The physician prescribes a loop diuretic for a client.

When administering this

drug, the nurse anticipates that the client may develop which electrolyte
imbalance?

A Hypervolemia
Hyperkalemia

C Hypokalemia
D Hypernatremia
Question 1 Explanation: 
A loop diuretic removes water and, along with it, sodium and potassium. This
may result in hypokalemia, hypovolemia, and hyponatremia.

Question 1
CORRECT
The physician prescribes a loop diuretic for a client. When administering this
drug, the nurse anticipates that the client may develop which electrolyte
imbalance?

A Hypervolemia
Hyperkalemia

C Hypokalemia
D Hypernatremia
Question 1 Explanation: 
A loop diuretic removes water and, along with it, sodium and potassium. This
may result in hypokalemia, hypovolemia, and hyponatremia.
Question 2
WRONG
Nurse Oliver is caring for a client with impaired mobility that occurred as a
result of a stroke. The client has right sided arm and leg weakness. The nurse
would suggest that the client use which of the following assistive devices
that would provide the best stability for ambulating?
 A Walker
Single straight-legged cane

C Crutches
Quad cane
Crutches and a walker can be difficult to maneuver for a client with weakness
on one side. A cane is better suited for client with weakness of the arm and
leg on one side. However, the quad cane would provide the most stability
because of the structure of the cane and because a quad cane has four legs.

Nurse John develops methods for data gathering. Which of the following
criteria of a good instrument refers to the ability of the instrument to yield the
same results upon its repeated administration?

A Specificity
B Sensitivity
Validity
Reliability

Reliability is consistency of the research instrument. It refers to the

repeatability of the instrument in extracting the same responses upon its
repeated administration.

Nurse Janah is collecting a sputum specimen for culture and sensitivity

testing from a client who has a productive cough. Nurse Janah plans to
implement which intervention to obtain the specimen?
Use a sterile plastic container for obtaining the specimen.

B Provide tissues for expectoration and obtaining the specimen.

Ask the client to expectorate a small amount of sputum into the emesis
C basin.
D Ask the client to obtain the specimen after breakfast.
Sputum specimens for culture and sensitivity testing need to be obtained
 using sterile techniques because the test is done to determine the presence
of organisms. If the procedure for obtaining the specimen is not sterile, then
the specimen is not sterile, then the specimen would be contaminated and
the results of the test would be invalid.

Nurse Patricia is reconstituting a powdered medication in a vial. After adding

the solution to the powder, she nurse should:
Roll the vial gently between the palms.

B Invert the vial and let it stand for 3 to 5 minutes.

C Shake the vial vigorously.
D Do nothing.
Rolling the vial gently between the palms produces heat, which helps dissolve
the medication. Doing nothing or inverting the vial wouldn't help dissolve the
medication. Shaking the vial vigorously could cause the medication to break
down, altering its action.

Question 1
CORRECT
The physician prescribes a loop diuretic for a client. When administering this
drug, the nurse anticipates that the client may develop which electrolyte
imbalance?

A Hypervolemia
Hyperkalemia

C Hypokalemia
D Hypernatremia
Question 1 Explanation: 
A loop diuretic removes water and, along with it, sodium and potassium. This
may result in hypokalemia, hypovolemia, and hyponatremia.
Question 2
WRONG
Nurse Oliver is caring for a client with impaired mobility that occurred as a
result of a stroke. The client has right sided arm and leg weakness. The nurse
would suggest that the client use which of the following assistive devices that
would provide the best stability for ambulating?

A Walker
Single straight-legged cane

C Crutches
Quad cane
Question 2 Explanation: 
Crutches and a walker can be difficult to maneuver for a client with weakness
on one side. A cane is better suited for client with weakness of the arm and
leg on one side. However, the quad cane would provide the most stability
because of the structure of the cane and because a quad cane has four legs.
Question 3
WRONG
Nurse John develops methods for data gathering. Which of the following
criteria of a good instrument refers to the ability of the instrument to yield the
same results upon its repeated administration?

A Specificity
B Sensitivity
Validity
Reliability
Question 3 Explanation: 
Reliability is consistency of the research instrument. It refers to the
repeatability of the instrument in extracting the same responses upon its
repeated administration.
Question 4
CORRECT
Nurse Janah is collecting a sputum specimen for culture and sensitivity
testing from a client who has a productive cough. Nurse Janah plans to
implement which intervention to obtain the specimen?
Use a sterile plastic container for obtaining the specimen.

B Provide tissues for expectoration and obtaining the specimen.

C Ask the client to expectorate a small amount of sputum into the emesis basin.
D Ask the client to obtain the specimen after breakfast.
Question 4 Explanation: 
Sputum specimens for culture and sensitivity testing need to be obtained
using sterile techniques because the test is done to determine the presence of
organisms. If the procedure for obtaining the specimen is not sterile, then the
specimen is not sterile, then the specimen would be contaminated and the
results of the test would be invalid.
Question 5
CORRECT
Nurse Patricia is reconstituting a powdered medication in a vial. After adding
the solution to the powder, she nurse should:
Roll the vial gently between the palms.

B Invert the vial and let it stand for 3 to 5 minutes.

C Shake the vial vigorously.
D Do nothing.
Question 5 Explanation: 
Rolling the vial gently between the palms produces heat, which helps dissolve
the medication. Doing nothing or inverting the vial wouldn't help dissolve the
medication. Shaking the vial vigorously could cause the medication to break
down, altering its action.
Question 6
WRONG
The maximum transfusion time for a unit of packed red blood cells (RBCs) is:
4 hours

B 3 hours
C 2 hours
6 hours

A unit of packed RBCs may be given over a period of between 1 and 4

hours. It shouldn't infuse for longer than 4 hours because the risk of
 contamination and sepsis increases after that time. Discard or return to the
blood bank any blood not given within this time, according to facility policy.

