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Part 2
Nursing Practice I-V Answers and Rationale
NURSING PRACTICE I
a. I.V
b. I.M
c. Oral
d. S.C
3. Dr. Garcia writes the following order for the client who has been recently
admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error,
how should the nurse document this order onto the medication
administration record?
4. A newly admitted female client was diagnosed with deep vein thrombosis.
Which nursing diagnosis should receive the highest priority?
6. Nurse Gail places a client in a four-point restraint following orders from the
physician. The client care plan should include:
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?
10. The physician prescribes a loop diuretic for a client. When administering
this drug, the nurse anticipates that the client may develop which
electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia
11. She finds out that some managers have benevolent-authoritative style of
management. Which of the following behaviors will she exhibit most likely?
12. Nurse Amy is aware that the following is true about functional nursing
13. Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3
days?"
a. Single order
b. Standard written order
c. Standing order
d. Stat order
14. A female client with a fecal impaction frequently exhibits which clinical
manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
16. Which instruction should nurse Tom give to a male client who is having
external radiation therapy:
17. In assisting a female client for immediate surgery, the nurse In-charge is
aware that she should:
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?
19. Which dietary guidelines are important for nurse Oliver to implement in
caring for the client with burns?
20. Nurse Hazel will administer a unit of whole blood, which priority
information should the nurse have about the client?
21. Nurse Michelle witnesses a female client sustain a fall and suspects that
the leg may be broken. The nurse takes which priority action?
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?
23. A newly admitted female client was diagnosed with agranulocytosis. The
nurse formulates which priority nursing diagnosis?
a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge
a. Autocratic.
b. Laissez-faire.
26. The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The
nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10
cc. How many cc’s of KCl will be added to the IV solution?
a. .5 cc
b. 5 cc
c. 1.5 cc
d. 2.5 cc
a. 50 cc/ hour
b. 55 cc/ hour
c. 24 cc/ hour
d. 66 cc/ hour
28. The nurse is aware that the most important nursing action when a client
returns from surgery is:
29. Which of the following vital sign assessments that may indicate
cardiogenic shock after myocardial infarction?
30. Which is the most appropriate nursing action in obtaining a blood pressure
measurement?
31. Asking the questions to determine if the person understands the health
teaching provided by the nurse would be included during which step of the
nursing process?
a. Assessment
b. Evaluation
c. Implementation
d. Planning and goals
32. Which of the following item is considered the single most important factor
in assisting the health professional in arriving at a diagnosis or
determining the person’s needs?
a. Trochanter roll extending from the crest of the ileum to the mid-
thigh.
b. Pillows under the lower legs.
c. Footboard
d. Hip-abductor pillow
34. Which stage of pressure ulcer development does the ulcer extend into the
subcutaneous tissue?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
35. When the method of wound healing is one in which wound edges are not
surgically approximated and integumentary continuity is restored by
granulations, the wound healing is termed
a. Hypothermia
b. Hypertension
c. Distended neck veins
d. Tachycardia
a. 0.75
b. 0.6
c. 0.5
d. 0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement
correctly describes an insulin unit?
a. 40.1 °C
b. 38.9 °C
c. 48 °C
d. 38 °C
40. The nurse is assessing a 48-year-old client who has come to the
physician’s office for his annual physical exam. One of the first physical
signs of aging is:
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:
42. Nurse Trish must verify the client’s identity before administering
medication. She is aware that the safest way to verify identity is to:
a. Check the client’s identification band.
b. Ask the client to state his name.
c. State the client’s name out loud and wait a client to repeat it.
d. Check the room number and the client’s name on the bed.
a. 30 drops/minute
b. 32 drops/minute
c. 20 drops/minute
d. 18 drops/minute
45. A female client was recently admitted. She has fever, weight loss, and
watery diarrhea is being admitted to the facility. While assessing the client,
Nurse Hazel inspects the client’s abdomen and notice that it is slightly
concave. Additional assessment should proceed in which order:
a. Fingertips
b. Finger pads
c. Dorsal surface of the hand
d. Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the teaching and
learning process?
a. Summative
b. Informative
c. Formative
d. Retrospective
48. A 45 year old client, has no family history of breast cancer or other risk
factors for this disease. Nurse John should instruct her to have
mammogram how often?
49. A male client has the following arterial blood gas values: pH 7.30; Pao2 89
mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values,
Nurse Patricia should expect which condition?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
50. Nurse Len refers a female client with terminal cancer to a local hospice.
What is the goal of this referral?
52. Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. He
should apply the bandage beginning at the client’s:
a. Knee
b. Ankle
c. Lower thigh
d. Foot
53. A 10 year old child with type 1 diabetes develops diabetic ketoacidosis
and receives a continuous insulin infusion. Which condition represents the
greatest risk to this child?
a. Hypernatremia
b. Hypokalemia
c. Hyperphosphatemia
d. Hypercalcemia
55. Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse
quickly looks at the monitor and notes that a client is in a ventricular
tachycardia. The nurse rushes to the client’s room. Upon reaching the
client’s bedside, the nurse would take which action first?
57. Nurse Janah is monitoring the ongoing care given to the potential organ
donor who has been diagnosed with brain death. The nurse determines
that the standard of care had been maintained if which of the following
data is observed?
58. Nurse Amy has an order to obtain a urinalysis from a male client with an
indwelling urinary catheter. The nurse avoids which of the following, which
contaminate the specimen?
a. Wiping the port with an alcohol swab before inserting the syringe.
b. Aspirating a sample from the port on the drainage bag.
c. Clamping the tubing of the drainage bag.
d. Obtaining the specimen from the urinary drainage bag.
59. Nurse Meredith is in the process of giving a client a bed bath. In the
middle of the procedure, the unit secretary calls the nurse on the intercom
to tell the nurse that there is an emergency phone call. The appropriate
nursing action is to:
a. Immediately walk out of the client’s room and answer the phone
call.
b. Cover the client, place the call light within reach, and answer the
phone call.
c. Finish the bed bath before answering the phone call.
d. Leave the client’s door open so the client can be monitored and the
nurse can answer the phone call.
60. Nurse Janah is collecting a sputum specimen for culture and sensitivity
testing from a client who has a productive cough. Nurse Janah plans to
implement which intervention to obtain the specimen?
61. Nurse Ron is observing a male client using a walker. The nurse
determines that the client is using the walker correctly if the client:
a. Puts all the four points of the walker flat on the floor, puts weight on
the hand pieces, and then walks into it.
b. Puts weight on the hand pieces, moves the walker forward, and
then walks into it.
c. Puts weight on the hand pieces, slides the walker forward, and then
walks into it.
d. Walks into the walker, puts weight on the hand pieces, and then
puts all four points of the walker flat on the floor.
62. Nurse Amy has documented an entry regarding client care in the client’s
medical record. When checking the entry, the nurse realizes that incorrect
information was documented. How does the nurse correct this error?
63. Nurse Ron is assisting with transferring a client from the operating room
table to a stretcher. To provide safety to the client, the nurse should:
a. Crutches
b. Single straight-legged cane
c. Quad cane
d. Walker
66. A male client with a right pleural effusion noted on a chest X-ray is being
prepared for thoracentesis. The client experiences severe dizziness when
sitting upright. To provide a safe environment, the nurse assists the client
to which position for the procedure?
67. Nurse John develops methods for data gathering. Which of the following
criteria of a good instrument refers to the ability of the instrument to yield
the same results upon its repeated administration?
a. Validity
b. Specificity
c. Sensitivity
d. Reliability
68. Harry knows that he has to protect the rights of human research subjects.
Which of the following actions of Harry ensures anonymity?
a. Descriptive- correlational
b. Experiment
c. Quasi-experiment
d. Historical
a. Interview schedule
b. Questionnaire
c. Use of laboratory data
d. Observation
71. Monica is aware that there are times when only manipulation of study
variables is possible and the elements of control or randomization are not
attendant. Which type of research is referred to this?
a. Field study
b. Quasi-experiment
c. Solomon-Four group design
d. Post-test only design
72. Cherry notes down ideas that were derived from the description of an
investigation written by the person who conducted it. Which type of
reference source refers to this?
a. Footnote
b. Bibliography
c. Primary source
d. Endnotes
73. When Nurse Trish is providing care to his patient, she must remember that
her duty is bound not to do doing any action that will cause the patient
harm. This is the meaning of the bioethical principle:
a. Non-maleficence
b. Beneficence
c. Justice
d. Solidarity
74. When a nurse in-charge causes an injury to a female patient and the injury
caused becomes the proof of the negligent act, the presence of the injury
is said to exemplify the principle of:
a. Force majeure
b. Respondeat superior
c. Res ipsa loquitor
d. Holdover doctrine
a. The Board can issue rules and regulations that will govern the
practice of nursing
b. The Board can investigate violations of the nursing law and code of
ethics
c. The Board can visit a school applying for a permit in collaboration
with CHED
d. The Board prepares the board examinations
76. When the license of nurse Krina is revoked, it means that she:
a. Is no longer allowed to practice the profession for the rest of her life
b. Will never have her/his license re-issued since it has been revoked
c. May apply for re-issuance of his/her license based on certain
conditions stipulated in RA 9173
d. Will remain unable to practice professional nursing
77. Ronald plans to conduct a research on the use of a new method of pain
assessment scale. Which of the following is the second step in the
conceptualizing phase of the research process?
78. The leader of the study knows that certain patients who are in a
specialized research setting tend to respond psychologically to the
conditions of the study. This referred to as :
79. Mary finally decides to use judgment sampling on her research. Which of
the following actions of is correct?
80. The nursing theorist who developed transcultural nursing theory is:
a. Florence Nightingale
b. Madeleine Leininger
c. Albert Moore
d. Sr. Callista Roy
81. Marion is aware that the sampling method that gives equal chance to all
units in the population to get picked is:
a. Random
b. Accidental
c. Quota
d. Judgment
82. John plans to use a Likert Scale to his study to determine the:
83. Which of the following theory addresses the four modes of adaptation?
a. Madeleine Leininger
b. Sr. Callista Roy
c. Florence Nightingale
d. Jean Watson
84. Ms. Garcia is responsible to the number of personnel reporting to her. This
principle refers to:
a. Span of control
b. Unity of command
c. Downward communication
d. Leader
85. Ensuring that there is an informed consent on the part of the patient
before a surgery is done, illustrates the bioethical principle of:
a. Beneficence
b. Autonomy
c. Veracity
d. Non-maleficence
87. A client is admitted with multiple pressure ulcers. When developing the
client's diet plan, the nurse should include:
88. The nurse prepares to administer a cleansing enema. What is the most
common client position used for this procedure?
a. Lithotomy
b. Supine
c. Prone
d. Sims’ left lateral
90. A 65 years old male client requests his medication at 9 p.m. instead of 10
p.m. so that he can go to sleep earlier. Which type of nursing intervention
is required?
a. Independent
b. Dependent
c. Interdependent
d. Intradependent
92. Nursing care for a female client includes removing elastic stockings once
per day. The Nurse Betty is aware that the rationale for this intervention?
93. Which nursing intervention takes highest priority when caring for a newly
admitted client who's receiving a blood transfusion?
a. Do nothing.
b. Invert the vial and let it stand for 3 to 5 minutes.
c. Shake the vial vigorously.
d. Roll the vial gently between the palms.
96. Which intervention should the nurse Trish use when administering oxygen
by face mask to a female client?
97. The maximum transfusion time for a unit of packed red blood cells (RBCs)
is:
a. 6 hours
b. 4 hours
c. 3 hours
d. 2 hours
99. Nurse May is aware that the main advantage of using a floor stock system
is:
100. Nurse Oliver is assessing a client's abdomen. Which finding should the
nurse report as abnormal?
1. May arrives at the health care clinic and tells the nurse that her last
menstrual period was 9 weeks ago. She also tells the nurse that a home
pregnancy test was positive but she began to have mild cramps and is
now having moderate vaginal bleeding. During the physical examination of
the client, the nurse notes that May has a dilated cervix. The nurse
determines that May is experiencing which type of abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic
2. Nurse Reese is reviewing the record of a pregnant client for her first
prenatal visit. Which of the following data, if noted on the client’s record,
would alert the nurse that the client is at risk for a spontaneous abortion?
a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who is newly admitted to the
hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel
develops a plan of care for the client and determines that which of the
following nursing actions is the priority?
