Fundamentals of Nursing 9.
The nurse is caring for a severely ill patient with acquired
Part 1
1. Which of the following is an example of a true health
promotion service provided by a nurse?
A. An immunization clinic.
B. A diabetic support group.
C. A prenatal nutrition class.
D. Zumba every Saturday.
2. The nurse initiated a support group for adolescent parents
and is teaching them about healthful eating habits and hygiene,
which are all examples of which of the following?
A. Health promotion.
B. Disease and injury prevention.
C. Supportive care.
D. Rehabilitation.
3. Within a health care system that is based on Betty
Neuman’s theory, what is the nurse’s goal in caring for a
patient who is having difficulty breathing and requires oxygen
and medication?
A. Strengthen the line of defences and focus on prevention.
B. Promote attainment of biological self-care requisites.
C. Assist in physiological adaptation to internal changes.
D. Achieve the 14 basic needs.
4. Although the different nursing theories have similarities,
key elements distinguish one from another. What is the
emphasis of Jean Watson’s conceptual model?
A. Self-care maintains wholeness.
B. Subsystems exist in dynamic stability.
C. Stimuli disrupt an adaptive system.
D. Caring is central to the essence of nursing.
5. While working on a postoperative unit, the nurse is
applying elements of self-care theory and is assisting a patient
to attain and manage self-care in wound management. Who
was the nursing pioneer who developed this theory?
A. Florence Nightingale.
B. Virginia Henderson.
C. Dorothea Orem.
D. Hildegard Peplau.
6. Whose theory is most pertinent in assisting the nurse who is
helping a patient focus on stress reduction?
A. Hildegard Peplau’s.
B. Virginia Henderson’s.
C. Betty Neuman’s.
D. Rosemarie Parse’s.
7. Interactionist theories focused on the relationships between
nurses and their patients. Which of the following was an
interactionist theorist?
A. Hildegard Peplau
B. Dorothea Orem
C. Florence Nightingale
D. Betty Neuman
8. The patient’s son requests to view the documentation in his
mother’s medical record. What is the nurse’s best response to
this request?
A. “I’ll be happy to get that for you.”
B. “You will have to talk to the physician about that.”
C. “You will need your mother’s permission.”
D. “You are not allowed to see it.”
immune deficiency syndrome (AIDS) who now requires
ventilator support. Which intervention is considered futile?
A. Administering the influenza vaccine.
B. Providing oral care every 5 hours.
C. Applying fentanyl patches prn for pain.
D. Supporting the patient’s lower extremities with pillows.
10. A new nurse at a health care unit notes that a listing of
patient names is kept in a closed book behind the front desk of
the nursing station so that patients can be located easily. What
action is most appropriate for the nurse to take?
A. Move the book to the upper ledge of the nursing station for
easier access.
B. Talk with the nurse manager about the listing being a
violation of confidentiality.
C. Use the book as needed while keeping it away from
individuals not involved in patient care.
D. Ask the nurse manager to move the book to a more
secluded area.
11. A confused patient with a urinary catheter, nasogastric
tube, and intravenous line keeps touching these items, which
are needed for care. The nurse has tried to explain to the
patient that he should not touch them, but the patient
continues. What is the best action by the nurse at this time?
A. Apply restraints loosely on the patient’s dominant wrist.
B. Try other approaches to prevent the patient from touching
these care items.
C. Notify the health care provider that restraints are needed
immediately to maintain the patient’s safety.
D. Allow the patient to pull out lines to prove that the patient
needs to be restrained.
12. The nurse calculates the medication dose for an infant on
the pediatric unit and determines that the dose is twice what it
should be. The pediatrician is contacted and says to administer
the medication as ordered. What is the next action that the
nurse should take?
A. Notify the nursing supervisor.
B. Give the medication as ordered.
C. Give the amount calculated to be correct.
D. Contact the pharmacy for clarification.
13. A nurse gives an incorrect medication to a patient without
doing all of the mandatory checks, but the patient has no ill
effects from the medication. What actions should the nurse
take after reassessing the patient and completing an incident
report?
A. Notify the health care provider of the situation.
B. Document in the patient’s medical record that an incident
report was filed.
C. Document in the patient’s medical record why the omission
occurred.
