RPN Integrated Practice Test Sept 2010 (A)

1. Of the four clients listed below, which responsibility should the nurse direct the
technician to carry out first?
a. 89 year old with COPD resting quietly on 2 liters of o2 needs morning vitals with
02 sat
b. 77 year old with gastrointestinal bleeding needs bedside commode emptied
c. 55 year old diabetic with fasting blood sugar of 75, at 80% of breakfast and needs
morning snack
d. 49 year old with rheumatoid arthritis needs splints reapplied to both hands.
Answer: B. 77 year old with gastrointestinal bleeding needs bedside commode emptied.
The nurse will check this first so the aide should carry this out first.

2. The RPN is assigned to care for a client who had a total right hip two days ago.
Which observation should the RPN report immediately to the nurse?
a. incisional paid rated on 6 on a scale of 0-10
b. reddened incision line with a temperature of 99.6° F
c. pain and redness in the left lower leg
d. the client is not tolerating 20lbs of weight bearing on the right leg
Answer: C - pain and redness in the left lower leg. This could be a sign of infection or
DVT.

3. The registered nurse is planning the client assignments. Which assignment is an

appropriate assignment for the nursing assistant?
a. assist a 12 year old boy with Down’s syndrome, who is profoundly,
developmentally disabled, to eat lunch
b. obtain a temperature of a 29 year old woman receiving the final 30 minutes of a
whole blood transfusion
c. complete initial vital signs on a 51 year old man who has just returned from
surgery and PACU for a bowel transfusion
d. complete a sterile dressing change on a 70 year old woman admitted for skin graft
Answer: B - obtain a temperature of a 29 year old woman receiving the final 30 minutes
of a whole blood transfusion.

4. Which task would be the least appropriate to delegate to a nursing assistant?

a. feed 10 month old a bottle who has crackles bilaterally, harsh, productive cough
and in room air
b. help 10 year old with cystic fibrosis, diminished breath sounds int he RLL up to
the bathroom
c. obtain vital signs of a 9 year old who was admitted yesterday for an acute asthma
exacerbation
d. obtain the respiratory rate of a 6 week old infant who was admitted two hours ago
with a respiratory rate of 64
Answer: D - obtain the respiratory rate of a 6 week old infant who was admitted two
hours ago with a respiratory rate of 64. While the assistant can technically count
respirations per minute, the infant's initial respiratory rate of 64 indicates a need for
further respiratory assessment that only the RN can perform.

5. In a busy medical unit, how would the RPN appropriately delegate the task among the
4 PSW?
a. Assign the same patients to keep continuity of care
b. Divide patients equally among the 4 PSWs
c. Ask the PSWs which patients they want to be assigned today
d. Ask the charge nurse to do the assignment

6. You are working in a busy surgical unit. When you look at your assignment, you
have 6 post-op patients in your assignment. What will you do?
a. This is too much for you. Notify the nurse in charge – LEGAL ISSUE
b. Know how to prioritize your work and attend to the patients who has the most
needs
c. File an incident report
d. Complaints to the nursing supervisor

7. You are assigned to a patient who is on PCA for his post op pain. You’d noticed that
the patient received 10 mgs more than the ordered dosage due to malfunctioning PCA
pump. What will you do?
a. Assess and observe the patient’s respiratory status
b. Notify the physician – 1st step in medication error
c. Record your observation in the progress notes
d. Inform your colleague

8. Marilyn is a young 24-year-old female patient who came in with a diagnosis of

hypothyroidism. She was placed on medication. When evaluating the patient’s
response to medication, which one is an indication that the medication is effective?
a. The patient’s weight remains the same
b. The patient has gained weight
c. The patient has very dry skin
d. The patient complains of feeling cold

9. You discontinued your patient’s IV and you noticed that the site is bleeding. What
will do?
a. Apply cold compress – Cold causes constriction, will minimize bleeding
b. Apply warm compress
c. Inform the physician
d. Asses the patient’s vital signs

10. You are working in a long term facility. One of the patients wander around and
unable to find her room. One time you noticed that she was sitting beside her bed.
What will do first?
a. Put her in her bed – Your patient is just sitting beside her beside
b. Ask her where she is
 c. Ask her to state her name
d. Ignore her
The statement, “One of the patients wander around and unable to find her room” is
just a distractor. The question is asking, “One time you noticed that she was sitting
beside her bed. What will do first?”

11. Two days following delivery of a normal infant, the mother noted a small, red spot on
her newborn and asked the nurse, “What is this?” What would be an appropriate
response?
a. This could be normal among newborn
b. This is caput succedaneum
c. Your baby is bleeding. Let me inform the physician
d. This is cephalohematoma

12. The mother delivers a 6.8 lb baby vaginally. While cuddling the infant, the mother
asks the nurse, “What do you mean by macro or micro when describing the size of
babies?” What would be an appropriate response?
a. Macro means small; micro means big
b. Macro mean big; micro means small
c. Those words have nothing to do with size of babies
d. These are medical terminologies that cannot be applied in children

13. In a certain facility, the medical unit has adopted therapeutic touch as adjunct to
nursing care. When performing this treatment regimen, the RPN is aware that
therapeutic touch consists of 4 sequences. Which one is correct?
a. Sweeping of hands starts from center of the body to the periphery
b. Sweeping of hands starts from head down
c. Sweeping of hands starts from leg up
d. Sweeping of hands in no particular order
Answer: B - to facilitate symmetrical flow of energy through the patient’s energy field,
by sweeping the hands above the patient’s body downward

14. The patient was admitted with anorexia nervosa. When evaluating the patient’s
progress on nutritional status, the RPN will appropriately perform which of the
following?
a. Weigh the patient
b. Ask the patient how much food she is eating
c. Check the patient’s skin turgor
d. Monitor the patient’s I/O’s
Answer: A

15. Post gastrectomy, the RPN was giving health teaching on diet. Which of the
following health teaching given by the RPN prevents or minimizes dumping
syndrome post gastrectomy?
a. High CHO diet with additional fluids while eating
 b. High protein diet with fluids in between meals – This is the diet… protein
travels slow.. no fluids during meals, make your patient drink fluids after
meals (in this case, “in between meals.” The question is asking about diet
c. Lie down right after meals
d. High fiber diet with fluids between meals

16. A patient in the pediatric unit was admitted with Cystic Fibrosis. When giving
information on diet to the patient’s mother, the RPN has correctly stated that:
a. The appropriate diet for the patient with cystic fibrosis is large of amount fluids
with Vit ADEK
b. The appropriate diet should for the patient with cystic fibrosis should be
high in protein with large amount of fluids
c. The appropriate diet for the patient with cystic fibrosis is high in fat and with Vit
ADEK
d. The appropriate diet for the patient with cystic fibrosis is high in fat soluble
vitamins

17. When administering iron injection on the patient who came in with anemia requires
Z-tract technique to prevent irritation of tissue. Which technique uses by the RPN is
correct?
a. Use large muscle; displace the skin and subcutaneous tissue 1-1.5 inches (2.5-
3.75 cm), laterally; release the tissue immediately after the injection
b. Use large muscles, displace the tissue laterally and release as soon as the needle is
inserted
c. Administer the medication using a 90° when injecting the medication
d. Rub the site vigorously after removing the needle
Answer: A - Z-track injection is a method of injecting medication into a large muscle
using a needle and syringe. This method seals the medication deeply within the muscle
and allows no exit path back into the subcutaneous tissue and skin. This is accomplished
by displacing the skin and subcutaneous tissue 1-1.5 inches (2.5-3.75 cm), laterally, prior
to injection and releasing the tissue immediately after the injection.