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
11. Nurse Ryan is aware that the best initial approach when trying to take a
crying toddler’s temperature is:
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?
13. Which action should nurse Marian include in the care plan for a 2 month
old with heart failure?
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?
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
a. 6 months
b. 4 months
c. 8 months
d. 10 months
16. Which of the following is the most prominent feature of public health
nursing?
a. It involves providing home care to sick people who are not confined
in the hospital.
b. Services are provided free of charge to people within the
catchments area.
c. The public health nurse functions as part of a team providing a
public health nursing services.
d. Public health nursing focuses on preventive, not curative, services.
a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness
18. Vangie is a new B.S.N. graduate. She wants to become a Public Health
Nurse. Where should she apply?
a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit
19. Tony is aware the Chairman of the Municipal Health Board is:
a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician
20. Myra is the public health nurse in a municipality with a total population of
about 20,000. There are 3 rural health midwives among the RHU
personnel. How many more midwife items will the RHU need?
22. Nurse Tina is aware that the disease declared through Presidential
Proclamation No. 4 as a target for eradication in the Philippines is?
a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus
23. May knows that the step in community organizing that involves training of
potential leaders in the community is:
a. Integration
b. Community organization
c. Community study
d. Core group formation
24. Beth a public health nurse takes an active role in community participation.
What is the primary goal of community organizing?
a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal
26. The nurse is caring for a primigravid client in the labor and delivery area.
Which condition would place the client at risk for disseminated
intravascular coagulation (DIC)?
27. A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate
would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute
28. The skin in the diaper area of a 7 month old infant is excoriated and red.
Nurse Hazel should instruct the mother to:
29. Nurse Carla knows that the common cardiac anomalies in children with
Down Syndrome (tri-somy 21) is:
30. Malou was diagnosed with severe preeclampsia is now receiving I.V.
magnesium sulfate. The adverse effects associated with magnesium
sulfate is:
a. Anemia
31. A 23 year old client is having her menstrual period every 2 weeks that last
for 1 week. This type of menstrual pattern is bets defined by:
a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea
32. Jannah is admitted to the labor and delivery unit. The critical laboratory
result for this client would be:
a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium
33. Nurse Gina is aware that the most common condition found during the
second-trimester of pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia
35. Maureen in her third trimester arrives at the emergency room with painless
vaginal bleeding. Which of the following conditions is suspected?
a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease
a. “I should check the diaphragm carefully for holes every time I use it”
b. “I may need a different size of diaphragm if I gain or lose weight
more than 20 pounds”
c. “The diaphragm must be left in place for atleast 6 hours after
intercourse”
d. “I really need to use the diaphragm and jelly most during the middle
of my menstrual cycle”.
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever
40. How should Nurse Michelle guide a child who is blind to walk to the
playroom?
42. The reason nurse May keeps the neonate in a neutral thermal
environment is that when a newborn becomes too cool, the neonate
requires:
43. Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure
to assess whether this infant has:
44. Nurse Carla should know that the most common causative factor of
dermatitis in infants and younger children is:
a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch
45. During tube feeding, how far above an infant’s stomach should the nurse
hold the syringe with formula?
a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches
48. Myrna a public health nurse knows that to determine possible sources of
sexually transmitted infections, the BEST method that may be undertaken
is:
a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects
49. A 33-year old female client came for consultation at the health center with
the chief complaint of fever for a week. Accompanying symptoms were
muscle pains and body malaise. A week after the start of fever, the client
noted yellowish discoloration of his sclera. History showed that he waded
in flood waters about 2 weeks before the onset of symptoms. Based on
her history, which disease condition will you suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis
50. Mickey a 3-year old client was brought to the health center with the chief
complaint of severe diarrhea and the passage of “rice water” stools. The
client is most probably suffering from which condition?
a. Giardiasis
b. Cholera
c. Amebiasis
51. The most prevalent form of meningitis among children aged 2 months to 3
years is caused by which microorganism?
a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis
52. The student nurse is aware that the pathognomonic sign of measles is
Koplik’s spot and you may see Koplik’s spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck
53. Angel was diagnosed as having Dengue fever. You will say that there is
slow capillary refill when the color of the nailbed that you pressed does not
return within how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease
a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants
a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR
a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
d. Use of protective footwear, such as rubber boots
58. Several clients is newly admitted and diagnosed with leprosy. Which of the
following clients should be classified as a case of multibacillary leprosy?
a. Macular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge
60. Marie brought her 10 month old infant for consultation because of fever,
started 4 days prior to consultation. In determining malaria risk, what will
you do?
61. Susie brought her 4 years old daughter to the RHU because of cough and
colds. Following the IMCI assessment guide, which of the following is a
danger sign that indicates the need for urgent referral to a hospital?
62. Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the
IMCI guidelines, how will you manage Jimmy?
63. Gina is using Oresol in the management of diarrhea of her 3-year old
child. She asked you what to do if her child vomits. As a nurse you will tell
her to:
64. Nikki a 5-month old infant was brought by his mother to the health center
because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after
a skin pinch and her eyes are sunken. Using the IMCI guidelines, you will
classify this infant in which category?
a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.
65. Chris a 4-month old infant was brought by her mother to the health center
because of cough. His respiratory rate is 42/minute. Using the Integrated
Management of Child Illness (IMCI) guidelines of assessment, his
breathing is considered as:
a. Fast
b. Slow
c. Normal
d. Insignificant
a. 1 year
b. 3 years
c. 5 years
d. Lifetime
67. Nurse Ron is aware that unused BCG should be discarded after how
many hours of reconstitution?
a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day
68. The nurse explains to a breastfeeding mother that breast milk is sufficient
for all of the baby’s nutrient needs only up to:
a. 5 months
b. 6 months
c. 1 year
d. 2 years
69. Nurse Ron is aware that the gestational age of a conceptus that is
considered viable (able to live outside the womb) is:
a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks
70. When teaching parents of a neonate the proper position for the neonate’s
sleep, the nurse Patricia stresses the importance of placing the neonate
on his back to reduce the risk of which of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
a. Flushed cheeks
b. Increased temperature
73. Marjorie has just given birth at 42 weeks’ gestation. When the nurse
assessing the neonate, which physical finding is expected?
74. After reviewing the Myrna’s maternal history of magnesium sulfate during
labor, which condition would nurse Richard anticipate as a potential
problem in the neonate?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia
75. Which symptom would indicate the Baby Alexandra was adapting
appropriately to extra-uterine life without difficulty?
a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60 breaths/minute
d. Respiratory rate 60 to 80 breaths/minute
76. When teaching umbilical cord care for Jennifer a new mother, the nurse
Jenny would include which information?
78. Dr. Esteves decides to artificially rupture the membranes of a mother who
is on labor. Following this procedure, the nurse Hazel checks the fetal
heart tones for which the following reasons?
79. Which of the following would be least likely to indicate anticipated bonding
behaviors by new parents?
82. A neonate begins to gag and turns a dusky color. What should the nurse
do first?
83. When a client states that her "water broke," which of the following actions
would be inappropriate for the nurse to do?
84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous
respirations but is successfully resuscitated. Within several hours she develops
respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's
diagnosed with respiratory distress syndrome, intubated, and placed on a
ventilator. Which nursing action should be included in the baby's plan of care to
prevent retinopathy of prematurity?
86. Nurse John is knowledgeable that usually individual twins will grow
appropriately and at the same rate as singletons until how many weeks?
a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks
87. Which of the following classifications applies to monozygotic twins for whom
the cleavage of the fertilized ovum occurs more than 13 days after fertilization?
a. conjoined twins
b. diamniotic dichorionic twins
88. Tyra experienced painless vaginal bleeding has just been diagnosed as
having a placenta previa. Which of the following procedures is usually performed
to diagnose placenta previa?
a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound
89. Nurse Arnold knows that the following changes in respiratory functioning
during pregnancy is considered normal:
90. Emily has gestational diabetes and it is usually managed by which of the
following therapy?
a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin
a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure
92. Cammile with sickle cell anemia has an increased risk for having a sickle cell
crisis during pregnancy. Aggressive management of a sickle cell crisis includes
which of the following measures?
a. Antihypertensive agents
b. Diuretic agents
c. I.V. fluids
d. Acetaminophen (Tylenol) for pain
94. Marlyn is screened for tuberculosis during her first prenatal visit. An
intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is
given. She is considered to have a positive test for which of the following results?
a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)
97. To promote comfort during labor, the nurse John advises a client to assume
certain positions and avoid others. Which position may cause maternal
hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
98. Celeste who used heroin during her pregnancy delivers a neonate. When
assessing the neonate, the nurse Lhynnette expects to find:
99. The uterus returns to the pelvic cavity in which of the following time frames?
100. Maureen, a primigravida client, age 20, has just completed a difficult,
forceps-assisted delivery of twins. Her labor was unusually long and required
oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert
for:
a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort
1. Nurse Michelle should know that the drainage is normal 4 days after a
sigmoid colostomy when the stool is:
a. Green liquid
b. Solid formed
c. Loose, bloody
d. Semiformed
2. Where would nurse Kristine place the call light for a male client with a
right-sided brain attack and left homonymous hemianopsia?
10. While monitoring a male client several hours after a motor vehicle
accident, which assessment data suggest increasing intracranial
pressure?
11. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the
following symptoms may appear first?
12. A male client has active tuberculosis (TB). Which of the following symptoms
will be exhibit?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping and her
respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have
which of the following reactions?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own
15. A 77-year-old male client is admitted for elective knee surgery. Physical
examination reveals shallow respirations but no sign of respiratory distress.
Which of the following is a normal physiologic change related to aging?
16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is
the most relevant to administration of this medication?
17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse
should teach the client to:
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:
19. Nurse Michelle is caring for an elderly female with osteoporosis. When
teaching the client, the nurse should include information about which major
complication:
a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowager’s hump
20. Nurse Len is teaching a group of women to perform BSE. The nurse should
explain that the purpose of performing the examination is to discover:
a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses
21. When caring for a female client who is being treated for hyperthyroidism, it is
important to:
23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client
following a:
a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.
24. A 55-year old client underwent cataract removal with intraocular lens implant.
Nurse Oliver is giving the client discharge instructions. These instructions should
include which of the following?
26. A male client undergone a colon resection. While turning him, wound
dehiscence with evisceration occurs. Nurse Trish first response is to:
27. Nurse Audrey is caring for a client who has suffered a severe
cerebrovascular accident. During routine assessment, the nurse notices Cheyne-
Strokes respirations. Cheyne-strokes respirations are:
28. Nurse Bea is assessing a male client with heart failure. The breath sounds
commonly auscultated in clients with heart failure are:
a. Tracheal
b. Fine crackles
c. Coarse crackles
d. Friction rubs
29. The nurse is caring for Kenneth experiencing an acute asthma attack. The
client stops wheezing and breath sounds aren’t audible. The reason for this
change is that:
30. Mike with epilepsy is having a seizure. During the active seizure phase, the
nurse should:
a. Place the client on his back remove dangerous objects, and insert a
bite block.
b. Place the client on his side, remove dangerous objects, and insert a
bite block.
c. Place the client o his back, remove dangerous objects, and hold down
his arms.
d. Place the client on his side, remove dangerous objects, and protect his
head.
32. Nurse Maureen is talking to a male client, the client begins choking on his
lunch. He’s coughing forcefully. The nurse should:
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?
34. When performing oral care on a comatose client, Nurse Krina should:
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?
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?
38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and
a decreased forced expiratory volume should be treated with which of the
following classes of medication right away?
a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two
packs of cigarettes per day has a chronic cough producing thick sputum,
peripheral edema and cyanotic nail beds. Based on this information, he most
likely has which of the following conditions?
40. The treatment for patients with leukemia is bone marrow transplantation.
Which statement about bone marrow transplantation is not correct?
