RENR REVIEW RAS PRACTICE TEST 32

A 58-year-old female was admitted to the surgical ward after having sustained full-
thickness (3rd. degree) burns to the anterior head and neck, right arm and part of the
chest, while cooking. Medical management was initiated immediately in order to avoid
potential complications.
1. Scar contractures tend to occur more in which of the following areas?
a) Where the skin is pliable
b) On the scalp
c) In muscular areas
d) Over bony areas

2. In the adult, scars from burns reach maturation within

a) 3 to 6 months
b) 6 to 12 months
c) 12 to 18 months
d) 18 to 24 months

3. Joint contractures are one of the most challenging aspects of burn management
and are the main source of disability for burn patients. Bringing about the best
functional outcomes in the rehabilitation of the patient involves
i. Splinting
ii. Bed rest
iii. Proper positioning
iv. Range of motion exercises
a) I, ii, and iii
b) I, iii, and iv
c) Ii, iii, and iv
d) I, ii, iii, and iv

4. The patient received burns to her anterior neck. Which of the following positions is
best to prevent contractures to the neck?
a) 15-degree flexion
b) 15 to 20-degree extension
c) 5 to 10-degree flexion
d) 10 to 15-degree extension

5. Which of the following is the most optimal time to do Range of Motion (ROM)
exercises for the burn patient?
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a) During bed bath
b) Two hours after breakfast
c) During dressing change
d) As prescribed by the doctor

6. How many times daily should ROM exercises be performed to the affected limbs of
a burns patient?
a) Two to three times daily
b) Three to four times daily
c) One to two times daily
d) Every four hours

7. Which of the following is the correct ROM exercises done to the elbow joint?
a) Adduction and abduction
b) Rotation and flexion
c) Supination and pronation
d) Extension and circumduction

8. Which of the following are clinical indications of inhalation burn injury?

i. Hoarseness
ii. Singeing of eyebrows
iii. Face and or neck burns
iv. Carbon particles in sputum
a) I, ii, and iii
b) I, iii, and iv
c) Ii, iii, and iv
d) I, ii, iii, and iv

9. The prognosis of burn injuries depends on

i. Depth of burn
ii. Body surface area affected
iii. Age of client
iv. Inhalation injury
a) I, and ii
b) I, and iv
c) Ii, and iii
d) Iii, and iv

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10. Through knowledge gained from her phenomenological qualitative study
identifying levels of experience of professional nurses, Patricia Benner would
identify which nurse as an expert?
a) A hospice nurse who values the unique wishes of each patient when providing
palliative care
b) A medical-surgical nurse who organizes care for a group of patients to ensure
timely administration of medications
c) A neonatal intensive care nurse who is skilled in inserting peripherally inserted
central catheters
d) A paediatric nurse who notes subtle changes and intervenes to prevent respiratory
failure

11. Which research technique would be used by a nurse researcher who wishes to
compare bonding patterns of neonatal intensive care infants to non-intensive care
infants to test various theories about infant-parent bonding?
a) Exploratory
b) Grounded theory
c) Experimental
d) Quasi-experimental

12. The nurse researcher wishes to review a body of qualitative studies about
women’s attitudes toward health care in order to develop an overall interpretation
of these findings. Which type of review will the nurse researcher use?
a) Meta-synthesis
b) Meta-analysis
c) Systematic review
d) Mixed-methods systematic review

13. Which of the following are components of Evidenced-Base Practice?

i. Best research evidence
ii. Expert opinion consensus
iii. Patient needs and values
iv. Safe, cost-effective care
a) I, ii, and iii
b) I, ii, and iv
c) I, iii, and iv
d) I, ii, iii, and iv

14. Which ethical principle protects human subjects from harm?

a) Ethics

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b) Justice
c) Beneficence
d) Respect for persons

15. A special concern when conducting research using terminally-ill cancer patients as
subjects is
a) An increased risk of harm with decreased benefits
b) An inability to randomly assign subjects to study groups
c) Poor control of extraneous variables
d) Difficulty enlisting subjects for participation in the study

16. The nurse is preparing a client for a bronchoscopy. The nurse asks several
questions regarding the client’s understanding of the procedure being done and
why. The client answers appropriately, therefore the nurse can expect the
following outcome from this procedure
a) The client’s outcome and diagnosis are inconsistent
b) The client has increased anxiety
c) The client demonstrates post-operative exercises as instructed
d) The client states concern over the possibility of choking and not being helped