18. You are working in a long term facility. One of your patients has dementia and has
frequent falls at night. How would you promote safety on this patient?
a. Leave the night light on; lower the bed so the patient can get out of bed
easily
b. Leave the night light on; attach the call bell on the patient’s gown so she can
readily call for help
c. Leave the night light on; raise the side rails so the patient cannot get out of bed
d. Leave the night light on; apply hand restraints and tied them on the side rails

19. Marie is a 16 year-old young female patient who was admitted with abdominal pain.
Blood test and abdominal ultrasound were ordered to confirm the diagnosis. When
doing physical assessment, the RPN has correctly assessed the abdomen by which of
the following?
a. Auscultate the abdomen and monitor the vital signs
 b. Percuss then auscultate the abdomen
c. Auscultate then palpate the tender area
d. Press the tender area and ask the patient if the pain intensifies while pressure is
applied

20. When performing neurological assessment on the patient, you observe that the
normal pupil reaction to light would be:
a. One eye constrict with light and one eye dilates when light is out
b. Both eyes constrict then dilate when light is applied
c. Both eyes constrict with light
d. One eye dilates with light and constrict when light is off

21. Pepe is a 6 year old boy who was admitted with sickle cell crisis. He was started on
IV fluids running at 85 ml/hour; warm compresses applied on painful extremities and
Morphine Sulphate at 5 mg IM every 4 to 6 hours were ordered. In light of the
Morphine order, what would be an appropriate nursing action?
a. Administer as ordered
b. Clarify the order with the physician
c. Inform the nurse – in-charge, the dosage is too much for the child
d. Do not give the medication

22. A 4-year-old girl was admitted in your unit. She came in with Leukemia. The
physician ordered Tylenol 500 mg for pain and fever. The child has a fever of 102.2°
C. Prior to administering the Tylenol, what would be an appropriate nursing action?
a. Verify the physician’s order, the dose is too large for the child
b. Administer the dose, the child has fever
c. Ask your colleague to check the Tylenol prior to administering it to the child
d. Perform tepid sponge bath prior to administering the Tylenol

23. How would the RPN transfer the patient with back injury from bed to the stretcher?
a. Ask the patient to use the overhead trapeze
b. Use the trochanter roll
c. Use the bottom sheet when transferring the patient
d. Raise the head of the bed and put the patient in sitting position then transfer

24. In the unit participates on pilot study on turning the patient with the use of draw
sheet. You’ve noticed that one of your colleagues does not follow the guideline stated
in the study. What will you do?
a. Report the colleague to the nurse spearheading the pilot study
b. Suggest that your colleague use an alternative method
c. Speak to your colleague and find out the reason of not following the guideline
d. Report your colleague to the nursing supervisor

25. Mr. SS is in your unit. He has a diagnosis of ALL. His WBC dropped to 0.5 mm3.
Due to severely decreased WBC count, Mr. SS was placed on reverse isolation. As
you transport Mr. SS to the Radiology Department for CXR, which one will you do?
 a. You wear mask when transporting Mr. SS for CXR
b. You put mask on Mr. SS when transporting for CXR
c. You put on extra gown to Mr. SS when transporting for CXR
d. You put on a clean gown when transporting Mr. SS for CXR

26. Mr. SS, with diagnosis of ALL, has bone marrow depression from chemotherapy.
When shaving, which one is appropriate?
a. Provide a razor blade
b. Provide an electric shaver – prevents unnecessary cuts on skin
c. Instruct him to shave opposite hair growth
d. Put shaving cream prior to shaving

27. Mr. D is in your unit. He had a diagnosis of diabetes type I. When doing foot care
which one is appropriate?
a. Soak his feet in warm water for 20 minutes
b. Soak his feet in warm water for 30 minutes
c. Wash his feet with soap and water then dry them using soft towel
d. Refuse to provide foot care as you are not familiar with this procedure

28. Anna Marie is a lovely 5-month-old infant who is going for brain operation. She was
assigned to you, however, you are not familiar with her pre-op care. What will you
do?
a. Inform the physician about your competency level
b. Perform some pre-op care that you are familiar with
c. Call her parents for some additional input that helps you with pre-op preparation
d. Inform the charge nurse about your competency level

29. Anthony is on Morphine ATC for his chronic pain. When you assess his vital signs,
you noticed that his RR was only 8 bpm. Which action taken is appropriate?
a. Report your finding to the physician
b. Monitor his RR
c. Monitor his HR
d. Document your finding

30. Which of the following assessment findings on the patient with DM needs to be
reported?
a. Nails are hard to touch
b. Nails with extra growth
c. Some nails are hanging out of toes
d. Redness on skin around the nails

31. Mr. CC is a 56-year-old patient admitted in your unit with a diagnosis of acute heart
failure. He is receiving IV fluids and Lasix. The nurse from the night shift has
reported that the patient’s urine output during the last 24 hours was only 250 cc. What
will be an appropriate nursing action?
a. Palpate his bladder first to find out if he had distention
 b. Palpate his stomach for abdominal distention
c. Notify the physician
d. Confirm if the output was correctly measured

32. Mr. Lovely was admitted with pneumonia. He is apprehensive, diaphoretic and with
open wounds with small bleeding on his open wounds in his arms, thighs and legs.
When providing care for Mr. Lovely, what precautionary measures will you
implement?
a. Ask the charge nurse to put him in a private room and implement contact
isolation - has open wounds so you need gloves too
b. Ask the charge nurse to put him in a private room and implement the use of
HEPA MASK
c. Ask the charge nurse to put him in a private room and implement reverse isolation
d. Ask the charge nurse to put him in a private room and implement respiratory
isolation

33. Post op, when the patient was trying to ambulate to the wash room, her abdominal
incision gaped open. What will be an appropriate nursing intervention?
a. Insert a wet sterile dressing inside the open operative site
b. Cover the surgical site with wet sterile gauze
c. Tell the patient not to worry and ask him to finish his toileting then usher him to
bed
d. Get a wet towel and cover the open site

34. A client had a Caesarean delivery and is postpartum day 1. She asks for pain
medication when the nurse enters the room to do her shift assessment. The client
states that her pain level is an 8 on a scale of 1 to 10. What should be the nurse's
priority of care?
a. Give the pain medication and return in an hour for further assessment to allow
time for the medication to work.
b. Complete the postpartum assessment and then give the client pain medication.
c. Give the pain medication first, do a quick assessment while administering the
medication to ensure the pain is not caused by a complication, and return
for the full assessment after the client's pain has subsided.
d. Instruct the patient to do relaxation exercises to relieve her discomfort.
Answer: C - Pain management is a priority, so the nurse should immediately bring pain
medication. However, the nurse should do a quick assessment while administering the
medication to ensure that a complication, such a hemorrhage, hasn't caused the increased
pain. A complete assessment can wait until the pain subsides. Control of pain will enable
the client to move, eliminating other potential complications of delivery. Bonding with
the infant will be facilitated as well if the client is without discomfort. Relaxation
techniques can act as an adjunct therapy but by themselves are not usually useful for pain
management during the early post-Caesarean period.

35. The nurse is caring for a client diagnosed with end-stage liver disease. The client has
completed an advance directive and a do-not-resuscitate (DNR) document and wishes
 to receive palliative care. Which of the following would correspond to the client's
wish for comfort care?
a. Positioning frequently to prevent skin breakdown and providing pain management
and other comfort measures.
b. Carrying out vigorous resuscitation efforts if the client were to stop breathing, but
no resuscitation if the heart stops beating.
c. Providing intravenous fluids when the client becomes dehydrated.
d. Providing total parenteral nutrition (TPN) if the client is not able to eat.
Answer: A - Palliative care includes measures to prevent skin breakdown, pain
management, management of other symptoms that cause discomfort, and encouraging
contact with family and friends. A DNR request precludes all resuscitative efforts related
to respiratory or cardiac arrest. Dehydration is a normal part of the dying process, so
intravenous fluids are inappropriate. Total parenteral nutrition (TPN) is an invasive
procedure meant to prolong life and is not part of palliative care.

36. The nurse is preparing to administer an I.M. injection in a client with a spinal cord
injury that has resulted in paraplegia. Which of the following muscles is best site for
the injection in this case?
a. Deltoid.
b. Dorsal gluteal.
c. Vastus lateralis.
d. Ventral gluteal.
Answer: A - I.M. injections should be given in the deltoid muscle in the client with a
spinal cord injury. Paraplegia involves paralysis and lack of sensation in the lower trunk
and lower extremities. Clients with spinal cord injuries exhibit reduced use of and
consequently reduced blood flow to muscles in the buttocks (dorsal gluteal and ventral
gluteal) and legs (vastus lateralis). Decreased blood flow results in impaired drug
absorption and increases the risk of local irritation and trauma, which could result in
ulceration of the tissue.