Question 7
CORRECT
The leader of the study knows that certain patients who are in a specialized
research setting tend to respond psychologically to the conditions of the
study. This referred to as :

A Horns effect
Hawthorne effect

C Halo effect
D Cause and effect
Hawthorne effect is based on the study of Elton Mayo and company about the
effect of an intervention done to improve the working conditions of the workers
on their productivity. It resulted to an increased productivity but not due to the
intervention but due to the psychological effects of being observed. They
performed differently because they were under observation.

Nursing care for a female client includes removing elastic stockings once per
day. The Nurse Betty is aware that the rationale for this intervention?

A To permit veins in the legs to fill with blood.

To increase blood flow to the heart

C To allow the leg muscles to stretch and relax

To observe the lower extremities
Question 8 Explanation: 
Elastic stockings are used to promote venous return. The nurse needs to
remove them once per day to observe the condition of the skin underneath the
stockings. Applying the stockings increases blood flow to the heart. When the
stockings are in place, the leg muscles can still stretch and relax, and the veins
can fill with blood.
Nurse Janah is monitoring the ongoing care given to the potential organ donor
who has been diagnosed with brain death. The nurse determines that the
standard of care had been maintained if which of the following data is
observed?

A Serum pH: 7.32

B Capillary refill: 5 seconds
Blood pressure: 90/48 mmHg
Urine output: 45 ml/hr
Adequate perfusion must be maintained to all vital organs in order for the
client to remain visible as an organ donor. A urine output of 45 ml per hour
indicates adequate renal perfusion. Low blood pressure and delayed capillary
refill time are circulatory system indicators of inadequate perfusion. A serum
pH of 7.32 is acidotic, which adversely affects all body tissues.

Which of the following item is considered the single most important factor in
assisting the health professional in arriving at a diagnosis or determining the
person’s needs?
Diagnostic test results
History of present illness

C Physical examination
D Biographical date
The history of present illness is the single most important factor in assisting
the health professional in arriving at a diagnosis or determining the person’s
needs.

Nurse Myrna is providing instructions to a nursing assistant assigned to give

a bed bath to a client who is on contact precautions. Nurse Myrna instructs
the nursing assistant to use which of the following protective items when
giving bed bath?
Gloves and goggles
B Gloves and shoe protectors
Gown and gloves
Gown and goggles
D
Contact precautions require the use of gloves and a gown if direct client
contact is anticipated. Goggles are not necessary unless the nurse
anticipates the splashes of blood, body fluids, secretions, or excretions may
occur. Shoe protectors are not necessary.

Nurse Linda prepares to perform an otoscopic examination on a female

client. For proper visualization, the nurse should position the client's ear by:

A Pulling the helix up and forward

B Pulling the lobule down and forward
C Pulling the lobule down and back
Pulling the helix up and back

To perform an otoscopic examination on an adult, the nurse grasps the helix

of the ear and pulls it up and back to straighten the ear canal. For a child, the
nurse grasps the helix and pulls it down to straighten the ear canal. Pulling
the lobule in any direction wouldn't straighten the ear canal for visualization.

Nurse May attends an educational conference on leadership styles. The

nurse is sitting with a nurse employed at a large trauma center who states
that the leadership style at the trauma center is task-oriented and directive.
The nurse determines that the leadership style used at the trauma center is:

Autocratic.
Situational

C Democratic.
Laissez-faire
D
 The autocratic style of leadership is a task-oriented and directive

Which is the most appropriate nursing action in obtaining a blood pressure

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

B Measure the client’s arm, if you are not sure of the size of cuff to use.
Document the measurement, which extremity was used, and the position
C that the client was in during the measurement.
Have the client recline or sit comfortably in a chair with the forearm at the
D level of the heart.

Question 14 Explanation: 
It is a general or comprehensive statement about the correct procedure, and it
includes the basic ideas which are found in the other options

The nurse is aware that the most important nursing action when a client
returns from surgery is:
Assess the dressing for drainage.
Assess the client for presence of pain.

C Assess the IV for type of fluid and rate of flow.

D Assess the Foley catheter for patency and urine output
Assessing the client for pain is a very important measure. Postoperative pain
is an indication of complication. The nurse should also assess the client for
pain to provide for the client’s comfort.
Nurse Ron is assisting with transferring a client from the operating room table
to a stretcher. To provide safety to the client, the nurse should:
Secures the client safety belts after transferring to the stretcher.

B Instructs the client to move self from the table to the stretcher.
C Moves the client rapidly from the table to the stretcher.
Uncovers the client completely before transferring to the stretcher.

During the transfer of the client after the surgical procedure is complete, the
nurse should avoid exposure of the client because of the risk for potential
D heat loss. Hurried movements and rapid changes in the position should be
avoided because these predispose the client to hypotension. At the time of
the transfer from the surgery table to the stretcher, the client is still affected
by the effects of the anesthesia; therefore, the client should not move self.
Safety belts can prevent the client from falling off the stretcher.

A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and
receives a continuous insulin infusion. Which condition represents the
greatest risk to this child?

A Hypernatremia
B Hyperphosphatemia
Hypokalemia
Hypercalcemia

D Insulin administration causes glucose and potassium to move into the

cells, causing hypokalemia.
Patient’s refusal to divulge information is a limitation because it is beyond the
control of Tifanny”. What type of research is appropriate for this study?
Descriptive- correlational
Quasi-experiment

C Experiment
D Historical
Descriptive- correlational study is the most appropriate for this study because
it studies the variables that could be the antecedents of the increased
incidence of nosocomial infection.