41. After several days of admission, Francis becomes disoriented and complains
of frequent headaches. The nurse in-charge first action would be:
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. Predominance of lymhoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial occlusion of the left leg
undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to
obtain pulses in his left foot using Doppler ultrasound. The nurse immediately
notifies the physician, and asks her to prepare the client for surgery. As the nurse
enters the client’s room to prepare him, he states that he won’t have any more
surgery. Which of the following is the best initial response by the nurse?
45. During the endorsement, which of the following clients should the on-duty
nurse assess first?
a. The 58-year-old client who was admitted 2 days ago with heart failure,
blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/
minute.
b. The 89-year-old client with end-stage right-sided heart failure, blood
pressure of 78/50 mm Hg, and a “do not resuscitate” order
c. The 62-year-old client who was admitted 1 day ago with
thrombophlebitis and is receiving L.V. heparin
d. The 75-year-old client who was admitted 1 hour ago with new-onset
atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of substernal chest pain and states
that her heart feels like “it’s racing out of the chest”. She reports no history of
cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus
tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the
respiratory rate is 26 breaths/minutes. Which of the following drugs should the
nurse question the client about using?
a. Barbiturates
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?
48. A 35-year-old client with vaginal cancer asks the nurse, "What is the usual
treatment for this type of cancer?" Which treatment should the nurse name?
a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy
a. Breast cancer
b. Lung cancer
c. Brain cancer
d. Colon and rectal cancer
52. Antonio with lung cancer develops Horner's syndrome when the tumor
invades the ribs and affects the sympathetic nerve ganglia. When assessing for
signs and symptoms of this syndrome, the nurse should note:
a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the
face.
b. chest pain, dyspnea, cough, weight loss, and fever.
c. arm and shoulder pain and atrophy of arm and hand muscles, both on
the affected side.
d. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should reply that it stands for:
54. What is the most important postoperative instruction that nurse Kate must
give a client who has just returned from the operating room after receiving a
subarachnoid block?
55. A male client suspected of having colorectal cancer will require which
diagnostic study to confirm the diagnosis?
a. Stool Hematest
b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy
d. Abdominal computed tomography (CT) scan
57. A female client with cancer is being evaluated for possible metastasis. Which
of the following is one of the most common metastasis sites for cancer cells?
a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to
confirm or rule out a spinal cord lesion. During the MRI scan, which of the
following would pose a threat to the client?
60. Before Jacob undergoes arthroscopy, the nurse reviews the assessment
findings for contraindications for this procedure. Which finding is a
contraindication?
a. Joint pain
b. Joint deformity
c. Joint flexion of less than 50%
d. Joint stiffness
a. Septic arthritis
b. Traumatic arthritis
c. Intermittent arthritis
d. Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with
stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of
saline solution. How many milliliters per hour should be given?
a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour
63. A 76-year-old male client had a thromboembolic right stroke; his left arm is
swollen. Which of the following conditions may cause swelling after a stroke?
64. Heberden’s nodes are a common sign of osteoarthritis. Which of the following
statement is correct about this deformity?
65. Which of the following statements explains the main difference between
rheumatoid arthritis and osteoarthritis?
66. Mrs. Cruz uses a cane for assistance in walking. Which of the following
statements is true about a cane or other assistive devices?
68. Nurse Len should expect to administer which medication to a client with
gout?
a. aspirin
b. furosemide (Lasix)
c. colchicines
d. calcium gluconate (Kalcinate)
a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid
70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wet-
to-dry dressing change every shift, and blood glucose monitoring before meals
and bedtime. Why are wet-to-dry dressings used for this client?
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory
data would the nurse expect to find?
a. Hyperkalemia
73. A female client tells nurse Nikki that she has been working hard for the last 3
months to control her type 2 diabetes mellitus with diet and exercise. To
determine the effectiveness of the client's efforts, the nurse should check:
a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm
76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle
twitching and hyperirritability of the nervous system. When questioned, the client
reports numbness and tingling of the mouth and fingertips. Suspecting a life-
threatening electrolyte disturbance, the nurse notifies the surgeon immediately.
Which electrolyte disturbance most commonly follows thyroid surgery?
a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
77. Which laboratory test value is elevated in clients who smoke and can't be
used as a general indicator of cancer?
78. Francis with anemia has been admitted to the medical-surgical unit. Which
assessment findings are characteristic of iron-deficiency anemia?
79. In teaching a female client who is HIV-positive about pregnancy, the nurse
would know more teaching is necessary when the client says:
80. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for
discharge to the home, the nurse should be sure to include which instruction?
81. Nurse Marie is caring for a 32-year-old client admitted with pernicious
anemia. Which set of findings should the nurse expect when assessing the
client?
83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to
reduce inflammation. When teaching the client about aspirin, the nurse discusses
adverse reactions to prolonged aspirin therapy. These include:
a. weight gain.
b. fine motor tremors.
c. respiratory acidosis.
d. bilateral hearing loss.
a. Neutrophil
b. Basophil
c. Monocyte
d. Lymphocyte
85. In an individual with Sjögren's syndrome, nursing care should focus on:
a. moisture replacement.
b. electrolyte balance.
c. nutritional supplementation.
d. arrhythmia management.
87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb
weight loss in 6 weeks. To confirm that the client has been infected with the
human immunodeficiency virus (HIV), the nurse expects the physician to order:
a. E-rosette immunofluorescence.
b. quantification of T-lymphocytes.
c. enzyme-linked immunosorbent assay (ELISA).
d. Western blot test with ELISA.
88. A complete blood count is commonly performed before a Joe goes into
surgery. What does this test seek to identify?
90. When taking a dietary history from a newly admitted female client, Nurse Len
should remember that which of the following foods is a common allergen?
a. Bread
b. Carrots
c. Orange
d. Strawberries
91. Nurse John is caring for clients in the outpatient clinic. Which of the following
phone calls should the nurse return first?
a. A client with hepatitis A who states, “My arms and legs are itching.”
b. A client with cast on the right leg who states, “I have a funny feeling in
my right leg.”
c. A client with osteomyelitis of the spine who states, “I am so nauseous
that I can’t eat.”
92. Nurse Sarah is caring for clients on the surgical floor and has just received
report from the previous shift. Which of the following clients should the nurse see
first?
93. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for
treatment of Grave’s disease. The nurse would be most concerned if which of the
following was observed?
94. Julius is admitted with complaints of severe pain in the lower right quadrant of
the abdomen. To assist with pain relief, the nurse should take which of the
following actions?
95. Nurse Tina prepares a client for peritoneal dialysis. Which of the following
actions should the nurse take first?
a. The client holds the cane with his right hand, moves the can forward
followed by the right leg, and then moves the left leg.
b. The client holds the cane with his right hand, moves the cane forward
followed by his left leg, and then moves the right leg.
c. The client holds the cane with his left hand, moves the cane forward
followed by the right leg, and then moves the left leg.
d. The client holds the cane with his left hand, moves the cane forward
followed by his left leg, and then moves the right leg.
97. An elderly client is admitted to the nursing home setting. The client is
occasionally confused and her gait is often unsteady. Which of the following
actions, if taken by the nurse, is most appropriate?
98. Nurse Evangeline teaches an elderly client how to use a standard aluminum
walker. Which of the following behaviors, if demonstrated by the client, indicates
that the nurse’s teaching was effective?
a. The client slowly pushes the walker forward 12 inches, then takes
small steps forward while leaning on the walker.
b. The client lifts the walker, moves it forward 10 inches, and then takes
several small steps forward.
c. The client supports his weight on the walker while advancing it forward,
then takes small steps while balancing on the walker.
d. The client slides the walker 18 inches forward, then takes small steps
while holding onto the walker for balance.
a. Pain
b. Weight
c. Hematuria
d. Hypertension
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that
acute hypoglycemia also can develop in the client who is diagnosed with:
a. Liver disease
b. Hypertension
c. Type 2 diabetes
d. Hyperthyroidism
a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia
a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.
9. Mario has burn injury. After Forty48 hours, the physician orders for Mario
2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is
10 gtt/ml. The nurse should set the flow to provide:
a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min
10. Terence suffered form burn injury. Using the rule of nines, which has the
largest percent of burns?
a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature
12. Nurse Sherry is teaching male client regarding his permanent artificial
pacemaker. Which information given by the nurse shows her knowledge
deficit about the artificial cardiac pacemaker?
a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports
13. The nurse is ware that the most relevant knowledge about oxygen
administration to a male client with COPD is
16. Nurse Tristan is caring for a male client in acute renal failure. The nurse
should expect hypertonic glucose, insulin infusions, and sodium
bicarbonate to be used to treat:
a. hypernatremia.
b. hypokalemia.
c. hyperkalemia.
d. hypercalcemia.
17. Ms. X has just been diagnosed with condylomata acuminata (genital
warts). What information is appropriate to tell this client?
a. The left kidney usually is slightly higher than the right one.
b. The kidneys are situated just above the adrenal glands.
c. The average kidney is approximately 5 cm (2") long and 2 to 3 cm
(¾" to 1-1/8") wide.
d. The kidneys lie between the 10th and 12th thoracic vertebrae.
19. Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The
nurse is aware that the diagnostic test are consistent with CRF if the result
is:
21. During a routine checkup, Nurse Mariane assesses a male client with
acquired immunodeficiency syndrome (AIDS) for signs and symptoms of
cancer. What is the most common AIDS-related cancer?
a. To prevent confusion
b. To prevent seizures
c. To prevent cerebrospinal fluid (CSF) leakage
d. To prevent cardiac arrhythmias
23. A male client had a nephrectomy 2 days ago and is now complaining of
abdominal pressure and nausea. The first nursing action should be to:
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?
26. Anthony suffers burns on the legs, which nursing intervention helps
prevent contractures?
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?
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:
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:
31. A male client has jugular distention. On what position should the nurse
place the head of the bed to obtain the most accurate reading of jugular
vein distention?
a. High Fowler’s
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position
32. The nurse is aware that one of the following classes of medications
maximizes cardiac performance in clients with heart failure by increasing
ventricular contractility?
a. Beta-adrenergic blockers
b. Calcium channel blocker
c. Diuretics
d. Inotropic agents
33. A male client has a reduced serum high-density lipoprotein (HDL) level
and an elevated low-density lipoprotein (LDL) level. Which of the following
dietary modifications is not appropriate for this client?
a. The CCU nurse gives a verbal report to the nurse on the telemetry
unit before transferring the client to that unit
b. The CCU nurse notifies the on-call physician about a change in the
client’s condition
c. The emergency department nurse calls up the latest
electrocardiogram results to check the client’s progress.
d. At the client’s request, the CCU nurse updates the client’s wife on
his condition
36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg.
Nurse Katrina determines that mean arterial pressure (MAP) is which of the
following?
a. 46 mm Hg
b. 80 mm Hg
c. 95 mm Hg
d. 90 mm Hg
37. A female client arrives at the emergency department with chest and stomach
pain and a report of black tarry stool for several months. Which of the following
order should the nurse Oliver anticipate?
38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which
of the following conditions is suspected by the nurse when a decrease in platelet
count from 230,000 ul to 5,000 ul is noted?
a. Pancytopenia
b. Idiopathic thrombocytopemic purpura (ITP)
c. Disseminated intravascular coagulation (DIC)
d. Heparin-associated thrombosis and thrombocytopenia (HATT)
39. Which of the following drugs would be ordered by the physician to improve
the platelet count in a male client with idiopathic thrombocytopenic purpura
(ITP)?
a. Allogeneic
b. Autologous
c. Syngeneic
d. Xenogeneic
41. Marco falls off his bicycle and injuries his ankle. Which of the following
actions shows the initial response to the injury in the extrinsic pathway?
a. Release of Calcium
b. Release of tissue thromboplastin
c. Conversion of factors XII to factor XIIa
d. Conversion of factor VIII to factor VIIIa
42. Instructions for a client with systemic lupus erythematosus (SLE) would
include information about which of the following blood dyscrasias?
a. Dressler’s syndrome
b. Polycythemia
c. Essential thrombocytopenia
43. The nurse is aware that the following symptoms is most commonly an early
indication of stage 1 Hodgkin’s disease?
a. Pericarditis
b. Night sweat
c. Splenomegaly
d. Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of the following functions must
frequently assessed?
a. Blood pressure
b. Bowel sounds
c. Heart sounds
d. Breath sounds
45. The nurse knows that neurologic complications of multiple myeloma (MM)
usually involve which of the following body system?
a. Brain
b. Muscle spasm
c. Renal dysfunction
d. Myocardial irritability
46. Nurse Patricia is aware that the average length of time from human
immunodeficiency virus (HIV) infection to the development of acquired
immunodeficiency syndrome (AIDS)?
