FUNDAMENTALS OF NURSING 2
The presence of any of
1. Which intervention is an example of primary
prevention?
A. Administering digoxin (Lanoxicaps) to a patient
with heart failure.
B. Administering measles, mumps, and rubella
immunization to an infant.
C. Obtaining a Papanicolaou smear to screen for
cervical cancer.
D. Using occupational therapy to help a patient cope
with arthritis.
Answer: B. Administering measles, mumps, and
rubella immunization to an infant.
Immunizing an infant is an example of primary
prevention, which aims to prevent health problems.
Primary prevention includes those preventive measures
that come before the onset of illness or injury and
before the disease process begins. Examples include
immunization and taking regular exercise to prevent
health problems developing in the future.
Option A: Administering digoxin to treat heart failure
and obtaining a smear for a screening test are examples
for secondary prevention, which promotes early
detection and treatment of disease. Those preventive
measures that lead to early diagnosis and prompt
treatment of a disease, illness, or injury to prevent
more severe problems developing. Here health
educators such as Health Extension Practitioners can
help individuals acquire the skills of detecting diseases
in their early stages.
Option C: Obtaining a Papanicolau smear is a
secondary prevention. Secondary prevention includes
those preventive measures that lead to early diagnosis
and prompt treatment of a disease, illness, or injury.
This should limit disability, impairment, or
dependency and prevent more severe health problems
developing in the future.
Option D: Using occupational therapy to help a patient
cope with arthritis is an example of tertiary prevention,
which aims to help a patient deal with the residual
consequences of a problem or to prevent the problem
from recurring. Tertiary prevention includes those
preventive measures aimed at rehabilitation following
significant illness. At this level, health educators work
to retrain, re-educate and rehabilitate the individual
who has already had an impairment or disability.
2. The nurse in charge is assessing a patient’s abdomen.
Which examination technique should the nurse use
first?
A. Auscultation
B. Inspection
C. Percussion
D. Palpation
Answer: B. Inspection
Inspection always comes first when performing a
physical examination. It is important to begin with the
general examination of the abdomen with the patient in
a completely supine position.
the following signs may indicate specific disorders.
Percussion and palpation of the abdomen may affect
bowel motility and therefore should follow
auscultation.
Option A: The last step of the abdominal examination
is auscultation with a stethoscope. The diaphragm of
the stethoscope should be placed on the right side of
the umbilicus to listen to the bowel sounds, and their
rate should be calculated after listening for at least two
minutes. Normal bowel sounds are low-pitched and
gurgling, and the rate is normally 2-5/min. Absent
bowel sounds may indicate paralytic ileus and
hyperactive rushes (borborygmi) are usually present in
small bowel obstruction and sometimes may be
auscultated in lactose intolerance.
Option C: A proper technique of percussion is
necessary to gain maximum information regarding the
abdominal pathology. While percussing, it is important
to appreciate tympany over air-filled structures such as
the stomach and dullness to percussion which may be
present due to an underlying mass or organomegaly
(for example, hepatomegaly or splenomegaly).
Option D: The ideal position for abdominal
examination is to sit or kneel on the right side of the
patient with the hand and forearm in the same
horizontal plane as the patient’s abdomen. There are
three stages of palpation that include the superficial or
light palpation, deep palpation, and organ palpation
and should be performed in the same order. Maneuvers
specific to certain diseases are also a part of abdominal
palpation.
3. Which statement regarding heart sounds is correct?
A. S1 and S2 sound equally loud over the entire
cardiac area.
B. S1 and S2 sound fainter at the apex.
C. S1 and S2 sound fainter at the base.
D. S1 is loudest at the apex, and S2 is loudest at the
base.
Answer: D. S1 is loudest at the apex, and S2 is
loudest at the base.
The S1 sound—the “lub” sound—is loudest at the apex
of the heart. It sounds longer, lower, and louder there
than the S2 sounds. The S2—the “dub” sound—is
loudest at the base. It sounds shorter, sharper, higher,
and louder there than S1. Heart sounds are created
from blood flowing through the heart chambers as the
cardiac valves open and close during the cardiac cycle.
Vibrations of these structures from the blood flow
create audible sounds — the more turbulent the blood
flow, the more vibrations that get created.
Option A: The S1 heart sound is produced as the mitral
and tricuspid valves close in systole. This structural
and hemodynamic change creates vibrations that are
audible at the chest wall. The mitral valve closing is
the louder component of S1. It also occurs sooner
because of the left ventricle contracts earlier in systole.
Option B: Changes in the intensity of S1 are more
attributable to forces acting on the mitral valve. Such
causes include a change in left ventricular contractility,
mitral structure, or the PR interval. However, under
normal resting conditions, the mitral and tricuspid
sounds occur close enough together not to be
discernible. The most common reasons for a split S1
are things that delay right ventricular contraction, like
a right bundle branch block.
Option C: The S2 heart sound is produced with the
closing of the aortic and pulmonic valves in diastole.
The aortic valve closes sooner than the pulmonic valve,
and it is the louder component of S2; this occurs
because the pressures in the aorta are higher than the
pulmonary artery.
4. The nurse in charge identifies a patient’s responses
to actual or potential health problems during which
step of the nursing process?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
Answer: B. Nursing diagnosis
The nurse identifies human responses to actual or
potential health problems during the nursing diagnosis
step of the nursing process. The formulation of a
nursing diagnosis by employing clinical judgment
assists in the planning and implementation of patient
care. The North American Nursing Diagnosis
Association (NANDA) provides nurses with an up to
date list of nursing diagnoses. A nursing diagnosis,
according to NANDA, is defined as a clinical
judgment about responses to actual or potential health
problems on the part of the patient, family or
community.
Option A: During the assessment step, the nurse
systematically collects data about the patient or family.
Assessment is the first step and involves critical
thinking skills and data collection; subjective and
objective. Subjective data involves verbal statements
from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake
and output, and height and weight.
Option C: During the planning step, the nurse develops
strategies to resolve or decrease the patient’s problem.
The planning stage is where goals and outcomes are
formulated that directly impact patient care based on
EDP guidelines. These patient-specific goals and the
attainment of such assist in ensuring a positive
outcome.
Option D: During the evaluation step, the nurse
determines the effectiveness of the plan of care. This
final step of the nursing process is vital to a positive
patient outcome. Whenever a healthcare provider
intervenes or implements care, they must reassess or
evaluate to ensure the desired outcome has been met.
Reassessment may frequently be needed depending
upon overall patient condition. The plan of care may
be adapted based on new assessment data.
5. A female patient is receiving furosemide (Lasix), 40
mg P.O. b.i.D. in the plan of care, the nurse should
emphasize teaching the patient about the importance of
consuming:
A. Fresh, green vegetables
B. Bananas and oranges
C. Lean red meat
D. Creamed corn
Answer: B. Bananas and oranges
Because furosemide is a potassium-wasting diuretic,
the nurse should plan to teach the patient to increase
intake of potassium-rich foods, such as bananas and
oranges. Potassium is a mineral in the cells. It helps the
nerves and muscles work as they should. The right
balance of potassium also keeps the heart beating at a
steady rate. Fresh, green vegetables; lean red meat; and
creamed corn are not good sources of potassium.
Option A: GLVs are considered as natural caches of
nutrients for human beings as they are a rich source of
vitamins, such as ascorbic acid, folic acid,
tocopherols, ?-carotene, and riboflavin, as well as
minerals such as iron, calcium, and phosphorous.
Option C: Lean red meat is an excellent source of high
biological value protein, vitamin B12, niacin, vitamin
B6, iron, zinc, and phosphorus. It is a source of
long?chain omega?3 polyunsaturated fats, riboflavin,
pantothenic acid, selenium, and, possibly, also vitamin
D. It is also relatively low in fat and sodium.
Option D: Corn has several health benefits. Because of
the high fiber content, it can aid with digestion. It also
contains valuable B vitamins, which are important to
your overall health. Corn also provides our bodies with
essential minerals such as zinc, magnesium, copper,
iron, and manganese.
6.The nurse in charge must monitor a patient receiving
chloramphenicol for adverse drug reaction. What is the
most toxic reaction to chloramphenicol?
A. Lethal arrhythmias
B. Malignant hypertension
C. Status epilepticus
D. Bone marrow suppression
Answer: D. Bone marrow suppression
The most toxic reaction to chloramphenicol is bone
marrow suppression. Chloramphenicol is a
synthetically manufactured broad-spectrum antibiotic.
It was initially isolated from the bacteria Streptomyces
venezuelae in 1948 and was the first bulk produced
synthetic antibiotic. However, chloramphenicol is a
rarely used drug in the United States because of its
known severe adverse effects, such as bone marrow
toxicity and grey baby syndrome. Chloramphenicol is
not known to cause lethal arrhythmias, malignant
hypertension, or status epilepticus.
Option A: Chloramphenicol is associated with severe
hematological side effects when administered
systemically. Since 1982, chloramphenicol has
reportedly caused fatal aplastic anemia, with possible
increased risk when taken together with cimetidine.
This adverse side effect can occur even with the topical
administration of the drug, which is most likely due to
the systemic absorption of the drug after topical
application.
Option B: Besides causing fatal aplastic anemia and
bone marrow suppression, other side effects of
chloramphenicol include ototoxicity with the use of
topical ear drops, gastrointestinal reactions such as
oesophagitis with oral use, neurotoxicity, and severe
metabolic acidosis.
Option C: Optic neuritis is the most commonly
associated neurotoxic complication that can arise from
chloramphenicol use. This adverse effect usually takes
more than six weeks to manifest, presenting with either
acute or subacute vision loss, with possible fundal
changes. It may also present with peripheral
neuropathy, which may present as numbness or
tingling. If optic neuropathy occurs, the drug should be
withdrawn immediately, which will usually lead to
partial or complete recovery of vision.
7. A female patient is diagnosed with deep-vein
thrombosis. Which nursing diagnosis should receive
highest priority at this time?
A. Impaired gas exchanges related to increased blood
flow.
B. Fluid volume excess related to peripheral vascular
disease.
C. Risk for injury related to edema.
D. Altered peripheral tissue perfusion related to
venous congestion.
Answer: D. Altered peripheral tissue perfusion
related to venous congestion.
Altered peripheral tissue perfusion related to venous
congestion” takes highest priority because venous
inflammation and clot formation impede blood flow in
a patient with deep-vein thrombosis. A deep-vein
thrombosis (DVT) is a blood clot that forms within the
deep veins, usually of the leg, but can occur in the
veins of the arms and the mesenteric and cerebral veins.
Deep-vein thrombosis is a common and important
disease. It is part of the venous thromboembolism
disorders which represent the third most common
cause of death from cardiovascular disease after heart
attacks and stroke.
Option A: Option A is incorrect because impaired gas
exchange is related to decreased, not increased, blood
flow. Depending on the relative balance between the
coagulation and thrombolytic pathways, thrombus
propagation occurs. DVT is commonest in the lower
limb below the knee and starts at low-flow sites, such
as the soleal sinuses, behind venous valve pockets.
Option B: Option B is inappropriate because no
evidence suggests that this patient has a fluid volume
excess. Nurses need to educate the patients on the
importance of ambulation, being compliant with
compression stockings, and taking the prescribed
anticoagulation medications.
Option C: Option C may be warranted but is secondary
to altered tissue perfusion. Thrombosis is a protective
mechanism that prevents the loss of blood and seals off
damaged blood vessels. Fibrinolysis counteracts or
stabilizes the thrombosis. The triggers of venous
thrombosis are frequently multifactorial, with the
different parts of the triad of Virchow contributing in
varying degrees in each patient, but all result in early
thrombus interaction with the endothelium. This then
stimulates local cytokine production and causes
leukocyte adhesion to the endothelium, both of which
promote venous thrombosis.
8. When positioned properly, the tip of a central
venous catheter should lie in the:
A. Superior vena cava
B. Basilica vein
C. Jugular vein
D. Subclavian vein
Answer: A. Superior vena cava
When the central venous catheter is positioned
correctly, its tip lies in the superior vena cava, inferior
vena cava, or the right atrium—that is, in central
venous circulation. Blood flows unimpeded around the
tip, allowing the rapid infusion of large amounts of
fluid directly into circulation. The basilica, jugular, and
subclavian veins are common insertion sites for central
venous catheters.
Option B: There are three main access sites for the
placement of central venous catheters. The internal
jugular vein, common femoral vein, and subclavian
veins are the preferred sites for temporary central
venous catheter placement. Additionally, for mid-term
and long-term central venous access, the basilic and
brachial veins are utilized for peripherally inserted
central catheters (PICCs).
Option C: The internal jugular vein (IJ) is often chosen
for its reliable anatomy, accessibility, low
complication rates, and the ability to employ
ultrasound guidance during the procedure. The
individual clinical scenario may dictate laterality in
some cases (such as with trauma, head and neck cancer,
or the presence of other invasive devices or catheters),
but all things being equal, many physicians prefer the
right IJ. As compared to the left, the right IJ forms a
more direct path to the superior vena cava (SVC) and
right atrium. It is also wider in diameter and more
superficial, thus presumably easier to cannulated.
Option D: The subclavian vein site has the advantage
of low rates of both infectious and thrombotic
complications. Additionally, the SC site is accessible
in trauma, when a cervical collar negates the choice of
the IJ. However, disadvantages include a higher
relative risk of pneumothorax, less accessibility to use
ultrasound for CVC placement, and the
non-compressible location posterior to the clavicle.
9. Nurse Nikki is revising a client’s care plan. During
which step of the nursing process does such revision
take place?

A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: D. Evaluation
During the evaluation step of the nursing process, the
nurse determines whether the goals established in the
care plan have been achieved, and evaluates the
success of the plan. If a goal is unmet or partially met
the nurse reexamines the data and revises the plan.
This final step of the nursing process is vital to a
positive patient outcome. Whenever a healthcare
provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has
been met. Reassessment may frequently be needed
depending upon overall patient condition. The plan of
care may be adapted based on new assessment data.
Assessment involves data collection. Planning involves
setting priorities, establishing goals, and selecting
appropriate interventions.
Option A: Assessment is the first step and involves
critical thinking skills and data collection; subjective
and objective. Subjective data involves verbal
statements from the patient or caregiver. Objective
data is measurable, tangible data such as vital signs,
intake and output, and height and weight.