D. Discuss what happened with all of the other nurses and
staff on the unit.
14. A Staff nurse is working with a student nurse. Which
behaviour by the student nurse will prompt the nurse to
intervene?
A. The student nurse reviews the patient’s medical record.
B. The student nurse reads the patient’s plan of care.
C. The student nurse shares patient information with a friend.
D. The student nurse documents medication administered to
the patient.
15. Which situation best indicates that the nurse has a good
understanding of auditing and monitoring of patients’ health
records?
A. The nurse determines the degree to which standards of care
are met by reviewing patients’ health records.
B. The nurse realizes that care not documented in patients’
health records still qualifies as care provided.
C. The nurse knows that reimbursement is based on the
diagnosis-related groups documented in patients’ records.
D. The nurse compares data in patients’ records to determine
whether a new treatment had better outcomes than the
standard treatment.
16. After providing care, a nurse charts in the patient’s record.
Which entry should the nurse document?
A. “Appears restless when sitting in the chair.”
B. “Drank adequate amounts of water.”
C. “Apparently is asleep with eyes closed.”
D. “Skin pale and cool.”
17. A staff nurse is working with a new nurse on
documentation. Which situation will cause the preceptor to
intervene?
A. The new nurse uses a black ink pen to chart.
B. The new nurse charts consecutively on every other line.
C. The new nurse ends each entry with signature and title.
D. None of the above
18. A nurse is charting on a patient’s record. Which action is
most accurate legally?
A. Charting after intervention.
B. Using pencil.
C. Using correction fluid to correct error.
D. Writing entry for another nurse.
19. A nurse needs to begin discharge planning for a patient
admitted with pneumonia and a productive cough. When is the
best time for the nurse to start discharge planning for this
patient?
A. Upon the patient’s admission.
B. Right before the patient’s discharge.
C. After the congestion is treated.
D. When the primary care provider writes the order.
20. According to documentation guidelines, which notation is
the most appropriate?
A. “1230 hours: Patient’s vital signs taken.”
B. “0700 hours: Patient drank adequate amount of fluids.”
C. “0900 hours: Morphine given for lower abdominal pain.”
D. “0830 hours: Increased IV fluid rate to 100 mL per hour for
dehydration.”
21. Which situation will require the nurse to obtain a
telephone order?
A. As the nurse and primary care provider leave a patient’s
room, the primary care provider gives the nurse an order.
B. At 0100 hours, a patient’s blood pressure drops from
120/80 to 90/50 and the incision dressing is saturated with
blood.
C. At 0800, the nurse and primary care provider make rounds
and the primary care provider tells the nurse a diet order.
D. A nurse reads an order correctly as written by the primary
care provider in the patient’s medical record.
22. A nurse obtained a telephone order (TO) from a primary
care provider for a patient in pain. Which chart entry should
the nurse document?
A. “12/16/23 0915 Tylenol 500mg, 2 tablets, every 6 hours for
incisional pain. Verval Order Dr. Day J. Winds, MD, read
back.”
B. “12/16/23 0915 Tylenol 500mg, 2 tablets, every 6 hours for
incisional pain. TO Jopay Winds, RN, read back.”
C. “12/16/23 0915 Tylenol 500mg, 2 tablets, every 6 hours for
incisional pain. TO Dr. Day/J. Winds, MD, read back.”
D. “12/16/23 0915 Tylenol, 2 tablets, every 6 hours for
incisional pain. TO J. Winds, MD.”
23. A slight hematoma has developed on the patient’s left
forearm. The nurse labels the problem as an infiltrated
intravenous (IV) line. The nurse elevates the forearm. The
patient states, “My arm feels better.” When using the DAR
notes of focus charting, the nurse would document the “R” as
which of the following?
A. “My arm feels better.”
B. “Slight hematoma on left forearm.”
C. “Infiltrated IV line.”
D. “Elevation of left forearm.”
24. The action that a nurse would take when documenting on
the patient’s record and notes that he or she has made an error
is which of the following?
A. Drawing a line through the error, Writing mistaken entry
and initialling
B. Erasing the error and writing over the material in the same
spot.
C. Using a dark-coloured marker to cover the error and
continuing immediately after that point.
D. Footnoting the error at the bottom of the page, including
initials and the date.