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. Influenza
b. Sickle cell anemia
c. Leukemia
d. Hodgkin’s disease
a. AB Rh-positive
b. A Rh-positive
c. A Rh-negative
d. O Rh-positive
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?
51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair.
The best response for the nurse is:
52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the
nurse in-charge should:
54. The term “blue bloater” refers to a male client which of the following
conditions?
55. The term “pink puffer” refers to the female client with which of the following
conditions?
a. 15 mm Hg
b. 30 mm Hg
c. 40 mm Hg
d. 80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80
mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
represents which of the following conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
58. Norma has started a new drug for hypertension. Thirty minutes after she
takes the drug, she develops chest tightness and becomes short of breath and
tachypneic. She has a decreased level of consciousness. These signs indicate
which of the following conditions?
a. Asthma attack
b. Pulmonary embolism
c. Respiratory failure
d. Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and
jaundice. To rule out cirrhosis of the liver:
60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales
is at increased risk for excessive bleeding primarily because of:
64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood
under his buttocks. Which of the following steps should the nurse take first?
65. Which of the following treatment is a suitable surgical intervention for a client
with unstable angina?
a. Cardiac catheterization
b. Echocardiogram
c. Nitroglycerin
d. Percutaneous transluminal coronary angioplasty (PTCA)
66. The nurse is aware that the following terms used to describe reduced cardiac
output and perfusion impairment due to ineffective pumping of the heart is:
a. Anaphylactic shock
b. Cardiogenic shock
c. Distributive shock
d. Myocardial infarction (MI)
67. A client with hypertension ask the nurse which factors can cause blood
pressure to drop to normal levels?
68. Nurse Rose is aware that the statement that best explains why furosemide
(Lasix) is administered to treat hypertension is:
69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic
lupus erythematosus (SLE) is:
70. Arnold, a 19-year-old client with a mild concussion is discharged from the
emergency department. Before discharge, he complains of a headache. When
offered acetaminophen, his mother tells the nurse the headache is severe and
she would like her son to have something stronger. Which of the following
responses by the nurse is appropriate?
71. When evaluating an arterial blood gas from a male client with a subdural
hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following
responses best describes the result?
72. When prioritizing care, which of the following clients should the nurse Olivia
assess first?
73. JP has been diagnosed with gout and wants to know why colchicine is used
in the treatment of gout. Which of the following actions of colchicines explains
why it’s effective for gout?
a. Replaces estrogen
b. Decreases infection
c. Decreases inflammation
d. Decreases bone demineralization
74. Norma asks for information about osteoarthritis. Which of the following
statements about osteoarthritis is correct?
75. Ruby is receiving thyroid replacement therapy develops the flu and forgets to
take her thyroid replacement medicine. The nurse understands that skipping this
medication will put the client at risk for developing which of the following life-
threatening complications?
a. Exophthalmos
b. Thyroid storm
c. Myxedema coma
d. Tibial myxedema
77. Cyrill with severe head trauma sustained in a car accident is admitted to the
intensive care unit. Thirty-six hours later, the client's urine output suddenly rises
above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which
laboratory findings support the nurse's suspicion of diabetes insipidus?
a. "I can avoid getting sick by not becoming dehydrated and by paying
attention to my need to urinate, drink, or eat more than usual."
b. "If I experience trembling, weakness, and headache, I should drink a
glass of soda that contains sugar."
c. "I will have to monitor my blood glucose level closely and notify the
physician if it's constantly elevated."
d. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in
carbohydrates."
a. Diabetes mellitus
b. Diabetes insipidus
c. Hypoparathyroidism
d. Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering from addisonian crisis about
the need to take fludrocortisone acetate and hydrocortisone at home. Which
statement by the client indicates an understanding of the instructions?
83. Capillary glucose monitoring is being performed every 4 hours for a client
diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of
regular insulin according to glucose results. At 2 p.m., the client has a capillary
glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse
Mariner should expect the dose's:
85. Rico with diabetes mellitus must learn how to self-administer insulin. The
physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100
isophane insulin suspension (NPH) to be taken before breakfast. When teaching
the client how to select and rotate insulin injection sites, the nurse should provide
which instruction?
a. "Inject insulin into healthy tissue with large blood vessels and nerves."
b. "Rotate injection sites within the same anatomic region, not among
different regions."
86. Nurse Sarah expects to note an elevated serum glucose level in a client with
hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other
laboratory finding should the nurse anticipate?
87. For a client with Graves' disease, which nursing intervention promotes
comfort?
89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the
development of this disorder?
90. Johnny a firefighter was involved in extinguishing a house fire and is being
treated to smoke inhalation. He develops severe hypoxia 48 hours after the
incident, requiring intubation and mechanical ventilation. He most likely has
developed which of the following conditions?
a. Asthma attack
b. Atelectasis
c. Bronchitis
d. Fat embolism
92. A client with shortness of breath has decreased to absent breath sounds on
the right side, from the apex to the base. Which of the following conditions would
best explain this?
a. Acute asthma
b. Chronic bronchitis
c. Pneumonia
d. Spontaneous pneumothorax
a. Bronchitis
b. Pneumonia
c. Pneumothorax
d. Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills the area of the thoracic
cavity?
95. Hemoptysis may be present in the client with a pulmonary embolism because
of which of the following reasons?
96. Aldo with a massive pulmonary embolism will have an arterial blood gas
analysis performed to determine the extent of hypoxia. The acid-base disorder
that may be present is?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22-year-old client is admitted with
a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest
drainage system. Bubbling soon appears in the water seal chamber. Which of the
following is the most likely cause of the bubbling?
a. Air leak
b. Adequate suction
c. Inadequate suction
d. Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a postoperative client. The
client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The
IV infusion set has a drop factor of 10 drops per milliliter. The nurse should
regulate the client’s IV to deliver how many drops per minute?
a. 18
b. 21
c. 35
d. 40
99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with
congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The
bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount
should the nurse administer to the child?
a. 1.2 ml
b. 2.4 ml
c. 3.5 ml
d. 4.2 ml
100. Nurse Alexandra teaches a client about elastic stockings. Which of the
following statements, if made by the client, indicates to the nurse that the
teaching was successful?
1. Mr. Marquez reports of losing his job, not being able to sleep at night, and
feeling upset with his wife. Nurse John responds to the client, “You may
want to talk about your employment situation in group today.” The Nurse is
using which therapeutic technique?
a. Observations
b. Restating
c. Exploring
d. Focusing
a. Check the client’s medical record for an order for an as-needed I.M.
dose of medication for agitation.
b. Place the client in full leather restraints.
c. Call the attending physician and report the behavior.
d. Remove all other clients from the dayroom.
3. Tina who is manic, but not yet on medication, comes to the drug treatment
center. The nurse would not let this client join the group session because:
a. Inform the mother that she and the father can work through this
problem themselves.
b. Refer the mother to the hospital social worker.
c. Agree to talk with the mother and the father together.
d. Suggest that the father and son work things out.
5. What is Nurse John likely to note in a male client being admitted for
alcohol withdrawal?
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains
that it “doesn’t help” and refuses to take it. What should the nurse say or
do?
a. Id
b. Ego
c. Superego
d. Oedipal complex
a. Short-acting anesthesia
b. Decreased oral and respiratory secretions.
c. Skeletal muscle paralysis.
d. Analgesia.
9. Nurse Gina is aware that the dietary implications for a client in manic
phase of bipolar disorder is:
a. Serve the client a bowl of soup, buttered French bread, and apple
slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.
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?
13. Meryl, age 19, is highly dependent on her parents and fears leaving home
to go away to college. Shortly before the semester starts, she complains
that her legs are paralyzed and is rushed to the emergency department.
When physical examination rules out a physical cause for her paralysis,
the physician admits her to the psychiatric unit where she is diagnosed
with conversion disorder. Meryl asks the nurse, "Why has this happened
to me?" What is the nurse's best response?
a. "You've developed this paralysis so you can stay with your parents.
You must deal with this conflict if you want to walk again."
b. "It must be awful not to be able to move your legs. You may feel
better if you realize the problem is psychological, not physical."
c. "Your problem is real but there is no physical basis for it. We'll work
on what is going on in your life to find out why it's happened."
d. "It isn't uncommon for someone with your personality to develop a
conversion disorder during times of stress."
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?
16. Richard with agoraphobia has been symptom-free for 4 months. Classic
signs and symptoms of phobias include:
17. Which medications have been found to help reduce or eliminate panic
attacks?
a. Antidepressants
b. Anticholinergics
c. Antipsychotics
d. Mood stabilizers
18. A client seeks care because she feels depressed and has gained weight.
To treat her atypical depression, the physician prescribes tranylcypromine
sulfate (Parnate), 10 mg by mouth twice per day. When this drug is used
to treat atypical depression, what is its onset of action?
a. 1 to 2 days
b. 3 to 5 days
c. 6 to 8 days
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:
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?
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?
22. Nurse Amy is providing care for a male client undergoing opiate
withdrawal. Opiate withdrawal causes severe physical discomfort and can
be life-threatening. To minimize these effects, opiate users are commonly
detoxified with:
a. Barbiturates
b. Amphetamines
c. Methadone
d. Benzodiazepines
23. Nurse Cristina is caring for a client who experiences false sensory
perceptions with no basis in reality. These perceptions are known as:
a. Delusions
b. Hallucinations
24. Nurse Marco is developing a plan of care for a client with anorexia
nervosa. Which action should the nurse include in the plan?
a. Restricts visits with the family and friends until the client begins to
eat.
b. Provide privacy during meals.
c. Set up a strict eating plan for the client.
d. Encourage the client to exercise, which will reduce her anxiety.
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:
27. Ramon is admitted for detoxification after a cocaine overdose. The client
tells the nurse that he frequently uses cocaine but that he can control his
use if he chooses. Which coping mechanism is he using?
a. Withdrawal
b. Logical thinking
c. Repression
d. Denial
a. Aggressive behavior
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:
31. Nicolas is experiencing hallucinations tells the nurse, “The voices are
telling me I’m no good.” The client asks if the nurse hears the voices. The
most appropriate response by the nurse would be:
a. “It is the voice of your conscience, which only you can control.”
b. “No, I do not hear your voices, but I believe you can hear them”.
c. “The voices are coming from within you and only you can hear
them.”
d. “Oh, the voices are a symptom of your illness; don’t pay any
attention to them.”
32. The nurse is aware that the side effect of electroconvulsive therapy that a
client may experience:
a. Loss of appetite
b. Postural hypotension
c. Confusion for a time after treatment
d. Complete loss of memory for a time
a. Anger stage
b. Denial stage
c. Bargaining stage
a. Driving at night
b. Staying in the sun
c. Ingesting wines and cheeses
d. Taking medications containing aspirin
36. Jen a nursing student is anxious about the upcoming board examination
but is able to study intently and does not become distracted by a
roommate’s talking and loud music. The student’s ability to ignore
distractions and to focus on studying demonstrates:
a. Mild-level anxiety
b. Panic-level anxiety
c. Severe-level anxiety
d. Moderate-level anxiety
a. Rigidity
b. Stubbornness
c. Diverse interest
d. Over meticulousness
38. Nurse Krina recognizes that the suicidal risk for depressed client is
greatest:
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:
42. Nurse Mylene recognizes that the most important factor necessary for the
establishment of trust in a critical care area is:
a. Privacy
b. Respect
c. Empathy
d. Presence
45. Nurse John is a aware that most crisis situations should resolve in about:
a. 1 to 2 weeks
b. 4 to 6 weeks
c. 4 to 6 months
d. 6 to 12 months
46. Nurse Judy knows that statistics show that in adolescent suicide
behavior:
48. Nurse Maureen knows that the nonantipsychotic medication used to treat
some clients with schizoaffective disorder is:
a. phenelzine (Nardil)
b. chlordiazepoxide (Librium)
c. lithium carbonate (Lithane)
d. imipramine (Tofranil)
49. Which information is most important for the nurse Trinity to include in a
teaching plan for a male schizophrenic client taking clozapine (Clozaril)?
a. Tardive dyskinesia.
b. Dystonia.
c. Neuroleptic malignant syndrome.
d. Akathisia.
