To evaluate a woman’s understanding about the use of diaphragm for family planning, Nurse Trish
asks her to explain how she will use the appliance. Which response indicates a need for further health
teaching?

d. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”

39.Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently

assess a child with laryngotracheobronchitis for:

c. Restlessness

40.How should Nurse Michelle guide a child who is blind to walk to the playroom?

b. Walk one step ahead, with the child’s hand on the nurse’s elbow

41.When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect that the
child most likely would have an:

a. Loud, machinery-like murmur

42.The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn
becomes too cool, the neonate requires:

c. More oxygen, and the newborn’s metabolic rate increases

43.Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to assess whether this infant
has:

d. Voided

44.Nurse Carla should know that the most common causative factor of dermatitis in infants and younger
children is:

c. Laundry detergent

45.During tube feeding, how far above an infant’s stomach should the nurse hold the syringe with
formula?

a. 6 inches
46.In a mothers’ class, Nurse Lhynnete discussed childhood diseases such as chicken pox. Which of the
following statements about chicken pox is correct?

a. The older one gets, the more susceptible he becomes to the complications of chicken pox

47.Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is the BEST
advice that you can give to women in the first trimester of pregnancy in the barangay Pinoy?

d. Consult a physician who may give them rubella immunoglobulin

48.Myrna a public health nurse knows that to determine possible sources of sexually transmitted
infections, the BEST method that may be undertaken is:

a. Contact tracing

49.A 33-year old female client came for consultation at the health center with the chief complaint of
fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start
of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood
waters about 2 weeks before the onset of symptoms. Based on her history, which disease condition will
you suspect?

d. Leptospirosis

50.Mickey a 3-year old client was brought to the health center with the chief complaint of severe
diarrhea and the passage of “rice water” stools. The client is most probably suffering from which
condition?

b. Cholera

TEST III - Care of Clients with Physiologic and Psychosocial Alterations

1. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the
stool is:

c. Loose, bloody

2. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left
homonymous hemianopsia?

a. On the client’s right side

3. A male client is admitted to the emergency department following an accident. What are the first
nursing actions of the nurse?

c. Check respirations, stabilize spine, and check circulation

4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and
relieves angina by:

d. Decreasing venous return through vasodilation

5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of
the bed and unresponsive to shaking or shouting. Which is the nurse next action?

a. Call for help and note the time

6. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:

c. Make sure that the client takes food and medications at prescribed intervals

7. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2
days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?

b. Continue treatment as ordered

8. A client undergone ileostomy, when should the drainage appliance be applied to the stoma?

b. In the operating room

9. A client undergone spinal anesthetic, it will be important that the nurse immediately position the
client in:

b.Flat on back

10.While monitoring a male client several hours after a motor vehicle accident, which assessment data
suggest increasing intracranial pressure?

c. The client is oriented when aroused from sleep, and goes back to sleep immediately

11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear
first?

a. Altered mental status and dehydration

12. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?

b. Chills, fever, night sweats, and hemoptysis

13. Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and
has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold.
Form this history; the client may have which of the following conditions?

a. Acute asthma

14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4
breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?

b. Respiratory arrest

15. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow
respirations but no sign of respiratory distress. Which of the following is a normal physiologic change
related to aging?

d. Decreased vital capacity

16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to
administration of this medication?

c. Presence of premature ventricular contractions (PVCs) on a cardiac monitor

17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:

b. Avoid foods high in vitamin K

18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess
hair at the site by:

c. Clipping the hair in the area

19. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse
should include information about which major complication:

a. Bone fracture

20. Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose
of performing the examination is to discover:

c. Changes from previous examinations

21. When caring for a female client who is being treated for hyperthyroidism, it is important to:

c. Balance the client’s periods of activity and rest

22. Nurse Kris is teaching a client with history of atherosclerosis. To decrease the risk of atherosclerosis,
the nurse should encourage the client to:

b. Increase his activity level

23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:

a. Laminectomy

24. A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving
the client discharge instructions. These instructions should include which of the following?

d. Avoiding straining during bowel movement or bending at the waist

25. George should be taught about testicular examinations during:

d. Before age 20

26. A male client undergone a colon resection. While turning him, wound dehiscence with evisceration
occurs. Nurse Trish first response is to:

b. Place a saline-soaked sterile dressing on the wound

27. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During
routine assessment, the nurse notices CheyneStrokes respirations. Cheyne-strokes respirations are:

a. A progressively deeper breaths followed by shallower breaths with apneic periods

28. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in
clients with heart failure are:

b. Fine crackles

29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and
breath sounds aren’t audible. The reason for this change is that:

b. The airways are so swollen that no air cannot get through

30. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:

d. Place the client on his side, remove dangerous objects, and protect his head.

