RPN Integrated Practice Test V (A)

1. What events or things are important to include in your report to the staff of the incoming shift?
a. The nursing interventions implemented
b. Changes that happened during your shift
c. Documents that have been done
d. Treatments that have been carried out
Answer: B – significant changes are reported to the incoming shift.

2. A 65-year old male patient was admitted to the unit. The family arrived to the unit shortly after the patient died. How will the
PN show respect to the family?
a. Tell them that it is alright to cry
b. Let the family wait and bring to them the patient’s belongings
c. Offer them a private room to sit
d. Introduce the family to the nursing supervisor/manager
Answer: C – one way of showing respect is acknowledging the need of the grieving family to express their emotion and grief with
privacy. B – this is the right of the family. A – more on emotional support.

3. Mr. BD who has stage 2 Alzheimer’s disease is admitted to the hospital. He is very confused and disoriented. A few hours
after admission, he jumps off from the bed, attempts to remove all intravenous lines and throws things near him. Because of
this behavior, the doctor orders restraints. The PN requested assistance to restrain both his hands and apply a restraint jacket.
His family was not happy with the intervention and the niece asked the PN why her uncle was restrained? What is the PN’s
best response?
a. It is the doctor’s order that we place him on restraints
b. It was for the patient’s safety that we placed him on restraints
c. It is the hospital policy that we place him restraints for behavior such as this
Answer: B – restraints are always for patient’s safety and not for nurses’ convenience.

4. In the emergency room, a 65-year-old female with a wrist fracture suddenly cried when asked about how she got a fracture.
She shared that her daughter abuses her and how she hits her all the time. She also shared that her daughter also abuses her
children. Which among the following situations poses the greatest danger?
a. The daughter takes all her retirement money away from her
b. The daughter is abusive to her children
c. The daughter can potentially kill someone
d. She constantly uses abusive and profane language
Answer: C - with the daughter’s unrestrained behavior, she can potentially kill someone.

5. Mr. K is concerned about his hyperactive 18 month old toddler Ryan. Mr. K asks the PN how he can manage his son
especially when eating. What is the best nursing response?
a. Discuss with Mr. K safety rules for Ryan
b. Put the child in the playpen when hyperactive
c. Discourage running while eating
d. Put the child in the car seat during camping trip or any trip.
Answer: C – the hyperactivity of the toddlers poses possible harm. “Preventing the child from running when eating” is a specific
action that can prevent physical harm on the child. A – safety rules is a general response; B – toddlers are no longer placed in the
playpen (this is for infants); D – car seat is not only for toddlers but for everyone.

6.How will the PN know that the participants of a breast-cancer prevention class are motivated in taking actions on preventing
such cancer?
a. The participants make verbal comments that the class was very beneficial
b. Some participants demonstrate the correct way of doing the breast-self examination
c. The participants are actively asking questions after the class
d. The participants are requesting for another similar class in the future
Answer: B – is a tangible and measurable evidence that the participants have learned something from the class,

7. MC has undergone a mastectomy and is admitted to your unit. How will you know that she is ready to care for herself?
a. She asks pertinent queries about wound care
b. She helps the nurse in changing the dressing
c. She looks at her wound
d. She informs the nurse about her concerns at how to take care of the wound
 Answer: B - being able to perform dressing change is an indication that the patient can continue this same care at home. A – indicates
that the patient still needs information about wound care. C – being able to look at the wound may mean “acceptance” of the fact that
the patient had mastectomy. D – shows that the patient is not ready yet.

8. How will the school nurse promote physical exercise to a group of students in the camp? (need to correct sentence
structure)
a. By physical fitness
b. By cultural backgrounds
c. By growth and development level
d. By physical growth
Answer: C - the appropriateness of exercise is tailored to the age of the group.

9. The daughter of a 92-year-old patient asked the community health nurse about the resources needed for her mother. While
she was asking the question, the patient interrupted and said “We need home care”. The PN was about to propose a nursing
home placement. What is the most appropriate response for the PN to take at this time?
a. Have the daughter tour a nursing home
b. Ask the mother and daughter discuss what resources they need
c. Tell the mother, “I would like to know your daughter’s opinion on what resources are needed”
d. Identify the resources needed.
Answer: B – the patient and her daughter should get involved in the decision making; D – seems to be the nurse is making decision
for the patient and her daughter.

10. A 73-year-old male patient who has some nutrition problems is going to be discharged. The patient’s brother who has limited
resources expressed his willingness to take care of his older brother. What should the PN do?
a. Refer the patient to appropriate community resources
b. Let the brother prepare nutritious food
c. Have a community nurse visit the patient
Answer: A – with financial support from community resources, the brother (who has financial problem) would be able to provide
nutritious food for the patient.

11. Ms. Sheila, 85 years old has an advanced stage of Alzheimer’s disease. Her family is providing care for her. For the past
week, her family members are uncertain to continue to care for her. The family also mentioned about community health nurse
who regularly visits the client. What would be your response to ensure the safety of the client?
a. Suggest for a nursing home placement
b. Refer to a social worker
c. Inform the family of available resources
d. Suggest for respite care.
Answer: C – the family should be able to make important decision about their need of “care”.

12. A patient is for discharge and is waiting for his wife. He has come on a weekly basis to the hospital for follow-up. How will
the PN ensure that he will comply with his follow-up plans?
a. Ask him if a neighbor could bring him to the hospital
b. Ask him if his wife can drive to the hospital
c. Ask him, “will this follow-up cause any problem for you?”
Answer: C – assessment of the patient’s needs is an important question to finding out if the patient is able to comply with the follow
up plans. A – the neighbor should not be responsible for the patient’s transport. B – although the wife can be responsible for
transporting her husband, it is still ideal to assess for any possible barrier to the implementation of the plan.

13. The PN is organizing a crosswalk to minimize the occurrences of motor accidents near the school area. What would be the
nurse’s initial step to do?
a. Send letters to the pupils about the plan of organizing a crosswalk
b. Conduct a meeting with the school principal and the parents
c. Conduct a meeting with the Ministry of Transportation
Answer: B – the support of the school (through the principal) and the parents is vital to the success of the plan.

14. The PN is visiting a group home for children with cerebral palsy. Which among the following is considered as the primary
source of data?
a. Doctor
b. Records
 c. Parents of the children
d. Observations of children’s behavior and activities
Answer: C – parents have the “first hand” information about their children’s health history.

15. The PN is developing health teaching plan on promotion of nutrition to a group of teenagers. Which one should be
considered?
a. Show video tape about proper nutrition
b. Introduce a game outlining the different food groups according to the Canada’s food guide
c. Develop a group discussion on the promotion of nutrition
d. Ask a dietician from the community to provide a lecture on the promotion on nutrition
Answer: B – “food game” will be enjoyable and a more efficient learning tool to teen agers.

16. A mother of a hyperactive child asks the home visiting nurse why she is recommending the Canadian Food Guide to be used
in her food planning. How would the visiting nurse respond?
a. Because of your son’s hyperactivity, you need to plan your meals according to the Canadian Food Guide.
b. It is for his growth and development that I am recommending the Canadian Food Guide
c. Your son needs to have the complete nutritional requirements at his age
Answer: B – the Canadian Food Guide will help the mother choose nutritious foods needed by the growing child.

17. A terminally ill patient with leukemia has decided to stay at home after receiving aggressive treatment in the hospital.
However, the family is concerned about taking care of the patient a she just had a bone marrow transplant six months ago.
What is your best nursing response in advocating the decision of the patient?
a. Refer the client to a respite care
b. Call the community health center
c. Immediately inform the attending physician
d. Refer the case to the community’s self-care group.
Answer: B – the nurse in the community health center should be able to provide necessary care specific to the patient and family’s
concern.

18. Which among the following statements made by a client in a smoking cessation program best indicates that your health
teachings are effective?
a. I cut back my smoking from 25 to 20 cigarettes each day
b. I started to quit smoking last week
c. I only smoke once in the morning and in the evening
d. I smoke only when I’m stressed
Answer: A – this is measurable goal indicating that health teaching was effective. B – although it is good – is very general; C – does
not give any information about smoking cessation; D – no indication of smoking cessation.

19. A terminally ill patient wants to say goodbye to his dog. The policy in the unit does not allow any pet to visit the unit. You
ask your nursing supervisor to advocate for the patient but your charge nurse refused to allow the patient’s dog to come and
visit. How can the PN continue to advocate for the client?
a. Apologize to the patient and tell the patient that nurses cannot change the policy
b. Approach the nursing supervisor to explore the hospital policy and possibly obtain a special permit to bring the
dog
c. Tell the family to bring the dog in the evening when no one could see them
d. Request that the nurse supervisor advocates for change on pet’s visitation.
Answer: B – the supervisor refuses, thus, the next step is to approach the administration

20. What would you include to your discharge teaching to a new mother about safety of her infant?
a. Proper positioning while sleeping
b. Put away toxic substances and poisonous things
c. Enforce restricting rules while playing
Answer: A – the newborn should not be positioned prone or side-lying – these are implicated in SIDS. Supine position is
recommended.

21. PN Regine was assigned to conduct a smoking cessation program for teenagers, ages 12-16 in an aboriginal school. The best
tool to assess the group’s learning needs would be to;
a. Conduct a quiz about the advantages and disadvantages of smoking
b. Inquire from the school counselor regarding the learning abilities and needs of the students
 c. Ask the non-smoking participants to talk about their side of not engaging in smoking
d. Allow an ex-smoker to talk about her story of quitting smoking
Answer: B – this is the most efficient methods that can be used in assessing the learning needs of the target group.

22. A normal baby was brought by her mother to the clinic for her regular check-up. How would the PN ask the mother to
determine if the mother is facilitating the baby’s developmental task of trust as defined by Erickson?
a. Do you hold the baby when she cries?
b. Do you give a pacifier to the baby when she cries – this is psycho social need
c. What positions does your baby assume when she sleeps? –this prevents SIDS
d. What immunizations did your child already have? – this health reason
Answer: A – “Trust” can be communicated to infants through cuddling.