52. Mr. Cruz visits the physician's office to seek treatment for depression,
feelings of hopelessness, poor appetite, insomnia, fatigue, low self-
esteem, poor concentration, and difficulty making decisions. The client
states that these symptoms began at least 2 years ago. Based on this
report, the nurse Tyfany suspects:
a. Cyclothymic disorder.
b. Atypical affective disorder.
c. Major depression.
d. Dysthymic disorder.
a. Ginkgo biloba
b. Echinacea
c. St. John's wort
d. Ephedra
55. Cely with manic episodes is taking lithium. Which electrolyte level should
the nurse check before administering this medication?
a. Calcium
b. Sodium
c. Chloride
d. Potassium
56. Nurse Josefina is caring for a client who has been diagnosed with
delirium. Which statement about delirium is true?
57. Edward, a 66 year old client with slight memory impairment and poor
concentration is diagnosed with primary degenerative dementia of the
Alzheimer's type. Early signs of this dementia include subtle personality
changes and withdrawal from social interactions. To assess for
progression to the middle stage of Alzheimer's disease, the nurse should
observe the client for:
60. Celia with a history of polysubstance abuse is admitted to the facility. She
complains of nausea and vomiting 24 hours after admission. The nurse
assesses the client and notes piloerection, pupillary dilation, and
lacrimation. The nurse suspects that the client is going through which of
the following withdrawals?
a. Alcohol withdrawal
b. Cannibis withdrawal
c. Cocaine withdrawal
d. Opioid withdrawal
61. Mr. Garcia, an attorney who throws books and furniture around the office
after losing a case is referred to the psychiatric nurse in the law firm's
employee assistance program. Nurse Beatriz knows that the client's
behavior most likely represents the use of which defense mechanism?
a. Regression
b. Projection
c. Reaction-formation
d. Intellectualization
62. Nurse Anne is caring for a client who has been treated long term with
antipsychotic medication. During the assessment, Nurse Anne checks the
client for tardive dyskinesia. If tardive dyskinesia is present, Nurse Anne
would most likely observe:
a. Weakness
b. Diarrhea
c. Blurred vision
d. Fecal incontinence
64. Nurse Jannah is monitoring a male client who has been placed inrestraints
because of violent behavior. Nurse determines that it will be safe to
remove the restraints when:
65. Nurse Irish is aware that Ritalin is the drug of choice for a child with
ADHD. The side effects of the following may be noted by the nurse:
66. Kitty, a 9 year old child has very limited vocabulary and interaction skills.
She has an I.Q. of 45. She is diagnosed to have Mental retardation of this
classification:
a. Profound
b. Mild
c. Moderate
d. Severe
67. The therapeutic approach in the care of Armand an autistic child include
the following EXCEPT:
68. Jeremy is brought to the emergency room by friends who state that he
took something an hour ago. He is actively hallucinating, agitated, with
a. Heroin
b. Cocaine
c. LSD
d. Marijuana
69. Nurse Pauline is aware that Dementia unlike delirium is characterized by:
a. Slurred speech
b. Insidious onset
c. Clouding of consciousness
d. Sensory perceptual change
70. A 35 year old female has intense fear of riding an elevator. She claims “
As if I will die inside.” The client is suffering from:
a. Agoraphobia
b. Social phobia
c. Claustrophobia
d. Xenophobia
72. Tristan is on Lithium has suffered from diarrhea and vomiting. What
should the nurse in-charge do first:
73. Nurse Sarah ensures a therapeutic environment for all the client. Which of
the following best describes a therapeutic milieu?
74. Anthony is very hostile toward one of the staff for no apparent reason. He
is manifesting:
a. Splitting
b. Transference
c. Countertransference
d. Resistance
75. Marielle, 17 years old was sexually attacked while on her way home from
school. She is brought to the hospital by her mother. Rape is an example
of which type of crisis:
a. Situational
b. Adventitious
c. Developmental
d. Internal
76. Nurse Greta is aware that the following is classified as an Axis I disorder
by the Diagnosis and Statistical Manual of Mental Disorders, Text
Revision (DSM-IV-TR) is:
a. Obesity
b. Borderline personality disorder
c. Major depression
d. Hypertension
77. Katrina, a newly admitted is extremely hostile toward a staff member she
has just met, without apparent reason. According to Freudian theory, the
nurse should suspect that the client is experiencing which of the following
phenomena?
a. Intellectualization
b. Transference
c. Triangulation
d. Splitting
78. An 83year-old male client is in extended care facility is anxious most of the
time and frequently complains of a number of vague symptoms that
interfere with his ability to eat. These symptoms indicate which of the
following disorders?
a. Conversion disorder
b. Hypochondriasis
c. Severe anxiety
79. Charina, a college student who frequently visited the health center during the
past year with multiple vague complaints of GI symptoms before course
examinations. Although physical causes have been eliminated, the student
continues to express her belief that she has a serious illness. These symptoms
are typically of which of the following disorders?
a. Conversion disorder
b. Depersonalization
c. Hypochondriasis
d. Somatization disorder
80. Nurse Daisy is aware that the following pharmacologic agents are sedative-
hypnotic medication is used to induce sleep for a client experiencing a sleep
disorder is:
a. Triazolam (Halcion)
b. Paroxetine (Paxil)\
c. Fluoxetine (Prozac)
d. Risperidone (Risperdal)
81. Aldo, with a somatoform pain disorder may obtain secondary gain. Which of
the following statement refers to a secondary gain?
82. Dervid is diagnosed with panic disorder with agoraphobia is talking with the
nurse in-charge about the progress made in treatment. Which of the following
statements indicates a positive client response?
84. Mark, with a diagnosis of generalized anxiety disorder wants to stop taking
his lorazepam (Ativan). Which of the following important facts should nurse Betty
discuss with the client about discontinuing the medication?
a. Anxiety disorder
b. Behavioral difficulties
c. Cognitive impairment
d. Labile moods
87. The nurse is aware that the following ways in vascular dementia different
from Alzheimer’s disease is:
88. Loretta, a newly admitted client was diagnosed with delirium and has history
of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix),
and diazepam (Valium) for anxiety. This client’s impairment may be related to
which of the following conditions?
a. Infection
b. Metabolic acidosis
89. Nurse Ron enters a client’s room, the client says, “They’re crawling on my
sheets! Get them off my bed!” Which of the following assessment is the most
accurate?
90. Which of the following descriptions of a client’s experience and behavior can
be assessed as an illusion?
a. The client tries to hit the nurse when vital signs must be taken
b. The client says, “I keep hearing a voice telling me to run away”
c. The client becomes anxious whenever the nurse leaves the
bedside
d. The client looks at the shadow on a wall and tells the nurse she
sees frightening faces on the wall.
91. During conversation of Nurse John with a client, he observes that the client
shift from one topic to the next on a regular basis. Which of the following terms
describes this disorder?
a. Flight of ideas
b. Concrete thinking
c. Ideas of reference
d. Loose association
92. Francis tells the nurse that her coworkers are sabotaging the computer.
When the nurse asks questions, the client becomes argumentative. This
behavior shows personality traits associated with which of the following
personality disorder?
a. Antisocial
b. Histrionic
c. Paranoid
d. Schizotypal
93. Which of the following interventions is important for a Cely experiencing with
paranoid personality disorder taking olanzapine (Zyprexa)?
94. Nurse Alexandra notices other clients on the unit avoiding a client diagnosed
with antisocial personality disorder. When discussing appropriate behavior in
group therapy, which of the following comments is expected about this client by
his peers?
a. Lack of honesty
b. Belief in superstition
c. Show of temper tantrums
d. Constant need for attention
95. Tommy, with dependent personality disorder is working to increase his self-
esteem. Which of the following statements by the Tommy shows teaching was
successful?
a. “I’m not going to look just at the negative things about myself”
b. “I’m most concerned about my level of competence and progress”
c. “I’m not as envious of the things other people have as I used to be”
d. “I find I can’t stop myself from taking over things other should be
doing”
97. Ivy, who is on the psychiatric unit is copying and imitating the movements of
her primary nurse. During recovery, she says, “I thought the nurse was my
mirror. I felt connected only when I saw my nurse.” This behavior is known by
which of the following terms?
a. Modeling
b. Echopraxia
c. Ego-syntonicity
d. Ritualism
a. Delusion
b. Disorganized speech
c. Hallucination
d. Idea of reference
a. Projection
b. Rationalization
c. Regression
d. Repression
100. Rocky has started taking haloperidol (Haldol). Which of the following
instructions is most appropriate for Ricky before taking haloperidol?
ANSWERS
&
RATIONALE
18. Answer: (D) Sudden onset of continuous epigastric and back pain.
Rationale: The autodigestion of tissue by the pancreatic enzymes results
in pain from inflammation, edema, and possible hemorrhage. Continuous,
unrelieved epigastric or back pain reflects the inflammatory process in the
pancreas.
21. Answer: (D) Immobilize the leg before moving the client.
Rationale: If the nurse suspects a fracture, splinting the area before
moving the client is imperative. The nurse should call for emergency help
if the client is not hospitalized and call for a physician for the hospitalized
client.
24. Answer: (B) Place the client on the left side in the Trendelenburg position.
Rationale: Lying on the left side may prevent air from flowing into the
pulmonary veins. The Trendelenburg position increases intrathoracic
pressure, which decreases the amount of blood pulled into the vena cava
during aspiration.
30. Answer: (A) Take the proper equipment, place the client in a comfortable
position, and record the appropriate information in the client’s chart.
Rationale: It is a general or comprehensive statement about the correct
procedure, and it includes the basic ideas which are found in the other
options
33. Answer: (A) Trochanter roll extending from the crest of the ileum to the
mid-thigh.
Rationale: A trochanter roll, properly placed, provides resistance to the
external rotation of the hip.
38. Answer: (D) It’s a measure of effect, not a standard measure of weight or
quantity.
Rationale: An insulin unit is a measure of effect, not a standard measure
of weight or quantity. Different drugs measured in units may have no
relationship to one another in quality or quantity.
50. Answer: (B) To provide support for the client and family in coping with
terminal illness.
Rationale: Hospices provide supportive care for terminally ill clients and
their families. Hospice care doesn’t focus on counseling regarding health
care costs. Most client referred to hospices have been treated for their
disease without success and will receive only palliative care in the
hospice.
51. Answer: (C) Using normal saline solution to clean the ulcer and applying
a protective dressing as necessary.
Rationale: Washing the area with normal saline solution and applying a
protective dressing are within the nurse’s realm of interventions and will
protect the area. Using a povidone-iodine wash and an antibiotic cream
require a physician’s order. Massaging with an astringent can further
damage the skin.
58. Answer: (D ) Obtaining the specimen from the urinary drainage bag.
Rationale: A urine specimen is not taken from the urinary drainage bag.
Urine undergoes chemical changes while sitting in the bag and does not
necessarily reflect the current client status. In addition, it may become
contaminated with bacteria from opening the system.
59. Answer: (B) Cover the client, place the call light within reach, and answer
the phone call.
Rationale: Because telephone call is an emergency, the nurse may need
to answer it. The other appropriate action is to ask another nurse to accept
the call. However, is not one of the options. To maintain privacy and
safety, the nurse covers the client and places the call light within the
client’s reach. Additionally, the client’s door should be closed or the room
curtains pulled around the bathing area.