37. The nurse is caring for a client with heart failure. Which of the following statements
by the client suggests that the client has left-sided heart failure?
a. "I sleep on three pillows each night."
b. "My feet are bigger than normal."
c. "My pants don't fit around my waist."
d. "I have to get up three times during the night to urinate."
Answer: A - Orthopnea is a classic sign of left-sided heart failure. The client often sleeps
on several pillows at night to help facilitate breathing because of pulmonary edema.
Peripheral edema is indicative or right-sided failure. Ascites is a late symptom of right-
sided heart failure and can increase girth. Nocturia is common with right-sided failure as
peripheral edema decreases when the feet are not dependent, increasing urinary output.

38. The nurse is teaching a client newly diagnosed with type 1 diabetes how to self-
administer subcutaneous insulin injections. How does the nurse best evaluate the
effectiveness of her teaching?
a. Have the client repeat the steps back to the nurse.
 b. Give the client a written test on self-administration of insulin.
c. Ask the client to write out the steps for self-administration of insulin injections.
d. Ask the client to give a return demonstration of self-administration of insulin.
Answer: D - Asking the client to give a return demonstration of his injection technique is
the best way to assess whether the client can perform the procedure. It also gives the
nurse the opportunity to provide feedback. Asking the client to recite the steps, pass a
written test, or write out the steps shows the nurse whether the client is able to recall the
steps but doesn't show that he has the necessary motor skills or the ability to perform the
procedure.

39. A nurse is caring for a client returning from an x-ray. The nursing assistant is helping
transfer the client back to bed. Which transfer technique by the nurse uses appropriate
ergonomic principles?
a. Lowering the bed for transfer and then raising the bed before leaving the room,
making sure to place the call light is within reach.
b. Maintaining a narrow base of support during transfer and encouraging the client
to hold onto her if afraid during transfer.
c. Raising the bed for transfer, maintaining a wide base of support during transfer,
and lowering the bed before leaving the room.
d. Explaining the procedure to the client and grabbing the client underneath the arms
to pull her over to the bed.
Answer: C - Raising the bed during transfer and maintaining a wide base of support
reduces the risk of back injury, and the bed should always be left in the low position to
reduce danger from falls. Transferring the patient with the bed in low position strains the
lower back. The client should not grab or hold onto staff members during transfers as this
can interfere with the transfer and cause the nurse injury. The nurse should not grab the
client under the arms, as this can cause the client shoulder injury or nerve damage. In
addition, pulling a client during transfers places the client at risk for skin shear injuries.

40. The nurse is caring for a client with cirrhosis of the liver. The client has developed
ascites and requires a paracentesis. Which of the following symptoms is associated
with ascites and should be relieved by the paracentesis?
a. Pruritus.
b. Dyspnea.
c. Jaundice.
d. Peripheral neuropathy.
Answer: B -Ascites (fluid buildup in the abdomen) puts pressure on the diaphragm,
resulting in difficulty breathing and dyspnea. Paracentesis (surgical puncture of the
abdominal cavity to aspirate fluid) is done to remove fluid from the abdominal cavity and
thus reduce pressure on the diaphragm in order to relieve the dyspnea. Pruritus, jaundice,
and peripheral neuropathy are signs of cirrhosis that aren't relieved or treated by
paracentesis.

41. A client underwent a colostomy for a ruptured diverticulum. He did well throughout
the surgery and returned to the medical-surgical floor in stable condition. The nurse
 assesses the client's colostomy stoma 2 days after surgery. Which assessment finding
should the nurse report immediately to the physician?
a. Blanched stoma.
b. Edematous stoma.
c. Reddish-pink stoma.
d. Brownish-black stoma.
Answer: D -A brownish-black stoma indicates a lack of blood flow to the stoma, and
necrosis is likely. Two days postoperatively, the stoma should still be edematous and
reddish-pink in color. A blanched or pale stoma indicates possible decreased blood flow
and should be assessed regularly. Stomas should be assessed for color, size,
characteristics (mucosa should be moist), shape, and protrusion (should be slightly above
skin level).

42. A 37-year-old forklift operator presents with shakiness, sweating, anxiety, and
palpitations and tells the nurse he has type 1 diabetes mellitus. Which of the follow
actions should the nurse do first?
a. Inject 1 mg of glucagon subcutaneously.
b. Administer 50 mL of 50% glucose I.V.
c. Give 4 to 6 oz (118 to 177 mL) of orange juice.
d. Give the client four to six glucose tablets.
Answer: C - Because the client is awake and complaining of symptoms, the nurse should
first give him 15 grams of carbohydrate to treat hypoglycemia. This could be 4 to 6 oz of
fruit juice, five to six hard candies such as Lifesavers, or 1 tablespoon of sugar. When a
client has worsening symptoms of hypoglycemia or is unconscious, treatment includes 1
mg of glucagon subcutaneously or intramuscularly, or 50 mL of 50% glucose I.V. The
nurse may also give two to three glucose tablets for a hypoglycemic reaction.

43. A client with cirrhosis of the liver develops ascites. Which of the following orders
would the nurse expect?
a. Restrict fluid to 1000 mL per day.
b. Ambulate 100 ft. three times per day.
c. High-sodium diet.
d. Maalox 30 ml P.O. BID.
Answer: A -Fluid restriction is a primary treatment for ascites. Restricting fluids
decreases the amount of fluid present in the body, thereby decreasing the fluid that
accumulates in the peritoneal space. A high sodium diet would increase fluid retention.
Physical activities are usually restricted until ascites is relieved. Loop diuretics (such as
furosemide) are usually ordered, and Maalox® (a bismuth subsalicylate) may interfere
with the action of the diuretics.

44. A client who underwent abdominal surgery now has a gaping open incision due to
delayed wound healing. The nurse must irrigate the wound with a piston syringe and
sterile normal saline and provide wound care. Which of the following procedures is
correct?
a. Rapidly instill a stream of irrigating solution into the wound to flush out debris.
b. Apply a wet-to-dry dressing to the wound after the irrigation.
 c. Moisten the area around the wound with normal saline solution after the
irrigation.
d. Irrigate slowly and continuously until the solution becomes clear or all of the
solution is used.
Answer: D - To wash away tissue debris and drainage effectively, the nurse should
slowly irrigate the wound until the solution becomes clear or all the solution is used.
Irrigating solution should always be instilled slowly and gently, as rapid or forceful
instillation can damage tissues. After the irrigation, the area around the wound should be
dried, as moistening it promotes microorganism growth and skin irritation. When the area
is dry, sterile dressing rather than a wet-to-dry dressing should be applied.

45. The nurse is doing teaching with the family of a client with liver failure. Which of the
following foods should the nurse advise them to limit in the client's diet?
a. Meats and beans.
b. Butter and gravies.
c. Potatoes and pasta.
d. Cakes and pastries.
Answer: A - Meats and beans are high-protein foods and are restricted with liver failure.
In liver failure, the liver is unable to metabolize protein adequately, causing protein by-
products to build up in the body rather than be excreted. This causes problems such as
hepatic encephalopathy (neurologic syndrome that develops as a result of rising blood
ammonia levels). Although other nutrients, such as fat and carbohydrates, may be
regulated, it's most important to limit protein in the diet of the client with liver failure.

46. The nurse is preparing to administer medications to two clients with the same last
name. The nurse checks the medication three times before entering the room to
administer medications to the first client. While leaving the room following
administration, the nurse realizes she did not check the identification of the client
prior to administering medication. Which of the following actions should the nurse
complete first?
a. Return to the room to check the client identification and complete a variance
report if an error was made.
b. Administer the remaining medication to the other client and check the client
identification.
c. Alert the charge nurse that a medication error has been committed.
d. Document completion of the variance report and the medication error in the
client's chart and notify the physician
Answer: A -The nurse should immediately return to the room to compare the client's
identification and the medication administration record to ensure the correct client
received the medication. If an error was made, the nurse must complete a variance report
per the facility policy. The variance report is used to report injury or high-risk events. In
this case, failure to follow correct procedure put the client at risk. The nurse should check
the remaining medication for the second client prior to administration. The charge nurse
should be notified of any variance or medical error. Completion of a variance report for a
medical error is not documented on the client's medical record.
47. After an abdominal resection for colon cancer, the client returns to her room with a
Jackson-Pratt drain in place. The client's spouse asks the nurse what the purpose of
the drain is. Which of the following is the nurse's best response?
a. "To irrigate the incision with a saline solution."
b. "To prevent bacterial infection of the incision."
c. "To measure the amount of fluid lost after surgery."
d. "To prevent accumulation of drainage in the wound."
Answer: D – The accumulation of fluid in a surgical wound interferes with the healing
process. A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from
the wound. The drain may be placed in the client's incision, or it may be placed in the
wound and brought out to the skin surface through a stab wound near the incision. The
drain doesn't need to be irrigated. A Jackson-Pratt drain doesn't prevent infection. Fluid
from the drain is absorbed into the dressings and can't be measured accurately.