23. Michelle had a periorbital edema, was feeling dizzy, and was in pain. She was accompanied to the emergency room by her
partner, Joan. Her partner told the PN that she “fell” the night before coming to hospital. What should the PN do initially?
a. Apply warm compress to Michelle’s eyes
b. Ask the partner to leave the interview room so the nurse can talk to the patient privately
c. Explore with Michelle and Joan the factual events of the incident
d. Give analgesic to Michelle
Answer: B – the patient’s presentation – “periorbital edema” is not consistent with the patient story. As the nurse suspect physical
abuse and would like to get more information from the patient, the possible abuser should get out of the interview room. A – cold
compress should be applied to decrease edema.

24. PN Nancy administers the wrong preoperative medication. She filed an incident report and informed her supervisor. In
addition to what she has done, who else should she notify?
a. The pharmacist
b. The patient
c. The doctor
d. Her colleague
Answer: C – the physician should be the first person to be informed for the welfare of the patient.

25. A patient with diabetes mellitus has a small ulcer on her toe and requires foot care. Who is the best person to administer such
care?
a. The nurse assigned to the patient
b. The diabetic nurse clinician
c. The nurse with foot care training
d. The infection control nurse
Answer: B – the diabetic nurse clinician has the appropriate training to provide care for a diabetic patient.

26. The PN is conducting health teaching class to a group of teenagers on nutrition. During the discussion part, one student asked
the PN why she was teaching nutrition to the teens only. How will the PN respond?
a. It is not appropriate for teens to skip meals
b. Anorexia nervosa and bulimia are very common disorders among teens
c. I teach to the teens only in order to decrease the incidence of anorexia nervosa and bulimia
d. I teach this class in order to improve your knowledge on nutrition
Answer: D – this is an appropriate respond. It does not exclude other groups.

27. You are the PN in a medical unit assigned to a patient who requires blood transfusion. What is your nursing responsibility
prior to starting blood transfusion?
a. Check the patient’s name against the MAR sheet
b. Check the ID band of the patient with MAR sheet – patient’s ID band against the blood bag
c. Check the blood product by two nurses
d. Run a normal saline first before administering the blood
Answer: C – the patient’s identity must be established prior to administering the blood.

28. The PN has developed a close relationship with a male patient who has been in the unit for a while now. When the PN enters
the patient’s room, one of his male friends who’s visiting, tells the patient, Hey! Your sweetheart is here. How will the PN
respond?
a. Ignore the remark and tell the patient that it is time for his therapy
b. Tell the visiting friend that his remarks were inappropriate
 c. Ask the visiting friend what the patient was telling him about her.
Answer: B – this is an objective course of action.

29. Often times, what kind of patients are most likely diagnosed with substance abuse?
a. Patients with chronic pain taking Tylenol
b. Patients on nitroglycerine patch
c. Patients who has previous psychiatric admissions
Answer: A – due to chronic pain, the patient has the tendency to develop dependence on drugs that oftentimes results to drug abuse.

30. A 28-year-old male patient, who was admitted to the hospital for sudden change of behavior, is presently angry. The PN puts
him in a private room. After a couple of minutes the PN left the room, the PN hears the patient shouting, yelling, and hitting
continuously on the wall. What should the PN do?
a. Go to the room immediately to find out what is happening and call the security
b. Call the security immediately for back up then wait for the security before entering the room
c. Call the security immediately for back up immediately and wait inside the patient’s room.
Answer: B – the nurse’s safety is considered when dealing with violent patients.

31. Mr. Harris is a policeman for 35 years, diagnosed with depression for 3 years and had undergone knee surgery five days ago.
How would you know that the patient is improving?
a. He tells the nurse that he takes his medications regularly
b. He realizes that his knee pain is causing him insomia
c. He tells the nurse that he called his friends to visit him
d. He informs his nurse that his pain is subsiding even with ambulation
Answer: D – this is an indication that the patient is improving from his knee surgery. B and C both pertain to the patient’s
depression (not the reason why the patient was admitted).

32. A terminally ill patient wants to say goodbye to his dog. The policy in the unit does not allow any pet to visit to the unit. How
can the PN advocate for the client?
a. Apologize to the patient and tell the patient that nurse cannot change the policy
b. Suggest to the patient to go to the hospital administrator to obtain a permit to bring the dog
c. Ask the PN’s direct supervisor and advocate for the change of the policy
d. Tell the family to bring the dog in the evening when no one could see them.
Answer: C – this is way going through proper channel of command

33. Upon collecting information from an independent 85-year old female patient who wears a hearing aid, the PN notices that the
patient gives inappropriate answers to her questions. What should the PN do?
a. Increase the one of her voice to facilitate good communication
b. Talk slowly in a low-pitched voice while positioning in front of the patient
c. Stay at the side of the patient where the hearing aid is located and talk in a moderate tone
d. Ask permission from the patient to check and adjust the volume of the hearing aid.
Answer: B – hearing impaired best hear low pitch tone (like male’s voice) and usually read lips.

34. A 70- year- old female who had pneumonia is ready for discharge. She has a hearing impairment for many years. How are
you going to give her discharge instructions?
a. Speak slowly in a low-pitched tone
b. Give her writing discharge instructions
c. Speak to her in simple terms
Answer: A – hearing impaired best hear low pitch tone voice.

35. The PN is having a great difficulty distancing herself from the care of her client when she leaves work. What would be the
best nursing strategy for her to adopt?
a. Recognize herself that she is just too compassionate and caring
b. Request that the client be assigned to another nurse
c. Share her concerns with the client
d. Share her concerns with the trusted colleague
Answer: D – the colleague is a safe sounding board and should be able to provide you with sound advise.

36. The PN enters W’s room for the first time and says, “W., I’m E. I’ll help you get settled” W. responds, “I want another nurse.
I don’t like you. You’re mean.” Before responding to W. initial outburst, the PN should:
 a. Make sure she is on a safe distance from the patient
b. Move closer to the patient to show that she is not afraid
c. Assess her own feelings and responses to the patient’s behavior
d. Recognize that it takes time for relationships to develop and not feel hurt.
Answer: C – the PN’s attitude should not be of the “defensive side”.

37. Which of the following nursing assessments indicates that the client with depression is improving?
a. Reduced level of anxiety
b. Changes in neurovegetative signs
c. Compliance with medications
d. Requests to talk with the nurse
Answer: D – increased socialization is a sign that a depress patient is improving.

38. The patient’s mother is teaching her daughter to take a deep breath and scream during the first stage of labor. What is the best
nursing action to take in this situation?
a. Tell the mother that she is doing the right thing
b. Explain to the mother the proper techniques of deep breathing
c. Teach the daughter the proper techniques of deep breathing
d. Tell the mother that she is teaching the wrong deep breathing technique
Answer: B – the nurse should teach the mother the correct breathing techniques. In this manner the mother can properly teach her
daughter.

39. The patient told you that he has decided together with his family to discontinue chemotherapy. How should you respond to
the patient?
a. Would you like to speak to somebody about your decisions?
b. Do you know the consequences of your decisions?
c. Has the physician discussed with you the benefits of chemotherapy?
d. Tell me your reasons for making that decision
Answer: D – the benefits of chemotherapy should be emphasized.

40. Brian attended a smoking cessation program and asks the PN on how he can help his friend quit smoking. What is your
appropriate nursing response?
a. Let your friend choose his own time to try to quit and support his decision.
b. Let him know that you believe he can do it every time the topic of quitting is brought up
c. Find out what community resources is available to help smokers quit.
d. Give him the Nicotine gum for a start
Answer: A – the “readiness” of the friend is the most important item to consider.

41. A 13- year- old patient with a diagnosis of gonorrhea requests you not to tell her parents about her disease. She asks you who
needs to know her diagnosis. How will you respond?
a. Because of your age, I need to call your parents
b. I’ll respect your request for confidentiality
c. The public health team needs to know about your diagnosis
d. “Sorry but I have nothing to do with this”
Answer: C - To promote the safety of the public, including the sexual contacts of the patient, the public health team is informed.

42. A 26- year- old Chinese female client who doesn’t speak English comes to the prenatal clinic for check-up and counseling.
The PN communicates with the client through an interpreter. On the third visit, the PN realizes that a nurse-client relationship
has not been established yet. How would the PN manage the situation?
a. Revalidate with the interpreter the client’ s first impressions and expectations
b. Provide informative materials in the patient’s own language
c. Transfer the care to the client’s own culture in the community
d. Use gestures and non-verbal communication techniques in communicating with her.
Answer: A – this gives the PN the ability to evaluate the effectivity of the relationship through the set patient’s set
goals.

43. A 16- year- old female patient with a 55% burn was due for a dressing change. The patient’s mother asked the PN if she
could observe the dressing change. How should the PN respond?
a. Allow the mother to observe the dressing change
 b. Use this opportunity to teach the mother about burn prevention
c. Tell the mother that she must leave the room before the dressing is
Answer: A – the mother’s request is appropriate and must be granted.

47. A community daycare centre has an outbreak of Pertussis or “whooping cough”. You are the PN assigned in the community,
what would be your most prompt response?
a. Report to the public health authorities
b. Provide test to all the children affected
c. Advise to close the operations of the day care centre
d. Conduct screening tests for immunizations
Answer: A – the public health authorities have set guidelines regarding outbreak of highly communicable diseases.

48. A mother and her 15 year old daughter came to the clinic. The mother tells the PN that her daughter has severe cough and
has been smoking since she was 10 years old. How would the PN initially establish rapport with the daughter? The PN
will say to the daughter:
a. “I want for us to talk about your coughing and smoking”
b. “I can offer you programs on smoking cessation if you like”
c. “Your mother is worried about your cough and smoking”
d. “ I heard your cough. Tell me about it”
Answer: D – this response is therapeutic, and indicates concern on the part of the PN as well as not putting the patient to the defensive
on the smoking issue.

49. A 45- year -old female came to the clinic asking about Hormone Replacement Therapy (HRT) as she had not been having
menstrual periods for four months now. She is thinking that she may be pregnant. What is the PN’s best response?
a. Give the patient necessary information about HRT
b. Refer the patient to her physician
c. Tell the patient that is possible that she is pregnant but that you need more information
d. Check the patient if she’s pregnant.
Answer: B – the physician would be able to confirm if the patient is indeed pregnant and/or provide necessary information about
HRT.

50. A two-day-post hysterectomy patient was admitted to the unit. One hour after receiving Meperidine (Demerol)
50mg po, the patient is still complaining of pain and asks for another tablet. How should the PN respond?
a. “It takes time for the medicine to take effect”.
b. “ I can’t give you another tablet since you had it an hour ago”
c. “I’ll ask the doctor to increase the dosage of the medicine.”
d. “This is usually a symptom after surgery”.
Answer: C – the physician is responsible and as the authority to prescribe medication. The nurse has appropriately advocated for
the patient.