31. After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein
distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension
pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?

b. Kinked or obstructed chest tube

32. Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing
forcefully. The nurse should:

d. Stay with him but not intervene at this time

33. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to
the nurse for planning care?

b. Current health promotion activities

34. When performing oral care on a comatose client, Nurse Krina should:

c. Place the client in a side lying position, with the head of the bed lowered

35. A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status.
He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of
103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client
may have which of the following conditions?

c. Pneumonia

36. Nurse Oliver is working in a out patient clinic. He has been alerted that there is an outbreak of
tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB?

c. A 43-yesr-old homeless man with a history of alcoholism

37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that
which of the following reasons this is done?

c. To determine the extent of lesions

38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced
expiratory volume should be treated with which of the following classes of medication right away?
b. Bronchodilators

39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per
day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this
information, he most likely has which of the following conditions?

c. Chronic obstructive bronchitis

Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.

40. The treatment for patients with leukemia is bone marrow transplantation. Which statement about
bone marrow transplantation is not correct?

a. The patient is under local anesthesia during the procedure

41. After several days of admission, Francis becomes disoriented and complains of frequent headaches.
The nurse in-charge first action would be:

d. Raise the side rails

42. During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my
white blood cell production?” The nurse in-charge best response would be that the increased number of
white blood cells (WBC) is:

a. Crowd red blood cells

43. Diagnostic assessment of Francis would probably not reveal:

b. Leukocytosis

44. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency
embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler
ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery.
As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery.
Which of the following is the best initial response by the nurse?

a. Explain the risks of not having the surgery

45. During the endorsement, which of the following clients should the on-duty nurse assess first?

d. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving
L.V. dilitiazem (Cardizem)

46. Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like
“it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a
cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear
and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question
the client about using?

c. Cocaine
47. A 51-year-old female client tells the nurse in-charge that she has found a painless lump in her right
breast during her monthly self-examination. Which assessment finding would strongly suggest that this
client's lump is cancerous?

b. Nonmobile mass with irregular edges

48. A 35-year-old client with vaginal cancer asks the nurse, "What is the usual treatment for this type of
cancer?" Which treatment should the nurse name?

c. Radiation

49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to
the TNM staging system as follows: TIS, N0, M0. What does this classification mean?

b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for
the neck stoma, the nurse should include which instruction?

d. "Keep the stoma moist."

TEST IV - Care of Clients with Physiologic and Psychosocial Alterations

1. Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect
organ rejection?

c. Hypertension

2. The immediate objective of nursing care for an overweight, mildly hypertensive male client with
ureteral colic and hematuria is to decrease:

a. Pain

3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal thyroidectomy is
performed. The nurse is aware that this medication is given to:

d. Decrease the size and vascularity of the thyroid gland

4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can
develop in the client who is diagnosed with:

a. Liver disease

5. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby
should monitor the client for the systemic side effect of:

c. Leukopenia

6. Norma, with recent colostomy expresses concern about the inability to control the passage of gas.
Nurse Oliver should suggest that the client plan to:
c. Avoid foods that in the past caused flatus

7. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would
evaluate that the instructions were understood when the client states, “I should:

b. Keep the irrigating container less than 18 inches above the stoma.”