Option B: The planning stage is where goals and
outcomes are formulated that directly impact patient
care based on EDP guidelines. These patient-specific
goals and the attainment of such assist in ensuring a
positive outcome. Nursing care plans are essential in
this phase of goal setting. Care plans provide a course
of direction for personalized care tailored to an
individual’s unique needs. Overall condition and
comorbid conditions play a role in the construction of a
care plan. Care plans enhance communication,
documentation, reimbursement, and continuity of care
across the healthcare continuum.
Option C: Implementation is the step that involves
action or doing and the actual carrying out of nursing
interventions outlined in the plan of care. This phase
requires nursing interventions such as applying a
cardiac monitor or oxygen, direct or indirect care,
medication administration, standard treatment
protocols, and EDP standards.
10. A 65-year-old female who has diabetes mellitus
and has sustained a large laceration on her left wrist
asks the nurse, “How long will it take for my scars to
disappear?” Which statement would be the
nurse’s best response?
A. “The contraction phase of wound healing can take
2 to 3 years.”
B. “Wound healing is very individual but within 4
months the scar should fade.
C. “With your history and the type of location of the
injury, it’s hard to say.”
D. “If you don’t develop an infection, the wound
should heal any time between 1 and 3 years from
now.”
Answer: C. “With your history and the type of
location of the injury, it’s hard to say.”
Wound healing in a client with diabetes will be
delayed. Providing the client with a time frame could
give the client false information. There is no doubt that
diabetes plays a detrimental role in wound healing. It
does so by affecting the wound healing process at
multiple steps. Wound hypoxia, through a combination
of impaired angiogenesis, inadequate tissue perfusion,
and pressure-related ischemia, is a major driver of
chronic diabetic wounds.
Option A: Ischemia can lead to prolonged
inflammation, which increases the levels of oxygen
radicals, leading to further tissue injury. Elevated
levels of matrix metalloproteases in chronic diabetic
wounds, sometimes up to 50-100 times higher than
acute wounds, cause tissue destruction and prevent
normal repair processes from taking place.
Furthermore, diabetes is associated with impaired
immunity, with critical defects occurring at multiple
points within the immune system cascade of the wound
healing process.
Option B: To further complicate matters, these wounds
have defects in angiogenesis and neovascularization.
Normally, wound hypoxia stimulates mobilization of
endothelial progenitor cells via vascular endothelial
growth factor (VEGF). In diabetic wounds, there are
aberrant levels of VEGF and other angiogenic factors
such as angiopoietin-1 and angiopoietin-2 that lead to
dysangiogenesis.
Option D: Diabetic neuropathy may also play a role in
poor wound healing. Lower levels of neuropeptides, as
well as reduced leukocyte infiltration as a result of
sensory denervation, have been shown to impair
wound healing. When combined, all these diverse
factors play a role in the formation and propagation of
chronic, debilitating wounds in patients with diabetes.
11. One aspect of implementation related to drug
therapy is:
A. Developing a content outline.
B. Documenting drugs given.
C. Establishing outcome criteria.
D. Setting realistic client goals.
Answer: B. Documenting drugs given.
Although documentation isn’t a step in the nursing
process, the nurse is legally required to document
activities related to drug therapy, including the time of
administration, the quantity, and the client’s reaction.
Developing a content outline, establishing outcome
criteria, and setting realistic client goals are part of
planning rather than implementation.
Option A: UE has a common goal with the
pharmaceutical care it supports: to improve an
individual patient’s quality of life through the
achievement of predefined, medication-related
therapeutic outcomes. Through its focus on the system
of medication use, the MUE process helps to identify
actual and potential medication-related problems,
resolve actual medication-related problems, and
prevent potential medication-related problems that
could interfere with achieving optimum outcomes from
medication therapy.
Option C: Although distinctions historically have been
made among the terms drug-use evaluation, drug-use
review, and medication use evaluation (MUE), they all
refer to the systematic evaluation of medication use
employing standard, observational
quality-improvement methods. MUE is a
quality-improvement activity, but it also can be
considered a formulary system management technique.
An MUE is a performance improvement method that
focuses on evaluating and improving medication-use
processes with the goal of optimal patient outcomes.
Option D: MUE encompasses the goals and objectives
of drug use evaluation (DUE) in its broadest
application, emphasizing improving patient outcomes.
The use of MUE, rather than DUE, emphasizes the
need for a more multifaceted approach to improving
medication use.
12. A female client is readmitted to the facility with a
warm, tender, reddened area on her right calf. Which
contributing factor would the nurse recognize
as most important?
A. A history of increased aspirin use.
B. Recent pelvic surgery.
C. An active daily walking program.
D. A history of diabetes.
Answer: B. Recent pelvic surgery
The client shows signs of deep vein thrombosis (DVT).
The pelvic area is rich in blood supply, and
thrombophlebitis of the deep vein is associated with
pelvic surgery. Thrombosis is a protective mechanism
that prevents the loss of blood and seals off damaged
blood vessels. Fibrinolysis counteracts or stabilizes the
thrombosis. The triggers of venous thrombosis are
frequently multifactorial, with the different parts of the
triad of Virchow contributing in varying degrees in
each patient, but all result in early thrombus interaction
with the endothelium. This then stimulates local
cytokine production and causes leukocyte adhesion to
the endothelium, both of which promote venous
thrombosis.
Option A: Aspirin, an antiplatelet agent, and an active
walking program help decrease the client’s risk of
DVT. The use of thrombolytic therapy can result in an
intracranial bleed, and hence, careful patient selection
is vital. Recently endovascular interventions like
catheter-directed extraction, stenting, or mechanical
thrombectomy have been tried with moderate success.
Option C: Treatment of DVT aims to prevent
pulmonary embolism, reduce morbidity, and prevent or
minimize the risk of developing post-thrombotic
syndrome. The cornerstone of treatment is
anticoagulation. NICE guidelines only recommend
treating proximal DVT (not distal) and those with
pulmonary emboli. In each patient, the risks of
anticoagulation need to be weighed against the
benefits.
Option D: In general, diabetes is a contributing factor
associated with peripheral vascular disease. In the
hospital, the most commonly associated conditions are
malignancy, congestive heart failure, obstructive
airway disease, and patients undergoing surgery. In the
hospital, the most commonly associated conditions are
malignancy, congestive heart failure, obstructive
airway disease, and patients undergoing surgery.
13. Which intervention should the nurse in charge try
first for a client that exhibits signs of sleep
disturbance?
A. Administer sleeping medication before bedtime.
B. Ask the client each morning to describe the
quantity of sleep during the previous night.
C. Teach the client relaxation techniques, such as
guided imagery, medication, and progressive muscle
relaxation.
D. Provide the client with normal sleep aids, such as
pillows, back rubs, and snacks.
Answer: D. Provide the client with normal sleep
aids, such as pillows, back rubs, and snacks
The nurse should begin with the simplest interventions,
such as pillows or snacks, before interventions that
require greater skill such as relaxation techniques.
Sleep is a complex biological process. It is a reversible
state of unconsciousness in which there are reduced
metabolism and motor activity. Sleep disorders are a
group of conditions that disturb the normal sleep
patterns of a person. Sleep disorders are one of the
most common clinical problems encountered.
Inadequate or non-restorative sleep can interfere with
normal physical, mental, social, and emotional
functioning. Sleep disorders can affect overall health,
safety, and quality of life.
Option A: Sleep medication should be avoided
whenever possible. Histamine type 1 receptor blockers:
due to their sedative effects, these drugs can be helpful
in patients with sleep disorders. Benzodiazepines
(BZD) are the mainstay in the treatment of insomnia.
Non-benzodiazepine hypnotics are used for the
treatment of acute and short term insomnia.
Option B: At some point, the nurse should do a
thorough sleep assessment, especially if common sense
interventions fail. The sleep diary, or sleep log, is a
subjective paper record of sleep and wakefulness over
a period of weeks to a month. Patients should record
the detailed description of sleep, such as bedtime,
duration until sleep onset, the number of awakenings,
duration of awakenings, and nap times.
Option C: Relaxation techniques may be implemented
before sleep. Meditation and breathing exercises are
some of the relaxation techniques. It begins with being
in a comfortable position and closing eyes. The mind
and thoughts should be redirected towards a peaceful
image, and relaxation should be allowed to spread
throughout the body.
14. While examining a client’s leg, the nurse notes an
open ulceration with visible granulation tissue in the
wound. Until a wound specialist can be contacted,
which type of dressings is most appropriate for the
nurse in charge to apply?
A. Dry sterile dressing
B. Sterile petroleum gauze
C. Moist, sterile saline gauze
D. Povidone-iodine-soaked gauze
Answer: C. Moist, sterile saline gauze
Moist, sterile saline dressings support would heal and
are cost-effective. If the wound is infected and there
are a lot of sloughs, which cannot be mechanically
debrided, then a chemical debridement can be done
with collagenase-based products. The goal is to help
the wound heal as soon as possible by using an
appropriate dressing material to maintain the right
amount of moisture. When the wound bed is dry, use a
dressing to increase moisture and if too wet and the
surrounding skin is macerated, use material that will
absorb excess fluid and protect the surrounding healthy
skin.
Option A: Dry sterile dressings adhere to the wound
and debride the tissue when removed. Tulle is a
non-adherent dressing impregnated with paraffin. It
aids healing but doesn’t absorb exudate. It also
requires a secondary dressing to hold it in place. It is
ideal for burns as one can add topical antibiotics to the
dressing. It is known to cause allergies, and this limits
its wider use.
Option B: Petroleum supports healing but is expensive.
The semipermeable dressing allows for moisture to
evaporate and also reduces pain. This dressing also
acts as a barrier to prevent environmental
contamination. The semipermeable dressing does not
absorb moisture and requires regular inspection. It also
requires a secondary dressing to hold the
semipermeable dressing in place.
Option D: Povidone-iodine can irritate epithelial cells,
so it shouldn’t be left on an open wound. Plastic film
dressings are known to absorb exudate and can be used
for wounds with a moderate amount of exudate. They
should not be used on dry wounds. They often require
a secondary dressing to hold the plastic in place.
15. A male client in a behavioral-health facility
receives a 30-minute psychotherapy session, and the
provider uses a current procedure terminology (CPT)
code that bills for a 50-minute session. Under the False
Claims Act, such illegal behavior is known as:
A. Unbundling
B. Overbilling
C. Upcoding
D. Misrepresentation
Answer: C. Upcoding
Upcoding is the practice of using a CPT code that’s
reimbursed at a higher rate than the code for the
service actually provided. Upcoding is fraudulent
medical billing in which a bill sent for a health service
is more expensive than it should have been based on
the service that was performed. An upcoded bill can be
sent to any payer—whether a private health insurer,
Medicaid, Medicare, or the patient. Unbundling,
overbilling, and misrepresentation aren’t the terms
used for this illegal practice.
Option A: Unbundling refers to using multiple CPT
codes for those parts of the procedure, either due to
misunderstanding or in an effort to increase payment.
Option B: Overbilling (sometimes spelled as
over-billing) is the practice of charging more than is
legally or ethically acceptable on an invoice or bill.
Option D: A misrepresentation is a false statement of a
material fact made by one party which affects the other
party’s decision in agreeing to a contract. If the
misrepresentation is discovered, the contract can be
declared void, and depending on the situation, the
adversely impacted party may seek damages.
16. A nurse assigned to care for a postoperative male
client who has diabetes mellitus. During the
assessment interview, the client reports that he’s
impotent and says that he’s concerned about its effect
on his marriage. In planning this client’s care,
the most appropriate intervention would be to:
A. Encourage the client to ask questions about
personal sexuality.
B. Provide time for privacy.
C. Provide support for the spouse or significant other.
D. Suggest referral to a sex counselor or other
appropriate professional.
Answer: D. Suggest referral to a sex counselor or
other appropriate professional
The nurse should refer this client to a sex counselor or
other professional. Making appropriate referrals is a
valid part of planning the client’s care. Therefore,
providing time for privacy and providing support for
the spouse or significant other are important, but not as
important as referring the client to a sex counselor.
Option A: The nurse doesn’t normally provide sex
counseling. The nurse is ideally placed in the primary
care field to help ease the upset caused; however, in
order to offer care that is effective, insight and
understanding of the condition are required as well as
the various treatment options available to help men
manage their health and wellbeing.
Option B: The key goal of management is to diagnose
and treat the cause of ED when this is possible,
enabling the man or couple to enjoy a satisfactory
sexual experience. This can occur when the nurse has
identified and treated any curable causes of ED,
initiating lifestyle change and risk factor modification,
including drug-related factors, and offering education
and counselling to patients and their partners.
Option C: The potential benefits of lifestyle changes
(e.g. weight management, smoking cessation) may be
particularly important in individuals with ED and
specific comorbid cardiovascular or metabolic diseases,
such as diabetes or hypertension. As well as improving
erectile function, lifestyle changes may also benefit
overall cardiovascular and metabolic health. Further
studies are needed to clarify the role of lifestyle
changes in the management of ED and related
cardiovascular disease.
17.Using Abraham Maslow’s hierarchy of human
needs, a nurse assigns highest priority to which client
need?
A. Security
B. Elimination
C. Safety
D. Belonging
Answer: B. Elimination
According to Maslow, elimination is a first-level or
physiological need and therefore takes priority over all
other needs. In 1943, Abraham Maslow developed a
hierarchy based on basic fundamental needs innate for
all individuals. Maslow’s hierarchy of needs is a
motivational theory in psychology comprising a
five-tier model of human needs, often depicted as
hierarchical levels within a pyramid. From the bottom
of the hierarchy upwards, the needs are: physiological
(food and clothing), safety (job security), love and
belonging needs (friendship), esteem, and
self-actualization. Security and safety are second-level
needs; belonging is a third-level need. Second- and
third-level needs can be met only after a client’s
first-level needs have been satisfied.
Option A: Once an individual’s physiological needs
are satisfied, the needs for security and safety become
salient. People want to experience order, predictability,
and control in their lives. These needs can be fulfilled
by the family and society (e.g. police, schools,
business, and medical care).
Option C: Physiological and safety needs provide the
basis for the implementation of nursing care and
nursing interventions. For example, emotional security,
financial security (e.g. employment, social welfare),
law and order, freedom from fear, social stability,
property, health, and wellbeing (e.g. safety against
accidents and injury).
Option D: After physiological and safety needs have
been fulfilled, the third level of human needs is social
and involves feelings of belongingness. The need for
interpersonal relationships motivates behavior.
Examples include friendship, intimacy, trust, and
acceptance, receiving and giving affection and love.
