RENR Comprehensive Test September 2018

1. . An older adult resident of a geriatric unit frequently attempts to get out of bed and is at
risk of sustaining an injury. The nurses planned intervention to minimize the patients risk
for injury is guided by:
a. the Patients cognitive ability to understand and follow directions.
b. the patients right to self-determination and to be free to get out of bed.
c. the knowledge that application of a vest restraint requires a physicians order
d. an understanding that nondrug interventions must be tried before medications.

2. An 87-year-old female patient is unsure of the purpose of a living will. The nurse describes
its purpose best when stating:
a. It assures you won’t be subjected to treatments you don’t want.
b. Its a legal document that Social Services can help you create.
c. It designates a family member to make decisions if you become incompetent.
d. It provides a written description of your wishes in the event you become terminally
ill.

3. Nurse J C is caring for an unresponsive patient who has terminal cancer with a Do Not
Resuscitate order in effect. A family member tells the nurse, Ill sue you and every other
nurse here if you don’t do everything possible to keep her alive. The nurse understands that
protection from legal prosecution in this situation is provided by:
a. legal immunity granted when acting according to the patients expressed wishes.
b. the legal view that the duty to put into effect the patients wishes falls to the
physician.
c. knowledge of and compliance with facility policies and procedures regarding end-
of-life care.
d. implementing interventions that preserve the patients right to self-determination.

4. The nurse is caring for a terminally ill older patient who has a living will that excludes
pulmonary and cardiac resuscitation. The family expresses a concern that the patient may
change her mind. The nurse best reassures the family by stating:
a. We will discuss her wishes with her regularly
b. She can change her mind about any provision in the document at any time.
c. Your mother was very clear about her wishes when she signed the document.
d. The nursing staff will watch her very closely for any indication she has changed her
mind.
5. Mrs CF an elderly patient residing in a long-term care facility has been experiencing
restlessness and has often been found by nursing staff wandering in and out of other
patients’ rooms during the night. The nurse views the patients PRN antipsychotic
medication order as:
a. an appropriate intervention to help assure his safety.
b. inappropriate unless the physician is notified and approves its use.
c. not an option because it should not be used to manage behaviors of this type.
d. an option to be used only when all other nondrug interventions prove ineffective

1
 6. An alert but disoriented older patient lives with family members. The district visiting nurse,
being aware of the role of patient advocate, recognizes the obligation to report possible
patient abuse based on:
a. patients report of always being hungry.
b. observation of mild changes in orientation
c. assessment showing bruises in the genital area.
d. a family member stating, Its hard being a caregiver
7. A nurse responsible for the care of older adult patients shows the best understanding of the
nursing standards of practice when basing nursing care on the:
a. physicians medical orders.
b. implementation of the nursing process.
c. stated requests of the individual patient.
d. care that a responsible geriatric nurse would provide.
SCENARIO 1 ITEM 8

A number of senior citizens age 65 and over are cared for in a private nursing home. They were
suffering from chronic illnesses that could be detrimental to their survival. The nurse manager at
the home realizing that these residents required specialized care and had to make a decision.

8. The most important approach the nurse manager should take is to _________.
a. ask relative to visit frequently
b. carry out frequent observation by the residents
c. assign one nurse to each resident on a daily basis
d. consult with a multi-disciplinary health care team including specialists

SCENARIO 2 ITEMS 9-14

A 52-year-old male was admitted to the Acute Psychiatric unit for management of schizophrenia.
He isolated himself by remaining in his room and was observed to be staring at the ceiling, his head
leaning to one side, and tugging at his left ear. He refused his medications because he said they
were poisonous.

9. Which form of schizophrenia is this patient most likely experiencing?

a. Paranoid
b. Catatonic
c. Disorganized
d. Undifferential
10. Which of the following areas are critical to the mental status assessment of this patient?
I. Hearing
II. Judgement
III. Thought process
IV. Personal appearance
a. I, II and III only
b. B. I, II and IV only
c. C. I, III and IV only
d. D. II, III and IV only

2
 11. Which of the following indicators is not a diagnostic criterion for schizophrenia?
a. Enhances intellectual skills
b. May lead to severe disability
c. Tends to increase socialization skills
d. May lead to deterioration in self-care

12. Which of the following behaviors is the nurse most likely to observe when caring for
this patient?
a. Regression
b. Suspiciousness
c. Emotional outbursts
d. Abnormal body posturing
13. Which of the following nursing strategies is most appropriate to address this patient’s
withdrawal?
a. Conduct one-on-one counselling sessions with him
b. Make group interaction the main focus of his therapy
c. Keep interactions short, frequent and non-demanding
d. Make infrequent attempts to establish a relationship with him

14. Which of the following pharmacological agents would not be prescribed for this
patient?
a. Diazepam
b. Haloperidol
c. Fluphenazine
d. Lithium carbonate

SCENARIO 3 ITEMS 15-19

Mr. AF a 50-year-old male is admitted to the surgical ward from the operating theatre after
having a laparotomy and an underwater seal placed in the right side of his chest following a
motor vehicle accident that resulted in chest and abdominal injuries
15. Which of the following manifestations can be detected by auscultation during collapse of a
lung?
a. Rhonchi
b. Wheezes
c. No breath sounds
d. Adventitious sounds

16. Mr. AF may have suffered a haemothorax requiring the underwater seal drainage system. A
haemothorax is the presence of
a. air inside the lungs and escaping into the trachea
b. air within the pleural cavity usually related to trauma
c. blood within the pleural cavity usually related to trauma
d. blood inside the lungs which is escaping into the trachea

17. The doctor ordered a computerized tomography (CT) scan. During transportation of the
patient with a chest tube in situ the nurse should
a. reinforce the dressing at the tube's insertion site

3
 b. clamp the chest tube in two places with blunt-tipped forceps*
c. milk the tube immediately before transportation to radiology from the ward
d. keep the underwater seal device upright below the level of tube insertion

18. During transportation, the patient’s chest tube is accidentally dislodged from the insertion
site. What is the first action that the nurse should take?
a. Immediately reinsert the chest tube.
b. Place the tip of the chest tube in sterile saline.
c. Clamp the chest tube with two rubber-tipped forceps.
d. Apply an occlusive dressing and seal it on three sides.

19. What nursing interventions may be used with a nursing diagnosis of “Risk for Infection…”
for Mr. AF who has an underwater seal?

I. Observe for foul-smelling discharge at the dressing site.

II. Clamp the underwater tube to prevent back-flow of fluid into the lungs.
III. Utilize strict aseptic technique when performing dressing change at insertion site.
a. I and II only
b. I and III only
c. II and III only
d. I, II and III

SCENARIO 4 ITEMS 20- 22

Nurse Manager C C was given the responsibility to organize the paediatric ward of twenty patients,
ensuring that the best quality care is given in spite of limited resources. She is aware that the
Director
of Nursing trusted her and has confidence in her capabilities, and is aware that she will need to do
some reorganization of the ward. She communicates effectively and uses the ideas and opinions of
her
staff. In organizing the ward Sister CC used an approach that will minimize risk and uncertainty,
provides her with a means of control and encourages the best possible use of resources

20. Sister C used the _______________ leadership style in carrying out her management functions.
a. creative
b. autocratic/directive
c. laissez-faire/permissive
d. democratic/participative

21. Sister C knows that the new unit needs competent staff to deliver quality care to these
children. When making up the schedule she takes into consideration the_______________.
a. Staff personal request
b. Most capable staff available
c. Opinion from upper level manager
d. Method of future appraisal of staff

4
 22. Sister C realized that she is having challenges with some of the newly assigned nurses. She
is aware that conflicts occur in any organization. One way to approach this situation in
order to resolve the problem is to______________.
a. Ignore the matter
b. Apologize to the staff
c. Seek help from the director of nursing
d. Identify the source of the conflict and request a meeting with the supervisor

23. Safe practice is required by all health care providers in the hospital. This is often violated as
various errors are made during the delivery of care. To prevent the frequent occurrences of
these errors the supervisors could_________________.
a. dismiss staff as necessary
b. provide disciplinary action for errors made
c. make provisions for refreshers courses in-in-service education
d. review staff description regularly to determine their competency

24. The Charge nurse identifies a patient's responses to actual or potential health problems
during which step of the nursing process?
a. Planning
b. Assessing
c. Diagnosing
d. Evaluation
25. A nurse is revising a client's care plan. During which step of the nursing process does such a
revision take place?
a. Planning
b. Assessing
c. Evaluation
d. Implementation
SCENARIO 5 Items 26-37

Epidemiology and Vital statistics are very important tools nurses use in controlling the spread of
disease in the community and at the same time, surveying the impact of the disease on the
population and prevent it’s future occurrence. It is concerned with the study of factors that
influence the occurrence and distribution of diseases, defects, disability or death which occurs in
groups or aggregation of individuals.