60. Answer: (C) Use a sterile plastic container for obtaining the specimen.
Rationale: Sputum specimens for culture and sensitivity testing need to
be obtained using sterile techniques because the test is done to determine
the presence of organisms. If the procedure for obtaining the specimen is
not sterile, then the specimen is not sterile, then the specimen would be
contaminated and the results of the test would be invalid.
Rationale: When the client uses a walker, the nurse stands adjacent to
the affected side. The client is instructed to put all four points of the walker
2 feet forward flat on the floor before putting weight on hand pieces. This
will ensure client safety and prevent stress cracks in the walker. The client
is then instructed to move the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the incorrect information and
then initials the change.
Rationale: To correct an error documented in a medical record, the nurse
draws one line through the incorrect information and then initials the error.
An error is never erased and correction fluid is never used in the medical
record.
63. Answer: (C) Secures the client safety belts after transferring to the
stretcher.
Rationale: During the transfer of the client after the surgical procedure is
complete, the nurse should avoid exposure of the client because of the
risk for potential heat loss. Hurried movements and rapid changes in the
position should be avoided because these predispose the client to
hypotension. At the time of the transfer from the surgery table to the
stretcher, the client is still affected by the effects of the anesthesia;
therefore, the client should not move self. Safety belts can prevent the
client from falling off the stretcher.
66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from the chest wall, the client is
positioned sitting at the edge of the bed leaning over the bedside table
with the feet supported on a stool. If the client is unable to sit up, the client
is positioned lying in bed on the unaffected side with the head of the bed
elevated 30 to 45 degrees.
75. Answer: (B) The Board can investigate violations of the nursing law and
code of ethics
Rationale: Quasi-judicial power means that the Board of Nursing has the
authority to investigate violations of the nursing law and can issue
summons, subpoena or subpoena duces tecum as needed.
89. Answer: (A) Arrange for typing and cross matching of the client’s blood.
Rationale: The nurse first arranges for typing and cross matching of the
client's blood to ensure compatibility with donor blood. The other options,
although appropriate when preparing to administer a blood transfusion,
come later.
94. Answer: (B) Decrease the rate of feedings and the concentration of the
formula.
Rationale: Complaints of abdominal discomfort and nausea are common
in clients receiving tube feedings. Decreasing the rate of the feeding and
the concentration of the formula should decrease the client's discomfort.
Feedings are normally given at room temperature to minimize abdominal
cramping. To prevent aspiration during feeding, the head of the client's
bed should be elevated at least 30 degrees. Also, to prevent bacterial
growth, feeding containers should be routinely changed every 8 to 12
hours.
95. Answer: (D) Roll the vial gently between the palms.
Rationale: Rolling the vial gently between the palms produces heat,
which helps dissolve the medication. Doing nothing or inverting the vial
wouldn't help dissolve the medication. Shaking the vial vigorously could
cause the medication to break down, altering its action.
96. Answer: (B) Assist the client to the semi-Fowler position if possible.
99. Answer: (A) The nurse can implement medication orders quickly.
Rationale: A floor stock system enables the nurse to implement
medication orders quickly. It doesn't allow for pharmacist input, nor does it
minimize transcription errors or reinforce accurate calculations.
7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
Rationale: Fetus at station plus two indicates that the presenting part is 2
cm below the plane of the ischial spines.
10. Answer: (D) First low transverse caesarean was for breech position.
Fetus in this pregnancy is in a vertex presentation.
Rationale: This type of client has no obstetrical indication for a caesarean
section as she did with her first caesarean delivery.
11. Answer: (A) Talk to the mother first and then to the toddler.
Rationale: When dealing with a crying toddler, the best approach is to talk
to the mother and ignore the toddler first. This approach helps the toddler
get used to the nurse before she attempts any procedures. It also gives
the toddler an opportunity to see that the mother trusts the nurse.
12. Answer: (D) Place the infant’s arms in soft elbow restraints.
Rationale: Soft restraints from the upper arm to the wrist prevent the
infant from touching her lip but allow him to hold a favorite item such as a
blanket. Because they could damage the operative site, such as objects
as pacifiers, suction catheters, and small spoons shouldn’t be placed in a
baby’s mouth after cleft repair. A baby in a prone position may rub her
face on the sheets and traumatize the operative site. The suture line
should be cleaned gently to prevent infection, which could interfere with
healing and damage the cosmetic appearance of the repair.
16. Answer: (D) Public health nursing focuses on preventive, not curative,
services.
Rationale: The catchments area in PHN consists of a residential
21. Answer: (B) Health education and community organizing are necessary in
providing community health services.
Rationale: The community health nurse develops the health capability of
people through health education and community organizing activities.
34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in
his mother’s arms and drooling.
Rationale: The infant with the airway emergency should be treated first,
because of the risk of epiglottitis.
38. Answer: (D) “I really need to use the diaphragm and jelly most during the
middle of my menstrual cycle”.
Rationale: The woman must understand that, although the “fertile” period
is approximately mid-cycle, hormonal variations do occur and can result in
early or late ovulation. To be effective, the diaphragm should be inserted
before every intercourse.
40. Answer: (B) Walk one step ahead, with the child’s hand on the nurse’s
elbow.
Rationale: This procedure is generally recommended to follow in guiding
a person who is blind.
42. Answer: (C) More oxygen, and the newborn’s metabolic rate increases.
Rationale: When cold, the infant requires more oxygen and there is an
increase in metabolic rate. Non-shievering thermogenesis is a complex
process that increases the metabolic rate and rate of oxygen
consumption, therefore, the newborn increase heat production.
46. Answer: (A) The older one gets, the more susceptible he becomes to the
complications of chicken pox.
Rationale: Chicken pox is usually more severe in adults than in children.
Complications, such as pneumonia, are higher in incidence in adults.
47. Answer: (D) Consult a physician who may give them rubella
immunoglobulin.
Rationale: Rubella vaccine is made up of attenuated German measles
viruses. This is contraindicated in pregnancy. Immune globulin, a specific
prophylactic against German measles, may be given to pregnant women.
62. Answer: (A) Refer the child urgently to a hospital for confinement.
Rationale: “Baggy pants” is a sign of severe marasmus. The best
management is urgent referral to a hospital.
63. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol
more slowly.
Rationale: If the child vomits persistently, that is, he vomits everything
that he takes in, he has to be referred urgently to a hospital. Otherwise,
vomiting is managed by letting the child rest for 10 minutes and then
continuing with Oresol administration. Teach the mother to give Oresol
more slowly.
76. Answer: (C) Keep the cord dry and open to air
Rationale: Keeping the cord dry and open to air helps reduce infection
and hastens drying. Infants aren’t given tub bath but are sponged off until
the cord falls off. Petroleum jelly prevents the cord from drying and
encourages infection. Peroxide could be painful and isn’t recommended.
80. Answer: (B) Instructing the client to use two or more peripads to cushion
the area
Rationale: Using two or more peripads would do little to reduce the pain
or promote perineal healing. Cold applications, sitz baths, and Kegel
exercises are important measures when the client has a fourth-degree
laceration.
82. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe.
Rationale: The nurse's first action should be to clear the neonate's airway
with a bulb syringe. After the airway is clear and the neonate's color
improves, the nurse should comfort and calm the neonate. If the problem
recurs or the neonate's color doesn't improve readily, the nurse should
notify the physician. Administering oxygen when the airway isn't clear
would be ineffective.
83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index.
96. Answer: (B) Rh-positive fetal blood crosses into maternal blood,
stimulating maternal antibodies.
Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells
cross into the maternal circulation and stimulate maternal antibody
production. In subsequent pregnancies with Rh-positive fetuses, maternal
antibodies may cross back into the fetal circulation and destroy the fetal
blood cells.
6. Answer: (C) Make sure that the client takes food and medications at
prescribed intervals.
Rationale: Food and drug therapy will prevent the accumulation of
hydrochloric acid, or will neutralize and buffer the acid that does
accumulate.
10. Answer: (C) The client is oriented when aroused from sleep, and goes
back to sleep immediately.
Rationale: This finding suggest that the level of consciousness is
decreasing.
21. Answer: (C) Balance the client’s periods of activity and rest.
Rationale: A client with hyperthyroidism needs to be encouraged to
balance periods of activity and rest. Many clients with hyperthyroidism are
hyperactive and complain of feeling very warm.
24. Answer: (D) Avoiding straining during bowel movement or bending at the
waist.
Rationale: The client should avoid straining, lifting heavy objects, and
coughing harshly because these activities increase intraocular pressure.
Typically, the client is instructed to avoid lifting objects weighing more than
15 lb (7kg) – not 5lb. instruct the client when lying in bed to lie on either
the side or back. The client should avoid bright light by wearing
sunglasses.
30. Answer: (D) Place the client on his side, remove dangerous objects, and
protect his head.
Rationale: During the active seizure phase, initiate precautions by placing
the client on his side, removing dangerous objects, and protecting his
head from injury. A bite block should never be inserted during the active
seizure phase. Insertion can break the teeth and lead to aspiration.
32. Answer: (D) Stay with him but not intervene at this time.
Rationale: If the client is coughing, he should be able to dislodge the
object or cause a complete obstruction. If complete obstruction occurs, the
nurse should perform the abdominal thrust maneuver with the client
standing. If the client is unconscious, she should lay him down. A nurse
should never leave a choking client alone.
34. Answer: (C) Place the client in a side lying position, with the head of the
bed lowered.
Rationale: The client should be positioned in a side-lying position with the
head of the bed lowered to prevent aspiration. A small amount of
toothpaste should be used and the mouth swabbed or suctioned to
remove pooled secretions. Lemon glycerin can be drying if used for
extended periods. Brushing the teeth with the client lying supine may lead
to aspiration. Hydrogen peroxide is caustic to tissues and should not be
used.
40. Answer: (A) The patient is under local anesthesia during the procedure
Rationale: Before the procedure, the patient is administered with drugs
that would help to prevent infection and rejection of the transplanted cells
such as antibiotics, cytotoxic, and corticosteroids. During the transplant,
the patient is placed under general anesthesia.
44. Answer: (A) Explain the risks of not having the surgery
Rationale: The best initial response is to explain the risks of not having
the surgery. If the client understands the risks but still refuses the nurse
should notify the physician and the nurse supervisor and then record the
client’s refusal in the nurses’ notes.
45. Answer: (D) The 75-year-old client who was admitted 1 hour ago with
new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
Rationale: The client with atrial fibrillation has the greatest potential to
become unstable and is on L.V. medication that requires close monitoring.
After assessing this client, the nurse should assess the client with
thrombophlebitis who is receiving a heparin infusion, and then the 58-
year-old client admitted 2 days ago with heart failure (his signs and
symptoms are resolving and don’t require immediate attention). The
lowest priority is the 89-year-old with end-stage right-sided heart failure,
who requires time-consuming supportive measures.
49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and
no evidence of distant metastasis
Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnormal regional
lymph nodes, and no evidence of distant metastasis. No evidence of
primary tumor, no abnormal regional lymph nodes, and no evidence of
distant metastasis is classified as T0, N0, M0. If the tumor and regional
lymph nodes can't be assessed and no evidence of metastasis exists, the
lesion is classified as TX, NX, M0. A progressive increase in tumor size,
no demonstrable metastasis of the regional lymph nodes, and ascending
degrees of distant metastasis is classified as T1, T2, T3, or T4; N0; and
M1, M2, or M3.
52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected
side of the face.
Rationale: Horner's syndrome, which occurs when a lung tumor invades
the ribs and affects the sympathetic nerve ganglia, is characterized by
miosis, partial eyelid ptosis, and anhidrosis on the affected side of the
face. Chest pain, dyspnea, cough, weight loss, and fever are associated
with pleural tumors. Arm and shoulder pain and atrophy of the arm and
hand muscles on the affected side suggest Pancoast's tumor, a lung
tumor involving the first thoracic and eighth cervical nerves within the
brachial plexus. Hoarseness in a client with lung cancer suggests that the
53. Answer: (A) prostate-specific antigen, which is used to screen for prostate
cancer.
Rationale: PSA stands for prostate-specific antigen, which is used to
screen for prostate cancer. The other answers are incorrect.