25. An older patient is wearing a hearing aid. Which technique
should the nurse use to facilitate communication?
A. Speak clearly and loudly.
B. Turn off the television.
C. Chew gum.
D. Use at least 14-point print.
26. Which of the following patients will cause the greatest
communication concerns for a nurse?
A. A patient who is alert, has strong self-esteem, and is hungry.
B. A patient who is oriented, pain free, and blind.
C. A patient who is cooperative, depressed, and hard of
hearing.
D. A patient who is dyspneic, has a tracheostomy, and is
anxious.
27. A patient says, “You are the worst nurse I have ever had.”
Which response by the nurse is the most assertive?
A. “If I were you, I’d feel grateful for a nurse like me.”
B. “I feel uncomfortable hearing that statement.”
C. “How can you say that when I have been checking on you
regularly?”
D. “You shouldn’t say things like that, it is not right.”
28. A nurse is asked about the goal of patient education. What
is the nurse’s best response?
A. “The goal of educating others is to help people meet
standards of hospital protocols.”
B. “The goal of educating others is to help people achieve
optimal levels of health.”
C. “The goal of educating others is to help people become
dependent on the health care team.”
D. “The goal of educating others is to help people provide
self-care only while they are in the hospital.”
29. A nurse is teaching a group of healthy adults about the
benefits of flu immunizations. Which purpose of patient
education is the nurse fulfilling?
A. Restoration of health.
B. Coping with impaired functions.
C. Promotion of health and illness prevention.
D. None of the above
30. You are educating your client about the management of his
disease, Which action best indicates that learning has occurred?
A. A nurse presents information about diabetes.
B. A patient demonstrates how to inject insulin.
C. A family member listens to a lecture on diabetes.
D. A primary care provider hands a diabetes pamphlet to the
patient.
31. Which learning objective/outcome has the highest priority
for a patient with life-threatening, severe food allergies that
necessitate use of an EpiPen (epinephrine)?
A. The patient will demonstrate the correct way to administer
epinephrine.
B. The patient will identify the main ingredients in several
foods.
C. The patient will list the side effects of epinephrine.
D. The patient will learn about food labels.
32. A patient with heart failure is learning to reduce salt in the
diet. When would be the best time for the nurse to address this
topic?
A. At bedtime, when the patient is relaxed.
B. At lunchtime while the patient is preparing to eat.
C. At bath time, when the nurse is cleaning the patient.
D. At medication time, when the nurse is administering
medication.
33. A patient has been taught how to cough and deep breathe.
Which evaluation method is most appropriate?
A. Return demonstration.
B. Computer instruction.
C. Verbalization of steps.
D. Recording the steps.
34. Which following situation would cause the nurse to
postpone a teaching session?
A. The patient is mildly anxious.
B. The patient is asking questions.
C. The patient is afebrile.
D. The patient is in the bargaining phase.
35. The nurse teaches stress reduction and relaxation training
to a health education group of patients after cardiac bypass
surgery. The nurse is performing which level of intervention?
A. Primary.
B. Secondary.
C. Tertiary.
D. Quad level.
36. Of the following mechanisms of heat loss by the body,
what is the mechanism that transfers heat away through the
use of air movement?
A. Radiation.
B. Conduction.
C. Convection.
D. Evaporation.
37. The patient has a temperature of 40.7°C (105.2°F). The
nurse is attempting to lower his temperature by providing
tepid sponge baths and placing cool compresses in strategic
body locations. The nurse is attempting to lower the patient’s
temperature through the use of which of the following?
A. Radiation.
B. Conduction.
C. Convection.
D. Evaporation.
38. In focusing on temperature regulation of newborns and
infants, what should the nurse know?
A. Temperatures are basically the same for infants and older
persons.
B. Infants have well-developed temperature-regulating
mechanisms.
C. The normal temperature range gradually increases as the
person ages.
D. Newborns need to wear a cap to prevent heat loss.
39. The nurse is working the night shift on a surgical unit and
is making rounds at 0400 hours. She notices that the patient’s
temperature is 36°C (96.8°F), whereas at 1600 hours the
preceding day, it was 37°C (98.6°F). What should the nurse do?
A. Call the physician immediately to report a possible
infection.