If a central venous catheter becomes disconnected accidentally, what should

the nurse in-charge do immediately?

A Apply a dry sterile dressing to the site.

B Call the physician
C Call another nurse
Clamp the catheter

If a central venous catheter becomes disconnected, the nurse should

immediately apply a catheter clamp, if available. If a clamp isn’t available, the
nurse can place a sterile syringe or catheter plug in the catheter hub. After
cleaning the hub with alcohol or povidone-iodine solution, the  nurse must
replace the I.V. extension and restart the infusion.

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

A Assess temperature frequently.

Check circulation every 15-30 minutes.

C Socialize with other patients once a shift.

D Provide diversional activities
Restraints encircle the limbs, which place the client at risk for circulation
being restricted to the distal areas of the extremities. Checking the client’s
circulation every 15-30 minutes will allow the nurse to adjust the restraints
before injury from decreased blood flow occurs.

The nurse In-charge in labor and delivery unit administered a dose of

terbutaline to a client without checking the client’s pulse. The standard that
would be used to determine if the nurse was negligent is:

A The statement in the drug literature about administration of terbutaline.

B The physician’s orders.
C The action of a clinical nurse specialist who is recognized expert in the field.
The actions of a reasonably prudent nurse with similar education and
experience.

The standard of care is determined by the average degree of skill, care, and
diligence by nurses in similar circumstances.

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

days?"

A Standing order
B Stat order
C Single order
Standard written order
This is a standard written order. Prescribers write a single order for
medications given only once. A stat order is written for medications given
immediately for an urgent client problem. A standing order, also known as a
protocol, establishes guidelines for treating a particular disease or set of
symptoms in special care areas such as the coronary care unit. Facilities also
may institute medication protocols that specifically designate drugs that a
nurse may not give.

Nurse Amy is aware that the following is true about functional nursing
Provides continuous, coordinated and comprehensive nursing services.

B Emphasize the use of group collaboration.

C One-to-one nurse patient ratio.
D Concentrates on tasks and activities
Functional nursing is focused on tasks and activities and not on the care of
the patients.

Which of the following theory addresses the four modes of adaptation?

A Florence Nightingale
Sr. Callista Roy

C Madeleine Leininger
Jean Watson
 Sr. Callista Roy developed the Adaptation Model which involves the
physiologic mode, self-concept mode, role function mode and dependence
mode.

Nurse Amy has documented an entry regarding client care in the client’s
medical record. When checking the entry, the nurse realizes that incorrect
information was documented. How does the nurse correct this error?
Uses correction fluid to cover up the incorrect information and writes in the
A correct information.
Covers up the incorrect information completely using a black pen and
B writes in the correct information
Draws one line to cross out the incorrect information and then initials the
change.

D Erases the error and writes in the correct information.

To correct an error documented in a medical record, the nurse draws one line
through the incorrect information and then initials the error. An error is never
erased and correction fluid is never used in the medical record

Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An
example of this power is:
The Board can visit a school applying for a permit in collaboration with
A CHED
 The Board can investigate violations of the nursing law and code of ethics

C The Board prepares the board examinations

The Board can issue rules and regulations that will govern the practice of
nursing

Quasi-judicial power means that the Board of Nursing has the authority to
investigate violations of the nursing law and can issue summons, subpoena
or subpoena duces tecum as needed.

Nurse Hazel is preparing to ambulate a female client. The best and the safest
position for the nurse in assisting the client is to stand:

A Behind the client.

In front of the client.

C On the unaffected side of the client.

On the affected side of the client
When walking with clients, the nurse should stand on the affected side and
grasp the security belt in the midspine area of the small of the back. The
nurse should position the free hand at the shoulder area so that the client can
be pulled toward the nurse in the event that there is a forward fall. The client is
instructed to look up and outward rather than at his or her feet.

A male client is receiving total parenteral nutrition suddenly demonstrates

signs and symptoms of an air embolism. What is the priority action by the
nurse?

A Notify the physician.

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

C Stop the total parenteral nutrition.

Place the client in high-Fowlers position
Lying on the left side may prevent air from flowing into the pulmonary veins.
D The Trendelenburg position increases intrathoracic pressure, which
decreases the amount of blood pulled into the vena cava during aspiration.
She finds out that some managers have benevolent-authoritative style of
management. Which of the following behaviors will she exhibit most likely?

A Communicates downward to staffs.

Allows decision making among subordinates.
Have condescending trust and confidence in their subordinates.
Gives economic and ego awards

Benevolent-authoritative managers pretentiously show their trust and

confidence to their followers.

A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV

drip factor is 60. The IV rate that will deliver this amount is:

A 24 cc/ hour
B 66 cc/ hour
50 cc/ hour
D 55 cc/ hour

A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8 hours =

50 cc/hr.

Which intervention should the nurse Trish use when administering oxygen by
D face mask to a female client?

A Secure the elastic band tightly around the client's head.

B Apply the face mask from the client's chin up over the nose.
C Loosen the connectors between the oxygen equipment and humidifier.
Assist the client to the semi-Fowler position if possible.
By assisting the client to the semi-Fowler position, the nurse promotes easier
chest expansion, breathing, and oxygen intake. The nurse should secure the
elastic band so that the face mask fits comfortably and snugly rather than
tightly, which could lead to irritation. The nurse should apply the face mask
from the client's nose down to the chin — not vice versa. The nurse should
check the connectors between the oxygen equipment and humidifier to
ensure that they're airtight; loosened connectors can cause loss of oxygen.