54. Answer: (D) "Remain supine for the time specified by the physician."
Rationale: The nurse should instruct the client to remain supine for the
time specified by the physician. Local anesthetics used in a subarachnoid
block don't alter the gag reflex. No interactions between local anesthetics
and food occur. Local anesthetics don't cause hematuria.
56. Answer: (B) A fixed nodular mass with dimpling of the overlying skin
Rationale: A fixed nodular mass with dimpling of the overlying skin is
common during late stages of breast cancer. Many women have slightly
asymmetrical breasts. Bloody nipple discharge is a sign of intraductal
papilloma, a benign condition. Multiple firm, round, freely movable masses
that change with the menstrual cycle indicate fibrocystic breasts, a benign
condition.
58. Answer: (D) The client wears a watch and wedding band.
Rationale: During an MRI, the client should wear no metal objects, such
as jewelry, because the strong magnetic field can pull on them, causing
injury to the client and (if they fly off) to others. The client must lie still
during the MRI but can talk to those performing the test by way of the
microphone inside the scanner tunnel. The client should hear thumping
sounds, which are caused by the sound waves thumping on the magnetic
field.
59. Answer: (C) The recommended daily allowance of calcium may be found
in a wide variety of foods.
66. Answer: (C) The cane should be used on the unaffected side
Rationale: A cane should be used on the unaffected side. A client with
osteoarthritis should be encouraged to ambulate with a cane, walker, or
other assistive device as needed; their use takes weight and stress off
joints.
70. Answer: (C) They debride the wound and promote healing by secondary
intention
Rationale: For this client, wet-to-dry dressings are most appropriate
because they clean the foot ulcer by debriding exudate and necrotic
tissue, thus promoting healing by secondary intention. Moist, transparent
dressings contain exudate and provide a moist wound environment.
Hydrocolloid dressings prevent the entrance of microorganisms and
79. Answer: (D) "I'll need to have a C-section if I become pregnant and have
a baby."
Rationale: The human immunodeficiency virus (HIV) is transmitted from
mother to child via the transplacental route, but a Cesarean section
delivery isn't necessary when the mother is HIV-positive. The use of birth
control will prevent the conception of a child who might have HIV. It's true
that a mother who's HIV positive can give birth to a baby who's HIV
negative.
80. Answer: (C) "Avoid sharing such articles as toothbrushes and razors."
Rationale: The human immunodeficiency virus (HIV), which causes
AIDS, is most concentrated in the blood. For this reason, the client
shouldn't share personal articles that may be blood-contaminated, such as
toothbrushes and razors, with other family members. HIV isn't transmitted
by bathing or by eating from plates, utensils, or serving dishes used by a
person with AIDS.
88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb)
levels
Rationale: Low preoperative HCT and Hb levels indicate the client may
require a blood transfusion before surgery. If the HCT and Hb levels
decrease during surgery because of blood loss, the potential need for a
transfusion increases. Possible renal failure is indicated by elevated BUN
or creatinine levels. Urine constituents aren't found in the blood.
Coagulation is determined by the presence of appropriate clotting factors,
not electrolytes.
89. Answer: (A) Platelet count, prothrombin time, and partial thromboplastin
time
Rationale: The diagnosis of DIC is based on the results of laboratory
studies of prothrombin time, platelet count, thrombin time, partial
thromboplastin time, and fibrinogen level as well as client history and other
assessment factors. Blood glucose levels, WBC count, calcium levels, and
potassium levels aren't used to confirm a diagnosis of DIC.
91. Answer: (B) A client with cast on the right leg who states, “I have a funny
feeling in my right leg.”
Rationale: It may indicate neurovascular compromise, requires immediate
assessment.
94. Answer: (D) Use comfort measures and pillows to position the client.
Rationale: Using comfort measures and pillows to position the client is a
non-pharmacological methods of pain relief.
96. Answer: (C) The client holds the cane with his left hand, moves the cane
forward followed by the right leg, and then moves the left leg.
Rationale: The cane acts as a support and aids in weight bearing for the
weaker right leg.
97. Answer: (A) Ask the woman’s family to provide personal items such as
photos or mementos.
Rationale: Photos and mementos provide visual stimulation to reduce
sensory deprivation.
98. Answer: (B) The client lifts the walker, moves it forward 10 inches, and
then takes several small steps forward.
Rationale: A walker needs to be picked up, placed down on all legs.
99. Answer: (C) Isolation from their families and familiar surroundings.
Rationale: Gradual loss of sight, hearing, and taste interferes with normal
functioning.
100. Answer: (A) Encourage the client to perform pursed lip breathing.
Rationale: Purse lip breathing prevents the collapse of lung unit and helps
client control rate and depth of breathing.
3. Answer: (D) Decrease the size and vascularity of the thyroid gland.
Rationale: Lugol’s solution provides iodine, which aids in decreasing the
vascularity of the thyroid gland, which limits the risk of hemorrhage when
surgery is performed.
7. Answer: (B) Keep the irrigating container less than 18 inches above the
stoma.”
Rationale: This height permits the solution to flow slowly with little force
so that excessive peristalsis is not immediately precipitated.
9. Answer:(B) 28 gtt/min
Rationale: This is the correct flow rate; multiply the amount to be infused
(2000 ml) by the drop factor (10) and divide the result by the amount of
time in minutes (12 hours x 60 minutes)
Rationale: The percentage designated for each burned part of the body
using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left
upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower
extremity 18%; Left lower extremity 18%; Perineum 1%.
13. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus
for breathing.
Rationale: COPD causes a chronic CO2 retention that renders the
medulla insensitive to the CO2 stimulation for breathing. The hypoxic state
of the client then becomes the stimulus for breathing. Giving the client
oxygen in low concentrations will maintain the client’s hypoxic drive.
15. Answer: (A) Food and fluids will be withheld for at least 2 hours.
Rationale: Prior to bronchoscopy, the doctors sprays the back of the
throat with anesthetic to minimize the gag reflex and thus facilitate the
insertion of the bronchoscope. Giving the client food and drink after the
procedure without checking on the return of the gag reflex can cause the
client to aspirate. The gag reflex usually returns after two hours.
18. Answer: (A) The left kidney usually is slightly higher than the right one.
Rationale: The left kidney usually is slightly higher than the right one. An
adrenal gland lies atop each kidney. The average kidney measures
approximately 11 cm (4-3/8") long, 5 to 5.8 cm (2" to 2¼") wide, and 2.5
cm (1") thick. The kidneys are located retroperitoneally, in the posterior
aspect of the abdomen, on either side of the vertebral column. They lie
between the 12th thoracic and 3rd lumbar vertebrae.
19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine
6.5 mg/dl.
Rationale: The normal BUN level ranges 8 to 23 mg/dl; the normal serum
creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C
are abnormally elevated, reflecting CRF and the kidneys' decreased ability
to remove nonprotein nitrogen waste from the blood. CRF causes
decreased pH and increased hydrogen ions — not vice versa. CRF also
increases serum levels of potassium, magnesium, and phosphorous, and
decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls
within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also
falls with the normal range of 60% to 75%.
24. Answer: (B) Lying on the left side with knees bent
Rationale: For a colonoscopy, the nurse initially should position the client
on the left side with knees bent. Placing the client on the right side with
legs straight, prone with the torso elevated, or bent over with hands
touching the floor wouldn't allow proper visualization of the large intestine.
25. Answer: (A) Blood supply to the stoma has been interrupted
Rationale: An ileostomy stoma forms as the ileum is brought through the
abdominal wall to the surface skin, creating an artificial opening for waste
elimination. The stoma should appear cherry red, indicating adequate
arterial perfusion. A dusky stoma suggests decreased perfusion, which
may result from interruption of the stoma's blood supply and may lead to
tissue damage or necrosis. A dusky stoma isn't a normal finding. Adjusting
the ostomy bag wouldn't affect stoma color, which depends on blood
supply to the area. An intestinal obstruction also wouldn't change stoma
color.
29. Answer: (C) In long, even, outward, and downward strokes in the
direction of hair growth
Rationale: When applying a topical agent, the nurse should begin at the
midline and use long, even, outward, and downward strokes in the
direction of hair growth. This application pattern reduces the risk of follicle
irritation and skin inflammation.
34. Answer: (C) The emergency department nurse calls up the latest
electrocardiogram results to check the client’s progress
Rationale: The emergency department nurse is no longer directly
involved with the client’s care and thus has no legal right to information
about his present condition. Anyone directly involved in his care (such as
the telemetry nurse and the on-call physician) has the right to information
about his condition. Because the client requested that the nurse update
his wife on his condition, doing so doesn’t breach confidentiality.
37. Answer: (C) Electrocardiogram, complete blood count, testing for occult
blood, comprehensive serum metabolic panel.
Rationale: An electrocardiogram evaluates the complaints of chest pain,
laboratory tests determines anemia, and the stool test for occult blood
determines blood in the stool. Cardiac monitoring, oxygen, and creatine
kinase and lactate dehydrogenase levels are appropriate for a cardiac
primary problem. A basic metabolic panel and alkaline phosphatase and
aspartate aminotransferase levels assess liver function. Prothrombin time,
partial thromboplastin time, fibrinogen and fibrin split products are
50. Answer: (B) “I will call my doctor if Stacy has persistent vomiting and
diarrhea”.
Rationale: Persistent (more than 24 hours) vomiting, anorexia, and
diarrhea are signs of toxicity and the patient should stop the medication
51. Answer: (D) “This is only temporary; Stacy will re-grow new hair in 3-6
months, but may be different in texture”.
Rationale: This is the appropriate response. The nurse should help the
mother how to cope with her own feelings regarding the child’s disease so
as not to affect the child negatively. When the hair grows back, it is still of
the same color and texture.
56. Answer: D 80 mm Hg
Rationale: A client about to go into respiratory arrest will have inefficient
ventilation and will be retaining carbon dioxide. The value expected would
be around 80 mm Hg. All other values are lower than expected.
62. Answer: (C) “I’ll lower the dosage as ordered so the drug causes only 2 to
4 stools a day”.
Rationale: Lactulose is given to a patients with hepatic encephalopathy to
reduce absorption of ammonia in the intestines by binding with ammonia
and promoting more frequent bowel movements. If the patient experience
diarrhea, it indicates over dosage and the nurse must reduce the amount
of medication given to the patient. The stool will be mashy or soft.
Lactulose is also very sweet and may cause cramping and bloating.
63. Answer: (B) Severe lower back pain, decreased blood pressure,
decreased RBC count, increased WBC count.
Rationale: Severe lower back pain indicates an aneurysm rupture,
secondary to pressure being applied within the abdominal cavity. When
ruptured occurs, the pain is constant because it can’t be alleviated until
68. Answer: (D) It inhibits reabsorption of sodium and water in the loop of
Henle.
Rationale: Furosemide is a loop diuretic that inhibits sodium and water
reabsorption in the loop Henle, thereby causing a decrease in blood
pressure. Vasodilators cause dilation of peripheral blood vessels, directly
relaxing vascular smooth muscle and decreasing blood pressure.
Adrenergic blockers decrease sympathetic cardioacceleration and
decrease blood pressure. Angiotensin-converting enzyme inhibitors
decrease blood pressure due to their action on angiotensin.
70. Answer: (C) Narcotics are avoided after a head injury because they may
hide a worsening condition.
Rationale: Narcotics may mask changes in the level of consciousness
that indicate increased ICP and shouldn’t acetaminophen is strong enough
ignores the mother’s question and therefore isn’t appropriate. Aspirin is
contraindicated in conditions that may have bleeding, such as trauma, and
for children or young adults with viral illnesses due to the danger of Reye’s
syndrome. Stronger medications may not necessarily lead to vomiting but
will sedate the client, thereby masking changes in his level of
consciousness.
78. Answer: (A) "I can avoid getting sick by not becoming dehydrated and by
paying attention to my need to urinate, drink, or eat more than usual."
Rationale: Inadequate fluid intake during hyperglycemic episodes often
leads to HHNS. By recognizing the signs of hyperglycemia (polyuria,
polydipsia, and polyphagia) and increasing fluid intake, the client may
prevent HHNS. Drinking a glass of nondiet soda would be appropriate for
hypoglycemia. A client whose diabetes is controlled with oral antidiabetic
agents usually doesn't need to monitor blood glucose levels. A high-
carbohydrate diet would exacerbate the client's condition, particularly if
fluid intake is low.