B. Realize that this is a normal temperature variation.
C. Provide another blanket to conserve body temperature.
D. Provide medication to lower the temperature further.
40. The nurse is caring for a patient who has a temperature
reading of 38° C (100.4°F). His last two temperature readings
were 37°C (98.6°F) and 36°C (96.8°F). What should the nurse
do?
A. Call the physician and anticipate an order to treat the fever.
B. Assume that the patient has an infection and order blood
cultures.
C. Recheck the patient’s temperature after 15 minutes
D. Be aware that temperatures this high are harmful and affect
patient safety.
41. The patient is restless and has a temperature of 39°C
(102.2°F). What is one of the first things the nurse should do?
A. Administer oxygen to the patient.
B. Restrict the patient’s fluid intake.
C. Increase the patient’s activity.
D. Increase the patient’s metabolic rate.
42. A patient’s temperature must be measured every 2 hours.
Which of the following tasks cannot be delegated to a nursing
assisstant?
A. Selecting appropriate route and device.
B. Obtaining temperature measurement at ordered frequency.
C. Being aware of the usual values for the patient.
D. Assessing changes in body temperature.
43. The nurse is caring for an infant and is measuring the
patient’s vital signs. The best site for the nurse to measure the
infant’s pulse would be which artery?
A. Radial.
B. Brachial.
C. Femoral.
D. Popliteal.
44. The patient is found to be unresponsive and not breathing.
To determine the presence of central blood circulation and
circulation of blood to the brain, the nurse checks which pulse?
A. Radial.
B. Brachial.
C. Posterior tibial.
D. Carotid.
45. The nurse needs to measure the radial pulse from a patient.
For accuracy, what must the nurse do?
A. Place the tips of the nurse’s first two fingers over the
groove along the thumb side of the patient’s wrist.
B. Place the thumb over the groove along the thumb side of
the patient’s wrist.
C. Apply a very light touch so that the pulse is not obliterated.
D. Apply very strong pressure to detect the pulse.
46. While the nurse is assessing the patient’s respirations, it is
important for the patient to do what?
A. Be aware of the procedure being done.
B. Not know that respirations are being assessed.
C. Understand that respirations are estimated to save time.
D. Not be touched until the entire process is finished.
47. The patient’s blood pressure is 140/60. How would the
nurse record the pulse pressure?
A. As 140.
B. As 60.
C. As 80.
D. As 200.
48. The patient is being admitted to the medical unit with
complaints of shortness of breath. The patient has had chronic
lung disease for many years but still smokes. What should the
nurse do?
A. Administer high levels of oxygen.
B. Use oxygen cautiously in this patient.
C. Place a paper bag over the patient’s face to allow
rebreathing of carbon dioxide.
D. Use partial rebreather mask
49. The nurse is caring for a patient who has a pulse rate of 44.
His blood pressure is within normal limits. In trying to
determine the cause of the patient’s low heart rate, what would
the nurse suspect?
A. That the patient would have a fever.
B. Possible hemorrhage or bleeding.
C. That the patient is taking calcium channel blockers or
digitalis medications.
D. Chronic obstructive pulmonary disease (COPD).
50. Of the following blood pressure values, which would be
considered as a high normal reading?
A. 98/50 in a 7-year-old child.
B. 115/70 in an infant.
C. 135/85 in an older person.
D. 120/80 in a middle-aged adult.
51. Patient develops dyspnea and shortness of breath what is
the most appropriate nursing intervention for a patient who
develops dyspnea and shortness of breath?
A. Maintain the patient on strict bed rest at all times
B. Maintain the patient in an orthopneic position as needed
C. Administer oxygen by Venturi mask at 24%, as needed
D. Allow a 1 hour rest period between activities
52. The nurse observes that Mr. Adams begins to have
increased difficulty breathing. She elevates the head of the
bed to the high Fowler position, which decreases his
respiratory distress. The nurse documents this breathing as:
A. Tachypnea
B. Eupnca
C. Orthopnea
D. Hyperventilation
53. The physician orders a platelet count to be performed on
Mrs. Smith after breakfast. The nurse is responsible for:
A. Instructing the patient about this diagnostic test
B. Writing the order for this test
C. Giving the patient breakfast
D. All of the above
54. Mrs. Mitchell has been given a copy of her diet. The
nurse discusses the foods allowed on a 500-mg low sodium
diet. These include:
A. A ham and Swiss cheese sandwich on whole wheat
bread
B. Mashed potatoes and steamed chicken
C. A tossed salad with oil and vinegar and olives
D. Chicken Adobo
55. In Maslow’s hierarchy of physiologic needs, the human
need of greatest priority is:
A. Love.
B. Elimination
C. Nutrition
D. Oxygen
56. The family of an accident victim who has been
declared brain-dead seems amenable to organ donation.