26. Which of the following is the backbone in disease prevention?

a. Epidemiology
b. Demographics
c. Vital Statistics
d. Health Statistics
27. An outbreak of measles has been reported in Community of Silver Lake. As a nurse, which of
the following is your first action for an Epidemiological investigation?
a. Report the incidence to the center for disease
b. Determine the first day when the outbreak occurred

5
 c. Identify if it is the disease which it is reported to be
d. Classify if the outbreak of measles is epidemic or just sporadic

28. After the epidemiological investigation produced final conclusions, which of the following is
your initial step in your operational procedure during disease outbreak?
a. Immunize nearby communities with Measles
b. Coordinate personnel from Parish to the National level
c. Collect pertinent laboratory specimen to confirm disease causation
d. Educate the community in future prevention of similar outbreaks

29. The main concern of a public health nurse is the prevention of disease, prolonging of life
and promoting physical health and efficiency through which of the following?
a. Organized Community Efforts
b. Use of epidemiological tools and vital health statistics
c. Determine the spread and occurrence of the disease
d. Political empowerment and Socio Economic Assistance

30. In order to control a disease effectively, which of the following must first be known?
a. Factors that do not favour its development, factors that favours its development
b. The conditions surrounding its occurrence, factors that favours its development
c. The conditions surrounding its occurrence, the condition that do not favour its
development
d. Factors that do not favour its development, the conditions that do not favour its
development

31. All of the following are uses of epidemiology except _____________.

a. To identify groups needing special attention
b. To provide summary data on health service delivery
c. To diagnose the health of the community and the condition of the people
d. To study the history of health population and the rise and fall of disease

32. Before reporting the fact of presence of an epidemic, which of the following is of most
importance to determine?
a. Is the disease real?
b. Is the disease tangible?
c. Is it epidemic or endemic?
d. Are the facts complete?

6
SCENARIO 6 Item 31

An unknown epidemic has just been reported in New Town. People said that affected person
demonstrates hemorrhagic type of fever. You are designated now to plan for epidemiological
investigation. Arrange the sequence of events in accordance with the correct outline plan for
epidemiological investigation:
.1.Report the presence of dengue
2. Summarize data and conclude the final picture of epidemic
3. Relate the occurrence to the population group, facilities, food supply and carriers
4. Determine if the disease is factual or real
5. Determine any unusual prevalence of the disease and its nature; is it epidemic, sporadic, endemic
or pandemic?
6. Determine onset and the geographical limitation of the disease.

33. Arrange
a. 4,1,3,5,2,6
b. 4,1,5,6,3,2
c. 5,4,6,2,1,3
d. 5,4,6,1,2,3
34. All of the following are function of Nurse J X in epidemiology except _________.
a. Laboratory Diagnosis
b. Follow up cases and contacts
c. Refer cases to hospitals if necessary
d. Isolate cases of communicable disease
35. This refers to systematic study of vital events such as births, illnesses, marriages, divorces
and Deaths
a. Epidemiology
b. Demographics
c. Vital Statistics
d. Health Statistics
36. These rates are referred to the total living population, It must be presumed that the total
population was exposed to the risk of occurrence of the event.
a. Rate
b. Ratio
c. Specific Rates
d. Crude/General Rates
37. This is the most sensitive index in determining the general health condition of a community
since it reflects the changes in the environment and medical conditions of a community
a. Fetal death rate
b. Crude death rate
c. Infant mortality rate
d. Maternal mortality rate

7
38. Nursing students subsequent to assisting the public health nurse with immunizations for 10
year old boys attending Goodwill Primary School, where asked to describe what constitutes
a school health programme. The student’s best description would be_______________.
a. Effective leader, clean classrooms, healthy diet and overhead projector & rules
b. Water, spiritual emphasis, qualified teachers, and well-behaved students
c. Rules, healthy diet, qualified teachers and well-behaved students and security and
family
d. Health services, nutrition services, health promotion for staff and physical education

39. There are different types of health centers in Dominica Mrs. J has decided to attended a
type three health center in her community. A type three health service offers_____________
services.
a. Maternal, child health, laboratory & dental health
b. Child health, maternal, laboratory & pharmacy
c. Dental health, maternal, child health and curative
d. Laboratory, pharmacy, dental, curative & diabetic

40. The client comes into the emergency room in severe pain and reports that a pot of boiling
hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled
red skin, and both feet are edematous. Which depth of burn should the nurse document?
a. First degree.
b. Full thickness
c. Deep partial thickness
d. Superficial partial thickness
41. The client with full-thickness burns to 40% of the body, including both legs, is being
transferred from a community center to a burn unit. Which measure should be instituted
before the transfer?
a. .No intravenous pain medication.
b. Wounds covered with moist sterile dressings
c. Adequate peripheral circulation to both feet ensured
d. A 22-gauge intravenous line with normal saline infusing.

42. The client has full-thickness burns to 65% of the body, including the chest area. After
establishing a patent airway, which collaborative intervention is priority for the client?
a. Monitor urine output hourly.
b. Replace fluids and electrolytes
c. Prevent contractures of extremities
d. Prepare to assist with an escharotomy

43. The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client’s
lower extremity burn. Which assessment data would require immediate attention by the
nurse?
a. The client complains of pain when the medication is administered.
b. The client’s potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
c. The client’s ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
d. The client is able to perform active range-of-motion exercises.

8
44. The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with
severe full-thickness and deep partial thickness burns over half the body. Which client
problem has priority?
a. Ineffective coping
b. Knowledge deficit
c. High risk for infection
d. Impaired physical mobility

45. The nurse writes the nursing diagnosis “impaired skin integrity related to open burn
wounds.” Which intervention would be appropriate for this nursing diagnosis?
a. Screen visitors for respiratory infections.
b. Encourage visitors to bring plants and flowers.
c. Clean the client’s wounds, body, and hair daily
d. Provide analgesia before pain becomes severe

46. The nurse is caring for a client with deep partial thickness and full-thickness burns to the
chest area. Which assessment data would warrant notifying the doctor
a. The client is complaining of severe pain.
b. The client’s pulse oximeter reading is 95%.
c. The client has T 100.4˚F, P 100, R 24, and BP 102/60.
d. The client’s urinary output is 50 mL in two (2) hours.