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Rationale: Regular insulin, which is a short-acting insulin, has an onset of
15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the
insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m.
and the peak from 4 p.m. to 6 p.m.
85. Answer: (B) "Rotate injection sites within the same anatomic region, not
among different regions."
Rationale: The nurse should instruct the client to rotate injection sites
within the same anatomic region. Rotating sites among different regions
may cause excessive day-to-day variations in the blood glucose level;
also, insulin absorption differs from one region to the next. Insulin should
94. Answer: (C) Serous fluids fills the space and consolidates the region
Rationale: Serous fluid fills the space and eventually consolidates,
preventing extensive mediastinal shift of the heart and remaining lung. Air
can’t be left in the space. There’s no gel that can be placed in the pleural
space. The tissue from the other lung can’t cross the mediastinum,
although a temporary mediastinal shift exits until the space is filled.
100. Answer: (D) “I should put on the stockings before getting out of bed in
the morning.
Rationale: Promote venous return by applying external pressure on veins.
4. Answer: (C) Agree to talk with the mother and the father together.
Rationale: By agreeing to talk with both parents, the nurse can provide
emotional support and further assess and validate the family’s needs.
6. Answer: (D) Suggest that it takes awhile before seeing the results.
Rationale: The client needs a specific response; that it takes 2 to 3 weeks
(a delayed effect) until the therapeutic blood level is reached.
11. Answer: (A) By designating times during which the client can focus on the
behavior.
Rationale: The nurse should designate times during which the client can
focus on the compulsive behavior or obsessive thoughts. The nurse
should urge the client to reduce the frequency of the compulsive behavior
gradually, not rapidly. She shouldn't call attention to or try to prevent the
behavior. Trying to prevent the behavior may cause pain and terror in the
client. The nurse should encourage the client to verbalize anxieties to help
distract attention from the compulsive behavior.
12. Answer: (D) Exploring the meaning of the traumatic event with the client.
Rationale: The client with PTSD needs encouragement to examine and
understand the meaning of the traumatic event and consequent losses.
Otherwise, symptoms may worsen and the client may become depressed
or engage in self-destructive behavior such as substance abuse. The
client must explore the meaning of the event and won't heal without this,
no matter how much time passes. Behavioral techniques, such as
relaxation therapy, may help decrease the client's anxiety and induce
sleep. The physician may prescribe antianxiety agents or antidepressants
cautiously to avoid dependence; sleep medication is rarely appropriate. A
special diet isn't indicated unless the client also has an eating disorder or
a nutritional problem.
13. Answer: (C) "Your problem is real but there is no physical basis for it.
We'll work on what is going on in your life to find out why it's happened."
Rationale: The nurse must be honest with the client by telling her that the
paralysis has no physiologic cause while also conveying empathy and
acknowledging that her symptoms are real. The client will benefit from
psychiatric treatment, which will help her understand the underlying cause
of her symptoms. After the psychological conflict is resolved, her
symptoms will disappear. Saying that it must be awful not to be able to
move her legs wouldn't answer the client's question; knowing that the
cause is psychological wouldn't necessarily make her feel better. Telling
her that she has developed paralysis to avoid leaving her parents or that
her personality caused her disorder wouldn't help her understand and
resolve the underlying conflict.
15. Answer: (A) A warning about the drugs delayed therapeutic effect, which
is from 14 to 30 days.
Rationale: The client should be informed that the drug's therapeutic effect
might not be reached for 14 to 30 days. The client must be instructed to
continue taking the drug as directed. Blood level checks aren't necessary.
NMS hasn't been reported with this drug, but tachycardia is frequently
reported.
24. Answer: (C) Set up a strict eating plan for the client.
Rationale: Establishing a consistent eating plan and monitoring the
client’s weight are very important in this disorder. The family and friends
should be included in the client’s care. The client should be monitored
during meals-not given privacy. Exercise must be limited and supervised.
34. Answer: (D) A higher level of anxiety continuing for more than 3 months.
Rationale: This is not an expected outcome of a crisis because by
definition a crisis would be resolved in 6 weeks.
40. Answer: (D) Encouraging the client to have blood levels checked as
ordered.
Rationale: Blood levels must be checked monthly or bimonthly when the
client is on maintenance therapy because there is only a small range
between therapeutic and toxic levels.
46. Answer: (D) Males are more likely to use lethal methods than are females
Rationale: This finding is supported by research; females account for 90%
of suicide attempts but males are three times more successful because of
methods used.
47. Answer: (C) "Your cursing is interrupting the activity. Take time out in your
room for 10 minutes."
Rationale: The nurse should set limits on client behavior to ensure a
comfortable environment for all clients. The nurse should accept hostile or
quarrelsome client outbursts within limits without becoming personally
offended, as in option A. Option B is incorrect because it implies that the
client's actions reflect feelings toward the staff instead of the client's own
misery. Judgmental remarks, such as option D, may decrease the client's
self-esteem.
51. Answer: (B) Advising the client to sit up for 1 minute before getting out of
bed.
Rationale: To minimize the effects of amitriptyline-induced orthostatic
hypotension, the nurse should advise the client to sit up for 1 minute
before getting out of bed. Orthostatic hypotension commonly occurs with
tricyclic antidepressant therapy. In these cases, the dosage may be
reduced or the physician may prescribe nortriptyline, another tricyclic
antidepressant. Orthostatic hypotension disappears only when the drug is
discontinued.
56. Answer: (D) It's characterized by an acute onset and lasts hours to a
number of days
Rationale: Delirium has an acute onset and typically can last from
several hours to several days.
58. Answer: (D) This medication may initially cause tiredness, which should
become less bothersome over time.
Rationale: Sedation is a common early adverse effect of imipramine, a
tricyclic antidepressant, and usually decreases as tolerance develops.
Antidepressants aren't habit forming and don't cause physical or
psychological dependence. However, after a long course of high-dose
therapy, the dosage should be decreased gradually to avoid mild
59. Answer: (C) Monitor vital signs, serum electrolyte levels, and acid-base
balance.
Rationale: An anorexic client who requires hospitalization is in poor
physical condition from starvation and may die as a result of arrhythmias,
hypothermia, malnutrition, infection, or cardiac abnormalities secondary to
electrolyte imbalances. Therefore, monitoring the client's vital signs, serum
electrolyte level, and acid base balance is crucial. Option A may worsen
anxiety. Option B is incorrect because a weight obtained after breakfast is
more accurate than one obtained after the evening meal. Option D would
reward the client with attention for not eating and reinforce the control
issues that are central to the underlying psychological problem; also, the
client may record food and fluid intake inaccurately.
64. Answer: (C) No acts of aggression have been observed within 1 hour
after the release of two of the extremity restraints.
Rationale: The best indicator that the behavior is controlled, if the client
exhibits no signs of aggression after partial release of restraints. Options
A, B, and D do not ensure that the client has controlled the behavior.
72. Answer: (D) Hold the next dose and obtain an order for a stat serum
lithium level
Rationale: Diarrhea and vomiting are manifestations of Lithium toxicity.
The next dose of lithium should be withheld and test is done to validate
the observation. A. The manifestations are not due to drug interaction. B.
Cogentin is used to manage the extra pyramidal symptom side effects of
antipsychotics. C. The common side effects of Lithium are fine hand
tremors, nausea, polyuria and polydipsia.
81. Answer: (D) It promotes emotional support or attention for the client
Rationale: Secondary gain refers to the benefits of the illness that allow
the client to receive emotional support or attention. Primary gain enables
the client to avoid some unpleasant activity. A dysfunctional family may
disregard the real issue, although some conflict is relieved. Somatoform
pain disorder is a preoccupation with pain in the absence of physical
disease.
82. Answer: (A) “I went to the mall with my friends last Saturday”
83. Answer: (A) “I’m sleeping better and don’t have nightmares”
Rationale:MAO inhibitors are used to treat sleep problems, nightmares,
and intrusive daytime thoughts in individual with posttraumatic stress
disorder. MAO inhibitors aren’t used to help control flashbacks or phobias
or to decrease the craving for alcohol.
84. Answer: (D) Stopping the drug can cause withdrawal symptoms
Rationale: Stopping antianxiety drugs such as benzodiazepines can
cause the client to have withdrawal symptoms. Stopping a benzodiazepine
doesn’t tend to cause depression, increase cognitive abilities, or decrease
sleeping difficulties.
86. Answer: (D) It’s a mood disorder similar to major depression but of mild to
moderate severity
Rationale: Dysthymic disorder is a mood disorder similar to major
depression but it remains mild to moderate in severity. Cyclothymic
disorder is a mood disorder characterized by a mood range from moderate
depression to hypomania. Bipolar I disorder is characterized by a single
manic episode with no past major depressive episodes. Seasonal-
affective disorder is a form of depression occurring in the fall and winter.
90. Answer: (D) The client looks at the shadow on a wall and tells the nurse
she sees frightening faces on the wall.
Rationale: Minor memory problems are distinguished from dementia by
their minor severity and their lack of significant interference with the
client’s social or occupational lifestyle. Other options would be included in
the history data but don’t directly correlate with the client’s lifestyle.
93. Answer: (C) Explain that the drug is less affective if the client smokes
Rationale: Olanzapine (Zyprexa) is less effective for clients who smoke
cigarettes. Serotonin syndrome occurs with clients who take a
combination of antidepressant medications. Olanzapine doesn’t cause
euphoria, and extrapyramidal adverse reactions aren’t a problem.
However, the client should be aware of adverse effects such as tardive
dyskinesia.
95. Answer: (A) “I’m not going to look just at the negative things about myself”
Rationale: As the clients makes progress on improving self-esteem, self-
blame and negative self evaluation will decrease. Clients with dependent
personality disorder tend to feel fragile and inadequate and would be
extremely unlikely to discuss their level of competence and progress.
These clients focus on self and aren’t envious or jealous. Individuals with
dependent personality disorders don’t take over situations because they
see themselves as inept and inadequate.
96. Answer: (C) Assess for possible physical problems such as rash
Rationale: Clients with schizophrenia generally have poor visceral
recognition because they live so fully in their fantasy world. They need to
have as in-depth assessment of physical complaints that may spill over
into their delusional symptoms. Talking with the client won’t provide as
assessment of his itching, and itching isn’t as adverse reaction of
antipsychotic drugs, calling the physician to get the client’s medication
increased doesn’t address his physical complaints.
PRACTICE TEST I
FOUNDATION OF NURSING
1. For the client who is using oral contraceptives, the nurse informs the client
about the need to take the pill at the same time each day to accomplish
which of the following?
a. Decrease the incidence of nausea
b. Maintain hormonal levels
c. Reduce side effects
d. Prevent drug interactions
2. When teaching a client about contraception. Which of the following would
the nurse include as the most effective method for preventing sexually
transmitted infections?
a. Spermicides
b. Diaphragm
c. Condoms
d. Vasectomy
3. When preparing a woman who is 2 days postpartum for discharge,
recommendations for which of the following contraceptive methods would
be avoided?
a. Diaphragm
b. Female condom
c. Oral contraceptives
d. Rhythm method
4. For which of the following clients would the nurse expect that an
intrauterine device would not be recommended?
a. Woman over age 35
b. Nulliparous woman
c. Promiscuous young adult
d. Postpartum client
5. A client in her third trimester tells the nurse, “I’m constipated all the time!”
Which of the following should the nurse recommend?
a. Daily enemas
b. Laxatives
c. Increased fiber intake
d. Decreased fluid intake
6. Which of the following would the nurse use as the basis for the teaching
plan when caring for a pregnant teenager concerned about gaining too
much weight during pregnancy?
a. 10 pounds per trimester
b. 1 pound per week for 40 weeks
c. ½ pound per week for 40 weeks
d. A total gain of 25 to 30 pounds
7. The client tells the nurse that her last menstrual period started on January
14 and ended on January 20. Using Nagele’s rule, the nurse determines
her EDD to be which of the following?
a. September 27