What should the nurse do?
A. Discourage them from making a decision until their
grief has eased
B. Listen to their concerns and answer their questions
honestly
C. Encourage them to sign the consent form right away
D. Tell them the body will not be available for a wake or
funeral
57. A new head nurse on a unit is distressed about the poor
staffing on the 11 p.m. to 7 a.m. shift. What should she do?
A. Complain to her fellow nurses
B. Wait until she knows more about the unit
C. Discuss the problem with her supervisor
D. Inform the staff that they must volunteer to rotate
58. If nurse administers an injection to a patient who refuses
that injection, she has committed:
A. Assault
B. Negligence
C. Malpractice
D. Battery
59. If patient asks the nurse her opinion about a particular
physicians and the nurse replies that the physician is
incompetent, the nurse could be held liable for:
A. Slander
B. Libel
C. Assault
D. Battery
60. A registered nurse reaches to answer the telephone on a
busy pediatric unit, momentarily turning away from a 3
month-old infant she has been weighing. The infant falls off
the scale, suffering a skull fracture. The nurse could be
charged with:
A. Defamation
B. Assault
C. Battery
D. Negligence
61. A patient about to undergo abdominal inspection is best
placed in which of the following positions?
A. Prone
B. Sitting
C. Supine
D. Dorsal recumbent
62. For a rectal examination, the patient can be directed to
assume which of the following positions?
A. Genupecteral
B. Sims position
C. Jack knife position
D. Fetal position
63. Palpating the midclavicular line is the correct technique
for assessing
A. Baseline vital signs
B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse
64. A male patient who had surgery 2 days ago for head and
neck cancer is about to make his first attempt to ambulate
outside his room. The nurse notes that he is steady on his feet
and that his vision was unaffected by the surgery. Which of
the following nursing interventions would be appropriate?
A. Encourage the patient to walk in the hall alone
B. Discourage the patient from walking in the hall for a few
more days
C. Accompany the patient for his walk.
D. Consuit a physical therapist before allowing the patient to
ambulate
65. Mrs. Lim begins to cry as the nurse discusses hair loss.
The best response would be:
A. “Don’t worry. It’s only temporary”
B. “Why are you crying? I didn’t get to the bad news yet”
C. “Your hair is really pretty”
D. “I know this will be difficult for you, but your hair will
grow back after the completion of chemotheraphy”
66. A patient has exacerbation of chronic obstructive
pulmonary disease (COPD) manifested by shortness of breath;
orthopnea: thick, tenacious secretions; and a dry hacking
cough. An appropriate nursing diagnosis would be:
A. Ineffective airway clearance related to thick, tenacious
secretions.
B. Ineffective airway clearance related to dry, hacking cough.
C. Ineffective individual coping to COPD.
D. Pain related to immobilization of affected leg.
67. Which of the following nursing interventions promotes
patient safety?
A. Asses the patient’s ability to ambulate and transfer from a
bed to a chair
B. Demonstrate the signal system to the patient
C. Check to see that the patient is wearing his identification
band
D. All of the above
68. Studies have shown that about 40% of patients fall out of
bed despite the use of side rails; this has led to which of the
following conclusions?
A. Side rails are ineffective
B. Side rails should not be used
C. Side rails are equipment to prevent a patient from falling
out of bed.
D. Side rails are a reminder to a patient not to get out of bed
69. The most common injury among elderly persons is:
A. Atheroscleotic changes in the blood vessels
B. Increased incidence of gallbladder disease
C. Urinary Tract Infection
D. Hip fracture
70. The nurse’s most important legal responsibility after a
patient’s death in a hospital is:
A. Obtaining a consent of an autopsy
B. Notifying the coroner or medical examiner
C. Labeling the corpse appropriately
D. Ensuring that the attending physician issues the death
certification
71. Although the client refused the procedure, the nurse
insisted and inserted a nasogastric tube in the right nostril. The
administrator of the hospital decides to settle the lawsuit
because the nurse is most likely to be found guilty of which of
the following?