47. The client is admitted with full-thickness and partial-thickness burns to more than 30% of
the body. The nurse is concerned with the client’s nutritional status. Which intervention
should the nurse implement?
a. Make a referral to the hospital social worker
b. Encourage the client’s family to bring favorite foods
c. Provide a low-fat, low-cholesterol diet for the client
d. Monitor the client’s weight weekly in the same clothes

48. A client sustained a hot grease burn to the right hand and called the A & E department for
advice. Which information should the nurse provide to the client?
a. Place the hand in cool water.
b. Apply an ice pack to the right hand.
c. Come immediately to the department
d. Be sure to rupture any blister formation

49. A client is being discharged after being in the burn unit for six (6) weeks. Which strategies
should the nurse identify to promote the client’s mental health?
a. Encourage the client to stay at home as much as possible.
b. Discuss the importance of not relying on the family for needs.
c. Tell the client to remember that changes in lifestyle take time.
d. Instruct the client to discuss feelings only with the therapist.

50. Early indicators of late-stage septic shock include all of the following except _________.

9
 a. renal failure
b. pale, cool skin
c. a full, bounding pulse
d. decreased pulse pressure

51. Nurse TC has just been assigned to the clinical care of a newly admitted patient. To know
how to best care for the patient, the nurse uses the nursing process. Which step would the
nurse probably do first?
a. Diagnosis
b. Assessment
c. Plan outcomes
d. Plan Interventions

52. Which of the following is an example of theoretical knowledge?

a. Room air has an oxygen concentration of 21%
b. A nurse uses sterile technique to catheterize a patient
c. Glucose monitoring machines should be calibrated daily.
d. An irregular apical heart rate should be compared with the radial pulse.

53. Which of the following is an example of practical knowledge?

a. The pancreas does not produce enough insulin in type 1 diabetes
b. When assessing the abdomen, you should auscultate before palpating
c. The tricuspid valve is between the right atrium and ventricle of the heart.
d. Research shows pain medication given intravenously acts faster than by other
routes.

54. Which of the following is the most important reason for nurses to be critical thinkers?
a. Nurses need to follow policies and procedures.
b. Nurses work with other healthcare team members.
c. Nurses have to be flexible and work variable schedules.
d. Nurses care for clients who have multiple health problems.

55. Nurse CW is administering pain medication every 4 hours. This is an example of which
aspect of patient care?
a. Patient outcome
b. Assessment data
c. Nursing diagnosis
d. Nursing intervention

56. How does nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is
a. A part of the clients medical diagnosis
b. A clients response to a health problem
c. The clients presenting signs and symptoms
d. Terminology for the clients disease or injury

57. Which statement about the nursing process is correct?

10
 a. It involves care that only the nurse will give.
b. It is a linear process with separate, distinct steps.
c. It was developed from the ANA Standards of Care.
d. It is a problem-solving method to guide nursing activities.

58. What do critical thinking and the nursing process have in common?
a. They both use similar steps to solve a problem.
b. They both use specific steps to solve a problem.
c. They are both thinking methods used to solve a problem
d. They are both linear processes used to guide ones thinking.

59. Nurse CW admits a patient to the unit after completing a comprehensive interview and
physical examination. To develop a nursing diagnosis, she must now
a. consult standards of care
b. analyze the assessment data
c. decide which interventions are appropriate
d. ask the client’s perceptions of her health problem

60. Nurse CW developed a care plan for a patient to help prevent Impaired Skin Integrity. She
has made sure that nursing assistant change the patients position every 2 hours. In the
evaluation phase of the nursing process, which of the following would the nurse do first?
a. Determine whether she has gathered enough assessment data.
b. Judge whether the interventions achieved the stated outcomes.
c. Follow up to verify that care for the nursing diagnosis was given.
d. Decide whether the nursing diagnosis was accurate for the patient’s condition.
Scenario 7 Item 61

A nurse is preparing to admit a patient from the emergency department. The transferring nurse
reports that the patient is obese. The nurse has been overweight at one time and works very hard
now to maintain a healthy weight. She immediately thinks, I know I tend to feel negatively about
obese people; I figure if I can stop eating, they should be able to. I must remember how very difficult
that is and be very careful not to be judgmental of this patient.

61. This best illustrates

a. Self-knowledge
b. Theoretical knowledge
c. Using reliable resources
d. Use of the nursing process

62. Which of the following examples includes both objective and subjective data
a. The clients blood pressure is 132/68 and her heart rate is 88.
b. The clients cholesterol is elevated, and he states he likes fried food
c. The client states he gets frequent headaches and that he takes aspirin for the pain.
d. The client states she has trouble sleeping and that she drinks coffee in the evening.

11
63. This aspect of the research process outlines the population being studied, the cause/effect
as well as the hypothesis. This process is called the _______________.
a. Hypothesis
b. Population
c. Problem statement
d. Statement of the purpose

64. Which of the following is not true about a hypothesis? Hypothesis is _____________.
a. Testable
b. Proven
c. states a relationship between variables
d. stated in a form that it can be accepted or rejected

65. Ms. M is conducting a research study. Which of the following procedures ensures that Ms. M
has fully described to prospective respondents the nature of the study and the respondent’s
rights?
a. Debriefing
b. Full disclosure
c. Informed consent
d. Covert data collection

66. The statement, “Ninety percent (90%) of the respondents are female staff nurses validates
previous research findings (Santos, 2001; Reyes, 2005) that the nursing profession is
largely a female dominated profession”, is an example of ___________.
a. Analysis
b. Implication
c. Conclusion
d. Interpretation

67. The study is said to be completed when Ms. M achieves which of the following activities?
a. Published the results in a nursing journal
b. Presented the study in a research forum
c. Submitted the research report to the CEO
d. The results of the study is used by the nurses in the hospital

68. S T is a nurse researcher of the Patient Care Services. She plans to conduct a literature
search for her study. Which of the following is the first step in selecting appropriate
materials for her review?
a. Copy relevant materials
b. Synthesize literature gathered
c. Organize materials according to function
d. Track down most of the relevant resources

69. She knows that the most important categories of information in literature review is the
____________.
a. Opinions

12
 b. Methodology
c. Research findings
d. Theoretical framework

70. While reviewing journal articles, S T got interested in reading the brief summary of the
article placed at the beginning of the journal report. Which of the following refers to this?
a. Preface
b. Abstract
c. Background
d. Introduction

71. She notes down ideas that were derived from the description of an investigation written by
the person who conducted it. Which type of reference source refers to this?
a. Endnotes
b. Footnotes
c. Bibliography
d. Primary source

72. This kind of research gathers data in detail about a individual or groups and presented in
narrative form, which is a______________.
a. Case study
b. Historical
c. Analytical
d. Experimental
73. S T is finished with the steps in the conceptual phase when she has conducted the last step,
which is ______________.
a. formulate a hypothesis
b. review of related literature
c. develop a theoretical framework
d. formulating and delimiting the problem

74. Regardless of the significance of the study, its feasibility needs to be considered. Which of
the following is considered a priority
a. Time frame
b. Budgetary allocation
c. Experience of the researcher
d. Availability of research subjects

75. Student X who is conducting a research knows that a good research problem exhibits the
following characteristics; which one is not included?
a. Specifies the population being studied
b. Implies the feasibility of empirical testing
c. Indicates the hypothesis to be tested
d. Clearly identified the variables/phenomenon under consideration
SCENARIO 7 Items 76 to 82

13
Sixty year old Mr. F R came to the ER, complaining of severe left sided pain to the chest and
numbness in the left arm. The pain started 2hrs ago and is unrelieved by rest. The patient is anxious
and diaphoretic. Cardiac monitoring and Oxygen therapy is begun. V/S B/P 128/70bpm, P 76bpm,
RR 20bpm. ECG reveals normal sinus rhythm with occasional premature ventricular contractions.
The doctor is considering Myocardial infarction as a possible diagnosis

76. The nurse in forecasting care for a patient with Coronary Artery disease (CAD) understands
that Myocardial Infarction (MI) can be classified as a condition that _____________.
a. may not have underlying severe CAD
b. has slight limitation of physical activity
c. causes pain without any physical activity
d. has marked limitation of physical activity