Affiliating, being part of a group (family, friends,
work)
18. A male client on prolonged bed rest has developed
a pressure ulcer. The wound shows no signs of healing
even though the client has received skin care and has
been turned every 2 hours. Which factor is most likely
responsible for the failure to heal?
A. Inadequate vitamin D intake.
B. Inadequate protein intake.
C. Inadequate massaging of the affected area.
D. Low calcium level.
Answer: B. Inadequate protein intake.
A client on bed rest suffers from a lack of movement
and a negative nitrogen balance. Therefore, inadequate
protein intake impairs wound healing. Decubitus ulcers,
also termed bedsores or pressure ulcers, are skin and
soft tissue injuries that form as a result of constant or
prolonged pressure exerted on the skin. These ulcers
occur at bony areas of the body such as the ischium,
greater trochanter, sacrum, heel, malleolus (lateral than
medial), and occiput. Inadequate vitamin D intake and
low calcium levels aren’t factors in poor healing for
this client. A pressure ulcer should never be massaged.
Option A: Decubitus ulcer formation is multifactorial
(external and internal factors), but all these results in a
common pathway leading to ischemia and necrosis.
Tissues can sustain an abnormal amount of external
pressure, but constant pressure exerted over a
prolonged period is the main culprit.
Option C: External pressure must exceed the arterial
capillary pressure (32 mmHg) to impede blood flow
and must be greater than the venous capillary closing
pressure (8 to 12 mmHg) to impair the return of
venous blood. If the pressure above these values is
maintained, it causes tissue ischemia and further
resulting in tissue necrosis. This enormous pressure
can be exerted due to compression by a hard mattress,
railings of hospital beds, or any hard surface with
which the patient is in contact.
Option D: Friction caused by skin rubbing against
surfaces like clothing or bedding can also lead to the
development of ulcers by contributing to breaks in the
superficial layers of the skin. Moisture can cause ulcers
and worsens existing ulcers via tissue breakdown and
maceration.
19. A female client who received general anesthesia
returns from surgery. Postoperatively, which nursing
diagnosis takes highest priority for this client?
A. Acute pain related to surgery.
B. Deficient fluid volume related to blood and fluid
loss from surgery.
C. Impaired physical mobility related to surgery.
D. Risk for aspiration related to anesthesia.
Answer: D. Risk for aspiration related to
anesthesia.
Risk for aspiration related to anesthesia takes priority
for this client because general anesthesia may impair
the gag and swallowing reflexes, possibly leading to
aspiration. The gag reflex, also known as the
pharyngeal reflex, is a reflex contraction of the
muscles of the posterior pharynx after stimulation of
the posterior pharyngeal wall, tonsillar area, or base of
the tongue. The gag reflex is believed to be an
evolutionary reflex that developed as a method to
prevent the aspiration of solid food particles. It is an
essential component of evaluating the medullary
brainstem and plays a role in the declaration of brain
death.The other options, although important, are
secondary.
Option A: Postoperative pain can additionally
characterize as somatic or visceral. The somatic
division of pain is composed of a rich input of
nociceptive myelinated, rapidly conducting
A-beta-fibers found in cutaneous and deep tissue,
which contribute to a more localized, sharp quality.
The visceral division of pain is composed of a network
of unmyelinated C-fibers and thinly myelinated
A-delta-fibers that span across multiple viscera and
converge together before entering the spinal cord. Also,
visceral afferent fibers run close to autonomic ganglia
before their entrance into the dorsal root of the spinal
cord. These characteristic features of visceral
nociceptive fibers are what contribute to a more diffuse,
poorly localized pattern of pain that may be
accompanied by autonomic reactions such as a change
in heart rate or blood pressure.
Option B: The acid-base and electrolyte changes
observed in the perioperative period could be
secondary to the underlying illness or surgical
procedure, for example, hyponatremia occurring with
transurethral resection of the prostate where glycine or
other hypotonic fluid is used for irrigation. Serum
sodium concentration <120 mmol/L will cause
confusion and irritability, whereas <110 mmol/L may
cause seizures and coma.
Option C: Complete physiologic recovery takes place
by 40 min in 40% of the patients. The functional
quality of recovery in all domains occurs in only 11%
of the patients by day 3. Thus, the concept of
awakening is involved with far greater dimensions than
judging the anesthetic effect as terminated and
assessing a patient as being “recovered” or “awakened.”
Patients cannot be considered fully recovered until
they have returned to their preoperative physiological
state.
20. The nurse inspects a client’s back and notices small
hemorrhagic spots. The nurse documents that the client
has:
A. Extravasation
B. Osteomalacia
C. Petechiae
D. Uremia
Answer: C. Petechiae
Petechiae are small hemorrhagic spots. Petechiae are
tiny purple, red, or brown spots on the skin. They
usually appear on the arms, legs, stomach, and
buttocks. They can also be found inside the mouth or
on the eyelids. These pinpoint spots can be a sign of
many different conditions — some minor, others
serious. They can also appear as a reaction to certain
medications.
Option A: Extravasation is the leakage of fluid in the
interstitial space. Extravasation is the leakage of a fluid
out of its container into the surrounding area,
especially blood or blood cells from vessels. In the
case of inflammation, it refers to the movement of
white blood cells from the capillaries to the tissues
surrounding them (leukocyte extravasation, also
known as diapedesis).
Option B: Osteomalacia is the softening of bone tissue.
Osteomalacia refers to a marked softening of the bones,
most often caused by severe vitamin D deficiency. The
softened bones of children and young adults with
osteomalacia can lead to bowing during growth,
especially in weight-bearing bones of the legs.
Osteomalacia in older adults can lead to fractures.
Option D: Uremia is an excess of urea and other
nitrogen products in the blood. Uremia is the condition
of having high levels of urea in the blood. Urea is one
of the primary components of urine. It can be defined
as an excess of amino acid and protein metabolism end
products, such as urea and creatinine, in the blood that
would be normally excreted in the urine.
21. Which document addresses the client’s right to
information, informed consent, and treatment refusal?
A. Standard of Nursing Practice
B. Patient’s Bill of Rights
C. Nurse Practice Act
D. Code for Nurses
Answer: B. Patient’s Bill of Rights
The Patient’s Bill of Rights addresses the client’s right
to information, informed consent, timely responses to
requests for services, and treatment refusal. A legal
document, it serves as a guideline for the nurse’s
decision making. Standards of Nursing Practice, the
Nurse Practice Act, and the Code for Nurses contain
nursing practice parameters and primarily describe the
use of the nursing process in providing care.
Option A: Standards of nursing practice developed by
the American Nurses’ Association (ANA) provide
guidelines for nursing performance. They are the rules
or definition of what it means to provide competent
care. The registered professional nurse is required by
law to carry out care in accordance with what other
reasonably prudent nurses would do in the same or
similar circumstances. Thus, provision of high-quality
care consistent with established standards is critical.
Option C: Every state and territory in the US set laws
to govern the practice of nursing. These laws are
defined in the Nursing Practice Act (NPA). The NPA
is then interpreted into regulations by each state and
territorial nursing board with the authority to regulate
the practice of nursing care and the power to enforce
the laws.
Option D: The ANA Code of Ethics for Nurses serves
the following purposes: It is a succinct statement of the
ethical obligations and duties of every individual who
enters the nursing profession. It is the profession’s
nonnegotiable ethical standard. It is an expression of
nursing’s own understanding of its commitment to
society.
22. If a blood pressure cuff is too small for a client,
blood pressure readings taken with such a cuff may do
which of the following?
A. Fail to show changes in blood pressure.
B. Produce a false-high measurement.
C. Cause sciatic nerve damage.
D. Produce a false-low measurement.
Answer: B. Produce a false-high measurement.
Using an undersized blood pressure cuff produces a
falsely elevated blood pressure because the cuff can’t
record brachial artery measurements unless it’s
excessively inflated.
Option A: Using a blood pressure cuff that’s too large
or too small can give inaccurate blood pressure
readings. The doctor’s office should have several sizes
of cuffs to ensure an accurate blood pressure reading.
When one measures their blood pressure at home, it’s
important to use the proper size cuff.
Option C: The sciatic nerve wouldn’t be damaged by
hyperinflation of the blood pressure cuff because the
sciatic nerve is located in the lower extremity.
Option D: The inflatable part of the blood pressure cuff
should cover about 40% of the distance around
(circumference of) the upper arm. The cuff should
cover 80% of the area from the elbow to the shoulder.
23. Nurse Elijah has been teaching a client about a
high-protein diet. The teaching is successful if the
client identifies which meal as high in protein?
A. Baked beans, hamburger, and milk
B. Spaghetti with cream sauce, broccoli, and tea
C. Bouillon, spinach, and soda
D. Chicken cutlet, spinach, and soda
Answer: A. Baked beans, hamburger, and milk
Baked beans, hamburger, and milk are all excellent
sources of protein. Good choices include soy protein,
beans, nuts, fish, skinless poultry, lean beef, pork, and
low-fat dairy products. Avoid processed meats.
Option B: The spaghetti-broccoli-tea choice is high in
carbohydrates. The quality of the carbohydrates (carbs)
one eats is important too. Cut processed carbs from the
diet, and choose carbs that are high in fiber and
nutrient-dense, such as whole grains and vegetables
and fruit.
Option C: The bouillon-spinach-soda choice provides
liquid and sodium as well as some iron, vitamins, and
carbohydrates.
Option D: Chicken provides protein but the
chicken-spinach-soda combination provides less
protein than the baked beans-hamburger-milk
selection.
24. A male client is admitted to the hospital with blunt
chest trauma after a motor vehicle accident.
The first nursing priority for this client would be to:
A. Assess the client’s airway.
B. Provide pain relief.
C. Encourage deep breathing and coughing.
D. Splint the chest wall with a pillow.
Answer: A. Assess the client’s airway.
The first priority is to evaluate airway patency before
assessing for signs of obstruction, sternal retraction,
stridor, or wheezing. Airway management is always
the nurse’s first priority. Blunt trauma, on the whole, is
a more common cause of traumatic injuries and can be
equally life-threatening. It is important to know the
mechanism as management may be different. Most
blunt trauma is managed non-operatively, whereas
penetrating chest trauma often requires operative
intervention. Pain management and splinting are
important for the client’s comfort but would come after
airway assessment.
Option B: Pain control greatly affects mortality and
morbidity in patients with chest trauma. Pain leads to
splints which worsen or prevent healing. In many cases,
it can lead to pneumonia. Early analgesia should be
considered to decrease splinting. In the acute setting,
push doses of short-acting narcotics should be used.
Option C: Coughing and deep breathing may be
contraindicated if the client has internal bleeding and
other injuries. Minor injuries may simply require close
monitoring and pain control. Care should be taken in
the young and the elderly. Patients with 3 or more rib
fractures, a flail segment, and any number of rib
fractures with pulmonary contusions,
hemopneumothorax, hypoxia, or pre-existing
pulmonary disease should be monitored at an advanced
level of care.
Option D: Immediate life-threatening injuries require
prompt intervention, such as emergent tube
thoracostomy for large pneumothoraces, and initial
management of hemothorax. For cases of hemothorax,
adequate drainage is imperative to prevent retained
hemothorax. Retained hemothorax can lead to
empyema requiring video-assisted thoracoscopic
surgery.
25. A newly hired charge nurse assesses the staff
nurses as competent individually but ineffective and
unproductive as a team. In addressing her concern, the
charge nurse should understand that the usual reason
for such a situation is:
A. Unhappiness about the charge in leadership.
B. Unexpected feelings and emotions among the staff.
C. Fatigue from overwork and understaffing.
D. Failure to incorporate staff in decision making.
Answer: B. Unexpected feelings and emotions
among the staff.
The usual or most prevalent reason for lack of
productivity in a group of competent nurses is
inadequate communication or a situation in which the
nurses have unexpected feelings and emotions.
Although the other options could be contributing to the
problematic situation, they’re less likely to be the
cause.
Option A: Providing employees with acknowledgment
of the good work that they have done is one of the
easiest management tasks. However, it is also as easily
neglected. For instance, a study in the financial sector
shows that only 20% of employees feel strongly valued
at work.
Option C: Another big issue that causes low
productivity is workplace stress. A study by Health
Advocate shows that there are about one million
employees who are suffering from low productivity
due to stress, which costs companies $600 dollars per
worker every single year.
Option D: An important reason for low employee
productivity might be the fact that they do not feel that
they belong with the company that they are part of. It
is important for every manager to make sure that the
environment in their business is welcoming to new
hires and does not make them feel underappreciated.
26. A male client blood test results are as follows:
white blood cell (WBC) count, 100ul; hemoglobin (Hb)
level, 14 g/dl; hematocrit (HCT), 40%. Which goal
would be most important for this client?
A. Promote fluid balance
B. Prevent infection
C. Promote rest
D. Prevent injury
Answer: B. Prevent infection
The client is at risk for infection because WBC count
is dangerously low. Neutrophils play an essential role
in immune defenses because they ingest, kill, and
digest invading microorganisms, including fungi and
bacteria. Failure to carry out this role leads to
immunodeficiency, which is mainly characterized by
the presence of recurrent infections. Hb level and HCT
are within normal limits; therefore, fluid balance, rest,
and prevention of injury are inappropriate.
Option A: Neutrophils play a role in the immune
defense against extracellular bacteria, including
Staphylococci, Streptococci, and Escherichia coli,
among others. They also protect against fungal
infections, including those produced by Candida
albicans. Once their count is below 1 x 10/L recurrent
infections start. As compensation, the monocyte count
may increase.
Option C: Application of granulocyte-colony
stimulating factor (G-CSF) can improve neutrophil
functions and number. Prophylactic use of antibiotics
and antifungals is reserved for some forms of alteration
in neutrophil function such as chronic granulomatous
disease CGD).
Option D: In primary neutropenia disorders such as
chronic granulomatous disease presents with recurrent
infections affecting many organs since childhood. It is
caused by a failure to produce toxic reactive oxygen
species so that the neutrophils can ingest the
microorganisms, but they are unable to kill them, as a
significant consequence granuloma can obstruct organs
such as the stomach, esophagus, or bladder. Patients
with this disease are very susceptible to opportunistic
infections by certain bacteria and fungi, especially with
Serratia and Burkholderia.
27. Following a tonsillectomy, a female client returns
to the medical-surgical unit. The client is lethargic and
reports having a sore throat. Which position would
be most therapeutic for this client?
A. Semi-Fowler’s
B. Supine
C. High-Fowler’s
D. Side-lying
Answer: D. Side-lying
Because of lethargy, the post-tonsillectomy client is at
risk for aspirating blood from the surgical wound.