Cherry notes down ideas that were derived from the description of
an investigation written by the person who conducted it. Which type
of reference source refers to this?

A Footnote
Primary source

C dnotes
D Bibliography
This refers to a primary source which is a direct account of the investigation
done by the investigator. In contrast to this is a secondary source, which is
written by someone other than the original researcher.

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

A Excess fluid volume related to peripheral vascular disease.

Ineffective peripheral tissue perfusion related to venous congestion.

C Risk for injury related to edema.

Impaired gas exchange related to increased blood flow

Ineffective peripheral tissue perfusion related to venous congestion takes

the highest priority because venous inflammation and clot formation impede
blood flow in a client with deep vein thrombosis.
 Nurse Ron is observing a male client using a walker. The nurse determines
that the client is using the walker correctly if the client:
Walks into the walker, puts weight on the hand pieces, and then puts all four
A points of the walker flat on the floor.
Puts weight on the hand pieces, moves the walker forward, and then walks
B into it.
Puts weight on the hand pieces, slides the walker forward, and then walks
C into it.
Puts all the four points of the walker flat on the floor, puts weight on the
hand pieces, and then walks into it.

When the client uses a walker, the nurse stands adjacent to the affected side.
The client is instructed to put all four points of the walker 2 feet forward flat
on the floor before putting weight on hand pieces. This will ensure client
safety and prevent stress cracks in the walker. The client is then instructed to
move the walker forward and walk into it.

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

B Having more frequent aches and pains.

Failing eyesight, especially close vision.

D Accepting limitations while developing assets

Failing eyesight, especially close vision, is one of the first signs of aging in
middle life (ages 46 to 64). More frequent aches and pains begin in the early
late years (ages 65 to 79). Increase in loss of muscle tone occurs in later
years (age 80 and older).
Dr. Garcia writes the following order for the client who has been recently
admitted “Digoxin .125 mg P.O. once daily.” To prevent a dosage error, how
should the nurse document this order onto the medication administration
record?

A “Digoxin 0.1250 mg P.O. once daily”

B “Digoxin .125 mg P.O. once daily”
“Digoxin 0.125 mg P.O. once daily”
“Digoxin .1250 mg P.O. once daily”

The nurse should always place a zero before a decimal point so that no one
misreads the figure, which could result in a dosage error. The nurse should
never insert a zero at the end of a dosage that includes a decimal point
because this could be misread, possibly leading to a tenfold increase in the
dosage.

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

B Takes a set of vital signs.

C Reassure the client that everything will be alright.
D Call the radiology department for X-ray

If the nurse suspects a fracture, splinting the area before moving the client is
imperative. The nurse should call for emergency help if the client is not
hospitalized and call for a physician for the hospitalized client.
A female client with a fecal impaction frequently exhibits which clinical
manifestation?

A Loss of urge to defecate

B Increased appetite
Liquid or semi-liquid stools
Hard, brown, formed stools

Passage of liquid or semi-liquid stools results from seepage of unformed

bowel contents around the impacted stool in the rectum. Clients with fecal
impaction don't pass hard, brown, formed stools because the feces can't move
past the impaction. These clients typically report the urge to defecate (although
they can't pass stool) and a decreased appetite.

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

A Dorsal surface of the hand

Ulnar surface of the hand
Finger pads

D Fingertips
The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus,
thrills, and vocal vibrations through the chest wall. The fingertips and finger
pads best distinguish texture and shape. The dorsal surface best feels
warmth.

Marion is aware that the sampling method that gives equal chance to all units
in the population to get picked is:
Random
B Judgment
C Quota
Accidental

Random sampling gives equal chance for all the elements in the population
to be picked as part of the sample.
Nurse Reese is teaching a female client with peripheral vascular
disease about foot care; Nurse Reese should include which instruction?

A Avoid using a nail clipper to cut toenails.

D Avoid using cornstarch on feet.

C Avoid wearing cotton socks.

Avoid wearing canvas shoes.

The client should be instructed to avoid wearing canvas shoes. Canvas

shoes cause the feet to perspire, which may, in turn, cause skin irritation
and breakdown. Both cotton and cornstarch absorb perspiration. The client
should be instructed to cut toenails straight across with nail clippers.

A newly admitted female client was diagnosed with agranulocytosis. The

nurse formulates which priority nursing diagnosis?

A Deficient knowledge
Constipation

C Diarrhea
Risk for infection
Agranulocytosis is characterized by a reduced number of leukocytes
(leucopenia) and neutrophils (neutropenia) in the blood. The client is at high
risk for infection because of the decreased body defenses against
microorganisms. Deficient knowledge related to the nature of the disorder
may be appropriate diagnosis but is not the priority.
Nurse Betty is assigned to the following clients. The client that the nurse
would see first after endorsement?
A 63 year-old post operative’s abdominal hysterectomy client of three days
A whose incisional dressing is saturated with serosanguinous fluid.
A 26 year-old client admitted for dehydration whose intravenous (IV) has
B infiltrated.
A 44 year-old myocardial infarction (MI) client who is complaining of
nausea.
A 34 year-old post operative appendectomy client of five hours who is
D complaining of pain.

Nausea is a symptom of impending myocardial infarction (MI) and should be

assessed immediately so that treatment can be instituted and further damage
to the heart is avoided.

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

A Stage I
B Stage IV
Stage II
Stage III
Clinically, a deep crater or without undermining of adjacent tissue is noted

The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8

hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V.
infusion at a rate of:
32 drops/minute

B 18 drops/minute
30 drops/minute

D 20 drops/minute
Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60
minutes). Find the number of milliliters per minute as follows: (Look for no. 43
of TEXT MODE answers for the computation).