77. The charge nurse asks a third (3rd) year student nurse to explain the pathophysiology of
Myocardial Infarction (MI). Her most appropriate response should be a/an ___________.
a. absence of oxygen to the middle tissue of the heart
b. absence of blood flow to the inner tissue of the heart
c. insufficient oxygen supply to the inner tissue of the heart
d. insufficient blood supply to the middle tissue of the heart

78. An MI is suspected because of ______indication

a. CK –MB and LDH
b. LDH and Troponin I
c. Troponin I and SGPT
d. CK-MB and Troponin I

79. Two hours after receiving a cardiac catheterization via the femoral artery, the client begins
to complain of pain and numbness in the right foot. The action the nurse should apply first
should be to__________________.
a. administer analgesics
b. apply compression to the area
c. inform the doctor immediately
d. assist the patient in ambulating

80. The priority nursing diagnosis for the patient with Cardiomyopathy is_____________.
a. Anxiety related to risk of declining health status.
b. Ineffective individual coping related to fear of debilitating illness
c. Fluid volume excess related to altered compensatory mechanisms
d. Decreased cardiac output related to reduced myocardial contractility

81. An early finding in the EKG for an infarcted myocardium would be ________________.
a. Flattened T waves
b. Absence of P wave
c. Elevated ST segments
d. Disappearance of Q waves

14
 82. Mr. FR asks the nurse why he is taking Morphine. The nurse explains that Morphine
_____________.
a. Decrease anxiety and restlessness
b. Prevents shock and relieves pain
c. Dilates coronary blood vessels
d. Helps prevent fibrillation of the heart

83. Nurse E formulates a nursing diagnosis of Activity intolerance related to imbalance in

oxygen supply and demand for a client with Chronic Bronchitis. To minimize this problem,
the nurse instructs the client to avoid conditions that increase oxygen demand. Such
conditions include______.
a. being overweight
b. eating a high-protein snack at bedtime
c. drinking more than 1,500 ml of fluid daily
d. eating more than three large meals per day
SCENARIO 8 ITEM 84

At 11 p.m., a male client was rushed to Accident and Emergency Department, with a respiratory
rate of 44 bpm. He was anxious, and wheezes could be heard. The client was immediately given
humidified oxygen by face mask and Methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the
client’s arterial blood oxygen saturation remained at 86% and he was still wheezing.

84. In planning, care for this client the nurse knows that a _____ should be prescribed and then
administered.
a. Benzodiazepine (Xanax)
b. Beta 2-agonist (Salbutamol )
c. Beta Adrenergic (Propranolol)
d. Narcotic Analgesic (Morphine)

85. Mrs. C H a 78 year old client is admitted with A diagnosis of mild Chronic Heart Failure. The
nurse expects to hear when listening to client’s lungs indicative of chronic heart failure
___________.
a. Stridor
b. Crackles
c. Wheezes
d. Friction rubs

86. In preparation for a client with pulmonary disease (COPD), the student nurse understands
that the action that would best promote adequate gas exchange is_________.
a. administering a sedative as prescribed
b. keeping the client in semi-Fowler’s position
c. using a high-flow oxygen Venturi mask as prescribed
d. encouraging the client to drink three glasses of fluid daily

87. Which of the following should the nurse teach the client about the signs of digitalis toxicity?

15
 a. Increased appetite
b. Elevated blood pressure
c. Skin rash over the chest and back
d. Visual disturbances such as seeing yellow spots

88. Nurse T teaches a client with heart failure to take oral Furosemide in the morning. The
rational for this is to help ___________.
a. Retard rapid drug absorption
b. Prevention of electrolyte imbalance
c. Prevents sleep disturbances during night
d. Excrete excessive fluids accumulated at night

89. What would be the primary goal of therapy for a client with pulmonary edema and heart
failure?
a. Enhance comfort
b. Increase cardiac output
c. Improve respiratory status
d. Peripheral edema decreased

90. Nurse R teaches a client who has been recently diagnosed with Hepatitis A about untoward
signs and symptoms related to Hepatitis that may develop. The one that should be reported
immediately to the physician is
a. Nausea
b. Yellow urine
c. Restlessness
d. Clay colored stools
91. Which of the following anti-tuberculosis drugs can damage the 8th cranial nerve?
a. Streptomycin
b. Isoniazid (INH)
c. Paraoaminosalicylic acid (PAS)
d. Ethambutol hydrochloride (Myambutol)
92. The client asks Nurse AD the causes of Peptic Ulcer. Nurse AD responds that recent research
indicates that Peptic Ulcers are the result of which of the following ________?
a. Stress
b. Diet high in fat
c. Helicobacter pylori infection
d. Genetic defect in gastric mucosa

93. Mr. RY has undergone subtotal Gastrectomy. The nurse should expect that Nasogastric Tube
(NGT) drainage will be what color for about 12 to 24 hours after surgery?
a. Bile green
b. Bright red
c. Dark brown
d. Cloudy white

16
94. A client suffered from a lower leg injury and seeks treatment in the emergency room. There
is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter
than the other leg. The affected leg is painful, swollen and beginning to become ecchymotic.
The nurse interprets that the client is experiencing _______.
a. strain
b. sprain
c. fracture
d. contusion

95. Nurse J K is instilling an otic solution into an adult male client left ear. Nurse JK avoids doing
which of the following as part of the procedure?
a. Placing client in side lying position
b. Pulling the auricle backward and upward
c. Warming the solution to room temperature
d. Pacing the tip of the dropper on the edge of ear canal

96. Nurse BN should instruct the male client with an ileostomy to report immediately which of
the following symptom
a. A temperature of 37.6 °C
b. Passage of liquid stool in the stoma
c. Occasional presence of undigested food
d. Absence of drainage from the ileostomy for 6 or more hours

97. Mr. Jerry has been diagnosed with Appendicitis. He develops a fever, hypotension and
tachycardia. The nurse suspects which of the following complications?
a. Peritonitis
b. Bowel ischemia
c. Deficient fluid volume
d. Intestinal obstruction
98. Nurse LL is caring for a client with head injury and monitoring the client with decerebrate
posturing. Which of the following is a characteristic of this type of posturing?
a. Flexion of the extremities after stimulus
b. Extension of the extremities after a stimulus
c. Upper extremity flexion with lower extremity flexion
d. Upper extremity flexion with lower extremity extension

99. During the second day of hospitalization of the client after a Myocardial Infarction. Which of
the following is an expected outcome?
a. Severe chest pain
b. Able to perform self-care activities without pain
c. Can recognize the risk factors of Myocardial Infarction
d. Can participate in cardiac rehabilitation walking program

100. A 68 year old client is diagnosed with a right sided Cerebrovascular Accident and is
admitted to the hospital. In caring for this client, the nurse should plan to _________.
a. Do passive range of motion exercise

17
 b. Use a bed cradle to prevent dorsiflexion of feet
c. Application of elastic stockings to prevent flaccid by muscle
d. Use hand roll and extend the left upper extremity on a pillow to prevent
contractions

101. In reducing the risk of Endocarditis, good dental care is an important measure. To
promote good dental care in client with mitral stenosis a teaching plan should include
proper use of _________.
a. Dental floss
b. Irrigation device
c. Electric toothbrush
d. Manual toothbrush

102. Among the following signs and symptoms, which would most likely be present in a
client with Mitral gurgitation?
a. Chest pain
b. Exceptional Dyspnea
c. Altered level of consciousness
d. Increase Creatine Phospholinase concentration

103. Patient K with a history of chronic infection of the urinary system complains of
urinary frequency and burning sensation. To figure out whether the current problem is in
the renal origin, the nurse should assess whether the client has discomfort or pain in the
_______.
a. Urinary meatus
b. Suprapubic area
c. Pain in the Labium
d. Right or left costovertebral angle
104. Nurse P is evaluating the renal function of a male client. After documenting urine
volume and characteristics, Nurse P assesses which signs as the best indicator of renal
function _________.
a. Pulse rate
b. Blood pressure
c. Consciousness
d. Distension of the bladder

105. Patient D suddenly experiences a seizure, and Nurse F noticed that he exhibits
uncontrollable jerking movements. Nurse F documents that the patient experienced which
type of seizure
a. Tonic seizure
b. Clonic seizure
c. Absence seizure
d. Myoclonic seizure

106. Nurse J should explain to a male client with diabetes that self-monitoring of blood
glucose is preferred to urine glucose testing because ____________.