17. Before surgery, a chest x-ray is requested. The nurse knows that the x-ray will
determine all of the following except
a) Size and shape of the heart
b) Presence of pneumonia
c) Presence of increased pulmonary pressure
d) Baseline information in event of surgical complications

18. The nurse knows that any electrolyte abnormality must be reported to the
anaesthetist. Which of the following occurs as a result of hypokalaemia?
a) Decrease blood pressure
b) Slows the recovery from anaesthesia
c) Decreases cardiac irritability
d) Decreases the risk for toxicity if the patient is taking digoxin

19. The laboratory results show the client to have a potassium level of 3.1 mEq/L. the
doctor has ordered KCL 10 mEq. The nurse would expect to administer this
medication by which method?

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 a) Infuse KCL 10 mEq over 1 hour
b) Administer KCL 5 mEq intramuscularly in 2 doses
c) Push KCL 10 mEq via a central venous line
d) Dilute KCL 20 mEq in 500 ml normal saline and infuse at 100 ml/hr

20. The doctor suspects that a 22-year-old client she has just seen is suffering from
infective endocarditis. The nurse explains to the client that this diagnosis is best
confirmed with
a) An echocardiogram
b) Blood cultures
c) Cardiac catheterization
d) A complete blood count with differential

21. The doctor has ordered that arterial blood gases be done in order to assess the pH
level. What does the pH level measure?
a) Carbon dioxide levels in the blood
b) HCO₃ˉ (bicarbonate buffer) in the blood
c) Hydrogen and oxygen levels combined
d) Free hydrogen ions in the blood

22. The nurse is assigned to the medical-surgical floor. She understands that stress-
relieving interventions are priority especially for which of the following patients
a) One with a diagnosis of peptic ulcers
b) Newly admitted patient with cholecystitis
c) Patient with bacterial exacerbation of bronchitis
d) Patient who is one-day post-op after knee surgery

23. A 40-year-old client with Rheumatoid Arthritis (RA) is seen to be reserved, and
does not interact with family. When the nurse questions the client about her
behaviour, the client tells the nurse that she must either withdraw or cry
constantly, because she cannot cope with the notion that her disease is chronic.
Which nursing diagnosis is most appropriate?
a) Denial of disease process related to inability to cope
b) Ineffective coping related to disruption of emotional bonds
c) Ineffective coping related to inadequate psychological resources
d) Impaired adjustment related to unwillingness to modify lifestyle
RAS

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24. A client is nil per orally while scheduled for afternoon surgery. She is a heavy user
of caffeine, more than 10 cups of coffee per day. Without the caffeine the nurse
would expect to monitor the client for which of the following?
a) Nervousness
b) Headaches
c) Mild tremors
d) Shortness of breath

25. A patient with suspected ulcers is scheduled for a diagnostic gastroscopy. During
the insertion of the scope, the patient experiences a vasovagal response. The nurse
should expect all of the following except
a) The patient’s pupils become dilated
b) The patient has a decrease in heart rate
c) The patient is given atropine before the procedure
d) The patient has an increase in gastric secretions

26. A patient has a chest tube placement post right thoracotomy. During assessment
the nurse expects all of the following findings except
a) The chest drainage flows into the first chamber
b) Use of accessory muscles with respirations
c) The water level in the chamber rises and falls with each respiration
d) Evaluate tidaling by disconnecting the chest tube from the wall suction

27. The AIDS virus can be transmitted under specific conditions and through infected
bodily fluids except
a) Faeces
b) Semen
c) Breast milk
d) Wound exudate

28. A urinalysis is done to determine all of the following except

a) Specific gravity
b) Presence of red blood cells
c) Presence of white blood cells
d) Validation of intake and output

29. Mrs. Elaine, a 68-year-old patient who has had a myocardial infarction 10 years
ago, is admitted to the medical ward with shortness of breath for the last week.
She recently received treatment for a respiratory infection. Upon auscultation of

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 the lungs, the nurse hears crackles in both lungs. She has oedema of both lower
extremities. The nurse understands that Mrs. Elaine is exhibiting signs of systolic
failure which include all of the following except
a) Right sided heart failure
b) Left sided heart failure
c) Hypertrophy of the cardiac wall
d) An ejection fraction of less than 50%