8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte
imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of
the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:

a. Administer Kayexalate

9. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be
administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

b. 28 gtt/min

10.Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?

d. Upper trunk

11.Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from
a 2-story building. When assessing the client, the nurse would be most concerned if the assessment
revealed:

c. Bleeding from ears

12.Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information
given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?

d. May engage in contact sports

13.The nurse is ware that the most relevant knowledge about oxygen administration to a male client
with COPD is

a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing

14.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted,
and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit
Tonny is placed in Fowler's position on either his right side or on his back. The nurse is aware that this
position:

b. Facilitate ventilation of the left lung

15.Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the
nurse's highest priority of information would be:

a. Food and fluids will be withheld for at least 2 hours

16.Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic
glucose, insulin infusions, and sodium bicarbonate to be used to treat:
c. hyperkalemia

17.Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is
appropriate to tell this client?

a. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou
(Pap) smear annually

18.Maritess was recently diagnosed with a genitourinary problem and is being examined in the
emergency department. When palpating the her kidneys, the nurse should keep which anatomical fact
in mind?

a. The left kidney usually is slightly higher than the right one

19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the
diagnostic test are consistent with CRF if the result is:

c. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl

20.Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while
the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse
provide?

d. Alteration in the size, shape, and organization of differentiated cells

21.During a routine checkup, Nurse Mariane assesses a male client with acquired immunodeficiency
syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?

d. Kaposi's sarcoma

22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal
(subarachnoid) block during surgery. In the operating room, the nurse positions the client according to
the anesthesiologist's instructions. Why does the client require special positioning for this type of
anesthesia?

c. To prevent cerebrospinal fluid (CSF) leakage

23.A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and
nausea. The first nursing action should be to:

a. Auscultate bowel sounds

24.Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the
nurse Patricia position the client for this test initially?

b. Lying on the left side with knees bent

25.A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after
surgery, Nurse Oliver notes that the client's stoma appears dusky. How should the nurse interpret this
finding?

a. Blood supply to the stoma has been interrupted

26.Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?

a. Applying knee splints

27.Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and
chest. Which finding indicates a potential problem?

b. Urine output of 20 ml/hour

28.Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To
help the client avoid pressure ulcers, Nurse Celia should:

a. Turn him frequently

29.Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over
the anterior chest. How should the nurse apply this topical agent?

c. In long, even, outward, and downward strokes in the direction of hair growth

30.Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium
by blocking catecholamines and sympathetic nerve stimulation is:

a. Beta -adrenergic blockers

31.A male client has jugular distention. On what position should the nurse place the head of the bed to
obtain the most accurate reading of jugular vein distention?

c. Raised 30 degrees

32.The nurse is aware that one of the following classes of medications maximizes cardiac performance in
clients with heart failure by increasing ventricular contractility?

d. Inotropic agents

33.A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density
lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?

b. Less than 30% of calories form fat

34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute
myocardial infarction. Which of the following actions would breach the client confidentiality?

c. The emergency department nurse calls up the latest electrocardiogram results to check the client’s
progress

35. A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from
paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the
client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a
heart rate of beats/minute with a palpable pulse. Which of the following actions should the nurse take
first?

b. Check endotracheal tube placement

36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines
that mean arterial pressure (MAP) is which of the following?

c. 95 mm Hg

37. A female client arrives at the emergency department with chest and stomach pain and a report of
black tarry stool for several months. Which of the following order should the nurse Oliver anticipate?

c. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic
panel

38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following
conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is
noted?

d. Heparin-associated thrombosis and thrombocytopenia (HATT)

39. Which of the following drugs would be ordered by the physician to improve the platelet count in a
male client with idiopathic thrombocytopenic purpura (ITP)?

b. Corticosteroids

40. A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the
following types of transplant is this?

d. Xenogeneic

41. Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the initial
response to the injury in the extrinsic pathway?

b. Release of tissue thromboplastin

42. Instructions for a client with systemic lupus erythematosus (SLE) would include information about
which of the following blood dyscrasias?

c. Essential thrombocytopenia

43. The nurse is aware that the following symptoms is most commonly an early indication of stage 1
Hodgkin’s disease?

b. Night sweat

44. Francis with leukemia has neutropenia. Which of the following functions must frequently assessed?

d. Breath sounds

45. The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of
the following body system?

b. Muscle spasm

46. Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV)
infection to the development of acquired immunodeficiency syndrome (AIDS)?
c. 10 years

47. An 18-year-old male client admitted with heat stroke begins to show signs of disseminated
intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC?

a. Low platelet count

48. Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss
over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node.
Which of the following is the most probable diagnosis?

d. Hodgkin’s disease

49. A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB
negative. Which blood type would be the safest for him to receive?

c. A Rh-negative

Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.

50. Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of
Stacy’s mother indicated that she understands when she will contact the physician?

b. “I will call my doctor if Stacy has persistent vomiting and diarrhea”

TEST V - Care of Clients with Physiologic and Psychosocial Alterations

1. Mr. Marquez reports of losing his job, not being able to sleep at night, and feeling upset with his wife.
Nurse John responds to the client, “You may want to talk about your employment situation in group
today.” The Nurse is using which therapeutic technique?

d. Focusing

2. Tony refuses his evening dose of Haloperidol (Haldol), then becomes extremely agitated in the
dayroom while other clients are watching television. He begins cursing and throwing furniture. Nurse
Oliver first action is to:

d. Remove all other clients from the dayroom.

3. Tina who is manic, but not yet on medication, comes to the drug treatment center. The nurse would
not let this client join the group session because:

a. The client is disruptive

4. Dervid, an adolescent boy was admitted for substance abuse and hallucinations. The client’s mother
asks Nurse Armando to talk with his husband when he arrives at the hospital. The mother says that she
is afraid of what the father might say to the boy. The most appropriate nursing intervention would be to:

c. Agree to talk with the mother and the father together

5. What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?

a. Perceptual disorders

6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t help” and
refuses to take it. What should the nurse say or do?

d. Suggest that it takes awhile before seeing the results

7. Dervid, an adolescent has a history of truancy from school, running away from home and “barrowing”
other people’s things without their permission. The adolescent denies stealing, rationalizing instead that
as long as no one was using the items, it was all right to borrow them. It is important for the nurse to
understand the psychodynamically, this behavior may be largely attributed to a developmental defect
related to the:

c. Superego

8. In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that
succinylcoline (Anectine) will be administered for which therapeutic effect?

c. Skeletal muscle paralysis

9. Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is:

d. Increase calories, carbohydrates, and protein.

10.What parental behavior toward a child during an admission procedure should cause Nurse Ron to
suspect child abuse?

c. Acting overly solicitous toward the child

11.Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for
long periods each day. How should the nurse respond to this compulsive behavior?

a. By designating times during which the client can focus on the behavior

12.After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is
diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic,
complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most
appropriate for Ruby?

d. Exploring the meaning of the traumatic event with the client

13.Meryl, age 19, is highly dependent on her parents and fears leaving home to go away to college.
Shortly before the semester starts, she complains that her legs are paralyzed and is rushed to the
emergency department. When physical examination rules out a physical cause for her paralysis, the
physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. Meryl asks
the nurse, "Why has this happened to me?" What is the nurse's best response?

c. "Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to
find out why it's happened

14.Nurse Krina knows that the following drugs have been known to be effective in treating obsessive-
compulsive disorder (OCD):

c. fluvoxamine (Luvox) and clomipramine (Anafranil)

15.Alfred was newly diagnosed with anxiety disorder. The physician prescribed buspirone (BuSpar). The
nurse is aware that the teaching instructions for newly prescribed buspirone should include which of the
following?

a. A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days

16.Richard with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of
phobias include:

b. Severe anxiety and fear

17.Which medications have been found to help reduce or eliminate panic attacks?

a. Antidepressants

18.A client seeks care because she feels depressed and has gained weight. To treat her atypical
depression, the physician prescribes tranylcypromine sulfate (Parnate), 10 mg by mouth twice per day.
When this drug is used to treat atypical depression, what is its onset of action?

b.3 to 5 days

19.A 65 years old client is in the first stage of Alzheimer's disease. Nurse Patricia should plan to focus
this client's care on:

b. Providing emotional support and individual counseling

20.The nurse is assessing a client who has just been admitted to the emergency department. Which
signs would suggest an overdose of an antianxiety agent?

c. Emotional lability, euphoria, and impaired memory

21.The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history
of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely
to uncover during assessment?

d. A low tolerance for frustration

22.Nurse Amy is providing care for a male client undergoing opiate withdrawal. Opiate withdrawal
causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users
are commonly detoxified with:

c. Methadone
23.Nurse Cristina is caring for a client who experiences false sensory perceptions with no basis in reality.
These perceptions are known as:

b. Hallucinations

24.Nurse Marco is developing a plan of care for a client with anorexia nervosa. Which action should the
nurse include in the plan?