51. A post-operative female patient was given Meperidine (Demerol) 50 mg po. After one hour of giving the medication, the
patient’s son complained to the nurse saying that the patient is moaning and restless. How will you respond to the patient’s
son?
a. Tell the son that the effect of the medication has not been achieved yet.
b. Inform the doctor
c. Assess if the patient is still in pain; telling the son “I will assess her further”
Answer: C – pain assessment will be the appropriate action at this time. The result of the assessment will help the nurse to take further
action.

52. What immunization does a teenager (11-16 years of age) typically receives?
a. MMR: 12 months or 15 months
b. Hepatitis
c. Varicella
d. Tetanus and Diphtheria: 15 years of age
Answer: B – this is when this age group become sexually active, hepatitis (B vaccine) is appropriate.

53. A 24-year-old man was not wearing a helmet was caught in a bicycle accident. Later on, he feels drowsy and seems to forget
the names of his friends. Attending to this situation, what should the PN do?
a. Check for neurological reflexes and Glasgow coma scale
 b. Do a neurological assessment and call for an ambulance
c. Tell the man to wear a helmet next time
d. Advice the man to seek help from a psychiatrist.
Answer: B – performing assessment is important then call for help.

54. A husband and a wife visit the well baby clinic. The PN notices that the husband is the only one answering the
nurse’s questions. The wife is staring on the floor, doesn’t smile and puts her chin down. You suspect the wife
with:
a. Anxiety
b. Panic attack
c. Depression
Answer: C – these mother’s presentation are signs of possible depression. A – an anxious patient will be restless, agitated and
communicative. B – in panic attack, the mother will be highly anxious, restless, agitated, ect.

55. Barbara, the PN received the following patient report from the outgoing night shift: Mrs. Smith had a chest pain
and was given nitroglycerine, at 7:15 a.m. Mrs. Jack complained of pain and is asking for analgesics. Mrs. Hansen is for
immediate transfer to physiotherapy. How will Barbara handle the situation in priority?
a. Assess Mrs. Smith, give analgesic to Mrs. Jack and facilitate the transfer of Mrs. Hansen
b. Administer the analgesic to Mrs. Jack, assess Mrs. Smith and facilitate the transfer of Mrs. Hansen
c. Transfer Mrs. Hansen, assess Mrs. Smith and medicate Mrs. Jack.
Answer: A – chest pain should be the priority; pain medication comes next; while the transfer can wait.

56. A 17-year - old girl reported to the hospital for amenorrhea. What assessment question is most appropriate for the
patient to ask.
a. Are you on any medications?
b. Are you taking family planning pills?
c. Are you pregnant?
d. Are you on strict diet?
Answer: A – given the information about amenorrhea, the nurse can start with something that is general in nature. Some
medications can actually affect the menses. B – contraceptive pills regulate the menstrual cycle. C –also appropriate but may
exclude other possibilities.

57. An 89-year-old female vomited blood and was brought to the hospital. She is scheduled for a gastric resection.
Who is going to explain the procedure?
a. Nurse
b. Family physician
c. Anesthesiologist
d. Surgeon
Answer: D – the surgeon is doing the surgery and he/she is responsible for providing comprehensive explanation about the
surgical procedure.

58. An unconscious patient in your unit is about to receive an antibiotic therapy. However in obtaining from his
history, you found out that three years ago when he was still conscious and mentally competent, he made an advance
directive stating that he would not wish to have any antibiotic under any circumstance. What would you do?
a. Tell the doctor to prescribe the medication anyway as this is in the best interest of the patient
b. Remind the doctor about the client’s wishes of not wanting to take any antibiotics and call the next of kin
c. Call the next of kin to provide substitute consent for treatment.
d. Refuse to administer the medication even if it is ordered by the physician.
Answer: D – the patient has already made a decision.

59. A scholar wants to stop smoking. How do you assess his readiness to stop smoking?
a. He asks his mother to book him into a smoking cessation program
b. He books himself for a smoking cessation program held at school
c. He obtains information about existing smoking cessation program
d. His parents participate in the development of a family care plan.
Answer: B – this is a good sign of readiness to quit smoking – he took the initiative and exerted effort took control of what he
would like to do.
 60. Furosemide (Lasix) 20 mg is ordered for 0800 hours stat for a patient with CHF. At 1100 hours, you notice that on
the MAR sheet, that your colleague has not administered the drug. What will be your immediate action?
a. Call the physician, document the medication error and give the medication
b. Notify the charge nurse, call the physician, document the medication error and assess the client
c. Clarify the medication error with your colleague then administer it
d. Clarify the medication error with your colleague and document the incident
Answer: B – this is complete – all concern people were notified. The physician will decide if the medication or additional medications
are needed. The incident was also properly documented.

61. A female client is admitted to the emergency room for abdominal bleeding. She was also shaking and appeared
very nervous. While you were collecting information about the history, the client was quiet and silent. It was the
husband who was answering the questions in behalf of the client. What would be your nursing action to determine
if she was abused?
a. Ask the husband to leave during assessment and interview
b. Use a tool or a set of guidelines in assessing abused clients
c. Continue with your assessment with both the husband and wife present.
d. Call the police

62. The grandmother has brought an infant to the clinic for a check up and has signed the consent for immunization
administration. Which of the following would the PN do first?
a. Ask who is the infant’s legal guardian
b. Notify the physician immediately
c. Administer the immunization as ordered
d. Call the infant’s mother for verbal consent
Answer: A – the legal guardian has the right to provide the consent.

63. A male patient diagnosed with AIDS requested the PN not to tell his wife about his diagnosis. How would the PN respond?
a. “The medical team has an obligation to tell your wife about your diagnosis. It’s for her protection”.
b. ”I will respect your request of confidentiality”
c. “Let us discuss about this issue of disclosing your diagnosis to your wife”.
Answer: B – the patient has the right to “confidentiality”.

64. Which of the following makes the final decision in revoking a Registered PN’s license?
a. Canadian Nurses Association
b. Registered Nurses of Ontario
c. A nurse’s regulatory body such as the College of Nurses of Ontario
d. Ontario Nurses Association
Answer: C – the Board of Nursing has the jurisdiction to issue and revoke nursing license.

65. A PN has realized that she didn’t know how to initiate an IV line on a client whom she performed CPR previously.
What should she do in order to gain knowledge on this specific procedure?
a. Buy and read an IV therapy book
b. Ask the nursing supervisor if she could attend an IV therapy session offered in the hospital
c. Seek the help of the most senior nurse in the unit
d. Call the IV team to teach her how to start an IV line.
Answer: B – the IV therapy training will help the nurse to meet her educational needs.

66. A 14-year- old female client has been placed on a “suicide watch’ after ingesting 10 tablets of Valium. Which of the
following offers best protection for the client?
a. Ensure that no sharp instrument will be at the client’s immediate environment
b. One to one watch 24 hours every day
c. Ensure that doors and windows are properly locked
d. Promote a trusting relationship with the client
Answer: B – continuous watch is necessary to highly suicidal patients.

67. A young couple who takes care of their 76- year- old chronically-ill mother decides to take a vacation for two weeks.
 What should the PN suggest to the couple in dealing with this situation?
a. Respite care in a long-term care facility
b. Nursing home placement
c. Daycare center for seniors
d. Hospital stay for 2 weeks
Answer: A - a hospital stay, while the couples are away, ensures appropriate care needed by the patient.

68. A drunk and verbally aggressive patient arrived to the hospital accompanied by a police officer and has a deep
laceration on his forehead in which the cause of it is yet to be investigated. What is the best personal safety measure for the
PN to take while providing care for the wound?
a. Ask the police officer to restrain the patient while giving wound care
b. Ask the assistance of a colleague - colleague may be security
c. Allow the patient to calm down first by placing him in a quiet room before administering the wound treatment
d. Go ahead and do the procedure
Answer: B – a colleague’s assistance not only affords physical safety but also help for patient’s care.

69. The PN collects specimen from a raped client. The client asks the PN about the purpose of the specimen collection. What
would be the best nursing response?
a. This is a policy of the hospital
b. These are legal evidences to be submitted to the court if you decide to press charges
c. These are useful for the police as reliable sources of information
d. This is routinely done for every patient
Answer: B – legal evidence are required at court proceedings.

70. How would you promote safety of an elderly client with Alzheimer’s disease (early stage) in the house?
a. Lock all doors
b. Remove hazardous equipment/objects
c. Find a continuous 1:1 (24hour) care-giver
d. Keep room well lighted to reduce misperceptions
Answer: B – this promotes patient’s safety. A – patient does not have the wandering behavior at this stage; C- this is not necessary; D
– the patient does not have hallucination or illusion problem.

71. The PN found Tommy, a cafeteria worker giving a back massage to a patient in the unit. Which of the following nursing actions
is the most appropriate for the PN to take?
a. Inform the nurse in charge of the unit about the incident
b. Inform the supervisor of the cafeteria worker about the incident
c. Ask the cafeteria worker to get out of the room and tell him that what he was doing was unacceptable
d. Ignore the cafeteria worker
Answer: C – the PN should be able to professionally discuss this with the other employee.

72. A nurse has prepared the IV fluids with medications already and states that she is ready to go for her break. She asks you to hang
the IV with medications as she is running late for her scheduled break time. What should you do?
a. Hang the IV medication as requested by your colleague
b. Ask the nurse to do it herself
c. Leave the IV medication to be hung later
d. Ask her to hang the bag after her break time
Answer: B – the nurse should not administer drugs that she did not prepare.

73. How would you best communicate to a client with a post CVA expressive aphasia?
a. Use written communications and signs – discourages the patient from verbally communicating
b. Read the client’s lips when he talks
c. Use sign languages and gestures
d. Talk slowly and in a low tone, clear voice
Answer: D – slow speech is good so that the patient does not have to respond using long sentences.

74. A patient suddenly became ill. The nurse rushed over to him and observed that he was not responding. What should
the PN do?
a. Open the patient’s airway
b. Place the patient in the recovery position
 c. Do a thorough examination
d. Shout for help and continue to examine the patient
Answer: D – once unresponsiveness is established, help should be summoned.