48. 13. An elderly client is recently diagnosed with hypothyroidism. He lives in his own
apartment in a community development designed for the elderly. He asks the nurse
for advice about his condition. What is the best advice for the nurse to give the client?
a. "Stop attending group activities."
b. "Increase fiber and fluids in your diet."
c. "Stop taking your self-prescribed daily aspirin."
d. "Keep the temperature in your apartment cooler than usual."
Answer: B -Clients with hypothyroidism typically have constipation. A diet high in fiber
and fluids can help prevent this. The client doesn't need to stop all group activities,
although he may need to limit them until his condition improves. Taking aspirin isn't
related to hypothyroidism management and does not interfere with treatment. Clients
with hypothyroidism have an intolerance to cold and need an environment warmer than
average.

49. The nurse is providing care needed to support the respiratory function of a client with
thick secretions. Which measure is most effective in helping a client with thick
secretions mobilize and expectorate them?
a. Drinking salty fluids such as broth and bouillon.
b. Drinking 3 to 4 L of water per day.
c. Inhaling cool mist from a vaporizer daily.
d. Sitting in a tub of warm water three times a day.
Answer: B - Adequate fluid intake decreases the viscosity of secretions. The nurse should
encourage the client to drink 3 to 4 L of water or other fluids per day. Consuming salty
fluids can cause secretions to thicken even further. Inhaling cool mist may help but only
if done more than once a day. Sitting in a tub of warm water may be relaxing, but it
doesn't loosen secretions.

50. The nurse is caring for a client newly diagnosed with chronic obstructive pulmonary
disease (COPD). Which of the following exercises is most appropriate for this client?
a. Intercostal muscle expansion exercises.
b. Isometric leg exercises.
c. Diaphragmatic and pursed-lip breathing exercises.
 d. Lumbar sacral strengthening exercises.
Answer: C -Clients with COPD are taught to use their diaphragmatic muscles, not their
intercostal muscles, to breathe. Because of air trapping due to COPD, pursed-lip
breathing exercises are indicated to help expel carbon dioxide. These exercises increase
expiratory time, decrease expiratory rate, and increase tidal volume. Isometric leg
exercises and lumbar sacral strengthening exercises don't improve breathing but may be
important for general health.

51. The nurse is giving instructions to a parent of a 13-month-old who weighs 18 lbs.
The child is being discharged from the pediatric unit after hospitalization for
gastroenteritis. When talking to the parent about car seat safety, the nurse knows the
parent understands the teaching when the mother states:
a. "My child can be in a front-facing car seat because he is 1 year old."
b. "My child can be in a front facing car seat as soon as he weighs 21 pounds."
c. "As long as I drive a sports utility vehicle, I can have my child rear or front
facing."
d. "My child will need to be in a rear facing care seat until her is three years old."
Answer: B -Any child under one year of age and/or 20 pounds must be in a rear facing
car seat. The make or model of the car does not relate to child safety laws. The general
rule for car seat application is that the child must be over one year of age and 20 pounds
to move from a rear facing to front facing car seat but must be in the back seat of the car.
Older children must use a booster seat until they are 7 to 8 years old, depending upon the
state law.

52. A client is admitted to the Emergency Department after a three-car accident. He's
exhibiting early signs of increased intracranial pressure. Which of the following
groups of symptoms is the nurse most likely to observe?
a. Decreasing pulse, increasing respiratory rate, and decreasing blood pressure.
b. Decreasing pulse, decreasing respiratory rate, and increasing systolic pressure.
c. Increasing pulse, decreasing respiratory rate, and increasing pulse pressure.
d. Decreasing pulse, increasing respiratory rate, and increasing pulse pressure.
Answer: B -In the early stages of increased intracranial pressure, the client's heart and
respiratory rates slow down. The result is an increase in systolic pressure with further
decrease in heart rate and respiratory rate, and a widening pulse pressure. With head
trauma, there may be significant swelling that decreases perfusion, causing hypoxia and
hypercapnia, triggering increased blood flow. The increase volume when injury has
impaired auto-regulation increases the edema, which in turn increases intracranial
pressure, causing further ischemia. If the intracranial pressure is not controlled, the brain
may herniate.

53. The nurse is caring for a child who was in a house fire that killed 7 people, including
his parents. He is the only survivor. The local newspapers and television stations are
at the hospital and are trying to receive information regarding his condition. Which of
the following is the correct action for the nurse?
a. The nurse does not give out any information regarding the child's condition.
b. The nurse does not give the name, only the condition of the patient.
 c. The nurse gives a statement about how sad she is for the family and friends of the
little boy.
d. The nurse contacts an attorney because of the legal issues regarding caring for the
child.
Answer: A -According to HIPAA standards, one cannot give information regarding a
child's care unless permission is granted by the parents/guardian of the child to divulge
information. In this case, the guardians may not yet have been identified. It would be
inappropriate to give the name of the child, and there is no need for the nurse to contact
an attorney. Although not illegal, giving a statement of feelings regarding the situation is
not professional. In most hospitals, a public relations officer may be directed to make a
public statement.

54. The nurse is caring for a client diagnosed with a stroke. Because of the stroke, the
client has dysphagia (difficulty swallowing). Which intervention by the nurse is best
for preventing aspiration?
a. Placing the client in high Fowler's position to eat.
b. Offering liquids and solids together.
c. Keeping liquids thinned.
d. Placing food on the affected side of the mouth.
Answer: A -Placing the client in high Fowler's position, such as in a chair, uses gravity to
reduce the risk of aspiration. Solids and liquids shouldn't be offered together because
when they're in the mouth together, the liquids can cause the solids to be swallowed
before they're properly chewed. However, water or other fluid should be sipped after
swallowing to clear the throat. Thin liquids should be thickened. Food should be placed
on the unaffected side to prevent it from being trapped in the cheek on the affected side.
Using smaller utensils to limit bite size and doing muscle-strengthening exercises may
reduce dysphagia.

55. The nurse is caring for a client who suddenly develops a tonic-clonic seizure. Which
nursing action is most appropriate during a seizure?
a. Forcing a padded tongue blade into the client's mouth.
b. Restraining the client's limbs.
c. Placing the client in a supine position.
d. Loosening constrictive clothing.
Answer: D – Constrictive clothing, especially around the client's neck, can interfere with
oxygenation, so it should be loosened. One should never force anything such as a padded
tongue blade into the mouth because it could break teeth or induce vomiting. A client
who is having seizures should not be restrained, as it can cause soft-tissue injury and
musculoskeletal damage. Instead, any dangerous objects should be removed from around
the client. Because a supine position increases the risk of aspiration, the client should be
helped into a side-lying position.