Therefore, placing the client in the side-lying position
until he awake is best. The semi-Fowler’s, supine, and
high-Fowler’s position don’t allow for adequate oral
drainage in a lethargic post-tonsillectomy client and
increase the risk of blood aspiration.
Option A: Semi-Fowler’s would not be able to
facilitate effective drainage. Bleeding is one of the
most common and feared complications following
tonsillectomy with or without adenoidectomy. A study
from 2009 to 2013 involving over one hundred
thousand children showed that 2.8% of children had
unplanned revisits for bleeding following
tonsillectomy, 1.6% percent of patients came through
the emergency department, and 0.8% required a
procedure.
Option B: Supine position predisposes the patient to
aspiration. Frequency is higher at night with 50% of
bleeding occurring between 10pm-1am and 6am-9am;
this is thought to be from changes in circadian rhythm,
vibratory effects of snoring on the oropharynx, or
drying of the oropharyngeal mucosa from mouth
breathing. Risk of bleeding in patients with known
coagulopathies may be significantly higher.
Option C: Tonsillectomy can be either extracapsular or
intracapsular. The “hot” extracapsular technique with
monopolar cautery is the most popular technique in the
United States.
28. The nurse inspects a client’s pupil size and
determines that it’s 2 mm in the left eye and 3 mm in
the right eye. Unequal pupils are known as:
A. Anisocoria
B. Ataxia
C. Cataract
D. Diplopia
Answer: A. Anisocoria
Unequal pupils are called anisocoria. Anisocoria, or
unequal pupil sizes, is a common condition. The varied
causes have implications ranging from life-threatening
to completely benign, and a clinically guided history
and examination is the first step in establishing a
diagnosis.
Option B: Ataxia is uncoordinated actions of
involuntary muscle use. Ataxia is a degenerative
disease of the nervous system. Many symptoms of
Ataxia mimic those of being drunk, such as slurred
speech, stumbling, falling, and incoordination. These
symptoms are caused by damage to the cerebellum, the
part of the brain that is responsible for coordinating
movement.
Option C: A cataract is an opacity of the eye’s lens. A
cataract is a clouding of the normally clear lens of the
eye. For people who have cataracts, seeing through
cloudy lenses is a bit like looking through a frosty or
fogged-up window. Clouded vision caused by cataracts
can make it more difficult to read, drive a car
(especially at night) or see the expression on a friend’s
face.
Option D: Diplopia is double vision. Diplopia is the
perception of 2 images of a single object. Diplopia
may be monocular or binocular. Monocular diplopia is
present when only one eye is open. Binocular diplopia
disappears when either eye is closed.
29. The nurse in charge is caring for an Italian client.
He’s complaining of pain, but he falls asleep right after
his complaint and before the nurse can assess his pain.
The nurse concludes that:
A. He may have a low threshold for pain.
B. He was faking pain.
C. Someone else gave him medication.
D. The pain went away.
Answer: A. He may have a low threshold for pain.
People of Italian heritage tend to verbalize discomfort
and pain. The pain was real to the client, and he may
need medication when he wakes up. Italian females
reported the highest sensitivity to both mechanical and
electrical stimulation, while Swedes reported the
lowest sensitivity. Mechanical pain thresholds differed
more across cultures than did electrical pain thresholds.
Cultural factors may influence response to type of pain
test.
Option B: Our pain threshold is the minimum point at
which something, such as pressure or heat, causes us
pain. For example, someone with a lower pain
threshold might start feeling pain when only minimal
pressure is applied to part of their body. Pain tolerance
and threshold varies from person to person.
Option C: When we feel pain, nearby nerves send
signals to the brain through the spinal cord. The brain
interprets this signal as a sign of pain, which can set
off protective reflexes. For example, when one touches
something very hot, the brain receives signals
indicating pain. This in turn can make one quickly pull
the hand away without even thinking.
Option D: Biofeedback is a type of therapy that helps
increase the awareness of how the body responds to
stressors and other stimuli. This includes pain. During
a biofeedback session, a therapist will teach the client
how to use relaxation techniques, breathing exercises,
and mental exercises to override the body’s response to
stress or pain.
30. A female client is admitted to the emergency
department with complaints of chest pain and shortness
of breath. The nurse’s assessment reveals jugular vein
distention. The nurse knows that when a client has
jugular vein distension, it’s typically due to:
A. A neck tumor
B. An electrolyte imbalance
C. Dehydration
D. Fluid overload
Answer: D. Fluid overload
Fluid overload causes the volume of blood within the
vascular system to increase. This increase causes the
vein to distend, which can be seen most obviously in
the neck veins. JVD is a sign of increased central
venous pressure (CVP). That’s a measurement of the
pressure inside the vena cava. CVP indicates how
much blood is flowing back into the heart and how
well the heart can move that blood into the lungs and
the rest of the body.
Option A: A neck tumor doesn’t typically cause
jugular vein distention. Right-sided heart failure is a
common cause. Right-sided heart failure usually
develops after a left-sided heart failure. The left
ventricle pumps blood out through the aorta to most of
the body. The right ventricle pumps blood to the lungs.
When the left ventricle’s pumping power weakens,
fluid can back up into the lungs. This eventually
weakens the right ventricle.
Option B: An electrolyte imbalance may result in fluid
overload, but it doesn’t directly contribute to jugular
vein distention. The pericardium is a thin, fluid-filled
sac that surrounds the heart. An infection of the
pericardium, called constrictive pericarditis, can
restrict the volume of the heart. As a result, the
chambers can’t fill with blood properly, so blood can
back up into veins, including the jugular veins.
Option C: Dehydration does not cause JVD. Another
common cause is pulmonary hypertension. Pulmonary
hypertension occurs when the pressure in your lungs
increases, sometimes as a result of changes to the
lining of the artery walls. This can also lead to
right-sided heart failure.
31. Critical thinking and the nursing process have
which of the following in common? Both:
A. Are important to use in nursing practice.
B. Use an ordered series of steps.
C. Are patient-specific processes.
D. Were developed specifically for nursing.

Answer: A. Are important to use in nursing
practice.
Nurses make many decisions: some require using the
nursing process, whereas others are not client related
but require critical thinking. Neither is linear. Critical
thinking applies to any discipline. n 1958, Ida Jean
Orlando started the nursing process that still guides
nursing care today. Defined as a systematic approach
to care using the fundamental principles of critical
thinking, client-centered approaches to treatment,
goal-oriented tasks, evidence-based practice (EDP)
recommendations, and nursing intuition. Holistic and
scientific postulates are integrated to provide the basis
for compassionate, quality-based care.
Option B: The nursing process has specific steps;
critical thinking does not. The nursing process
functions as a systematic guide to client-centered care
with 5 sequential steps. These are assessment,
diagnosis, planning, implementation, and evaluation.
Option C: The utilization of the nursing process to
guide care is clinically significant going forward in this
dynamic, complex world of patient care. Aging
populations carry with them a multitude of health
problems and inherent risks of missed opportunities to
spot a life-altering condition.
Option D: Critical thinking skills will play a vital role
as we develop plans of care for these patient
populations with multiple comorbidities and embrace
this challenging healthcare arena. Thus, the trend
towards concept-based curriculum changes will assist
us in the navigation of these uncharted waters.
32. In which step of the nursing process does the nurse
analyze data and identify client problems?
A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
Answer: B. Diagnosis
In the diagnosis phase, the nurse identifies the client’s
health status. The North American Nursing Diagnosis
Association (NANDA) provides nurses with an up to
date list of nursing diagnoses. A nursing diagnosis,
according to NANDA, is defined as a clinical
judgment about responses to actual or potential health
problems on the part of the patient, family, or
community.
Option A: In the assessment phase, the nurse gathers
data from many sources for analysis in the diagnosis
phase. Assessment is the first step and involves critical
thinking skills and data collection; subjective and
objective. Subjective data involves verbal statements
from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake
and output, and height and weight.
Option C: In the planning outcomes phase, the nurse
formulates goals and outcomes. The planning stage is
where goals and outcomes are formulated that directly
impact patient care based on EDP guidelines. These
patient-specific goals and the attainment of such assist
in ensuring a positive outcome. Nursing care plans are
essential in this phase of goal setting. Care plans
provide a course of direction for personalized care
tailored to an individual’s unique needs. Overall
condition and comorbid conditions play a role in the
construction of a care plan. Care plans enhance
communication, documentation, reimbursement, and
continuity of care across the healthcare continuum.
Option D: In the evaluation phase, which occurs after
implementing interventions, the nurse gathers data
about the client’s responses to nursing care to
determine whether client outcomes were met. This
final step of the nursing process is vital to a positive
patient outcome. Whenever a healthcare provider
intervenes or implements care, they must reassess or
evaluate to ensure the desired outcome has been met.
Reassessment may frequently be needed depending
upon overall patient condition. The plan of care may
be adapted based on new assessment data.
33. In which phase of the nursing process does the
nurse decide whether her actions have successfully
treated the client’s health problem?
A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
Answer: D. Evaluation
During the implementation phase, the nurse carries out
the interventions or delegates them to other health care
team members. During the evaluation phase, the nurse
judges whether her actions have been successful in
treating or preventing the identified client health
problem. This final step of the nursing process is vital
to a positive patient outcome. Whenever a healthcare
provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has
been met. Reassessment may frequently be needed
depending upon overall patient condition. The plan of
care may be adapted based on new assessment data.
Option A: In the assessment phase, the nurse gathers
data from many sources for analysis in the diagnosis
phase. Assessment is the first step and involves critical
thinking skills and data collection; subjective and
objective. Subjective data involves verbal statements
from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake
and output, and height and weight.
Option B: In the diagnosis phase, the nurse identifies
the client’s health status. The North American Nursing
Diagnosis Association (NANDA) provides nurses with
an up to date list of nursing diagnoses. A nursing
diagnosis, according to NANDA, is defined as a
clinical judgment about responses to actual or potential
health problems on the part of the patient, family or
community.
Option C: In the planning outcomes phase, the nurse
and client decide on goals they want to achieve. In the
intervention planning phase, the nurse identifies
specific interventions to help achieve the identified
goal. The planning stage is where goals and outcomes
are formulated that directly impact patient care based
on EDP guidelines. These patient-specific goals and
the attainment of such assist in ensuring a positive
outcome.
34.What is the most basic reason that self-knowledge
is important for nurses? Because it helps the nurse to:
A. Identify personal biases that may affect his
thinking and actions.
B. Identify the most effective interventions for a
patient.
C. Communicate more efficiently with colleagues,
patients, and families.
D. Learn and remember new procedures and
techniques.
Answer: A. Identify personal biases that may affect
his thinking and actions.
The most basic reason is that self-knowledge directly
affects the nurse’s thinking and the actions he chooses.
Indirectly, thinking is involved in identifying effective
interventions, communicating, and learning procedures.
However, because identifying personal biases affect all
the other nursing actions, it is the most basic reason.
Option B: In philosophy, “self-knowledge” standardly
refers to knowledge of one’s own sensations, thoughts,
beliefs, and other mental states. At least since
Descartes, most philosophers have believed that our
knowledge of our own mental states differs markedly
from our knowledge of the external world (where this
includes our knowledge of others’ thoughts).
Option C: Perhaps the most widely accepted view
along these lines is that self-knowledge, even if not
absolutely certain, is especially secure, in the following
sense: self-knowledge is immune from some types of
error to which other kinds of empirical
knowledge—most obviously, perceptual
knowledge—are vulnerable.
Option D: Self-awareness is important because when
we have a better understanding of ourselves, we are
able to experience ourselves as unique and separate
individuals. We are then empowered to make changes
and to build on our areas of strength as well as identify
areas where we would like to make improvements.
35. Arrange the steps of the nursing process in the
sequence in which they generally occur.
Assessment
Diagnosis
Planning outcomes
Planning interventions
Evaluation
The correct order is shown above.
Logically, the steps are assessment, diagnosis,
planning outcomes, planning interventions, and
evaluation. Keep in mind that steps are not always
performed in this order, depending on the patient’s
needs and that steps overlap.
Option A: Assessment is the first step and involves
critical thinking skills and data collection; subjective
and objective. Subjective data involves verbal
statements from the patient or caregiver. Objective
data is measurable, tangible data such as vital signs,
intake and output, and height and weight.
Option B: This final step of the nursing process is vital
to a positive patient outcome. Whenever a healthcare
provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has
been met. Reassessment may frequently be needed
depending upon overall patient condition. The plan of
care may be adapted based on new assessment data.
Option C: The planning stage is where goals and
outcomes are formulated that directly impact patient
care based on EDP guidelines. These patient-specific
goals and the attainment of such assist in ensuring a
positive outcome. Nursing care plans are essential in
this phase of goal setting. Care plans provide a course
of direction for personalized care tailored to an
individual’s unique needs. Overall condition and
comorbid conditions play a role in the construction of a
care plan. Care plans enhance communication,
documentation, reimbursement, and continuity of care
across the healthcare continuum.
Option D: Implementation is the step which involves
action or doing and the actual carrying out of nursing
interventions outlined in the plan of care. This phase
requires nursing interventions such as applying a
cardiac monitor or oxygen, direct or indirect care,
medication administration, standard treatment
protocols, and EDP standards.
Option E: The formulation of a nursing diagnosis by
employing clinical judgment assists in the planning
and implementation of patient care. The North
American Nursing Diagnosis Association (NANDA)
provides nurses with an up to date list of nursing
diagnoses. A nursing diagnosis, according to NANDA,
is defined as a clinical judgment about responses to
actual or potential health problems on the part of the
patient, family, or community.
36. How are critical thinking skills and critical thinking
attitudes similar? Both are:
A. Influences on the nurse's problem solving and
decision making.
B. Like feelings rather than cognitive activities.
C. Cognitive activities rather than feelings.
D. Applicable in all aspects of a person's life.
Answer: A. Influences on the nurse’s problem
solving and decision making.
Cognitive skills are used in complex thinking
processes, such as problem-solving and decision
making. Critical thinking attitudes determine how a
person uses her cognitive skills. Critical thinking
attitudes are traits of the mind, such as independent
thinking, intellectual curiosity, intellectual humility,
and fair-mindedness, to name a few. Critical thinking
skills refer to the cognitive activities used in complex
thinking processes. A few examples of these skills
involve recognizing the need for more information,
recognizing gaps in one’s own knowledge, and
separating relevant information from irrelevant data.
Critical thinking, which consists of intellectual skills
and attitudes, can be used in all aspects of life.