18
 a. More accurate
b. It is easy to perform
c. It is not influenced by drugs
d. Can be done by the client

107. JJ a patient, weighed 210 lbs on admission to the hospital. After 2 days of diuretic
therapy, JJ weighs 205.5 lbs. The nurse could estimate the amount of fluid JJ has lost
_________.
a. 0.3 L
b. 1.5 L
c. 2.0 L
d. 3.5 L

108. Nurse Delaware is aware that the shift of body fluids associated with Intravenous
administration of albumin occurs in the process of ____________.
a. Osmosis
b. Diffusion
c. Filtration
d. Active transport

109. A female client is experiencing painful and rigid abdomen and is diagnosed with
perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted.
The nurse should place the client before surgery in _______________.
a. Sims position
b. Supine position
c. Semi-fowlers position
d. Dorsal recumbent position

110. Which nursing intervention ensures adequate ventilating exchange after surgery?
a. Maintain humidified oxygen via nasal canula
b. Position client laterally with the neck extended
c. Remove the airway only when client is fully conscious
d. Assess for hypoventilation by auscultating the lungs

111. A male client with a history of cirrhosis and alcoholism is admitted with severe
dyspnea which resulted to ascites. The nurse should be aware that the ascites is most likely
the result of increased ____________.
a. Secretion of bile salts
b. Interstitial osmotic pressure
c. Pressure in the portal vein
d. Production of serum albumin

112. A newly admitted client is diagnosed with Hodgkin’s disease undergoes an

excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess
first after the procedure?
a. Airway

19
 b. Vital signs
c. Incision site
d. Level of consciousness

113. A client has 15% blood loss. Which of the following nursing assessment findings
indicates hypovolemic shock?
a. Pupils unequally dilated
b. Pulse rate less than 60bpm
c. Respiratory rate of 4 breath/min
d. Systolic blood pressure less than 90mm Hg

114. Mr. P is admitted to the hospital due to metabolic acidosis caused by Diabetic
Ketoacidosis (DKA). The nurse prepares which of the following medications as an initial
treatment for this problem?
a. Potassium
b. Regular insulin
c. Calcium gluconate
d. Sodium bicarbonate

115. Dr. Martin tells a client that an increase intake of foods that are rich in Vitamin E and
beta-carotene are important for healthier skin. The nurse teaches the client that excellent
food sources of both of these substances are ___________.
a. Fish and fruit jam
b. Carrots and potatoes
c. Spinach and mangoes
d. Oranges and grapefruit
116. A client has Gastro-esophageal Reflux Disease (GERD). The nurse should teach the
client that after every meals, the client should ____________.
a. Take a short walk
b. Drink plenty of water
c. Rest in sitting position
d. Lie down at least 30 minutes

117. After gastroscopy, an adaptation that indicates major complication would be

___________.
a. Nausea and vomiting
b. Abdominal distention
c. Increased GI motility
d. Difficulty in swallowing

118. A patient who has undergone a Cholecystectomy asks the nurse whether there are
any dietary restrictions that must be followed. Nurse H would recognize that the dietary
teaching was understood when the client tells a family member that __________.
a. “I should avoid fatty foods as long as I live”
b. “I should not eat those foods that upset me before the surgery”
c. “Most people can tolerate regular diet after this type of surgery”

20
 d. “Most people need to eat a high protein diet for 12 months after surgery”

119. Nurse J is assigned to care for a client who has just undergone eye surgery. Nurse
Jones plans to teach the client activities that are permitted during the post operative period.
Which of the following is best recommended for the client?
a. Bending over
b. Watching TV
c. Lifting objects
d. Watching circus

SCENARIO 9 ITEMS 120-125

A 24-year-old female presented at the Accident and Emergency department with pleuritic chest
pain, dyspnoea, slight fever and cough productive of blood-tinged sputum. A provisional diagnosis
of pulmonary

120. Which of the following materials are necessary in preparation for a lung scan?
a. Face mask and intravenous line
b. Naso-gastric tube and face mask
c. Urethral catheter and nasogastric tube
d. Intravenous line and urethral catheter

121. Following the procedure the nurse instructs the client to drink
a. little water, and empty bladder four hourly
b. little water, and empty bladder on demand
c. plenty of water, and empty bladder four hourly
d. plenty of water, and empty bladder on demand

122. The patient returned to the ward with the diagnosis of PE confirmed. The primary
physician has prescribed medications. Which of the following would be the nurse’s priority
actions?
I. Commence antibiotics.
II. II. Place the patient in the Fowler’s position.
III. III. Initiate the anticoagulant
a. I and II only
b. I and III only
c. II and III only
d. I, II and III

123. The nurse caring for the patient with PE reports that the patient becomes
tachycardic, tachpnoeic and cyanotic. The nurse’s priority action should be to
I. Increase the vitamin C intake.
II. Report signs or symptoms of bleeding.
III. Keep appointment for regular follow-up.
IV. Report symptoms of nausea to your doctor
a. I and III only

21
 b. II and IV only
c. I, III and IV only
d. II, III and IV only

124. The nurse is preparing a 50-year-old patient for discharge after hospitalization for
diabetic ketoacidosis when the patient states that “on sick days” he neglects himself. What
advice should the nurse give this patient?

I. Take insulin, even if too ill to eat.

II. Engage in at least 30 minutes of vigorous exercise each day.
III. Check blood glucose and urine ketones every 2 to 4 hours.
IV. Stay hydrated by drinking 8 ounces of caffeine-free liquids every hour.
a. . I, II and III only
b. I, III and IV only
c. II, III and IV only
d. I, II, III and IV

125. When caring for a client who has had a colostomy done, the nurse assesses the
stoma and observes that it is swollen and bluish in colour. What should be the nurse’s
priority intervention?
a. Reinforce client teaching in colostomy care.
b. Carry out colostomy care as soon as possible.
c. Document accurately exactly what is observed.
d. Make a request that the doctor assesses the client

126. The registered nurse in a rural community discovers that at least 60% of the women
do not recognize the need to have a mammogram. Which initial approach is most likely to
motivate change among these clients?
a. Administering a survey to assess the exact nature of the women's self-care
behaviours before planning the next step
b. Arranging for reduced-cost mammograms and free transportation to the hospital in
town
c. Planning some small group sessions with these women to allow them to explore
their beliefs and attitudes
d. Presenting another educational session that includes a speech by a well-known
physician and then distributing additional literature

127. The registered nurse is preparing a male patient for discharge. The patient states, "I
will never learn how to inject myself with the medication because I am terrified of needles."
Which approach by the nurse is most likely to be effective with this patient in the initial
stage of acceptance?
a. Engaging the patient in activities that sensitize him to self-injection
b. Arranging for the home health agency to give the injection to the patient at home
c. Providing the patient with an instructional DVD on the self-injection of medications
d. Acknowledging the patient's fears, and suggesting a different route for the
medication ?