56. 140.A client with AIDS complains of a weight loss of 20 pounds in the past month.
Which diet is suggested for the client with AIDS?
a.High calorie, high protein, high fat
b.High calorie, high carbohydrate, low protein
 c.High calorie, low carbohydrate, high fat
d.High calorie, high protein, low fat
Answer: D

57. 138.A client with diverticulitis is admitted with nausea, vomiting, and dehydration.
Which finding suggests a complication of diverticulitis?
a.Pain in the left lower quadrant ?????????
b.Boardlike abdomen
c.Low-grade fever
d.Abdominal distention
Answer: B

58. 133.The physician has discussed the need for medication with the parents of an infant
with congenital hypothyroidism. The nurse can reinforce the physician's teaching by
telling the parents that:
a.The medication will be needed only during times of rapid growth.
b.The medication will be needed throughout the child's lifetime.
c.The medication schedule can be arranged to allow for drug holidays.
d.The medication is given one time daily every other day.
Answer: B

59. 132 The nurse has taken the blood pressure of a client hospitalized with methicillin-
resistant staphylococcus aureus. Which action by the nurse indicates an understanding
regarding the care of clients with MRSA?
a.The nurse leaves the stethoscope in the client's room for future use.
b.The nurse cleans the stethoscope with alcohol and returns it to the exam room.
c.The nurse uses the stethoscope to assess the blood pressure of other assigned
clients.
d.The nurse cleans the stethoscope with water, dries it, and returns it to the nurse's
station.
Answer: A

60. A client with breast cancer is returned to the room following a right total mastectomy.
The nurse should:
a.Elevate the client's right arm on pillows
b.Place the client's right arm in a dependent sling
c.Keep the client's right arm on the bed beside her
d.Place the client's right arm across her body
Answer: A

61. The nurse is caring for a client with an above-the-knee amputation (AKA). To
prevent contractures, the nurse should:
a.Place the client in a prone position 15–30 minutes twice a day
b.Keep the foot of the bed elevated on shock blocks
c.Place trochanter rolls on either side of the affected leg
d.Keep the client's leg elevated on two pillows
Answer: A

62. Which statement describes the contagious stage of varicella?

a.The contagious stage is 1 day before the onset of the rash until the appearance of
vesicles.
b.The contagious stage lasts during the vesicular and crusting stages of the lesions.
c.The contagious stage is from the onset of the rash until the rash disappears.
d.The contagious stage is 1 day before the onset of the rash until all the lesions are
crusted.
Answer: D

63. A client with congestive heart failure has been receiving Digoxin (lanoxin). Which
finding indicates that the medication is having a desired effect?
a.Increased urinary output
b.Stabilized weight
c.Improved appetite
d.Increased pedal edema
Answer: A

64. Which of the following symptoms is associated with exacerbation of multiple

sclerosis?
a.Anorexia
b.Seizures
c.Diplopia-
d.Insomnia
Answer: C- plus blurred vision, and transient blindness; fatigue, weakness, ataxia and
vertigo, tremors and spasticity of LE, paresthesias, nystagmus, dysphasia, decreased
perception to pain, touch and temperature, bowel and bladder disturbances, abnormal
reflexes (hyperreflexia, positive babinski’s reflex), emotional changes such as apathy,
euphoria, irritability and depression, memory changes and cofusion

65. A client with a bowel resection and anastamosis returns to his room with an NG tube
attached to intermittent suction. Which of the following observations indicates that
the nasogastric suction is working properly?
a.The client's abdomen is soft.
b.The client is able to swallow.
c.The client has active bowel sounds
d.The client's abdominal dressing is dry and intact.
Answer: A

66. The nurse is reviewing with a client how to collect a urine specimen for culture and
sensitivity. What is the appropriate sequence to teach the client?
a. Clean the meatus, begin voiding, then catch urine stream
b. Void a little, clean the meatus, then collect specimen
c. Clean the meatus, then urinate into container
d. Void continuously and catch some of the urine
Answer: A: urine for C & S requires sterile urine. The meatus, begin voiding, then catch
urine stream. A clean catch urine is difficult to obtain and requires clear directions.
Instructing the client to carefully clean the meatus, then void naturally with a steady
stream prevents surface bacteria from contaminating the urine specimen. As starting and
stopping flow can be difficult, once the client begins voiding it's best to just slip the
container into the stream. Other responses do not reflect correct technique.

67. When caring for a client receiving warfarin sodium (Coumadin), which lab test would
the nurse monitor to determine therapeutic response to the drug?
a. Bleeding time
b. Coagulation time
c. INR
d. Partial thromboplastin time
Answer: C: INR. Coumadin is ordered daily, based on the client's prothrombin time
(PT). This test evaluates the adequacy of the extrinsic system and common pathway in
the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors. Heparin
(PTT)

68. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for
the nurse to include at the change of shift report?
a. The client lost 2 pounds in 24 hours
b. The client’s potassium level is 4 mEq/liter.
c. The client’s urine output was 1500 cc in 5 hours
d. The client is to receive another dose of Lasix at 10 PM
Answer: C: The client’s urine output was 1500 cc in 5 hours. Although all of these may
be correct information to include in report, the essential piece would be the urine output.

69. The nurse has performed the initial assessments of 4 clients admitted with an acute
episode of asthma. Which assessment finding would cause the nurse to call the
provider immediately?
a. prolonged inspiration with each breath
b. expiratory wheezes that are suddenly absent in 1 lobe
c. expectoration of large amounts of purulent mucous
d. appearance of the use of abdominal muscles for breathing
Answer: B: expiratory wheezes that are suddenly absent in 1 lobe. Acute asthma is
characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a
high pitched musical sounds produced by air moving through narrowed airways. Clients
often associate wheezes with the feeling of tightness in the chest. However, sudden
cessation of wheezing is an ominous or bad sign that indicates an emergency -- the small
airways are now collapsed.

70. The nurse has performed the initial assessments of 4 clients admitted with an acute
episode of asthma. Following a bronchodilator treatment which finding is expected?
a. prolonged inspiration with each breath
b. expiratory wheezes disappear
c. expectoration of large amounts of purulent mucous
 d. appearance of the use of abdominal muscles for breathing
Answer: B

71. During the initial home visit, a nurse is discussing the care of a client newly
diagnosed with Alzheimer's disease with family members. Which of these
interventions would be most helpful at this time?
a. leave a book about relaxation techniques
b. write out a daily exercise routine for them to assist the client to do
c. list actions to improve the client's daily nutritional intake
d. suggest communication strategies
Answer: D: suggest communication strategies. Alzheimer''s disease, a progressive
chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in
helping the family to use communication strategies to enhance their ability to relate to the
client. By use of select verbal and nonverbal communication strategies the family can
best support the client’s strengths and cope with any aberrant behavior.

72. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident
has had a blood pressure from 160/100 to 180/110 over the past 2 hours. The nurse
has also noted increased lethargy. Which assessment finding should the nurse report
immediately to the provider?
a. Slurred speech
b. Incontinence
c. Muscle weakness
d. Rapid pulse
Answer: A: Slurred speech. Changes in speech patterns and level of conscious can be
indicators of continued intracranial bleeding or extension of the stroke. Further diagnostic
testing may be indicated.

73. A client is admitted to the emergency room following an acute asthma attack. Which
of the following assessments would be expected by the nurse?
a. Diffuse expiratory wheezing
b. Loose, productive cough
c. No relief from inhalant
d. Fever and chills
Answer: A: Diffuse expiratory wheezing. In asthma, the airways are narrowed, creating
difficulty getting air in. A wheezing sound results.

74. A client has been admitted with a fractured femur and has been placed in skeletal
traction. Which of the following nursing interventions should receive priority?
a. Maintaining proper body alignment
b. Frequent neurovascular assessments of the affected leg
c. Inspection of pin sites for evidence of drainage or inflammation
d. Applying an over-bed trapeze to assist the client with movement in bed
Answer: B: Frequent neurovascular assessments of the affected leg. The most important
activity for the nurse is to assess neurovascular status. Compartment syndrome is a
serious complication of fractures. Prompt recognition of this neurovascular problem and
early intervention may prevent permanent limb damage
75. The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days
ago. The client has many questions about this condition. What area is a priority for
the nurse to discuss at this time?
a. Daily needs and concerns
b. The overview cardiac rehabilitation
c. Medication and diet guideline
d. Activity and rest guidelines
Answer: A: Daily needs and concerns. At 2 days post-MI, the client’s education should
be focused on the immediate needs and concerns for the day.

76. The nurse is assigned to care for a client who had a myocardial infarction (MI) 5 days
ago and now for discharge to home. The client has many questions about this
condition. What area is a priority for the nurse to discuss at this time?
a. Daily needs and concerns
b. The overview cardiac rehabilitation
c. Medication and diet guideline
d. Activity and rest guidelines
Answer: C

77. The nurse is developing a meal plan that would provide the maximum possible
amount of iron for a child with anemia. Which dinner menu would be best?
a. Fish sticks, french fries, banana, cookies, milk
b. Ground beef patty, lima beans, wheat roll, raisins, milk
c. Chicken nuggets, macaroni, peas, cantaloupe, milk
d. Peanut butter and jelly sandwich, apple slices, milk
Answer: B: Ground beef patty, lima beans, wheat roll, raisins, milk. Iron rich foods
include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and
dried fruits such as raisins. This dinner is the best choice: It is high in iron and is
appropriate for a toddler.

78. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every
day. Which of these foods would the nurse reinforce for the client to eat at least
daily?
a. Spaghetti
b. Watermelon
c. Chicken
d. Tomatoes
Answer: B: Watermelon. Watermelon is high in potassium and will replace potassium
lost by the diuretic. The other foods are not high in potassium

79. The nurse is giving instructions to the parents of a child with cystic fibrosis. The
nurse would emphasize that pancreatic enzymes should be taken
a. once each day
b. 3 times daily after meals
 c. with each meal or snack
d. each time carbohydrates are eaten
Answer: C: with each meal or snack. Pancreatic enzymes should be taken with each meal
and every snack to allow for digestion of all foods that are eaten.

80. The nurse notes that a 2 year-old child recovering from a tonsillectomy has an
temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's parent
reports that the child "feels very warm" to touch. The first action by the nurse should
be to
a. reassure the parent that this is normal
b. offer the child cold oral fluids
c. reassess the child's temperature
d. administer the prescribed acetaminophen
Answer: C: reassess the child's temperature. A child's temperature may have rapid
fluctuations. The nurse should listen to and show respect for what parents say. Parental
caretakers are often quite sensitive to variations in their children's condition that may not
be immediately evident to others.

81. The nurse is caring for a client who was successfully resuscitated from a pulseless
dysrhythmia. Which of the following assessments is critical for the nurse to include in
the plan of care?
a. hourly urine output
b. white blood count
c. blood glucose every 4 hours
d. temperature every 2 hours
Answer: A: hourly urine output. Clients who have had an episode of decreased
glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal
decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs
when the effective arterial blood volume falls. Examples of this phenomena include a
drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion
states such as congestive heart failure associated with a cardiomyopathy. Close
observation of hourly urinary output is necessary for early detection of this condition.

82. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or
milk. The physiological basis for this instruction is that the medication
a. retards pepsin production
b. stimulates hydrochloric acid production
c. slows stomach emptying time
d. decreases production of hydrochloric acid
Answer: B: stimulates hydrochloric acid production. Decadron increases the production
of hydrochloric acid, which may cause gastrointestinal ulcers

83. old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and
halo vision. Which of the following laboratory results should the nurse analyze first?
a. Potassium levels
b. Blood pH
 c. Magnesium levels
d. Blood urea nitrogen
Answer: A: Potassium levels. The most common cause of digitalis toxicity is a low
potassium level. Clients must be taught that it is important to have adequate potassium
intake especially if taking diuretics that enhance the loss of potassium while they are
taking digitalis.

84. The nurse caring for a 9 year-old child with a fractured femur is told that a medication
error occurred. The child received twice the ordered dose of morphine an hour ago.
Which nursing diagnosis is a priority at this time?
a. Risk for fluid volume deficit related to morphine overdose
b. Decreased gastrointestinal mobility related to mucosal irritation
c. Ineffective breathing patterns related to central nervous system depression
d. Altered nutrition related to inability to control nausea and vomiting
Answer: C: Ineffective breathing patterns related to central nervous system depression.
Respiratory depression is a life-threatening risk in this overdose

85. The nurse is teaching a class on HIV prevention. Which of the following should be
emphasized as increasing risk?
a. Donating blood
b. Using public bathrooms
c. Unprotected sex
d. Touching a person with AIDS
Answer: C: Unprotected sex. Because HIV is spread through exposure to bodily fluids,
unprotected intercourse and shared drug paraphernalia remain the highest risks for
infection.

86. Therapeutic nurse-client interaction occurs when the nurse

a. assists the client to clarify the meaning of what the client has said
b. interprets the client’s covert communication
c. praises the client for appropriate feelings and behavior
d. advises the client on ways to resolve problems
Answer: A: assists the client to clarify the meaning of what the client has said.
Clarification is a facilitating/therapeutic communication strategy. Interpretation, changing
the focus/subject, giving approval, and advising are non-therapeutic/barriers to
communication.

87. 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.

88. 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.

89. 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.

90. 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.

91. 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.

92. 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.

93. 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.
 94. 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.

95. 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.

96. 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.

97. 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.

98. 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.

99. 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

100. 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.

101. 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.

102. 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

103. 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.

104. 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.

105. 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.

106. 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)

107. 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.

108. 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.

109. 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

110. 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

111. 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
112. 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

113. 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

114. 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.

115. 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.

116. 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

117. 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

118. 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 -- question is about prevention
b. Drink cranberry juice
c. Limit fluid intake
d. Frequent perineal washing

119. 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”

120. 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

121. A 46-year old patient was diagnosed with multiple sclerosis 20 years ago.
Which of the following symptoms would you expect your patient to manifest:
a. Muscle weakness, numbness and tingling sensation
b. Stationary tremors, bradykinesia, and muscle weakness
c. Muscle weakness, rigidy, and difficulty in breathing
d. Dysphagia, diplopia, and tremors

122. Referring to question #121, which of the following are predisposing

factors of Multiple Sclerosis:
a. High fat and high purine diet
b. Young adults and lives away from the equator
c. African-American race
d. Stress and old age
Answer: B - MS is more common in people who live farther from the equator,
although many exceptions exist. Decreased sunlight exposure has been linked
with a higher risk of MS. Decreased vitamin D production and intake has been
the main biological mechanism used to explain the higher risk among those less
exposed to sun
123. Four call bells went off at the same time. Which of the following patients
should you see first?
a. Patient with compartment syndrome
b. Patient complaining of pain
c. Patient complaining of chest pain
d. Patient with anaphylactic shock
Answer: C – This is poor oxygenation to the heart muscles or even cell death
already. This tramples option D.

124. The PN is about to give blood transfusion. However, the PN noticed that
the IV fluid that is currently being administered is D5LR. What would be the
most appropriate nursing action of the PN?
a. Change the IV fluid to NS then administer the blood
b. Change the IV tubing and change the IV fluid to NS then administer the blood
c. Flush the IV tubing with NS through the Y-port of the tubing then administer the
blood
d. Flush the IV with NS through the Y-port then piggyback the blood
Answer: A – This will flush out the D5LR. Changing the tubing is not necessary.

125. The PN is giving IM injection to a 12-year old child. Which size of the
needle should the PN use?
a. ½ Inch
b. 1 Inch
c. 1 ½ Inch
d. 2 Inches

126. A patient was having seizure. The PN did the appropriate nursing
interventions. Aside from the duration and characteristics of a seizure, the PN
should also document which of the following?
a. Aura of seizure
b. Hallucination
c. Confusion
d. Respiratory Rate
Answer: C - Document all activity observed during a seizure, including time,
location, circumstances, length of seizure activity, and vital signs. This is to
identify what type of seizure the patient is having to determine what type of
treatment should be done. Some seizure occurs with loss of LOC or without loss
of LOC.

127. When performing abdominal assessment on a 12-year old child, which of

the following sequence is most appropriate?
a. Auscultation, percussion, inspection, palpation
 b. Auscultation, inspection, palpation, percussion
c. Inspection, auscultation, palpation, percussion
d. Inspection, auscultation, percussion, palpation

128. The PN is teaching the patient how to use an incentive spirometer. The PN
will instruct the patient to:
a. Inhale when using the spirometer
b. Hold breath after puffing
c. Make sure there is a one-minute interval between puffs - this is for inhaler
d. Hold the canister upright

129. A patient was diagnosed with ovarian cancer. The patient’s daughter often
visits her in hospital. During one of your shifts, the daughter asks you about her
mother’s condition. What should the PN consider when answering the daughter’s
inquiry?
a. Confidentiality
b. Informed consent
c. Hospital policy
d. Nursing standard

130. The PN is doing a stoma dressing of a patient’s colostomy. The PN

noticed that the stoma is bluish and is swollen. What would be the PN’s
appropriate action?
a. Request that the physician be notified
b. Continue the dressing
c. Check vital signs
d. Do pain assessment

Case Study 1 (Questions 11-16)