75. What important information will the nurse give to mothers about newborn babies?
a. Place in prone position when asleep
b. Place in side-lying position when asleep
c. Place in supine position when asleep
Answer: C – this is the safest position for the newborn. A and B are implicated with SIDS.

76. Based on the nursing assessment, which behavior indicates that the patient is no longer depressed?
a. The patient is taking his anti-depressant medications as prescribed.
b. The patient was able to perform his activities of daily living.
c. He complains that he couldn’t sleep well at night due to the pain in his knee.
d. He maintains regular social contact with his friends.
Answer: D – improved socialization is a sign of improvement in a depressed patient.

77. Mr. SD, 66 y/o has AIDS and is hospitalized with pneumonia. He has just arrived on the respiratory unit. Should Mr. SD’s nurse
take special precautionary measures?
a. No, standard (universal) precautions are sufficient.
b. Yes, gown, mask and gloves should be worn at all times.
c. Yes, it is important to wear a mask because of pneumonia.
d. No, since the risk and transmission of this disease is limited.
Answer: C- pneumonia is transmitted through droplets.

78. Doreen, 75 y/o lost sight in her L eye as a result of poorly controlled glaucoma. What must the PN include in Doreen’s plan of
care?
a. Place the bedside table and personal effects close to Doreen
b. Approach Doreen from the R side as much as possible
c. Maintain subdued lighting on the R side of the room
d. Position Doreen on her L side
Answer: B – this is the patient’s good eye.

79. Ms. Branson, 65 years old, is post-operative client who suddenly develops hematemesis. She is pale, diaphoretic and says she
feels faint. The PN asks the student nurse to take Ms. Branson vitals sign when she calls the physician. On returning to the
client rooms, the student nurse reports that the vital signs have not changed since earlier in the shift. What should the PN do?
a. Places the client in trendelenburg position.
b. Instructs the student nurse to recheck the vital signs in 10 minutes.
c. Rechecks the vital signs.
d. Administers a bolus of 200 ml of normal saline.
Answer: C- to ensure accuracy, the RN needs to recheck the patient’s VS.

80. You’ll be teaching a patient’s wife how to suction his tracheostomy. When developing the teaching plan, you must,
a. assess the wife’s knowledge and skills.
b. set up a schedule to demonstrate the technique.
c. provide the wife with written materials about the procedure.
d. establish goals and learning objectives.
Answer: A = to develop an effective teaching plan, first assess the wife’s knowledge of the procedure and her ability to carry it out
properly. Setting up a schedule, providing written materials, and establishing goals and learning objectives can be done after you
assess the wife’s knowledge and skills.

81. Which of the following nursing assessments indicate that the health teaching on colostomy care was effective?
a. The patient states, ‘I was able to empty my colostomy bag once today.’
b. The patient states, ‘I will ask you to show me how I should put my colostomy bag.’
c. The patient states, ‘My mom can empty the colostomy bag for me.’
d. The patient states, ‘I am afraid that my boyfriend may leave me…
Answer: A – this is tangible evidence that the patient learned something.

82. A patient who sustained paraplegia stated, ‘I cannot feel when my bladder is full.’ The PN would anticipate that the patient
 will
a. be taught how to do self-catheterization.
b. have condom catheter.
c. be taught how to perform keagal exercise.
d. have his bladder massage.
Answer: A – due to loss of sensation and to prevent autonomic dysreflexia, self catheterization is a MUST to learn by the patient.

83. Ms. Mills receives Demerol and Atropine Sulfate pre-operatively. Which of the following should the nurse recognize as the
expected outcome of these medications?
a. The effectiveness of the anesthesia was increased.
b. There was no postoperative dehydration.
c. The tone of smooth muscle was improved, thus preventing hemorrhage.
d. The respiratory secretions were reduced during surgery.
Answer: A – this includes both drugs; D – this is only for Atropine.

84. A colleague’s license expired a week ago. She says she forgot to renew it. She is working with you on the evening shift. What
are you required to do?
a. Notify the registration organization.
b. Notify the nursing supervisor.
c. Notify the doctor.
d. Remind the nurse that she must get it done.
Answer: B - the license must be renewed.

85. A native Aboriginal teenager asked you where he could avail a place to stay after being devastated of knowing his positive HIV
results. He further told you, “You don’t understand the situation I am in right now.” What would be your best nursing response?
a. Make an arrangement to the nearest Friendship community center.
b. Refer him to a psychologist and a social worker.
c. Contact the community health center for an immediate follow up.
d. Inform the medical doctor for another consultation.
Answer: A – this is a safe place for those who do not have place to stay for the night.

86. An elderly male individual with COPD is living with his wife and his younger son in an apartment. Everyone of them is
smoking. As a community health nurse, how will you plan your health teaching to this family in preventing respiratory illnesses
and infection?
a. Ask the family what they do in preventing infection.
b. Encourage and offer them an annual flu vaccination.
c. Encourage the family to take multivitamins daily and to increase their daily fluid intake.
Answer: A – assessment is the first step.

87. What is your best health teaching to a group of IV drug users in fighting against AIDS?
a. Avoid exchanging and sharing needles.
b. Abstain from drugs.
c. Emphasize rehabilitation programs.
d. Provide reading materials on drug cessation.
Answer: A – the safest.

88. A conscious male individual is found on the scene of a car accident with a large laceration on his leg. You are the first person to
witness. What should you do?
a. call for help
b. open airway
c. immobilize leg
d. apply pressure
Answer: D – stop the bleeding should be the priority.

89. Provision of fluid hydration is one of your nursing goals for an Alzheimer’s patient in the nursing home. What is the best nursing
action to implement to improve his fluid intake?
a. Encourage him to take1,500 mls. of fluid in 24 hours
b. Assist and encourage him to increase his fluid intake
c. Let him take a large amount of fluids during the early part of the day.
 d. Start giving intravenous fluid.
Answer: B – assisting and encouraging are good ways of increasing the fluid intake of the patient with Alzheimer’s

90. A patient who has been on Elavil for 3 days complains of not feeling better. How should the PN respond?
a. Suggest to the patient to report it to the doctor.
b. Suggest to the patient to stop taking the medication.
c. Encourage the patient to continue taking the medication.
d. Record the patient’s response to the medication.
Answer: C – it takes few weeks for the drug to work.

91. How will you promote sensory stimulation to an unconscious female child?
a. Give the child her favorite toy.
b. Ask her mother to help you with the care.
c. Give medications as ordered.
d. Talk to her while giving care.
Answer: D – hearing usually remains intact in the unconscious patient.

92. A patient is complaining to the PN that he didn’t have enough sleep last night because his roommate was too noisy. What
would the best nursing action to this?
a. Draw the curtain that divides the two patients.
b. Transfer the patient to a quiet room once available.
c. Inform the doctor about the patient’s concerns.
d. Inform the doctor for some medication to help relieve the patient’s insomnia.
Answer: B- this addresses the patient who has the problem

93. Roy tells his nurse that he has multiple sexual partners and usually does not use condom. He tells his PN that he will die soon.
What is the PN’s best response?
a. “Would you like to talk to someone who works the same with your case?”
b. “Where there is a problem, there is a solution.”
c. “You have a long way to go, Roy.”
d. “Not everyone who has HIV-positive develops AIDS and die.”
Answer: A - this is the most therapeutic response. The other responses are giving false reassurance.

94. Rogers who had a stroke is going to be discharged soon and is going to have some rehabilitation after discharge. The wife of
the patient has been complaining that she couldn’t handle taking care of her husband anymore. Which among the following
statements made by the wife signifies that she may be able handle the care for her husband? (question was changed)
a. “I have been working in a rehabilitation institution for 20 years now.”
b. “My son is a carpenter and he said he is going to help me with his father.”
c. “My sister will come every Thursday to help me out and I can go out to buy groceries.”
Answer: C – this is a concrete plan that the wife can live by.

95. In conducting a seminar for a group of people with ages10-14, which of the following will you include in your health teachings
about safety?
a. proper wearing of helmet when riding bicycles
b. proper wearing of seatbelt
c. Keeping all poisonous substance away from the house
d. proper wearing of hiking gears
Answer: A – biking, roller blading, ect are activities that are more enjoyable in this age group.

96. While the other nurse is on her break, you were asked by one of her patients to change the IV bag as it was almost finished.
What should you do?
a. Change the bag according to doctor’s orders.
b. Remind the patient to use a call bell next time.
c. Wait for the other nurse to come back from her break and then let the other nurse change the bag.
Answer: A - it is the nurse’s responsibility to provide the needed care for the patient. It is prudent to always check the doctor’s order
prior to administering the care (in this case, the IV fluid)

97. Mrs. Kent has recently finished her chemotherapy for breast cancer. She is anxious to return to work as an accountant in the
bank. She expressed that she is depressed and that her therapist thinks it is premature for her to return to work. Which of the
 following is the most appropriate action for the PN to take?
a. Encourage Mrs. Kent to attend the upcoming support group.
b. Facilitate ways to get her involved in community activities.
c. Call the therapist to come and observe her perform some of her duties.
d. Ask Mrs. Kent to consult another therapist.
Answer: A – networking with the support group will help her not only with her depression but as well as with other aspect of her
emotional problems related to cancer.

98. You are admitting a 58-year-old female client to your unit with a history of COPD. She was brought in by family members. How
will you establish a therapeutic nurse-client relationship?
a. “Hi, my name is Carol, a registered nurse. I will be your nurse for the shift.”
b. “Hello, I am the registered nurse in the unit. Let me know if you have any problems.”
c. “Hi, just ring the bell whenever you feel like to.”
d. “Hi, my name is Carol. I will be your nurse for the shift.”
Answer: A – this is the most professional way of introducing self to the patient.