The nurse prepares to administer a cleansing enema. What is the

most common client position used for this procedure?

A Prone
B Lithotomy
C Supine
Sims’ left lateral
The Sims' left lateral position is the most common position used to administer
a cleansing enema because it allows gravity to aid the flow of fluid along the
curve of the sigmoid colon. If the client can't assume this position nor has
poor sphincter control, the dorsal recumbent or right lateral position may be
used. The supine and prone positions are inappropriate and uncomfortable for
the client.

When the license of nurse Krina is revoked, it means that she:

A Is no longer allowed to practice the profession for the rest of her life
B Will remain unable to practice professional nursing
May apply for re-issuance of his/her license based on certain conditions
stipulated in RA 9173

D Will never have her/his license re-issued since it has been revoked
RA 9173 sec. 24 states that for equity and justice, a revoked license maybe re-
issued provided that the following conditions are met: a) the cause for
revocation of license has already been corrected or removed; and, b) at least
four years has elapsed since the license has been revoked.
The nursing theorist who developed transcultural nursing theory is:
Madeleine Leininger

B Sr. Callista Roy

C Albert Moore
D Florence Nightingale

Madeleine Leininger developed the theory on transcultural theory based on

her observations on the behavior of selected people within a culture.

Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly

admitted client. Immediately afterward, the client may experience:

A Drowsiness or blurred vision.

B Tinnitus or diplopia.
Throbbing headache or dizziness
Nervousness or paresthesia.

D Headache and dizziness often occur when nitroglycerin is taken at the

beginning of therapy. However, the client usually develops tolerance

Ensuring that there is an informed consent on the part of the patient before a

surgery is done, illustrates the bioethical principle of:

A Veracity
Autonomy
Beneficence

D Non-maleficence
Informed consent means that the patient fully understands about the surgery,
including the risks involved and the alternative solutions. In giving consent it is
done with full knowledge and is given freely. The action of allowing the patient
to decide whether a surgery is to be done or not exemplifies the bioethical
principle of autonomy.

John plans to use a Likert Scale to his study to determine the:

A Level of satisfaction
B Compliance to expected standards
Degree of agreement and disagreement
Degree of acceptance
Likert scale is a 5-point summated scale used to determine the degree of
agreement or disagreement of the respondents to a statement in a study

Ronald plans to conduct a research on the use of a new method of

pain assessment scale. Which of the following is the second step in
D the conceptualizing phase of the research process?

A Formulating the research hypothesis

B Formulating and delimiting the research problem
Review related literature

D Design the theoretical and conceptual framework

After formulating and delimiting the research problem, the researcher
conducts a review of related literature to determine the extent of what has
been done on the study by previous researchers.

A client is admitted with multiple pressure ulcers. When developing

the client's diet plan, the nurse should include:
Fresh orange slices

B Ice cream
C Steamed broccoli
 Ground beef patties
Meat is an excellent source of complete protein, which this client needs to
repair the tissue breakdown caused by pressure ulcers.Oranges and broccoli
supply vitamin C but not protein. Ice cream supplies only some incomplete
protein, making it less helpful in tissue repair.

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

B Metabolic alkalosis
C Metabolic acidosis
D Respiratory alkalosis
The client has a below-normal (acidic) blood pH value and an above-normal
partial pressure of arterial carbon dioxide (Paco2) value, indicating respiratory
acidosis. In respiratory alkalosis, the pH value is above normal and in the
Paco2 value is below normal. In metabolic acidosis, the pH and bicarbonate
(Hco3) values are below normal. In metabolic alkalosis, the pH and Hco3
values are above normal.

Monica is aware that there are times when only manipulation of study
variables is possible and the elements of control or randomization are not
attendant. Which type of research is referred to this?

A Post-test only design

B Field study
C Solomon-Four group design
Quasi-experiment

Quasi-experiment is done when randomization and control of the variables

 are not possible.

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

B Increase the I.V. fluid infusion rate

C Notify the physician
D Irrigate the indwelling urinary catheter
Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour).
Therefore, this client's output is normal. Beyond continued evaluation, no
nursing action is warranted.

A male client is admitted and diagnosed with acute pancreatitis after a

holiday celebration of excessive food and alcohol. Which assessment finding
reflects this diagnosis?

A Hyperactive bowel sounds

Sudden onset of continuous epigastric and back pain.

C Presence of crackles in both lung fields.

D Blood pressure above normal range.

The autodigestion of tissue by the pancreatic enzymes results in pain from

inflammation, edema, and possible hemorrhage. Continuous, unrelieved
epigastric or back pain reflects the inflammatory process in the pancreas.

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

A Palpation, percussion, and auscultation.

Auscultation, percussion, and palpation.

C Palpation, auscultation, and percussion.

D Percussion, palpation, and auscultation
The correct order of assessment for examining the abdomen is inspection,
auscultation, percussion, and palpation. The reason for this approach is that
the less intrusive techniques should be performed before the more intrusive
techniques. Percussion and palpation can alter natural findings during
auscultation.

Nurse Monique is monitoring the effectiveness of a client's drug

therapy. When should the nurse Monique obtain a blood sample to measure
the trough drug level?

A 30 minutes after administering the next dose.

Immediately before administering the next dose.
1 hour before administering the next dose.

D Immediately after administering the next dose.

