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

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

PRN comes from the Latin “pro re nata” meaning, “for an

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

Option A: The practice of spelling out an abbreviation

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