99. Mrs. Brown is about to receive her Humulin NPH and Humulin R in the morning. What is your responsibility before giving the
drug?
a. shake both vials
b. check last night’s glucometer result
c. check the expiration date on each vial
d. tell the patient about her glucometer result
Answer: C - an expired drug should not be used anymore; A – shaking (agitating) the vials of insulin may result to loss of potency; B
– insulin dosages is based on the latest blood sugar; D – informing the patient about her blood sugar level is good but this is not a
prerequisite prior to administering the drug

100. A patient with AIDS is discharge on palliative care. However, he doesn’t have any family member to care for him at home. What
is the most appropriate care setting for this patient?
a. respite care
b. rehabilitation center
c. hospice
d. nursing home
Answer: C – hospice ensures comfort to a dying patient; A – respite care is for clients who needed assistance with their ADLs; B
-rehab center is for those who needed rehabilitation; D – nursing home is for patients who sick but not too sick to be taken to the
hospital

101. Debbie died of cancer of the sigmoid colon. When you entered the patient’s room you saw the husband lying beside the patient
who died just 15 minutes ago. As a nurse, what is your best nursing action?
a. Leave them alone.
b. Tell the husband that he is not allowed to lie beside her.
c. Tell the husband to go out of the room.
d. Stay in the room and offer comfort to the husband.
Answer: A – the husband should be allowed to go through the grieving process

102. The patient has been receiving 2500 ml of IV fluid and 300 to 400 ml of oral intake daily for 2 days.
The patient’s urine output has been decreasing and now has been less than 40 ml per hour for the past 3
hours. The PN should immediately:
a. Catheterize the patient to empty the bladder.
b. Assess breath sounds and obtain the patient’s vital signs.
c. Check for dependent edema and continue to monitor I/O.
d. Decrease the IV flow rate and increase oral fluids to compensate.
Answer: B – the imbalance in intake and output, with a decreasing urinary output, may indicate renal failure
with an increase of body fluid and the incipient development of congestive heart failure; assessing breath
sounds and vital signs are the first steps when

103. Hyponatremia is defined as decreased sodium level. Which of the following reflects possible
 hyponatremia?
a. Vomiting
b. Hypertension
c. Sodium level of 146 mEq/L
d. Loss of weight
Answer: A – vomiting causes decreased sodium, potassium, HCL, calcium, ect

104. The nurse is caring for a client with uncontrolled hypertension. Which findings require immediate
nursing action?
a. lower extremity pitting edema
b. rales
c. jugular vein distension
d. weakness in left arm
Answer: D - In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral
infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining 3 choices
indicate mild fluid overload and are not medical emergencies.

105. An elderly lady has a maintenance of Inderal (beta blockers), the nurse must be aware that the medication has to be given too
which of the following critical assessment?
a. Client has no headache.
b. No verbalization of dizziness.
c. Client has a blurring vision.
d. BP 128/80.

106. A client undergoes procedure that requires the use of general anesthesia. During the postoperative period, the client is most at
risk for:
a. Atelectasis --
b. Anemia
c. Dehydration
d. Peripheral edema

107. While suctioning a client’s tracheostomy tube, the patient HR was noted to go down from 100 to 58. What should the nurse do?
a. Continue suctioning to remove the mucus
b. Stop suctioning and provide oxygen --
c. Turn the client to the left side
d. Administer a precordial thump

108. A pregnant mother, on her first trimester, develops urinary tract infection (UTI). What would be the appropriate health teaching
to prevent UTI in the future?
a. Increase fluid intake --
b. Drink cranberry juice
c. Limit fluid intake
d. Frequent perineal washing

109. Which of the following statement indicates that the patient requires further teaching?
a. “I will ask my friend to put sugar in my cheek when I get hypoglycemic” -
b. “I will put peanut butter and sugar in my sandwich when I get hypoglycemic”
c. “I will drink a lot of orange juice when I started feeling dizzy”
d. “I will bring hard candies with me all the time”

110. A 5-year-old was admitted with asthma attack. Her grandmother is at the bedside. Oxygen 4 to 6 L/min was ordered along with
nebulizers. Following treatments, the nurse noted that the wheezing sound has already disappeared and the child is now fast
asleep. What would you tell the grandmother who called your attention?
a. Tell the grandmother that the child is a lot better now --
b. Tell the grandmother that you are anticipating transfer to ICU
c. Tell the grandmother that you will stop the oxygen therapy
 d. Tell the grandmother that you need to re-assess and monitor the child more frequently

111. A multi gravida client at 24 weeks gestation tells the nurse that she has been experiencing
backache. The client explains that she’s a secretary and is seated most of the day at work. Which of the
following exercises should the nurse recommend for relieving back ache?
a. Pelvic rock –this decreases backache
b. Keagel exercise
c. Squatting exercises
d. Abdominal crunches

112. Health teachings given to the mother, on foods rich in folic acid to prevent complication
on the growing fetus, is under:
a. Health promotion
b. Primary
c. Secondary
d. Tertiary
Answer: A – health promotion is aimed at decreasing possible health problem

113. Screening for high blood cholesterol in the community is under:

a. Health promotion
b. Primary
c. Secondary --
d. Tertiary
Answer: C - treating a disease is secondary

114. The nurse who is performing venipuncture, Guthrie test, on a newborn to assess for PKU
is under:
a. Health promotion.
b. Primary prevention
c. Secondary prevention
d. Tertiary prevention
Answer: This is screening – secondary prevention. The purpose of screening is to confirm the problem and treat.

115. An employer has established a physical exercise area in the workplace and encourages all
employees to use it. This is an example of what level of health promotion?
a. Primary prevention – is the level of health promotion that prevents the occurrence of a disease
b. Secondary prevention
c. Tertiary prevention
d. Passive prevention

116. A nurse is teaching high school students about human immunodeficiency virus (HIV)
transmission. Which comment by the student requires clarification by the nurse?
a. “A man should wear a latex condom during intimate sexual contact”
b. “I’ve heard about people who’ve developed HIV after receiving blood transfusion”
c. “I won’t donate blood because I don’t want to get HIV” – blood and all blood products are now well-
screened for HIV virus prior to transfusion
d. “IV drugs users can get HIV from sharing needles”

117. A 6-year-old has AIDS. The nurse should emphasize that the parents not allow their child
to come in contact with:
 a. A school age child who has scoliosis
b. A 16-year-old who has just received a tetanus booster
c. A neonate who just received oral polio vaccine – this virus in the vaccine may cause infection to a
immunosuppressed patient
d. A toddler who has eczema

118. An 89-year-old client is suffering from Alzheimer’s. Which intervention would be most
useful in managing his dementia?
a. Provide a safe environment –optimum safety is essential to patient’s with mental problem
(Alzheimer’s)
b. Provide a stimulating environment
c. Avoid the use of touch
d. Use restraints whenever necessary

119. The nurse is providing prenatal instructions to a client with diabetes mellitus. Which
instruction will best meet the needs of the client during her pregnancy?
a. Restrict weight gain to 5 lb each trimester
b. Continue taking her Tolbutamide (Orinase) daily – this will affect the fetus
c. Restrict fluid intake to 34 oz per day
d. Attend all schedule prenatal visits – this is recommended

120. A mother brought her infant to the well baby clinic for immunization. After giving the
vaccine, the baby stopped breathing. What would be the most important nursing action?
a. Initiate CPR
b. Palpate the child’s carotid artery and start CPR
c. Cover the infant’s nose and mouth with nurse’s mouth when giving mouth-to-mouth
d. Call the doctor immediately for help – calling for help is the first step when someone is confirmed to
be unresponsive

121. A 15-year-old student approached the school nurse for pregnancy test. What would be an
appropriate nursing action?
a. Perform pregnancy test and refer the client to the physician
b. Gather information about her recent sexual contact and LMP – assessment is essential prior to
submitting to the patient’s request
c. Teach her about the different birth control methods and safe sex practices
d. Discuss the risks of unprotected sexual practices

122. Ten days following vaginal delivery, the community health nurse notes that the patient
statement correlates to a normal finding when the patient says:
a. “I have bright red vaginal discharge”
b. “I have small amount of pinkish, foul-smelly vaginal discharge”
c. “I have frequent urination”
d. “I have moderate amount of whitish vaginal discharge”—10 days post delivery
lochia alba is normal

123. A 22-year-old male patient who had undergone above the knee amputation is for
discharge to home. The patient’s mother called the unit and said that her son is going to
live with her for quite sometime following discharge and wanted to find out other needs
her son might have. What would be the best nursing response?
 a. “Tell her to call her son and speak to him about his needs” – the nurse cannot disclose information without
the patient’s consent
b. “I will tell your son to call you”
c. “What do you think your son needs for his rehabilitation”
d. “What did your son tell you about the plan”

Case Study

The nurse is conducting a pre natal class for pregnant adolescence at an urban secondary school. The group consists of
10 students who occasionally bring their partners with them.

124. Which of the following strategies would be most effective when teaching this group?
a. Invite some of their teachers to share their own birthing experiences
b. Present well organized lectures
c. Recommend a book on childbirth and early parenting
d. Include activities that encourage the sharing of personal experiences
Answer: D – sharing personal experiences is one of the most empowering tool to participants

125. Participants in the prenatal class ask about sexual intercourse after childbirth. The nurse
will base her response on which of the following information?
a. Sexual intercourse should not happen until lochia has stopped and the perineum has healed – this is the
safest
b. It is necessary to wait until after the “6-week postpartum examination”
c. Sexual intercourse may commence anytime provided that penetration is not deep
d. Couples may have intercourse after the woman has had her first menstrual period

Case Study

Mrs. G, 70 years old, was admitted to the hospital with a diagnosis of reactivation of pulmonary tuberculosis. After one
week of medication therapy, she is discharged home. Daily visits by the home care nurse are scheduled on the first week.

126. Which of the following questions should the nurse ask during the initial assessment
interview?
a. “Have you asked your family and friends not to visit” – he is allowed to receive visitors as long as precautionary
measures are implemented
b. “Are you taking your medication as prescribed?” – TB drugs must be taken religiously
c. “How much weights have you gained in the past year?”
d. “Did you have a Mantoux test with your first episode of tuberculosis?”