Measuring the blood drug concentration helps determine whether the dosing
has achieved the therapeutic goal. For measurement of the trough, or lowest,
blood level of a drug, the nurse draws a blood sample immediately before
administering the next dose. Depending on the drug's duration of action and
half-life, peak blood drug levels typically are drawn after administering the
next dose.
Nurse Hazel will administer a unit of whole blood, which priority information
should the nurse have about the client?
Calcium and potassium levels
Blood pressure and pulse rate.

C Height and weight.

Hgb and Hct levels.

D The baseline must be established to recognize the signs of an anaphylactic

or hemolytic reaction to the transfusion.

Nurse Oliver is assessing a client's abdomen. Which finding should the nurse

report as abnormal?
Shifting dullness over the abdomen.

B Dullness over the liver.

C Bowel sounds occurring every 10 seconds.
D Vascular sounds heard over the renal arteries
Shifting dullness over the abdomen indicates ascites, an abnormal finding.
The other options are normal abdominal findings.

Nurse Marian is preparing to administer a blood transfusion. Which

action should the nurse take first?

A Measure the client’s vital signs.

Compare the client’s identification wristband with the tag on the unit of
blood.

C Start an I.V. infusion of normal saline solution.

Arrange for typing and cross matching of the client’s blood.
The nurse first arranges for typing and cross matching of the client's blood to
ensure compatibility with donor blood. The other options,although appropriate
when preparing to administer a blood transfusion, come later.
Ms. Garcia is responsible to the number of personnel reporting to her.
This principle refers to:
Span of control

B Leader
C Downward communication
D Unity of command
Span of control refers to the number of workers who report directly to a
manager.

A male client who has severe burns is receiving H2 receptor antagonist

therapy. The nurse In-charge knows the purpose of this therapy is to:

A Enhance gas exchange

Facilitate protein synthesis.

C Block prostaglandin synthesis

Prevent stress ulcer
Curling’s ulcer occurs as a generalized stress response in burn patients. This
results in a decreased production of mucus and increased secretion of gastric
acid. The best treatment for this prophylactic use of antacids and H2 receptor
blockers.

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

B State the client’s name out loud and wait a client to repeat it.
C Check the room number and the client’s name on the bed.
Check the client’s identification band
Checking the client’s identification band is the safest way to verify a client’s
identity because the band is assigned on admission and isn’t be removed at
any time. (If it is removed, it must be replaced). Asking the client’s name or
having the client repeated his name would be appropriate only for a client
who’s alert, oriented, and able to understand what is being said, but isn’t the
safe standard of practice. Names on bed aren’t always reliable

Harry knows that he has to protect the rights of human research subjects.
Which of the following actions of Harry ensures anonymity?

A Provide equal treatment to all the subjects of the study.

Keep the identities of the subject secret

C Obtain informed consent

D Release findings only to the participants of the study

Keeping the identities of the research subject secret will ensure anonymity
because this will hinder providing link between the information given to
whoever is its source.

Nurse Amy has an order to obtain a urinalysis from a male client with an
indwelling urinary catheter. The nurse avoids which of the following, which
contaminate the specimen?

A Clamping the tubing of the drainage bag.

Obtaining the specimen from the urinary drainage bag.

C Wiping the port with an alcohol swab before inserting the syringe.
Aspirating a sample from the port on the drainage bag.

A urine specimen is not taken from the urinary drainage bag. Urine
D undergoes chemical changes while sitting in the bag and does not
necessarily reflect the current client status. In addition, it may become
contaminated with bacteria from opening the system.

Nurse May is aware that the main advantage of using a floor stock system is:

A The nurse receives input from the pharmacist.

B The system reinforces accurate calculations.
The nurse can implement medication orders quickly.

D The system minimizes transcription errors.

A floor stock system enables the nurse to implement medication orders
quickly. It doesn't allow for pharmacist input, nor does it minimize
transcription errors or reinforce accurate calculations.

A male client complains of abdominal discomfort and nausea while receiving

tube feedings. Which intervention is most appropriate for this problem?

A Change the feeding container every 12 hours.

B Place the client in semi-Fowler's position while feeding.
C Give the feedings at room temperature.
Decrease the rate of feedings and the concentration of the formula.

Complaints of abdominal discomfort and nausea are common in clients

receiving tube feedings. Decreasing the rate of the feeding and the
concentration of the formula should decrease the client's discomfort.
Feedings are normally given at room temperature to minimize abdominal
cramping. To prevent aspiration during feeding, the head of the client's bed
should be elevated at least 30 degrees. Also, to prevent bacterial growth,
feeding containers should be routinely changed every 8 to 12 hours.

The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as

needed, to control a client’s postoperative pain. The package insert is
“Meperidine, 100 mg/ml.” How many milliliters of meperidine should the client
receive?
0.25
0.75
C 0.6
D 0.5
To determine the number of milliliters the client should receive, the nurse uses
the fraction method in the following equation. (Look for no. 37 of the TEXT
MODE to see the solution)

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

A 1.5 cc
2.5 cc
5 cc

D .5 cc
2.5 cc is to be added, because only a 500 cc bag of solution is being
medicated instead of a 1 liter.

Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse
quickly looks at the monitor and notes that a client is in a ventricular
tachycardia. The nurse rushes to the client’s room. Upon reaching the client’s
bedside, the nurse would take which action first?

A Prepare for cardioversion

Call a code

C Prepare to defibrillate the client

Check the client’s level of consciousnes
Determining unresponsiveness is the first step assessment action to
take. When a client is in ventricular tachycardia, there is a significant decrease
in cardiac output. However, checking the unresponsiveness ensures whether
the client is affected by the decreased cardiac output.
In preventing the development of an external rotation deformity of the hip in a
client who must remain in bed for any period of time, the most appropriate
nursing action would be to use:
Trochanter roll extending from the crest of the ileum to the midthigh.