Mrs. Clarke, a 73 year old widow, is brought to hospital after a fall. She is slightly
confused, complains of pain in her right hip, and is unable to move her right leg. X-rays
indicate that she has a fracture of her right femur.
131. An observation of Mrs. Clarke that would likely indicate a fracture of the
right hip would be that the right leg is:
a. rotated internally
b. held in a flexed position
c. moved away from the body midline
d. shorter than the leg on the unaffected side
ANSWER: D- due to the dislocated hip, the affected leg is shorter than the unaffected
leg
132. Mrs. Clarke is slightly confused and anxious. The best nursing approach
would to be to
a. explain to Mrs. Clarke what is going to happen to her
 b. call Mrs. Clarke by her first name
c. visit Mrs. Clarke frequently
d. listen to what Mrs. Clarke has to say
ANSWER: A – the changes in the patient’s LOC should not prevent the patient from
receiving what she is entitled to –“the right to receive information about her care”
133. During the night Mrs. Clarke wakes up and does not remember her
daughter had visited her early in the evening. She asks, “Why has my daughter
not been to see me. Didn’t you call her?” The best reply would be
a. “Are you afraid she won’t come to visit you?”
b. “I’m sure you will hear from her soon.”
c. “You’re confused, she was here earlier tonight.”
d. “Your daughter was here just after supper this evening.”
ANSWER: D- this is the correct information and it must be provided for the patient
134. Mrs. Clarke has an open reduction of the hip and a pin is inserted. After
surgery when positioning Mrs. Clarke, the RPN should
a. elevate the affected limb on a pillow
b. log roll her when positioning her on her side
c. place pillows between her legs at all times
d. place sand bags along the entire lateral aspect of the limbs
ANSWER: C – an abduction pillow must be placed between the patient’s leg post hip
replacement to maintain good alignment of the replaced hip
135. On the second day post-op Mrs. Clarke is to get out of bed into a chair.
The best way to accomplish this is to have her
a. lifted from her bed to the chair
b. stand on her unaffected leg and pivot to the chair
c. put weight equally on both legs and step to the chair
d. slide from the bed to the chair without weight-bearing
ANSWER: B – the good leg bears most of the weight to prevent strain on the replaced
hip
136. Which of the following would provide Mrs. Clarke with a balanced,
nutritious lunch?
a. milk, cheese, omelets, whole wheat toast
b. tuna sandwich, milk, sliced tomato, banana
c. fried chicken, beef bouillon, peas, herbal tea
d. macaroni and cheese, tomato and lettuce salad, apple, coffee
ANSWER: B- tuna (protein); bread (CHO); tomato and banana (vitamins and
minerals); milk (fat and protein) this is balanced diet
Case Study 2 (Questions 17-26)
David Stewart is a 20 year old who has a compound fracture of the femur of the right leg
and a simple fracture of the right ulna as a result of a motorcycle accident.
137. At the accident site a splint is applied. It is important that the splint
a. be applied to the right leg in the position of good alignment
b. be applied to the right leg in the position in which it is found
c. extend from the fracture site downward
d. extend from the fracture site upward
ANSWER: B –the PN should not manipulate the injured leg. The physician is
responsible for the treatment of the injured leg; application of splint will immobilize
and prevent further injury to the affected leg
138. When Mr. Stewart is being transported in the ambulance to the hospital, he
should be positioned with affected limbs
a. elevated
b. in a low flat position
c. lower than his heart
d. slightly abducted
ANSWER: A- this will minimize edema formation though good venous return
Mr. Stewart is taken to the operating room. The wound caused by the fractured femur is
cleansed and debrided. The fracture is then reduced and a Steinmann pin for skeletal
traction is inserted. A closed reduction of the ulna is performed and a cast applied.
139. The most important nursing measure in the immediate postoperative
period will be
a. encouragement of isometric exercises
b. cleansing of the area around the Steinmann pin
c. observation of vital signs
d. massage of pressure areas
ANSWER: C – vital signs will allow the PN to assess possible complication (bleeding;
poor circulation) on the immediate post op period
140. After Mr. Stewart returns to his room, he complains of pain in his right
arm. The initial action of the RPN should be to
a. administer analgesics as ordered
b. check his fingers
c. notify the doctor immediately
d. pad the edges of the cast
ANSWER: B- due to the application of cast, circulation can be altered from a tight cast
– pain is a manifestation. Initial action – Assessment.
141. In dealing with the weights that are applied to the traction, the RPN should
a. allow them to hang freely in place
b. hold them up if the client is shifting position in bed
c. remove them if the client is being moved up in bed
d. lighten them for short periods if the client complains of pain
ANSWER: A – weights in the traction must be hanging freely
142. Mr. Stewart has a Thomas splint in place. In addition to the usual nursing
procedures for a client in traction, it will be important that the RPN observe
a. the groin area for pressure
b. for constipation
c. his skin for signs of breakdown
d. for signs of hypostatic pneumonia
ANSWER: B – constipation may result to immobility due to splint.
143. In caring for a wet cast, the RPN should
a. use a hair dryer to help dry the cast
b. cover the cast to prevent the client from feeling chilled
c. use a fan in the room to help dry the cast
 d. move the cast using only the finger tips to lift it
ANSWER: C – Principle is: Use room air temperature to dry cast. Fingertips may
cause dents.
144. If. Mr. Stewart should show a increase in blood pressure, signs of
confusion, and increased restlessness the RPN should suspect
a. a concussion
b. impending shock
c. fat emboli
d. anxiety
ANSWER: C – fat emboli from bone manipulation is a common serious complication
following orthopedic procedure
145. Because of the nature of Mr. Stewart’s wound and the insertion of a
Steinmann pin, it is especially important that the RPN observe for
a. a foul odor
b. foot drop
c. pulmonary congestion
d. fecal impaction
ANSWER: A – foul odor on the pin site is a sign of infection
146. On discharge the patient was given three different types of eye drops, to be
taken QID daily. The patient asked the RPN, “In what order do I have to put the
drops in.” The RPN should reply
a. it really does not matter, you can put the drops in at any time
b. the order you follow does not matter, but wait at least two minutes between drops
c. you can use your judgment, as long as you put them in one time
d. put the three drops in then close your eyes for two minutes
ANSWER: B- for best absorption, time between two eye drop medications is important
147. The doctor ordered Culture and Sensitivity Urine Test. How would the PN
collect the specimen?
a. Obtain first stream of urine
b. Obtain midstream urine
c. Obtain any stream of urine
d. Obtain specimen by swabbing the urinary orifice

148. The patient with Type I Diabetes Mellitus was seen by the UCP
unconscious. Which task should the RPN delegate to the UCP?
a. Obtain a glass of Orange Juice
b. Obtain the glucometer
c. Check the vital signs
d. Stay with the patient while the RPN obtain the glucometer

149. On the 3rd day post hip replacement, your patient complained of swollen
and painful legs. What would be your first action?
a. Remove the abduction pillow
b. Notify RN – the physician might be informed to prescribe appropriate
treatment
c. Put patient back to bed – there’s nothing there that states that patient might be
possibly out of bed.
d. Abduct the patient’s affected leg

150. Your patient has renal failure. The doctor ordered the administration of
insulin. The patient’s family asks, “Why is my father being given insulin?” What
would be your most appropriate response?
a. Your father developed Diabetes Type I
b. Your father developed Diabetes Type II
c. Your father has increased ammonia level in the blood
d. Your father has increased potassium level in the blood – Insulin will cause
Potassium, glucose and other electrolytes to go to the cells FROM the
bloodstream.

151. The PN observed the IV site and find signs of phlebitis. The patient
complains of pain on the IV site and that the pain is graded 4 out of 10 using the
pain scale. After discontinuing the IV, what will the PN do next?
a. Give PRN analgesics – analgesics are specific for pain. The issue is that the
patient is in pain.
b. Apply warm moist compress on the IV site
c. Apply cold compress on the IV site
d. Report to RN

152. The patient is on respiratory isolation because he developed cough and it

has been going on for 3 days. The doctor ordered chest xray. What would be the
most appropriate action of the PN before wheeling the client to the xray room?
a. The client will wear mask
b. The PN will wear mask
c. Inform the xray staff that the patient is on his way
d. Inform nurse

153. The patient has oliguria secondary to acute renal failure. Which of the
following signs and symptoms would the PN expect to find?
a. Decrease K+ and decreased Na+
b. Generalized edema and chest pains
c. Edematous ankles and crackles
d. Wheezing and Pitting edema
154. The doctor ordered NPO for a female patient that is experiencing
dysphagia. When the nurse comes into the patient’s room for morning rounds, the
PN notices that the patient’s husband is feeding the patient with a homecooked
meal. The PN informed the husband about the patient’s NPO status. However, the
husband conveyed to the patient, “How can my wife survive if she does not eat?”
What would be the PN’s most appropriate response?
a. Do you know what would be the complication if your wife does not follow proper
doctor’s orders?
b. You sound very concerned of your wife not eating - Reflecting
c. Do not worry, your wife is getting nutrition from the IV.
d. Next time, do not feed anything to your wife unless you let me know first.