127. Mrs. G is taking Isonized (Isotamine) and Rifampin (Rifadin) daily. Which of the
following suggestions should the nurse make to Mrs. G to help her adhere to the
medication regimen?
a. “Continue to take the medications depending on how you are feeling”
b. “Increase fat in your diet while taking your medications”
c. “If the medications are upsetting your stomach, you can take them with food” – TB drugs must be taken
religiously
d. “Ask your physician which medication is the most important to take”

128. What finding should indicate to the nurse that Mrs. G’s medication regimen is effective?
a. Unproductive cough
b. Her urine changes to orange color
c. Consecutive sputum cultures are negative – at least 3 negative AFB
d. Her appetite has increased
129. The nurse is now visiting Mrs. G twice weekly. She tells the nurse that she stopped taking
her medications. What should the nurse do?
a. Emphasize the importance of completing the medication regime to avoid hospital readmission – TB drugs must
be taken as prescribed
b. Suggest that the family physician visit Mrs. G and assess her condition
c. Ask Mrs. G if she is feeling any better
d. Ask Mrs. G if she is feeling worse

130. Robinson, 40 years old, has chronic pain. What should the patient expect from an
effective analgesic treatment regimen?
a. Pain control is sufficient to continue normal activities –many chronic pains have no cure
b. Variable pain control and difficulty scheduling daily activities
c. Good pain control but possible confinement to home due to sedation
d. Complete freedom from pain if compliant with regimen

131. An 81-year-old man who is receiving palliative care is visited by the nurse. The client
states, “My doctor doesn’t know anything, there’s nothing wrong with me. Look I’m
stronger today and I’m going to be fine in a month or so.” What is an appropriate nursing
action?
a. Listen as he expresses denial – this is an appropriate way of dealing with denial
b. Tell him that he may be right
c. Observe him for signs of anger
d. Suggest that he talk to his doctor

132. Following a fall accident from a bicycle, Mr. Mark, 24 years old, presents at the
occupational health clinic with headache, blurred vision, nausea, and vomiting. He was
not wearing a helmet and does not remember exactly what happened. What should the
nurse do first?
a. Position him in semi fowler’s and administer an anti emetic
b. Assess his neurological reflexes and complete a Glasgow Coma Scale
c. Allow him to rest and provide him with a brochure on helmet use
d. Assess his neurological status and arrange for an ambulance to transport him to the hospital–initial assessment is
appropriate and help me be sought

133. Mrs. B, 29 years old, is in rehabilitation following a car accident that left her paraplegic.
She requires passive exercises in the lower extremities and strengthening exercises for her
upper extremities. The PN who provides care for Mrs. B refuses these duties and explains
that they are the physiotherapist’s responsibility. What should the nurse in charge do?
a. Explain to the PN that physiotherapy is not the only service responsible for the client’s rehabilitation
b. Remind the nurse that range of motion exercises are a part of basic nursing care –promotion of patient’s
mobility is a nursing responsibility
c. It is indeed the physiotherapist’s responsibility
d. Suggest to the nurse that she reread the practice standards for registered nurses

134. A community health nurse is giving a teaching session to a group of retired women. Part
of other presentation covers the safe use of medications. Which one of the following
statements best reflects an aspect of polypharmacy?
a. Always take as few medications as possible
b. There are possible interactions between prescribed and over-the-counter medications –medications may
potentiate or counteract each other
c. Some medications should be avoided if a person has high blood pressure
d. Always consult your physician before taking over-the-counter medications

135. Mrs. Collins, a 50-year-old woman, is newly diagnosed with diabetes. The PN at the
 Community Clinic has helped her prepare a plan of care to manage her disease and
promote her overall health. How can the PN best facilitate Mrs. Collins’ participation
in this plan of care?
a. Encourage her to organize her responsibilities so that she will have more time to focus on her health needs
b. Introduce her to other people in the community who have diabetes so she can learn from them
c. Encourage her to set realistic goals and meet regularly to reconsider her changing priorities – goals
promote good sense of direction
d. Encourage her to prepare a separate meal for herself when eating with her family to make her diet therapy easier

136. The daughter of diabetic mother has difficulty in measuring blood glucose level of her
mother with glucometer strip. What should the nurse do?
a. Teach and demonstrate to her how to monitor blood glucose
b. Assess her knowledge about diabetes mellitus
c. Let her demonstrate how to use glucometer test strips – this option partly address the issue
d. Show her and let her demonstrate how to monitor blood glucose – this addresses the issue of “difficulty
measuring the blood glucose”. It is more specific than option C

137. A community health nurse visited a 54-year-old woman with a history of 5 days
pacemaker placement. Which of the following environmental factor would be a concern to
the patient?
a. The patient lives in a two-storey building
b. A small throw rag in noted on the floor
c. A microwave oven in the kitchen –this will interfere with the pacemaker function
d. A poisonous plant in the house

138. Mrs. Lowe, 35 years old, divorced, mother of 3 children, was admitted 5 days ago with a
diagnosis of major depression. She also has a history of suicide attempt. She was placed
on Prozac, an antidepressant. Today, she was noted to have improved appetite and took
her morning shower. Which nursing diagnosis formulated for this patient is appropriate?
a. Risk for self-directed violence and possible suicide attempt – the depress patient is more suicidal when energy
is regained
b. Knowledge deficit related to anti depressant therapy
c. Chronic low self-esteem related to recurrent depression
d. Anxiety related to disruption in role performance

139. During his annual physical examination, a 60-year-old client, informs the PN that he
takes care of his wife who has Alzheimer’s disease. He appears tired and said, “She
doesn’t sleep at all and just wanders around in the house.” Which responses made by the
PN is appropriate?
a. “A daily exercise routine will be good for her”
b. “Perhaps she needs to be placed in a long term facility” - the husband is tired from taking care of his wife and
services in the long term facility will be of helped
c. “Check with her physician perhaps she needed extra sedation at night”
d. “Just make sure all doors and windows are locked”

140. The nurse is providing feeding instructions to a postnatal client. The client states, “At least
I don’t have to worry about getting pregnant while I am breastfeeding”. Which response
made by the PN is appropriate?
a. “To ensure contraception, you should resume taking birth control pills before leaving the hospital if you’re
breastfeeding”
b. “Although you may not have normal menstrual period while you breastfeed, breastfeeding is not an effective
contraceptive”—the mother will still get pregnant even if breastfeeding; the follicle stimulating hormone
returns within 6 to 10 weeks of delivery
 c. Breastfeeding prevents ovulation and provide contraception as long as you continue breastfeeding at least once a
day”
d. “Breastfeeding is effective in preventing pregnancy as long as you experience no menses”

141. Mr. Boone develops wound infection. The physician prescribes Gentamycin Sulfate
(Garamycin) 80 mg every 8 hours. The Gentamycin is mixed in 50 ml of D 5W and it is to
be given over 30 minutes. The drop factor of the infusion set is 15 drops equal 1 ml. The
PN should regulate the Gentamycin infusion at:
a. 12 gtts/min
b. 25 gtts/min 50 ml X 15 gtt/ml/ 30 minutes = 25
c. 50 gtts/min
d. 100 gtts/min

142. First-line treatment for any shock state is the administration of

a. isotonic fluid – promotes expansion of the intravascular compartment
b. hypertonic fluid
c. packed RBC
d. hypotonic fluid

143. The physician orders KCL to be incorporated to the patient’s IV fluids. Which of the following method is the safest
prior to administering IV with KCL?
a. Ask another nurse to check the IV with KCL. – potassium can lead to cardiac arrest
b. Regulate the IV regularly.
c. Use an IV pump.
d. Calculate the accurate amount to be administered per hour.

144. Normal Saline solution is infusing at a rate of 62 gtt/min in a patient who has had
a craniotomy for brain tumor. The drip factor is 60 gtt/ml. How much fluid will
infuse in 4 hours?
a. 194 ml
b. 240 ml
c. 248 ml – 62 gtt/min 60 gtt/ml = 1.0333 X 60 min = 62 ml/min X 4 hours = 248
d. 275 ml

145. A patient is to receive a fluid challenge due to hypovolemic shock. He needs 500 of NS
solution over 2 hours. What is the infusion rate?
a. 150 ml/hour
b. 175 ml/hour
c. 250 ml/hour = 500 ml/2 = 250 ml
d. 500 ml/hour

146. At 6:00 AM, a patient receives a preoperative infusion of 1000 ml of D 5 in ½ NS

at 125 ml/hour, followed by 1000 ml of D5W at 100 ml/hour. What is the total
infusion time?
a. 10 hours
b. 12 hours
c. 18 hours = 1000 ml/125 ml/hour = 8 hours; 1000 ml/100 ml/hour = 10 hours thus, 8 + 10 = 18 hours
d. 24 hours

147. A post partum patient is dehydrated and requires 0.5 L of D 5W infusing at 50 ml/hour.
If the solution was hung at 1:00 PM, what time will the infusion be completed?
a. 1:00 PM
b. 6:00 PM
c. 9:00 PM
 d. 11:00 PM = 500 ml/50 ml = 10 hours

148. The PN has prepared an IV fluid with medication. She asks another nurse to hang the
IV on a certain patient for she was already running late for her scheduled lunch break.
Which one is an appropriate nursing action?
a. The nurse who prepares should hang the IV fluid – this a professional
guideline
a. The IV with medication should be hanged at a later time.
b. Another nurse can hang the IV fluid.
c. The nurse can hang the IV when she returns from break.

149. A client is receiving an IV infusion of dextrose 5% in water and lactated Ringers solution
at 125ml/hr to treat a fluid volume deficit. Which of these signs indicate a need for
additional IV fluids? 
a. Serum Sodium level of 135meq/L
b. Dry mucous membranes – this is more appropriate sign of dehydration
c. Jugular vein distention
d. Dark amber coloured urine- the urine in dehydration is highly diluted; dark amber
urine could mean liver problems such as in hepatitis; a higher specific gravity will
rather indicate dehydration

150. When performing an assessment the nurse identifies the following S&S: impaired
coordination, decrease muscle strength, limited range of motions and client's reluctance
to move. Which of the following nursing diagnosis do these S & S indicate? 
a. Health-seeking behaviour (can you provide an example of this please) – this is more like
people who are insecured and need attention, thus the person behaves in such a way
that others will notice him/her
b. Impaired physical mobility – the symptoms indicate this problem
c. Disturbed sensory perception
d. Deficient knowledge

151. A staff PN in an intensive care unit has difficulty taking directions from her supervisor
regarding a client assignment change. What strategy would a nurse-manager use to best
help an employee who has difficulty communicating verbally with authority figures? 
a. Encourage the employee to develop alternative communication strategies – improved
communication strategy will certainly help the employee
b. Refer the employee for counseling – this is usually indicate to employees who have
problems other than communication
c. Disregard the deficiency because many employees have trouble talking with authority
figures
d. Ignore the deficiency to make the employee feel less self-conscious.