B Pillows under the lower legs.

C Hip-abductor pillow
Footboard

D A trochanter roll, properly placed, provides resistance to the external rotation

of the hip.

A 65 years old male client requests his medication at 9 p.m. instead of

10 p.m. so that he can go to sleep earlier. Which type of nursing intervention is
required?

A Interdependent
Intradependent
Independent

D Dependent
Nursing interventions are classified as independent, interdependent, or
dependent. Altering the drug schedule to coincide with the client's daily
routine represents an independent intervention, whereas consulting with the
physician and pharmacist to change a client's medication because of adverse
reactions represents an interdependent intervention. Administering an
already-prescribed drug on time is a dependent intervention. An
intradependent nursing intervention doesn't exist.
When Nurse Trish is providing care to his patient, she must remember that her
duty is bound not to do doing any action that will cause the patient harm. This
is the meaning of the bioethical principle:

A Justice
B Solidarity
Beneficence
Non-maleficence
Non-maleficence means do not cause harm or do any action that will cause
any harm to the patient/client. To do good is referred as beneficence.

Nurse Oliver must apply an elastic bandage to a client’s ankle and calf. He
should apply the bandage beginning at the client’s:

A Knee
Foot

C Ankle
D Lower thigh
An elastic bandage should be applied form the distal area to the proximal
area. This method promotes venous return. In this case, the nurse should
begin applying the bandage at the client’s foot. Beginning at the ankle, lower
thigh, or knee does not promote venous return.

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

A I.V
B Oral
C S.C
 I.M
With a platelet count of 22,000/μl, the clients tends to bleed easily. Therefore,
the nurse should avoid using the I.M. route because the area is a highly
vascular and can bleed readily when penetrated by a needle. The bleeding can
be difficult to stop.

Which nursing intervention takes highest priority when caring for a

newly admitted client who's receiving a blood transfusion?

A Documenting blood administration in the client care record.

Assessing the client’s vital signs when the transfusion ends.
Instructing the client to report any itching, swelling, or dyspnea.

D Informing the client that the transfusion usually take 1 ½ to 2 hours.

Because administration of blood or blood products may cause serious
adverse effects such as allergic reactions, the nurse must monitor the client
for these effects. Signs and symptoms of life-threatening allergic reactions
include itching, swelling, and dyspnea. Although the nurse should inform the
client of the duration of the transfusion and should document its
administration, these actions are less critical to the client's immediate health.
The nurse should assess vital signs at least hourly during the transfusion.

Nurse Ronald is aware that the best tool for data gathering is?
Use of laboratory data

B Observation
Questionnaire

D Interview schedule
Incidence of nosocomial infection is best collected through the use of
biophysiologic measures, particularly in vitro measurements, hence laboratory
data is essential.
When the method of wound healing is one in which wound edges are not
surgically approximated and integumentary continuity is restored by
granulations, the wound healing is termed
Third intention healing

B First intention healing

Second intention healing

D Primary intention healing

When wounds dehisce, they will allowed to heal by secondary intention

A male client with a right pleural effusion noted on a chest X-ray is being
prepared for thoracentesis. The client experiences severe dizziness when
sitting upright. To provide a safe environment, the nurse assists the client to
which position for the procedure?
Left side-lying with the head of the bed elevated 45 degrees.

B Right side-lying with the head of the bed elevated 45 degrees.

C Sims’ position with the head of the bed flat.
Prone with head turned toward the side supported by a pillow
To facilitate removal of fluid from the chest wall, the client is positioned sitting
at the edge of the bed leaning over the bedside table with the feet supported
on a stool. If the client is unable to sit up, the client is positioned lying in bed
on the unaffected side with the head of the bed elevated 30 to 45 degrees.

An 80-year-old male client is admitted to the hospital with a diagnosis of

pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been
eating or drinking. When assessing him for dehydration, nurse Oliver would
expect to find:

A Hypertension
Distended neck veins
 Tachycardia

D Hypothermia
With an extracellular fluid or plasma volume deficit, compensatory
mechanisms stimulate the heart, causing an increase in heart rate.

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

Centigrade temperature?
38.9 °C

B 48 °C
C 40.1 °C
38 °C
To convert Fahrenheit degreed to Centigrade, look for no. 39 of TEXT MODE to
see the formula.

Which dietary guidelines are important for nurse Oliver to implement in caring
for the client with burns?

A Monitor intake to prevent weight gain.

B Provide high-fiber, high-fat diet
Provide high-protein, high-carbohydrate diet.
Provide ice chips or water intake.
D
A female client is to be discharged from an acute care facility after treatment
for right leg thrombophlebitis. The Nurse Betty notes that the client's leg is
pain-free, without redness or edema. The nurse's actions reflect which step of
the nursing process?

A Assessment
Evaluation

C Diagnosis
D Implementation
The nursing actions described constitute evaluation of the expected
outcomes. The findings show that the expected outcomes have been
achieved. Assessment consists of the client's history, physical examination,
and laboratory studies. Analysis consists of considering assessment
information to derive the appropriate nursing diagnosis. Implementation is the
phase of the nursing process where the nurse puts the plan of care into
action.

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

B Encourage family and friends to visit.

C Encourage the client to take frequent rest periods.
Admit the client into a private room
The client who has a radiation implant is placed in a private room and has a
limited number of visitors. This reduces the exposure of others to the
radiation.

When caring for a male client with a 3-cm stage I pressure ulcer on the
coccyx, which of the following actions can the nurse institute independently?

A Massaging the area with an astringent every 2 hours.