A. An unintentional tort
B. Assault
C. Invasion of privacy
D. Battery
72. You received a telephone order for a patient with SLE;
when is the appropriate time for the physician to countersign
the order?
A. As soon as possible
B. After 6 hours
C. After 24 hours
D. As hospital protocol
73. When performing an abdominal examination, the patient
should be in a supine position with the head of the bed at what
position?
A. 30 degrees
B. 90 degrees
C. 45 degrees
D. 0 degree
74. The nurse is performing an assessment on a client who is
cachectic and has developed an enterocutaneous fistula
following surgery to relieve a small bowel obstruction. The
client's total protein level is reported as 4.5. Which of the
following would the nurse anticipate?
A. Additional potassium will be given IV
B. Blood for coagulation studies will be drawn
C. Total parenteral nutrition (TPN) will be started
D. Serum lipase levels will be evaluated
 A. Ensuring that the patient does not eat or drink 2 hours
75. A 1-year-old child is scheduled to receive an intravenous before the examination.
(IV) line. The most appropriate type of restraint to use for this B. Removing all of the patient’s metallic jewellery.
patient to prevent removal of the IV line is which of the C. Administering a colon-cleansing product 12 hours before
following? the examination.
A. A wrist restraint. D. Obtaining an order for a pain medication before the test is
B. A jacket restraint. performed.
C. An elbow restraint.
D. A mummy restraint. 84. After a patient returns from a barium swallow study, what
is the nurse’s priority?
76. The nurse knows that most nutrients are absorbed in which A. Encourage the patient to increase fluids to flush out the
portion of the digestive tract? barium.
A. Stomach. B. Monitor stools closely for bright red blood or mucus,
B. Duodenum. which indicates trauma from the procedure.
C. Ileum. C. Inform the patient that the bowel movements are
D. Cecum. radioactive and that the patient should be sure to flush the
toilet three times.
77. The nurse would expect the least formed stool to be D. Thicken all patient drinks to prevent aspiration.
present in which portion of the digestive tract?
A. Ascending colon. 85. A nurse is educating a patient on how to irrigate an ostomy
B. Descending colon. bag. Which statement by the patient indicates the need for
C. Transverse colon. further instruction?
D. Sigmoid colon. A. “I can use a Fleet enema to save money because it contains
the same irrigation solution.”
78. Which of the following is not a function of the large B. “Sitting on the toilet lets the irrigation sleeve eliminate into
intestine? the bowl.”
A. Absorbing nutrients. C. “I should never attempt to reach into my stoma to remove
B. Absorbing water. fecal material.”
C. Secreting bicarbonate. D. “Using warm tap water will reduce cramping and
D. Eliminating waste. discomfort during the procedure.”

79. Which patient is most at risk for increased peristalsis?
A. A 5-year-old child who ignores the urge to defecate owing
to embarrassment.
B. A 21-year-old patient with three final examinations on the
same day.
C. A 40-year-old woman with major depressive disorder.
D. An 80-year-old man in an assisted-living environment.
80. A patient expresses concerns over having black stool. The
fecal occult test is negative. Which response by the nurse is
most appropriate?
A. “This is probably a false-negative result; we should rerun
the test.”`
B. “Do you take iron supplements?”
C. “You should schedule a colonoscopy as soon as possible.”`
D. “Sometimes severe stress can alter stool colour.”
81. The nurse would anticipate which diagnostic examination
for a patient with black tarry stools?
A. Ultrasound
B. Barium enema study.
C. Upper endoscopy.
D. Flexible sigmoidoscopy.
82. The nurse has attempted to administer a tap water enema
for a patient with fecal impaction with no success. What is the
next priority nursing action?
A. Preparing the patient for a second tap water enema.
B. Donning gloves for digital removal of the stool.
C. Positioning the patient on the left side.
D. Inserting a rectal tube.
83. A nurse is preparing a patient for magnetic resonance
imaging (MRI). Which nursing action is most important?