c. Set up a strict eating plan for the client

25.Tim is admitted with a diagnosis of delusions of grandeur. The nurse is aware that this diagnosis
reflects a belief that one is:

a. Highly important or famous

26.Nurse Jen is caring for a male client with manic depression. The plan of care for a client in a manic
state would include:

d. Listening attentively with a neutral attitude and avoiding power struggles

27.Ramon is admitted for detoxification after a cocaine overdose. The client tells the nurse that he
frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he
using?

d. Denial

28.Richard is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client
exhibit during social situations?

b. Paranoid thoughts

29.Nurse Mickey is caring for a client diagnosed with bulimia. The most appropriate initial goal for a
client diagnosed with bulimia is to:

c. Identify anxiety-causing situations

30.Rudolf is admitted for an overdose of amphetamines. When assessing the client, the nurse should
expect to see:

a. Tension and irritability

31.Nicolas is experiencing hallucinations tells the nurse, “The voices are telling me I’m no good.” The
client asks if the nurse hears the voices. The most appropriate response by the nurse would be:

b. “No, I do not hear your voices, but I believe you can hear them

32.The nurse is aware that the side effect of electroconvulsive therapy that a client may experience:

c. Confusion for a time after treatment

33.A dying male client gradually moves toward resolution of feelings regarding impending death. Basing
care on the theory of Kubler-Ross, Nurse Trish plans to use nonverbal interventions when assessment
reveals that the client is in the:
d. Acceptance stage

34.The outcome that is unrelated to a crisis state is:

d. A higher level of anxiety continuing for more than 3 months

35.Miranda a psychiatric client is to be discharged with orders for haloperidol (haldol) therapy. When
developing a teaching plan for discharge, the nurse should include cautioning the client against:

b. Staying in the sun

36.Jen a nursing student is anxious about the upcoming board examination but is able to study intently
and does not become distracted by a roommate’s talking and loud music. The student’s ability to ignore
distractions and to focus on studying demonstrates:

d. Moderate-level anxiety

37.When assessing a premorbid personality characteristics of a client with a major depression, it would
be unusual for the nurse to find that this client demonstrated:

c. Diverse interest

38.Nurse Krina recognizes that the suicidal risk for depressed client is greatest:

a. As their depression begins to improve

39.Nurse Kate would expect that a client with vascular dementis would experience:

d. Disturbance in recalling recent events related to cerebral hypoxia.

40.Josefina is to be discharged on a regimen of lithium carbonate. In the teaching plan for discharge the
nurse should include:

d. Encouraging the client to have blood levels checked as ordered

41.The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female client. Nurse Katrina would be
aware that the teaching about the side effects of this drug were understood when the client state, “I will
call my doctor immediately if I notice any:

b. Fine hand tremors or slurred speech

42.Nurse Mylene recognizes that the most important factor necessary for the establishment of trust in a
critical care area is:

d. Presence

43.When establishing an initial nurse-client relationship, Nurse Hazel should explore with the client the:

a. Client’s perception of the presenting problem

44.Tranylcypromine sulfate (Parnate) is prescribed for a depressed client who has not responded to the
tricyclic antidepressants. After teaching the client about the medication, Nurse Marian evaluates that
learning has occurred when the client states, “I will avoid:
b. Chocolate milk, aged cheese, and yogurt’”

45.Nurse John is a aware that most crisis situations should resolve in about:

b. 4 to 6 weeks

46. Nurse Judy knows that statistics show that in adolescent suicide behavior:

d. Males are more likely to use lethal methods than are females

47.Dervid with paranoid schizophrenia repeatedly uses profanity during an activity therapy session.
Which response by the nurse would be most appropriate?

c. "Your cursing is interrupting the activity. Take time out in your room for 10 minutes."

48.Nurse Maureen knows that the nonantipsychotic medication used to treat some clients with
schizoaffective disorder is:

c. lithium carbonate (Lithane)

49.Which information is most important for the nurse Trinity to include in a teaching plan for a male
schizophrenic client taking clozapine (Clozaril)?

b. Report a sore throat or fever to the physician immediately.

50.Ricky with chronic schizophrenia takes neuroleptic medication is admitted to the psychiatric unit.
Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which
lifethreatening reaction:

c. Neuroleptic malignant syndrome