30. An ECG contains all of the following components except

a) There are 12 leads on the ECG tracing
b) Each small square on the ECG paper represents 0.04 seconds vertically
c) A graphic tracing of the electrical vector moving through the heart
d) The ECG tracing can indicate structural changes or damages to the heart

31. When considering unstable angina, the nurse expects all of the following findings
except
a) Pain lasting longer than 15 minutes
b) Pain poorly relieved by nitro-glycerine
c) Pain that occurs during strenuous exercise
d) Fewer women than men present with “classic” signs of unstable angina

32. A patient arrives at the Accident and Emergency department with a heart rate of
58 bpm and irregular. After assessment by the physician, the patient is found to
have a cardiac conduction problem. Which of the following nursing diagnoses best
suits this patient?
a) Ineffective tissue perfusion related to interruption of blood flow
b) Impaired physical mobility related to fear of movement or death
c) Pain related to imbalance between myocardial oxygen supply and demand
d) Low activity endurance related to imbalance between oxygen supply and demand

33. When giving a thiazide diuretic, what electrolyte replacement should be

supplemented?
a) Sodium
b) Calcium
c) Potassium
d) Magnesium

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 34. During discharge planning, the nurse instructs the patient about the storage of the
nitro-glycerine tablets. She recommends that the tablets be placed in a dark glass
bottle out of the sunlight because
a) The medication is easily destroyed
b) The dose effectiveness will change if it is exposed to light
c) The medication will become toxic if left to mix with the substance of a plastic
bottle
d) Child-proof bottles are a hindrance as the medication must be made available
quickly

35. A nurse manager receives several time-off requests for the same time through the
holidays. She has come up with ideas but schedules a staff meeting to discuss
solutions to the problem. She is demonstrating which type of management style?
a) Participative
b) Democratic
c) Authoritative
d) Transformational

Items 36 to 38 refer to the following management concepts.

a) Management
b) Supervision
c) Authority
d) Leadership
Match each of the following definitions with the appropriate concept above. You may use
one concept once, more than once or not at all.
36. The right to give orders and to expect compliance
37. The ability to influence other people’s behaviour
38. The ability to get things done through others

39. When studying the problem of overcrowding, the researcher made the statement
that: “A high prevalence of communicable diseases will result from overcrowding.”
This statement is most reflective of which of the following steps of the research
process?

a) The problem statement

b) The statement of hypothesis
c) An operational definition of variables
d) Formulating a theoretical framework
Items 40 to 44 refer to the following scenario.

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In order to elicit data to determine the effects of overcrowding, a research questionnaire
poses the various types of questions
a) Close-ended
b) Open-ended
c) Leading
d) Double-barrelled
Match the following questions in items 40 to 44 with the appropriate type of question
above. You can use one option once, more than once or not at all.
40. What do you think would be some of the ill effects of overcrowding?
41. Are you satisfied with your housing situation?
42. Do you believe that an effect of overcrowding is low sexual morality?
43. Do you believe that overcrowding can have any positive effects?
44. Do you think that overcrowding is the cause of a high incidence of teenage
pregnancy and school dropout?

Carl Valerio, a 3-year-old boy was admitted to the paediatric ward in a semiconscious
state. His mother claimed her child was assaulted by another child. The doctors suspect
child abuse.
45. One behaviour that is most typical of the parents of the physically abused child is
that they
a) Blame the child for the accident
b) Become irritated about having the history taken
c) Give contradictory explanation about what happened
d) Present many details related to how the trauma occurred

46. A common clue that would suggest that Carl was abused is, he
a) Ignores offers of toys and favours
b) Cries for longer periods of time
c) Shows no expectation of being comforted
d) Does not cry during painful procedures

47. There are many common reactions of parents who batter their children. Reactions
the nurse should look for in Carl’s parents are that they

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 i. Seldom touch or look at Carl
ii. Show signs of guilt about his injury
iii. Are quick to inquire about the discharge date
iv. Are very concerned about the child’s physical health
a) I, and ii
b) Ii, and iii
c) Ii, and iv
d) Iii, and iv