22
128. The registered nurse, working with community leaders, identifies the need for a
healthy lifestyle class addressing obesity and hypertension. The most important
information to relay to the community leaders is
a. the available community resources
b. an overview of the scope of the problem
c. the role of the nurse in community activities
d. a communication plan for the members of the class

129. The registered nurse is a member of a team working to design a programme to

reduce the number of patient falls. After determining the fall rate on the unit, the next
actions of the team, in correct sequence, will be to
a. contact the risk management department; incorporate specific interventions;
evaluate nursing practice interventions; determine outcome reporting mechanisms
b. contact the risk management department; incorporate specific interventions;
determine outcome reporting mechanisms; evaluate nursing practice interventions
c. incorporate specific interventions; evaluate nursing practice interventions; contact
the risk management department; determine outcome reporting mechanisms
d. determine outcome reporting mechanisms; contact the risk management
department; incorporate specific interventions; evaluate nursing practice
interventions

130. A 52-year-old has a history of emphysema and attended a discharge teaching

session. Which statement made by the patient will allow the nurse to think that he has fully
understood and can care for himself?
a. “When the air is polluted I should limit how often I go outside.”
b. “My breathing problems will get worse in the cold temperatures.”
c. “To regain my physical strength I will need to exercise extensively.”
d. “I need to eat balanced meals and reduce the amount of fluid I consume

131. During the category five hurricane Maria, a shelter manager used her skills in
decision making to effectively and efficiently care for all the clients at her shelter. The steps
in proper decision making include____________.
a. incubation and insight into patient planning and resource needs
b. triaging and controlling the types of patients and material resources
c. default and consultative categorization of patients and financial resources
d. identifying purpose, resources and setting criteria for patient categorization

132. The hospital administration at a particular hospital decided to review their disaster
management plan in an effort to prepare for the upcoming hurricane season. Planning for
disaster – staff training, disaster simulations, revise policies, procedures, and guidelines
necessary to protect lives, limit injury and protect properties. A comprehensive disaster
plan would include ________________.
a. individual influence and reaction to a disaster
b. identification of situational and personal factors during the disaster
c. cooperative effort among the people, agencies and levels of government
d. specific geographic area and social space requested by the disaster agent

23
133. A hospital in Trinidad responds to a local mass casualty event. Which action should
the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass
casualty event?
a. Schedule 16-hour shifts to allow for greater rest between shifts.
b. Provide water and healthy snacks for energy throughout the event.
c. Assign staff to different roles and units within the medical facility.
d. Encourage counseling upon deactivation of the emergency response plan.

134. A patient taking a thiazide diuretic has the following blood laboratory values for
kidney function. Which value does the nurse report to the prescriber immediately?
a. Sodium 124 mEq/L
b. Potassium 3.6 mEq/L
c. Creatinine 0.9 mg/dL
d. Blood urea nitrogen 16 mg/dL

135. Which precaution is most important for the nurse to teach a patient who has been
prescribed a beta blocker for hypertension?
a. . Avoid alcoholic beverages while taking this drug.
b. Weigh yourself daily at the same time every morning.
c. Wear gloves and other warm clothing during cold weather.
d. Do not suddenly stop taking this drug without notifying your prescriber
.
136. The number of calories per day supplied as carbohydrate for older adults who
require 2000 kcal per day would be
a. 450 to 650.
b. 750 to 1250.
c. 900 to 1300.
d. 1100 to 1450

137. Factors that commonly contribute to malnutrition in older adults include

a. type 2 diabetes and heart disease.
b. loss of teeth or poorly fitting dentures.
c. a weight 10% above desirable standards.
d. increased energy and nutrient needs.

138. Which of the following is an example of nursing malpractice?

a. The nurse administers penicillin to a patient with a documented history of allergy to
the drug. The patient experiences an allergic reaction and has cerebral damage
resulting from anoxia.
b. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient
with abdominal cramping.
c. The nurse assists a patient out of bed with the bed locked in position; the patient
slips and fractures his right humerus.

24
 d. The nurse administers the wrong medication to a patient and the patient vomits.
This information is documented and reported to the physician and the nursing
supervisor.

139. On which of the following grounds would a nurse Most likely be

disciplined__________.?
a. Failure to carry out a reasonable order
b. Advocating on the behalf of a patient
c. Asking to be assigned to another patient
d. Failure to carry out a doctor’s order which was questioned

140. For which of the following would a nurse most likely be cited for unprofessional
conduct
a. Wearing a short skirt to a professional setting
b. Having100mg of Oxycodone in her possession
c. Attending a function at Mirage night club on her way home
d. Using alcohol beverages on his way to reporting for work

141. Nursing is best defined as ________________.

a. a profession that promotes health care
b. the diagnosis and care of human being
c. the diagnosis and treatment of human to promote and treat illness
d. the diagnosis and treatment of human responses to health and illness
Scenario 10 Items 142-145

Mr. G, 75 year’s old retired asbestos worker was admitted to the ICU with a diagnosis of Acute
Respiratory Distress. He was intubated and mechanically ventilated, but efforts to wean him was
not successful due to his degenerative lung disease.

142. Which parameter/s would indicate that the patient is not yet ready for weaning?
a. Poor gag with SpO2 96%
b. Psychological unreadiness
c. Profuse sweating and restlessness
d. Respiratory rates 28 b/min and SpO2 96%

143. The nurse in assessing the client is most likely to arrive at a nursing diagnosis
of_____________.
a. Anxiety
b. Risk for infection
c. Risk for ineffective airway clearance
d. Dysfunctional ventilator weaning response

144. The nurse caring for Mr. G observed that his saturation is gradually decreasing,
checks done ascertain that the pulse oximeter is in place. The most appropriate action for
the nurse to take is ________________.
a. Suction patient

25
 b. Monitoring the patient SpO2
c. Assess the patient for coughing
d. Putting the patient in semi-fowler’s position

145. Nurse MN is monitoring a patient who has respiratory acidosis, Nurse MN would
expect which of the following arterial blood gas levels?
a. pH 7.50, pCO2 30mm Hg: pO2 80 mm Hg
b. pH, 7.30, pCO2, 56mm Hg; pO2 68 mmHg
c. pH 7.38, pCO2, 42mm Hg; pO2 88 mmHg
d. pH, 7.26; pCO2 37 mm Hg; pO2 75 mm Hg

146. Which of the following arterial blood gas levels would the nurse MN expect to
observe when monitoring another patient who has metabolic acidosis?
a. pH, 7.50; pCO2 30mm Hg; HCO3 31 mEq
b. pH, 7.30; pCO2 56 mmHg; HCO3 23 mEq
c. pH 7.38; pCO2 42 mm Hg; HCO3 25 mEq
d. pH, 7.26; pCO2 37mm Hg; HCO3 12 mEq

147. Mrs. LM , 63 years old with a history of Asthma is admitted to the intensive care
unit with Pneumonia. Vital signs and laboratory results on admission were: T38.6˚C, PR
118 b/min, RR 30 b/min and BP 148/90 mmHg. ABGs were: pH 7.35,Pa CO2 48 mmHg,
HCO3 28mEq/L, BE 1 mEq/L, PaO2 80 mmHg and SaO2 89%. Mrs. LM’s oxygen status is
indicated by____________constraints/parameters.
a. PaCO2 and pH
b. PaO2 and SaO2
c. PaO2, SaO2 and pH
d. PaO2 and Respiratory rate

148. Which of the following arterial blood gas levels would a nurse expect to observe
when monitoring a patient who is metabolic alkalosis?
a. pH, 7.50; pCO2 38mm Hg; HCO3 30mEq
b. pH, 7.30; pCO2 56 mm Hg; HCO3 24mEq
c. pH 7.38, pCO2 42mm Hg; HCO3 25mEq
d. pH, 7.26; pCO2 37mm Hg; HCO3 18mEq