152. The mother of a child who has been recently diagnosed as having hemophilia, is pregnant
with her 2nd child and asks the nurse what chances are that this baby will also have
hemophilia. The PN’s best response would be:
a. “There is no chance that the baby will be affected.”
b. “There is a 25% chance the baby will be affected.”
c. “There is a 75% chance the baby will be affected.”
d. “There is a 50% chance the baby will be affected.”
Answer: B – before the sex of the unborn child is known, the odds are 25%; 50% of pregnancies will result in boys and
each has a 50% chance of having hemophilia.

153. In addition to the relief of pain, the PN should direct the care for a patient with sickle
cell crisis toward:
 a. Antibiotics and narcotic regulation.
b. Oxygenation and adequate hydration.
c. Hydration and physiologic counseling.
d. Oxygenation and Factor VIII replacement.
Answer: B – during sickle cell crisis, the RBCs are sickled and clumped and the hemoglobin is ineffective in providing
oxygen; therefore fluids to liquefy the clumping cells and additional oxygen are necessary.

154. During a health history on the 4-month-old child of a migrant worker, the PN learns
that the child recently had a fever, runny nose, cough, and white spots in the mouth for 3
days. The child then developed a rash that started on the face and spread to the whole
body. The PN should suspect that the child had:
a. Rubella
b. Rubeola – white (koplik) spots and rash are signs of measles (Rubeola)
c. Varicella
d. Scarlet fever

155. When teaching a mother about communicable diseases, the PN informs her that
chickenpox is:
a. Still communicable until all the vesicles have dried. – when all vesicles have
dried, chickenpox is no longer transmissible; dried vesicles do not harbor the
varicella virus
b. Still communicable even when just dried scabs remain.
c. No longer communicable after a high fever has subsided.
d. Not communicable as long as the vesicles are intact and surrounded by a red areola.

156. After giving a bed bath to a 2 ½ year-old child in Bryant traction for a fractured femur,
the PN should be sure that the child’s hip angle is maintained at:
a. 45 degrees
b. 60 degrees
c. 90 degrees
d. 180 degrees
Answer: C - the legs must be kept perpendicular to the trunk in order for the child’s body eight to serve as

countertraction.

157. During newborn assessment a positive Ortolani sign would be indicated by:
a. A unilateral droop of the hip.
b. A broadening of the perineum.
c. An apparent shortening of one leg.
d. An audible click on hip manipulation.
Answer: D – with specific manipulation, an audible click may be heard or felt as the femoral head slips into the
acetabulum.

158. A 28-year-old male with history of diabetes has been found wandering around in a
confused pattern. The male is sweaty and pale. Which of the following tests will be most
likely tperformed first?
a. Blood sugar
b. CT scan
c. Blood culture
d. ABG

159. The PN has just started her rounds delivering medication. A new patient on her rounds is
a 4-year-old boy who is non-verbal. This child does not have on any ID. What should the
PN do?
 a. Contact the provider
b. Ask the child to write his name on the paper.
c. Ask the co-worker about the ID of the child.
d. Ask the father who is in the room about the name of the child.—the father can
confirm the patient’s ID

160. You are taking the history of a 14-year-old girl who has a BMI of 18. The girl reports of
inability to eat, induced vomiting and severe constipation. Which of the following would
you most likely suspect?
a. Multiple sclerosis
b. Anorexia nervosa – starve self
c. Bulimia – purge or induce vomiting
d. Systemic sclerosis

161. In the Long Term Facility, a 50-year-old blind and deaf patient has been admitted to your
unit. As the charge nurse, your primary responsibility for this patient is?
a. Let other know about the patient’s deficits.
b. Communicate with your supervisor your patient safety concerns.
c. Continuously update the patient on the social environment.
d. Provide a secure environment for the patient.

162. A patient is getting discharged from a long term facility. The patient has a history of
severe COPD and PVD. The patient is primarily concerned about his ability to breathe
easily. Which of the following would be the best instruction for this patient?
a. Deep breathing techniques to increase O2 levels. 
b. Cough regularly and deeply to clear airway passages.- COPD patients have
problems with thick, tenacious secretions sticking in the airways
c. Cough following bronchodilator utilization.

163. A patient asks a PN, “My doctor recommended I increase my intake of folic acid. What
type of foods contain the highest concentration of folic acids?
a. Green vegetables and liver. – these are rich in folic acid
b. Yellow vegetables and red meat.
c. Carrots
d. Milk

164. A PN is administering blood to a patient who has a low hemoglobin count. The patient
asks how long the RBC last in the body? The correct response is:
a. The life span of RBC is 45 days.
b. The life span of RBC is 60 days.
c. The life span of RBC is 90 days.
d. The life span of RBC is 120 days.--

165. A 65-year-old man has been admitted to the hospital for spinal stenosis surgery. When
does the discharge training and planning begin for this patient?
a. Following surgery.
b. Upon admit. - – discharge teaching and planning occurs at the earliest possible
time of the patient’s hospitalization
c. Within 48 hours.
d. Preoperative discussion.

166. After receiving report for the 3pm-11p.m. shift, which client should the PN care for
first?
a. A woman with Crohn's disease who is ordered a potassium infusion for a K + level
 of 2.7mEq. – hypokalemia can precipitate cardiac arrest
b. A woman with cystic fibrosis who is scheduled to receive chest physiotherapy.
c. A man with sepsis who needs to have a gentamycin trough level drawn for the 4pm
dose.
d. A man with a bleeding ulcer and is receiving a platelet infusion for a platelet level of
148,000.

167. A diabetic patient with Type 1 Diabetes tells you on your rounds that she has been
drinking water all morning, and that she still feels thirsty and request more water. The
most appropriate nursing intervention in this situation would be:
a. Provide the patient with the water she requested
b. Tell the patient not to drink anymore water, but offer ice chips to ally the thirst
c. Obtain a fingerstick for serum glucose – polydispsia is a sign of high blood glucose
d. Notify M.D. and place patient on strict I/O

168. You are assigned to teach a Patient Care Technician to care for the patients with
Tuberculosis. Which of the following actions by the Care Technician indicate the need
for further teaching?
a. Wash her hands before and after caring each patients
b. Assist patient with activities, avoiding fatigue and or excessive exertion on the part of the patient
c. Wear a mask after client has been on anti-tubercular medications for two to three weeks with negative
sputum – after two weeks of religiously taking anti-TB drugs, the patient is rendered “no longer infectious”
d. Assist patient with menu, and or discusses food likes and dislikes with patient to maintain adequate nutritional
status

169. A woman who is 1 day post partum tells the PN she doesn’t have any milk yet. The
PN instruct her to:
a. Supplement with formula until the let down reflex occurs
b. Continue breastfeeding – this stimulate milk production
c. Place icepacks on the chest
d. Discontinue breastfeeding and choose a commercially prepared formula

170. A breastfeeding mother has begun to complain that her nipples have become sore. The
would instruct her to:
a. Discontinue breastfeeding until they improve
b. Put olive oil on her nipples
c. Utilize different positions for the baby during feeding – wrong positions of the baby during feeding cause
sore nipple
d. Pump the breast and give the baby the expressed milk

171. A woman delivered a set of twins two hours ago via C-section and is now in the
recovery room. The following fundal assessment findings would be expected:
a. Fundus at umbilicus hard and midline – this is the level of the fundus
b. Fundus 1-2 finger breaths above umbilicus, hard and midline
c. Fundus 1-2 finger breaths below umbilicus, hard and midline
d. Fundus would not be assessed because of the C-section

172. A client has an ulcer in the sacral area. The PN has been treating it with an antibiotic.
Which of the following indicated the effectiveness of therapy?
a. The area appears reddened
b. The area is bleeding
c. The wound edges is irregular
d. The drainage was decreased – this is an indication that the antibiotic therapy is effective
173. Joe, 69-year-old client, is on IV therapy. The PN assigned to him has noticed that he
receives 300 ml of fluids in an hour. The most appropriate initial action by the PN
would be to
a. Check the client`s apical pulse and determine if it went lower than his normal pulse
b. Maintain the client in a supine position
c. Administer oxygen
d. Place the client in an upright position
Answer: D – upright position causes the fluids to gravitate to the lower portion that makes breathing easier.

174. The following are signs and symptoms of blood transfusion reaction:
a. Pain at the intravenous site, rashes all over the body, palpitations
b. Dysphagia, diplopia, hematuria
c. Hypertension, back pain, confusion
d. Flank pain, hypotension, fever
Answer: D – flank pain is a sign of kidney damage; while hypotension is caused by profound vasodilation in transfusion
reaction; fever is due to reaction from the pyrogens.

175. The PN who is assigned to the patient receiving blood transfusion is aware that one of
the following is essential:
a. Expect the use a blood warmer during blood transfusion.
b. Expect the blood, one unit, to be transfused in 4 to 5 hours.
c. Closely monitor the child for possible blood transfusion reaction during the first few minutes of blood
transfusion.
d. Monitor the child’s vital signs every 30 minutes.
Answer: C – transfusion reaction usually occurs during the first few minutes of blood transfusion

176. Due to prolonged bedrest, Mrs. Cox is very prone to skin breakdown. Which of the
following nursing action will promote the patient’s skin integrity?
a. Massage the patient’s bony prominences with cream.
b. Apply liberal amount of talcum powder and alcohol to the patient’s dry skin.
c. Turn the patient every 2 hours and avoid wrinkles on the bedsheets.
d. Wash the patient’s skin daily with soap and warm water and keep it dry at all times.
Answer: C – skin breakdown is caused by pressure from staying in one position and wrinkles from bedsheets

177. Which of the following assessment accurately determine fluid loss in a 78-year- old
male patient with dehydration?
a. Urine specific gravity is lesser than normal.
b. Dry mucus membrane and delayed capillary refill.
c. Loose skin and poor skin turgor.
d. Pull the skin around the chest and weigh daily.
Answer: D – assessment of skin turgor is more accurate in the chest and forehead of an elderly patient; weight is the best
way of quantifying fluid loss or gain.

178. A 50-year-old woman is admitted for hip repair and splenectomy following a motor
vehicle accident. Three hours post-op her LOC is decreased. VS are BP 82/56; HR 120;
RR 28; skin cool and clammy; no c/o SOB; lungs sounds clear; u/o 20 ml/hour; T
36.5°C; WBCs 9000. Based on this information, what condition appears to be
developing?
a. LV failure
b. Neurogenic shock
c. Septic shock
d. Hypovolemic shock
Answer: D – the most probable cause is hypovolemic shock.