48. When educating abusive parents, the nurse must consider

i. The child’s normal needs and development
ii. Realistic expectations and family therapy
iii. The child’s development and new modes of discipline
iv. New modes of discipline and the need for foster home
a) I, ii, and iii
b) I, ii, and iv
c) I, iii, and iv
d) Ii, iii, and iv

49. Which of the following diagnostic tools is most commonly used to determine the
location of myocardial damage?
a) Cardiac enzymes
b) Coronary angiogram
c) Electrocardiogram
d) Echocardiogram

50. Which of the following classes of medications protects the ischemic myocardium
by blocking catecholamines and sympathetic nerve stimulation?
a) Narcotics
b) Nitrates
c) Calcium channel blockers
d) Beta-adrenergic blockers

51. Toxicity from which of the following medications may cause a client to see a green
halo around lights?

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 a) Digoxin
b) Metoprolol
c) Enalapril
d) Furosemide

52. In which of the following areas is an abdominal aortic aneurysm most commonly
located?
a) Distal to the iliac arteries
b) Distal to the renal arteries
c) Adjacent to the aortic arch
d) Proximal to the renal arteries

53. What is the most common symptom in a client with abdominal aortic aneurysm?
a) Headache
b) Diaphoresis
c) Abdominal pain
d) Upper back pain

54. Which of the following layers of the blood vessel wall may be damaged in a client
with an aneurysm?
a) Tunica interna
b) Tunica externa
c) Tunica media
d) Tunica interna and media

55. When assessing a client with an abdominal aortic aneurysm, which area of the
abdomen is most commonly palpated?
a) Right upper quadrant
b) Directly over the umbilicus
c) Middle lower abdomen to the right of the midline
d) Middle lower abdomen to the left of the midline
RAS

In many countries where there are numerous socio-economic difficulties, attitudes such as
assertiveness, autonomy and mastery of the environment, contribute to the maintenance
of good mental health, and preservation of personal integration.

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56. Which of the following indicate positive self-attitudes among youths?
i. Having a feeling of wholeness
ii. Being aware of one’s individuality
iii. Continuously seeking new challenges
iv. Having a sense of one’s identity
a) I, ii, and iii
b) I, ii, and iv
c) I, iii, and iv
d) I, ii, iii, and iv

57. An individual in the community who is mentally healthy should be able to

i. Change perceptions in the light of previous information
ii. Show a sense of belongingness
iii. Learn from other’s experiences
iv. Influence decisions based on intuition
a) I, ii, and iii
b) I, ii, and iv
c) Ii, iii, and iv
d) I, ii, iii, and iv

58. Autonomy is evidenced when the individual demonstrates all of the following
except
a) Responsibility for himself
b) Refusal to adjust to sudden changes
c) Responsibility for his own decisions
d) Respect for the choices of others

59. Which of the following are included in concepts of personal integration?

i. Egoistic philosophy of life
ii. Measure of social sensitivity
iii. Regulation of one’s moods and emotions
iv. Balance between inner and outer conflicts
a) I, ii, and iii
b) I, ii, and iv
c) I, iii, and iv
d) Ii, iii, and iv

60. Environmental mastery is achieved by which of the following?

i. Working out problems of living
ii. Obtaining satisfaction from life

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 iii. Coping with frustration and loneliness
iv. Having free access to other’s feelings
a) I, ii, and iii
b) I, ii, and iv
c) I, iii, and iv
d) Ii, iii, and iv

The results of a research study conducted, revealed that 25% of adolescents have
considered committing suicide at some point in time.
61. Which of the following factors are commonly cited as a cause for suicide?
i. Problems with family
ii. Financial problems
iii. Identity crisis
iv. Academic and social pressure
a) I, ii, and iii
b) I, ii, and iv
c) Ii, iii, and iv
d) I, ii, iii, and iv

62. Which of the following is factual about suicide?

a) Suicidal individuals are mentally ill and most are psychotic
b) Suicide occurs at the height of an individual’s morbid feelings
c) Suicidal people are frequently undecided about living or dying
d) Suicidal people are intent on dying and habitually gamble with death

63. Emile Durkheim theorized that men are most protected from suicide by
a) Physical health
b) Financial success
c) Aggressive traits
d) Marital relationships