Option B: Critical Thinking is, in short, self-directed,
self-disciplined, self-monitored, and self-corrective
thinking. It presupposes assent to rigorous standards of
excellence and mindful command of their use. It
entails effective communication and problem-solving
abilities and a commitment to overcome our native
egocentrism and sociocentrism.
Option C: Critical Thinking is a domain-general
thinking skill. The ability to think clearly and
rationally is important whenever one chooses to do.
But critical thinking skills are not restricted to a
particular subject area. Being able to think well and
solve problems systematically is an asset for any
career.
Option D: A critical thinking attitude is related to the
motivation to try to reason well, but it can also
motivate an attempt to use various strategies to
overcome personal limitations. Additionally, a person
with a critical thinking attitude should often rely on the
expertise of others rather than trying to assess all
arguments on her own because expertise is often
required to properly evaluate an argument.
37. The nurse is preparing to admit a patient from the
emergency department. The transferring nurse reports
that the patient with chronic lung disease has a 30+
year history of tobacco use. The nurse used to smoke a
pack of cigarettes a day at one time and worked very
hard to quit smoking. She immediately thinks to
herself, “I know I tend to feel negative about people
who use tobacco, especially when they have a serious
lung condition; I figure if I can stop smoking, they
should be able to. I must remember how physically and
psychologically difficult that is, and be very careful not
to let it be judgmental of this patient.”
This best illustrates:
A. Theoretical knowledge
B. Self-knowledge
C. Using reliable resources
D. Use of the nursing process
Answer: B. Self-knowledge
Personal knowledge is self-understanding—awareness
of one’s beliefs, values, biases, and so on. That best
describes the nurse’s awareness that her bias can affect
her patient care. Self-knowledge refers to knowledge
of one’s own mental states, processes, and dispositions.
Most agree it involves a capacity for understanding the
representational properties of mental states and their
role in shaping behavior.
Option A: Theoretical knowledge consists of
information, facts, principles, and theories in nursing
and related disciplines; it consists of research findings
and rationally constructed explanations of phenomena.
Theoretical knowledge is a knowledge of why
something is true. A set of true affirmations (factual
knowledge) does not necessarily explain anything. In
order to explain something, it is necessary to state why
these truths are true. An explanation is required.
Option C: Using reliable resources is a critical thinking
skill. Critical thinking is, in short, self-directed,
self-disciplined, self-monitored, and self-corrective
thinking. It presupposes assent to rigorous standards of
excellence and mindful command of their use. It
entails effective communication and problem-solving
abilities and a commitment to overcome our native
egocentrism and sociocentrism.
Option D: The nursing process is a problem-solving
process consisting of the steps of assessing, diagnosing,
planning outcomes, planning interventions,
implementing, and evaluating. The nurse has not yet
met this patient, so she could not have begun the
nursing process.
38. Which organization’s standards require that all
patients be assessed specifically for pain?
A. American Nurses Association (ANA)
B. State nurse practice acts
C. National Council of State Boards of Nursing
(NCSBN)
D. The Joint Commission
Answer: D. The Joint Commission
The Joint Commission has developed assessment
standards, including that all clients be assessed for
pain.
Option A: The ANA has developed standards for
clinical practice, including those for assessment, but
not specifically for pain. The American Nurses
Association (ANA) is the premier organization
representing the interests of the nation’s 4 million
registered nurses. ANA is at the forefront of improving
the quality of health care for all. Founded in 1896, and
with members in all 50 states and U.S. territories,
ANA is the strongest voice for the profession.
Option B: State nurse practice acts regulate nursing
practice in individual states. An NPA is enacted by
state legislation and its purpose is to govern and guide
nursing practice within that state. An NPA is actually a
law and must be adhered to as law. Each state has a
Board of Nursing (BON) that interprets and enforces
the rules of the NPA.
Option C: The NCSBN asserts that the scope of
nursing includes a comprehensive assessment but does
not specifically include pain. National Council of State
Boards of Nursing (NCSBN) is an independent,
not-for-profit organization through which nursing
regulatory bodies act and counsel together on matters
of common interest and concern affecting public health,
safety, and welfare, including the development of
nursing licensure examinations.

39. Which of the following is an example of data that
should be validated?
A. The urinalysis report indicates there are white
blood cells in the urine.
B. The client states she feels feverish; you measure the
oral temperature at 98°F.
C. The client has clear breath sounds; you count a
respiratory rate of 18.
D. The chest x-ray report indicates the client has
pneumonia in the right lower lobe.
Answer: B. The client states she feels feverish; you
measure the oral temperature at 98°F.
Validation should be done when subjective and
objective data do not make sense. For instance, it is
inconsistent data when the patient feels feverish and
you obtain a normal temperature. The other distractors
do not offer conflicting data. Validation is not usually
necessary for laboratory test results.
Option A: When this test is positive and/or the WBC
count in urine is high, it may indicate that there is
inflammation in the urinary tract or kidneys. The most
common cause for WBCs in urine (leukocyturia) is a
bacterial urinary tract infection (UTI), such as a
bladder or kidney infection.
Option C: Breath sounds are the noises produced by
the structures of the lungs during breathing. Normal
lung sounds occur in all parts of the chest area,
including above the collarbones and at the bottom of
the rib cage. Using a stethoscope, the doctor may hear
normal breathing sounds, decreased or absent breath
sounds, and abnormal breath sounds. Normal
respiration rates for an adult person at rest range from
12 to 16 breaths per minute.
Option D: The most common organisms which cause
lobar pneumonia are Streptococcus pneumoniae, also
called pneumococcus, Haemophilus influenza, and
Moraxella catarrhalis. Mycobacterium tuberculosis, the
tubercle bacillus, may also cause lobar pneumonia if
pulmonary tuberculosis is not treated promptly.
40. Which of the following is an example of
appropriate behavior when conducting a client
interview?
A. Recording all the information on the
agency-approved form during the interview.
B. Asking the client, "Why did you think it was
necessary to seek health care at this time?"
C. Using precise medical terminology when asking the
client questions.
D. Sitting, facing the client in a chair at the client's
bedside, using active listening.
Answer: D. Sitting, facing the client in a chair at the
client’s bedside, using active listening.
Active listening should be used during an interview.
The nurse should face the patient, have relaxed posture,
and keep eye contact. Nonjudgmental interest in the
patient’s problems (active listening), empathy
(communicating to the patient an accurate assessment
of emotional state), and concern for the patient as a
unique person are among the most important tools in
the physician’s interpersonal repertoire. The difference
between interviewing a patient who is lying flat in bed
and one who is sitting in a chair can be striking. This
simple act can emphasize patient autonomy and active
involvement in the interview.
Option A: Note-taking interferes with eye contact. By
recognizing the patient’s emotions and responding to
them in a supportive manner, the clinician can conduct
an effective patient-centered interview.
Option B: Asking “why” may make the client
defensive. Frequently used opening questions include,
“What problems brought you to the hospital (or office)
today?” or “What kind of problems have you been
having recently?” or “What kind of problems would
you like to share with me?” These open-ended,
non-directive questions encourage the patient to report
any and all problems. At this point in the interview, it
is important to let the patient talk spontaneously rather
than restricting and directing the flow of information
with multiple questions.
Option C: The client may not understand medical
terminology or health care jargon. Questions should be
worded so that the patient has no difficulty
understanding what is being asked. Avoid using
technical terms and diagnostic labels. The
interviewer’s questions should indicate what type of
information is requested, but not what answer is
expected.
41. The nurse wishes to identify nursing diagnoses for
a patient. She can best do this by using a data
collection form organized according to: Select all that
apply.
A. A body systems model
B. A head-to-toe framework
C. Maslow's hierarchy of needs
D. Gordon's functional health patterns
E. Adaptation Model of Nursing
Answer: C & D
Nursing models produce a holistic database that is
useful in identifying nursing rather than medical
diagnoses. Body systems and Maslow’s hierarchy is
not a nursing model, but it is holistic, so it is
acceptable for identifying nursing diagnoses. Gordon’s
functional health patterns are a nursing model.
Option A: A body system model is not a nursing model.
It is a representation of all the systems of the body in a
figurine.
Option B: Head-to-toe framework is not a nursing
model, and they are not holistic; they focus on
identifying physiological needs or disease.
Option C: Maslow’s hierarchy of needs is a
motivational theory in psychology comprising a
five-tier model of human needs, often depicted as
hierarchical levels within a pyramid. From the bottom
of the hierarchy upwards, the needs are: physiological
(food and clothing), safety (job security), love and
belonging needs (friendship), esteem, and
self-actualization.
Option D: Gordon’s functional health patterns is a
method devised by Marjory Gordon to be used by
nurses in the nursing process to provide a more
comprehensive nursing assessment of the patient.
Option E: The Adaptation Model of Nursing is a
prominent nursing theory aiming to explain or define
the provision of nursing science. In her theory, Sister
Callista Roy’s model sees the individual as a set of
interrelated systems that strives to maintain a balance
between various stimuli.
42. The nurse is recording assessment data. She writes,
“The patient seems worried about his surgery. Other
than that, he had a good night.” Which errors did the
nurse make? Select all that apply.
A. Used a vague generality.
B. Did not use the patient's exact words.
C. Used a "waffle" word (e.g., appears).
D. Recorded an inference rather than a cue.
E. Did not record the patient’s vital signs.
Answer: A, C, D & E
The initial nursing assessment, the first step in the five
steps of the nursing process, involves the systematic
and continuous collection of data; sorting, analyzing,
and organizing that data; and the documentation and
communication of the data collected. Subjective and
objective data collection are an integral part of this
process.
Option A: The nurse recorded a vague generality: “he
has had a good night.” The assessment identifies
current and future care needs of the patient by allowing
the formation of a nursing diagnosis. The nurse
recognizes normal and abnormal patient physiology
and helps prioritize interventions and care.
Option B: The nurse did not use the patient’s exact
words, but she did not quote the patient at all, so that is
not one of her errors.
Option C: The nurse used the “waffle” word, “seems”
worried instead of documenting what the patient said
or did to lead her to that conclusion. Asking about how
the client feels and their response to those feelings is
part of a psychological assessment.
Option D: The nurse recorded these inferences:
worried and had a good night. The psychological
examination may include perceptions, whether
justifiable or not, on the part of the patient or client.
Religion and cultural beliefs are critical areas to
consider.
Option E: Part of the assessment includes data
collection by obtaining vital signs such as temperature,
respiratory rate, heart rate, blood pressure, and pain
level using age or condition appropriate pain scale.
43. A patient is admitted with shortness of breath, so
the nurse immediately listens to his breath sounds.
Which type of assessment is the nurse performing?
A. Ongoing assessment
B. Comprehensive physical assessment
C. Focused physical assessment
D. Psychosocial assessment
Answer: C. Focused physical assessment
The nurse is performing a focused physical assessment,
which is done to obtain data about an identified
problem, in this case shortness of breath. Detailed
nursing assessment of specific body system(s) relating
to the presenting problem or current concern(s) of the
patient. This may involve one or more body systems.
Option A: An ongoing assessment is performed as
needed, after the initial data are collected, preferably
with each patient contact. Repeat of the focused or
rapid emergency department assessment of a
prehospital patient to detect changes in condition and
to judge the effectiveness of treatment before or during
transport. Repeated every 5 minutes for an unstable
patient and every 15 minutes for a stable patient.
Option B: A comprehensive physical assessment
includes an interview and a complete examination of
each body system. A comprehensive health assessment
gives nurses insight into a patient’s physical status
through observation, the measurement of vital signs,
and self-reported symptoms. It includes a medical
history, a general survey, and a complete physical
examination.
Option D: A psychosocial assessment examines both
psychological and social factors affecting the patient.
The nurse conducting a psychosocial assessment
would gather information about stressors, lifestyle,
emotional health, social influences, coping patterns,
communication, and personal responses to health and
illness, to name a few aspects.
44. The nurse is assessing vital signs for a patient just
admitted to the hospital. Ideally, and if there are no
contraindications, how should the nurse position the
patient for this portion of the admission assessment?
A. Sitting upright.
B. Lying flat on the back with knees flexed.
C. Lying flat on the back with arms and legs fully
extended.
D. Side-lying with the knees flexed.
Answer: A. Sitting upright.
If the patient is able, the nurse should have the patient
sit upright to obtain vital signs in order to allow the
nurse to easily access the anterior and posterior chest
for auscultation of heart and breath sounds. It allows
for full lung expansion and is the preferred position for
measuring blood pressure. Additionally, patients might
be more comfortable and feel less vulnerable when
sitting upright (rather than lying down on the back) and
can have direct eye contact with the examiner.
However, other positions can be suitable when the
patient’s physical condition restricts the comfort or
ability of the patient to sit upright.
Option B: Lying flat on the back with knees flexed or
supine horizontal recumbent is most commonly used
during breast exam.
Option C: Lying flat on the back with arms and legs
fully extended can make the patient feel
uncomfortable.
Option D: Sim’s position is usually used to obtain
rectal temperature.
45. For all body systems except the abdomen, what is
the preferred order for the nurse to perform the
following examination techniques?
Inspection
Palpation
Percussion
Auscultation
The correct order is shown above.
Inspection begins immediately as the nurse meets the
patient, as she observes the patient’s appearance and
behavior. Observational data are not intrusive to the
patient. When performing assessment techniques
involving physical touch, the behavior, posture,
demeanor, and responses might be altered. Palpation,
percussion, and auscultation should be performed in
that order, except when performing an abdominal
assessment. During abdominal assessment,
auscultation should be performed before palpation and
percussion to prevent altering bowel sounds.
Option A: The ideal position for abdominal
examination is to sit or kneel on the right side of the
patient with the hand and forearm in the same
horizontal plane as the patient’s abdomen. There are
three stages of palpation that include the superficial or
light palpation, deep palpation, and organ palpation
and should be performed in the same order. Maneuvers
specific to certain diseases are also a part of abdominal
palpation.
Option B: The last step of the abdominal examination
is auscultation with a stethoscope. The diaphragm of
the stethoscope should be placed on the right side of
the umbilicus to listen to the bowel sounds, and their
rate should be calculated after listening for at least two
minutes. Normal bowel sounds are low-pitched and
gurgling, and the rate is normally 2-5/min. Absent
bowel sounds may indicate paralytic ileus and
hyperactive rushes (borborygmi) are usually present in
small bowel obstruction and sometimes may be
auscultated in lactose intolerance.