86. A nurse is providing discharge teaching for a patient who
is going home with a guaiac test. Which statement by the
patient indicates the need for further education?
A. “If I get a positive result, I have gastrointestinal bleeding.”
B. “I should not eat red meat before my examination.”
C. “I should schedule to perform the examination when I am
not menstruating.”
D. “I will need to perform this test three times if I have a
positive result.”
87. A nurse is caring for a patient who has had diarrhea for the
past week. Which additional assessment finding would the
nurse expect?
A. Increased energy levels.
B. Distended abdomen.
C. Decreased serum bicarbonate level.
D. Increased blood pressure.
88. The nurse is caring for a patient who had a colostomy
placed yesterday. The nurse should report which assessment
finding immediately?
A. Stoma is protruding from the abdomen.
B. Stoma is moist.
C. Stool is discharging from the stoma.
D. Stoma is purple.
89. A guaiac test has been ordered. The nurse knows that this
is a test for which of the following?
A. Bright red blood.
B. Dark black blood.
C. Blood that contains mucus.
D. Blood that cannot be seen.
90. The nurse should place the infant patient in which position
when preparing to administer an enema?
A. Left Sims’s position.
B. Dorsal recumbent
C. Supine.
D. Semi-Fowler’s.
91. A client’s family tells the nurse that their culture does not
permit a dead person to be left alone before burial. Hospital
policy states that after 6:00 PM when mortuaries are closed,
bodies are to be stored in the hospital morgue refrigerator until
the next day. How would the nurse best manage this situation?
A. Gently explain the policy to the family and then implement
it.
B. Inquire of the nursing supervisor how an exception to the
policy could be made.
C. Call the client’s primary care provider for advice.
D. Move the deceased to an empty room and assign an aide to
stay with the body
92. You are assessing patient after surgery, Which statement
best reflects the nurse’s assessment of the fifth vital sign?
A. “Do you have any complaints?”
B. “Are you experiencing any discomfort right now?”
C. “Is there anything I can do for you now?”
D. “Do you have any complaints of pain?”
98. You are doing catheterization and you secure the penis
laterally to his thigh. The primary reason for taping an
indwelling catheter laterally to the thigh of a male client is to:
A. Eliminate pressure at the penoscrotal angle.
B. Prevent the catheter from kinking in the urethra.
C. Prevent accidental catheter removal.
D. Allow the client to turn without kinking the catheter
99. A 19-year-old male client is diagnosed with a chlamydial
infection. Azithromycin (Zithromax) 1 g is ordered. The
supply of azithromycin is in 250-mg tablets. How many
tablets should the nurse administer?
A. 3 tablets
B. 4 tablets
C. 2 tablets
D. 5 tablets
100. When teaching a client to perform testicular self-
examination, the nurse explains that the examination should
be performed:
A. After intercourse.
B. At the end of the day.
C. After a warm bath or shower.
D. After exercise.

93. You suggested the patient who was due for discharge Prepared by:
today eat in accordance with the food pyramid; at what degree Sir Darryl Custodio Locañas, RN, MScN-AdMedSurg
of prevention does your suggestion fall out?
A. Screening
B. Rehabilative
C. Promotive
D. Detection

94. After the first dose of an anti-hypertensive agent, your

client suddenly becomes hypotensive. You should position
the client:
A. In a semi-Fowler’s position
B. In a side-lying position
C. In Trendelburg position
D. With legs elevated 30 degrees

95. A client is to receive gavage feeding through an NG tube.

Which of the following nursing actions should be instituted to
prevent complications?
A. Flush with 20 mL of air
B. Place client in high-Fowler’s position
C. Advance tube 1 cm
D. Plug the air vent during feeding

96. A client is to receive NG tube as ordered. Which of the

following nursing actions should be instituted?
A. Assess nasal potency
B. Assess tube potency
C. Place in sitting position
D. Place in high fowlers position

97. A client asks the nurse, “Where is cancer usually found in

the breast?” When responding to the client, the nurse uses a
diagram of a left breast and indicates that most malignant
tumors occur in which quadrant of the breast?
A. Upper outer quadrant.
B. Upper inner quadrant.
C. Lower outer quadrant.
D. Lower inner quadrant.