64. Nurses can assist in the prevention of suicide by

i. Mobilizing resources to relieve clients’ personal responsibilities

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 ii. Assessing the client’s ability to cope with stress
iii. Teaching the client stress-relieving measures
iv. Offering continual support to families
a) I, ii, and iii
b) I, ii, and iv
c) Ii, iii, and iv
d) I, Ii, iii, and iv

65. In a telephone conversation with a person who is suicidal, the nurse should be
directed by all of the following principles except
a) Encouraging the caller to do most of the talking
b) Writing down all important data given by the caller
c) Mobilizing help for the caller if indicated
d) Being optimistic and ensuring the caller that the problems will abate

As a caregiver, the nurse must facilitate the client in achieving health goals which may
include measures to restore emotional and social well-being, and the ability to develop
self-care skills.
66. Which of the following actions will encourage the client to care for himself?
i. Assessing his daily intake of calories
ii. Observing a client test his urine
iii. Teaching a diabetic to use a glucometer
iv. Ensuring that the client’s dressing is changed
a) I, ii, and iii
b) I, ii, and iv
c) I, iii, and iv
d) Ii, iii, and iv

67. When deciding to teach a 14-year-old how to administer his insulin for the first
time, the best principle for the nurse to apply is
a) Ability to learn
b) Readiness to learn
c) Learning environment
d) Previous knowledge

68. Which of the following is the best method for the nurse to use when teaching a 2-
year-old to use the “potty”?
a) Sit him on the potty three times daily

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 b) Tell him to tell you when he wants to “pee”
c) Spank the child and put him on the potty
d) Use games and pictures to show him how to use the potty

Ms. Claire is the senior Staff Nurse on the medical ward. She has three student nurses to
supervise. While serving meals, she heard a loud noise in the ward. On investigation she
saw Mr. Cox a diabetic, lying on the floor beside his bed.
69. In assessing Mr, Cox, the best actions for SN Claire to take would be to
i. Write up an incident form
ii. Assess Mr. Cox’s condition and seek medical aid
iii. Instruct 2 of the student nurses to put Mr. Cox back on the bed
iv. Get 2 of the student nurses to assist her to put Mr. Cox in bed
a) I, and ii
b) I, and iv
c) Ii, and iii
d) Ii, and iv

70. While SN Claire was supervising Mr. Cox’s bed bath the following day, a very irate
relative demanded to see him immediately. The best response from SN Claire
should be
a) “It is not visiting time, so you cannot see him”
b) “Mr. Cox is being bathed, please wait a little while”
c) “Is there a message I can give him for you?”
d) “We are bathing him now; could you return later?”

71. Nurse Claire discussed with the student nurses, combination of techniques utilized
for effective ward management. Which of the following would be the best
response made by the students?
a) Counselling, teaching and interviewing
b) Research, teaching and counselling
c) Teaching surveillance and interviewing
d) Evaluation, research and surveillance

72. A 33-year-old female client is diagnosed with endometriosis and is scheduled for
conservative surgery as part of the treatment of endometriosis. This type of
surgery will entail
a) Removal of the uterus and the cervix

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 b) Removal of endometrial implants
c) Removal of the uterus and endometrial implants
d) Restoration of normal anatomy and removal of endometrial implants

Mrs. Masie 35-years-old, discovered a lump in her left breast during a routine self-breast
examination. She is admitted for a breast biopsy and possible surgery.
73. Mrs. Masie’s biopsy is positive and she consents to have a modified radical
mastectomy. On return from surgery, she has a drainage tube in situ. The main
purpose of this tube is to help
a) Decrease intrathoracic pressure and facilitate easy breathing
b) Increase collateral lymphatic flow toward the operative area
c) Remove accumulations of serum and blood in the operative site
d) Prevent formation of adhesions between the skin and chest wall

74. As a result of the surgery, which activities should Mrs. Masie avoid on discharge?
a) Shampooing her dog
b) Caring for her fishes
c) Working in her flower garden
d) Taking a late-evening swim

75. A cervical radiation implant is placed in a client for the treatment of cervical
cancer. Which of the following is the most appropriate activity ordered for this
client, that the nurse should initiate?
a) Bed rest
b) Out of bed ad lib
c) Bathroom privileges only
d) Out of bed into a chair only