Option C: It is important to begin with the general
examination of the abdomen with the patient in a
completely supine position. The presence of any of the
following signs may indicate specific disorders.
Distension of the abdomen could be present due to
small bowel obstruction, masses, tumors, cancer,
hepatomegaly, splenomegaly, constipation, abdominal
aortic aneurysm, and pregnancy.
Option D: A proper technique of percussion is
necessary to gain maximum information regarding the
abdominal pathology. While percussing, it is important
to appreciate tympany over air-filled structures such as
the stomach and dullness to percussion which may be
present due to an underlying mass or organomegaly
(for example, hepatomegaly or splenomegaly)
46. The nurse is assessing a patient admitted to the
hospital with rectal bleeding. The patient had a hip
replacement 2 weeks ago. Which position should the
nurse avoid when examining this patient’s rectal area?
A. Sims'
B. Supine
C. Dorsal recumbent
D. Semi-Fowler's
Answer: A. Sims’
Sims’ position is typically used to examine the rectal
area. However, the position should be avoided if the
patient has undergone hip replacement surgery The
patient with a hip replacement can assume the supine,
dorsal recumbent, or semi-Fowler’s positions without
causing harm to the joint.
Option B: Supine position is lying on the back facing
upward. The supine position means lying horizontally
with the face and torso facing up, as opposed to the
prone position, which is face down. When used in
surgical procedures, it allows access to the peritoneal,
thoracic, and pericardial regions; as well as the head,
neck, and extremities.
Option C: The patient in dorsal recumbent is on his
back with knees flexed and soles of feet flat on the bed.
A position in which the patient lies on the back with
the lower extremities moderately flexed and rotated
outward. It is employed in the application of obstetrical
forceps, repair of lesions following parturition, vaginal
examination, and bimanual palpation.
Option D: In semi-Fowler’s position, the patient is
supine with the head of the bed elevated and legs
slightly elevated. The Semi-Fowler’s position is a
position in which a patient, typically in a hospital or
nursing home is positioned on their back with the head
and trunk raised to between 15 and 45 degrees,
although 30 degrees is the most frequently used bed
angle.
47. How should the nurse modify the examination for a
7-year-old child?
A. Ask the parents to leave the room before the
examination.
B. Demonstrate equipment before using it.
C. Allow the child to help with the examination.
D. Perform invasive procedures (e.g., otoscopic) last.
Answer: B. Demonstrate equipment before using it.
The nurse should modify his examination by
demonstrating equipment before using it to examine a
school-age child. The physical examination is often the
first direct contact between the nurse and the child.
Establishing a trusting relationship between the child
and the examiner is important. Throughout the
examination the nurse should be sensitive to the
cultural needs of and differences among children.
Providing a quiet, private environment for the history
and physical examination is important. The classic
systematic approach to the physical examination is to
begin at the head and proceed through the entire body
to the toes. When examining a child, however, the
examiner tailors the physical assessment to the child’s
age and developmental level.
Option A: The nurse should make sure parents are not
present during the physical examination of an
adolescent, but they usually help younger children feel
more secure. To establish trust with the school-age
child, the examiner asks the child questions the child
can answer. Children in elementary school will talk
about school, favorite friends, and activities. Older
school-age children may have to be encouraged to talk
about their school performance and activities. The
examiner encourages the parent to support and
reinforce the child’s participation in the examination.
Option C: The nurse should allow a preschooler to help
with the examination when possible, but not usually a
school-age child. The examination proceeds from head
to toe. Children of this age prefer a simple drape over
their underpants or a colorful examination gown, and
the examiner should be sensitive to the child’s modesty.
The examination is a wonderful opportunity to teach
the child about the body and personal care. The nurse
answers questions openly and in simple terms.
Option D: It is best to perform invasive procedures last
for all age groups; therefore, this does not represent a
modification. Toddlers are often fearful of invasive
procedures, so those should be performed last in this
age group.
48. The nurse must examine a patient who is weak and
unable to sit unaided or to get out of bed. How should
she position the patient to begin and perform most of
the physical examination?
A. Dorsal recumbent
B. Semi-Fowler's
C. Lithotomy
D. Sims'
Answer: B. Semi-Fowler’s
If a patient is unable to sit up, the nurse should place
him lying flat on his back, with the head of the bed
elevated. The Semi-Fowler’s position is a position in
which a patient, typically in a hospital or nursing home
is positioned on their back with the head and trunk
raised to between 15 and 45 degrees, although 30
degrees is the most frequently used bed angle.
Option A: Dorsal recumbent position is used for
abdominal assessment if the patient has abdominal or
pelvic pain. The patient in dorsal recumbent is on his
back with knees flexed and soles of feet flat on the
bed.
Option C: Lithotomy position is used for female pelvic
examination. It is similar to dorsal recumbent position,
except that the patient’s legs are well separated and
thighs are acutely flexed. Feet are usually placed in
stirrups. Fold sheet or bath blanket crosswise over
thighs and legs so that genital area is easily exposed.
Keep the patient covered as much as possible.
Option D: The patient in Sim’s position is on the left
side with right knee flexed against abdomen and left
knee slightly flexed. Left arm is behind the body; the
right arm is placed comfortably. Sims’ position is used
to examine the rectal area. In semi-Fowler’s position,
the patient is supine with the head of the bed elevated
and legs slightly elevated.
49. The nurse should use the diaphragm of the
stethoscope to auscultate which of the following?
A. Heart murmurs
B. Jugular venous hums
C. Bowel sounds
D. Carotid bruits
Answer: C. Bowel sounds
The bell of the stethoscope should be used to hear
low-pitched sounds, such as murmurs, bruits, and
jugular hums. The diaphragm should be used to hear
high-pitched sounds that normally occur in the heart,
lungs, and abdomen. The diaphragm is best for
higher-pitched sounds, like breath sounds and normal
heart sounds. The bell is best for detecting lower pitch
sounds, like some heart murmurs, and some bowel
sounds.
Option A: Earpieces should be angled forwards to
match the direction of the practitioner’s external
auditory meatus. The bell is used to hear low-pitched
sounds. Use for mid-diastolic murmur of mitral
stenosis or S3 in heart failure.
Option B: The stethoscope bell is lightly applied in
each supraclavicular fossa over the subclavian artery.
As usual, the examiner’s free hand palpates the
contralateral carotid pulse for timing purposes. If a
bruit is appreciated, firmly compress the patient’s
ipsilateral radial artery, noting the effect on the
murmur.
Option D: If the intensity of sound is greater above the
clavicle it is most likely a carotid bruit. If it is louder
below the clavicle it is most likely a heart murmur. Use
either the bell or the diaphragm when listening for the
carotid bruit, at a point just lateral to Adam’s apple.
50. The nurse calculates a body mass index (BMI) of
18 for a young adult woman who comes to the
physician’s office for a college physical. This patient is
considered:
A. Obese
B. Overweight
C. Average
D. Underweight
Answer: D. Underweight
For adults, BMI should range between 20 and 25.
Body mass index (BMI) is a person’s weight in
kilograms divided by the square of height in meters.
BMI is an inexpensive and easy screening method for
the weight category—underweight, healthy weight,
overweight, and obesity.
Option A: BMI greater than 30 is considered obese For
adults 20 years old and older, BMI is interpreted using
standard weight status categories. These categories are
the same for men and women of all body types and
ages.
Option B: BMI 25 to 29.9 is overweight. The
prevalence of adult BMI greater than or equal to 30
kg/m2 (obese status) has greatly increased since the
1970s. Recently, however, this trend has leveled off,
except for older women. Obesity has continued to
increase in adult women who are 60 years and older.
Option C: BMI less than 20 is considered underweight.
BMI can be a screening tool, but it does not diagnose
the body fatness or health of an individual. To
determine if BMI is a health risk, a healthcare provider
performs further assessments. Such assessments
include skinfold thickness measurements, evaluations
of diet, physical activity, and family history.
51. Using the principles of standard precautions, the
nurse would wear gloves in what nursing
interventions?
A. Providing a back massage.
B. Feeding a client.
C. Providing hair care.
D. Providing oral hygiene.
Answer: D. Providing oral hygiene
Doing oral care requires the nurse to wear gloves.
Standard precautions apply to the care of all patients,
irrespective of their disease state. These precautions
apply when there is a risk of potential exposure to (1)
blood; (2) all body fluids, secretions, and excretions,
except sweat, regardless of whether or not they contain
visible blood; (3) non-intact skin, and (4) mucous
membranes. This includes the use of hand hygiene and
personal protective equipment (PPE), with hand
hygiene being the single most important means to
prevent transmission of disease.
Option A: Must be worn when touching blood, body
fluids, secretions, excretions, mucous membranes, or
non-intact skin. Change when there is contact with
potentially infected material in the same patient to
avoid cross-contamination. Remove before touching
surfaces and clean items. Wearing gloves does not
mitigate the need for proper hand hygiene.
Option B: Hand washing after feeding the client is
sufficient. Handwashing with soap and water for at
least 40 to 60 seconds, making sure not to use clean
hands to turn off the faucet, must be performed if
hands are visibly soiled, after using the restroom, or if
potential exposure to spore-forming organisms.
Option C: Gloves are not needed in providing hair care.
Hand rubbing with alcohol applied generously to cover
hands completely should be performed and hands
rubbed until dry.
52. The nurse is preparing to take vital signs in an alert
client admitted to the hospital with dehydration
secondary to vomiting and diarrhea. What is
the best method used to assess the client’s
temperature?
A. Oral
B. Axillary
C. Radial
D. Heat sensitive tape
Answer: B. Axillary
Axilla is the most accessible body part in this situation.
Body temperature is a numerical expression of the
body’s heat and metabolic activity balance and can be
a major indicator of a person’s health status. Assessing
a patient’s body temperature is a common procedure
nurses perform to monitor for signs of infection,
environmental exposure, shock, ovulation, or
therapeutic response to medications or medical
procedures. A normal body temperature can be a
potentially positive sign that the patient isn’t
experiencing a disease process, infection, or trauma
and that the body’s cells, tissues, and organs aren’t
under metabolic distress.
Option A: The esophageal temperature probe (ETP) is
an 18-in (45.7 cm) long, thin, flexible catheter that has
a rounded tip that should be lubricated with
water-soluble lubricant before being placed through
the nares or mouth, extending into the esophagus at
least 2 to 3 in (5 to 7.6 cm). The external end portion
of the catheter has a small, coated wire with a plug that
can be attached to a telemetry monitor for continuous
temperature monitoring.
Option C: The ETP and RTP (rectal temperature probe)
are the same device but can be used in either orifice
depending on the patient’s medical condition. Again,
the tip should be lubricated with water-soluble
lubricant, and then placed approximately 3 in (7.6 cm)
inside the rectal vault. The RTP can also be attached to
a telemetry monitor cable for continuous temperature
monitoring.
Option D: This is a latex-free, disposable, adhesive
strip that can be applied to the forehead. These strips
contain embedded liquid crystals and chemical
compounds that react to the temperature (heat) of the
skin by changing colors. After it has been on the
forehead for approximately 2 minutes, the color will
illuminate a line and correlate numeric temperature.
The strips measure temperatures ranging from
96.6[degrees] F to 104.6[degrees] F (35.8[degrees] C
to 40.3[degrees] C). Consider use for infants, children,
and adults with cognitive deficits because they’re
painless.
53. A nurse obtained a client’s pulse and found the rate
to be above normal. The nurse document these findings
as:
A. Tachypnea
B. Hyperpyrexia
C. Arrhythmia
D. Tachycardia

Answer: D. Tachycardia
Tachycardia means rapid heart rate. Tachycardia refers
to a heart rate that’s too fast. How that’s defined may
depend on age and physical condition. Generally
speaking, for adults, a heart rate of more than 100
beats per minute (BPM) is considered too fast.
Option A: Tachypnea refers to rapid respiratory rate.
Tachypnea is a respiration rate greater than normal,
resulting in abnormally rapid breathing. In adult
humans at rest, any respiratory rate between 12 and 20
breaths is normal and tachypnea is indicated by a rate
greater than 20 breaths per minute.
Option B: Hyperpyrexia means increase in temperature.
Hyperpyrexia is another term for a very high fever.
The medical criterion for hyperpyrexia is when
someone is running a body temperature of more than
106.7°F or 41.5°C. Hyperpyrexia is an emergency that
needs immediate attention from a medical professional.
Option C: Arrhythmia means irregular heart rate. An
arrhythmia is a problem with the rate or rhythm of the
heartbeat. During an arrhythmia, the heart can beat too
fast, too slowly, or with an irregular rhythm. When a
heart beats too fast, the condition is called tachycardia.
When a heart beats too slowly, the condition is called
bradycardia.
54. Which of the following actions should the nurse
take to use wide base support when assisting a client to
get up in a chair?
A. Bend at the waist and place arms under the client’s
arms and lift.
B. Face the client, bend knees, and place hands-on
client’s forearm and lift.
C. Spread his or her feet apart.
D. Tighten his or her pelvic muscles.
Answer: B. Face the client, bend knees, and place
hands-on client’s forearm and lift.
This is the proper way of supporting the client to get
up in a chair that conforms to safety and proper body
mechanics. It is important to use proper body
mechanics as a health care professional for many
reasons, foremost of which is to prevent injuries to
both patient and provider. Health care professionals at
the front line, especially those who deliver direct care
to patients, are often in situations where they have to
assist with moving patients from one position to
another.
Option A: Keep the back straight throughout the
transfer to avoid bending or straining the back. Get as
close to the person as possible while still allowing
him/her to lean forward as needed to assist with the
transfer.
Option C: Allow the patient to help as much as
possible. Estimate the patient’s weight and mentally
practice. Make sure that the floor is free of any
obstacles or liquids. Keep your feet shoulder-width
apart. Keep the person (or object) as close to your body
as possible. Tighten your stomach muscles.
Option D: Position patients appropriately for transfer.
While standing in front of the patient, maintain proper
posture with the back straight and knees bent. Hold a
strong abdominal contraction. Position the body close
to the patient to decrease strain on the back. Before
movement, contract the abdominal muscles to protect
the back. Use the knees and the lower body during
transfer to decrease strain on the back.
55. A client had oral surgery following a motor vehicle
accident. The nurse assessing the client finds the skin
flushed and warm. Which of the following would be
the best method to take the client’s body temperature?