149. The charge nurse was conducting an educational session on suctioning and advised
nurses not to instill normal saline before bagging a patient. Which scientific data maybe the
most appropriate explanation for this discouraging this practice?
a. Normal saline contributes to hypoxia
b. Normal saline generate too much secretion
c. Normal saline contributes to the patient’s acidosis
d. Normal saline is of no benefit when suctioning the patient

150. An MI is suspected because of ______indication

a. CK –MB and LDH
b. LDH and Troponin I

26
 c. Troponin I and SGPT
d. CK-MB and Troponin I

151. The nurse is describing the HIV virus infection to a client who has been told that he
is HIV positive. Which information regarding the virus is important to teach?
a. The HIV virus is a retrovirus, which means it never dies as long as it has a host to
live in
b. b) The HIV virus can be eradicated from the host body with the correct medical
regimen
c. c) It is difficult for the HIV virus to replicate in humans because it is a monkey virus
d. d) The HIV virus uses the client’s own red blood cells to reproduce the virus in the
body

152. A client who has engaged in needle-sharing activities has developed a flulike
infection. An HIV antibody test is negative. Which scientific rationale explains this finding?
a. The client is fortunate to not have contracted HIV from an infected needle.
b. The client must be repeatedly exposed to HIV before becoming infected.
c. The client may be in the primary infection phase of an HIV infection.
d. The antibody test is negative because the client has a different flu virus.

153. The nurse caring for a client who is HIV positive is stuck with the stylet used to start
an IV. Which action should the nurse implement first?
a. Flush the skin with water and try to get the area to bleed.
b. Notify the charge nurse and complete an incident report.
c. Report to the employee health nurse for prophylactic medication.
d. Follow up with the infection control nurse to have lab work drawn.

154. The client on a medical ward is diagnosed with HIV encephalopathy. Which nursing
diagnosis would be a priority?
a. Risk for injury
b. Anticipatory grieving
c. Knowledge deficit, procedures and prognosis
d. Altered nutrition, less than body requirements

155. The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client
should be seen first?
a. The client who has flushed warm skin with tented turgor.
b. The client who states that the staff ignores the call light.
c. The client who is unable to provide a sputum specimen.
d. The client whose vital signs are T 99.9F, P 101, R 26, and BP 110/68.

156. The client diagnosed with AIDS is angry and yells at everyone entering the room and
none of the staff members want to care for the client. Which intervention is the most
appropriate for the nurse manager to use in resolving this situation?
a. Assign a different nurse every shift to the client.

27
 b. Ask the doctor to tell the client not to yell at the staff.
c. Call a team meeting and discuss options with the staff.
d. Force one (1) staff member to care for the client a week at a time.
157. Twenty one (21) year old male involved in a motor vehicle crash presents to the
emergency department with severe internal bleeding. The client is severely hypotensive
and unresponsive. The nurse anticipates that which intravenous IV solution will most likely
be prescribed for this client?
a. 0.33% sodium chloride (1/3 normal saline)
b. 0.45% sodium chloride (1/2 normal saline)
c. 0.225% sodium chloride (1/4 normal saline
d. 5% dextrose in lactated Ringer’s solution

158. Intravenous (IV) fluids have been infusing at (100 mL/hour via a central line
catheter in the right internal jugular for approximately 24 hours to increase urine output
and maintain the client’s blood pressure. Upon entering the client’s room. The nurse notes
that the client is breathing rapidly and coughing. For which additional signs of a
complication should the nurse assess based on the previously known data?
a. Crackles in the lungs
b. Excessive bleeding
c. Incompatibility of the infusion
d. Chest pain radiating to the left arm
159. Mrs. ER a 75 yr old a client. is receiving 0.9% sodium chloride should be monitored
for signs of
a. Fluid deficit
b. Hypotension
c. Fluid overload
d. Distended neck vein

160. Nurse AF is inserting an intravenous (IV) line into a client’s vein. After the initial
stick, the nurse would continue to advance the catheter in which situation?
a. The catheter advances easily
b. The vein is distended under the needle
c. The client does not complain of discomfort
d. Blood return shows in the back flash
161. By which mechanism do diuretics such as furosemide improve the symptoms of
heart failure?
a. Reducing fluid /plasma volume
b. Blockading beta-adrenergic receptors
c. Causing the heart to beat with more strength
d. Slowing heart rate, thus reducing cardiac work load

28
162. Beta- adrenergic blockers are used to treat a large number of cardiovascular
disease. Which of the following is not one of the uses of beta-blockers?
a. Hypertension
b. Heart failure
c. Dysrhythmias
d. Anticoagulant

163. Which of the following will stimulate the secretion of aldosterone?

a. Diuretics
b. ACE inhibitors
c. Alpha blockers
d. Calcium channel blockers

164. What is potentially the most serious adverse effect of digoxin?

a. Hyperkalemia
b. Hypotension
c. Dysrhythmias
d. Permanent visual disturbance

165. By which mechanism do diuretics such as furosemide improve the symptoms of

heart failure?
a. Reducing fluid /plasma volume
b. Blockading beta-adrenergic receptors
c. Causing the heart to beat with more strength
d. Slowing heart rate, thus reducing cardiac work load
166. The nurse accidentally give a patient an over dose of Morphine. What would the
priority nursing assessment include?
a. Diarrhea
b. Dilated pupil
c. Hypertension
d. Depressed respiration

167. Nurse K is assessing a client with a suspected diagnosis of hypocalcemia. Which

clinical manifestation would Nurse K expect to note in the client?
a. Twitching
b. Hypoactive bowel sounds
c. Negative Trousseau sign
d. Hypoactive deep tendon reflexes

168. Which client is at risk for the development of sodium level at

130mEq/L(130mmol/L?
a. The client who is taking diuretics
b. The client with hyperaldosteronism

29
 c. The client with Cushing’s syndrome
d. The client who is taking corticosteroids

169. The nurse reviews a client’s laboratory report and notes that the client’s serum
phosphorus (phosphate) level is 1.8 mg/dl (0.45 mmol/L). Which condition most likely
caused this serum phosphorus level?
a. Malnutrition
b. Renal insufficiency
c. Hypoparathyroidism
d. Tumor lysis syndrome

170. Which client is at risk for development of a potassium level of 5.5mKq/L (5.5
mmol/L)?
a. The client with colitis
b. The client with Cushings’s syndrome
c. The client who has been over using laxatives
d. The client who has sustained a traumatic burn?

171. A 46 year old client has been admitted to the hospital for urinary tract infection and
dehydration. The nurse determines that the client has received adequate volume
replacement if the blood urea nitrogen (BUN) level drops to which value?
a. 3mg/dL (1.05 mmol/L)
b. 15mg/dL (5.25 mmol/L)
c. 29mg/dL (10.15mmol/L)
d. 35mg/dL (12.25 mmol/L)

172. A patient with a history of cardiac disease is due for a morning dose of furosemide.
Which serum potassium level, if noted in the patient’s lab results, should be reported before
administering the dose of furosemide?
a. 3.2mEq/L (3.2mmol/L)
b. 3.8mEq/L (3.8mmol/L)
c. 4.2mEq/L (4.2 mmol/L)
d. 4.8mEq/L (4.8mmol/L)

173. A 56-year-old female, who weighed 200 lb (90.9 kg), was admitted to the medical
ward complaining of severe chest pain. A diagnosis of myocardial infarction was made.
Which of the following laboratory results will confirm a diagnosis of myocardial infarction?
a. CK-MB ≥9 U/L
b. Troponin I ≥ 0.4 ng/mL
c. Creatine Kinase ≥ 150 U/L
d. Total cholesterol ≥ 7.6 mmols

174. A 40 year old patient with Atrial fibrillation is receiving maintenance therapy of
warfarin sodium and has a prothrombin time (PT) of 35 (35) seconds and an international
normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates
which prescription?