76. A nurse is planning a teaching session for a group of adolescents. The nurse
understands that by adolescence, the individual is in which stage of cognitive
development?
a) Concrete operations
b) Conventional thought
c) Formal operations
d) Post-conventional thought
RAS
77. An adolescent boy tells the nurse that he has recently had homosexual feelings.
The nurse’s response should be based on knowledge that

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a) This indicates that the adolescent is homosexual
b) The adolescent should be referred for psychotherapy
c) This indicates that the adolescent will become homosexual as an adult
d) The adolescent should be encouraged to share his feelings and experiences

78. The nurse on the paediatric ward is admitting a child with a Wilm’s tumour. Which
of the following is the initial assessment finding associated with this tumour?
a) Hypotension
b) Weight gain
c) Abdominal swelling
d) Increased urine output

79. A client with a history of suicide attempts has been taking fluoxetine (Prozac) for
one month. The client suddenly presents with a bright affect, rates mood as 9 out
of 10, and is much more communicative. Which action should be the nurse’s
priority at this time?
a) Give the client off-unit privileges as positive reinforcement
b) Increase the level of the client’s suicide precautions
c) Encourage the client to share the mood improvement during group sessions
d) Request that the psychiatrist re-evaluate the current medication protocol

80. A nurse reviews the laboratory data of a client suspected of having the diagnosis of
major depressive episode. Which laboratory value would potentially rule out this
diagnosis?
a) Thyroid Stimulating Hormone level of 25 U/mL
b) Potassium level of 4.2 mEq/L
c) Sodium level of 140 mEq/L
d) Calcium level of 9.5 mg/dL

81. Nurse Bell is assigned to a 41-year-old client with a diagnosis of acute pancreatitis.
The nurse reviews the laboratory result, anticipating a report that indicates a
serum amylase level of
a) 45 units/L
b) 100 units/L
c) 300 units/L
d) 500 units/L

82. Nurse Joy is preparing to administer medication through a nasogastric tube that is
connected to suction.to administer the medication, nurse Joy would

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a) Clamp the nasogastric tube for 30 minutes following administration of the
medication
b) Position the client supine to assist in absorption of the medication
c) Aspirate the nasogastric tube after medication administration to maintain patency
d) Change the suction setting to low intermittent suction for 30 minutes after
medication administration

83. Which of the following nursing interventions should the nurse perform for a
female client receiving enteral feedings through a gastrostomy tube?
a) Check the gastrostomy tube for position every 2 days
b) Change the tube feeding solutions and tubing at least every 24 hours
c) Maintain the client on bed rest during the feedings
d) Maintain the head of the bed at a 15-degree elevation continuously

84. An adolescent girl gets hit in the eye during a fight. The school nurse using a
flashlight, notes the presence of gross hyphema. The nurse should
a) Apply a Fox shield
b) Instruct the adolescent to apply ice for 24 hours
c) Have the adolescent rest with the eye closed and ice applied
d) Notify the parents that the adolescent needs to see an ophthalmologist

85. Guidelines for intramuscular administration of medication in school-age children,

include which action?
a) Inject the medication as quickly as possible
b) Insert the needle quickly, using a dart-like motion
c) Have the child stand if possible and if the child is cooperative
d) Penetrate the skin immediately after cleansing site, before skin has dried

86. Which of the following is an example of an intentional tort?

a) A nurse gives patient information to an unauthorized person
b) A nurse makes a medication error and does not report the incident
c) A nurse physically places an irritating client in a four-point restraints
d) A nurse fails to assess a client’s obvious symptoms of neuroleptic malignant
syndrome

87. The nurse is presenting a workshop on wellness and health promotion and the
initiatives of “Healthy People 2020” as a resource for this topic. After the session,
which of the following statements by a participant indicates an understanding
concerning the initiatives proposed?