A. Oral
B. Axillary
C. Arterial line
D. Rectal
Answer: B. Axillary
Taking the temperature via the axilla is the most
appropriate route. Body temperature is a numerical
expression of the body’s heat and metabolic activity
balance and can be a major indicator of a person’s
health status. Assessing a patient’s body temperature is
a common procedure nurses perform to monitor for
signs of infection, environmental exposure, shock,
ovulation, or therapeutic response to medications or
medical procedures. A normal body temperature can
be a potentially positive sign that the patient isn’t
experiencing a disease process, infection, or trauma
and that the body’s cells, tissues, and organs aren’t
under metabolic distress.
Option A: Taking the temperature via the oral route is
incorrect since the client had oral surgery. The
esophageal temperature probe (ETP) is an 18-in (45.7
cm) long, thin, flexible catheter that has a rounded tip
that should be lubricated with water-soluble lubricant
before being placed through the nares or mouth,
extending into the esophagus at least 2 to 3 in (5 to 7.6
cm). The external end portion of the catheter has a
small, coated wire with a plug that can be attached to a
telemetry monitor for continuous temperature
monitoring.
Option C: A PiCCO thermodilution catheter (Pulsion
Medical Systems) containing a temperature thermistor
was inserted into the brachial artery at the antecubital
fossa and doubled as the arterial pressure monitoring
line and arterial blood sampling portal. This measured
brachial artery temperature from the time of insertion
to the time the patient left the operating room.
Option D: This is unnecessary. The ETP and RTP
(rectal temperature probe) are the same device but can
be used in either orifice depending on the patient’s
medical condition. Again, the tip should be lubricated
with water-soluble lubricant, and then placed
approximately 3 in (7.6 cm) inside the rectal vault. The
RTP can also be attached to a telemetry monitor cable
for continuous temperature monitoring.
56. A client who is unconscious needs frequent mouth
care. When performing mouth care, the best position of
a client is:
A. Fowler’s position
B. Side-lying
C. Supine
D. Trendelenburg
Answer: B. Side-lying
An unconscious client is best placed on his side when
doing oral care to prevent aspiration. An unconscious
patient is placed in the side-lying position when mouth
care is provided because this position prevents pooling
of secretions at the back of the oral cavity, thereby
reducing the risk of aspiration. Oral hygiene is
especially important for patients receiving oxygen
therapy, patients who have nasogastric tubes, and
patients who are NPO. Their oral mucosa dries out
much faster than normal due to their mouth-breathing.
Option A: A soft toothbrush or gauze-padded tongue
blade may be used to clean the teeth and mouth. The
patient should be positioned in the lateral position with
the head turned toward the side to provide for drainage
and to prevent aspiration.
Option C: This is the most common position for
surgery with a patient lying on his or her back with
head, neck, and spine in neutral positioning and arms
either adducted alongside the patient or abducted to
less than 90 degrees.
Option D: A variation of supine in which the head of
the bed is tilted down such that the pubic symphysis is
the highest point of the trunk facilitates venous return
and improves exposure during abdominal and
laparoscopic surgeries.
57. A client is hospitalized for the first time, which of
the following actions ensure the safety of the client?
A. Keep unnecessary furniture out of the way.
B. Keep the lights on at all times.
C. Keep side rails up at all times.
D. Keep all equipment out of view.
Answer: C. Keep side rails up at all time
Keeping the side rails up at all times ensures the safety
of the client. The risk of falling increases with age and
the number of times someone has been in hospital.
During the client’s hospital stay, he may be more
unsteady on his feet because of illness or surgery, or
because he is unfamiliar with the hospital environment
or is taking new medication.
Option A: Home health care providers need to know
the risk factors for falls and demonstrate effective
assessment and interventions for fall and injury
prevention. Falls are generally the result of a complex
set of intrinsic patient and extrinsic environmental
factors. Use of a fall-prevention program, standardized
tools, and an interdisciplinary approach may be
effective for reducing fall-related injuries.
Option B: Make sure the client’s pajamas, dressing
gown, and day clothes are the right length so they
don’t trip over them. Check that their slippers or other
footwear fit properly and are not slippery. If they have
to wear pressure stockings, wear slippers over them so
they do not slip.
Option D: Keep personal items and the call button
within reach to avoid standing and walking to get them.
Ask for help when in need to get out of bed to use the
toilet if not feeling at all unsteady.
58. A walk-in client enters the clinic with a chief
complaint of abdominal pain and diarrhea. The nurse
takes the client’s vital sign hereafter. What phrase of
the nursing process is being implemented here by the
nurse?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Answer: A. Assessment
Assessment is the first phase of the nursing process
where a nurse collects information about the client.
Assessment is the first step and involves critical
thinking skills and data collection; subjective and
objective. Subjective data involves verbal statements
from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake
and output, and height and weight.
Option B: Diagnosis is the formulation of the nursing
diagnosis from the information collected during the
assessment. The formulation of a nursing diagnosis by
employing clinical judgment assists in the planning
and implementation of patient care. The North
American Nursing Diagnosis Association (NANDA)
provides nurses with an up to date list of nursing
diagnoses. A nursing diagnosis, according to NANDA,
is defined as a clinical judgment about responses to
actual or potential health problems on the part of the
patient, family, or community.
Option C: In Planning, the nurse sets achievable and
measurable short and long-term goals. The planning
stage is where goals and outcomes are formulated that
directly impact patient care based on EDP guidelines.
These patient-specific goals and the attainment of such
assist in ensuring a positive outcome. Nursing care
plans are essential in this phase of goal setting. Care
plans provide a course of direction for personalized
care tailored to an individual’s unique needs. Overall
condition and comorbid conditions play a role in the
construction of a care plan. Care plans enhance
communication, documentation, reimbursement, and
continuity of care across the healthcare continuum.
Option D: Implementation is where nursing care is
given. Implementation is the step which involves
action or doing and the actual carrying out of nursing
interventions outlined in the plan of care. This phase
requires nursing interventions such as applying a
cardiac monitor or oxygen, direct or indirect care,
medication administration, standard treatment
protocols, and EDP standards.
59.It is best described as a systematic, rational method
of planning and providing nursing care for individual,
families, group, and community
A. Assessment
B. Nursing Process
C. Diagnosis
D. Implementation
Answer: B. Nursing Process
The statement describes the Nursing Process. The
Nursing Process is the essential core of practice for the
registered nurse to deliver holistic, patient-focused care.
Defined as a systematic approach to care using the
fundamental principles of critical thinking,
client-centered approaches to treatment, goal-oriented
tasks, evidence-based practice (EDP)
recommendations, and nursing intuition. Holistic and
scientific postulates are integrated to provide the basis
for compassionate, quality-based care.
Option A: Assessment is the first step and involves
critical thinking skills and data collection; subjective
and objective. Subjective data involves verbal
statements from the patient or caregiver. Objective
data is measurable, tangible data such as vital signs,
intake and output, and height and weight.
Option C: The formulation of a nursing diagnosis by
employing clinical judgment assists in the planning
and implementation of patient care. The North
American Nursing Diagnosis Association (NANDA)
provides nurses with an up to date list of nursing
diagnoses. A nursing diagnosis, according to NANDA,
is defined as a clinical judgment about responses to
actual or potential health problems on the part of the
patient, family, or community.
Option D: Implementation is the step which involves
action or doing and the actual carrying out of nursing
interventions outlined in the plan of care. This phase
requires nursing interventions such as applying a
cardiac monitor or oxygen, direct or indirect care,
medication administration, standard treatment
protocols, and EDP standards.
60. Exchange of gases takes place in which of the
following organs?
A. Kidney
B. Lungs
C. Liver
D. Heart
Answer: B. Lungs
Gas exchange is the transport of oxygen from the lungs
to the bloodstream and the expulsion of carbon dioxide
from the bloodstream to the lungs. It transpires in the
lungs between the alveoli and a network of tiny blood
vessels called capillaries, which are located in the
walls of the alveoli.
Option A: The renal system consists of the kidney,
ureters, and urethra. The overall function of the system
filters approximately 200 liters of fluid a day from
renal blood flow which allows for toxins, metabolic
waste products, and excess ions to be excreted while
keeping essential substances in the blood. The kidney
regulates plasma osmolarity by modulating the amount
of water, solutes, and electrolytes in the blood. It
ensures long-term acid-base balance and also produces
erythropoietin which stimulates the production of red
blood cells.
Option C: The liver is a critical organ in the human
body that is responsible for an array of functions that
help support metabolism, immunity, digestion,
detoxification, vitamin storage among other functions.
It comprises around 2% of an adult’s body weight. The
liver is a unique organ due to its dual blood supply
from the portal vein (approximately 75%) and the
hepatic artery (approximately 25%).
Option D: The heart is a muscular organ situated in the
center of the chest behind the sternum. It consists of
four chambers: the two upper chambers are called the
right and left atria, and the two lower chambers are
called the right and left ventricles. The right atrium and
ventricle together are often called the right heart, and
the left atrium and left ventricle together functionally
form the left heart.
61. The chamber of the heart that receives oxygenated
blood from the lungs is the:
A. Left atrium
B. Right atrium
C. Left ventricle
D. Right ventricle
Answer: A. Left atrium
The left atrium receives oxygenated blood from the
lungs and pumps it to the left ventricle. In the lungs,
the blood oxygenates as it passes through the
capillaries where it is close enough to the oxygen in
the alveoli of the lungs. This oxygenated blood is
collected by the four pulmonary veins, two from each
lung. All four of these veins open into the left atrium
that acts as a collection chamber for oxygenated blood.
Just like the right atrium, the left atrium passes the
blood onto its ventricle both by passive flow and active
pumping.
Option B: The right atrium receives blood from the
veins and pumps it to the right ventricle. The right
atrium receives deoxygenated blood from the entire
body except for the lungs (the systemic circulation) via
the superior and inferior vena cavae. Also,
deoxygenated blood from the heart muscle itself drains
into the right atrium via the coronary sinus. The right
atrium, therefore, acts as a reservoir to collect
deoxygenated blood.
Option C: The left ventricle (the strongest chamber)
pumps oxygen-rich blood to the rest of the body, its
vigorous contractions create the blood pressure.
Oxygenated blood thus fills the left ventricle, passing
through the mitral valve. The left ventricle, which is
the main pumping chamber of the left heart, then
pumps, sending freshly oxygenated blood to the
systemic circulation through the aortic valve
Option D: The right ventricle receives blood from the
right atrium and pumps it to the lungs, where it is
loaded with oxygen. The right ventricle pumps blood
through the right ventricular outflow tract, across the
pulmonic valve, and into the pulmonary artery that
distributes it to the lungs for oxygenation.
62.A muscular enlarged pouch or sac that lies slightly
to the left which is used for temporary storage of
food…
A. Gallbladder
B. Urinary bladder
C. Stomach
D. Lungs
E. Rugae of the stomach
Answer: C. Stomach
The stomach is a muscular organ located on the left
side of the upper abdomen. It is a saclike expansion of
the digestive tract of a vertebrate that is located
between the esophagus and duodenum. The major part
of the digestion of food occurs in the stomach.
Option A: The gallbladder is a small hollow organ
about the size and shape of a pear. It is a part of the
biliary system, also known as the biliary tree or biliary
tract. The biliary system is a series of ducts within the
liver, gallbladder, and pancreas that empty into the
small intestine. There are intrahepatic (within the liver)
and extrahepatic (outside of the liver) components. The
gallbladder is a component of the extrahepatic biliary
system where bile is stored and concentrated.
Option B: The bladder forms an integral part of the
genitourinary system. Urine, created by the kidneys, is
drained into the bladder by the bilateral ureters. The
bladder then acts as the storage site for this waste
product until higher-order centers within the central
nervous system initiate the micturition (i.e., urination)
process, which permits the expulsion of urine into the
urethra, located on the inferior aspect of the bladder.
Option D: The purpose of the lung is to provide
oxygen to the blood. Anatomically, the lung has an
apex, three borders, and three surfaces. The apex lies
above the first rib. The function of the lung is to get
oxygen from the air to the blood, performed by the
alveoli. The alveoli are a single cell membrane that
allows for gas exchange to the pulmonary vasculature.
There are a couple of muscles that help with
inspiration and expiration, such as the diaphragm and
intercostal muscles.
Option E. The inner layer of the stomach is full of
wrinkles known as rugae (or gastric folds). Rugae both
allow the stomach to stretch in order to accommodate
large meals and help to grip and move food during
digestion
63. The ability of the body to defend itself against
scientific invading agent such as bacteria, toxin,
viruses, and foreign body:
A. Hormones
B. Secretion
C. Immunity
D. Glands
Answer: C. Immunity
Immunity is the ability of an organism to resist a
particular infection or toxin by the action of specific
antibodies or sensitized white blood cells. The Immune
response is the body’s ability to stay safe by affording
protection against harmful agents and involves lines of
defense against most microbes as well as specialized
and highly specific responses to a particular offender.
This immune response classifies as either innate which
is non-specific and adaptive acquired which is highly
specific.
Option A: The endocrine hormones are a wide array of
molecules that traverse the bloodstream to act on
distant tissues, leading to alterations in metabolic
functions within the body. They can broadly divide
into peptides, steroids, and tyrosine derivatives that
may work on either cell surface or intracellular
receptors.
Option B: Secretion, in biology, production and release
of a useful substance by a gland or cell; also, the
substance produced. In addition to the enzymes and
hormones that facilitate and regulate complex
biochemical processes, body tissues also secrete a
variety of substances that provide lubrication and
moisture.
Option D: A gland is an organ which produces and
releases substances that perform a specific function in
the body. There are two types of gland. Endocrine
glands are ductless glands and release the substances
that they make (hormones) directly into the
bloodstream.
64. Hormones secreted by Islets of Langerhans
A. Progesterone
B. Testosterone
C. Insulin
D. Hemoglobin
Answer: C. Insulin
The Islets of Langerhans are the regions of the
pancreas that contain its endocrine cells. Insulin is a
peptide hormone secreted in the body by beta cells of
islets of Langerhans of the pancreas and regulates
blood glucose levels. Medical treatment with insulin is
indicated when there is inadequate production or
increased demands of insulin in the body.
Option A: Progesterone (Choice A) is produced by the
ovaries. Progesterone is an endogenous steroid
hormone that is commonly produced by the adrenal
cortex as well as the gonads, which consist of the
ovaries and the testes. Progesterone is also secreted by
the ovarian corpus luteum during the first ten weeks of
pregnancy, followed by the placenta in the later phase
of pregnancy.