30
 a. Adding a dose of heparin sodium
b. Holding the next dose of warfarin
c. Increasing the next dose of warfarin
d. Administering the next dose of warfarin

175. The nurse is conducting a dietary assessment on a client who is on a vegan diet. The
nurse provides dietary teaching and should focus on foods high in which vitamin that may
be lacking in a vegan diet?
a. Vitamin A
b. Vitamin B12
c. Vitamin C
d. Vitamin D
176. The nurse instructs a client with chronic kidney disease who is receiving
hemodialysis about dietary modifications. The nurse determines that the client understands
these dietary modifications if the client selects items from the dietary menu?
a. Cream of wheat, blueberries, coffee
b. Bacon, cantaloupe melon, tomato juice
c. Sausages and eggs, banana, orange juice
d. Curried pork, frits strawberries, orange juice

177. Mr. Katz, who is 48 years old, is admitted to the hospital with a fracture to his
left hip. He weighs 248 lb (54 lb above his desired weight). He is considered to be in a
state of over nutrition. The statement most true regarding his state of over-nutrition is
a. Desired nutrients are consumed in excess amounts without the risk of malnutrition.
b. Because excess body fat is evident and excess calories are consumed, there is no risk
of nutrient deficiency leading to malnutrition.
c. Even though excess body fat and excess nutrient intake are evident, there still may
be a risk for some type of nutrient deficiency leading to malnutrition.
d. Excess body weight may or may not be present along with excess consumption of
carbohydrates and fat, which results in inadequate vitamin and mineral intake.

178. You are asked to explain the Dietary Guidelines to a group in an adult
community evening class at the local college. The most appropriate areas to cover in
teaching this topic include
a. appropriate amounts of sodium, saturated fat, cholesterol, transfatty acids, whole
grains, and alcohol.
b. adequate calories and protein for weight maintenance, smoking cessation, herbal
supplements, and food fads.
c. importance of low-carbohydrate diets, smoking cessation, herbal supplements,
appropriate food groups, and sodium and potassium.
d. food security, weight maintenance, glucose monitoring, and blood pressure
monitoring technique.

179. The label reads Heparin Sodium 10,000 USP Units/mL. The order is for Heparin
6,000 U q6h sc. How many milliliters will you administer to the patient? Answer: 0.6
milliliters

31
 a. 0.10 ml
b. 0. 06 mls
c. 0.6 mls
d. 0.100mls

180. The physician ordered: Digoxin 250 mcg po qid. The label reads 1 tablet equals 0.25
mg. How many tablets will the nurse administer to the patient? Answer:
a. 1 tab
b. 2 tabs
c. 0.5 tabs
d. 1.5 tabs
181. The order is to give 600 mg of Ampicillin IM q8h. The directions for dilution on the 2
gm vial reads: Reconstitute with 4.8 mL of sterile water to obtain a concentration of 400 mg
per mL. How many mL will you adminster per dose?
a. 1ml
b. 0.5 mls
c. 1.5 mls
d. 2.5 mls

182. The physician ordered 180 mg of Dilantin po q8h. The patient weighs 98 lb. The
label of the drug reads 250 mg per 5 mL. How many milliliters will you administer to this
patient per dose?
a. 1.6 mls
b. 3. 6 mls
c. 3. 66 mls
d. 2.6mls
183. The doctor ordered Atropine 0.6 mg IM. Label reads 0.3 mg per 0.5 mL. How many
milliliters will the nurse give per dose?
a. 1 ml
b. O.15 mls
c. 0. 13 mls
d. 0.33 mls

184. Doctor's order says: "Infuse 1500 mL of Lactated Ringer's over 12 hours." Drip
factor: 15 gtt/mL
a. 31 gtt/min
b. 32 gtt/min
c. 95 gtt/min
d. 15 gtt/min

185. Doctor's order says: "300 mL of Ampicillin Sodium 500 mg to infuse over 40
minutes." Drip factor: 20 gtt/mL
a. 20 gtt/min
b. 80 gtt/min
c. 100 gtt/min
d. 150 gtt/min

32
186. Doctor's order says: "Two 250 mL Packed Red Blood Cells to infuse over 4 hours."
Drip factor: 15 gtt/mL
a. 31 gtt/min
b. 19 gtt/min
c. 30 gtt/min
d. 32 gtt/min

187. Doctor's order says: "2L of D5 1/2 Normal Saline with 50 meq Potassium Chloride to
infuse over 48 hours." Drip factor: 15 gtt/mL
a. 50 gtt/min
b. 20 gtt/min
c. 10 gtt/min
d. 16 gtt/min

188. Doctor's order says: "0.5 L of Normal Saline to infuse over 6 hours." Drip factor: 30
gtt/mL
a. 42 gtt/min
b. 24 gtt/min
c. 425 gtt/min
d. 68 gtt/min

189. Doctor's order says: "50 ml of a drug called ‘Zofran’ to infuse over 15 minutes." Drip
factor: 15 gtt/mL
a. 25 gtt/min
b. 5 gtt/min
c. 50 gtt/min
d. 300 gtt/min

190. Doctor's order says: "3 L of D5W with 20 meq of potassium chloride to infuse over
24 hours" Drip factor: 10 gtt/mL
a. 21 gtt/min
b. 20 gtt/min
c. 72 gtt/min
d. 86 gtt/min

191. Doctor's order says: "650 mL of D5W to infuse over 6 hours." Drip factor: 10 gtt/mL
a. 360 gtt/min
b. 96 gtt/min
c. 9 gtt/min
d. 18 gtt/min

192. Although the criterion is arbitrary, acute pain can be classified as chronic when it
has persisted for_________________.

33
 a. 1 to 2 months
b. 3 months
c. 3 to 5 months
d. longer than 6 months

193. A physiologic response not usually associated with acute pain is_______________.
a. altered insulin response
b. increased metabolic rate
c. decreased cardiac output
d. decreased production of cortisol
194. A physiologic indicator of acute pain is ______.
a. diaphoresis
b. bradycardia
c. hypotension
d. lowered respiratory rate
SCENARIO 10 Items 195- 197

Courtney is a young, healthy adult who slipped off the stairs going down to the basement and struck
his forehead on the cement flooring. CY did not lose consciousness but did sustain a mild
concussion and a hematoma that was 5 cm in width and protruded outward about 6 cm. He
experienced immediate acute pain at the site of injury plus a pounding headache

195. An immediate assessment of the localized pain, based on the patient’s description, is
that it should be___________________.
a. brief in duration
b. placid in intensity
c. recurrent for 3 to 4 months
d.  persistent after healing has occurred

196. During the assessment process, the nurse attempts to determine CY’s physiologic
and behavioral responses to his pain experience. The nurse is aware that a patient can be in
pain yet appear to be “pain free.” A behavioral response indicative of acute pain is
_______________.
a. muscle tension
b. physical inactivity
c. an expressionless face
d. clear verbalization of details

197. The nurse uses distraction to help Courtney cope with his pain experience. An
activity the nurse would not suggest is ______________.
a. promoting relaxation
b. reading an interesting novel
c. conversing with his neighbor
d. playing music or using a videotape

34
198. A semiconscious patient presents with restlessness and weakness. He has a dry,
swollen tongue. His body temperature is 99.3_F, and his urine specific gravity is 1.020.
Choose the most likely serum sodium (Na_) value for this patient
a. 110 mEq/L
b. 140 mEq/L
c. 155 mEq/L
d. 165 mEq/L

199. To return a patient with hyponatremia to normal sodium levels, it is safer to restrict
fluid intake than to administer sodium _______________.
a. to prevent fluid overload
b. to prevent dehydration
c. in patients who are unconscious
d. in patients who show neurologic symptoms

200. An expected nursing diagnosis for a patient with hypertension is ____________.

a. heart failure
b. knowledge deficit
c. renal insufficiency
d. myocardial infarction

35