179. The patient had a successful surgery few hours ago. He came back to your unit from the
Recovery Room (RR). He was confused and complaining of pain. When the PN checked
the MAR there was no record that the patient was given pain medication in the RR.
Which of the following action taken by the PN is most appropriate?
a. Call the RR and speak with the nurse who took care of the patient – the PN can verify with the
nurse in the RR if the patient has received pain medication in the RR
b. Go to the RR and speak with the PN who took care of the patient – this is not necessary
c. Check the doctor’s order and medicate the patient as ordered – verification of the pain medication is
necessary for the safety of the patient
d. Monitor the vital signs and ask the patient – although vital signs need to be monitored, it is important to
verify pain medication first

180. Few minutes following the administration of the preop medication, the patient
was taken to the operating room. The nurse in the operating room has found out
that the patient does not have signed consent for his surgery. What should the
PN do?
a. The surgeon should obtain the consent – the surgeon who performs the surgery is responsible
for obtaining the consent
b. Wake the patient up and obtain consent – it is not appropriate to obtain consent on the patient who is
under the influence of drugs
c. Call the patient’s parents and obtain a consent – this is the surgeon’s prerogative
d. Cancel the surgery – this is not the PN’s responsibility

181. In about 30 minutes, the patient will be transported to the operating room for his surgery. There
was about 25 cc left in the patient’s IV bag and the IV tubing is due for change. What is an
appropriate nursing action?
a. Change the IV tubing and hang a new IV bag before the patient goes to the operating room --
b. Ask the nurse in the operating room to change the IV tubing and hang a new IV bag when the
fluids in the IV bag is finished
c. Only prepare the patient for surgery
d. Change the IV bag but do not change the IV tubing

182. A woman is admitted to the hospital due to her large intake of medication. On discharge session,
her husband verbalizes fear of taking her back home for she might repeat the incidence. The PN,
being the patient advocate, will ask the husband one of the following:
a. “Are you considering the possibility of taking her to a long term facility?”
b. “Would you like to have a home care nurse who can visit her and provide assistance?”--
c. “How would you like a social worker that can assist you for long care placement?”
d. “Let us discuss the possibility of asking your relative to help and provide you relief with your wife’s care”

183. An adolescent with the developmental age of a four – year - old requires placement of a chest
tube. The best way to prepare the patient for this procedure is to
a. use short simple sentences and limit descriptions to concrete explanations
b. show the patient a chest tube and explain how it will feel
c. explain in detail why a chest tube is needed and how it work
d. tell the parents what will be done so they explain it to the child

184. Of the following combination of symptoms the most indicative of increased intracranial pressure
is:
 a. Weak rapid pulse, normal blood pressure, intermittent fever, lethargy.
b. Rapid weak pulse, fall in blood pressure, low temperature, restlessness.
c. Slow bounding pulse, rising blood pressure, elevated temperature, stupor.
d. Slow bounding pulse, fall in blood pressure, temperature below 97°F, stupor.
Answer: C –increased intracranial pressure places tension on the brain stem, causing signs such as increased systolic blood pressure,
slow bounding pulse, elevated temperature, and changes in the respiratory pattern.

185. Dexamethasone may be administered to a patient after a stroke to:

a. Improve renal blood flow.
b. Maintain circulatory volume.
c. Reduce intracranial pressure.
d. Prevent the development of thrombi.
Answer: C – As an inflammatory agent, dexamethasone helps prevent cerebral edema, which generally peaks between day 3 and day
5 after a cerebral aneurysm.

186. A patient who suffered burns 48 hours ago is entering the second phase of burn injury. What
Physiological change can you expect?
a. Edema development
b. Diuresis
c. Decrease in hemoglobin level
d. Increase WBC
Answer: B – the second phase of burn is known as remobilization phase, starts at about 48 hours after initial injury. During this phase,
fluid shifts back to the vascular compartment. Edema at the burn site decreases and blood flow to kidneys increases, which increases
urine output.

187. During labor the patient is sometimes catheterized to empty her bladder. The rationale for this is:
a. To prevent urinary stasis.
b. To encourage fetal descent.
c. Minimize discomfort.
d. Prevent the patient from having to get up and void.
Answer: B—a full bladder delays the progress (descent) of labor.

188. The mother brought her toddler for immunization. Before administering the drug, which
important question should be asked by the nurse to the mother?
a. History of allergy
b. Any reactions to the vaccine.
c. Last immunization.
d. Preferred site of immunization.
Answer: A – MMR is given at 12 to 15 months. Allergic reaction to eggs must be assessed.

189. A patient is admitted to the hospital with the diagnosis of autoimmune compromise syndrome,
has an order of Prednisone, tablet 5 mg PO BID. She is on strict isolation room and visitor has to
be monitored. What is your nursing action in giving the medication?
a. Give the medication at 0800 with food then 2000 with milk.
b. Check the ID band of the client—the patient is by himself in the room.
c. Document at MAR sheet—this is not specific to prednisone; all drugs are signed out in the
MAR.
d. Ask the client name—there’s only one patient in the room.

190. The physician orders non weight bearing with crutches for a patient with a leg injury. The nurse
understands that before ambulation is begun, the most important activity to facilitate walking with crutches is
a. Sitting up in a chair to help strengthen back muscles.
b. Keeping the unaffected leg in extension and abduction.
c. Exercising the triceps, finger flexors, and elbow extensors.
d. Using the trapeze frequently to strengthen the biceps muscles.
Answer: D- these sets of muscles will be used in crutch walking.

191. On the third day post partum day, a mother asks why her newborn’s skin has begun to appear
yellow. The PN should plan to teach her that the change in skin tone is a result of:
 e. Breast milk ingestion.
f. Inadequate fluid intake.
g. Breakdown of red blood cells.
h. An immature vascular system.
Answer: C- physiologic jaundice is caused by elevated bilirubin level resulting from breakdown of excessive fetal red blood cells; this
occurs on the second to third day of life.

192. A 13-year-old with asthma is readmitted just a week after discharge from the hospital. On
questioning, the PN learns that the patient refuses to use the inhalers at school. The PN
should:
a. talk to the teen about long term consequences of the disease if the treatment plan is not followed
b. talk to the school nurse to find out why they are not monitoring the meds at school
c. arrange for the teen to attend an asthma support group
d. help the parents set up a disciplinary contract with the teen

193. A client is admitted with fatigue, anorexia, weight loss, and inability to sleep that started a month
after the death of his spouse. Which nursing priority is essential to consider in the nursing care
plan?
a. Restricts the patient’s physical mobility
b. The patient should be moved to a room closer to the nursing station --
c. The patient should be referred to the dietician for diet consult
d. The patient needs assistance with physical activities

194. Which intervention has the highest priority when a nurse is caring for a client receiving a blood
transfusion?
a. Instruct the client to notify the nurse if itching, headache, or dyspnea occur --
b. Inform the client that the transfusion usually takes 1 ½ to 2 hours
c. Document the blood administration in the client care record
d. Assess the client’s vital signs when the transfusion is completed

195. A 75-year-old client is two days postoperative after a hip replacement. When administering
injections IM to an older client, the PN should remember that an older client has:
a. Less subcutaneous tissue and muscle mass than a younger client --
b. More subcutaneous tissue and muscle mass than a younger client
c. Less subcutaneous tissue and more muscle mass than a younger client
d. More subcutaneous tissue and less muscle mass than a younger client

196. A 40-year-old client who’s receiving chemotherapy for breast cancer develops nausea and
vomiting. For this client, the PN should give the highest priority to which action in the care
plan?
a. Serve small portions of bland food --
b. Encourage rhythmic breathing exercises
c. Administers Reglan and Decadron as prescribed
d. Withhold fluids for the first 4 to 6 hours after chemotherapy administration

197. What is the meaning of universal health care?

a. Health for all people covered 100% if qualified --
b. All are covered in each province if the person was to move
c. Portability of health care
d. Every Province has the same type of health services

198. The patient with ulcerative colitis is for discharge to home. She lives by herself. Based on nursing
assessment, the patient is not capable of taking care of herself. Which action taken by the PN is
best for this patient?
a. Connect the patient to self help group
b. Connect the patient to ulcerative colitis society
c. Refer the patient to the community services --
d. Call family members for support
199. Following mastectomy, with hemovac still in place, the patient is about to be discharged. Which
discharged teachings given by the PN is appropriate?
a. Teach how the hemovac works including some precautionary measures --
b. Instruct her to use gloves when emptying the hemovac
c. Tell her where she obtain some supplies
d. Teach her the proper way of caring for the hemovac

200. A patient with placenta previa was advised to have C-section delivery. The patient and her
husband are both anxious about the surgery. What is the best nursing action?
a. Provide privacy and explore for any possible concern
b. Explain the procedure to them
c. Tell them that the procedure is very simple
d. Call the doctor to give more information about the surgery –

201. A fat lady was admitted with a diagnosis of pneumonia. When collecting information, which
strategy taken by the PN will avoid the patient from getting upset about her weight?
a. “I will weigh you first”
b. “I will take your vital signs and weigh you after”
c. “I will perform physical assessment then weigh you” --
d. “I don’t need to take your weight right now”

202. Following above the knee amputation, Peter is for discharge to home. He informs the PN that
he is going to live with his children. What should the PN teach the patient and his children?
a. Teach them how to care for the stump --
b. Encourage them to use all rehabilitation techniques
c. Teach him how to walk
d. Teach them the importance of using the prosthesis

203. A 2 - month-old baby has a fever. The physician ordered 40 mgs Tylenol and the PN has given
120 mg instead. What should the PN do?
a. Inform the nursing supervisor
b. Give ipecac syrup
c. Inform the nurse in charge --
d. Write an incident report

134. A 9-month-old baby died in the ER from baby shaken syndrome. What would be the expected
autopsy report confirming the diagnosis?
a. The child has cerebral hemorrhage --
b. The child’s brain has blood clots and petechiae
c. The child’s brain has shifted or herniated
d. The child has undetected decreased level of consciousness

135. A patient with manic behavior becomes sarcastic, cursing and using foul language. Some of the
patients who hear her were threatened. The PN should:
a. Firmly tell the patient that her behavior is unacceptable.
b. Request that the behavior should stop.
c. Explore with the patient factors that may precipitate the behavior.
d. Call the doctor and request for an increase dose of the patient’s anti-manic drug.
Answer: A – setting limit to unacceptable behavior is therapeutic.