Option B: Testosterone (Choice B) is secreted by the
testicles of males and ovaries of females. Testosterone
is the primary male hormone responsible for regulating
sex differentiation, producing male sex characteristics,
spermatogenesis and fertility. Testosterone is
responsible for the development of primary sexual
development, which includes testicular descent,
spermatogenesis, enlargement of the penis and testes,
and increasing libido.
Option D: Hemoglobin (Choice D) is a protein
molecule in the red blood cells that carries oxygen
from the lungs to the body’s tissues and returns carbon
dioxide. Hemoglobin is an oxygen-binding protein
found in erythrocytes which transports oxygen from
the lungs to tissues. Each hemoglobin molecule is a
tetramer made of four polypeptide globin chains. Each
globin subunit contains a heme moiety formed of an
organic protoporphyrin ring and a central iron ion in
the ferrous state (Fe2+). The iron molecule in each
heme moiety can bind and unbind oxygen, allowing for
oxygen transport in the body.
65. It is a transparent membrane that focuses the light
that enters the eyes to the retina.
A. Lens
B. Sclera
C. Cornea
D. Pupils
Answer: A. Lens
The lens is located in the eye. By changing its shape,
the lens changes the focal distance of the eye. In other
words, it focuses the light rays that pass through it (and
onto the retina) in order to create clear images of
objects that are positioned at various distances. It also
works together with the cornea to refract, or bend, light.
The lens consists of the lens capsule, the lens
epithelium, and the lens fibers. The lens capsule is the
smooth, transparent outermost layer of the lens, while
the lens fibers are long, thin, transparent cells that form
the bulk of the lens. The lens epithelium lies between
these two and is responsible for the stable functioning
of the lens. It also creates lens fibers for the lifelong
growth of the lens.
Option B: The sclera is the white part of the eye that
surrounds the cornea. In fact, the sclera forms more
than 80 percent of the surface area of the eyeball,
extending from the cornea all the way to the optic
nerve, which exits the back of the eye. Only a small
portion of the anterior sclera is visible.
Option C: The cornea is the eye’s clear, protective
outer layer. Along with the sclera (the white of your
eye), it serves as a barrier against dirt, germs, and other
things that can cause damage. The cornea can also
filter out some of the sun’s ultraviolet light. It also
plays a key role in vision. As light enters the eye, it
gets refracted, or bent, by the cornea’s curved edge.
This helps determine how well the eye can focus on
objects close-up and far away.
Option D: Pupils are the black center of the eye. Their
function is to let in light and focus it on the retina (the
nerve cells at the back of the eye) so one can see.
Muscles located in the iris (the colored part of your eye)
control each pupil.
66. Which of the following is included in Orem’s
theory?
A. Maintenance of a sufficient intake of air.
B. Self perception.
C. Love and belongingness.
D. Physiologic needs.
Answer: A. Maintenance of a sufficient intake of
air.
Dorothea Orem’s Self-Care Theory defined Nursing as
“The act of assisting others in the provision and
management of self-care to maintain or improve
human functioning at home level of effectiveness.”
The Self-Care or Self-Care Deficit Theory of Nursing
is composed of three interrelated theories: (1) the
theory of self-care, (2) the self-care deficit theory, and
(3) the theory of nursing systems, which is further
classified into wholly compensatory, partial
compensatory and supportive-educative. Choices B, C,
and D are from Abraham Maslow’s Hierarchy of
Needs.
Option B: At the fourth level in Maslow’s hierarchy is
the need for appreciation and respect. When the needs
at the bottom three levels have been satisfied, the
esteem needs begin to play a more prominent role in
motivating behavior. At this point, it becomes
increasingly important to gain the respect and
appreciation of others. People have a need to
accomplish things and then have their efforts
recognized. In addition to the need for feelings of
accomplishment and prestige, esteem needs include
such things as self-esteem and personal worth.
Option C: The social needs in Maslow’s hierarchy
include such things as love, acceptance, and belonging.
At this level, the need for emotional relationships
drives human behavior. In order to avoid problems
such as loneliness, depression, and anxiety, it is
important for people to feel loved and accepted by
other people. Personal relationships with friends,
family, and lovers play an important role, as does
involvement in other groups that might include
religious groups, sports teams, book clubs, and other
group activities.
Option D: The basic physiological needs are probably
fairly apparent—these include the things that are vital
to our survival. In addition to the basic requirements of
nutrition, air and temperature regulation, the
physiological needs also include such things as shelter
and clothing. Maslow also included sexual
reproduction in this level of the hierarchy of needs
since it is essential to the survival and propagation of
the species.
67. Which of the following cluster of data belong to
Maslow’s hierarchy of needs
A. Love and belonging
B. Physiological needs
C. Self actualization
D. All of the above
Answer: D. All of the above
All of the choices are part of Maslow’s Hierarchy of
Needs. Maslow first introduced his concept of a
hierarchy of needs in his 1943 paper “A Theory of
Human Motivation” and his subsequent book
Motivation and Personality. This hierarchy suggests
that people are motivated to fulfill basic needs before
moving on to other, more advanced needs. As a
humanist, Maslow believed that people have an inborn
desire to be self-actualized, that is, to be all they can be.
In order to achieve these ultimate goals, however, a
number of more basic needs must be met such as the
need for food, safety, love, and self-esteem.
Option A: The social needs in Maslow’s hierarchy
include such things as love, acceptance, and belonging.
At this level, the need for emotional relationships
drives human behavior. In order to avoid problems
such as loneliness, depression, and anxiety, it is
important for people to feel loved and accepted by
other people. Personal relationships with friends,
family, and lovers play an important role, as does
involvement in other groups that might include
religious groups, sports teams, book clubs, and other
group activities.
Option B: The basic physiological needs are probably
fairly apparent—these include the things that are vital
to our survival. In addition to the basic requirements of
nutrition, air and temperature regulation, the
physiological needs also include such things as shelter
and clothing. Maslow also included sexual
reproduction in this level of the hierarchy of needs
since it is essential to the survival and propagation of
the species.
Option C: At the very peak of Maslow’s hierarchy are
the self-actualization needs. “What a man can be, he
must be,” Maslow explained, referring to the need
people have to achieve their full potential as human
beings. According to Maslow’s definition of
self-actualization, “It may be loosely described as the
full use and exploitation of talents, capabilities,
potentialities, etc. Such people seem to be fulfilling
themselves and to be doing the best that they are
capable of doing. They are people who have developed
or are developing to the full stature of which they are
capable.”
68. This is characterized by severe symptoms
relatively of short duration.
A. Chronic Illness
B. Acute Illness
C. Pain
D. Syndrome
Answer: B. Acute Illness
Acute illnesses are different than chronic illnesses in
that they usually develop quickly and they only last a
short time – usually a few days or weeks. Acute
illnesses are often caused by viral or bacterial
infections.
Option A: Chronic Illness (Choice A) are illnesses that
are persistent or long-term. A chronic illness is a
condition that develops over time and is present for a
long period of time. Some people have chronic
conditions for many years. Technically, a chronic
disease is defined as a health condition that lasts
anywhere from three months to a lifetime. Chronic
conditions may get worse over time.
Option C: Pain refers to the product of higher brain
center processing; it entails the actual unpleasant
emotional and sensory experience generated from
nervous signals.
Option D: A syndrome is a set of medical signs and
symptoms which are correlated with each other and
often associated with a particular disease or disorder.
The word derives from the Greek ?????????, meaning
“concurrence”.
69. Which of the following is the nurse’s role in health
promotion?
A. Health risk appraisal
B. Teach client to be effective health consumer
C. Worksite wellness
D. None of the above
Answer: B. Teach client to be effective health
consumer
Nurses play a huge role in illness prevention and health
promotion. Nurses assume the role of ambassadors of
wellness. The World Health Organization (WHO)
defines health promotion as a process of enabling
people to increase control over and to improve their
health (WHO, 1986). Nurses are best qualified to take
on the job of health promoter due to their expertise.
There are few health care occupations that have the
high level of health education knowledge, skills, theory,
and research to be able to focus on prevention because
it is considered part of their professional development
focus.
Option A: An HRA may be a simple questionnaire
eliciting self-reported information on risk factors,
behaviors, or diagnoses. Questionnaires may be
supplemented with clinical examinations to obtain data
on variables such as height, weight, body mass index
(BMI), heart rate, or blood pressure. Some HRAs may
include performance tests such as grip strength,
timed-up-and-go, chair rise, or four-meter walk test.
Option C: Studies show that employees are more likely
to be on the job and performing well when they are in
optimal health. Benefits of implementing a wellness
program include: improved disease management and
prevention, and a healthier workforce in general, both
of which contribute to lower health care costs.
Option D: One of the most critical roles that nurses
have in health promotion and disease preventions is
that of an educator. Nurses spend the most time with
the patients and provide anticipatory guidance about
immunizations, nutrition, dietary, medications, and
safety.
70. It is described as a collection of people who share
some attributes of their lives.
A. Family
B. Illness
C. Community
D. Nursing
Answer: C. Community
A community is defined by the shared attributes of the
people in it, and/or by the strength of the connections
among them. When an organization is identifying
communities of interest, the shared attribute is the most
useful definition of a community.
Option A: In human society, family is a group of
people related either by consanguinity (by recognized
birth) or affinity (by marriage or other relationship).
The purpose of families is to maintain the well-being
of its members and of society. Ideally, families would
offer predictability, structure, and safety as members
mature and participate in the community.
Option B: Illness is a condition of being unhealthy in
the body or mind; a specific condition that prevents the
body or mind from working normally; a sickness or
disease.
Option D: Nursing encompasses autonomous and
collaborative care of individuals of all ages, families,
groups, and communities, sick or well, and in all
settings. Nursing includes the promotion of health,
prevention of illness, and the care of ill, disabled, and
dying people.
71. Five teaspoons is equivalent to how many
milliliters (ml)?
A. 30 ml
B. 25 ml
C. 12 ml
D. 22 ml
Answer: B. 25 ml
One teaspoon is equal to 5ml. Drug calculations
require the use of conversion factors, for example,
when converting from pounds to kilograms or liters to
milliliters. Simplistic in design, this method allows
clinicians to work with various units of measurement,
converting factors to find the answer. These methods
are useful in checking the accuracy of the other
methods of calculation, thus acting as a double or triple
check.
Option A: 30 ml is equal to 6 teaspoons. When
clinicians are prepared and know the key conversion
factors, they will be less anxious about the calculation
involved. This is vital to accuracy, regardless of which
formula or method employed.
Option C: 12 ml is equal to 2.4 teaspoons. Units of
measurement must match, for example, milliliters and
milliliters, or one needs to convert to like units of
measurement.
Option D: 22 ml is equal to 4.4 teaspoons. Medication
errors can be detrimental and costly to patients. Drug
calculation and basic mathematical skills play a role in
the safe administration of medications.
72. 1800 ml is equal to how many liters?
A. 1.8
B. 18000
C. 180
D. 2800
Answer: A. 1.8
1,800 ml is equal to 1.8 liters.
Option B: 18000 liters is equal to 18,000,000 ml.
Option C: 180 liters is equal to 180,000 ml.
Option D: 2800 liters is equal to 280,000 ml.
73. Which of the following is the abbreviation of
drops?
A. Gtt.
B. Gtts.
C. Dp.
D. Dr.
Answer: B. Gtts.
Gtt (Choice A) is an abbreviation for drop. Dp and Dr
are not recognized abbreviations for measurement.
Standardization and uniform use of codes, symbols,
and abbreviations can improve communication and
understanding between health care practitioners,
leading to safer and more effective care for patients.
Option A: Appropriate use of abbreviations is
particularly important. Numerous studies have focused
on health care practitioners’ understanding and
interpretation of abbreviations in medical documents,
such as medical records, discharge summaries, and
medication orders. Findings indicate that it is not
uncommon for practitioners to have difficulty
understanding the abbreviations used in their hospitals.
Option C: To prevent misunderstandings and potential
risks to patient safety, MOI.4 requires hospitals to
establish lists for approved and do-not-use
abbreviations and monitor for appropriate abbreviation
use. There are resources for identifying abbreviations
for the do-not-use list, such as the Institute for Safe
Medication Practices (ISMP), which publishes a list of
dangerous abbreviations not to be used due to frequent
misinterpretation and associated medication errors.
Option D: When developing lists, hospitals need to
ensure that abbreviations on the approved list are not
also on the do-not-use list, and vice versa. In addition,
abbreviations can have only one meaning within the
entire organization—for example, the abbreviation
NKDA could mean “no known drug allergies,” or it
could mean “nonketotic diabetic acidosis,” but it
cannot have both meanings in an organization.
74. The abbreviation for microdrop is…
A. µgtt
B. gtt
C. mdr
D. mgts
Answer: A. µgtt
The abbreviation for microdrop is µgtt. When
abbreviations are used in documents given to the
patient, the potential for misunderstanding can increase.
Information needs to be clear and unambiguous to
improve patients’ comprehension.

Option B: When abbreviations are used in documents

given to the patient, the potential for misunderstanding
can increase. Information needs to be clear and
unambiguous to improve patients’ comprehension.
Option C: As stated in MOI.4, ME 5, “Abbreviations
are not used on informed consent and patient rights
documents, discharge instructions, discharge
summaries, and other documents patients and families
receive from the hospital about the patient’s care.”
Option D: No abbreviations of any kind should appear
in informed consent documents, patient rights
documents, and discharge instructions. These
documents are meant for the patient and every effort
should be made to increase the readability and clarity
of the documents.

75. Which of the following is the meaning of PRN?

A. When advice
B. Immediately
C. When necessary
D. Now.

Answer: C. When necessary

PRN comes from the Latin “pro re nata” meaning, “for
an occasion that has arisen or as circumstances
require”. When an abbreviation is less known outside
of the organization or clinical specialty, it is necessary
to spell out the abbreviation throughout the discharge
summary to prevent misunderstanding and confusion
by the physician or health care organization that
receives the summary.

Option A: The practice of spelling out an abbreviation

when first mentioned, then using the abbreviation
thereafter in the document is acceptable only in
discharge summaries. Abbreviations are not to be used
in the other types of documents listed in the
measurable element.
Option B: Laboratory test results sometimes go to
patients, but it is not the intent of the standard for the
abbreviations of the laboratory tests to be spelled out.
When test results are given to patients, they are shared
with their physician who can help explain the results.
Option D: Hospitals may want to consider providing a
separate form or resource to patients for information
about the tests — such as a handout or website that has
the names of common laboratory tests along with their
definitions or descriptions. Results of diagnostic
imaging studies also go to a patient’s physician, after
interpretation by a radiologist.