B Applying an antibiotic cream to the area three times per day.
C Using a povidone-iodine wash on the ulceration three times per day.
Using normal saline solution to clean the ulcer and applying a protective
dressing as necessary.
Washing the area with normal saline solution and applying a protective
dressing are within the nurse’s realm of interventions and will protect the area.
Using a povidone-iodine wash and an antibiotic cream require a physician’s
order. Massaging with an astringent can further damage the skin.

Nurse Len refers a female client with terminal cancer to a local hospice. What
is the goal of this referral?
To provide support for the client and family in coping with terminal illness.

B To ensure that the client gets counseling regarding health care costs.
C To help the client find appropriate treatment options.
D To teach the client and family about cancer and its treatment.
Hospices provide supportive care for terminally ill clients and their families.
Hospice care doesn’t focus on counseling regarding health care costs. Most
client referred to hospices have been treated for their disease without
success and will receive only palliative care in the hospice.

When a nurse in-charge causes an injury to a female patient and the

injury caused becomes the proof of the negligent act, the presence of the
injury is said to exemplify the principle of:

A Force majeure
B Holdover doctrine
C Respondeat superior
Res ipsa loquitor
Res ipsa loquitor literally means the thing speaks for itself. This means in
operational terms that the injury caused is the proof that there was a negligent
act.
Asking the questions to determine if the person understands the health
teaching provided by the nurse would be included during which step of the
nursing process?
Evaluation

B Assessment
C Planning and goals
Implementation
D Evaluation includes observing the person, asking questions, and comparing
the patient’s behavioral responses with the expected outcomes.

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

A Every 2 years
B Once, to establish baseline
Once per year

D Twice per year

Yearly mammograms should begin at age 40 and continue for as long as the
woman is in good health. If health risks, such as family history, genetic
tendency, or past breast cancer, exist, more frequent examinations may be
necessary.

The physician inserts a chest tube into a female client to treat a

pneumothorax. The tube is connected to water-seal drainage. The nurse in-
charge can prevent chest tube air leaks by:
Checking and taping all connections.

B Checking patency of the chest tube.

C Keeping the head of the bed slightly elevated.
Keeping the chest drainage system below the level of the chest.
Air leaks commonly occur if the system isn’t secure. Checking all connections
and taping them will prevent air leaks. The chest drainage system is kept
lower to promote drainage – not to prevent leaks.

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

A BP – 180/100, Pulse – 90 irregular

B BP – 130/80, Pulse – 100 regular
C BP – 90/50, Pulse – 50 regular
BP – 80/60, Pulse – 110 irregular
The classic signs of cardiogenic shock are low blood pressure, rapid and
weak irregular pulse, cold, clammy skin, decreased urinary output, and
cerebral hypoxia.

Mary finally decides to use judgment sampling on her research. Which of the
following actions of is correct?

A Decides to get 20 samples from the admitted patients

Assigns numbers for each of the patients, place these in a fishbowl and
B draw 10 from it.
C Plans to include whoever is there during his study.
Determines the different nationality of patients frequently admitted and
decides to get representations samples from each.
Judgment sampling involves including samples according to the knowledge
of the investigator about the participants in the study.
Tony, a basketball player twist his right ankle while playing on the court and
seeks care for ankle pain and swelling. After the nurse applies ice to the ankle
for 30 minutes, which statement by Tony suggests that ice application has
been effective?
“My ankle looks less swollen now”.

B “I need something stronger for pain relief”

“My ankle feels warm”.

D “My ankle appears redder now”.

Ice application decreases pain and swelling. Continued or increased pain,
redness, and increased warmth are signs of inflammation that shouldn't occur
after ice application

Which type of evaluation occurs continuously throughout the teaching and

learning process?

A Summative
B Retrospective
Formative

D Informative
Formative (or concurrent) evaluation occurs continuously throughout the
teaching and learning process. One benefit is that the nurse can adjust
teaching strategies as necessary to enhance learning. Summative, or
retrospective, evaluation occurs at the conclusion of the teaching and learning
session. Informative is not a type of evaluation.

In assisting a female client for immediate surgery, the nurse In-charge is

aware that she should:

A Encourage the client to void following preoperative medication.

B Encourage the client to drink water prior to surgery.
Assist the client in removing dentures and nail polish.
Explore the client’s fears and anxieties about the surgery.

Dentures, hairpins, and combs must be removed. Nail polish must be

removed so that cyanosis can be easily monitored by observing the nail
beds.

A male client with diabetes mellitus is receiving insulin. Which statement

correctly describes an insulin unit?

A It’s a common measurement in the metric system.

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

C It’s the basis for solids in the avoirdupois system.

It’s the smallest measurement in the apothecary system.
D An insulin unit is a measure of effect, not a standard measure of weight or
quantity. Different drugs measured in units may have no relationship to one
another in quality or quantity.

Nurse Meredith is in the process of giving a client a bed bath. In the middle of
the procedure, the unit secretary calls the nurse on the intercom to tell the
D nurse that there is an emergency phone call. The appropriate nursing action
is to:
Leave the client’s door open so the client can be monitored and the nurse
A can answer the phone call.

B Immediately walk out of the client’s room and answer the phone call.
C Finish the bed bath before answering the phone call.
Cover the client, place the call light within reach, and answer the phone call

Because telephone call is an emergency, the nurse may need to answer it. The
other appropriate action is to ask another nurse to accept the call. However, is
not one of the options. To maintain privacy and safety, the nurse covers the
client and places the call light within the client’s reach. Additionally, the
client’s door should be closed or the room curtains pulled around the bathing
area.