155. A patient with sundowning syndrome is assigned to the PN. The PN

knows that the patient would be at risk for injury during the night time. To ensure
patient’s safety, which of the following would be the most appropriate action of
the PN?
a. Provide night light – question is asking preventing injury specific during
night time
b. Remove obstructions from the floor
c. Provide nonslip carpet
d. Put signs on each room

156. An 85-year old patient whose husband died three years ago woke up at 3
AM. When asked by the PN to go back to bed, she told the PN that she needs to
cook for her husband because her husband would be going to work at 5 AM.
What would be the most appropriate response by the PN?
a. Go back to bed, no cooking til morning.
b. Your husband died 3 years ago. It is sometimes easy to forget, isn’t it? –
Presenting reality
c. You really must have missed your husband so much.
d. If you sleep now, I’ll let you cook tomorrow.

157. How often should an IV tubing be changed?

a. Every 12 hours
b. Every 24 hours
c. Every 48 hours
d. Every 72 hours

158. What is the most accurate way of checking NGT placement?

a. Flushing tubing with NS
b. Instilling air through the tubing
c. Aspirating gastric contents through the tubing
d. Chest X-Ray

159. A patient on bed became agitated. The PN who assessed the patient
diagnosed risk for injury. How can the PN ensure safety?
a. Side rails up
b. Implement safety precautions
c. Lower the bed
d. Raise the bed

160. A patient was rushed to the Emergency Department due to a Vehicular

Accident. The patient is losing a lot of blood. The doctor ordered blood
transfusion. However, the patient refused blood transfusion as treatment due to
religious belief. What would the PN do next?
a. Respect the patient’s decision and inform RN
b. Present an alternative solution to the doctor
c. Present an alternative solution to the patient
d. Explain the importance of blood transfusion to the patient

161. The patient’s IV site is red , swollen, and has purulent discharge. The PN
used her initiative by discontinuing the IV as the PN knows that these are signs
and symptoms of infection. The patient is complaining of pain on the IV site.
What would be the best nursing action?
a. Give analgesics as ordered
b. Apply warm moist compress
c. Apply cold compress to numb the painful site
d. Report to RN – This is infection therefore we need the physician to prescribe
antibiotics

162. What is the fastest route of administration for Nitroglycerin?

a. Sublingual – Takes 22 seconds to start working.
b. IV
c. Spray
d. Patch

163. When a patient with history of angina is having an attack, which would be
the best route of administration?
a. Sublingual
b. IV
c. Spray
d. Patch
164. A PN knows that nitroglycerin in this type of form is useless to give to a
patient that is having an ongoing angina attack:
a. Sublingual
b. IV
c. Spray
d. Patch – This is slow-release

165. A patient is receiving blood transfusion at 8:00 AM. The patient

complained that the PN might have transfused the one unit of blood too quickly as
the blood product was done transfusing at 10:30 AM. As the nurse-in-charge, how
would you respond?
a. I’m sorry that this happened, what the nurse did was inappropriate.
b. The nurse was concerned of bacterial growth in the blood that is why she
regulated the blood to finish in 2 ½ hours.
c. What the nurse did was appropriate. – This is right but D will explain everything
d. One unit of blood can also be given in a minimum of 2 hours as long as there
are no complications.

166. You are about to get one unit of blood for your patient when another PN
who is a colleague of yours asked you to get one unit of blood for her patient as
well. How should you proceed?
a. Get the blood product for your patient then return for the blood product of
your colleague’s patient. – Principle is: You can take blood products as long
as it is one at a time.
b. Inform your colleague that she has to get her own patient’s blood product herself.
c. Take both blood products as longs both are in separate containers and are
properly identified and marked.
d. Get the blood product of your patient only.

167. An outbreak of Norwalk virus is happening in the long-term facility that

you are working in. The PN knows that Norwalk virus is spread through:
a. Airborne
b. Contact
c. Food borne
d. Droplet

168. Because of the Norwalk virus outbreak, the longterm facility sent out a
memo stating the standard procedure to prevent more spread of the virus. The PN
would expect the memo to state:
a. Proper handwashing
b. Respiratory isolation
c. Restricting visitors – There should be no one else entering the facility
d. Wearing of gloves, masks, and gowns

169. The PN is taking care of a patient with spica cast. Which of the following
signs or symptoms would opt the PN to notify the physician immediately?
a. Delayed capillary refill
b. Extremity is slightly cool to touch
c. Patient complains of pain
d. Affected extremity is painful upon movement

170. A community daycare center has an outbreak of Pertussis or “whooping

cough’’ As a community health nurse, what would be your most prompt
response?
a. Report to the public health authorities – Pertussis is a reportable
communicable disease.
b. Provide test to all the children affected
c. Advise to close the operations of the day care center
d. Conduct screening tests for immunization

171. A female client is admitted to the emergency room for abdominal

bleeding and anxiety. 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 the reassessment interview
b. Use a tool or a set of guidelines in assessing abused clients
c. Inform the physician for the data collected
d. Ask assistance from your colleague to witness the interview.

172. A nurse 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 to the most senior nurse in the unit
d. Call the IV team to teach her how to start and IV line

173. A media reporter came to your institution and asked you regarding an
outbreak in the hospital of a certain disease. How will you respond?
a. Tell the reporter that hospital problems are confidential to the institution
b. Redirect the reporter to the public relations officer of the hospital
 c. Answer the reporter’s questions as appropriately as possible as you have a duty to
share to the community’s right to information
d. Tell the reporter that you are not on the authority to divulge the back ground of
this problem and request your supervisor to release the appropriate information
instead.

174. A nurse received a call from a lady who is 75 years old and stated that her
husband took a full bottle of Tylenol tables which was brought by her few hours
ago, and inquired if her husband is admitted to the hospital. It sounds to the nurse
that the lady herself is a drug overdosed. What action the nurse is supposed to
take?

a. Inform police
b. Inform nurse supervisor
c. Prepare for admission, send a security person to ER to find out whether her
husband collapsed in ER
d. Call the family Doctor

175. Tim 32 years old fall from a motorcycle ride and was admitted to the
hospital with a close reduction on his left leg and was on skin traction. Nurse B
was assigned to the client and nurse a saw nurse B lifting the weight as she’s
going to turn the patient. What will be the best nursing action
a. Tell a colleague about the incident
b. Inform the Doctor
c. I will inform the nurse supervisor
d. Order for an x-ray of left leg

176. A colleague’s license has expired a week ago She says she forgot to renew
it. She is working with you on the evening shift. What are your 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

177. A newly hired RN confronted two aids because they didn’t turn the patient
every 2 hours- as they were sleeping while on duty and even told the nurse, ‘’
Wow know what we are doing, just take care of your own pills. ‘’ How would the
nurse respond to this ?
a. Explain to them the possible consequences of their actions
b. Report the incident to the supervisor
c. Confront both nurses
d. Inform the administrator

178. You are giving a shift report to nurse Anita, the incoming nurse for the
new shift. She told you in the past that she has another job and has lots of
 problems at home. You notice her to be tired and feel she can’t give a good and
safe nursing care to the patients. What is your best nursing action?
a. Inform the manager
b. Encourage her to quit her other job
c. Offer to take care of her patient assignment
d. Encourage her to discuss these difficulties with the charge nurse and go home
to rest.

179. A client is admitted with substance abuse, and frequently asking the nurse
for narcotic pain medication every 3-4 hours. You notice his nurse pocketed the
medication. What should you do?
a. Make an incident report to the nurse in charge
b. Confront the nurse
c. Inform the client that medication was taken by his nurse
d. Report the nurse to CNO

180. When you were doing your rounds you overheard that, one nurse is saying
we are very busy and cannot finish our documentation. Another nurse has to be
called for documentation. What should be the right response?
a. It is in appropriate to proceed with this type of documentation
b. Report to the nurse manager about the accountability
c. Leave the documentation to the incoming shift
d. Documentation has to be written by the nurse who performed the procedure