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a) It will allow health care providers to lobby legislators for more funding
b) The primary goal of Healthy People 2020 is to assist health care providers in
determining risk factors for premature birth
c) The initiatives will outline standards of care for providers in the management of
diseases
d) Healthy People 2020 seeks to promote health, prevent illness disability and
premature death

88. The nurse is developing the plan of care for a client who is recovering from
abdominal surgery. When planning interventions, the nurse recognizes which of
the following will best meet the needs of the client experiencing pain?
a) The physician will prescribe additional analgesics
b) The client will have reduced pain after administration of analgesics
c) The client will vocalize reduced levels of pain within three hours
d) Assist the client with guided imagery to manage pain levels

89. During step three of the nursing process, which of the following activities is
performed?
a) Statement of client goals
b) Collection of subjective data
c) Performance of care activities
d) Review of client goal achievement

90. The nurse is caring for a client complaining of a backache and administers
ibuprofen as prescribed. The client asks the nurse how the medication will help the
pain. The nurse understands that ibuprofen effect occurs during which phase of
nociception?
a) Transduction
b) Transmission
c) Perception
d) Modulation

91. The nurse is performing an assessment on a 23-year-old client who is being seen
for chronic back pain. During the assessment, which of the following findings can
be anticipated?
i. Increased pulse rate
ii. Normal blood pressure

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 iii. Increased respiratory rate
iv. Normal pulse rate
a) I, and ii
b) I, and iii
c) Ii, and iv
d) Iii, and iv

92. During shift report, a nurse learns that a patient has a macular rash. As the nurse
inspects the patient’s skin, what finding will confirm the rash?
a) Elevated, firm, well-defined lesions less than 1 cm in diameter
b) Depressed, firm, or scaly, rough lesions greater than 1 cm in diameter
c) Elevate, fluid-filled lesions less than 1 cm in diameter
d) Flat, well-defined, small lesions less than 1 cm in diameter

93. A patient has come to the clinic complaining of a bump behind his right ear. Upon
inspection, the nurse notes a lesion that is elevated, solid and 4 cm in diameter.
What does the nurse call this lesion when she reports her findings to the
physician?
a) Tumour
b) Nodule
c) Keloid
d) Papule

94. A nurse notices several reddish-purple, non-blanchable spots of different sizes on

the arms and legs of a patient with thrombocytopenia. How does the nurse
distinguish ecchymosis from purpura?
a) Ecchymosis is irregularly-shaped and purpura is round
b) Ecchymosis does not blanch and purpura does blanch
c) Ecchymosis has raised lesions and purpura has flat lesions
d) Ecchymosis is variable in size and purpura is greater than 0.5 cm in diameter

95. A nurse shines the penlight in the right pupil to test constriction and notices that
the left pupil constricts as well. Based on these data, which of the following actions
should the nurse take?
a) Assess the patient’s corneal light reflex
b) Document this finding as a consensual reaction
c) Assess the patient eyes for accommodation

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d) Document this finding as an abnormal finding

96. During a history, a nurse notices a patient is short of breath, is using pursed-lip
breathing, and maintains a tripod position. Based on these data, what abnormal
finding should the nurse expect to find during the examination?
a) Increased tactile fremitus
b) Tracheal deviation
c) Inspiratory and expiratory wheezing
d) An increased anteroposterior diameter of chest

97. A nurse notices a patient’s chest wall moving in during inspiration and out during
expiration. What additional assessment must the nurse perform immediately?
a) Palpate for tracheal deviation
b) Palpate posterior thoracic muscles for tenderness
c) Auscultate for the absence of breath sounds in the lung periphery
d) Auscultate for Broncho-vesicular breath sounds in the lung periphery

98. A nurse had previously heard crackles over both lungs of a patient. As the patient
improves, what lung sounds does the nurse expect to hear in the patient’s lungs?
a) Rhonchi heard over the main bronchi
b) Bronchial breath sounds heard over the bronchi
c) Vesicular breath sounds heard in peripheral lung fields
d) Broncho-vesicular breath sounds heard over the apices

99. A patient reports having abdominal distention. The nurse notices that the patient’s
sclera are yellow. What question is appropriate for the nurse to ask in response to
this information?
a) Has there been a change in your usual pattern of urination?
b) Have you had any nausea or vomiting?
c) Has there been a change in your bowel habits?
d) Have you had indigestion or heartburn?

100. How does the nurse accurately assess bowel sounds?

a) Hold the diaphragm of the stethoscope lightly against the abdomen in each
quadrant
b) Hold the diaphragm of the stethoscope firmly against the abdomen in each
quadrant

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 c) Press the bell of the stethoscope firmly against the abdomen in each quadrant
d) Hold the bell of the stethoscope lightly against the abdomen in each quadrant
RAS

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